total knee arthroplasty (TKA, TKR)
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Indications
- cost-effective for end-stage knee osteoarthritis[6]
- radiographic evidence of moderate-to-severe knee osteoarthritis[42]
- moderate-to-severe pain, loss of function, or both[42]
- no improvement with physical therapy or joint injection[42]
- cost-effective for adults with morbid obesity & knee osteoarthritis[34]
- superior to medical management alone[35]
* recommendations from[42] conditional, not strong
Contraindications
- not cost-effective for patients with less severe knee osteoarthritis[22]
- obesity regardless of BMI not a contraindication[42]
- delay for poorly-controlled diabetes mellitus, but HgbA1c requirements are not defined[42]
- delay for trial of smoking cessation[42]
* recommendations from[42] conditional, not strong
Radiology
- X-ray of knee including standing view if loosening of artificial knee joint suspected[11]
Complications
- deep vein thrombosis
- 54%, 7% of these proximal DVT[2]
- complete resolution of DVT (97%) in 6 months WITH or WITHOUT anticoagulation[2]
- NO increased risk of pulmonary embolism WITHOUT anticoagulation[2]
- mean total blood loss 1500 mL of which 760 mL is hidden mean hemoglobin drop is 3 g/dL[4]
- increased risk of myocardial infarction (30-fold at 2 weeks, returning to baseline at 6 weeks)[8][17]
- preoperative glycemic control in patients with type 2 diabetes is not associated with risk of complications[9]
- joint infection
- loosening of artificial knee joint
- pain on bearing weight that resolves after a short period of time
- most commonly occurs >= 5 years after joint replacement[11]
- risk for revision: lifetime risk for revision is 35%[20]
- women with significantly lower risk for revision[20]
- delirium
- poor preoperative performance on Mini-Cog test predicts postoperative delirium[25]
- long-term cognitive trajectories similar to individuals with total knee arthroplasty[39]
- 30 day major postoperative complication rate is 5.0%[27]
- if BMI >= 40 kg/m2 postoperative complication rate is 6.7%
- 14 obese patients would need to be denied surgery to prevent 1 30-day major complication[27]
Management
- do not delay for trials of physical therapy, NSAIDs, bracing, intra-articular glucocorticoid injections, or hyaluronic acid injections (conditional recommendation)[42]
- perioperative antibiotic prophylaxis with cefazolin monotherapy
- anticoagulation for 2-4 weeks, 4 weeks better[5]
- high risk for venous thromboembolism
- both mechanical & pharmacologic prophylaxis for venous thromboembolism
- see prophylaxis for venous thromboembolism
- rivaroxaban monotherapy is the most effective strategy for preventing DVT after elective total knee replacement[30]
- aspirin may be non-inferior to anticoagulants[28]
- no difference in symptomatic pulmonary embolism or symptomatic proximal DVT, incidence of serious bleeding or death for enoxaparin 40 mg QD vs aspirin 100 mg QD for 14 days[38]
- small difference in distal (below knee) DVT favoring enoxaparin
- no difference in symptomatic pulmonary embolism or symptomatic proximal DVT, incidence of serious bleeding or death for enoxaparin 40 mg QD vs aspirin 100 mg QD for 14 days[38]
- bisphosphonate use is associated with a lower rate of revision after hip arthroplasty & knee arthroplasty & longer implant survival[7]
- rehabilitation
- home rehabilitation as effective as inpatient rehabilitation[11][14][21][33]
- begin rehabilitation the day after surgery[11]
- analgesia is helpful in promoting patient participation
- combinations of recumbent bicycle, treadmill, & neuromuscular stimulation useful[32]
- discharge to a skilled-nursing facility after total knee arthroplasty is associated with higher 30 & 90 day hospital readmission, & higher overall cost[11][37]
- preoperative exercise for obese patients can improve postoperative functional mobility & increase the likelihood of discharge home[15]
- threshold for urinary catheterization of 800 mL rather than 500 mL may prevent unnecessary catheterization[18]
- anlagesia
- electrotherapy & acupuncture might help decrease opioid use for pain relief after total knee arthroplasty[24]
- perioperative gabapentinoids associated with excess pulmonary complications & do not spare opioid use[31]
- patients with rheumatic diseases
- DMARDs methotrexate, leflunomide, hydroxychloroquine, sulfasalazine may be continued during the perioperative period[23]
- biologics (adalimumab, etanercept ..)
