Dr. William Barrett

Patient Satisfaction after Knee Replacement

At the most recent Knee Society meeting in New Orleans, Louisiana, March 15, 2014, there were several papers published revealing the percentage of patients who were happy or satisfied after receiving a knee replacement. As was noted by Michael Dunbar, MD, patient satisfaction encompassed many intrinsic and extrinsic factors related to the patient’s experience.

The Swedish Knee Arthroplasty registry, which is a large population study, noted that 17% of patients who had a knee replacement were dissatisfied with some aspect of their knee replacement outcome.  Several other large registries have noted a similar rate of patient dissatisfaction.  All of these studies indicate the satisfaction after knee replacement correlates most strongly with pain relief, followed by improvement of function.  Satisfaction is noted to be a function of the duration of the disease process leading to the knee replacement with patients who have a longstanding history of arthritic problems reporting higher rates of satisfaction compared to those with more acute onset of knee problems.

Unmet expectations are a significant factor associated with dissatisfaction after knee replacement.

The authors pointed out that it is important for the patient and their care team to have a discussion about what is and what is not to be expected after knee replacement and to have a discussion about the anticipated pain relief in function and activity after knee replacement surgery.

Posted in Joint pain prevention / relief, Knee Replacement, Knee Replacement (Partial), Pain management, Surgery outcomes & quality, The Joint Center at VMC | Tagged , , , , , , | Leave a comment
Dr. William Barrett

Patient-Specific Cutting Guides for TKA

At the 23rd annual meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas, November 8 through 10, 2013, a paper was presented by Dr. Hamula, Et Al, evaluating the use of patient-specific cutting guides for total knee replacement.  Their study demonstrated use of these guides was not superior to standard instrumentation with regard to alignment of the knee replacement.  There was an increased cost associated with these guides associated with the preop MRI or CT scan that was required as well as the additional expense of the cutting guide. 

This study comes to a similar conclusion as one that I recently had accepted in “The Journal of Arthroplasty” in 2013.  We found that use of patient-specific cutting guides yielded similar results to conventional instrumentation as well as computer-assisted instrumentation.  There is some additional cost, which is partially offset by the increased efficiency of the procedure. 

We currently use these guides in patients who have specific deformities that preclude the use of conventional instrumentation.  In that setting, they are extremely useful for improving accuracy of the knee replacement.  While widespread use for routine cases may not be justified, use of these guides is extremely helpful in specific situations. 

William P. Barrett, MD

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Dr. William Barrett

Total Hip Replacement in Younger Patients

At the 23rd annual meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas, November 8 through 10, 2013, Doctors Lang, Et Al, reviewed a large retrospective database using a Nationwide Inpatient Sample (NIS).  They found that the total number of hip replacements increased by 73% in the decade from 2000 to 2009, but breaking that down, it increased by 123% in patients age 45 to 64, and by 54% in patients 65 to 84.  This reflects the growing demand for hip replacement in a younger age group who are limited by osteoarthritis.  This trend makes it incumbent upon orthopedic surgeons and orthopedic implant manufacturers to try to improve results and longevity as patients can anticipate having implants in their body for a longer period of time.

— William P. Barrett, MD

Posted in Arthritis, Hip Replacement, Osteoarthritis, Uncategorized | Leave a comment
Dr. William Barrett

Increasing Popularity of Anterior-Approach Total Hip

As worldwide experience increases with anterior approach to total hip replacement, more and more patients are coming in asking about the potential benefits versus drawbacks.  In a study we published in “The Journal of Arthroplasty” in October 2013, we highlighted the benefits including less postoperative pain, earlier discharge from the hospital, and earlier return to function.  These benefits persisted for 3 months, and at 6 and 12 months the differences between anterior-approach and posterior-approach patients decreased, and at 1 year there was no obvious difference between the 2 groups.  It is clear from this study and others, as well as the experiences of patients, that there is less postoperative pain, earlier discharge, earlier return to activity with anterior-approach total hip replacement.  The majority of our patients now go home the day after surgery with an anterior-approach total hip.  Those who are obese or have underlying medical problems may require a 2-day hospital stay.  Clearly, several factors influence the outcome from hip replacement.  These include the surgeon and surgical technique, the patient, and their underlying medical health.  The good news is total hip replacement is a very successful procedure regardless of which approach is used.  As we focus on increasing value and earlier return to activity, the benefits of anterior hip replacement may become more apparent and appreciated. 

We have seen a significant increase in the number of patients seeking anterior hip replacement, and at our hospital we have now purchased a third hana table to accommodate the volume.  We will continue to study these patients and investigate their potential benefits and long-term function of hip replacement. 

