total knee arthroplasty: indications, contraindications ......aaos comprehensive orthopaedic review,...

Total Knee Arthroplasty:

Indications, Contraindications,

Post-operative Considerations

Andrew M. Pepper, MD

Orthopaedic Adult Joint Reconstruction Surgeon

Andrews institute for Orthopaedic Surgery and Sports Medicine

Disclosure

I have no disclosures that pertain to the discussion given today

Total Knee Arthroplasty

• Replacement of the tibiofemoral joint, with or without resurfacing of the patellofemoral joint1

https://orthoinfo.aaos.org/en/treatment/total-knee-replacement/

Indications

• Anyone who has Osteoarthritis?

• Post-traumatic arthritis• Rheumatoid arthritis• Psoriatic arthritis • Avascular Necrosis

• Diagnosis is less important than true

surgical indications

Indications

• Pain Relief• Functional Impairment • Limb-Alignment• Quality of Life • Failed Conservative Management

Indications

• Pain Relief• Functional Impairment • Limb-Alignment• Quality of Life • Failed Conservative Management

• Weight loss

• Activity Modification

• Non-steroidal Anti-inflammatories (NSAIDs)

• Corticosteroid/Viscosupplementation injections

• Physical Therapy

Indications

• Osteoarthritis(OA) is the leading cause of MSK disability worldwide1

• Incidence/prevalence of OA associated w/ aging2

• WHO: Top 10 causes of years lost due to disability3

Indications

• In 2004, TKA costs in the US = $14.3 billion

• Rate of TKA continues to rise

Contraindications

• Medical Co-Morbidities • Active infection • Non-functioning Extensor Mechanism

• Injury/incompetent extensor mechanism• Neurologic disease

• Chronic Lower Extremity Ischemia• Non-ambulatory • Skeletally Immature

Post-Operative Considerations

• Wound Healing• Hemostasis

• Inflammatory Phase

• Proliferation Phase

• Remodeling Phase

• Skin integrity is usually complete within 2-4 weeks

in healthy individuals5

Post-Operative Considerations

• Wound Healing

• Pain Control• Allows early participation with PT• Early ROM:

• Decreases deep vein thrombosis (DVT)• Improves final knee motion

Post-Operative Considerations

• Wound Healing

• Pain Control• Multimodal Pain Control6,7: the use of multiple agents that affect different regions of the nociception pathway. • The goal is to achieve improved pain control with less

reliance on opioids, which thereby decreases associated

opiate side effects.

• Multimodal pain management has been shown to

decrease narcotic usage, improve pain scores,

increase patient satisfaction, enhance early recovery

and facilitate earlier hospital discharge

Post-Operative Considerations

• Wound Healing

• Pain Control• Patients should take pain medication 1 hour prior to PT sessions to allow for adequate participation

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability1

• Goal of TKA is to achieve an immediately stable knee replacement• If stability is not achieved intra-operatively, follow surgeon instructions

• Communication is key:• If concerns arise, communicate with the surgical team!

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability• ACL is removed. PCL may or may not be removed

• � Does not affect recovery or post-op PT

• Collateral ligaments are retained

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability• Muscle atrophy can mimic instability• PT focused on strengthening improves mobility, gait, proprioception8

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability• Post-operative weakness can put patients as risk for falls9

• Assistive devices are to prevent falls, not for instability

• Avoiding falls prevents fracture and complications

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling• Limits motion • Contributes to pain• Generally decreases, but can worsen during therapy

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling• Simple cryotherapy (icing) & aggressive elevation help

• Persistent swelling is normal, but may be associated with complications (DVT)

• Communicate with surgical team if unsure!

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion• Important for final outcome• Minimum of 70° knee flexion to rise from a chair

• 90° or greater knee flexion ideal• Lack of full extension affects gait

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion• If flexion is limited by 6 – 12 weeks, can consider Manipulation Under Anesthesia (MUA)• If unsuccessful, consider surgical treatment of arthrofibrosis

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion

• Strength• Immediate weakness and subsequent atrophy after TKA

• Gradual strengthening as part of post-operative PT

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion

• Strength• Regaining normal strength affects function of TKA

• Weakness increases stress on the arthroplasty components

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion

• Strength

• Proprioception• The body’s awareness of limb position and movement

• Altered after TKA• Gait re-training and proprioceptive therapy important in recovery/satisfaction10

Post-Operative Considerations

• Wound Healing

• Pain Control

• Stability

• Swelling

• Range of Motion

• Strength

• Proprioception

• Assistive Devices • Help prevent falls (i.e. fractures, head injuries)

• Walker and then transition to cane• Most patients will not require any assistive device after complete recovery

Questions?

References

1. Insall & Scott, Surgery of the Knee. 3rd Ed.

2. The Global Burden of Disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors

in 1990 and projected to 2020. In Murray CJL, Lopez AD, editors: Cambridge, MA, 1996, Harvard University Press, on behalf

of the World Health Organization and the World Bank.

3. <who.int/healthinfo/global_burden_disease/GBD_report_2004update _part3>

4. Campbell’s Operative Orthopaedics, 9th Ed. Canale ST (Ed), Mosby, 1999.

5. Taylor C, Lillis C, LeMone P, Lynn P. Fundamentals of Nursing, The Art And Science Of Nursing Care, 6th Ed. Lippincott

Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins

6. Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesthesia and analgesia

77(5): 1048, 1993

7. Lamplot JD, Wagner ER, Manning DW. Multimodal pain management in total knee arthroplasty: a prospective randomized

controlled trial. The Journal of arthroplasty 29(2): 329, 2014

8. Orthopaedic Knowledge Update (OKU) 5: Hip and Knee Reconstruction. Mont, MA; Tanzer, M. 2017

9. AAOS Comprehensive Orthopaedic Review, 2nd Edition. Boyer, MI. 2014

10. Orthopaedic Knowledge Update (OKU) 12. Grauer, JN. 2017.

Thank You!