What Can I Expect At Hss
Hospital for Special Surgery has been at the forefront of modern knee replacement since the operation was first introduced in the late 1960s. We have led the field ever since in a number of ways:
- : HSS has been ranked the No. 1 hospital for orthopedics by U.S. News & World Report for 11 years straight.
- Along with high rankings in patient satisfaction, HSS performs the most knee replacements with the lowest reported infection rates in the United States.
- Research and advancement: Smaller incisions, new implant materials and design, and sophisticated instrumentation have been â and continue to be â the areas of expertise of the hip and knee replacement surgeons of the HSS .
- HSS routinely uses the latest surgical techniques and technology, such as robotic-assisted and computer-assisted surgery.
- : Isolating the anesthesia to a particular body area helps avoid the potential problems that may accompany a general anesthetic. These techniques have been developed and refined by the HSS . Learn more about
What Happens During Total Knee Replacement
Your provider can help explain the details of your particular surgery. An orthopedic surgeon will perform the surgery aided by a team of specialized healthcare professionals. The whole procedure may take a couple of hours. In general, you can expect the following:
Most likely, you will be given spinal or general anesthesia so that youâll sleep through the surgery and wonât feel any pain or discomfort during the procedure. Or you may receive local anesthesia and a medicine to keep you relaxed but awake.
A healthcare professional will carefully watch your vital signs, like your heart rate and blood pressure, during the surgery.
You may receive antibiotics, during and after the procedure, to help prevent infection.
Your surgeon will make an incision over the middle of your knee, cutting through your skin and underlying tissue.
He or she will remove the damaged portions of your thigh and shin bone, removing a little of the bone beneath as well.
Next, metal implants are placed into the joint space, usually cementing them into the remaining bone.
In most cases, your surgeon will also remove part of the underside of the kneecap.
A plastic spacer is inserted into the space between the metal implants, for ease of movement.
The layers of your skin and muscle will be surgically closed.
Types Of Knee Implants Used In A Knee Replacement Surgery:
A whole knee joint implant is primarily made up of 3 components. A femoral component that is attached to the resurfaced thigh bone, a tibial component that is affixed to the prepared shin bone, a plastic spacer that is placed between them and a patellofemoral component that replaces the natural knee cap.
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Ial Knee Replacement Overview
A is also known as unicompartmental knee arthroplasty or unicondylar knee arthroplasty. In this surgery, damaged cartilage and bone are removed and replaced only in one diseased compartment of the knee. This differs from a total knee replacement, in which bone and cartilage from the entire joint are replaced.
Partial knee replacement is suitable for people who experience arthritis only in one compartment of the knee joint, rather than throughout the joint. It can also provide relief from pain and stiffness in some people who have medical conditions that make them poor candidates for total knee replacement surgery.
J How To Modify Care For Patients With Known Allergies
Patients presenting for knee arthroscopy are treated no differently than patients presenting for other types of surgery in terms of known allergies. Triggering agents must be avoided. Allergies that are significant in relation to anesthetics for knee arthroscopy are those to tape, antibiotics, local anesthetics, pain medications, and soy or egg products .
Patients allergic to tape should be queried about the specifics of their allergy. Often there is a specific type of tape that the patient is allergic to allowing the safe use of other, non-allergic reaction producing, tape to be used. If the history is unclear, the use of an LMA without being secured by tape is an option. If an endotracheal tube is used, tracheal ties are reasonable options.
Patients are usually given prophylactic antibiotics for these procedures. The primary organisms being covered are skin flora. A cephalosporin is used to provide protection against these organisms. Patients allergic to cephalosporins, and those allergic to penicillins , can receive clindamycin or vancomycin.
If a patient receives a regional technique for his/her anesthetic it is often combined with sedation. The most common agent used is propofol. Propofol is also commonly used as part of a general anesthetic. Occasionally a patient is allergic to soy or lecithin and, therefore, should avoid this medication. Alternatives to propofol sedation include dexmedetomidine, versed, and ketamine.
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How The Operation Is Done
The worn ends of the bones in your knee joint are removed and replaced with metal and plastic parts which have been measured to fit.