—William P. Barrett, MD

Posted in Hip Replacement, Joint pain prevention / relief, Recovery & post surgery, Surgery outcomes & quality, Surgical procedures or techniques, Uncategorized | Leave a comment
Dr. William Barrett

New Methods Of Fixation For Revision Knee Replacement

At the 23rd Annual Meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas, November 8-10, 2013, Dr. Patel, Dr. Barnett, Dr. Gorab, and Dr. Gondusky presented results of a multicenter study using cementless metaphyseal sleeves for fixation in the femur and tibia (thigh bone and shin bone) of patients who were undergoing revision knee replacement. They found that this type of combined cementless sleeve in association with cemented components provided good short-term outcome and made the feeling of bony defects easier.

In a study reported by Dr. Dalury from Baltimore, Maryland and myself, we found a similar outcome in over 70 cases of revision total knee. The use of these cementless cones in the end of the femur and top of the shin bone facilitate filling of defects often encountered at the time of revision knee replacement. These cones are attached to femoral and tibial components that are cemented to the surface of the bones. In this fashion, a combination of cemented and cementless fixation can be used in these challenging revision total knee cases. Long-term followup is required to conclude whether or not this is a preferred way, but in the short run appears to be a better way of dealing with failed total knee replacements.

—William P. Barrett, MD

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Dr. William Barrett

Anterior Hip Replacement Studies Show Quicker Recovery

At the 23rd annual meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas, November 8 through 10, 2013, Dr. Mason, Et Al, described their study comparing one group of patients who underwent an anterior hip replacement with a second group who underwent a posterior hip replacement.  They found that patients who had the anterior-approach hip replacement voluntarily stopped using all walking aids on average 12 days earlier than patients with a small incision posterior-approach hip replacement.  This data corresponds to an article published by me in October 2013, in “The Journal of Arthroplasty.”  We found that patients undergoing an anterior approach had less pain, were able to walk a greater distance, get off of their walking aids earlier when compared to a similar group who underwent a posterior-approach hip replacement.  These studies emphasize the early benefits of anterior hip replacement with regard to pain relief, function, and the avoidance of postoperative precautions.  In our study, after 6 to 12 months there was no difference between the 2 procedures, but patients who I have performed prior posterior hip replacement and subsequently performed an anterior hip replacement uniformly feel the anterior hip replacement allows a quicker recovery with less restrictions.  For that reason, we now perform in excess of 90% of our hip replacements from an anterior approach and have noted a shorter length of stay and earlier return to activity.

Posted in Hip Replacement, Joint pain prevention / relief, Pain management, Recovery & post surgery, Surgery outcomes & quality, Surgical procedures or techniques, Uncategorized | Leave a comment
Dr. William Barrett

The Importance of Surgeon Volume in Outcomes of Unicompartmental or Partial Knee Replacement

Drs. Baker et al in the April 17th issue of the Journal of Bone and Joint Surgery reported on a registry-based study evaluating outcomes of medial unicompartmental knee replacements. This study was performed in the United Kingdom and utilized the National Joint Registry of England and Wales data base. They evaluated 23,400 medial Oxford unicompartmental knee replacements performed in the UK between 2003 and 2010.  Revision rates from centers with the lowest volume were greater than revision rates from centers with higher volume.  They also noted that the incidence of revisions with surgeons who performed a lower volume were significantly higher than surgeons with a higher volume. 

The 5 year survival rate was also higher in the higher volume sites/surgeons.  Low volume surgeons had a 90 percent 5 year survival rate which is inferior to total knee replacement.  The authors based on the evaluation of this data suggested that surgeons should perform a minimum of 13 or more unicompartmental replacements per year to yield results that are similar to those of higher volume surgeons.  This points out the importance of evaluating not only the implant or technique, but the surgeon experience with the particular implant and/or technique. 

There has been a lot of media coverage and advertising about certain types of partial knee replacements, as well as certain techniques i.e., robotically assisted techniques.  Until individual centers and surgeons publish their data it is important to note that in this study surgeons who performed less than 13 partial knee replacements per year had a higher revision rate than surgeons who performed a greater number and also a significantly higher revision rate than patients who underwent complete knee replacement. 

  1. When considering what option is best for you I think you should:
    Find out your diagnosis and whether or not a partial or complete knee replacement would be better for you.
  2. Determine the volume of these procedures a surgeon does.
  3. Whether or not there is any peer reviewed published data regarding a particular technique and/or implant to help you make a sound shared decision with your surgeon.  

