Obesity and Joint Replacement Surgery: What You Need to Know

March 10, 2017 By Stefan D. Tarlow MD 7 Comments

Obesity and Joint Replacement Surgery

Orthopedic Surgeons do not possess the tools or the clinical skills needed to guide patients in the treatment of obesity. I am a knee specialist in Scottsdale, Arizona, and I face this dilemma daily. The Hippocratic Oath instructs physicians to “do no harm” to the people we treat.

Morbid Obesity, defined as a BMI (body mass index) of greater than 40, is a proven risk factor for adverse events before, during and after orthopedic surgery. There is an increased likelihood of knee infections, blood clots, wound healing problems, reoperation and readmission to the hospital. There are specific anesthesia risks such as vascular access (harder IV placement), accurate vital sign monitoring (usually need arterial line), harder breathing tube placement, difficulty getting oxygen into the lungs, and problems with safe positioning on operating room tables. Finally, there is a greater chance for serious heart and lung problems during and in the days following surgery. Patients with normalized body weight are more likely to have an uneventful surgery free of complications. For the stated reasons, I embrace the Hippocratic Oath and avoid joint replacement surgery in my patients with morbid obesity.

The paradox is apparent – we, the medical community, are not smart enough to help our patients afflicted with obesity to overcome their disease. Sadly, modern medicine does not have a predictable treatment for obesity.

Orthopedic Surgeons do not possess the tools or clinical skills needed to guide patients in the treatment of obesity. Race, ethnicity and gender contribute to the obesity epidemic in poorly understood ways. Cultural differences between blacks, caucasians and latinos need to be better defined for treatment programs to be successful.

In America there is a lack of knowledge as to how to best incorporate a variety of medical and non medical specialists to combat obesity. There is no network of treatment resources to address the multitude of obstacles obese patients require to treat malnutrition and psychological disease (anxiety/depression). For some, socioeconomic inequalities such as lack of healthy food marketplaces and lack of public places to safely exercise propagate the problem.

Obese patients know they have a life threatening disease. Obese patients do not want to be heavy. America must come together to find answers to treat our sickest citizens. The answer lies in finding ways to alter cultures, environments, economics, and education. We have to do better. Neglect is not a treatment plan. Knee arthritis surgery is not the first step in the treatment plan for curing obesity because it is not safe to perform major surgical procedures on our morbidly obese patients – the health risk is too great.

I believe the orthopedic surgeon should optimize patient function with mobility assist devices such as bracing, canes, walkers, scooters and Segway’s. We will manage pain with oral and topical medications, knee injections, and low impact land and water based exercise. As always we will provide our patients with clear rational, reasoning as the basis for our recommendations and treatments.

Orthopedic surgeons need help from our medical colleagues. Patients will need treatment of the emotional component of their disease. We suggest the patient explore culturally specific guidance. Some of our patients need guidance with shopping and eating healthier. It is the duty of health professionals to mandate exercise.

Lastly, as physicians, we offer support, encouragement and guidance. Our American system has to do better – Our Patients Need Help.

Infection Risk After Knee Replacement Skyrockets in Morbidly Obese

The benefits of joint replacement should be carefully considered since there is a high risk of infection when joint replacement is performed in patients that are morbidly obese (defined as BMI > 30).

Study from July 2012 Journal of Bone and Joint Surgery.

Infection rate if normal weight is 4 in one thousand cases.

Infection rate if morbidly obese is 1 in ten cases.

A morbidly obese person is 25 times more likely to suffer an infection after joint replacement.
These risks are even higher if there is both Diabetes and Obesity.

The mental, physical and monetary cost to treat an infected total joint include minimum 2 more surgeries including removal of implant for a period of months, mobility with a walker, hard to drive and go to work for months, intravenous antibiotics for 4-8 weeks, and cost is at least $50,000 “extra” compared to no infection.

Current best practices recommend advising most patients to optimize body weight and exercise to improve leg function prior to Total Joint Replacement surgery. There are rare exceptions when the benefits of surgery warrant taking such a high risk.

Obesity Doubles Failure Rates After Total Knee Replacement

Complications after Total Knee Replacement (TKR) can require reoperation, implant removal, and months of intravenous antibiotics and months off work. Avoidance of complications include Patient Health Optimization to address and correct risk factors known to lead to adverse outcomes prior to surgery. It makes sense for the patient and it makes sense for society (cost and loss of productivity burden is high with TKR complications).

From J Bone Joint Surg Am, 2012 Oct .

Obesity (body mass index ≥30 kg/m²) is a well-documented risk factor for the development of osteoarthritis. An increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades.

Infection occurred more often in obese patients, with an odds ratio of 1.90. Deep infection occurred more often in obese patients, with an odds ratio of 2.38. Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason. Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30.
Conclusions:

Obesity had a negative influence on outcome after total knee arthroplasty.

