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

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

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

4. THROMBOPROPHYLAXIS

5. 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%

6. RISK FACTORS FOR VENOUS THROMBOEMBOLIC EVENT

7. 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%

8. 16 RCT STUDIES
24,930 PTS
THA, TKA
4-5 W PROPHYLAXIS VS 15 D PROPHYLAXIS + PLACEBO

11. BLOOD MANAGEMENT STRATEGIES

12. BLOOD MANAGEMENT STRATEGIES

13. 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

14. 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. 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

16. 15 STUDIES
1495 PTS

17. 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)

18. BLOOD MANAGEMENT STRATEGIES

19. 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< TRANSFUSION BASED ON
ONGOING LOSSES
CARDIOVASCULAR RISK
SYMPTOMATIC ANEMIA

20. PERI-OPERATIVE ANALGESIA

21. 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

22. MULTIMODAL ANALGESIA
INTRA-OP
POST-OP

23. INTRA-OP MANAGEMENT
BILATERAL TKA
PRE-OP MANAGEMENT

24. PROSTHETIC JOINT INFECTION

25. POST-OP INFECTION
MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION

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

27. POST-OP INFECTION 2nd GENERATION CEPHALOSPORIN
CLINDA OR VANCO IN B-LACTAM ABX ALLERGY
VANCO IN MRSA
ADMINISTRATION 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

28. 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

29. 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

30. 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