The first change was going away from using a tourniquet on the vast majority of our total knee patients. A tourniquet is a cuff placed around the thigh that most surgeons use during knee replacement surgery. It squeezes the thigh tightly to prevent bleeding during the surgical case. However, it can also increase post-operative pain and mask potential areas of bleeding that are then not addressed.
We have gone to a “tourniquet-less” knee replacement for over 90% of our patients with significant success. Patients now have less postoperative thigh pain and less postoperative swelling. In order to treat bleeding during surgery we began using the Aquamantis which is a bipolar water-based cautery system. This allows us to treat bleeding as it occurs during surgery such that when the case is complete all areas of bleeding have been treated yielding less postoperative swelling. We have also gone to a smaller, more minimally invasive incision and instituted twice-a-day physical therapy post-operatively starting the day of surgery. With these changes we have observed much improved patient satisfaction and pain control. Average time in the hospital after knee replacement surgery has fallen from 3.2 days in 2010 to 36-48 hours today.
Another major change that we have made in knee replacement is the type of fixation used to secure the prosthesis to the bone. Traditionally, knee replacements are fixed to bone with a bone cement, polymethylmethacrylate (PMMA). For older patients with poor bone quality, this is still the method of choice.
However, for young, active patients with good bone quality, we have moved strongly to biologic fixation. In this scenario, the prosthesis has a porous coating which is friction fit to the bone allowing the bone to grow into the implant. Once this biologic fixation occurs, the risk of future prosthesis loosening is markedly decreased. The implant has essentially become part of the body. This is called “cementless” total knee replacement and is our choice for the vast majority of our patients. This is especially attractive for patients who want to return to high demand activity and need the knee replacement to last for decades.
“Why doesn’t everyone do this?” you may ask. The answers are variable. The cementless implants are more expensive and some hospitals resist this technology due to cost. Furthermore, in order to be successful with cementless total knee replacement technology, the surgeon needs to be technically skilled at getting every bone cut correct and balancing the knee well.
We feel very comfortable in accomplishing these goals and are backed up by a long record of clinical success. Every year we are performing hundreds of knee replacement procedures. Our failure rate due to early prosthesis loosening (first 2 years after surgery) with cementless knee replacement is 1%. If I or a family member needed a knee replacement at a young age, I would certainly want a cementless total knee. Therefore, that is what I offer to my patients who are good candidates.
I would like to also mention the strong work done by CJW Medical Center (Chippenham and Johnston-Willis Hospitals) in developing a world-class total joint program. Our success and growth would not be possible without the strong support of CJW for our patients. We have a Total Joint Replacement coordinator employed by the hospital whose sole job it is to inspect the program and constantly work towards better patient outcomes.
Some of the changes made in the last several years to improve patient care include use of tranexamic acid (TXA) to reduce surgical bleeding, a blood conservation program to reduce need for postoperative blood transfusion, MRSA and Hemoglobin A1C screening to reduce infection and complication rates, a rapid recovery protocol to speed patient return to function, and a multi-modal pain control program to significantly improve pain control after surgery.
We are very fortunate to have CJW Medical Center as a strong partner in the constant quest to improve joint replacement for our patients in metro Richmond and Central Virginia.
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