Patient Health Optimization: Why You Have To Lose the Weight Before Knee Surgery

Patient Health Optimization is the most significant issue patients and their Orthopedic Surgeons face today.

Optimize body weight, control diabetes and stop smoking.

Why ?

Show the doctor that you are willing to help yourself by losing weight and exercising regularly – if you can not help yourself with weight loss and exercise prior to surgery studies shows it is unlikely that you will be able to make these changes after the surgery. Surgeons are unlikely to initiate a treatment path that has a high likelihood of a poor result or a serious complication.

Better outcomes: Studies show higher satisfaction rating by patients with optimal health status.

Lower chance of complications: If a patient has the above risk factors which are out of control the chances of problems/pain after Knee Replacement with a Failure of the Surgery (instability, bone fracture, continued pain, infection) are a strong possibility. IT IS NOT EVEN WORTH TRYING THE SURGERY IF THE ABOVE FACTORS EXIST – a disappointing result is to be avoided.

Live longer: Above risk factors shorten life expectancy up to 6 years.

Feel Better: This speaks for itself – if your health is optimized you feel better and will live a happier life.

How to Lose Weight on your own:

Change your behavior patterns regarding eating and exercise
Eliminate wasted calories – Soda/Sweetened drinks is number one
Keep a record of what you eat – Food Journals are shown to be effective way to help with weight loss.

Whether your knee hurts or not – Exercise 30 minutes every day – even if you are tired or do not have time.

Gender and Race in Knees and Joint Replacement

March 8, 2017 By Stefan D. Tarlow MD Leave a Comment

Male and Female Differences in Knee Injuries and Disease

Gender variances exist due to anatomic differences, hormones, and genetic factors.

ACL knee injuries occur at a higher frequency in female athletes – on the order of 3:1 vs age and sport matched males.

Osteoarthritis in the knee develops more frequently in women. One explanation is that women lose healthy joint surface cells (articular cartilage) at 4 times the rate as men. Obesity afflicts women more than men and this is one link to the greater incidence of knee OA. Estrogen may play a role.

Replacing Knees Sooner in Women May Enhance Outcome

Conventional Orthopedic Surgical wisdom is to delay joint replacement until the patient is seriously impaired by their symptoms, even though on x-ray the patient’s knee joint is destroyed by arthritis. This means delaying surgery for serious knee arthritis until patients can not walk more than a block or two, can only ascend and descend stairs one at a time, patients are limping and patients have sleep disturbance from arthritis pain. Additionally, conventional wisdom recommends trials of NSAIDS (ibuprofen like meds), physical therapy, bracing, steroid injections or Hyaluronic Acid injections (synvisc and the like).

The lead article in the November, 2007 Journal of Bone and Joint surgery challenges this precept and presents strong scientific evidence to support the conclusion to operate sooner on women with serious knee arthritis that have measured functional deficits. The article is entitled Disease-Specific Gender Differences Among Total Knee Arthroplasty Candidates and was done at the University of Delaware.

Arthritis of the knee has a greater effect on knee function and strength in women, reflecting a gender difference in the disease impact. This larger impact on knee function in women is manifest by lower quadriceps muscle strength ( large muscle group in the front of the thigh), longer timed up and go standing test, longer timed stair climb, and shorter 6 minute walk distance compared to men with knee arthritis.

The logical and yet revolutionary conclusion is that strength and functional decline should be closely monitored (this functional testing could be documented by a Physical Therapist) in women with knee arthritis and when worsening is observed, joint replacement should be carried out. In some cases this may mean joint replacement is done sooner (compared to using traditional standards for deciding on the timing of surgery).

Closing the Gender Gap in Joint Replacement

It has been observed that there is an under use of Total Joint Replacement among willing and appropriate women who suffer from severe hip or knee arthritis. Even though women are as likely as men to seek treatment physicians are less likely to refer and recommend joint replacement surgery for women. Now that recognition of gender and cultural differences have been made, the focus is on more training for physicians in culturally competent patient care and shared decision making so that there will be a reduction in this disparity. Changes need to occur at the primary care level for referral to an orthopedic surgeon, better communication by all care providers so as to fully understand the severity of symptoms, the patient perceiving how severely debilitating their symptoms actually are, and dealing with issues related to surgery ( risks, interference with caregiver role, perceived burden on others during recovery process).

Knee Surgery for Obese Patients: Problems and Solutions

March 5, 2017 By Stefan D. Tarlow MD Leave a Comment

Why Obesity Poses Greater Risks for Surgical Complications

A literature review published in the May issue of the Journal of Arthroplasty attempts to define and identify areas of concern for obese patients undergoing total joint arthroplasty (TJA). “Obesity risk assessment is compounded by the fact that obesity is rarely an isolated diagnosis,” the authors write, “and tends to cluster with other co-morbidities that may independently lead to increased risk such as diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, and sleep apnea.” Among the authors’ findings:

- Despite improvements in patient-related outcome measures, all obese patients undergoing total joint arthroplasty are at increased risk for perioperative complications.
- Patients with a body mass index greater than or equal to 40 who undergo total knee arthroplasty are at risk for the majority of perioperative complications.

