Dr. William Barrett

THE EFFECTS OF SMOKING AND POSTOPERATIVE COMPLICATIONS AFTER TOTAL HIP REPLACEMENT

Dr. Sahota, MD and colleagues at the 25th anniversary meeting of the American Association of Hip and Knee Surgeons presented a poster on their findings with regard to smoking and the incidence of complications. They used the American College of Surgeons National Surgical Quality Improvement Program database. They reviewed 60,353 patients and included 12,588 from that who had appropriate inclusion criteria. Of that group, there were 1501 smokers. After adjusting for differences, they found that smoking was associated with higher rates of overall surgical complications, surgical site infection, and readmission following surgery for hip replacement. They noted that smoking is the modifiable condition that adversely affects outcomes after hip replacement and smoking cessation should be attempted prior to elective joint replacement surgery.

Posted in Recovery & post surgery, Surgery outcomes & quality | 1 Comment
Dr. William Barrett

PROPHYLAXIS FOR DEEP VENOUS THROMBOSIS AFTER JOINT REPLACEMENT SURGERY

Dr. Tan and coauthors from the Rothman Clinic presented their results at the 25th anniversary of the American Association of hip and knee surgeons in Dallas, Texas November 2015, looking at a multicenter study of 63,526 primary and revision joint replacements. In low risk patients, they found the incidence of lower extremity blood clots using aspirin to be the lowest at 0.17%. In high-risk individuals (those with prior DVT history of clotting or other factors that make them high risk) the incidence of lower extremity blood clots using aspirin was 1.5% versus 3.48% for more potent anticoagulation agents. They concluded that high-risk patients can be adequately prophylaxed with aspirin to try and prevent postoperative blood clots. Further work on this subject needs to be performed before there is overall consensus with this recommendation.

It should be noted that in patients who had no prior blood clots in their lower extremities and do not have some genetic preponderance to lower extremity blood clots, aspirin is evolving to be the most common form of prophylaxis after hip and knee replacement surgery.

Posted in Knee Replacement, Knee Replacement (Partial), Pain management, Surgery outcomes & quality | Leave a comment
Dr. William Barrett

LONG-TERM OUTCOME OF UNICOMPARTMENTAL OR PARTIAL KNEE REPLACEMENT VERSUS TOTAL KNEE REPLACEMENT

Dr. Masonis and colleagues from Ortho Carolina presented a poster at the 25th annual meeting of the American Association of Hip and Knee Surgeons in November 2015. They reviewed the outcomes of 174 patient who underwent either unicompartmental or total knee replacement. They found that a mean followup of approximately 10 years, the revision rate for the partial knee replacement was significantly higher. It is 16.5% versus 6.9% for total knee replacement. The partial knee replacement occurred earlier at an average of 33 months postop. The most common failure mode for partial knee replacement was loosening in 53% and progression of arthritis in other compartments in 23%. The most common failure mode for total knee replacement was aseptic loosening or infection. They found no difference between total knee replacement and partial knee replacement with regard to patient reported outcome measures at an average of 9.3 years. The 10-year survivorship was significantly lower for a partial knee replacement at 84% versus 93% for total knee replacement.

There is a definite indication for partial knee replacement in the appropriately selected individual, but this averages approximately 5% of all patients who are indicated for knee replacement procedures.

A 2nd poster was presented at the same meeting by Dr. Lee and coauthors from Orange County, California. They reviewed a group of patients all less than 60 years old with minimum 5-year followup of either a partial or unicompartmental knee replacement (49 knees) or a total knee replacement (91 knees). They found that all patients improved with regard to various clinical ratings. There was a higher occurrence of adverse events in the partial knee replacement group and revision for the partial knee replacement group were greater at 13.7% versus 3.3% for the total knee group. They concluded that young patients undergoing either a partial knee replacement or appropriately done total knee replacement showed no differences with regard to pain relief and function, however, there was a significantly higher revision rate for the partial knee replacement in these patients.

Posted in Knee Replacement, Knee Replacement (Partial), Recovery & post surgery | Leave a comment
Dr. William Barrett

TOTAL KNEE REPLACEMENT

A paper presented at the 25th annual meeting of the American Association of Hip and Knee Surgeons in November 2015, reviewed the complications following bilateral simultaneous total knee replacement versus bilateral staged, i.e., separate dates total knee replacement. Dr. Sheth and colleagues reviewed over 11,000 patients from an integrated health system joint registry program. They found overall death rates and complications for both the simultaneous and staged group were quite rare. They concluded there is no increased risk of revision, infection or death or complications in bilateral simultaneous versus staged total knee replacement. This agrees with our indications for patients with bilateral simultaneous total knee replacement which includes patient’s under the age of 70, normal weight, without a history of cardiac or pulmonary problems. In appropriately selected individuals, the overall total recovery can be shortened by doing both knees at once, but patients need to be in excellent health and appropriate weight to accomplish this safely.