You may have either a total or a partial knee replacement. This will depend on how damaged your knee is. Total knee replacements are the most common.
Read more information about what happens on the day of your operation.
I What Should Be Recommended With Regard To Continuation Of Medications Taken Chronically
Cardiac: continue aspirin and beta-blockers. Cease angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prior to surgery.
Pulmonary: continue all medications prior to surgery.
Renal: continue all medications prior to surgery.
Neurologic: continue all medications prior to surgery.
Anti-platelet: aspirin is safe to continue prior to surgery for any method of anesthesia employed. Other antiplatelet modalities will usually have been terminated prior to this type of procedure due to its elective nature. However, if after a consultation with both the cardiologist and orthopedic surgeon, it has been deemed that this is a mandatory therapy, a bridging therapy plan might be in place. This will affect the choice of regional anesthesia techniques.
Psychiatric: continue all medications preoperatively. Lithium is a consideration if a general anesthetic is employed, but usually regional anesthesia is preferred for this type of surgery.
Blood conservation: Anti-fibrinolytic therapy with tranexamic acid has been consistently shown to decrease perioperative blood loss and more importantly, decrease perioperative allogeneic red blood cell transfusion requirements. Due to the overwhelming evidence basis for its efficacy, the perioperative administration of TXA should be considered for all TKA procedures .
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Supporting Patient Recovery At Home
The study period was just after TPMG began transitioning total hip and knee replacement patients from overnight stays to outpatient procedures in 2017. Over the next few years, the region went from about 10% outpatient hip and knee replacements to over 80%.
Outpatients are supported by a multidisciplinary team who meet with them before surgery and by KP Northern Californias Care at Home and Enhanced Recovery After Surgery program teams who assist their recovery at home. The teams include a wide variety of caregivers including physicians, nurses, physical therapists, and care coordinators.
Anesthesia choice has an impact on our patients recovery, and this research provides important insight on spinal vs. general anesthesia for these outpatient procedures, said Smita Rouillard, MD, associate executive director of The Permanente Medical Group. This study highlights the value of our integrated, multidisciplinary care delivery system.
Anesthesia that results in shorter recovery times benefits outpatient surgery, the authors wrote. An anesthetic plan that improves patient outcomes, reduces harm, and helps facilitate discharge home is important in deciding on the type of anesthesia for outpatient total joint arthroplasty, and can also affect patient satisfaction, they said.
The study was funded by a Kaiser Permanente Northern California Community Benefit Grant.
Knee Replacement Recovery Time And Recuperation
Total knee replacement surgery generally takes about 60 to 90 minutes, but you should expect to be in the operating room for over two hours. Rehabilitation will begin within 24 hours of surgery.
After your surgery, the nursing staff will position you in bed and help you turn until you are able to move on your own. You may have a pillow between your legs if ordered by your surgeon.
Very soon after surgery, a physical therapist will come to your room to teach you appropriate exercises and review your progress. Gentle exercises to improve your range of motion can help prevent circulation problems as well as strengthen your muscles.
Your rehabilitation program will begin as soon as you are medically stable and there are orders from your doctor to begin postoperative mobility. All patients begin rehabilitation within 24 hours of their surgery. Your motivation and participation in your physical therapy program is key to the success of your surgery and recovery. The physical therapist will assist you in the following activities:
- sitting at bedside with your feet on the floor
- transferring in and out of bed safely
- walking with the aid of a device
- climbing stairs with aid of a device
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History Effectiveness And The Future
Total joint replacement is regarded as among the most valued developments in the history of orthopedics. The procedure relieves pain and restores function to patients whose joints have been destroyed by trauma or disease. Although natural, human articular cartilage is the best bearing surface for joints, when there is too much damage to these tissues, man-made joint replacements are required. However, the higher level of friction in man-made implants compared to a persons natural bearings means that wear becomes an ongoing concern for joint replacement patients.
This article covers the following aspects of joint implant materials:
Knee Replacement Alternatives To Consider
Crunching sounds as you climb stairs, chronic aching and swelling: Knee osteoarthritis is a real pain. If youre suffering with it, you may be considering surgery.