Published data on perioperative complications among obese patients undergoing total hip arthroplasty appear to be less clear.

New Procedure Offers Treatment Option for Obese Patients With Knee Pain

Subchondrplasty Joint Preservation Treatment Less Invasive Than Joint Replacement Surgery.

MRI of BME-Xray normal
From Zimmer Institute

Subchondroplasty® Procedure is the innovative new joint preservation procedure developed by Zimmer Knee Creations to treat the microfractures that develop just under the joint surface in painful knees. These lesions are similar to stress fractures and develop due to overload of the bones that make up the knee joint.

Rather than replacing the entire knee, this treatment aims to stimulate nature to heal the bone lesion which can lead to reduced knee pain and better knee function. Subchondroplasty is an arthroscopic knee surgical procedure done as an outpatient. This is a safer and less invasive procedure than Total or Partial knee replacement and as such may be carried out in higher risk surgical patients, such as the obese patient, with less fear of an adverse outcome such as infection or blood clot.

BML-MRI image
From Zimmer Institute

Bone Marrow Edema (BME), or Bone Marrow Lesions (BML) are thought to cause pain in knees with early or late osteoarthritis. These lesions can only be diagnosed with high resolution 3 T MRI scans. In 2001 Felson identified BME/BML as the strongest predictor of the presence of pain associated with knee OA. They also determined that arthroscopy alone will not predictably relieve knee pain associated with arthritis.

This observation has been confirmed by other investigators. However, the novel Subchondroplasty® Procedure is a percutaneous outpatient intervention that addresses the painful defects associated with subchondral bone marrow lesions (BME/BML). BMLs are related to stress fractures or micro-fractures, that can only be visualized using MRI scans. Left untreated, these defects have been shown to lead to cartilage degeneration, limited function, pain and greater risk for joint deterioration.

Theoretically, mechanical enhancement and/or biologic stimulation of chronically damaged and structurally compromised SubChondral bone, juxtaposed to a region of the joint with deficient cartilage, will relieve Knee pain emanating from the SubChondral bone and slow progression both bone and cartilage deterioration.

From Zimmer Institute

In this minimally invasive, arthroscopically-assisted procedure, navigation instruments are used to inject specialized Ceramic Calcium Phosphate bone filler (Etex), without violating the joint. As the bone filler is resorbed, the pain due to BML subsides as the lesion is replaced with new, healthy bone. The substitution of abnormal bone with healthy bone is the reason patients experience pain relief. The Subchondroplasty Procedure is the first procedure to treat bone-based changes within a painful joint, and addresses an unmet clinical need between early interventions, such as NSAIDs and joint arthroscopy, and total joint replacement. Subchondroplasty was introduced in November 2010. This procedure is now available in the Greater Phoenix area from Makoplasty Surgeon Stefan D. Tarlow, M.D. of Advanced Knee Care, PC.

Why Choose an Ambulatory Surgery Center: Safety and Cost

March 3, 2017 By Stefan D. Tarlow MD 1 Comment

Safety

Ambulatory Surgery Centers May Be Safer Than Hospitals for Surgical Care

A recent article in HealthLeaders Magazine explored the volume, pricing and quality of surgical care delivered in an ASC (ambulatory surgery center).

The conclusions are that the numbers of ASC’s are growing in the U.S. (and this is a good thing). The good news is that the cost of procedures performed at ASC’s are 55% of the cost of the same service performed at a hospital outpatient department. Even better, the number of adverse events (complications) are “significantly below the rates reported for inpatient hospital setting”.

The explanation, says Michael Cruz, MD, OSF Saint Francis’s vice president of quality and safety, is simple. The ambulatory environment “is more expeditious and efficient. Some of our patients are much better served—their patient experience is much improved—than if they were brought to a complicated medical center for a routine procedure.

At SurgCenter of Greater Phoenix, in Scottsdale, we render same day services for Makoplasty Partial knee resurfacing, Makoplasty Direct Anterior hip replacement, and total knee replacement. Our emphasis is on advancing surgical patient care to the most sophisticated levels found in the U.S.. By offering traditional services using new principles and innovative ideas, our patients experience high quality care, benefit from going directly home after their procedure and may even save a little money in the process.

Low Complication Rate Reported from New Outpatient TJA Facility

Bottom Line

The study examined results for 432 patients undergoing TJA at a newly opened outpatient surgery facility over approximately 13 months.
The overall rate of hospital readmission was 1.2 percent.
The rate of unplanned access of the healthcare system was 10.9 percent.
A statistically significant lower rate of unplanned access to care was seen in the concluding 4.5-month period of the survey versus that in the first 9 months.

