Younger Patients Driving Increase in Total Knee Replacement Surgery
From 1997 to 2007, the number of total knee arthroplasty (TKA) procedures performed annually in the United States doubled, with much of the increase taking place in younger patients, according to a study presented at the 2011 AAOS Annual Meeting. Data has shown that younger and healthier patients have better post-TKA outcomes, the indications for performing surgery have been expanded to include these patients. Keep in mind that more surgery in younger patients drives up the cost of US Healthcare, but better outcomes in young people justify the increase in costs. Treating severe knee disability increases the productivity of these working aged people and improves quality of life for 20-30 years.
During the study period, the overall U.S. adult population grew slightly (1.13-fold and the prevalence of obesity grew 1.12-fold). But the number of TKAs performed more than doubled—from 264,311 in 1997 to 549,707 in 2007. When researchers examined population growth, obesity rates, and number of TKAs performed by age group, they found the greatest growth in TKAs among those younger than age 65.
What is driving the increase?
Obesity and population size accounted for 22.6 percent of the approximately 100 percent increase in the number of TKAs performed,” said author Elena Losina, PhD, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston.
The rapid expansion of TKA utilization can not be fully explained by increases in population and obesity prevalence.
4 Million Total Knees Walking Around the U.S.
From March, 2013 Journal of Bone and Joint Surgery
We estimated that 4.0 million adults in the U.S. currently live with a total knee replacement, representing 4.2% of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age.
Among older adults in the U.S., total knee replacement is nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement.
No Benefit Found For Continuous Passive Motion (CPM) After Total Knee Replacement
Advanced Knee Care, experts in knee replacement surgery, is not able to recommend for the use of CPM after Total or Partial Knee Replacement surgery. Unfortunately, some things that we do in medicine, we do because we’ve always done it, not because there are good data to support that practice. Patients have come to expect the CPM — they hear previous patients talking about how it helped them recover, and they think they need it. Here’s the thing — current data does not support it. Over the past 10 years, hospitals that specialize in total joint replacement have studied the use of CPM versus moving a patient rapidly into active therapy, and found that CPM is no better for a patient than introducing physical therapy shortly after the surgery. Evidence based treatment decisions show that CPM had no significant advantage in terms of improving function or range of movement, and that its use increased blood loss and pain medication requirements. Another study concluded Continuous passive motion (CPM) gives no benefit in immediate functional recovery post-total knee arthroplasty (TKA), and the postoperative knee swelling persisted longer. A third study concluded CPM did not lead to improved knee range of motion after Knee Replacement Surgery.
Dr.Tarlow says: “It is time that we as surgeons only prescribe treatments in which costs are justified because of improved patient outcomes after knee surgery. CPM machines do not satisfy this criteria. It’s time to break the bad habit of prescribing things that do not aid in patient recovery”.
High-Impact Sports After Total Knee Arthroplasty
Patient reported activities often reveal non compliant behaviors after total knee
replacement (TKR). Although surgeons generally recommend avoiding heavy manual labor and high impact sports, there has been few medical studies to guide these traditional recommendations.
Mont et. al.reported on thirty one patients with knee replacements that participated in high impact sports including jogging, singles tennis, racquetball, squash and basketball on average 4 times per week. After an average four year followup, thirty two of the thirty three knees had successful clinical and x-ray outcomes. These results indicate that some patients will participate in high-impact sports and enjoy excellent clinical outcomes at a minimum 4 years after surgery. Clearly, patients with TKR participate in activities considered risky by surgeons.
At least in the short term, doing so does not appear to detract from the success of the procedure.
Total Knee Patient Experience Survey for Dr. Tarlow
The quality department at an inpatient surgical facility has provided the following survey summary.
What is New in Total Knee Replacement
A summary appeared in the January, 2016 JBJS and here are the highlights.
Risk stratification is predictable and accurate for Knee Replacement patients. Patients at higher risk for complications should postpone (if risk factors are modified) or avoid knee replacement surgery. These risks are uncontrolled diabetes (higher risk of deep infection, blood clot, periprosthetic fracture, aseptic loosening, and poorer Knee Society function score. Morbid obesity (BMI > 40) is a patient factor associated with increased medical costs and complications including medical complication (heart attack, pneumonia, etc), postop knee infection, return to the operating room for a second procedure and longer hospitalization. Morbidly obese patients have a higher risk of in hospital death after knee replacement surgery.
There is no evidence to support a particular design, brand, or material impact range of motion, clinical scores or quality of life.
The value of computer assisted TKR surgery remains undefined. One study showed an insignificant improvement of leg alignment but no better rotation of tibial or femoral components compared to standard non navigated surgery.
Patient specific custom cutting blocks showed no improved clinical, operative or radiographic results.
