All posts by Dr. Stickney

Should There Be Strict BMI Cutoffs for TKA and THA?

happy senior couple hiking on the mountainDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

Recently we posted a blog about candidacy for and outcomes of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) in morbidly obese patients who underwent pre-operative weight loss. Operating on obese patients for TKA and THA continues to be a hot button topic of risk versus reward.

Two well-respected orthopedic authorities, recently faced off to have a deeper conversation about whether or not orthopedic surgeons should have strict BMI cutoffs for performing primary TKA or THA. Benjamin F. Ricciardi, MD engaged Thomas K. Fehring, MD, from OrthoCarolina and Nicholas Giori, MD and PhD, a Stanford University professor, to face off. Highlights are summarized below.

Q: To what degree does the evidence support a strict BMI cutoff to determine eligibility for primary TKA and THA?

Dr. Fehring noted many Americans (35%) are obese and the association between patients with a BMI above 40 and surgical complications/infection is irrefutable. He recommends looking at big data such as Medicare or Veterans Affairs, meta-analysis, and position statements by specialty medical societies. All findings to date underscore the need to have a strict cutoff, but Dr. Fehring noted it’s important to develop weight loss strategies for patients prior to arthroplasty. 

Dr. Giori agreed that obesity is undeniably related to complications, but BMI is a weak risk factor compared to others that are commonly accepted (such as heart and metabolic disorders).

Q: Given the expansion of strict BMI cutoffs at the administrative level, how should safety (non-maleficence) be balanced against access to care?

Dr. Giori said that while BMI cutoffs are well-intended, the ones currently used have the effect of arbitrarily rationing care without medical justification. Also, he feels it disproportionately affects minorities, women and patients in low socio-economic classes. In his opinion, the decision should be based on joint decision making between the doctor and the patient. Risk adjustments in payment models (for doctors’ compensation) would help in the future.

Dr. Fehring agreed with many of the points, but at a certain point the risk outweighs the benefit, and attempting to operate on all patients regardless of BMI becomes dangerous. Keeping his “do no harm” obligation in mind, Dr. Fehring stated a BMI cutoff of 40 as a reasonable goal for patient safety.

Q: If a patient with morbid obesity is to undergo arthroplasty, what steps should be taken before surgery to make hip or knee arthroplasty safer?

Dr. Fehring recommended the patient be in the best possible health they can be prior to elective surgery to avoid complications. An optimization program, factoring in body weight, blood glucose control, serum albumin, and smoking status are part of his clinic’s protocol; patients get tools to meet and stick to set goals before getting surgery. It’s not just about treating the knee or hip; it’s about treating the whole patient as well, he said.

Dr. Giori recognized that optimization programs can help and his clinic also offers one, but the best that can be done regarding obesity is encouragement and education, and referring the patient to a structured weight-reduction program. On the flipside, the patient should do his or her best to lose weight to get below a given BMI threshold. From there, doctor and patient can create a shared decision-making plan that may or may not involve surgery.

If you’d like to discuss weight concerns prior to your total knee or hip, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Can Weight Loss Before Total Knee Arthroscopy Help?

Senior man having medical exam.When obese patients undergo total knee arthroplasty (TKA), many surgeons require or request preoperative weight loss. A group of researchers sought to determine the amount of weight loss needed in this patient population, to improve TKA operative time, length of stay, discharge to a rehab facility, and functional improvement after surgery. This is the first known study to look exclusively at obese patients to understand how preoperative weight loss might improve outcomes after TKA.

Those considered morbidly obese have a body mass index (BMI) of 40 or higher. This study looked at 203 patients with a BMI of 40 or more. They were evaluated 90 days before their TKA, and again immediately preceding TKA, to assess weight loss. Of those who lost weight preoperatively, 41% had lost five or more pounds, 29% lost 10 or more pounds, and 14% lost 20 or more pounds.

Losing 10 or less pounds before surgery made no difference in operative time, length of stay, the need for discharge to a rehab facility, or post-operative functional improvement. However, the preoperative loss of 20 pounds or more showed benefits: It lowered the odds of discharge to a rehab facility, and was associated with a shortened length of stay. There were, however, no significant differences in surgery times or functional improvements for those who lost 20-plus pounds.

A longer stay in the hospital or discharge to a rehab facility is a driver of higher costs in primary total knee arthroplasty. Preoperative weight loss may reduce overall costs. The need for Discharge to a rehab facility is also correlated with an increased rate of post-operative infection. In the future, this study could help surgeons target a specific level of weight loss prior to TKA, for their patients to improve outcomes.