This study appeared in the July AAOS Now.

Our results at SurgCenter of Greater are similar, with no hospital admissions of our series of Outpatient Joint replacements and high patient satisfaction from being able to sleep in their own beds with reasonable pain management.

Lead author Daniel P. Hoeffel, MD, a surgeon at Summit Orthopaedics in Woodbury, Minn., which opened the ambulatory surgery center in 2014, said that the study represented one of the largest series to date on outpatient total TJA. He said the rates of hospital readmission reported in the study are “lower than those historically reported” for inpatient TJA

The study, presented in a scientific poster at the AAOS Annual Meeting, reported results for 432 patients who underwent either total hip arthroplasty (THA; n = 177) or total knee arthroplasty (TKA; n = 255) in the outpatient surgery center over 13 months. A total of 12 adverse events occurred, with five patients (1.2 percent) requiring hospital readmission. Two of these were due to swelling with pain or hematoma, and three were for dislocation, pneumonia, or infection.

Cost

What Should Knee Replacement Surgery Cost?

Total Knee Replacement is one of the most expensive surgical procedures performed in the United States. Comparing costs for services is confusing to say the least. Trying to get pricing information using your health insurance is impossible until after the Explanation of Benefits arrives from the insurance carrier. The best way to compare apples to apples is to compare all-inclusive cash pricing (the price one would pay assuming payment at time of services from the patient to the facility – includes surgeon fee, assistant surgeon fee, anesthesia fee, facility fee and implant cost)

This is also true: Total Knee Replacement performed in our ambulatory surgery center, SurgCenterGreaterPHX as an outpatient is significantly less expensive than the exact same procedure performed in a Hospital.

Here are the fees from Stefan D. Tarlow, M.D. of Advanced Knee Care, P.C :

Ambulatory Surgical Center: Total Knee Replacement @ SurgCenter GreaterPHX -(implant included) — $22,300

Hospital: Total Knee Replacement @Scottsdale Healthcare Thompson Peak- (implant included) — $30,700

There are several helpful sites for patients to view

HealthCare Blue Book — For Scottsdale “total fair price” said to be $22,899.

https://www.healthgrades.com/procedures/how-much-does-knee-replacement-cost –The United States is known for wide variation in healthcare costs. The average national price for a knee replacement in 2012 was about $20,000 plus the cost of the implant. Implants can cost up to $10,000.

https://health.costhelper.com/knee-replacement.html – Estimate cash cost to be $35,000 or more for people with insurance but note cash price for uninsured $20,000-$34,000 depending on geographic location.

https://www.kneereplacementcost.com/ — The United States has among the highest costs in the world for knee replacement surgery. An American with no health insurance can expect to pay $45,000 – $70,000 at a typical hospital. Those with insurance will, barring a few exceptions, be covered by their provider. However, out-of-pocket expenses can still be costly for those who have health insurance. Patients with medicare are eligible for knee replacement surgery.

Surgery Center of Oklahoma – Price is $19,400 plus the cost of the implant (typically $4,500 – $10,000).

Consumer Patients Choose Ambulatory Surgery Centers When Costs Revealed

Freestanding ASC (ambulatory surgery centers) saved the consumer patient 17 % compared to the hospital outpatient department.

A California price study found hospital cost $6640 and ASC cost $4795 for knee arthroscopy.

Consumer patients became sensitive to price differences when transparent pricing was revealed. Patients respond strongly to pricing incentives.

Dr. Tarlow supports and practices transparent pricing on his website.

Consumers need to be accorded a greater decision making role when accessing the health care system. They should be provided information on price and quality.

Preventing Deep Vein Thrombosis After Knee Replacement Surgery

February 26, 2017 By Stefan D. Tarlow MD Leave a Comment

Prevention of Deep Venous Thrombosis (Blood Clots) After Knee Replacement

Orthopedic Surgeons, and in particular Knee Surgeons, are vigilant with regard to preventing serious complications after total knee replacement surgery. Selecting a treatment regimen is a balance between effectiveness and safety, recognizing too much bleeding has a harmful effect on outcome.

It is agreed that some regimen be used for 14 days. Drug choices include Lovenox (and other low molecular weight heparins),
Coumadin, Aspirin. Mechanical prophylaxis alone is an appropriate option.

The ideal prophylactic regimen has not been identified. Doctors and patients have to look at each case individually with the goal of optimizing the protection for their patient. Patients are stratified based on their risk for clotting and their risk for bleeding.

Home DVT Prevention – Preventing Serious Complications After Knee Replacement Surgery

Advanced Knee Care, PC and Stefan D. Tarlow, M.D. strive to attain the best outcomes for our patients after major knee surgery such as Total Knee Replacement and Makoplasty (robotic partial knee replacement). VenaPro home sequential compression device lowers the DVT risk during our patient’s first 2 weeks at home. Additionally, patients are treated with Aspirin at home for 14 days. These devices wrap around both lower legs and use rapid air inflation to move the blood out of the lower leg, minimizing blood clots. The VenaPro device is used at rest (in bed or sitting on chair or couch) for 2 weeks. No device is needed when walking normally. Utilizing both medication and mechanical compression, we now have a two pronged attack against DVT formation.

