Advanced Knee Care

Total Knee Replacement Surgery

Less Traumatic TKR – The current approach to Total Knee Replacement

Total Knee Replacement cartoon with femoral,
tibial, tibial polyethylene and patellar polethylene
components depicted.

Modern state of the art Total Knee Replacement means less traumatic techniques to minimize swelling and bleeding and pain for a quicker recovery and faster return back to an normal, active life. Cutting edge protocols include multimodal pain control, bracing and cryotherapy for pain and swelling management, multi faceted infection avoidance treatments, smallest workable knee incisions with careful handling of knee tissue, and meticulous surgical attention to detail for proper implant sizing, alignment, rotation and balancing. Standardized surgical teams improve surgical processes and maximize best practices and minimize complications. Less Traumatic Total Knee Replacement is the culmination of years of innovative improvements in all facets of surgical strategies and techniques, with the ultimate goal to attain the best possible outcome for every patient. Let our team show you how Less Traumatic TKR can improve your life.

Knee Arthritis Treatment Options

Advanced arthritis of the knee symptoms (pain, stiffness, limited motion, decreased walking and standing tolerance) often times intensify to the point of interfering with daily activities and causing intolerable pain during some or all activities. For these people, surgical intervention using knee joint replacement implants often times returns patients back into their normal life style with markedly diminished or no knee pain.

Non Surgical “Step Treatment” Alternatives to Total Knee Replacement

Xray showing healthy knee on left, advanced
OA with varus collapse – bone on bone
(single orange arrow) – on right

Includes self directed treatments such as weight loss, daily aerobic low impact exercise, activity modification/rest, ice and OTC pills such as ibuprofen, naproxen, or acetaminophen. Physician directed treatments include physical therapy, prescription anti inflammatory NSAID like Celebrex or Mobic, Cortisone injections, Visco gel injections, arthritis unloader bracing, acupuncture, and if indicated for meniscal tear or loose body – knee arthroscopy.

Deciding Between Total and Partial Knee Replacement

Total Knee replacement is done when 2 or 3 of the knee compartments are completely worn out and accompanied by advanced deformity (varus- bow leg or valgus- knock knee) and/or limited knee motion. Partial or Unicompartmental Knee replacement is done robotically using the Makoplasty technique when only one compartment is worn.

Patient Health Optimization

Patient health optimization is key to a good surgical outcome. Patients should get 30 minutes of low impact, aerobic exercise (break a sweat) for at least 6 weeks prior to Knee Replacement surgery, even if it causes knee pain. Patients should have a reasonable Body Mass Index (lower than 35 is good). Successful weight loss patients use exercise and food portion control (using Food Diary). We can refer you to a physician to help with weight loss. Smokers should refrain from smoking for 6 weeks prior to surgery and not smoke for the 2 months after their joint replacement. Help to stop smoking is available from ASHLINE. Diabetics, type 1 and 2, need to have Hemoglobin A1C less than 7 around the time of surgery and on the day of surgery blood sugar should be less than 150. Much higher risks for a bad outcome are associated with obesity, smoking and diabetes, with complications occurring in 25% of patients with all three of these risk factors. Morbid obese patients are 25 times more likely to suffer a post-operative infection. Failure Rates (all causes – infection, reported pain, instability, loosening, reoperation) are double in this patient population. Complications such as wound bleeding, blood clots and Surgical Site Infections (SSI) usually result in repeat hospital admissions, repeat surgery, prolonged recovery and unfavorable outcomes. So if your goal is to have a positive experience with Knee Replacement Surgery the best action is to optimize you health to minimize complications.

MIS – CAS Total Knee Surgery Use is Waning

At this writing (11/2012) the use of computer navigation and limited incision techniques for total knee replacement is uncommon. While this issue was at the forefront of Orthopedic Debate in the mid 2000’s, it is rarely discussed at National Orthopedic Meetings today. The matter has been resolved. There is no patient benefit with MIS – CAS technique for Total Knee Replacement. Now, Less Traumatic Total Knee Replacement patients also recover with less pain and faster return to normal function due to multimodal pain management, improved traditional surgical techniques, and rapid rehabilitation protocols. Back in the early 2000’s when MIS – CAS TKA came into being, the expectations were that outcomes using these techniques would revolutionize Total Knee Replacement.

What I see in my day-to-day practice is that hospital length of stay and return to work and recreational activities are excellent for Less Traumatic Total Knee Replacement patients. These good outcomes are from advances in surgical technique including using the smallest workable knee incisions with careful handling of knee tissue, improved implant design, multimodal pain management, multi faceted infection avoidance treatments and improved rehabilitation methods (cold therapy, compression, early activity). Standardized surgical teams improve surgical processes and maximize best practices and minimize complications.

I will continue to evolve surgical techniques and incorporate new technologies into the practice of orthopedic surgery to improve patient experience and patient outcomes.