Getting a knee replacement is one approach, but you may not need surgery, at least not right away. And some patients cannot undergo knee replacement surgery for various reasons. Other people with knee pain are too young for a knee replacement the artificial knee is only likely to last 15 or 20 years, after which the person may need revision surgery.
There are several things you can try first, on your own or with a professionals help, that can help with knee pain and even delay the need for replacement.
Arthritis doesnt go away, but there are things you can do to lessen the pain and stay more active.
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Types Of Knee Implants
Thinking about a total knee replacement? There are a few different kinds of knee implants that are used in this procedure. The different types are categorized by the materials that rub against each other when you flex your knee:
Metal on plastic. This is the most common type of implant. It features a metal femoral component that rides on a polyethylene plastic spacer attached to the tibial component. The metals commonly used include cobalt-chromium, titanium, zirconium, and nickel. Metal-on-plastic is the least expensive type of implant and has the longest track record for safety and implant life span. However, one problem that can happen with plastic implants is an immune reaction triggered by tiny particles that wear away from the spacer. This can cause bone to break down, leading to loosening and failure of the implant. Advances in manufacturing have greatly reduced the rate of wear in the plastic.
Ceramic on plastic. This type uses a ceramic femoral component instead of metal . It also rides on a plastic spacer. People who are sensitive to the nickel used in metal implants might get the ceramic type. Plastic particles from this type of implant also can lead to an immune reaction.
To learn more about your options for knee replacement surgery, read the Harvard Medical School guide Total Knee Replacement.
Use Of Peripheral Nerve Blocks With Sedation For Total Knee Arthroplasty In A Patient With Contraindication For General Anesthesia
1McGaw Medical Center of Northwestern University, Chicago, IL 60611, USA
2Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
Although peripheral nerve blocks are commonly used to provide postoperative analgesia after total knee arthroplasty and other lower extremity procedures, these blocks are rarely used for intraoperative anesthesia. Most TKAs are performed under general anesthesia or neuraxial anesthesia . The knee has a complex sensory innervation that makes surgical anesthesia difficult with peripheral nerve blocks alone. Rarely are both GA and NA relatively contraindicated and alternatives are considered. We present a patient who underwent TKA performed under peripheral nerve block and sedation alone.
Although peripheral nerve blocks are commonly used to provide postoperative analgesia after total knee arthroplasty and other lower extremity procedures, these blocks are rarely used as the sole anesthetic. The majority of TKAs are performed under general anesthesia in the United States , with most other cases utilizing neuraxial anesthesia . The knee has a complex sensory innervation that makes surgical anesthesia difficult with peripheral nerve blocks alone. The knee is innervated by the lumbosacral plexus. Few publications exist about lumbar plexus block in combination with sciatic nerve block.
2. Case Description
3. Block Descriptions
Conflict of Interests
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Depuy Attune Knee Replacement Lawsuits
Attune knee lawyers filed the first DePuy Attune knee replacement lawsuit in September 2017. Several more Attune patients have filed suits since then.
People filing Attune knee replacement lawsuits claim:
- The Attune knee failed earlier than expected
- They experienced tibial loosening with an Attune knee
- Patients needed revision surgery
Attune lawsuits are still in the early stages. There have been no court verdicts or publicized settlements yet. Attune knee lawyers are taking new cases.
Based on the number of reported failures, there could be hundreds of Attune knee replacement lawsuits. If that happens, attorneys may ask to combine them in a multidistrict litigation . MDLs let several, similar cases move more quickly through the legal process.
Why Are There So Many Different Types Of Joint Implants
The ongoing problem of wear in joint replacement implants has led to the reintroduction of many alternative bearing combinations.
Compared to healthy, organic cartilage surfaces, which have a surface friction of nearly zero, the friction between these man-made bearing surfaces is hundreds of times higher. This friction subjects the implant components to wear that can limit the longevity of the joint replacement and induce inflammatory responses in the tissues surrounding the joint itself.