Today, we can lower DVT rates and save lives. We call this high quality patient care in action.

Federal Safety Guidelines since 2008 have mandated that patients undergoing total hip or knee arthroplasty receive at least one of a list of prophylactic regimens for at least 10 days following surgery.

Options for Elective total knee or total hip replacement

Aspirin
Low molecular weight heparin (Lovenox-injection)
Factor Xa inhibitor – (Xarelto-pill form)
Vitamin K antagonist (Warfarin-pill form)
Intermittent pneumatic compression devices (Venoflow Elite-Home device)
Low-dose unfractionated heparin (injection heparin)

Knee Replacement: DVT Prevention Without Risky Medications

Vena Flow Elite – A Mobile Home Compression Device for Blood Clot Prevention After Knee Surgery — For Total and Partial Knee Replacement Patients

VenaFlow Elite with Calf Cuff, Tubing and Compression Pump – photo from DJO website

Advanced Knee Care will be utilizing the DJO VenaFlow Elite home sequential compression device to lessen deep venous thrombosis (DVT) risk during our patient’s first 2 weeks at home. Designed as a prophylaxis for Deep Vein Thrombosis, the VenaFlow Elite System combines two proven technologies, rapid inflation and graduated sequential compression that work to mimic ambulation and accelerate venous velocity.

Joint replacement patients have typically been treated with blood thinners such as Coumadin or Lovenox. These strong medicines are also the cause of serious complications related to excessive bleeding. Current research suggests DVT prevention is accomplished more safely with leg compression/Aspirin. This combination avoids the bleeding risk associated with Coumadin and Lovenox. Recent studies prove that the VenaFlow Elite home program is equally effective as Coumadin or Lovenox at lowering the risk of blood clots after Knee Replacement Surgery.

Dr. Tarlow believes best practice mandates the use of this device.The device is shipped to your home (with return prepaid shipping label). Inside the box are complete instructions on the use of the device, disposable cuffs for each lower leg, tubing and the electronic compression pump unit. The prepaid fee of $200 includes up to 3 weeks of rental of the pump/tubing {fee refunded to our patient if payment received for your health insurance carrier}. These devices wrap around both lower legs and use rapid air inflation to move the blood out of the lower leg, minimizing blood clots. The VenaFlow device is used at rest (in bed or sitting on chair or couch) for 2 weeks, then returned to DJO Global. The device is NOT needed when walking normally.

The CPT code for the rental of this unit is E0676,RR.

Advanced Knee Care – Scottsdale, AZ

Improving Your Knee Replacement Results

February 24, 2017 By Stefan D. Tarlow MD 1 Comment

How to Improve Total Knee Replacement (TKR) Results

Here are five “fun facts” about Total Knee Replacement.

1. Have the same surgical team for every case (Surgeon, Assistant Surgeon, Circulating Nurse, Scrub Tech, Second assistant, and anesthesia). 30 day readmission rates due to complications are lower when consistent teams are used.

2. Use Saphenous Nerve blocks (adductor canal blocks). This 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.

4. Unexplained knee pain 6 months after TKR surgery predicts a poor functional outcome at 2 years post op.

5. Total Joint clinics see a higher percentage of obese people than are present in the total population. Obesity is a modifiable risk factor for hip and knee osteoarthritis.

Research suggests spinal and epidural anesthesia, peripheral nerve blocks safe to use

Released: 2/14/2014 4:00 PM EST
Source Newsroom: American Society of Anesthesiologists (ASA

Citations Anesthesiology

Newswise — Two types of regional anesthesia do not make patients more prone to falls in the first days after having knee replacement surgery as some have previously suggested, according to a study based on nearly 200,000 patient records in the March issue of Anesthesiology.

Regional forms of anesthesia – spinal or epidural (neuraxial) anesthesia and peripheral nerve blocks (PNB) – which only numb the area of the body that requires surgery, provide better pain control and faster rehabilitation and fewer complications than general anesthesia, research shows. But some surgeons avoid using them due to concerns regional anesthesia may cause motor weakness, making patients more likely to fall when they are walking in the first days after knee replacement surgery.

“We found that not only do these types of anesthesia not increase the risk of falls, but also spinal or epidural anesthesia may even decrease the risk compared to general anesthesia,” said Stavros G. Memtsoudis, M.D., Ph.D., professor of anesthesiology and public health and director of critical care services, Hospital for Special Surgery, New York, and lead author. “This work suggests that fear of in-hospital falls is not a reason to avoid regional anesthesia for orthopedic surgery.”