- withhold for one dosing schedule before elective surgery
- resume with evidence of wound healing (minimum of 14 days)[41]
- no increase in infections when infliximab given within 4 weeks of hip replacement or knee replacement[26]
- patients on chronic glucocorticoid therapy should be given stress dose perioperative glucocorticoids to avoid an adrenal crisis
- metformin reduces need for TKA/TKR 30% in patients with type 2 diabetes[40]
Notes
- improved pain & function at 1 year
- outcomes depend on comorbid back pain & other joint disease[10]
- Medicare will pay for inpatient rehabilitation only if bilateral knee replacement[11]
- ceramic-on-ceramic bearings, modular femoral necks, & high-flexion implants associated with higher rates of revision[16]
- 93%, 90%, & 82% of total knee replacements lasted 15, 20, & 25 years, respectively[29]
More general terms
Additional terms
- hemiarthroplasty of knee; compartmental arthroplasty of knee
- prophylaxis for venous thromboembolism (VTE)
References
- ↑ Genova A. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 2.0 2.1 2.2 2.3 Journal Watch 23(19):150, 2003 Wang C-J et al, J Bone Joint Surg Br 85:841, 2003
- ↑ Journal Watch 24(13):104, 2004
- ↑ 4.0 4.1 Journal Watch 24(13):104, 2004 Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br. 2004 May;86(4):561-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15174554
- ↑ 5.0 5.1 Bjornara BT et al, Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br 2006; 88:386 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16498018
- ↑ 6.0 6.1 Losina E et al Cost-effectiveness of Total Knee Arthroplasty in the United States Arch Intern Med. 2009;169(12):1113-1121 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19546411
- ↑ 7.0 7.1 Prieto-Alhambra D et al. Association between bisphosphonate use and implant survival after primary total arthroplasty of the knee or hip: Population based retrospective cohort study. BMJ 2011 Dec 6; 343:d7222 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22147909
- ↑ 8.0 8.1 Lalmohamed A et al Timing of Acute Myocardial Infarction in Patients Undergoing Total Hip or Knee Replacement: A Nationwide Cohort Study Arch Intern Med. 2012;():1-7. July 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22826107 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1221716
Wallace AW Risk of Acute Myocardial Infarction in Patients With Total Hip or Knee Replacement: Comment on "Timing of Acute Myocardial Infarction in Patients Undergoing Total Hip or Knee Replacement" <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22825029 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1221723 - ↑ 9.0 9.1 Adams AL et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am 2013 Mar 20; 95:481. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23446446 <Internet> http://jbjs.org/article.aspx?articleid=1566977
- ↑ 10.0 10.1 Ayers DC et al. Patient-reported outcomes after total knee replacement vary on the basis of preoperative coexisting disease in the lumbar spine and other nonoperatively treated joints: The need for a musculoskeletal comorbidity index. J Bone Joint Surg Am 2013 Oct 16; 95:1833 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24132356 <Internet> http://jbjs.org/article.aspx?articleid=1746510
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ Kauppila AM, Kyllonen E, Ohtonen P et al Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized controlled study of its effects on functional capacity and quality of life. Clin Rehabil. 2010 May;24(5):398-411. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20354057
- ↑ Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004957. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18425906
- ↑ 14.0 14.1 Mahomed NN, Davis AM, Hawker G et al Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008 Aug;90(8):1673-80. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18676897
- ↑ 15.0 15.1 Robbins CE, Bono JV, Ward DM et al Effect of preoperative exercise on postoperative mobility in obese total joint replacement patients. Orthopedics. 2010 Sep 7;33(9):666. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20839706
- ↑ 16.0 16.1 Nieuwenhuijse MJ et al Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies. BMJ 2014;349:g5133 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25208953 <Internet> http://www.bmj.com/content/349/bmj.g5133
