Total Knee Arthroplasty (or Replacement)
Hello again
I am posting this late and I apologize. Have been very busy as of late and just returned from vacation today.
Anyway, I chose to discuss the Total Knee Arthroplasty surgical procedure for this month. As previously stated I work at the NORTH Institute where we specialize in spine surgery, general orthopedics, and physical rehabilitation (post-operative and non-operative). The Total Knee Replacement procedure is one of the most common surgeries of this current era of health care. As we all know the life expectancy of the American population continues to rise. This fact combined with the knowledge that an unprecedented amount of American citizens from the “Baby Boom” era are just reaching senior citizen age means that the incidence of this surgical procedure will increase dramatically.
Why consider the Total Knee Arthroplasty (TKA)? The TKA is indicated for patients that have persistent knee pain secondary to severe or moderate degenerative joint disease. The procedure is specifically meant to decrease pain and increase functional mobility; therefore, increasing quality of life. Most of the patients that fall into this category are over the age of 65. Most have endured significant pain for a prolonged period of time with their activities of daily life. Most have had several rounds of intra-articular corticosteroid injections that initially helped with pain and swelling but no longer do the trick. Some have been through 1 or 2 series of Synvisc injections with a varying degree of success or failure. So to sum it up: we recommend TKA for patients that continue to have significant debilitating knne pain that no longer or never did respond to conservative treatment. There should be some evidence of degenerative joint changes.
What are degenerative changes? Is this Arthritis? Will everybody need this is they live past the age of 70? Degenerative joint changes can occur gradually over time as people age or they may occur in a relative short period of time secondary to some injury hat may have altered the bio-mechanics of the patients body. What we often see on Xray is a decreased joint space - either medially, laterally, or evenly throughout the joint; this is evidence that the cartilage in the joint has diminished. We also often see bone spurs (osteophytes) within and around the joint. Intra-operatively this excess bone is easily visualized; it is often rough (as opposed to a normal smooth cartilage surface) with a poor quality of bone. Sometimes there a pebbles or rocks of bone that we find in the joint. In summary, all of the above can be termed degenerative and can be linked in some way to osteoarthritis (NOT rheumatoid). Not everyone, no matter their age, will develop degenerative joint disease (DJD) to the degree that requires a TKA. However, it must be noted that there are many elderly people out there with significant DJD that do not complain of limiting pain.
Is the procedure safe? Is it effective? As previously stated this is a very common surgical procedure. It is relatively safe. People that have other co-morbid medical conditions (i.e. heart disease, diabetes, kidney failure, history of blood clots, etc…) are at an increased risk of complications. However, these patients will always have an increased risk of complications with any surgical procedure. The statistics demonstrate that this procedure is very effective in both decreasing pain and increasing functional mobility; hence why it is so popular. For a more detailed review about the possible risks and compications speak directly to your orthopedic surgeon.
Describe the procedure. How long does it take? How long will I be in the hospital? Will I be able to go home at the time of discharge? The procedure itself takes anywhere from 60-90 minutes unless there are intraoperative complications. Without getting too technical, the procedure consists of the orthopedic surgeon measuring and sawing off the distal end of the femur, the proximal end of the tibia, and the backside of the patella and replacing them with prosthetic components either metal or plastic. By doing this we re-create a smooth joint surface. In our practice we perform most of these procedures on a Tuesday and the patient either goes home or to a skilled nursing facility on that Friday depending on heir functional mobility status. Most of our patients receive femoral and sciatic nerve blocks just prior to the procedure; these can sometimes numb the majority of the involved leg eliminating a significant amount of post-op pain. However, they may also cause weakness in the leg. When the patient wakes up Tuesday after surgery, their pain should be minimal. If they experience pain there is acess to pain medications either by mouth or through their IV line; some patients may hae a PCA (patient controlled anesthesia - “push the button when it hurts”). A CPM (continuous passive motion) device is applied to the patient’s leg in the operating room; so they wake up with this contraption on their leg. The first day post-op is spent mostly in bed and at a bedside chair. The following morning (Thursday), the nerve blocks, the PCA, and the foley catheter (for urine) are removed. The patient will get out of bed and will walk using a rolling walker (in most cases); the patient can put as much weight on their operated leg as they can handle. Some patients do very well and are able to go home that evening but most patients go home on Friday morning. Patients that go home receive home health physical therapy 3-5 times a wk for 1-4wks as needed. A small percentage of patients struggle withpain and mobility issues and therefore, they are transferred to a skilled nursing facility where they have continuous care and receive physical therapy twice a day. If transferred to a skilled nursing facility, patients are required to stay there for at least 3wks. The 3wk thing is a fiancial issue. Medicare and most insurance companies require this in order to justify the transfer and therefore pay or reimburse the facility.
So there you have it. If contemplating this procedure Dr. Texada or myslef will be happy to discuss everthing in great detail in the office. It is the Tuesday morning after labor day and I am off the operating room. Our first case is a TKA.
Sincerely,
Michael Beninato MPAS, PA-C
