Dr. William Barrett

What is the “Ideal” Alignment of the Limb after Knee Replacement

At the recent Knee Society meeting in New Orleans, Louisiana, from March 15, 2014, there are several papers relating to the question of what is the ideal alignment of a leg after knee replacement.  There was no clear consensus on what ideal alignment is other than making sure that the leg is mechanically straight and the soft tissue is well balanced.  There are several options for obtaining alignment during a knee replacement.  These include conventional instruments, which are based on fixed points on the thigh bone and shin bone, computer-assisted surgery that uses computers to help with alignment, and patient-specific guides which are developed from preoperative CT scans or MRIs of the patient’s lower extremity and then custom or one-time use cutting guides are made for that particular surgical procedure.  All of these options have enjoyed success, and there is no clearcut winner based on literature data from 2014.  The custom cutting guides as well as computer-assisted surgery increase the cost and time associated with the replacement procedure.  Studies will continue to help elucidate whether or not one form of alignment is more reliable for use in knee replacement surgery.

 

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

Preventing Joint Infection After Hip and Knee Replacement

In a paper presented at the Knee Society Meeting in New Orleans, Louisiana 03/15/2014, Dr. Javad Parvizi presented results of their work on preventing joint infection after total joint replacement. They found strong evidence to support preoperative health and nutritional status optimization, the use of prophylactic IV antibiotics, antibiotic impregnated cement, and preoperative skin preparation prior to surgery.

 This supports the program that we instituted atValley Medical Center, which includes preoperative skin decolonization, use of chlorhexidine preparation of the skin prior to surgery and in the operating room itself, nasal decolonization with diluted iodine solution, and vigilant follow up of patients to minimize the risk of infection. There are multi-modal approaches to minimizing risk of infection that begin with optimization of the patient prior to surgery and extending through the preoperative and postoperative period.

Posted in Hip Replacement, infection, Joint pain prevention / relief, Knee Replacement, Uncategorized | Leave a comment
Dr. William Barrett

Morbid Obesity And Its Effects On Complications After Knee Replacement

Dr. Browne and Associates presented an award winning paper at the Knee Society Meeting in New Orleans, Louisiana 03/15/2014 looking at the effect of morbid obesity on complications after knee replacement. They used a nation wide inpatient sample database to identify patients undergoing primary knee replacement from October 2005 to December 2008. Morbid obesity was defined as a Body Mass Index over 40. Of the 1,777,068 primary total knees 98,410 or 5.5% of patients were categorized as morbidly obese. These individuals had a statistically higher risk of postoperative in-hospital wound complications including infection, and higher risk for anemia and renal complications. They also noted that morbidly obese patients were at a significantly higher risk of in-hospital death following total knee replacement compared to non-obese patients. They concluded that morbid obesity by itself appears to be associated with a higher risk for complications following total knee replacement. They also noted that comorbidities that are often associated with obesity including diabetes and hypertension appear to be responsible for some of the increased risks of complication following surgery. They also noted that morbid obesity appears to be associated with higher costs, longer length of stay, and a lower rate of discharge home after knee replacement surgery.

Posted in Knee Replacement, Knee Replacement (Partial), Rehabilitation, The Joint Center at VMC | Leave a comment
Dr. William Barrett

Recent Presentations At The 42nd Annual Meeting Of The Hip Society

The American Academy of Orthopedic Surgeons had their annual meeting in New Orleans, Louisiana March 11th through the 16th. On March 15th, the hip society had their annual open meeting and there were several papers focused on preventing readmission to the hospital after joint replacement. There is emerging information particularly when looking at Medicare claims data, which allows the analysis of tens of thousands of patients. The focus of these papers was how to prevent readmission following surgery. Readmission often involves several causes. The most common being some type of cardiac event related to either coronary artery disease or irregular heart rates. Another source of readmission is infection as well as blood clots in the lower extremities. Several authors noted that there are many modifiable risk factors that if addressed prior to a surgery can avoid complications and readmission to the hospital. Looking at the most common risk factors associated with patients undergoing joint replacement they are in order or prevalence:  Hypertension, elevated cholesterol, diabetes, depression, morbid obesity, and heart disease. Having appropriate preoperative evaluation by a patient’s internist or a hospital associated internal medicine group can help identify and hopefully treat many of these modifiable risk factors. High blood pressure can be controlled with medication as can elevated cholesterol. Diabetes can be appropriately managed so that the patient metabolically is as stable as possible prior to surgery. Obesity has gotten quite a bit of exposure over the last year to add the importance of losing weight to decrease the risk of infection and other complications after hip replacement. Most large volume centers are starting or have clinics in place to help patients with modifiable risk factors prior to surgery. Patients should look into these prior to considering joint replacement surgery.

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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

Posted in Hip Replacement, Knee Replacement, Surgical procedures or techniques, Uncategorized | Leave a comment
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