- ↑ 17.0 17.1 Lu N et al. Total joint arthroplasty and the risk of myocardial infarction: A general population, propensity score-matched cohort study. Arthritis Rheumatol 2015 Oct; 67:2771. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26331443
- ↑ 18.0 18.1 Bjerregaard LS, Hornum U, Troldborg C et al Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty: A Randomized, Open-label, Controlled Trial. Anesthesiology. 2016 Jun;124(6):1256-64. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27054365
- ↑ Kurtz S, Ong K, Lau E, Mowat F, Halpern M Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17403800
- ↑ 20.0 20.1 20.2 Bayliss LE, Culliford D, Monk AP et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: A population-based cohort study. Lancet 2017 Feb 13; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28209371
Schreurs BW, Hannink G. Total joint arthroplasty in younger patients: Heading for trouble? Lancet 2017 Feb 13 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28209372 - ↑ 21.0 21.1 Buhagiar MA, Naylor JM, Harris IA et al Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty. The HIHO Randomized Clinical Trial. JAMA. 2017;317(10):1037-1046. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28291891 <Internet> http://jamanetwork.com/journals/jama/article-abstract/2610335
Buhagiar MA. Naylor JM, Harris IA et al. Assessment of outcomes of inpatient or clinic-based vs home-based rehabilitation after total knee arthroplasty: A systematic review and meta-analysis. JAMA Netw Open 2019 Apr 26; 2:e192810. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2731681 - ↑ 22.0 22.1 Ferket BS, Feldman Z, Zhou J et al Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative. BMJ 2017;356:j1131 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28351833 Free full text <Internet> http://www.bmj.com/content/356/bmj.j1131
- ↑ 23.0 23.1 Goodman SM, Springer B, Guyatt G et al 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care & Research. June 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28620917 https://www.rheumatology.org/Portals/0/Files/ACR-AAHKS-Perioperative-Management-Guideline.pdf
- ↑ 24.0 24.1 Tedesco D, Gori D, Desai KR et al Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty. A Systematic Review and Meta- analysis. JAMA Surg. Published online August 16, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28813550 <Internet> http://jamanetwork.com/journals/jamasurgery/article-abstract/2647847
- ↑ 25.0 25.1 Culley DJ, Flaherty D, Fahey MC et al. Poor performance on a preoperative cognitive screening test predicts postoperative complications in older orthopedic surgical patients. Anesthesiology 2017 Nov; 127:765 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28891828
- ↑ 26.0 26.1 George MD, Baker JF, Hsu JY et al. Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty. Arthritis Care Res (Hoboken) 2017 Dec; 69:1845 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28129484 <Internet> http://onlinelibrary.wiley.com/doi/10.1002/acr.23209/abstract
- ↑ 27.0 27.1 27.2 Giori NJ et al. Risk reduction compared with access to care: Quantifying the trade-off of enforcing a body mass index eligibility criterion for joint replacement. J Bone Joint Surg Am 2018 Apr 4; 100:539 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29613922
- ↑ 28.0 28.1 Hood BR, Cowen ME, Zheng HT et al Association of Aspirin With Prevention of Venous Thromboembolism in Patients After Total Knee Arthroplasty Compared With Other Anticoagulants. A Noninferiority Analysis. JAMA Surg. Published online October 17, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30347089 https://jamanetwork.com/journals/jamasurgery/fullarticle/2708020
Sterling RS, Haut ER. Should Aspirin Be Routinely Used for Venous Thromboembolism Prophylaxis After Total Knee Arthroplasty? Even the Authors of This Commentary Cannot Agree. JAMA Surg. Published online October 17, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30347046 https://jamanetwork.com/journals/jamasurgery/fullarticle/2708018 - ↑ 29.0 29.1 Evans JT et al. How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019 Feb 16; 393:655. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30782341 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32531-5/fulltext
- ↑ 30.0 30.1 Lewis S, Glen J, Dawoud D et al Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis. Lancet Haematology. Published:August 20, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31426937 https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(19)30155-3/fulltext
