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CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT

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. CONTENT. THROMBOPROPHYLAXIS BLOOD MANAGEMENT STRATEGIES

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CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT

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

  4. THROMBOPROPHYLAXIS

  5. 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. 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

  9. BLOOD MANAGEMENT STRATEGIES

  10. BLOOD MANAGEMENT STRATEGIES

  11. 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 STORESGIVE FERRITIN CARVOXYMALTOSE IV IV IRON IMPROVE Hb 1 g/dL OVER 10 DAYS 67% RESOLUTION OF ANEMIA

  12. 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

  13. 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

  14. 15 STUDIES • 1495 PTS

  15. BLOOD MANAGEMENT STRATEGIES TXA 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) CONTRA-INDICATIONS STROKE THROMBOEMBOLISM ALLERGY SEVERE CAD

  16. BLOOD MANAGEMENT STRATEGIES

  17. 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

  18. PERI-OPERATIVE ANALGESIA

  19. 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

  20. MULTIMODAL ANALGESIA INTRA-OP POST-OP

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

  22. PROSTHETIC JOINT INFECTION

  23. POST-OP INFECTION MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION

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

  25. 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

  26. TKA IN PTS WITH INFLAMMATORY ARTHRITIS RA, PsA 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

  27. 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

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

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