Protocols

Pain Control Protocol
Post surgical pain is a major concern for all patients. We take great care in alleviating pain by a combination of methods. Patients are explained in detail what to expect after surgery and the plan for mobilisation and discharge well ahead. All post-op exercise programs are commenced before surgery itself. Patients are given epidural anesthesia in most cases so the same catheter is used for post surgical pain medication infusion. They also receive regional anaesthetic infiltration at the time of surgery. In the ward top-up narcotic pain medication is prescribed as required. Cryotherapy is given for 48 hrs after surgery.

Infection Control Protocol
Routine pre-op screening for septic focus is carried out during the Pre-surgical counseling visit. Prophylactic antibiotics administered as per the guidelines of the American Academy of Orthopedic Surgeons. Urinary catheter is placed for patients who choose to undergo both knee surgeries simultaneously. Centrally air-conditioned Operation Theatres with Positive Pressure ventilation and surgical hoods are used

DVT Prophylaxis Policy
All patients are put on Triflometer chest physiotherapy and Kendall SCD devices/Stocking for 1 week. Chemical prophylaxis is administered as per the guidelines of the American Academy of Orthopedic Surgeons. Early mobilisation and intensive physiotherapy is given to all patients.

What To Expect
Start walking with a walker 1 day after surgery. Can use a portable commode or walk to the toilet with assistance
Climb stairs 3 days after surgery with minimal assistance
Discharge home 5 days after surgery - Physiotherapist will visit you at home frequently as required
Suture removal at home 10 days after surgery - No need to visit the hospital until 3 weeks

3 months after surgery most patients are able to achieve the following;
A scar about 6 inches long. Occasional clunking noise on certain movements
Knee looks straight. No bow legs or knock knees!
No pain on walking, standing / getting up from chair or commode
Climb up and down stairs easily with no pain or stiffness
No use for walking aids like walker, crutches or stick
No swaying to sides whilst walking, like you used to, before surgery
Get in and out of a car quickly without having to manoeuvre to clear the door.
Can stand up from a low chair or settee
Can stand for long time without looking out for a chair
Can sit comfortably with your legs crossed.
At 1 year, Can squat, on the floor or kneel for praying but may need assistance to get up.

Pre Anesthetic evaluation is typically done 1 week prior to admission for surgery. Kindly arrive at 8 AM preferably on empty stomach and be prepared to spend 3 hrs in the hospital.


HOW TO IMPROVE TKR IN OBESE PATIENTS

 

Obesity affects 35% of the adult population in the U.S. A new literature review published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) identifies strategies to improve total knee replacement (TKR) outcomes in patients with obesity. The work, entitled, “Morbid Obesity and Total Knee Arthroplasty: A Growing Problem,” appears in the March 2017 edition.

Researchers found that excess soft tissue in patients with obesity can obstruct visibility in the treatment site during surgery. This lack of visibility can result in difficulty achieving proper alignment and implant fixation as well as longer surgical time. Compared to patients that were obese that did not undergo bariatric surgery prior to TKA, the bariatric patients did worse even with a lower body mass index. This project demonstrated that obesity is a complex issue and further research is necessary to improve outcomes in this patient population undergoing primary TKA.

Preoperatively, nutritional optimization appears to be a limitation of many of the current studies available. This may improve patient outcomes but further investigation is necessary before recommendations can be made. Intraoperatively, utilizing exposure techniques that improve visualization may decrease intraoperative complications. Additionally, the use of a stemmed tibial component may decrease the risk of aseptic tibial loosening in this patient population. Postoperatively, obese patients may have multiple medical comorbidities including diabetes, coronary artery disease, etc. These comorbidities should be closely monitored as they may impact patient outcomes.

Performing a TKA in an obese patient is not a routine TKA. Careful perioperative planning can lead to significantly improved results in this patient population. Nutritional and medical optimization appear to be two key factors in improving outcomes.


Combination unfractionated heparin and aspirin do not appear to decrease the incidence of VTE following Arthroplasty
The addition of unfractionated heparin (UH) to aspirin did not decrease the incidence of venous thromboembolism (VTE) following total joint arthroplasty (TJA) compared to aspirin alone, according to a study published in the May 1 issue of Orthopedics. Researchers retrospectively reviewed data from a single hospital system and identified 5,350 patients: 1,024 received aspirin only, 1,695 received aspirin plus one UH dose, and 2,631 received aspirin plus multiple UH doses. Rates of deep vein thrombosis and pulmonary embolism did not significantly vary; however, transfusion rates were significantly greater with one and multiple UH doses compared to aspirin alone.

 

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