For this reason, producing a low-friction bearing is fundamental to replacing damaged joint surfaces with implants fabricated from man-made materials. This will hopefully eliminate the need for an additional revision surgery by minimizing:
- surface wear
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Did You Know That The Use Of Regional Anesthesia For Total Knee Replacement Surgery Isnt All That Uncommon
General anesthesia brings with it fear in many people that theyll never wake up.
Dont let the fear of general anesthesia stop you from pursuing total knee replacement surgery if your knee has reached a point of hopelessness with conservative treatment.
Yes, there are surgeons who use regional anesthesia to perform total knee replacements.
Now that you know that, its very logical to wonder why this approach isnt utilized more often than general for knee replacement surgery, since the risk of dangerous blood clots is less with the regional.
A blood clot that results from surgery is called a deep vein thrombosis . A DVT can break loose and migrate to the lungs and kill a patient.
In general, the risk of DVT is slightly higher with general anesthesia than with regional, says orthopedic surgeon David Fisher, MD, Director of the Total Joint Center at the Indiana Orthopedic Hospital. With prophylaxis of anticoagulation, the risk is between 1-2%.
Anticoagulation refers to the use of blood thinning drugs. The risk with regional tends to be on the lower side.
Thus, there is no doubt that regional anesthesia wins over general for knee replacement surgery as far as yielding a lower risk of DVT development.
What Is The Authors Preferred Method Of Anesthesia Technique And Why
The authors preferred technique is a combination of oral multimodal analgesia , continuous adductor canal blockade, and spinal anesthesia. A multi-faceted approach to TKA is often necessary given the intensity of postoperative pain. Using PO multimodal analgesics prior to surgery and continued postoperatively is a very simple but efficacious way of reducing opioid consumption postoperatively.
Recent data has demonstrated that adductor canal block has been shown to not only reduce postoperative opioid consumption and postoperative pain, but also facilitates more rapid ambulation. Finally, the avoidance of general anesthesia through the use of a neuraxial technique reduces recovery time and the incidence of surgical site infections.
a. What prophylactic antibiotics should be administered?
Cefazolin 1-3 g IV is the preferred antibiotic for TKA. However, if the patient has significant reactions to penicillin, then clindamycin or vancomycin should be employed. Finally, if the patient has a known history of methicillin-resistant staphylococcus aureus infection, vancomycin should be used.
b. What do I need to know about the surgical technique to optimize my anesthetic care?
c. What can I do intraoperatively to assist the surgeon and optimize patient care?
d. What are the most common intraoperative complications and how can they be avoided/treated?
Prioritize them by urgency.
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How Does The Artificial Knee Joint Get Lubricated
After a joint replacement, the artificial bearing gets its lubrication from synovial fluid, just like the natural knee joint. After surgery, the synovial lining re-forms and secretes synovial fluid. In cars, oil must be changed regularly, but in the body, synovial fluid is recycled by the cells. No external lubrication of the knee joint is ever necessary. In fact, any injections placed into your artificial knee joint increase the risk of infection.
Intraoperative Management: What Are The Options For Anesthetic Management And How To Determine The Best Technique
There are several anesthetic techniques that can be employed for this procedure, including neuraxial anesthesia with or without peripheral nerve block, general anesthesia with or without peripheral nerve block, and a combination of peripheral nerve blocks only. The knee itself is innervated, in most cases, by the femoral and sciatic nerves, with a small minority of patients also having some innervation from the obturator nerve.
a. Regional anesthesia
Options include epidural, spinal, femoral nerve block, sciatic nerve block, lumbar plexus nerve block, and high volume local infiltration by the surgeon.
2. Peripheral Nerve Block
3. Local Infiltration
High volume local anesthetic infiltration into the subcutaneous and periarticular tissues surrounding the joint capsule is a rather simple technique that should be routinely performed by the surgical team to reduce postoperative pain. Local anesthetic infiltration analgesia has become an integral part of multimodal perioperative analgesia.
b. General Anesthesia
c. Monitored Anesthesia Care
Benefits: This is only possible through neuraxial anesthesia or a combination of peripheral nerve blocks. See Regional Anesthesia above.
Drawbacks: See Regional Anesthesia above.
Other Issues: See Regional Anesthesia above.
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