Perioperative Management in Total Knee Arthroplasty
Perioperative Management in Total Knee Arthroplasty
There are no universal indications for TKA. Yet, the preoperative pain scores and function profiles of patients undergoing TKA are consistent among United States surgeons. The decision to perform TKA is a risk-benefit analysis for each individual patient. The history, physical examination, and radiographic evaluation are essential tools in selecting patients for TKA. Management of patient expectations is critical. Patient satisfaction after TKA is reported to be between 81–89%, with only minor improvements the past 2 decades. Several risk factors are related to poor outcomes, and patients need to be counseled accordingly.
TKA is an elective procedure. Patients should be selected appropriately, counseled regarding the risks and benefits of surgery, and undergo preoperative medical clearance to ensure that risks of surgery are minimized. First, nonoperative interventions for knee arthritis should be exhausted (Table 1). Second, the patient's functional limitation and pain should be affecting their quality of life enough to warrant a surgical treatment. Third, radiographic evaluation of the knee should be consistent with the patient's functional limitation and pain. Patients with more severe radiographic arthritis have significantly better satisfaction scores after TKA; nearly 20% more patients with severe radiographic signs are more satisfied compared with those with mild to moderate radiographic signs of arthritis. If the etiology of the knee pain is not clear, especially in the setting of mild radiographic knee arthritis, diagnostic imaging of the hip or back as well as diagnostic anesthetic intraarticular injection(s) of the hip or knee, or both, can further delineate the source of the pain. Unlike the hip, there is little data correlating relief from a diagnostic anesthetic intraarticular knee injection with postoperative satisfaction scores.
Management of patient expectations increases patient satisfaction after TKA. Patients undergoing TKA are on average younger than in previous decades. Young age (i.e. <60 yr) is not a contraindication for TKA, but thorough evaluation and counseling are necessary, since younger patients have increased pain scores and postoperative opioid usage. Women have poorer functional outcomes and patient satisfaction than men. Other independent risk factors for poor functional outcomes and patient satisfaction include poor mental health (e.g., depression, delirium, dementia), and severe preoperative or postoperative pain. A body mass index greater than 30 (i.e., obese), uncontrolled diabetes, and smoking each reduce functional scores and are associated with a high complication rate, including a venous thromboembolic event or infection. Therefore, smoking cessation, weight loss, and proper management of diabetes should be considered modifiable risk factors, if possible, and should be emphasized during preoperative management.
Patient Selection and Counseling
There are no universal indications for TKA. Yet, the preoperative pain scores and function profiles of patients undergoing TKA are consistent among United States surgeons. The decision to perform TKA is a risk-benefit analysis for each individual patient. The history, physical examination, and radiographic evaluation are essential tools in selecting patients for TKA. Management of patient expectations is critical. Patient satisfaction after TKA is reported to be between 81–89%, with only minor improvements the past 2 decades. Several risk factors are related to poor outcomes, and patients need to be counseled accordingly.
TKA is an elective procedure. Patients should be selected appropriately, counseled regarding the risks and benefits of surgery, and undergo preoperative medical clearance to ensure that risks of surgery are minimized. First, nonoperative interventions for knee arthritis should be exhausted (Table 1). Second, the patient's functional limitation and pain should be affecting their quality of life enough to warrant a surgical treatment. Third, radiographic evaluation of the knee should be consistent with the patient's functional limitation and pain. Patients with more severe radiographic arthritis have significantly better satisfaction scores after TKA; nearly 20% more patients with severe radiographic signs are more satisfied compared with those with mild to moderate radiographic signs of arthritis. If the etiology of the knee pain is not clear, especially in the setting of mild radiographic knee arthritis, diagnostic imaging of the hip or back as well as diagnostic anesthetic intraarticular injection(s) of the hip or knee, or both, can further delineate the source of the pain. Unlike the hip, there is little data correlating relief from a diagnostic anesthetic intraarticular knee injection with postoperative satisfaction scores.
Management of patient expectations increases patient satisfaction after TKA. Patients undergoing TKA are on average younger than in previous decades. Young age (i.e. <60 yr) is not a contraindication for TKA, but thorough evaluation and counseling are necessary, since younger patients have increased pain scores and postoperative opioid usage. Women have poorer functional outcomes and patient satisfaction than men. Other independent risk factors for poor functional outcomes and patient satisfaction include poor mental health (e.g., depression, delirium, dementia), and severe preoperative or postoperative pain. A body mass index greater than 30 (i.e., obese), uncontrolled diabetes, and smoking each reduce functional scores and are associated with a high complication rate, including a venous thromboembolic event or infection. Therefore, smoking cessation, weight loss, and proper management of diabetes should be considered modifiable risk factors, if possible, and should be emphasized during preoperative management.
Source...