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BLOOD MANAGEMENT + PAIN CONTROL & REHAB Matteo Denti, Piero Volpi Humanitas Institute, Milan, Italy Blood management, pain management and rehabilitation are important aspects during for fast recovery after total knee arthroplasty (TKA). 1. Blood management The risk of bleeding is between 500-700 ml but the total true blood loss following TKA is twice the volume of the visible loss (drainage). We could have different strategies: Pre-operative strategies * Erythropoietin supplementation * Preoperative autologous donation High costs (Erythropoietin supplementation) Wastage up 55% of autologous blood when routinely used (reinfusion) Decreased preoperative Hb levels (preop donation) Intra-op. and Post-op. Strategies * Surgical techniques to minimize blood loss (cemented component, careful homeostasis, etc..) * Perioperative blood salvage The use of Tranexamic acid reduce in a significant way the risk of blood transfusion in TKA. The use of fibrin sealant did not show any reduction in the transfusion rate. 2. Pain management The pain could be control with: Epidural analgesia Epidural catheter infusion of Ropivacaine: 2 or 3mg /millilitre. Maximum 28mg /hour Ropivacaine is a god sensory blocker but realises less motor blocking effects Femoral nerve block Local anesthetic blockade of femoral nerve, is an excellent technique for anaesthesia of the knee Continuous femoral nerve block (perineural catheter), provides postoperative analgesia after knee arthroplasty. Endovenouse analgesia Continuous endovenouse analgesia with oppioid and NSAIDs Patient controllaed analgesia PCA morphine pump is programmed to give an intravenous bolus of morphine (2mg/dose) on demand, with a lock out time of 6 minimum and maximum dose of 35mg over 4 hours. In addition to PCA, patients may receive NSAIDs i.v, Paracetamol (1gr x 4). 3. Rehabilitation - full weight bearing as early as possible - crutches related to the patient and without as soon as possible - CPM only during the hospitalization - Quadriceps exercises - Lymph drainage 36
WHO WILL PAY THE COSTS OF NEW TECHNOLOGIES IN ARTHROPLASTY Jean-Noël Argenson France 1. The economic and medical challenge for TJA - increasing life expectancy - growing demand for TJA procedures - increased cost related to new technologies 2. Increased projected OA knee younger patients - the less than 65 to represent 60% of all TKA in 2030 - average 25% increase life expectancy with implant - active life style - increased expectations - more likely to use more costly premium implants 3. Reasons for increased TKA utilization - increased population - epidemic obesity - sport-related injuries - newer components to last longer and accommodate high activity - better preoperative health to provide better outcome 4. Cost-effectiveness analysis of TJA - quality adjusted life gained - cost per quality of life gained - TJA is effective clinically and in terms of effectiveness 5. Payers for new technologies in TJA - patients - hospitals - national systems - private insurance - health suppliers References: 1. Bozic JJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics. J Bone Joint Am.2006; 88-A:706-14 2. Kurtz SM, Lau ED, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement. Clin Orthop. 