Less Traumatic TKR – The current approach to Total Knee Replacement.

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Advances for 2015- Same Day Total Joint Surgery.

Dr. Tarlow’s Interview on US News & World Report

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Dr. Tarlow on US News & World Report

Cutting edge protocols:  Modern state of the art Total Knee Replacement means less traumatic techniques to minimize pain, swelling, and bleeding for a quicker recovery and faster return back to a normal, active life.  In 2014 some healthy, carefully selected patients were discharged to home directly from the recovery room after Less Traumatic TKR.  The feedback continues to be overwhelming in favor of this pathway in this population group.   In 2015 our top surgical team of RN’s, Surgical Tech’s, and Periop Nurses have moved to SurgCenterGreaterPHX (opens February, 2015), a same day surgery center. This center is our preferred surgical location.  We continue to improve on outpatient total knee pathways.  Same day surgery is not suitable for every patient.  For those more comfortable with the traditional inpatient delivery model I continue to operate at Honor Health Thompson Peak Hospital.

Outpatient Total Knee replacement has advantages.  Think no hospital room charges, no exorbitant hospital medication and physical therapy costs.  Think Less Overtreatment because there will be fewer blood tests and fewer doctor/nurse encounters.  Less testing, less overtreatment, and no medication error can help avoid unwanted complications from unnecessary medical care.  We can not say for sure infections rates are lower when patients avoid hospital stays but we think it to be true: the germs in your home are your friends.  They know you, they live with you everyday and they do not often harm you.  The germs in the hospital are germs you have never met.  They do not know you.  They are often nasty germs that are can harm you.

For patient comfort, continuity of care and peace of mind we offer our patients the option to have home PT visits for the first several days at home after Same Day Total Joint Replacement.

  1. Multimodal Pain Control
  2. Bracing and Cryotherapy for Pain and Swelling Management
  3. Thirteen Step Infection Avoidance Protocol
  4. Bleeding Control with Pharmological Agent Tranexamic Acid
  5. Smallest Workable Knee Incisions with Careful Handling of Knee Tissue
  6. Meticulous Surgical Attention to Detail for Proper Implant Sizing, Alignment, Rotation and Balancing.
  7. Standardized Surgical Teams Improve Surgical Processes and Maximize Best Practices and Minimize Complications
  8. Home DVT prophylaxis with VenaPro sequential compression and oral Aspirin for 2 weeks duration.

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.   Here are three important strategies to emphasize with TKR.

1.  Having the same surgical team like I do at SurgCenter of Greater Phoenix for every case (Surgeon, Assistant Surgeon, Circulating Nurse, Scrub Tech, Second assistant, and anesthesia) has been show to improve quality.  30 day readmission rates from complications are lower when consistent teams are in place.

2.  Using Saphenous Nerve blocks (adductor canal blocks) and short acting Spinal Anesthesia in addition to low dose general anesthesia provides better post op pain relief and shorter hospital stays (or allows for same day Total Knee surgery).

3.  Emphasize the importance of post op rehabilitation.  Stronger quadriceps muscles are correlated with increased patient satisfaction after TKR.

Let our team show you how Less Traumatic TKR can improve your life.

total-knee-replacement-2Knee 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

Self directed treatments can be helpful in cases of mild to moderate knee osteoarthritis.  These measures includes optimizing body weight, 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.

Total or Makoplasty Partial Replacement Replacement – How to decide which is best ?

Total Knee replacement is done when 2 or 3 of the knee compartments are completely worn out.  These patients typically limp, have crooked legs (varus- bow leg or valgus- knock knee) and limited knee motion. Partial or Unicompartmental Knee replacement is done robotically using the Makoplasty technique when only one compartment is diseased or injured.

Total Knee Implants Systems:

The key for a successful Less Traumatic Total Knee Replacement is precise implantation by a skilled and experienced surgeon.  Doctor Tarlow’s system of choice is the Ortho Development Balanced Knee System for primary TKR (first time surgery).  The Ortho Development Balanced Knee System is the revision system preferred by Dr. Tarlow.

