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Evidence Based Treatments for Knee Osteoarthritis
What works:
Strengthening Exercises with neuromuscular education*
NSAID (pills such as ibuprofen and naproxen)
Appropriate weight loss if BMI > 25
Total or partial Knee Replacement
Cannot Recommend for or against:
IA steroid injection
Acetaminophen
Manual therapy, electrotherapeutics
Knee arthroscopy for meniscus
Cannot Recommend:
IA Hyaluronic Acid (viscosupplementation)
Braces
Arthroscopy – clean out
Glucosamine and Chondroitin
Acupuncture
Insoles
*The Alexander Technique (AT) is a method of neuromuscular re-education which aims to teach individuals how to improve postural support, reduce potentially harmful patterns of muscle tension and improve control of response. AT lessons provide an individualised approach to developing skills that help people recognise, understand, and avoid poor habits adversely affecting postural tone and neuromuscular coordination.
Avoiding Complications in Total Knee Replacement Surgery – Body Weight Matters
Study: Is there a reasonable BMI criterion for TJA?
A study published in the April 4 issue of The Journal of Bone & Joint Surgery attempts to assess various body mass index (BMI) criteria for total joint arthroplasty (TJA). The authors conducted a retrospective, cohort study of 27,671 TJAs to determine if various BMI eligibility criteria had been enforced, how many short-term complications would have been avoided, how many complication-free surgical procedures would have been denied, and the positive predictive value of BMI eligibility criteria as tests for major complications. They found that with a BMI criterion of ≥40 kg/m 2, 1,148 patients would have been denied a surgical procedure free of major complications, and 83 patients would have avoided a major complication. They write that the positive predictive value of a complication based on a BMI of ≥40 kg/m 2 as a test for major complications was 6.74 percent, while the positive predictive value of a complication using a BMI criterion of ≥30 kg/m 2 was 5.33 percent. “Although the acceptable balance between avoiding complications and providing access to care can be debated,” they write, “such a quantitative assessment helps to inform decisions regarding the advisability of enforcing a BMI criterion for [TJA].”
Smoking and Surgery is a Poor Mix
It’s becoming increasingly clear that orthopaedic patients who smoke have worse outcomes than those who don’t. The clinical effects of smoking on bone and wound healing have been well-studied, and include longer times to union, higher rates of nonunion, and higher rates of infection and wound complications.
Cigarette smoke contains about 5,000 chemical agents and more than 60 carcinogens, toxins, and poisons such as arsenic, ammonia, methane, butane, and cadmium. The most addictive substance known to man is nicotine!
Smokers may not realize the adverse impact of smoking in orthopaedic procedures. Some of the highlighted effects of smoking include worse fracture healing, more unsuccessful reconstructive procedures, wound healing problems and higher infection rates. Patients that smoke, have diabetes and are obese have extraordinary high complication rates with surgical treatment.
Women are more vulnerable to nicotine addition, experience greater negative effects from smoking, and find it more difficult to quit than men. Although genetic factors make some individuals more susceptible to smoking than others, the following may also be contributing factors: multiple military deployments, menthol cigarettes, nocturnal body rhythms, and peer pressure.
Doctors have good reason to advise patients that they are not candidates for surgery; it won’t help them. Based on a study of more than 5,000 patients, smokers had more pain and showed the least improvement, regardless of the treatment (surgical or nonsurgical).
The goal is for the patient to be smoke-free for a minimum of 6 weeks.
In Sweden, orthopaedic surgeons have taken a strong stand against smoking. It’s a matter of patient safety. The tobacco pandemic is one of the biggest public health problems we face.”Swedish hospitals have adopted a program to help surgery patients stop smoking—and have seen their incidence of postoperative complications drop. Prior to surgery, patients who smoke are given help to quit. Identify smokers immediately and put them on a track to help them stop.Smoking is the most costly and most preventable risk factor in postoperative complications. Smoking cessation can improve perioperative outcomes, demonstrate to the public that we care about our patients, and increase the lifespans of our patients.Each state has a free Quitline (1-800-QUIT-NOW)
*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:
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- 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.
How Long Until My Knee Replacement Feels Normal
As a surgeon my aim is to replicate the function and feel of a natural knee when performing joint replacement surgery.
Researchers measure outcomes following surgery and place a “forgotten knee score” to measure satisfaction.
6 months after replacement surgery the score is 59, 12 months after replacement surgery the score is 72, and 24 months after replacement surgery the score is 76.
The answer to the question “How Long Until My Knee Replacment Feels Normal” is 1-2 years for your artificial knee to feel the best it can be.
2 Supplements Might Improve Recovery after Knee Joint Replacement Surgery
Essential Amino Acids and Vitamin D might prove to be a safe and easy way to improve recovery after knee replacement surgery.
One study found that 2 grams of essential amino acids (protein available OTC) daily for 1 week prior and 2 weeks after surgery will improve your recovery.
Additionally, some basic science research has suggested Vitamin D in the peri operative period may lower the infection risk.
These are two good ideas that are not harmful and may benefit my patients.
Cementless Mako Total Knee
Porous Coating allows for cementless fixation
Stryker’s Joint Replacement division today announced that its cementless Mako Total Knee with Triathlon Tritanium has received market clearance by the U.S. Food and Drug Administration for Q4 2017.
Triathlon Tritanium combines Triathlon knee implant with the latest in highly porous biologic fixation technology for a knee system that holds the promise of improved fixation and longevity in younger and obese total knee replacement patients. The innovation of Tritanium’s tibial baseplate and metal-backed patella components allow the components to be implanted without bone cement. Bone cement loosening is one of the mechanisms of failure of artificial knees. The though is that if one eliminates the bone cement the implant can potentially last longer.
Cementless procedures rising in popularity and becoming a fast-growing trend, especially in the under 50 year old patient. Coupling robotics and cementless fixation solution allows orthopaedic surgeons to be more precise in the bone preparation which could increase the success of cementless total knee replacement.
If you are under 50 or have a high BMI this cementless Mako Total Knee is a procedure you should give serious consideration. The combination of robotic surgery and ingrowth fixation is the latest advancement of total knee replacement technology.
How To Achieve The Perfect Total Knee Replacement
The perfect total knee is known as “the forgotten knee”. Patients with a forgotten artificial knee state that the artificial knee always feel normal in daily activities. This occurs approximately 66 % of the time, according to French surgeons.
Gender, age, body mass index, and preoperative pain were not predictive of outcome.
Inability to fully straighten the replaced knee, preoperative anterior or popliteal knee pain, patellar maltracking, and the diagnosis of psychological depression are associated with an abnormally feeling total knee replacement.
Better or improved knee flexion (bend) is predictive of a naturally feeling knee.
Both the patient and the surgeon have some influence on surgical outcome. The ability to straighten the knee is often dependent on strict adherence to a post operative rehabilitation protocol (patient controlled factor). Better pre-operative knee flexion is associated with more post operative knee bend (surgeon selection of patient for surgical treatment).
Opioids and Total Knee Replacement – Preoperative Use Detrimental
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.