Researchers analyzed the types of anesthesia used in 191,570 knee replacement surgeries in the Premier Perspective database: 76.2 percent of patients had general anesthesia, 10.9 percent had spinal or epidural anesthesia, and 12.9 percent had a combination of neuraxial and general anesthesia. In addition, 12.1 percent of all patients had PNB. Researchers then analyzed the type of anesthesia used for those who suffered a fall in the hospital. Of patients who had general anesthesia, 1.62 percent fell, compared to 1.3 percent of those who had neuraxial anesthesia and 1.5 percent who had general and neuraxial anesthesia. Patients who also received a PNB had a fall rate of 1.58 percent.

When patients fall during recovery, they are more likely to have worse outcomes, including more heart and lung problems and higher rates of death within 30 days of surgery. Spinal or epidural anesthesia and PNB are used far less often than general anesthesia because of concern that regional forms of anesthesia – particularly PNB – may increase muscle weakness and make patients more prone to falls. However, there has never been a large study based on real-world practices to determine if that is true.

“In this study using data from a wide range of hospital settings we found this concern seems unfounded, especially because hospitals and physicians performing these procedures use fall-prevention programs and are able to reduce the impact of other factors shown to increase fall risk, such as higher narcotic use,” said Dr. Memtsoudis.

How to Get Back on Your Feet Quickly After Knee Surgery

February 24, 2017 By Stefan D. Tarlow MD Leave a Comment

Predictors for Returning to Work After Total Knee Replacement

A study from Cleveland identified factors that are important in estimating a patients return to work following Total Knee Replacement surgery. Average time to return for all patients is 9 weeks.

An accelerated group returning to work in 4-5 weeks had some of these qualities: had a sense of urgency to return, were female, were self employed, had high mental health scores, had higher physical function scores, and had good overall health.

Patients with some of these qualities were likely to return to work 9 or more weeks after Knee Replacement surgery: a physically demanding job, were receiving Workman’s Compensation or had less pre operative pain.

In my practice – Advanced Knee Care – most patients return to work 4-12 weeks after Knee Replacement (a few return sooner, a few return later).

The report concluded that although the physical demands of a patients job has a moderate influence on the ability to return to work, individual characteristics including physical and mental well being and motivation are the most predictive factors for estimating return to work after Total Knee Replacement surgery.

Lifestyle Modification Key to Great Outcomes Following Knee Replacement Surgery

After recovering from knee replacement surgery, patients’ physical activity levels with their new joint were varied.

Total knee replacement is primarily for pain relief, it’s not a lifestyle intervention. After surgery patients need to change their lifestyle in order to attain expected improvement in Function and Mobility and Exercise Tolerance.

Most people who have the surgery are pleased with the results in terms of having less pain and gaining more day-to-day function. These people are not always pleased with their ability to participate in recreational activities, such as participating in sports, yoga or gardening.

At the time of surgery, study participants reported spending about two hours a week being active, mostly doing moderate-intensity activities such as yard work, strength training and walking.

After surgery patients spent about 11 hours a week being physically active, according to findings published in The Journal of Arthroplasty.

Commitment to a lifestyle change including eating healthy, exercising regularly and avoiding harmful behaviors will go a long way towards improving a patients outcome from Total Knee Replacement surgery.

Internet Based Outpatient Physical Therapy

After recovering from knee replacement surgery, patients’ physical activity levels with their new joint were varied.

At the time of surgery, study participants reported spending about two hours a week being active, mostly doing moderate-intensity activities such as yard work, strength training and walking.

After surgery patients spent about 11 hours a week being physically active, according to findings published in The Journal of Arthroplasty.

Key to Better Knee Replacement Outcomes: An Experienced Surgeon

February 22, 2017 By Stefan D. Tarlow MD Leave a Comment

Optimal Delivery of Total Knee Replacement Surgery – Surgeon Experience Improves Outcomes

High volume Total Knee surgeons working at high volume facilities deliver the best outcomes for patients undergoing total knee replacement surgery.

The Hospital for Special Surgery in New York published data on meaningful surgeon and hospital volume thresholds in the October, 2016 Journal of Bone and Joint Surgery.

Here are the key numbers.

Surgeon volume of 60 or more cases per year had the best 90 day complication and 2 year revision rates. Choose a surgeon that performs 5 or more knee joint replacement surgeries per month.

Facility volume of 236 cases per year had lower 90 complication rates. Mortality rates were lowest for facilities performing more than 645 cases per year.

Higher Hospital and Orthopedic Surgeon Volume Linked to Improved Patient Outcomes

An analysis of 182,146 patients undergoing primary total hip and knee replacement concludes higher surgeon volume was associated with lower rates of readmission and reoperation, shorter length of hospital stay and higher likelihood of being discharged to home (JBJS November 17, 2010). Higher hospital volume was associated with lower risk of mortality and readmission and higher likelihood of being discharged home.

