August 19, 2021

The procedure improves the quality of life for patients — including older individuals with high BMIs.

EFFECTIVE INTERVENTION New research says that in many cases, surgeons are less hesitant to treat osteoarthritis with total knee replacement surgery.

A new study finds that treating patients who have knee osteoarthritis with total knee replacement (TKR) surgery is more cost-effective than other treatments, no matter the age or weight of the patient.

Knee osteoarthritis affects more than 14 million U.S. adults, many of whom have extreme obesity, defined by body mass index (BMI) greater than 40 kg/m2. While TKR is often recommended to treat advanced knee osteoarthritis, many surgeons are hesitant to treat the condition surgically in extremely obese patients due to concerns about increased risks of tissue infection, poor wound healing and implant failure. The study, published in the June 2021 Annals of Internal Medicine, sought to shed light on this quandary.

Researchers from Brigham and Women's Hospital in Boston, with collaborators from Yale and Boston University Schools of Medicine, employed an established, validated and widely published computer simulation called the Osteoarthritis Policy (OAPol) Model to quantify the tradeoff between the benefits and adverse events of forgoing versus pursuing TKR with these patients, while also taking into consideration the costs. They found TKR is a cost-effective treatment across older and younger age groups alike who have the condition — including extremely obese patients. The study concluded, "From a cost-effectiveness perspective, TKR offers good value in patients with a BMI of 40 kg/m2 or greater, including those with multiple comorbidities."

Specifically, they found TKR increased quality-adjusted life-years (QALYs) by 0.71 and lifetime medical costs by $25,200 among patients with 40+ BMIs who were aged 50 to 65 years, resulting in an incremental cost-effectiveness ratio (ICER) of $35,200. For similar patients older than 65 years, QALYs increased by 0.39 and lifetime medical costs by $21,100, resulting in an ICER of $54,100. For 40+ BMI patients who also had diabetes and cardiovascular disease, ICERs were below $75,000 per QALY. "At a $55,000-per-QALY willingness-to-pay threshold, TKR had a 100% and 90% likelihood of being a cost-effective strategy for patients aged 50 to 65 years and patients older than 65 years, respectively," the study says.

The authors say that patients with extreme obesity enjoy substantial pain reduction from TKR, which can in turn lead to improvements in QALYs. They added that their findings could also help reduce concerns about the value of TKR in younger patients with 40+ BMIs.

A Hospital for Special Surgery study says duloxetine may reduce opioid use while improving pain management.

BEYOND THE BLOCK Because regional blocks only provide relief for total knee patients for a couple days, researchers are examining the benefits of duloxetine for extended pain management.

Researchers at the Hospital for Special Surgery (HSS) in New York City say cumulative opioid use was reduced by 30% in a patient group that received the antidepressant duloxetine after total knee arthroplasty (TKA) compared with patients who received a placebo.

Patients who received duloxetine also reported higher pain management satisfaction and less pain interference with mood, walking, normal sleep and work activities, according to the study, which was presented at the 2021 Spring American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting.

"Previous research has shown us how to keep most patients relatively comfortable for the first one to two days after TKA," says principal investigator Jacques Ya Deau, MD, PhD, an anesthesiologist at HSS. "However, patients often have significant and troubling pain during the first two weeks, once the nerve blocks wear off. They often take large amounts of opioids. It is important to reduce postoperative opioid use without increasing pain or worsening the patient experience."

In the study, patients took 60 mg of oral duloxetine or a placebo once daily for 14 days after surgery, and answered questions on postoperative days one, two, seven, 14, six weeks and 90 days. The pain management regimen also included acetaminophen, ketorolac, meloxicam and oxycodone as needed. Numerical rating scale (NRS) scores for pain management, opioid consumption, patient satisfaction and questions based on the Brief Pain Inventory were collected.

Duloxetine was found to be superior to placebo in terms of reducing opioid use, increasing patient satisfaction and mitigating the effect of pain on mood, walking, working and sleeping. It was found of equal efficacy to placebo for reducing pain.

"Duloxetine, given on the day of surgery and once daily for 14 days afterward, reduces opioid use by about 30%," says Dr. Ya Deau. "Patients receiving duloxetine are more satisfied with their pain management, and pain interferes less with their activities and mood."

Dr. Ya Deau adds that future research could examine the optimum duration of therapy and determine whether duloxetine is useful for other orthopedic procedures. "We also need to try to understand barriers to adoption of duloxetine as a postoperative analgesic," he says.

Patients need to protect their knees after surgery to achieve optimal recovery.

Credit: Bone Foam Inc.
Following a knee replacement, the Zero Degree Knee maintains optimal postoperative knee extension.

Knee replacement surgery can help relieve pain and restore function in severely diseased knee joints. This procedure involves cutting away damaged bone and cartilage from the thighbone, shinbone, and kneecap and replacing it with an artificial joint prosthesis. The most common reason for knee replacement surgery is to relieve severe pain caused by osteoarthritis. People who need knee replacement surgery usually have problems walking, climbing stairs and getting in and out of chairs. Some also have knee pain even at rest.

For most people, knee replacement provides both pain relief and improved mobility as well as an overall better quality of life. Currently, more than 90% of modern total knee replacements are still functioning 15 years after the surgery.

Following the orthopedic surgeon's instructions after surgery and taking care to protect the new knee replacement are important ways patients can contribute to the final success of their TKA surgery. Significant among the ways to properly treat the postoperative knee are special positioners that alleviate pain and aid in the healing process.