If you’d like to discuss weight concerns prior to your total knee arthroplasty or just want to learn more about the procedure, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total and partial knee arthroplasty, exercise and health, and more.

After One Joint Wears Out, Will More Go?

Hip, back and spinal problems in young ages.Here’s a question I’m often asked by patients: “If one of my joints has worn out, how likely are the others to go?” A recent publication from the Osteoarthritis Initiative (OAI) lends some insights into this question. The study, found in the Aug. 12, 2019 issue of Clinical Orthopaedics and Related Research, is the first of its kind. The likelihood of undergoing a 2nd Arthroplasty (Joint replacement) after hip or knee replacement had not previously been evaluated.

The authors prospectively asked 2 questions.  “What is the likelihood of second Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) after primary TKA or THA?” and “What risk factors are associated with undergoing addition joint replacement. The study identified 332 patients who underwent primary TKA and another 132 who underwent THA across five OAI-participating centers in the U.S., who hadn’t previously had a THA or TKA. The patients were followed for 8 years after their primary joint replacement.

  • The incidence of contralateral (opposite Knee) TKA after primary TKA was 40%
  • The incidence of THA after any TKA was 13%
  • The incidence of contralateral (opposite) THA after primary THA was 8%
  • The incidence of any TKA after primary THA was 32%

As for the second question in the study: Risk factors for undergoing contralateral TKA were younger age and a loss of medial joint space with a varus angulation, or bow leg deformity.

The conclusion is clear: Patients who underwent TKA or THA for osteoarthritis had a relatively high rate of subsequent joint arthroplasty. There’s no question that osteoarthritis is common and debilitating, and often it affects more than one large, weight-bearing joint.

If you need a joint replacement or want to learn more about the procedure, recovery process and quality-of-life prognosis, please contact our office. We’ll help you return to your healthy, pain-free lifestyle. Dr. Stickney, a Kirkland orthopedic surgeon, is a knee and hip expert specializing in joint replacement surgery.

Less Pain, Less Opioid Use After Total Knee Arthroscopy

Senior man on his mountain bike outdoorsDr. Stickney, a Kirkland orthopedic surgeon, is a knee expert specializing in new knee surgery procedures, total knee replacementsports medicine, and more.

Managing postsurgical pain after total knee arthroscopy (TKA) is critical to successful surgical outcomes including patient recovery, rehabilitation and overall satisfaction. Local infiltration analgesia (LIA) with anesthetic agents is shown to improve pain and reduce morphine consumption. It also shortens the length of hospital stays compared with using peripheral nerve blocks, which can hinder mobility. A randomized control PILLAR study conducted by Michael A. Mont, M.D., Walter B. Beaver, M.D., Stanley H. Dysart, M.D., John W. Barrington, M.D., and Daniel J. Gaizo, M.D. took a closer look at the efficacy of LIA with Liposomal Bupivacaine (LB) in improving patient pain scores and reducing opioid use after TKA.

Here, the study team compared the effects of LIA with or without LB on pain scores, opioid consumption including opioid-free patients, time to first opioid rescue, and safety after primary unilateral total knee arthroscopy.

The study involved 140 TKA patients randomized to LIA with LB to 266mg/20mL (admixed with bupivacaine HCI %0.5, 20mL) or LIA with Bupivacaine HCI %0.5, 20mL. Standardized infiltration techniques and standardized multimodal pain protocol were used. Co-primary efficacy endpoints were the area under the curve (AUC) visual analog scale pain intensity scores 12-48 hours post-surgery, and total opioid consumption 0-48 hours post-surgery.

Findings were notable. AUC 12-48 post-surgical visual analog pain intensity scores were 180.8 with LB, and 209.3 without the use of LB. Total opioid consumption 0-48 hours post-surgery was 18.7mg with and 84.9 without LB. Significant differences favoring LB were observed for the percentage of opioid-free patients (p<.01) and time to first opioid rescue (P=.0230).  In the TKA setting, LIA with LB administered with optimal techniques significantly improved post-surgical pain, opioid use and time to first opioid rescue, with more opioid free patients and no unexpected safety concerns.

My past TKA patients will tell you the SwiftPath protocols I utilize are well aligned to this study. With a reduction in (or no) opioids after TKA, less post-operative pain and overall patient satisfaction, the use of LIA with LB is well-supported.