The process of standardization- adhering to evidence based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of surgeon or hospital volume. Annual surgeon volume high to low in quartiles is 278, 127, 62 and 24 cases per year. Annual hospital volume high to low in quartiles is 1007, 604,361 and 181 cases per year.

Dr. Tarlow’s surgical volume is in the highest Quartile (above 278 cases per year)

Makoplasty Partial Knee Replacement: A Primer

February 15, 2017 By Stefan D. Tarlow MD 3 Comments

What Is a Makoplasty Partial Knee?

Dr. Tarlow utilizes the world’s most advanced orthopedic robotic arm and computer software system at HonorHealth’s Scottsdale Healthcare Thompson Peak. Each implant is customized to precisely optimize your knee alignment, tracking, and ligament tensioning to extend the life of your implant. Makoplasty Robotic partial knee resurfacing is a less invasive solution designed to restore the feeling of a natural knee. Every patient is unique. Every result is precisely beautiful. Walk away from your knee pain today!

Advanced Knee Care, P.C. and Scottsdale Healthcare Thompson Peak is one of a few locations worldwide to offer partial knee resurfacing with MAKOplasty®, a technique that resurfaces the damaged area of the knee without compromising the healthy bone, ligaments and tissue surrounding it. The robotic-arm assisted, minimally invasive procedure may offer a smaller incision and a faster, less painful recovery than traditional joint replacement surgery, with many patients back on their feet in just days.

The process begins with a detailed evaluation including an office visit with Dr. Tarlow for specific knee history, detailed physical exam and standing 4 view knee x-ray series. Other special imaging tests might be required. After the decision to perform Makoplasty is finalized, three main steps are completed to assure accurate sizing, precise implant alignment, and proper balancing of the knee.

Step One: CT Scan of the knee done at Scottsdale Healthcare Thompson Peak (must be done at this facility – CT machine is specifically calibrated for Makoplasty procedure). The CT provides precise, unique anatomic detail of your knee. This data is entered into the Makoplasty computer and is used both before and during the procedure to accurately plan implant size, orientation and alignment utilizing CT-derived 3-D modeling. A provisional sizing and positioning of components is done before surgical implantation.

Step Two: Intra operative placement of Computer Navigation. This “tells the computer” exactly where the knee bones are in space and provides kinematic detail about knee motion and balance. This information is used to refine exact placement of the implant, still in the virtual realm at this point in time.

Step Three: Integration of step one and two allow precise virtual placement of the implant through real-time intra-operative adjustments for correct knee kinematics and soft-tissue balance.

Makoplasty Partial Knee Replacement Recovery

Makoplasty is an inpatient procedure with a usual one-night hospital stay. Typical recovery includes using a walker for a week and return to driving within 2 weeks. As a knee arthroplasty procedure, MAKOplasty® is typically covered by most health insurers.

The Robotic Arm Interactive Orthopedic System is now introduced into the knee using
minimally invasive exposure and bone sparing removal of damaged tissue to form a shallow trough to allow the Restoris implants to be permanently placed into the knee replicating the precise sizing and location derived from CT scan, Computer Navigation, and virtual kinematics. RIO® assists the surgeon in achieving natural knee kinematics and optimal results at a level of precision previously unattainable with conventional instrumentation.

Commonly Identified Benefits of Robotic Knee Resurfacing

Less Pain vs. Total Knee has been observed
Rapid Recovery is commonly seen
Minimal Rehab
Minimally invasive incision
Precision Implant Position
One Night Stay is usual
Easier Recovery Than Total Knee has been observed
Preservation of Healthy Tissues
Patient Specific, Custom Fit for Men and Women
Return to Activity including Golf ,Tennis, Hiking, Biking, Work

Factors That Favor A Successful Partial Knee Replacement (Makoplasty)

Implant Design, Surgeon Experience, and Patient Age greater than 65 years are associated with improved outcomes for unicompartmental knee replacement. This is sometimes termed Makoplasty or partial knee replacement. In Dr. Tarlow’s opinion, precise implant placement using computer navigation and virtual modeling and robotic arm guided resection will be shown further improve outcomes.

In a report from Kaiser Permanente California from 2013 the following factors are associated with better patient outcomes.

1. Implant design Zimmer

Unicompartmental Knee arthroplasty (ZUKA) had a 1 % revision rate, the Oxford Mobile Bearing 1.7 % revision rate and all others tested were 6 % or greater. The Restoris implant used for Makoplasty incorporates all the important design characteristics of the ZUKA implant.

2. Surgeon Experience

A surgeon case volume of less than 12 cases per year had double the revision rate compared to surgeons with greater than 12 cases per year. Dr. Tarlow performs greater than 75 cases per year.

3. Patients younger than 55 are in most cases more physically active than patients older than 65 years of age

The revision rate in the Kaiser report observed a 5 times higher revision rate in patients under 55 years of age. This is not a universal finding and other studies can be found showing similar revision rates in patients of all ages.