Koziel M, Lip GYH Venous thromboembolism prophylaxis strategies for patients undergoing elective total knee replacement. Lancet Haematology. Published:August 20, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31444125 https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(19)30164-4/fulltext - ↑ 31.0 31.1 Ohnuma T, Raghunathan K, Moore S et al. Dose-dependent association of gabapentinoids with pulmonary complications after total hip and knee arthroplasties. J Bone Joint Surg Am 2020 Feb 5; 102:221 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31804238
- ↑ 32.0 32.1 Hsieh CJ et al. Effect of outpatient rehabilitation on functional mobility after single total knee arthroplasty: A randomized clinical trial. JAMA Netw Open 2020 Sep 17; 3:e2016571 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32940679 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770729
- ↑ 33.0 33.1 Hamilton DF et al Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial. BMJ 2020;371:m3576 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33051212 PMCID: PMC7551789 Free PMC article https://www.bmj.com/content/371/bmj.m3576
- ↑ 34.0 34.1 Chen AT, Bronsther CI, Stanley EE et al The Value of Total Knee Replacement in Patients With Knee Osteoarthritis and a Body Mass Index of 40 kg/m2 or Greater. A Cost-Effectiveness Analysis. Ann Intern Med 2021. March 23. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33750190 https://www.acpjournals.org/doi/10.7326/M20-4722
- ↑ 35.0 35.1 Blom AW, Donovan RL, Beswick AD et al. Common elective orthopaedic procedures and their clinical effectiveness: Umbrella review of level 1 evidence. BMJ 2021 Jul 7; 374:n1511 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34233885 PMCID: PMC8262448 Free PMC article https://www.bmj.com/content/374/bmj.n1511
- ↑ Menon N, Turcotte J, Stone A et al. Outpatient, home-based physical therapy promotes decreased length of stay and post-acute resource utilization after total joint arthroplasty. J Arthroplasty. 2020;35(8):1968-1972 https://www.arthroplastyjournal.org/article/S0883-5403(20)30279-5/fulltext
- ↑ 37.0 37.1 Welsh RL, Graham JE, Karmarkar AM et al. Effects of postacute settings on readmission rates and reasons for readmission following total knee arthroplasty. J Am Med Dir Assoc. 2017;18(4):367.e1-367.e10 https://www.jamda.com/article/S1525-8610(16)30672-7/fulltext
- ↑ 38.0 38.1 CRISTAL Study Group. Effect of aspirin vs enoxaparin on symptomatic venous thromboembolism in patients undergoing hip or knee arthroplasty: The CRISTAL randomized trial. JAMA 2022 Aug 23/30; 328:719. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35997730 PMCID: PMC9399863 (available on 2023-02-23) https://jamanetwork.com/journals/jama/fullarticle/2795528
Chan NC & Bhandari M. Thromboprophylaxis after hip or knee arthroplasty. JAMA 2022 Aug 23/30; 328:712. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35997752 https://jamanetwork.com/journals/jama/fullarticle/2795552 - ↑ 39.0 39.1 Vassilaki, M, Kremers WK, Machulda MM et alDavid S. Long-term Cognitive Trajectory After Total Joint Arthroplasty JAMA Netw Open. 2022;5(11):e2241807. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36374499 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2798386
- ↑ 40.0 40.1 Monaco K Metformin Protective Against Joint Replacement in Type 2 Diabetes. Daily users saw lower risks for total knee, hip replacements. MedPage Today December 19, 2022 https://www.medpagetoday.com/endocrinology/diabetes/102293
Zhu Z, Huang JY, Ruan G et al Metformin use and associated risk of total joint replacement in patients with type 2 diabetes: a population-based matched cohort study. CMAJ December 19, 2022 194 (49) E1672-E1684 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36535678 Free article https://www.cmaj.ca/content/194/49/E1672 - ↑ 41.0 41.1 Goodman SM, Springer BD, Chen AF, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Care Res. 2022;74:1399-1408. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35718887
- ↑ 42.0 42.1 42.2 42.3 42.4 42.5 42.6 42.7 42.8 42.9 Hannon CP, Goodman SM, Austin MS et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons clinical practice guideline for the optimal timing of elective hip or knee arthroplasty for patients with symptomatic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy is ineffective. Arthritis Care Res (Hoboken) 2023 Nov; 75:2227. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37743767 https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr.25175