1. What’s New in Knee Replacement
Kenneth D. Kleist, M.D.
HealthPartners Medical Group
Regions Hospital
St. Paul, MN
Introduce yourself and the plan or plans available to the members. Let members know that you are happy to answer their questions.

2. Goals of Knee Replacement
Improve the quality of life by improving pain and function while maintaining range of motion and avoiding complications.
85% of Knee replacement patients say they would have the surgery again.

3. Trends In case anyone asks,
US News – HP commercial plans are rated 62 in the nation (Blue Plus is 126, Medica is 146) We’re top plan in the state. The magazine only lists the top 50 plans – the Web site lists more.
Consumer Reports – Scored highest among local plans
NCQA – one of our regions top 5 plans – only MN plan in the top five

4. What is a joint replacement?

5. What is a partial knee replacement?

6. Minimally Invasive Surgery
No good consensus on what this means
Less skin incision
Less tendon/muscle splitting and damage
??? More rapid recovery
Certainly there are benefits
Cosmetic, psychological, blood loss, recovery
Bottom Line
Need to have pieces put in right!
Long-term survival of the joint is most important

7. Approach Medial Parapatellar Mini-Medial Parapatellar Mid Vastus
Sub Vastus
Quad Sparing

8. Pain Control and Rehabilitation Protocols
Regional Anesthesia increasing
Spinal or Epidural Anesthesia
Femoral Nerve Blocks
Pre-op Medicines
Pain Catheters, continuous or on demand
Local anesthetic intra-operatively
Cryocuff for icing
Long-Acting Narcotics
Less Intravenous narcotics
Pain as a vital sign

9. Better Nausea Control Much more focus Regional Anesthesia Helps
Multimodal approach
Less intravenous narcotics
Scopolamine patches
Odansetron
Prochlorperazine
Metoclopramide

10. Post-operative Physical Therapy
Early mobility is helpful
Continuous Passive Motion (CPM) the night of surgery
Start at high flexion right away
Set goals for range of motion
Up on your feet the first post-operative day
Discharge on the third post-operative day
Transition from walker to cane to nothing

11. How much flex is enough? High flexion implants
Theoretically allow higher range of motion
Traditional Implants 125, maybe 135 degrees
Some now up to 155 Degrees
Caution: High flexion does not mean you definitely will get better motion.
Setting Expectations is Important
Best predictor is pre-op motion
Knee will not be normal.
Can make the surgery slightly easier by removing extra bone
Can provide additional implant options.

12. Gender Specific 3 anatomical shape differences Females are narrower
They have a different angle the knee cap glides through
They have thinner area at the front of the bone
Most companies now address this in some way
Shape change
Sizing

13. Mobile Bearing TKA Rotating Platform
Plastic liner rotates in the metal
May decrease wear
May improve motion
May allow fudge factor
However may also increase wear.
More difficult to insert plastic

14. Highly Crosslinked Polyethylene
Relatively New
Not as accepted as in the hip
Goal is to reduce wear
Still long-term questions about mechanica strength to fracture resistance and delamination
Not common used by most surgeons yet except in limited cases
Very young patient

15. Other Alternative Bearings
New approaches to femoral components
Ceramics
Oxidized Zirconium

16. Computer Navigation Still Controversial May improve overall alignment
May improve the accuracy of sizing
Possible it may improve long term outcome
Increases time
“Garbage In, Garbage out”
May place you at a minimal risk for fracture
Awaiting long-term data

17. Direct to Consumer Marketing

18. Current State of Patient’s Decision Making in Today’s Market!
The best advice is to have a discussion with your surgeon.
Balancing Act
Patients needs/desires
Surgeon training, experience, and skill