CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT MARIOS LYKISSAS, MD METROPOLITAN HOSPITAL

Kurtz S et al. Projections of primary and revision hip and knee arthroplasty in the US JBJS Am 2007;89:783

BLOOD MANAGEMENT STRATEGIES PROSTHETIC JOINT INFECTION PREVENTION CONTENT THROMBOPROPHYLAXIS BLOOD MANAGEMENT STRATEGIES PROSTHETIC JOINT INFECTION PREVENTION PERI-OPERATIVE ANALGESIA

THROMBOPROPHYLAXIS

88% DVT RATE IN UNTREATED PTS 7-28% DVT RATE IN TREATED PTS PERI-OP TKA MANAGEMENT THROMBOPROPHYLAXIS 88% DVT RATE IN UNTREATED PTS 7-28% DVT RATE IN TREATED PTS 0.5% IN MULTIMODAL APPROACH MECHANICAL COMPRESSION DECREASES DVT RATE BY 15%

RISK FACTORS FOR VENOUS THROMBOEMBOLIC EVENT

NO RCT STUDIES OUTLINE DURATION OF PROPHYLAXIS PERI-OP TKA MANAGEMENT THROMBOPROPHYLAXIS NO RCT STUDIES OUTLINE DURATION OF PROPHYLAXIS PROPHYLAXIS FOR 4-6 WEEKS PO REDUCES DVT BY 70%

16 RCT STUDIES 24,930 PTS THA, TKA 4-5 W PROPHYLAXIS VS 15 D PROPHYLAXIS + PLACEBO

BLOOD MANAGEMENT STRATEGIES

BLOOD MANAGEMENT STRATEGIES

BLOOD MANAGEMENT STRATEGIES THRESHOLD VALUS BLOOD MANAGEMENT STRATEGIES PRE-OP ANEMIA SCREEN PTS 2-3 M BEFORE SURGERY IRON STUDIES IF Hb<12 g/dL IF IRON DEFICIENCY GIVE IRON MINIMUM 1M PRE-OP (250 MG/DAY FOR 1 M) IRON ORAL (NOT EFFICACIOUS IN MALABSORPTION, SLOW EFFECT) IRON IV IF DEFICIENT IRON STORES GIVE FERRITIN CARVOXYMALTOSE IV IV IRON IMPROVE Hb 1 g/dL OVER 10 DAYS 67% RESOLUTION OF ANEMIA

BLOOD MANAGEMENT STRATEGIES PRE-OP ANEMIA EPO IS A POWERFUL BUT EXPENSIVE AGENT FOR CORRECTING ANEMIA INDICATED IN PTS WITH ANEMIA SECONDARY TO CRF PRE-OP AUTOLOGOUS DONATION IS ASSOCIATED WITH HIGH RATE OF WASTED BLOOD AND IS NOT COST EFFECTIVE

15 RCT STUDIES 837 PTS TXA vs PLACEBO TXA RESULTED IN FEWER BLOOD TRANSFUSIONS LESS BLOOD LOSS LESS CHANGE IN Hb NO DIFFERENCE IN DVT NO DIFFERENCE IN PE

15 STUDIES 1495 PTS

CONTRA-INDICATIONS VARIOUS REGIMENS BLOOD MANAGEMENT STRATEGIES TXA STROKE THROMBOEMBOLISM ALLERGY SEVERE CAD VARIOUS REGIMENS 1 GR IV AFTER TOURNIQUET RELEASE (15 MG/KG) 1-3 GR INTRA-ARTICULARLY AFTER FASCIA CLOSURE 1 GR IV IN 5 H (2 H HALF-LIFE)

BLOOD MANAGEMENT STRATEGIES

Hb> 8g/dL NO TRANSFUSION Hb<6 g/dL TRANSFUSION IN ALL PTS BLOOD TRANSFUSION Hb> 8g/dL NO TRANSFUSION Hb<6 g/dL TRANSFUSION IN ALL PTS 6<Hb<8 TRANSFUSION BASED ON ONGOING LOSSES CARDIOVASCULAR RISK SYMPTOMATIC ANEMIA

