Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from randomized studies cited in the January 21, 2015 Specialty Update on adult reconstructive knee surgery:
Minimizing Blood Loss
–A randomized study of 101 patients undergoing total knee arthroplasty (TKA) found that those receiving topical tranexamic acid (TXA) intra-articularly at the end of surgery had less blood loss and better postoperative hemoglobin levels than those who received a placebo.
–A randomized study of 50 TKA patients and 50 people undergoing total hip arthroplasty found that those receiving TXA had a significantly smaller decline in postoperative hemoglobin levels and needed 39% fewer units of transfused blood than a group that received normal saline solution.
–A randomized study of 126 patients who underwent denervation or not after TKA with unresurfaced patellae found that the denervation group had better pain scores at three months and higher satisfaction and better range of motion at two years.
–Two randomized studies evaluated the impact of patellar eversion versus lateral retraction/subluxation for joint exposure. One study (n=117) found no between-group differences in quadriceps strength at one year, and the other (n=66) found no between-group differences in pain scores or flexion at three months and one year.
Most of the implant-design studies summarized in this Specialty Update can be summed up as “no difference.” Specifically,
–Three randomized studies attempting to evaluate high-flexion TKA designs (n=74, n=278, and n=122) caused the authors of the update to suggest that “the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes.”
–A randomized study of 124 patients found no differences in maximal post-TKA flexion or functional scores between a group that received a bicruciate-substituting implant and one that received a standard posterior-stabilized design.
–A randomized trial of 34 patients who received prostheses with either highly cross-linked polyethylene or conventional polyethylene found no differences in wear-particle number, size, or morphology after one year.
–A 4- to 6.5-year follow-up study of 56 patients who received either mobile or fixed bearings during TKA found that the mobile-bearing group had greater mean range of motion, but there were no between-group differences in satisfaction or functional scores.
Instrumentation and Technique
–A randomized study of 47 patients whose surgeons used either customized cutting blocks or traditional instruments found no differences in clinical outcomes or mean component alignment. Moreover, surgeons abandoned customized blocks in 32% of the cases because of malalignment.
–A randomized study of 129 patients whose surgical approach was either medial parapatellar or subvastus, all of whom were managed with minimally invasive techniques, found no differences in pain, narcotic consumption, functional outcomes, and Knee Society Scores at postoperative times ranging from three days to three months.
Postoperative Care and Pain Management
–A trial among 249 post-TKA patients who received either one-to-one physical therapy (PT), group-based PT, or a monitored home program found no difference in outcomes at 10 weeks and one year.
–A randomized study of 160 post-TKA patients investigating the effect of continuous passive motion (CPM) machines led the study authors to conclude that CPM is neither beneficial nor cost-effective.
–A small randomized study of pain-management protocols found that a “multimodal” approach that included peri-articular injection led to less pain, less narcotic use, and higher satisfaction for up to six weeks after surgery than a patient-controlled analgesia approach.
–A three-way randomized pain-management study of 100 patients led study authors to recommend against posterior capsule injections and to conclude that “a sciatic nerve block [for TKA] has a minimal effect on pain control.”
–A three-way randomized study of 120 TKA patients found that those receiving preoperative dexamethasone and ondansetron had less nausea, shorter hospital stays, and used less narcotic medication than those who received ondansetron alone. “Dexamethasone should be part of a comprehensive total joint arthroplasty protocol,” the study authors concluded.
As medical practice continues to evolve, one thing that has become clear is that teamwork is a key ingredient for achieving success. In the field of medicine, the goal is improved patient outcomes and the teamwork involves the combined efforts of the patients and their caregivers. Indeed, it has been demonstrated that highly activated patients (i.e., those who take proactive collaborative roles in maintaining their health) incur lower medical costs and achieve improved therapeutic outcomes and greater satisfaction in comparison with less-activated patients.
In this issue of JBJS Reviews, Tzeng et al. take the position that patient activation is a dynamic continuum and that clinicians can boost activation by working together with patients to overcome barriers such as social and environmental disadvantages, low self-confidence, and lack of problem-solving and self-management skills. Thus, clinicians should understand that patient activation can be used to inform and personalize plans of medical care in a way that will foster cooperation between patients and their caregivers.
The recent shift toward consumer-driven health care has led to a need to define and understand the patient’s role in health care. Historically, little attention has been paid to the key factors and research priorities that govern patient engagement. In 2012, the Patient-Centered Outcomes Research Institute brought this concept to national attention by demonstrating that the factors that govern this type of collaboration are specifically required for financial rewards from the Medicare and Medicaid Electronic Health Records Incentive Programs.
Tzeng et al. describe how there are two types of patient activation. The first type is individual patient activation, in which a patient’s ability to handle his or her health and health care is established. In the second type of activation, there is participation from the community. Community activation is a health-promotion strategy in which organizations, companies, and provider groups make a concerted effort to improve health awareness, to plan prevention programs, to allocate resources, and to involve citizens in these processes. There are, however, barriers to patient activation. In particular, the level of patient and community engagement is often lower in populations with minority backgrounds, low incomes, limited education, and poor self-reported health. As an example, Caucasians typically have higher activation levels than African Americans and other minority groups, a manifestation of the fact that activation is associated with social-environmental factors.
For orthopaedic surgeons, integrating patient activation into clinical practice may require substantial change, but the benefits of doing so are substantial. More investigation is required in order to determine the best approaches for different medical specialties and patient populations, but current evidence clearly affirms that the activated patient is healthier and happier.
Thomas A. Einhorn, MD, Editor