The Zero Degree Knee by Bone Foam maintains optimal postoperative knee extension during their total knee surgery journey. This surgeon designed positioner helps patients recover faster by achieving and maintaining terminal knee extension after joint replacement and ACL surgery.

Key benefits can include: improved range of motion, faster return to activities of daily living, and lower need for outpatient physical therapy.

The patient may experience less complications and reduce the likelihood of flexion contracture by elevating the foot and controlling rotation at the hip. The Zero Degree Knee provides a safe and consistent tool for home therapy and eliminates the need for bulky, inconsistent and unstable bed pillows.

Ultimately, the goal is to return to everyday activities. Following all of the surgeon’s postoperative instructions, maintaining postoperative knee extension contributes to an expedited recovery by maximizing knee range of motion (ROM) and returning to pre-surgery activity.

Note: For more information, please go to www.bonefoam.com

Simple digital interventions could pay off big for patients, providers and facilities.

A recent study from Penn Medicine in Philadelphia shows that monitoring patients remotely could lead to a significant decline in rehospitalization after joint replacements.

The study, published in JAMA Network Open, enrolled 242 total hip and total knee replacement patients over a period of 14 months. The patients were randomly placed into two groups: one receiving the standard of care at their hospitals, and the other enrolled in a “hovering” program powered by a Penn-developed software platform called Way to Health. Penn Medicine describes the hovering program as keeping tabs on patients’ recovery through wearable activity trackers, text messages detailing postoperative goals and milestones, pain score tracking and easily accessible remote connections with clinicians.

Researchers sought to determine whether this automated hovering over patients would lead to a drop in readmissions, and an increased ability for providers to address postoperative issues remotely before they require hospitalization. The intervention involved monitoring the patient postoperatively for 45 days. Penn Medicine says hovering brought about a "fourfold decline" in readmission rates. Just 3% of "hovered" patients required readmission, while 12% of the non-hovering group did.

"Hospital readmission is a metric of low-quality care and recovery and high cost for patients and healthcare providers," says study co-author Eric Hume, MD, FAAOS, FACS, an associate clinical professor of orthopedic surgery and director of quality and safety in orthopedic surgery at Penn Medicine. "Clinicians always respond to poor quality, of course, but accountable care organizations and those working under bundled payment agreements are very interested in value — the ratio of quality over cost. Work like this points to the benefit of technology as a way to support quality care."

"There are great opportunities for health systems and clinicians to improve the quality and value of care for patients getting hip and knee joint replacement surgery, and some of the most important advances are focused on what happens when patients return home," adds the study’s lead author Shivan Mehta, MD, MBA, MSHP, an associate chief innovation officer at Penn Medicine. "Technology, behavioral science insights and care redesign can help to improve care at home and prevent patients from coming back to the hospital unnecessarily."

The Penn researchers believe expanding the duration of the hovering program could improve outcomes. "It would be interesting to see what happens to activity levels in the months after the 45 days immediately post-discharge that we studied this time," says Dr. Mehta.

Study finds decreased length of stay and increased range of motion in patients.

New research shows that a rapid recovery protocol (RRP) leads to decreased length of stay (LOS) and increased range of motion (ROM) in the 12 months after total knee arthroplasty (TKA).

The conclusion is the result of examining the cases of 323 patients who underwent TKA performed by a single orthopedic surgeon emdash lead author Vinod Dasa, MD, FAAOS, who practices at LSU Health and Oschner Medical Center-Kenner in New Orleans. Of those patients, 129 were treated with a standard recovery protocol (SRP) in the year following their procedures, while 124 were treated with RRP.

SRP includes a femoral nerve block, spinal anesthesia, multimodal analgesia and little patient education prior to surgery. RRP includes engaging and educating patients about the procedure, freezing nerves around the knee one week preoperatively, using an adductor nerve block during the surgery, quick enrollment in postoperative physical therapy and multimodal pain management that limits or eliminates postoperative narcotics.

Dr. Dasa and his team had been using SRP regularly, but the surgeon was interested if RRP could lead to shorter LOS and greater ROM for patients. Soon, patients were being discharged within 24 hours, and Dr. Dasa looked to quantify RRP's effectiveness.

"I was getting frustrated because I didn't have any metrics to see if what I was doing with RRP was actually making an impact," says Dr. Dasa. "My team and I wanted to put some numbers behind what we were seeing in the exam room with the right evidence to support what we thought was happening and ultimately help guide higher-quality patient care."

The study, published last year in Journal of the American Academy of Orthopaedic Surgeons (JAAOS), employed two metrics to gauge the success of RRP: ROM and LOS. ROM was measured both preoperatively and postoperatively using a goniometer, while LOS was determined by the number of days a patient remained in the hospital postoperatively. The results showed mean LOS for the RRP group was 0.8 days, compared to the SRP group's 2.5 days. More importantly, RRP was associated with a higher flexion (ROM) in the 12 weeks after surgery.

Dr. Dasa says that over the past year, many of his patients in RRP have experienced opioid-free recoveries. "When we use RRP, we don't need to keep patients in the hospital any longer than needed, which helps decrease the risks of complications and increases the quality of care and recovery," he says. "There is a significant amount of cost savings, making heath care more sustainable and accessible."

Dr. Dasa notes that RRP should only be used with qualified patients. Elderly, extremely ill and morbidly obese patients may not be candidates for RRP. For qualified patients, however, he is excited about its effectiveness and potential. "I think we owe it to our patients to keep enabling and deploying the innovations, technologies, processes, workflows and whatever else it takes to improve their quality of life and provide them with the most optimal results," he says.