Perioperative Care of the TKA Patient
17 July 2018 (online)
Total knee arthroplasty (TKA) is one of the most successful procedures in medicine today, and has improved the quality of life for millions of people over the years to an extent that was not imaginable 50 years ago. Back in its infancy, TKA was performed primarily in elderly patients with minimal functional demands and a limited life expectancy. Over the years, as the results held up over time, the indications expanded to include younger patients and those with significant medical comorbidities.
While the basic operation has not changed significantly over the years, our care of the patient throughout the continuum of care has. Thirty years ago, patients were admitted to the hospital 2 days before surgery and stayed for 2 weeks postoperatively. Protective weight bearing was standard for up to 3 months. Today, many centers across the United States are performing outpatient TKA, something that the Centers for Medicare and Medicaid Services, an agency of the U.S. Department of Health and Human Services, finally recognized in January of 2018. How has this come about?
As the number of TKA is increasing every year, standardization of procedures and patient care has evolved to minimize complications and improve outcomes. Protocols have evolved defining best practices that have resulted in improved outcomes and patient satisfaction, and have been widely adopted. This special focus section of the Journal of Knee Surgery presents currently accepted perioperative protocols, detailing the authors' clinical experience, that have led to the success that TKA enjoys today. We are fortunate to have leading experts in the field contributing to this special focus section, and the authors come from a wide range of clinical practices with a wealth of clinical experience.
As White et al outline in their article, many different protocols have been investigated over the years trying to minimize blood loss and blood transfusions in the postoperative period. It appears that the use of tranexamic acid has now become the standard of care for minimizing blood loss and reducing the incidence of allogeneic blood transfusions, and represents one of the few instances in modern medicine where a medical advance occurs with a decrease in cost compared with previous treatments!
Drew et al present current techniques for intraoperative anesthesia and postoperative pain control, with the goal being to minimize the use of narcotics and mobilize the patient as quickly as possible. The use of regional anesthesia, peripheral nerve blocks, and multimodal pain protocols represents the most significant improvement in patient care over the years.
Two of the most serious postoperative complications remain venous thromboembolic disease (VTE) and infection. While many of the strategies outlined above have decreased the incidence of these, such as controlling a patients' diabetes before surgery and early mobilization, these complications still exist and we need to do a better job of decreasing their incidence. Box et al discuss the current state of the art with regard to VTE prophylaxis and the choices available in 2018, along with their risks and benefits. We have more options now than ever, and more information to help us understand what is best for each individual patient. Papas et al present their approach to minimizing the risk of infection, detailing options available throughout the entire surgical process.
Finally, Barnes et al discuss the preoperative care of the TKA, with the goal to identify potential problems and minimize risks around the surgery. Improving outcomes and decreasing complications also lower costs and patient suffering, thereby increasing the value of the procedure.
I am indebted to all the authors for their hard work and efforts that went into producing this special focus section. Without their commitment to excellent patient care and interest in sharing their knowledge with orthopaedic surgeons, this would not have been possible. I believe strongly that the information presented in this special focus section will provide orthopaedic surgeons with the resources necessary to improve the care of their patients, leading to better outcomes and higher patient satisfaction.