PERI-OPERATIVE ANALGESIA

MULTIMODAL ANALGESIA MAXIMIZES POSITIVE ASPECTS PERI – OP ANALGESIA MULTIMODAL ANALGESIA MAXIMIZES POSITIVE ASPECTS WHILE LIMITING SIDE EFFECTS IV OPIOIDS NEGATIVELY IMPACT REHABILITATION & HOSPITAL DISCHARGE (DOSE DEPENDENT) AMERICAN SOCIETY OF ANESTHESIOLOGISTS RECOMMENDS 2 OR MORE ANALGETICS WITH DIFFERENT MECHANISMS OF ACTION

MULTIMODAL ANALGESIA INTRA-OP POST-OP

INTRA-OP MANAGEMENT BILATERAL TKA PRE-OP MANAGEMENT

PROSTHETIC JOINT INFECTION

POST-OP INFECTION MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION

POST-OP INFECTION MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION ALBUMIN < 3.5 g/dL LYMPHOCYTE COUNT < 1500 CELLS/MM3

POST-OP INFECTION 2nd GENERATION CEPHALOSPORIN CLINDA OR VANCO IN B-LACTAM ABX ALLERGY VANCO IN MRSA ADMINISTRATION 30-60 MIN BEFORE INCISION FINISHED >10 MIN BEFORE TOURNIQUET IV & CEMENT ABX MORE EFFECTIVE THAN EITHER ALONE ASYMPTOMATIC BACTERIURIA PRE-OP TREATMENT IS NOT NECESSARY MAJOR DENTAL PROCEDURES BEFORE TKA NASAL PRE-OP TREATMENT WITH MUPIROCIN OINTMENT FOR PTS WITH S. AUREUS CARRIAGE

RA, PsA TKA IN PTS WITH INFLAMMATORY ARTHRITIS 4.2% 5-YEAR PROSTHETIC JOINT INFECTION RATE IN RA PTS (1.4% IN OA PTS) IN RA, RISK OF INFECTION IS ASSOCIATED WITH EXTRA-ARTICULAR DISEASE (RHEUMATOID NODULES, ESR-MARKERS FOR DISEASE SEVERITY) HIGHER RATES OF CARDIOVASCULAR DISEASE THAN GENERAL POPULATION RA PTS HAVE A 30-60% INCREASE IN CARDIOVASULAR MORBIDITY PULMONARY DISEASE COMMON IN PTS WITH RA ~40% OF RA PTS REFERRED FOR ARTHROPLASTY HAVE ASYMPTOMATIC C-SPINE INSTABILITY - NEED SCREENING WITH DYNAMIC C-SPINE XRAYS PTS WITH C1-2 OR SUBAXIAL INSTABILITY AND SAC <13 MM OR MYELOPATHY ON MRI REQUIRE C-SPINE DECOMPRESSION +/- FUSION PRIOR TO TKA

ANTIRHEUMATIC THERAPY TKA IN PTS WITH INFLAMMATORY ARTHRITIS ANTIRHEUMATIC THERAPY INFECTION RISK STEROIDS > MTX (RISK INCREASES WITH DOSE) STEROIDS HAVE NEGATIVE EFFECT ON WOUND HEALING AND INFECTION PTS WHO D/C MTX HAVE HIGHER INFECTION RATE & FLARE RATE MTX SHOULD BE CONTINUED THROUGH PERI-OP PERIOD HYDROXYCHLOROQUINE IS NOT IMMUNOSUPPRESANT (SHOULD BE CONTINUED) POST-OP ADRENAL INSUFFICIENCY AND DEATH IN STEROID-TREATED PTS USE OF SUPRAPHYSIOLOGIC “STRESS DOSE” STEROIDS (INTRA-OP SUPPLEMENTAL HYDROCORTISONE 100 MG) VISSER ET AL. ANN RHEUM DIS 2009;68:1086 HOES ET AL. ANN RHEUM DIS 2007;66:1560

BIOLOGIC AGENTS TKA IN PTS WITH INFLAMMATORY ARTHRITIS ASSOCIATION OF ANTI-TNF WITH PROSTHETIC JOINT INFECTION HIGHER INFECTION RISK IN THE FIRST 6 M OF THERAPY RESTART BIOLOGIC AGENTS 2 W PO