Given the prevalence of opioid prescriptions, many patients present for total knee arthroplasty (TKA) having been on long-term opioid therapy. In the January 4, 2017 edition of The Journal of Bone & Joint Surgery, Ben-Ari et al. determined that patients taking opiate medications for more than three months prior to their TKA were significantly more likely than non-users of opioids to undergo revision surgery within a year after the index procedure.
Among the more than 32,000 TKA patients from Veterans Affairs (VA) databases included in the study, nearly 40% were long-term opioid users prior to surgery. Despite that high percentage, the authors found that chronic kidney disease was the leading risk factor for knee revision among the relevant variables they examined. And even though the authors used a sophisticated natural language/machine-learning tool to analyze postoperative notes, they found no association between long-term opioid use and the etiology of the revisions.
In a commentary accompanying the study, Michael Reich, MD and Richard Walker, MD, note that the study’s very specific VA demographic (94% male) may hamper the generalizability of the findings, especially because most TKAs are currently performed in women. Nevertheless, the commentators conclude that:
- “The study illuminates the value in limiting opioid use during the nonoperative treatment of patients with knee arthritis.”
- “Patients who are taking opioids when they present for TKA could reasonably be encouraged to decrease opioid use during preoperative preparation.”
- “Preoperative use of opioids should be considered among modifiable risk factors and comorbidities when deciding whether to perform TKA.”
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.
The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.
The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”
Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.
This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence. This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.
Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.
Moderate evidence: Diabetic patients have a higher risk of complications after TKA.
Moderate evidence: An 8-month delay to TKA does not worsen outcomes.
Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.
Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.
Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.
Strong evidence: The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.
Strong evidence: Drains do not help reduce complications or improve outcomes.
Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.
Strong evidence: All-polyethylene and modular components yield similar outcomes.
Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.
Strong evidence: There is no difference in pain/function with patellar resurfacing.
Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.
Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).
Moderate evidence favors TKA over UKA to avoid future revisions.
Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.
Strong evidence: Rehab/PT started on day of surgery reduces length of stay.
Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.
Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
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.
As an end-of-year thank-you to the orthopaedic community, we’re offering limited-time full-text access to the five most-read JBJS articles of 2016. The fact that several of these most-read articles were published prior to 2016 is testament to the durable utility of orthopaedic research published in The Journal of Bone & Joint Surgery.
- Bariatric Orthopaedics: Total Hip Arthroplasty in Super-Obese Patients
- Antibiotic-Impregnated Cement Spacers for the Treatment of Infection Associated with Total Hip or Knee Arthroplasty
- The Surgical Management of Chronic Tophaceous Gout
- Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment
- An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation
“Necessity is the mother of invention.” In recent years, the demand for total hip, total knee, and unicompartmental knee arthroplasty has grown substantially. However, with limited resources and health-care budgets, there is a need to reduce hospital costs. To that end, a number of surgeons have begun to perform these procedures on an outpatient basis.
Indeed, as the demand for joint replacements grows, it will be imperative to improve patient safety and satisfaction while minimizing costs and optimizing the use of health-care resources. In order to accomplish this goal, surgical teams, nursing staff, and physiotherapists will need to work together to discharge patients from the hospital as soon as safely possible, including on the same day as the operation. The development of accelerated clinical pathways featuring a multidisciplinary approach and involving a range of health-care professionals will result in extensive preoperative patient education, early mobilization, and intensive physical therapy.
In the December 2016 issue of JBJS Reviews, Pollock et al. report on a systematic review that was performed to determine the safety and feasibility of outpatient total hip, total knee, and unicompartmental knee arthroplasty. The authors hypothesized that outpatient arthroplasty would be safe and feasible and that there would be similar complication rates, similar readmission and revision rates, similar clinical outcomes, and decreased costs in comparison with the findings associated with the inpatient procedure. The investigators demonstrated that, in selective patients, outpatient total hip, total knee, and unicompartmental knee arthroplasty can be performed safely and effectively.
A major caveat of this well-conducted study, however, is that, like any systematic review, its overall quality is based on the quality of the individual studies that make up the analysis. In this case, the studies included those that lacked sufficient internal validity, sample size, methodological consistency, and standardization of protocols and outcomes. Thus, going forward, there is a need for more rigorous and adequately powered randomized trials to definitively establish the safety, efficacy, and feasibility of outpatient hip and knee arthroplasty.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
Of the hundreds of thousands of total knee arthroplasties (TKAs) performed annually around the world, very few result in failure so irreparable that transfemoral amputation is the last resort. But what does “very few” really mean? In the December 7, 2016 issue of The Journal of Bone & Joint Surgery, Gottfriedsen et al. determine the cumulative incidence of amputation for failed TKAs among nearly 93,000 registered knee replacements performed in Denmark from 1997 to 2013.
The authors used a competing-risk model (which took into account the competing risk of death) to avoid overestimating incidence. From a total of 115 amputations performed for causes related to failed TKA, they calculated a cumulative 15-year incidence of amputation of 0.32%. They noted a tendency toward decreasing incidence during the 2008-2013 period, relative to the 1997-2002 period.
The three most common causes of post-TKA amputation were periprosthetic infection (83%), soft-tissue deficiency (23%), and severe bone loss (18%). The authors add, however, that the latter two causes are “most likely the result of long-term infection together with several revision procedures, in which soft tissue and bone stock are gradually damaged.”
The authors encourage orthopaedists to consider newer treatment options to avoid amputation (such as skin grafts and muscle flaps for soft-tissue loss), but they also assert that, in each individual case, those contemporary approaches should be balanced against the “psychological and physical strains related to repeated surgery performed in an attempt to salvage the knee.”