Posted in Hip Replacement, infection, Knee Replacement, Surgery outcomes & quality | Leave a comment
Dr. William Barrett

SEVERITY OF ARTHRITIS PREDICTS OUTCOMES IN YOUNG PATIENTS WITH TOTAL HIP REPLACEMENT

A poster presented at the 25th anniversary meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas November 5th through 8th from the University of Iowa reviewed the outcome of 146 hip replacements in patients less than 55 years of age. They noted an inverse relationship between the preop x-ray and amount of joint space loss, and improvements in function, pain and quality of life. They concluded that patients with less severe radiographic evidence of osteoarthritis had less predictable improvements in terms of function, pain relief and activity. They concluded that young patients who had greater than 1.5 mm of joint space remaining on plain radiographs, had suboptimal outcomes from total hip replacement. This reinforces one of our commonly held beliefs that the severity of arthritis preoperatively predicts the reliability of the outcome after surgery. That is the reason we try and maximize patient’s native hip using therapy, weight reduction and anti-inflammatories prior to proceeding with joint replacement surgery.

Posted in Hip Replacement, Surgery outcomes & quality | Leave a comment
Dr. William Barrett

ASSOCIATION BETWEEN MULTIPLE DRUG ALLERGIES AND INFERIOR OUTCOMES WITH JOINT REPLACEMENT

In the July, 2015 issue of the “Journal of Arthroplasty”, authors Alexander McLawhor and M.D. and colleagues from Hospital for Special Surgery in New York reviewed the association of patient-reported multiple drug allergies and outcome following joint replacement. They reviewed patient reported drug allergies in 274 patients undergoing primary total hip and 257 patients undergoing primary total knee replacement. They looked at multiple patient-reported outcomes after surgery and length of stay following surgery. What they found is that patients with increasing numbers of reported allergies to medication had statistically significant lower satisfaction scores, lower patient reported outcomes, and longer lengths of stay after hip and knee replacement. This study is significant in that patient-reported outcomes may have a role in future contracts for joint replacement surgery. It is therefore important to recognize that certain factors may lead to inferior results and that may influence whether or not hospital systems and/or healthcare systems will want to evaluate the significance of the patient with multiple drug allergies. It is important to determine whether or not an allergy to a medication or metal is a true allergic response or more of a minor side effect. All of these factors will need to be evaluated in the future as they will impact the outcome of joint replacement surgery and also potentially affect the selection of implants down the road.

Posted in infection, Joint implants, Surgery outcomes & quality, Uncategorized | Leave a comment
Dr. William Barrett

AFFECT OF HIGH BMI ON OUTCOMES FOLLOWING TOTAL JOINT ARTHROPLASTY

In the July, 2015, issue of the “Journal of Arthroplasty” authors Hasham Alvi. M.D. et al from Northwestern University in Chicago, Illinois, evaluate the affect of obesity on outcomes following total joint arthroplasty. They used a Surgeon National Surgical Quality Improvement Program database of 13,250 patients. They looked at the affect of obesity on outcomes after total joint replacement. They noted that over 1/3 of the U.S. population is overweight or obese and the association between obesity and degenerative joint disease has been well documented. While obesity does not preclude functional improvement following joint replacement, it does increase the risks associated with this procedure. After reviewing the data and eliminating confounding variables. They found that a BMI equal to or greater than 40, was associated with increased risk of medical and surgical complications following joint replacement when compared to patients who were more normal weight or even those classified as overweight. This takes on increasing importance in the future when hospitals will have to pay for readmissions or postoperative complications. It will be in the hospital’s, the surgeon’s and the patient’s best interest to optimize patients prior to surgery and this includes strategies for weight loss that focus both on nutritional as well as exercise modifications and optimizing medical conditions including diabetes, hypertension, and anemia. There is increasing pressure on the healthcare system to eliminate some potentially preventable complications and this starts with optimizing the patient prior to surgery.

Posted in Preparation for Surgery, Recovery & post surgery, Rehabilitation, Surgery outcomes & quality | Leave a comment
Dr. William Barrett

The Year 2014 In Review

The year 2014 saw over 1,300 joint replacement procedures done at the Joint Center at Valley Medical Center. After reviewing the data from that year, we would like to share our results so that consumers can compare outcomes among various centers. Our infection rate for primary total hip and knee replacement was 0.6%, below the national average of approximately 1%. Our average length of stay for total hip replacements was 1.7 days, less than the national average of 2.3 days. Our length of stay for total knee replacements was 2.4 days, which is equal to the national benchmark average for top 10th percentile. Our readmission rate within 90 days (i.e., patients who have to be readmitted to the hospital for any reason) was 1.5% for total knees, which is one-quarter of the average readmission rate in 90 days compared to the national average. For total hips, it was 1.3%, which is one-fifth of the national average for readmission for total hip replacement. Our anterior approach hip replacements had an average length of stay of 1.2 days, and the majority of these patients now go home the following day after surgery.

