ArthroplastyManagement post -op

Mike Gross

Risk

Management of surgical patients is all about risk identification and Mitigation.

Pre-op assessment of Arthroplasty patients is essential to identify risk factors that can be mitigated prior to surgery.

Pre-op assessment allows for a better post op monitoring program for complications

Know factors that increase Risk

Diabetes

BMI >40

Length of Surgery

Smoking

malnutrition

ALL INCREASE THE RISK OF INFECTION.

DVT Prophylaxis

DVT is not clinically measureable nor detectable

DVT is associated with PE’s

DVT prophylaxis is a Billion $ industry

Aspirin is now seen as safe for low risk patients

It is a proxy for the prevention of PE’s

The incidence of PE’s as a cause of death has stayed static

An editorial in the JBJS(br) suggested that Industry had tainted the whole process

Current Practice

Risk assessment for DVT Prophylaxis : Previous DVT, known factors, obesity, diabetes, cancer, low activity all support LMWH or oral medications

Low risk patients treated with ASA 81mg bid

Emphasis on early mobilisation and discharge should decrease DVT post op.

Other complications

Nerve damage : Hip replacements with traction to sciatic nerve, resulting in foot drop. Rare, <1%, but prevalent.

Can also be associated with prior spinal disease and nerve root impingement

Requires a 2 year wait for full recovery if there is axonal interuption.

EMG and Nerve Conduction studies at 6 weeks give one an indication of potential recovery. Repeat at 3 months.

General complications

Stoke, MI, PE are all around 0.03% in high volume centers that screen patients pre-op to optimise their physical condition, eg treat anaemia, smoking cessation etc.

Specific complications relate to pre-op status, COPD associated with increased general complications and opioid sensitivity.

Changing Practice

When I started, arthroplasty patients stayed in hospital for weeks

Now I am looking for 1 day stays for healthy patients

In the USA out patients surgery is now supported for low risk patients and some insurance companies are only paying for day surgery for knee replacements.

How does this affect post op management

The Discharge Gap

US practice is to have ongoing contact between patients and providers to monitor home progress and decrease both complications and unnecessary return visits

But we do not know how patients do in the first week following surgery.

Family Doctors, now a rare species in NS, may also not get notification of discharge for a week

Discharge Gap

This is a fertile area for the use of technology to monitor patients at home

Most patients get too much information on discharge and forget a lot

Common issues:

Pain, increasing usage of analgesics and a requirement for more

Heat, redness and swelling.

Pain Management

Starts in hospital, early movement and adequate pain control prior to discharge

Knee replacements often swell up more on day 2

2 intrinsic factors that predict poor pain control : Depression and Anxiety (assoc with Catastrophic ideation)

Pre-op Opioids associated with poor pain control and 33% prolonged usage post op

Infection

Should be 1% or less of all arthroplasties, best figures are 0.03% for all patients in high volume centers

High risk patients need closer following

Early intervention with IV antibiotics and wound washouts can control an early infection.

Pre-op risk assessment should guide ones post op oversight of such patients

The role of Physiotherapy

Hip Replacements:Depending on the approach, different muscle groups need strengthening when the soft tissues are healed;

Posterior approach associated with a higher risk of dislocation, need strengthening of external rotators and glutes

Lateral and Anterior approaches require more abductor strengthening exercises, eg side lifts.

Physio in Knees

The most important issue for knee Range of motion is pain and swelling

Physio needs to augment successful pain management, they cannot control pain or make progress with ROM if pain is controlling the agenda

Once a patient has pain control they should be established on a home ROM program with Straight leg raising for Quads.

The more the patient the better the recovery.

Expectations

Patients need to know what to expect from the surgery.

Many surgeons are variable in both discussing expectations and in delivery

Hip Arthroplasty : Best result is the forgotten hip

Knee Arthroplasty : 20% of patients dissatisfied with results, Why?

Summary

Joint Arthroplasties are increasing in numbers

They can be prevented with weight reduction for knee replacements

They are increasingly being done as outpatients

Small incision surgery and better soft tissue management result in less pain.

Complications should be rare, Opioid tolerance is a key issue for post op pain management