Tag Archives: knee surgical outcomes

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 in surgical outcomes.

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 replacement surgery, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Can Weight Loss Before Total Knee Arthroplasty 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 knee surgical 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 knee surgical outcomes.

If you’d like to discuss obesity or weight concerns prior to your total knee arthroplasty, or just want to learn more about the knee replacement 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.

Should You Consider Partial Knee Replacement?

kneeA partial knee replacement, also known as unicompartmental knee arthroplasty (UKA), can be a very appealing alternative to a total knee replacement for those suffering from severe knee pain. UKA is less-invasive, more cost-effective, promises the preservation of important bone, ligaments, and knee function, and provides an enhanced postoperative recovery. But is it the right procedure for you? The Medial Unicompartmental Arthroplasty of the Knee article by Jennings, J. M., Kleeman-Forsthuber, L. T., and Bolognesi, M. P. takes a closer look.

In years past, isolated anteromedial osteoarthritis or spontaneous osteonecrosis of the knee were the only primary indications for partial knee replacement. Patients needed to be under age 60, less than 180 pounds, avoiding heavy labor, and experiencing minimal baseline pain, among other restrictions, which left only 6% of patients meeting all parameters.

Over the last two decades, however, studies have shown that the traditional indications for UKA can be expanded significantly with excellent results still obtained. Focused preoperative examination and imaging are needed to identify appropriate surgical candidates, but once selected, patients who undergo UKA experience faster recovery, improved kinematics, and better functional outcomes compared with total knee replacement, also known as total knee arthroplasty (TKA).

What’s more, the ten-year survival rates for partial knee replacement in cohort studies have shown to be greater than 90% with outcomes after conversion to total knee replacement being very similar to outcomes for revision TKA. While this information is encouraging, survivorship data should continue to be scrutinized and take both patient factors and functional outcomes into careful consideration.

As more long-term data on partial knee replacement becomes available, it will further guide clinicians in counseling patients on whether UKA is the right procedure for them. When performed at high-volume centers with advanced surgical techniques and on the correct patient populations, partial knee replacement has the potential to be a great alternative to total knee replacement.

If you want to learn more and discuss whether or not UKA is the right procedure for you, 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. 

Is Yoga Safe After Joint Replacement Surgery?

yogaIf you’re one of the 35 million people in the US practicing yoga, you may be wondering if you can return to your practice after joint replacement surgery. Or maybe you’ve heard about the benefits of yoga and are interested in starting it up postoperatively. But is yoga safe and recommended for your new joint? Carried out with awareness of your limitations after surgery, yoga can be a very useful tool in the rehabilitation process.

Physical activity, including yoga, is an important part of recovery after joint replacement surgery. It helps to restore function and mobility in your joint, ease pain and swelling, and more. Yoga, specifically, helps to strengthen the muscles surrounding your new joint, increase flexibility, reduce stress, and can help you become more aware of your body’s alignment and posture.

Consult with Your Orthopedic Surgeon First. Remember, your situation is unique to you, and no one knows the condition of your new joint better than your orthopedic surgeon. Whether or not your orthopedic doctor recommends yoga can depend on how your joint replacement surgery went, how your recovery is expected to go, and what kind of restrictions you may have. For example an anterior hip replacement would allow for unrestricted yoga a few months after surgery. However a posterior approach hip replacement would require restrictions that would limit flexion poses like down dog child’s pose. It’s extremely important to consult with your orthopedic doctor before starting any type of physical activity, including yoga.

Talk to Your Yoga Instructor. If your orthopedic doctor gives you the go-ahead, it’s wise to also talk with your yoga instructor(s). Qualified instructors will know about the anatomy and movement of the hip and knee. They should be able to give you advice on what poses and movements will be beneficial, and what poses and movements you may need to avoid, either permanently or just while you heal. Modifications will most likely be necessary for a safe postoperative yoga practice. Your instructor can also help you correct your alignment to stay safe and provide help with any props.

Choose the Right Practice Style. Early on in the recovery, a restorative yoga class may be beneficial. Restorative yoga classes are typically slow and gentle, use a lot of helpful props, and focus on relaxation. Once you receive an okay from your orthopedic doctor to do so, any style of yoga, including Vinyasa or Bikram yoga, is possible as long as proper modifications are made to your practice.

Trust Yourself. After joint replacement surgery, it’s even more important to listen to your body’s cues while practicing yoga to maintain proper alignment and protect your joint replacement. Remember, never force yourself into a pose that’s painful or feels wrong.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more. Contact Dr. Stickney to return to your healthy, pain-free lifestyle.