—Willliam P Barrett, MD

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

The Benefits of Spinal/Epidural Anesthesia for Joint Replacement

Drs. Memtsoudis et al from the Hospital for Special Surgery in New York published in the Journal of Arthroplasty in May 2013 a large national data base study looking at 400 hospitals from 2006 through 2010.  They evaluated the anesthesia type and outcomes for patients undergoing primary and total hip and knee arthroplasty.  They evaluated 382, 236 patients.  Eleven percent of these patients had a spinal/epidural type anesthetic and 14 percent a spinal/epidural plus general anesthetic and 75 percent had a general anesthetic.  After reviewing this large national data base they found several significant findings.  First, the patients who had a spinal or epidural anesthetic had a significantly lower 30 day mortality rate after their surgical procedure.  They also noted a significantly lower length of stay in the hospital and decreased costs and in-hospital complications with the spinal anesthetic group.  They concluded that spinal and/or epidural anesthetic was associated with superior perioperative outcomes for primary hip and knee replacement when compared to general anesthesia.  We perform the overwhelming majority of our joint replacements with a spinal anesthetic and use general only for those who are unable to have a spinal type anesthetic due to prior back surgery and/or specific medical conditions.  We feel this gives the patient the best opportunity for an early successful outcome.

—William P. Barrett, MD

Posted in Hip Replacement, Knee Replacement, Knee Replacement (Partial), Preparation for Surgery, Surgery outcomes & quality, Uncategorized | Leave a comment
Dr. William Barrett

Interpretation of “stiffness” post knee replacement surgery

Study presented at the 2013 Knee Society meeting in Chicago, IL, on March 23, 2013 analyzed residual stiffness at 6 months following knee replacement. The authors surveyed patients both preoperatively and at 6 months. They also surveyed the surgeons and recorded the expectations of the patient and the surgeon preoperatively. There were 246 patients studied in this survey. At 6 months, the perceived stiffness above what the patients expected was 40%. The impression of the surgeon at 6 months was often quite different from that of the patient. Of note, many patients complained of stiffness despite the fact that they also reported that they could bend and straighten their knee fully. This points to the fact that residual swelling and inflammation at 6 months can be interpreted by the patient as stiffness while the surgeon notes very good range of motion on the part of the patient. This underscores the need of patients and surgeons to talk honestly about the results after knee replacement. We as surgeons often equate full range of motion, i.e. 0 to 120+ degrees as a very good result while the patient may interpret that range of motion as satisfactory, but the knee still feels swollen and “stiff.” It generally takes up to 12+ months for the inflammation and swelling from the knee replacement to fully resolve and motion will continue to improve even after the 12-month followup.

—William P. Barrett, MD

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

Decreasing the Risk of Infection Following Joint Replacement Surgery

At the 2013 American Academy of Orthopedic Surgeons annual meeting in Chicago, IL, March 19 through 23, 2013, there were several papers evaluating ways to decrease infection following joint replacement surgery. These can be lumped into things that the patient can do preoperatively to minimize the risk as well as things surgeons can do intraoperatively and postoperative.

We have taken many of the “best practices” information and tried to educate our patients as to ways they can maximize the outcome after their surgery. Certainly taking an inventory of your skin prior to a joint replacement surgery is important to make sure there are no significant skin lesions or superficial infections. If you have any dental problems, these should be addressed well before surgery so there is no contamination from an oral infection. If you have extra pounds leading to folds around your waist, it is important to make sure that these are clean and free of any type of fungal infection, which can manifest itself as redness in these folds.

The day before surgery, many surgeons will have their patient’s cleanse their body with some type of antiseptic soap, washing the area of surgery and the surrounding extremity and the remainder of the body. The morning of surgery, further cleansing of the skin with chlorhexidine wipes can be helpful to decrease the bacterial load prior to surgery. Nasal swabs with dilute Betadine can also be effective in decreasing nasal bacteria. Use of dedicated operating rooms for joint replacement, efficient use of surgical time and careful soft tissue treatment will all help decrease the risk of infection.

Decreasing postoperative blood loss and using appropriate surgical dressings can also help minimize the risk. While the risk can be decreased, the risk of infection cannot be driven to 0 because of multiple factors including the patient’s overall health and their immune system. We try to do everything we can to minimize that risk and patients trying to optimize their health and wellbeing prior to surgery can also help ensure the best possible outcome.

—William P. Barrett, MD

Posted in Hip Replacement, Knee Replacement, Knee Replacement (Partial), Recovery & post surgery, Surgery outcomes & quality, Uncategorized | Leave a comment