#1 Debated Issue in Total Knee Arthroplasty Is…
When joint replacement luminaries gather ‘round at the upcoming American Academy of Orthopaedic Surgeons (AAOS) meeting, Jay Lieberman, M.D., chair of the Department of Orthopaedic Surgery at the Keck School of Medicine of USC and outgoing president of the American Academy of Hip and Knee Surgeons, will be stirring the pot with a panel discussion on “Great Debates in Total Knee Arthroplasty.”
Dr. Lieberman told OTW, “One of the biggest issues in the total joint replacement is whether or not to resurface the patella. Generally speaking, in the U.S., the majority of the patellas are resurfaced; in Europe it is the opposite.”
“There are three ‘camps:’ those who believe that all patellas should be resurfaced, those who resurface virtually no one, and those who do selective resurfacing. Those who do selective resurfacing make their decisions based on the thickness of the patella, the extent of the degenerative changes, and the overall size and activity level of the patient. Some surgeons are avoiding patellar resurfacing on younger, active patients because they are concerned about loosening and fractures. This apprehension is understandable because we do not have great solutions for treating a loose or fractured patella.”
“Although randomized controlled trials (RCTs) indicate that the results are equivalent between those resurfaced and those not, 10% of patients who do not undergo resurfacing have some type of pain and may require revision. However, just resurfacing the patella may not eliminate the pain. Patients with a resurfaced patella may also complain of pain. Some patients have mild anterior knee pain going up and down stairs, something that may occur because the person’s quadriceps and hamstrings are not strong enough.”
“As for patient selection, one should consider the degeneration of the joint surface of the patella, the thickness of the patella, the patient’s diagnosis, age, weight, and activity level.”
“Going forward, total joint registries will give us more data about how patients are faring; more multicenter RCTs will help us ask more specific questions. Some of these might be: ‘Is it better to avoid resurfacing the patella in younger, active males over 250 pounds?’ ‘What is the outcome of those with a thinner patella who are resurfaced versus those who are not?’ Time—and research—will tell.”
Cryo-Ortho? Freezing Nerves Before TKA
You might call it “cryo-ortho.” A new first-of-a-kind study on what is known as “cryoneurolysis” has found that if you freeze nerves prior to total knee arthroplasty (TKA), and add in traditional pain management approaches, then patient outcomes are significantly improved. The retrospective chart review, led by Vinod Dasa, M.D., Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine, involved 100 patients with advanced osteoarthritis. The researchers found that those treated with cryoneurolysis had shorter hospital stays and required fewer opioids for pain.
Dr. Dasa, who uses something called the iovera device to freeze nerves, told OTW, “I first used iovera to provide my knee OA patients with an additional treatment option beyond injections and surgery. After treating a number of patients, I realized that the impact of the pain improvement could be used beyond knee arthritis and that I could leverage these outcomes to improve surgical outcomes. When, I began using iovera pre operatively to reduce post-operative pain and improve function, our therapists and nurses were the first to notice a significant improvement. Patients were recovering more quickly and we were getting a lot fewer patient phone calls after the surgery because patients were feeling so much better.”
“I was most surprised to learn that this made the physical therapist’s job much easier. Because of the improved pain control, we’ve been able to completely redesign our therapy protocol so not only can patients leave the hospital sooner but we’ve also significantly reduced the amount of therapy needed after surgery.”
“Most surgeons should understand that this technology is very easy to use and probably safer and more effective than many of the treatments in our current multimodal pain management strategies. I think it has the potential to become a major part of post-surgical pain management for many procedures beyond total knee replacement.”
“I think a well done prospective randomized study is needed before there is large adoption. The physicians who are early adopters will most likely see a benefit, but for a majority of physicians I think more research is needed.”
Dr. Dasa consults with and holds equity options in Myoscience, developers of the iovera.
African-Americans With RA: Elevated Risk of Heart Attack, Stroke, Death
Cardiology research from the University of Chicago (U of C) has found that African-American patients with diseases such as rheumatoid arthritis (RA) or lupus were twice as likely as Caucasians to have narrowed or atherosclerotic blood vessels, thus increasing the chances of heart attack, stroke or death.
The study, led by Francis Alenghat, M.D., Ph.D., assistant professor of medicine at U of C, involved patient records from more than 287, 000 African-American and Caucasian patients.
Dr. Alenghat told OTW, “The biggest milestone in this process was the discovery that race can alter the relationship between inflammatory diseases like rheumatoid arthritis and cardiovascular disease. Doctors have recognized that these diseases might raise cardiovascular risk, but no one realized how high the rates could be in African American patients.”
“Another important finding is that this relationship with cardiovascular disease exists not only for RA, but for several other autoimmune diseases including lupus, systemic sclerosis (scleroderma), Sjögren Syndrome, dermatomyositis, polymyositis, and mixed connective tissue disease (MCTD). These other diseases are less common, so understanding cardiovascular risk has been historically more difficult.”
“Patients with these inflammatory diseases, particularly rheumatoid arthritis, often see orthopedic surgeons and have joint surgery. The current findings should encourage a full assessment of cardiovascular risk factors perioperatively, when we know cardiovascular events can occur. It is an opportunity to intervene by controlling blood pressure, cholesterol, and diabetes, and to help patients stop smoking. This can be accomplished by a team including the surgeon, the primary care provider, and the cardiologist as needed. The current findings also support the idea of treating many patients with these inflammatory diseases with statins regardless of their other risk factors.”
“Many risk factors for atherosclerosis—particularly smoking, hypertension, and diabetes—can also play roles in how a patient recovers and heals from surgery. One strategy is to approach patients in this way—by addressing their risk factors, they are not only reducing their long term cardiovascular risk, but also optimizing their chances for good surgical outcome in the near term.”
“For the long term, the perioperative encounters should be used as extra opportunities to discuss the importance of gaining control of these risk factors. Many patients are more attuned to issues of overall health when they are considering surgery. For the short term, good control of blood sugar may improve surgical outcomes like healing and avoidance of infection. Cholesterol is probably less tied to these immediate outcomes.”
My dealership does cold therapy now and I would be interested to learn more