For 2015 – Patient choice can be an important criteria.  If you prefer a different manufacturer, I will help you choose from one of the major joint replacement brands including DepuySmith and NephewStryker, and Zimmer to be used in your knee.

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Ortho Development Balanced Knee Implant

Ortho Development Balanced Knee System

The Ortho Development knee implant is US designed by Engineers and Orthopedic Surgeons.   Components are manufactured in Utah, Massachusetts, Ohio.  The materials are sourced in the US.  The original design has been modified three times since the introduction of this implant in 1998, incorporating engineering refinements that are associated with improved patient knee function. Design highlights include Vitamin E antioxidant polyethylene tibia and patella components,  patented tibial insert locking mechanism to limit micromotion, anatomic low profile femoral components with narrow sized options for precise fit, tibial inserts that are available in 1mm increments in the most popular thicknesses to give the surgeon the ability to micro tune the stability of the knee.  16 years on the market and no mechanical failures or recalls with the Balanced Knee System.

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, 40 may be acceptable). 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, re-operation) 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. The goal is to have a positive experience with Knee Replacement Surgery.  The best course of action is to optimize your health to minimize complications.

Less Traumatic Total Knee Replacement

knee-replacementWhat 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. In 2015 healthy, motivated people can go home the same day as the Less Traumatic Total Knee Replacement. 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, thirteen step infection avoidance treatments, pharmacologic bleeding control, and improved rehabilitation methods (cold therapy, compression, early activity). Standardized surgical teams improve surgical processes and maximize best practices and minimize complications.  Less Traumatic Total Knee Replacement patients routinely recover with less pain and have a faster return to normal function due to multimodal pain management, improved traditional surgical techniques, and rapid rehabilitation protocols.

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 instruments and does not require the use of computer navigation. Improvements over the last decade in traditional surgery techniques, multimodal pain management, infection prevention and rapid rehabilitation protocols produce the best patient recovery paths. Our patients do great!

Typical Recovery: Hospitalization 0-2 nights. Walker/cane 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. Aspirin, Sequential Compression Devices 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.

Billing and Coding: 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(CPT code 27447) include surgeon fee ($3500-4500), surgical assistant fee ($300), anesthesiologist fee ($1100), hospital fee (30% less at SurgCenterGreaterPHX vs. inpatient hospital) and physical therapy fee. If you would like to know more or have specific questions about medical costs, email me.

ProPublica Surgeon Scorecard Data

Rating surgeons is still an inexact science.  Dr. Tarlow chooses to include a link to his data so that patients are informed.  Dr. Tarlow’s adjusted complication scale is in the best quartile.  Of the 19 surgeons rated in Dr. Tarlow’s geographic area 14 surgeons had a greater and 4 surgeons had a lesser complication scale.  That being said, the range of complication scale for our geographical area is 1.4% – 3.3%.  I would opine that all surgeons in our area are performing well. Healthline analyzed data on over 1.5 million Medicare and privately insured people to take a closer look at these complications. Based on this analysis, 4.5 percent of patients under the age of 65 experience complications during this period. However, the same data set showed that the complication rate more than doubles for older adults   ProPublica (Medicare data – patients 65 year or older) has a uniform rating system that compiles hospital derived data on 300 potential complications that can occur anytime within the first 30 days after Total Knee Replacement surgical procedures.  These include procedure specific complications such as post op infection, blood clots and other complications such as heart attack, breathing problems or kidney failure.  Since all orthopedic surgeons are rated using the same system there is some validity to adjusted complication scale.  It is also important to state that a zero complication rate is not reality for major surgery such as total knee replacement.

Guidelines for Antibiotics After Total Knee Replacement:

From AAOS Clinical Practice Guide
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 2012 this recommendation was changed once again: Current recommendation is use only in the first year after joint replacement if healthy patient without dental infection.  Susceptible patients (diabetes, HIV, Rheumatoid on immunosuppresive meds, Cancer patients immunocompromised – to name a few) should always use prophylactic antibiotics for Dental work.

Partial vs. Total Knee Replacement – What are the differences?


Saphenous Nerve Block for Outpatient Knee Surgery *Warning: graphic surgical content


13 Steps That Protect Our Patients From Surgical Site Infections