Meniscectomy Biomechanics and Clinical Outcomes

Stickney_kneeThough the knee meniscus is just a small part of the knee, it plays a very important biomechanical role in regular knee function including load bearing, shock absorption, and joint stability. Unfortunately, meniscus tears are one of the most common injuries orthopedic surgeons encounter, and thus, partial meniscectomy is one of the most common procedures performed.

But not all tears require surgery. In fact, according to Biomechanics and Clinical Outcomes of Partial Meniscectomy by Freeley, Briant T., MD; Lau, Brian C. MD published in Journal of the American Academy of Orthopaedic Surgeons, an MRI study found that 61% of aging asymptomatic patients had a meniscus tear identified on imaging.

Because orthopedic physicians must identify patients who will likely benefit from a partial meniscectomy, it’s vital that they understand the biomechanical implications and knee surgical outcomes of partial meniscectomy. As a patient, it’s always best to be educated on the latest research as well, so you can be an advocate for your own health.

For cases that do require partial meniscectomies, there has been extensive research conducted evaluating the biomechanical consequences and knee surgical outcomes. It was found that as the portion of the meniscus that is removed increases, the greater the contact pressure experienced by the Articular cartilage attached to the bone. This can lead to altered knee mechanics and early cartilage wear. However, leaving a mobile meniscus tear untreated in an otherwise healthy knee, which is creating mechanical symptoms of popping or locking, can result in further tearing of the meniscus and early wear of the cartilage above and below the tear. This leads to early arthritis.

It’s important to note that the use of partial meniscectomy to manage degenerative meniscus tears in knees with mild preexisting arthritis and mechanical symptoms can be beneficial; however, its routine use in the degenerative, arthritic knees is not likely to provide long term benefit. Physical therapy may be more successful in this situation . In younger age groups, partial meniscectomies may provide long-term symptom relief, earlier return to activity, and lower revision surgery rate compared with meniscal repair. If a large peripheral tear in the vascular part of the meniscus is present in a young person this would be where meniscal repair can result in a near normal knee long term.

Perhaps the most valuable takeaway from this biomechanical study is a greater understanding of the implications of meniscectomy. Orthopedic surgeons must subscribe to the current principle of maintaining as much meniscal tissue as possible. Partial meniscectomy remains a mainstay of treatment for unstable, central meniscus tears and offers favorable clinical outcomes with a low risk to patients when done correctly. Treatment should always be patient specific in a shared decision-making process with the patient.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more. Contact Dr. Stickney to return to your healthy, pain-free lifestyle.

Home Exercise vs. Outpatient Physical Therapy Following Total Knee Arthroplasty

at-home-exerciseDr. Jeff Stickney, a Kirkland orthopedic surgeon, can help you determine whether outpatient physical therapy or home exercise is better suited for your recovery following total knee arthroplasty. He specializes in orthopedic surgeries and health care including total knee replacement, joint replacement, sports medicine, and more. Contact doctor Stickney’s office today to learn more.

Outpatient physical therapy (OPT) is the practice of visiting a healthcare facility such as a clinic or office to perform exercises to treat musculoskeletal problems. This strategic physical activity with the guidance of a physical therapist is a common means of both injury prevention and recovery from sports injuries, because it helps patients address joint pain and regain range of motion. While OPT has a long history as a fundamental part of proper treatment plans for recovery and maintenance following total knee arthroplasty (TKA), recent studies have questioned the need for OPT following total knee replacement surgery.

A new study, “Home Exercises vs. Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change”, explored the “health safety, efficacy, and home economics of routine home exercises following TKA compared with OPT immediately afterward”. It compared 251 patients who were prescribed OPT following TKA, and 269 who followed a home exercise program instead after their operations. Ultimately the study found that patients who practice home-directed exercise programs in place of formal OPT have seen comparable outcomes, and can even experience significantly reduced costs. They concluded that while some patients required OPT following their home exercise program, the majority did not.

As the study above highlights, the use of home-healthcare for knee postoperative knee rehabilitation following TKA is increasing. Many other publications have reported the same, claiming that supervised rehab such as OPT may not be necessary for optimal recovery following TKA. However, another recent study explored the association between physical therapy (PT) and functional improvements for patients in home settings. This study also explored factors related to PT utilization, meaning it identified the reasons patients did or did not use their home healthcare.

The study found that lower home-healthcare utilization was correlated with worse recovery. Participation in home-healthcare was generally lower for patients who had the help of physical therapists from rural agencies that came to their home. Medical complexity – such as depressive symptoms or dyspnea – factored into the patients’ levels of participation too.

Comparing the results of both studies, we can conclude that home exercise for joint replacement postoperative rehabilitation is effective, however it’s important that patients actually follow through on utilizing the home practice, performing the necessary amount for an optimal recovery. We can also see that those with medical complexities may need additional monitoring to verify that they perform the necessary amount of home PT sessions to achieve optimal knee surgical outcomes for a complete recovery.