Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

Vitamin D, Knee Surgery and Sports

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Vitamin D has hypothetical and proven benefits for orthopedic surgery patients and athletes.

I advise my joint replacement patients to begin 800 IU of VitaminD3 one week prior to continuing for 3 weeks total due to theoretical benefits for reduced infection risk.

Vitamin D has been shown to increase muscle strength, reduced injury rates and improve sports performance.

Vitamin D is also known to be importance for  bone metabolism.

 

Opioids and Total Knee Replacement – Preoperative Use Detrimental

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Most patients with advanced arthritis of the knee do not use strong pain pills in the year prior to knee replacement surgery.  America has an opioid epidemic with many accidental deaths and social problems linked to use of this class of drug.  Most of this use can be traced to the abuse of doctor prescribed hydrocodone and oxycodone.

A report published in the Journal of Bone and Joint Surgery calls to our attention an orthopedic concern in people using opioids in the 2 year period prior to Total Knee Replacement surgery. Specifically, the chronic opioid group obtain less pain relief from the joint replacement surgery.  This group of patients had lower satisfaction scores and a greater number of patients in the opioid group had additional knee surgeries for pain and stiffness.

In summary, patients that are on opioids for an extended period of time prior to their joint replacement are at a greater likelihood of having a surgical failure.

Obesity and Joint Replacement Surgery: What You Need to Know

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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.

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