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

total-knee-replacement-1Cutting 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 are able to be discharged to home directly from the recovery room after Less Traumatic TKR.

  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 VenaFlow Elite 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. 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.

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.

MIS – CAS Total Knee Surgery Uncommonly Done By Today’s Joint Replacement Surgeons

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 2014 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. At this writing (05/2014) the use of computer navigation and limited incision techniques for total knee replacement is uncommon (6% of total joint surgeons worldwide). 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 Replacementpatients also 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. 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.

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, infection prevention and rapid rehabilitation protocols produce the best patient recovery paths. Our patients do great!

Typical Recovery: Hospitalization 0-3 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 Systems:

The various branded Implants for all Less Traumatic Total Knee Replacement are similar.  The key for a successful patient outcome is precise implantation by a skilled and experienced surgeon; good outcomes are not brand dependent.  Doctor Tarlow uses the Ortho Development Balanced Knee System and the Smith and Nephew Legion for primary (first time surgery).  The Ortho Development Balanced Knee System is the revision system used by Dr. Tarlow.  These implants are engineered for superior range of motion in knee flexion and rotation, while offering conforming fit on both the male and female knee. All product lines offer “Gender” models specific to female anatomy.

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 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 and FDA approved (in limited release as of May, 2014) Vitamin E antioxidant polyethylene.  16 years on the market and no mechanical failures or recalls with the Balanced Knee System.

 

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Ortho Development Balanced Knee Implant

 

Smith and Nephew Legion Knee

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Smith &Nephew Legion Oxinium Knee

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.

 

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 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:

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. Susceptable patients (diabetes, HIV, Rheumatoid on immunosuppresive meds, Cancer patients immunocompromised – to name a few) should always use prophylactic antibiotics for Dental work.

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