Early on, patients with knee osteoarthritis (OA) often get sufficient pain relief with nonsteroidal anti-inflammatory drugs. But as the condition progresses, many opt for knee replacement. Although knee replacement shows remarkable long-term results, immediate postsurgical pain management is a crucial consideration for orthopaedists and patients.
On Tuesday, December 13, 2016 at 12:30 PM EST, The Journal of Bone & Joint Surgery (JBJS) and PAIN, the official journal of the International Association for the Study of Pain, will host a complimentary webinar focused on relieving pain before and after surgery for knee arthritis.
- Sachiyuki Tsukada, MD, coauthor of a study in JBJS, will compare pain relief and side effects from intraoperative periarticular injections versus postoperative epidural analgesia after unilateral knee replacement.
- PAIN author Lars Arendt-Nielsen, Dr.Med.Sci, will delve into findings from a study examining biomarker and clinical outcomes associated with the COX-2 inhibitor etoricoxib in patients with knee OA.
Moderated by JBJS Associate Editor Nitin Jain, MD, the webinar will include an additional perspective from musculoskeletal pain-management expert Michael Taunton, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all three panelists.
Seats are limited, so register now!
The recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.
Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of November 2016:
- Comparative Survivorship of Different Tibial Designs in Primary Total Knee Arthroplasty
- All-Polyethylene Versus Metal-Backed Tibial Components
- Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty
- Risk of Total Knee Arthroplasty After Operatively Treated Tibial Plateau Fracture
- Long-Term Clinical Outcomes and Survivorship of Press-Fit Condylar Sigma Fixed-Bearing and Mobile-Bearing Total Knee Prostheses in the Same Patients
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.
The incidence of primary total knee and hip arthroplasty is increasing steadily. While the success rates of these procedures are remarkable, failures do occur, and periprosthetic joint infection is the leading culprit in such failures. The standard treatment when deep infection strikes is a two-stage revision.
On Monday, November 14, 2016 at 8:00 PM EST, The Journal of Bone & Joint Surgery (JBJS) will host a complimentary webinar that examines prognostic factors affecting the success of two-stage revision arthroplasty for infected knees and hips.
- Tad M. Mabry, MD, coauthor of a matched cohort study in JBJS, will examine the impact of morbid obesity on the failure of two-stage revision TKA.
- JBJS author Antonia F. Chen, MD, will discuss results from a retrospective study that revealed an association between positive cultures at the time of knee/hip component reimplantation and the risk of subsequent treatment failure.
Moderated by JBJS Deputy Editor Charles R. Clark, MD, the webinar will include additional perspectives from two expert commentators—Daniel J. Berry, MD and Andrew A. Freiberg, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.
Seats are limited, so register now!
Hyaluronic Acid Injections for Treatment of Advanced Osteoarthritis of the Knee: Utilization and Cost in a National Population Sample
There is a rise in knee osteoarthritis, particularly in the aging U.S. population. A practice known as hyaluronic acid (HA) injections is used for the treatment of knee osteoarthritis; however, its efficacy and cost-effectiveness are being debated. In this study, the utilization and costs of HA injections were evaluated during the 12 months preceding total knee arthroplasty (TKA) and the usage of HA injections in end-stage knee osteoarthitis management in relation to other treatments was also evaluated. Truven Health Analytics databases (MarketScan Commercial Claims and Encounters and Medicare Supplemental and Cooridination of Benefits) were reviewed in order to find patients who underwent TKA from 2005 to 2012. All patient-specific osteoarthritis-related health care, including medications, corticosteroid injections, HA injections, imaging, and office visits, as well as payment information were analyzed during the 12 months before TKA.
244,059 patients met the inclusion criteria, and 35,935 (14.7%) of them had > 1 HA injections in the 12-month period. HA accounted for 16.4% of all payments related to osteoarthritis, coming in second only to imaging studies (18.2%). In terms of treatment-specific payments, HA injections accounted for 25.2%, a rate higher than that of any other treatment. Compared with patients who did not receive HA injections, patients who had the injections were significantly more likely to receive additional knee osteoarthritis-related treatment.
HA injections are still frequently used to treat osteoarthritis of the knee even though there have been numerous studies that question their efficacy and cost-effectiveness for that purpose. Based on the results and a lack of data supporting the effectiveness of HA injections in the current cost-conscious health-care climate, the authors of this study concluded that decreasing the use of HA injections for patients with end-stage knee osteoarthritis may substantially reduce cost without adversely affecting the quality of care.
When Verburg et al. designed their randomized clinical trial, published in the June 15, 2016 edition of The Journal of Bone & Joint Surgery, they hypothesized that a mini-midvastus (MMV) approach to total knee arthroplasty (TKA) would yield better outcomes than a conventional approach. However, during short- and mid-term follow-up (up to 5 years postoperatively) on 84 TKAs (42 in each group), the researchers found no relevant clinical or radiographic differences between the two groups, both of which received the same brand of posterior-stabilized implant.
On average, the MMV procedure took 6 minutes longer, and those in the MMV group had better range of motion on postoperative day 3. On the downside, more wound-healing problems such as blisters were observed in the MMV group, especially in large male patients, which the authors attribute to soft-tissue interactions caused by the use of necessarily large components with small incision lengths.
Verburg et al. concluded that “the advantage of the MMV approach was merely a smaller scar,” and they do not recommend MMV or other minimally invasive/quadriceps-sparing approaches for “larger patients or muscular men.”