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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
Manual therapy, electrotherapeutics
Knee arthroscopy for meniscus
IA Hyaluronic Acid (viscosupplementation)
Arthroscopy – clean out
Glucosamine and Chondroitin
*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.
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.
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.
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.
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.
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).
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.
Scottsdale Knee Specialist & Surgeon – Stefan D. Tarlow M.D
Stefan D. Tarlow, MD, is Arizona’s premier “knees only” orthopedic surgeon.
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