Evidence based approach

It seems that non surgical factors play more important role in achieving good functional outcomes after TKA, than the surgical ones!!

This is a table showing practices that is in use for a while. 

In NHS for a while, and this is a recent debate making BOA to make a stance, there are Hospitals which do not accept patients for arthroplasty in their waiting lists who have BMI more than 34. 

In a lot of hospitals there are schemes of rehabilitation which include intraoperative injections that either include adrenaline or not with the local anaesthetic which is given.

Blocks are not of favourable for some surgeons who fear the potential influence of the anaesthetic to the peripheral nerve if this is by mistake is injected in the nerve than the peri the nerve area. Epidural catheter can be more acceptable.

There are people who are using CPM straight post-op as the patient is under the influence of the spinal and the local anaesthetic, in their try to mobilise and discharge early the patient.

Trenaxemic acid is followed by some surgeons but there is the fear of thrombi formation when a tourniquet is used (some give this just before the release of the tourniquet).

There is a lot of discussion for pain relief and it is mentioned to all patients within their consent that in 1% of the cases pain will be present even post-op.

The role of Diabetes in complications is discussed at all times with the patients.

Very few surgeons do not use tourniquet and there is no tendency to abolish this habit for the moment.

The patella is still resurfaced by a lot of surgeons and almost all who are using cemented components use antibiotic impregnated cement.

There is a lot of this information with numbers and statistics in the NJR (National Joint Registry)

Hope this will be helpful

(You are right to say that a lot of the criteria are not just the surgical technique).

Thank you, George. It is often difficult surgeons to change their practices despite available evidences. But, surely non surgical factors are influencing the outcomes more than the surgical ones!!!

Whatis your thoughts on CPM in h early phase for those patients at risk of Manipulation, such as very poor early range (30-50 degrees) in the first 5 days post op??

CPM can and in my opinion has to be used for all the patients who do not have a satisfactory progress during the initial period. It is much better than manipulation at a later stage as there is a risk of fracture. 

During my professional life I changed my practice and sometimes my technique in order to achieve a better outcome. It is possible and this evolution has to happen. It is the "maturity"  of a surgeon. More older you are more mature become. 

Dear Raju. Please allow some comments.

I am very influenced by a danish Group of orthopedic surgeons that focus on perioperative management in TKA/THA. The main Focus is: how can we mobilise our patients as fast as possible to avoid thrombosis/embolia and cardiac/pulmonary complications. The mastermind here is Prof Hendrik Kehlet. They were doing dozends of RCT´s on Topics like: Tourniquet yes or no, CPM, Mobilisation on day of surgery, what is the best analgetic Management, spinal or General anesthesia.

To summarize the best practice for TKA in 2016 for me:

1. fast track surgery

2.LIA with epinephrine (if no contraindic)

3. tranexamic acid i.v. or local/both

4. NO Tourniquet

5. No Drainage

6. Mobilisation on day of surgery

7. no CPM: let them walk and not lie in bed

8. distinct physio Programm at Hospital and after discharge at day 3-5

9. Patient School preoperative

If you are interested i can provide literature

greetings

René

Thank you Rene. Please do send me the relevant literature. I would be interested to go through it.

Fast track surgery

1. everybody ASA 1 to 3

2.LIA with epinephrine (if no contraindic)

3. tranexamic acid i.v. 

4 Tourniquet = no problem

5. No Drainage

6. Mobilisation and stand and walk on 3 hours after  surgery

7. not fasting more than 6 hours and sugar beverage 250cc two hours before surgery

8. physio Programm at Hospital after 3 hours

9. discharge at day 2-4

9.  patient preoperative nurse consultation

What are the best practices for TKA in 2016? - ResearchGate. Available from: https://www.researchgate.net/post/What_are_the_best_practices_for_TKA_in_2016 [accessed May 25, 2016].

Thank you, Dr Schwartz

I would agree with all these comments above.  I find patients often have thigh pain from the tourniquet and I have been told that they lose up to 40% of quads strength also.  We have started using adductor canal blocks which have eliminated motor block with good pain cover.  I also highly value cryocuff therapy in the acute post-op period but can be difficult as needs to satisfy infection control.

We are currently doing a comparative study of tourniquet use and no use in bilateral tka

My experience of not using tourniquet is very good and it is not creating any long term  problem with cementation. 

Do you find any problem in patients who had been taking blood thinners and also who had uncontrolled hypertension, without tourniquet use

I am stopping all agents 1 week before surgery so I have no problems. 

Uncontrolled hypertension patients usually are not having operation due to the anaesthetic blocks.