Through collaboration with our colleagues and Anesthesia, we have been able to decrease the postoperative discomfort, minimize some of the side effects associated with pain medicine, and allowed our patients to transition from surgery to home in a smooth, seamless fashion. As noted in a previous blog, 93% of our patients go from the hospital to home with only 7% requiring a rehabilitation facility.

By managing the preoperative, operative, and postoperative care, we are able to take advantage of opportunities for improvement and offer the highest quality care to our patients. We are proud of our numbers and continue to strive to improve on them.

Posted in Hip Replacement, Joint implants, Uncategorized | Leave a comment
Dr. William Barrett

THE EVOLUTION OF LENGTH OF STAY FOR A JOINT REPLACEMENT SURGERY

Traditionally, joint replacement surgery required a several-day stay in the hospital. In the 1980s, the average length of stay was approximately 7 days, and now it has decreased nationally to approximately 2 days. There is an evolution in the thought process of length of stay for joint replacement surgery. With improved techniques, particularly improved pain management, the length of stay has dropped significantly over the last 10 years. Now, centers are looking into and beginning short-stay or outpatient joint replacement surgery. For healthy individuals who have few risk factors, this will be a reality if not now then in the near future. At Valley Medical Center, our anterior hip replacement patients spend the night and go home the following day after their hip replacement surgery. These patients are up walking around within a few hours of their procedure and become independent going up and down stairs and carrying out other activities necessary for going home. Knee replacement patients typically will stay a bit longer due to the increased discomfort associated with a knee replacement. Usually, patients are very comfortable the first 24 hours and probably could go home at that point, but often experience a rebound in pain as the various blocks wear off from surgery. Improved patient education and better support in the early postoperative period will enable many patients who spend the night to go home sooner.

Ten years ago, orthopedic surgeons began evaluating surgical exposures, length of the incision, and other factors. There was a great shift to “minimally invasive surgery,” and perhaps we overshot our mark and now use a more sensible approach to the skin incision and surgical exposure. I think the same will happen regarding length of stay with joint replacement. Some patients will be suitable for outpatient joint replacement; others will benefit from an overnight stay. This is a quickly evolving subject, and both patients and physicians will use a shared decision-making model to come up with the proper decision and also strategize about how to optimize patients for shorter-stay surgery. Stay tuned. We will continue to update this exciting story.

Posted in Hip Replacement, Joint implants, Joint pain prevention / relief, Knee Replacement, Knee Replacement (Partial), Preparation for Surgery, Recovery & post surgery, Rehabilitation, Surgery outcomes & quality, The Joint Center at VMC, Uncategorized | Leave a comment
Dr. William Barrett

STUDY TO EXAMINE BENEFITS OF PRE-OPERATIVE FITNESS ON SURGERY OUTCOMES

2015 marks the start of the 12th year of our research department. 2015 will see us initiate a study to evaluate the effectiveness of preoperative optimization of patients undergoing hip and knee replacement. The goal of this program is to take patients who are significantly overweight and not only lower their weight, but improve their fitness and make them better candidates to succeed after total hip and knee replacement. This will be an ongoing study to evaluate the effectiveness of this program that is being run in conjunction with Valley Medical Center and Pinnacle Physical Therapy to modify patients’ weight and fitness through a combination of nutritional counseling and exercise optimization. We are also going to initiate a study evaluating the effectiveness of computer assistance in placing the socket and stem in anterior hip replacement patients. This will be a study conducted at 4 sites across the United States, the aim of which is to improve the accuracy of cup and stem placement in total hip replacement to lower the risk of dislocation, improve the function of the hip replacement, and ensure proper limb length. We look forward to validating our techniques and the use of this exciting new technology.

We continue to monitor the outcomes of hip and knee replacement patients in our joint registry and are embarking on the 5-year followup of our patients who were enrolled in 2010 and 2011 in our anterior versus posterior hip replacement study. The 1-year results of this study were published in 2013 in the “Journal of Arthroplasty.”

We are on the cusp of many exciting changes in joint replacement as we evolve from long inpatient stays to short inpatient and overnight and even outpatient stays for joint replacement surgeries.

Stay tuned for more exciting news.

Posted in Fitness, Hip Replacement, Joint implants, Knee Replacement, Knee Replacement (Partial), Surgery outcomes & quality, The Joint Center at VMC | Tagged | 2 Comments