If you are a total knee arthroscopy candidate and want to learn more about treatments such as LIA with LB, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Considering Injections for Knee Osteoarthritis

kneeDr. Stickney, a Kirkland orthopedic surgeon, is a knee expert specializing in new knee surgery procedures, knee reconstruction surgeryexercise and health, and more.

Recently, the prevalence of knee osteoarthritis (OA) has climbed swiftly because of an increase in human life expectancy, physical activity, and obesity. With knee OA on the rise, doctors are in search of the best treatment for their patients. As a result, interest in intra-articular hyaluronic acid (HA) injections and platelet-rich plasma (PRP) injections has been rapidly increasing. But which treatment is the most effective, if any? A study on injections for knee OA conducted by Kuan-Yu Lin, M.D., Chia-Chi Yang, Ph.D., Chien-Jen Hsu, M.D., Ming-Long Yeh, Ph.D., and Jenn-Huei Renn, M.D., Ph.D. takes a closer look.

The study’s purpose was to prospectively compare the efficacy of intra-articular injections of PRP and HA with a sham control group (using normal saline solution [NS]) for knee OA in a randomized, dose-controlled, placebo-controlled, double-blind, triple-parallel clinical trial.

The clinical trial involved 53 patients with a total of 87 OA knees who were randomly assigned to one of three groups receiving three weekly injections of either 1. Leukocyte-poor PRP (31 OA knees) 2. HA (29 OA knees) or 3. NS (27 OA knees). To analyze the results, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and International Knee Documentation Committee (IKDC) subjective score were utilized and collected at baseline and at one, two, six, and 12 months after treatment.

The results? While all three groups showed statistically significant improvements after one month, only the PRP group reached the minimal clinically important difference in the WOMAC score at every evaluation and the minimal clinically important difference in the IKDC score at six months, while sustaining significant improvement in both the WOMAC score and IKDC score at 12 months. Also interestingly enough, there was no significant difference in the functional outcomes between the HA and NS groups at any point in time.

The most significant finding of this study was that intra-articular injections of leukocyte-poor PRP can in fact provide clinically significant functional improvement for at least one year in patients with mild to moderate osteoarthritis of the knee. If you want to learn more and discuss whether or not PRP injections are the right treatment for you, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

A New Chapter in Knee Implants

kneeappointmentDr. Stickney, a Kirkland orthopedic surgeon, is a knee expert specializing in new knee surgery procedures, knee reconstruction surgery, sports medicine, and more.

New developments in biomedical engineering and robotics have recently opened a new chapter in high-performance knee implants with the creation of the JOURNEY II XR Active Knee System, which combines an implant designed to restore the stability and natural motion of the human knee with low-friction materials that may help extend the longevity of the implant itself. We are proud to be offering this new product to our patients.

Conventional Knee Implants
All knee implants are faced with the challenge of mimicking the normal swing-and-rotate motion of the knee while making sure the joint remains stable and has durability after surgery. Conventional knee implants have attempted to recreate this natural, fluid motion of the knee with a rotating platform or plastic insert design that allows flex and rotation. Unfortunately, both of these options force the muscles around the patient’s joint to work harder as they adjust to the joint’s new pattern of movement. The anterior cruciate ligament and sometimes the posterior cruciate ligaments are removed with conventional Knee designs. These ligaments aid in position sense or proprioception. There have been many different designs of the plastic insert to replicate the function of these ligaments. The JOURNEY II XR is designed to keep the ligaments and build the knee around them. This does make the technical aspect of inserting the knee more complicated. It will also provide a much more natural feeling knee with activity.

The JOURNEY II XR Knee Implant pays attention to anatomical detail, more accurately replicating the true anatomy of the knee. With an anatomically molded femoral component (bottom of the thigh bone) and two plastic inserts, the JOURNEY II XR active knee system recreates the knee’s original shape and range of motion, preventing surrounding muscles and other tissue from straining to compensate for unfamiliar stress. A U-shaped tibial base plate (top of the shin bone in the lower leg) fits around the healthy ACL and PCL, allowing them to function as they normally would rather than being removed.

Knee surgery patients with the JOURNEY II XR total knee system will likely feel less of a difference from a normal healthy knee, and greater stability. The end result may be a quicker recovery, better function, and greater satisfaction. While some may benefit, not all patients qualify for the JOURNEY II XR Knee implant. For instance, many people have ruptured their anterior cruciate ligament in their lifetime, or have developed significant angular contraction of ligaments around the knee and the JOURNEY II XR would not be appropriate in these patients. Please consult with orthopedic expert Dr. Stickney to evaluate your condition and implant options.