The Current State of Affairs in Total Knee Replacement Surgery

Less Traumatic Total Knee Replacement surgery uses standard instrumentation and does not require the use of computer navigation. Improvements over the last decade in traditional surgery techniques, multimodal pain management and rapid rehabilitation protocols produce the best patient recovery paths. Our patients do great!

Typical Recovery: Hospitalization 1-3 nights. Walker for 5-10 days. Driving within 2-4 weeks. Return to work in 1-3 months. Results vary depending on individual’s physical condition, other constitutional characteristics. Many patients take a year to reach a completely healed state.

Typical Risks include infections, blood clots, wound bleeding and knee stiffness. Antibiotics are used in the peri operative period to lower infection risk. Blood thinners and early mobilization are used to lower risk of blood clots. Aggressive, early Physical Therapy for 6-8 weeks is used to maximize range of motion and function.

Total Knee Implants

Smith and Nephew Legion Oxinium
(black ceramic) Total Knee Implant

Implants for all Knee replacement techniques are identical. Doctor Tarlow uses the Smith and Nephew Legion, and the Stelkast Proven Gen-Flex. These implants are engineered for superior range of motion in knee fexion and rotation, while offering conforming fit on both the male and female knee. Both lines offer “Gender” models specific to female anatomy.

Smith and Nephew Legion. This implant has many technical advantages for all different knee variations, including “complex options” with stems and wedges and revision components. The Smith and Nephew Legion is from the Genesis 2 family of proven performance implants. By virtue of the unique implant design features and materials the Legion Total Knee System is ideally suited to address the common and uncommon patient factors including age, motion, anatomy, gender, pathology and metal sensitivity. The Legion Narrows are specifically designed for the female anatomy. This knee is available in an Oxinium (ceramic) femoral component. Recently introduced is the so called “30 Year Knee” with Verilast Technology. Smith and Nephew uses a highly cross-linked polyethylene technology to minimize wear and maximize longevity (polyethylene insert is most likely to fail years later from wear – this is teflon like pad between that the metal components rub on step after step, year after year). The verilast knee is hypoallergenic with no nickel or cobalt.

Stelkast Proven Gen-Flex Knee System

Stelkast Proven Gen-Flex Primary
Total Knee Components

The StelKast Knee Replacement Systems are long term, quality solutions based on clinically proven designs and provide the flexibility required to address patients’ needs. Stelkast is a unique private US company that is 100% focused on total joint implants. The implants are well made, been on the market for 20 + years, have clinical data supporting good outcomes, and have NEVER had recalls for product failures. The parent company has been manufacturing implants for ALL the major orthopedic companies since the late 1970’s and Stelkast has been an implant company since 1992. This is a growing private company that is east coast based but has been moving into western markets. People in Arizona may not have heard of Stelkast but you are now because this is a unique company that is at the cutting edge of hip and knee implant innovations.

The Proven Gen-Flex femoral component has the highest (96%) medial-lateral plane congruency of any knee on the market, which contributes to improved wear and stability characteristics of a total knee implant. The Stelkast Revision knee system is acknowledged as one of the best on the market with offset femoral and tibial stem capabilities. Stelkast offers a Vitamin E blended, highly cross linked polyethylene insert which helps to reduce the chance of oxidation and increase wear performance, all while maintaining mechanical properties. (Polyethylene insert is most likely to fail years later from wear – this is teflon like pad between that the metal components rub on step after step, year after year). The Stelkast Knee System incorporates advanced design to improve knee function, such as climbing stairs with minimal difficulty or pain and high-flexion activities like golf, working in your garden, and those activities that require bending deeply at the knee can be addressed.

Custom Cutting Block Knee Replacement

Stelkast Revision Proven Gen-Flex
Total Knee Components

This is available commercially under the trade names Otis Med, Patient Matched Instrumentation and Signature. The technique utilizes preoperative Knee MRI to produce a Custom computer generated virtual knee model unique for each patient from which custom cutting blocks are fabricated in advance of the procedure and hold the “code” for implant sizing and bone cut placement for accurate implant alignment and rotation. This method is not used by Dr. Tarlow.

Cost of Total Knee Replacement

The CPT billing code for TKR is 27447, for unicompartmental knee replacement 27446 and for patellofemoral arthroplasty 27438. These codes are useful to patients when discussing cost with insurance companies or surgeons. Surgeon fee varies between physicians but is typically several thousand dollars (Dr. Tarlow fees). Charges typically associated with TKR include surgeon fee for total knee (27447), surgical assistant fee (12-20% of surgeon payment – not fee), anesthesiologist fee, hospital fee and physical therapy fee. If you would like to know more or have specific questions about medical costs, email me.

Guidelines for Antibiotics after total knee replacement

For routine dental prophylaxis, one dose Amoxicillin 2 grams orally one hour prior to dental work is standard.

Use Clindamyacin 600 mg if PCN allergic.

In 2009 this recommendation was extended from use only in the first 2 years after joint replacement to a lifetime recommendation.