2010; 467:2606-12 3. Gioe TJ, Sharma A, Tatman P, Mehle S. Do “premium” joint implants add value Clin Orthop 2010; 469:48-54 4. Losina EL, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am. 2012; 94-A:201-7. 5. Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR. Predicting the cost-effectiveness of total hip and knee replacement. Bone Joint J 2013; 95-B:115-21 6. Kremers MH, Visscher SL, Moriarty JP, Reinalda MS, Kremers WK, Naessens JM, Lewallen DG. Determinants of direct medical costs in primary and revision total knee arthroplasty. Clin Orthop 2013; 471:206-14 37
Page 1 and 2: The Osteoarthritic Knee Best Curren
Page 3 and 4: Patellofemoral + medial OA in a 60
Page 5 and 6: SESSION 8 INFECTION Chairmen: S. Ho
Page 7 and 8: LOAD ABSORPTION - A SOLUTION TO DEL
Page 9 and 10: THE ROLE OF HIGH TIBIAL OSTEOTOMY P
Page 11 and 12: PATIENTS EXPECTATIONS AND OUTCOME A
Page 13 and 14: CASE 1 OSTEOARTHRITIS GRAD II MEDIA
Page 15 and 16: CASE 1 GRADE II OA NEUTRAL ALIGNMEN
Page 17 and 18: CASE 2 GRADE II MEDIAL OA IN ACTIVE
Page 19: CASE 3 OSTEOARTHRITIS GRAD III MEDI
Page 22 and 23: CASE 3 GRADE III MEDIAL OA IN ACTIV
Page 24 and 25: CASE 4 GRADE III LATERAL OA IN ACTI
Page 26 and 27: CASE 5 PATELLOFEMORAL + MEDIAL OSTE
Page 28 and 29: CASE 5 PATELLOFEMORAL + MEDIAL OA I
Page 30 and 31: PLANNING + APPROACH Roland Becker D
Page 32 and 33: BONE CUTS +ROTATIONAL POSITION Norb
Page 34 and 35: SOFT TISSUE BALANCING + PATELLAR TR
Page 38 and 39: WHO WILL PAY THE COSTS OF NEW TECHN
Page 40 and 41: HOW TO IMPROVE PATELLO-FEMORAL TRAC
Page 42 and 43: placement (in flexion and posterior
Page 44 and 45: PLANNING WITH CONVENTIONAL X-RAY OR
Page 46 and 47: MULTIMODAL APPROACHES FOR A SHORTER
Page 48 and 49: STAYING OUT OF TROUBLE AT PRIMARY T
Page 50 and 51: GAP BALANCING TECHNIQUE AND STABILI
Page 52 and 53: “ADAPTED” MEASURED RESECTION TE
Page 54 and 55: PATELLAR RESURFACING TECHNICAL TIPS
Page 56 and 57: TKA IN POST-TRAUMATIC OSTEOARTHRITI
Page 58 and 59: TKA IN THE STIFF KNEE Michel Bonnin
Page 60 and 61: HOW DO I MANAGE SEVERELY DEFORMED K
Page 62 and 63: which will create easier extension
Page 64 and 65: PLANNING AND CORRECTION OF EXTRA-AR
Page 66 and 67: Fig. 2. Case number 10, a 74-year-o
Page 68 and 69: INFECTION DIAGNOSIS - A EUROPEAN PE
Page 70 and 71: MANAGEMENT EARLY WOUND HEALING COMP
Page 72 and 73: DEBRIDEMENT AND POLYETHYLENE LINER
Page 74 and 75: 4. Barrack RL, Engh G, Rorabeck C,
Page 76 and 77: FAILURE ANALYSIS AND PATIENT SELECT
Page 78 and 79: APPROACH / IMPLANT REMOVAL + 3 STEP
Page 80 and 81: References 1. Meneghini RM, Lewalle
Page 82 and 83: LEVEL OF CONSTRAINT + EXTENSOR MECH
Page 84 and 85: WHICH IS THE BEST STEM EXTENSION FO
Page 86 and 87:
WHICH IS THE BEST STEM EXTENSION FO
Page 88 and 89:
FILLING THE DEFECT. METAPHYSEAL SOL
Page 90 and 91:
THE BEST SPACER FOR THE INFECTED TK
Page 92 and 93:
EXPOSURE FOR REVISION TKA: HOW DO Y
Page 94 and 95:
USE OF HINGES IN REVISION TOTAL KNE
Page 96 and 97:
References 1. Lachiewicz PF. Tantal
Page 98 and 99:
DIAPHYSEAL PREPARATION AND FIXATION
Page 100 and 101:
HOW TO TREAT A DAMAGED PATELLA DURI
Page 102 and 103:
REVISION TKA WITH ASSOCIATED EXTRA-
Page 104:
CASE - BILATERAL INFECTED TKA: EVAL
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