Optimizing Makoplasty Partial Knee Replacement for Our Patients

Advanced Knee Care and Stefan D. Tarlow, MD have had the Makoplasty robot for use at Scottsdale Healthcare Thompson Peak since January 2011. Our team has continued to refine the delivery of this service to our patients. “State of the Art” is an Outpatient surgical procedure with minimally invasive techniques, multimodal pain management and faster recovery.

An office visit with Stefan D. Tarlow, MD at his Scottsdale location starts the process. In most cases the decision for Makoplasty can be made on the initial visit including Patient History, Comprehensive Knee examination, and orthopedic quality “4 view” standing xray done in his office.

On arrival at the hospital our RN team prepares the patient for the procedure including our 13 Steps to help prevent surgical site infections and initiation of multimodal pain control. Saphenous Nerve Block, a quick and painless anesthesia procedure performed in the Pre operative area, is one of the keys to Outpatient Makoplasty.

The Makoplasty Partial Knee replacement is done in our operating room with our hand-picked team of anesthesiologist, nurses and physician assistants. The procedure duration is 90 minutes in most cases.

Once awake, a Physical Therapist consult in the recovery room is the last step before heading home, leaving the hospital on a walker.

Three Pain medications are used in combination to keep our patients comfortable as they recover from their surgery. The three include oxycodone (sometimes hydrocodone) are narcotics that works by binding to receptors in the brain and blocking the feeling of pain. Lyrica is thought to work by blocking pain in the brain and spinal cord. Acetaminophen is thought to block pain receptors in the brain.

VenaFlow Elite is a home sequential compression device to lower DVT
risk during our patient’s first 2 weeks at home. In addition, Aspirin in used twice daily for 2 weeks.

Finally, Outpatient Physical Therapy is initiated the week after surgery and continues for 3-4 weeks.

These are the keys as to how we optimize recovery for our Makoplasty patients.

Partial Knee Replacements: Who Is a Candidate?

February 13, 2017 By Stefan D. Tarlow MD 4 Comments

What Are Partial Knee Replacements?

Usually, osteoarthritis of the Knee involves the entire joint, and a Total Knee Replacement is the treatment of choice. Perhaps one in ten people with knee osteoarthritis with severe enough involvement of the joint to consider surgery are fortunate enough to have the arthritis limited to only one compartment of the knee. In this case Makoplasty partial knee replacement is the best surgical choice. The knee has 3 compartments (think of the knee as a 3 room home). When just one compartment has all the articular cartilage or joint surface damaged (one bad room, two good room) partial knee replacement is done. This is also known as unicompartmental knee replacement (uni) if the medial or lateral compartment between the femur and tibia (thigh and shin bone) is replaced or patellofemoral replacement if the joint between the femur and patella (thigh and knee cap bone) is replaced.

Unicompartmental knee replacements function better than total knee replacements because less of the normal anatomy is disturbed ( no knee ligaments removed, less bone removed) and the uni knee bends, straightens and rotates more naturally. Recover after unicompartmental knee replacement is quicker and the postoperative pain is less compared to total knee replacement.

Longevity of a unicompartmental knee is very good, with nine in ten uni’s working well at 10 years after surgery and many functioning well 20 years after surgery. The most common cause of failure after uni knee replacement is advancing arthritis in one or both of the previously uninvolved compartments of the knee.

Here is an excerpt of an article in the Arizona Republic about one of my patients in whom I performed partial knee replacement in one knee, then 3 months later the other knee. This is an example of how well partial knee replacements function. Outcomes like this is why I wanted to practice medicine.

“After suffering for years with knee damage that limited her mobility, Sarah Panepinto does not take dancing with her husband or playing tag with her kids for granted.

Last year, the 41-year-old Gilbert mother of five children had partial knee-replacement surgery on both of her knees. Since then, Panepinto said her recovery has been a miracle.

I can dance. I’m speed-walking. And I can even play Dance, Dance, Revolution with my kids,” Panepinto said.

The more active lifestyle is a blessing for Panepinto who needs the energy to keep up with the home-schooling of her two teens and two elementary school-age kids.

I’m off anti-depressants . . . I feel like I have my life back,” said Panepinto who has suffered from knee problems since she was 12.”

Read the full article

Patient Selection Crucial

20 year survival rates of unicompartmental knee replacement approach 75 % or better. Implant design and Makoplasty surgical technique (robot technology) are important contributing factors.

Berlin surgeons performed a medical study evaluating 5 year survival of German patients from 2006 to 2012. This was published in the JBJS in October of 2016.

Risk factors associated with failure of the implant in the first 5 years after implantation are:

1. age younger than 55

2. Obesity (BMI > 30)

3. Diabetes, complicated

4. Depression

5. Low volume facility (less than 10 cases per year)