Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries. This month, Michael J. Taunton, MD, author of the January 16, 2019 “What’s New in Adult Reconstructive Knee Surgery,” selected the five most compelling findings from among the more than 100 noteworthy studies summarized in the article.
Cementless vs Cemented TKA Fixation
—A matched case-control study of 400 primary total knee arthroplasties (TKAs) found that cementless TKAs had a 0.5% rate of aseptic loosening over a mean follow-up of 2.5 years, while cemented TKAs had an aseptic loosening rate of 2.5%.1
TKA Component Size in Obese Patients
—Among 35 revision-TKA patients with a varus collapse of the tibia, 29 weighed >200 lbs. Fehring et al. found that patients with implants at the small end of the range of the manufacturer’s tibial size offering and with >5° of preoperative varus were at increased risk of tibial-component failure.2
—A retrospective multivariate analysis of >4,300 patients who underwent outpatient TKA and >128,900 patients who underwent inpatient TKA found that, within 1 year, those who had outpatient procedures were more likely to experience a tibial and/or femoral component revision due to a noninfectious cause, irrigation and debridement, explantation of the prosthesis, and stiffness requiring manipulation under anesthesia.
—In a randomized trial of patients undergoing TKA, one group received 15 mg/kg of systemic intravenous vancomycin, and a second group received intraosseous regional administration of 500 mg vancomycin into the tibia. Mean tissue concentrations of the antibiotic were 34.4 mg/g in the intraosseous group and 6.1 mg/g in the intravenous group, suggesting that intraosseous administration provides a significantly higher tissue concentration of that antibiotic. 3
TKA Anesthesia Protocol
—A retrospective review of 156 consecutive patients who underwent primary TKA found that procedures performed with mepivacaine spinal anesthesia led to fewer episodes of urinary catheterization and shorter mean length of stay compared with procedures performed with bupivacaine spinal anesthesia.4
- Miller AJ, Stimac JD, Smith LS, Feher AW, Yakkanti MR, Malkani AL. Results of cemented vs cementless primary total knee arthroplasty using the same implant design. J Arthroplasty.2018 Apr;33(4):1089-93. Epub 2017 Dec
- Fehring TK, Fehring KA, Anderson LA, Otero JE, Springer BD. Catastrophic varus collapse of the tibia in obese total knee arthroplasty. J Arthroplasty.2017 May;32(5):1625-9. Epub 2017 Jan 30.
- Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS Clinical Research Award: intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee arthroplasty: a randomized trial. J Arthroplasty.2018 Jul;33(7S):S13-8. Epub 2018 Mar 15.
- Mahan MC, Jildeh TR, Tenbrunsel TN, Davis JJ. Mepivacaine spinal anesthesia facilitates rapid recovery in total knee arthroplasty compared to bupivacaine. J Arthroplasty.2018 Jun;33(6):1699-704. Epub 2018 Jan 16.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD and Shahriar Rahman, MS.
Recovery after surgery is an outcome that matters to everyone. The concept of enhanced recovery after surgery (ERAS) was first introduced in 1997 in Denmark by general surgeon Henrik Kehlet. The key objective is to accelerate postoperative recovery, reduce the length of hospital stay, and improve patient experience and clinical outcomes.
There are four key elements to ERAS:
- Optimizing preoperative care – The patient, surgeon, anesthesiologist, and nurses form a single team. A preoperative plan and classes help patients manage expectations.
- Reducing the physical stress of surgery –This may include minimally invasive techniques, reduced surgical times, optimized anesthetic techniques (e.g., spinal anesthesia or blocks), and maintenance of normovolemia. Traditionally, patients have nothing by mouth for many hours prior to surgery. ERAS, however, allows patients to receive clear fluids by mouth up to two hours prior to the operation. This practice has proven to be of limited risk and may better optimize fluid balance perioperatively.
- Enhancing postoperative comfort – This entails effective multimodal analgesia and prophylaxis against nausea. Narcotics are minimized, especially in elderly patients. A well-structured and consistent plan is developed among the patient, physicians, nurses, social workers, family/ caretakers, and physical therapists. Orthopaedic-floor staff standardize protocols to provide consistent, structured care with well-defined roles.
- Optimizing postoperative care – Early mobilization, normal feeding and hydration, and unambiguous discharge and post-discharge instructions are the goals here. Many ERAS programs also employ a Bring Your Own Gum initiative. Evidence suggests that chewing gum diminishes postoperative gastrointestinal dysfunction by preserving efferent vagal nerve activity, even when the surgical procedure did not involve the gastrointestinal tract.
The ERAS protocol was used initially in colorectal patients. A 2014 ERAS pilot of colorectal patients at Boston’s Brigham and Women’s Hospital found lower rates of complications after surgery. Cardiac events dropped by as much as 90 percent; there were 66 percent fewer surgical site infections, and patients left the hospital two days earlier on average. The Brigham is expanding ERAS guidelines to at least three other departments, and a study by Dwyer et al. in 2012 found that ERAS benefits seem to be universal and confer an advantage regardless of the patient’s preoperative condition.
Elective total joint arthroplasty (TJA) is one area of orthopaedics that has adopted several principles of ERAS. Reilly et al. (2005) were able to show that ERAS is beneficial in the treatment of patients undergoing unicompartmental knee replacement. As ERAS adoption increases among the orthopaedic surgery specialty, it is reasonable that its implementation may extend to subspecialties beyond TJA, such as hip fractures and upper extremity surgery. Macfie et al. (2012) demonstrated ERAS benefits in patients with a fractured femoral neck.
The improvements to quality of care and efficiency that are gained by implementing ERAS programs are largely due to changes in the underlying organizational structure of hospitals. To make further progress in orthopaedic care, we have to not only introduce new interventions that are proven beneficial, but also (and perhaps more importantly) stop doing things that are not beneficial and may even cause harm to patients.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh.