Perioperative Management in Total Knee Arthroplasty


45 Perioperative Management in Total Knee Arthroplasty


Sebastian M. Klim MD and Mathias Glehr MD


Department of Orthopaedics and Traumatology, Medical University of Graz, Graz, Austria


Clinical scenario



  • A 63‐year‐old patient is awaiting his total knee arthroplasty (TKA), which is scheduled for the next day. As you search his medical records you find that the patient has had a surgical site infection (SSI) after being treated with open reduction internal plate fixation for a broken clavicle in the past. Therefore, you are thinking about taking additional prevention measures.
  • Your patient is an active person in good physical condition with no significant co‐morbidities. Since he wants to exercise with his new joint like he did prior to surgery, he asks you if there are any perioperative therapy plans that could improve the surgical result regarding knee function and shorten the hospitalization time.
  • The patient is concerned about postoperative pain. He wants to take as few pain pills as necessary and knows the pain reduction potential of cryotherapy from his sports activities. He therefore asks you if cryotherapy could help to reduce the required pain medication, and if a postoperative outcome improvement can be expected.

Top three questions



  1. In patients scheduled for primary TKA, does preoperative bathing/showering or wiping with antiseptics result in fewer SSIs compared to nonantiseptic preparations?
  2. In patients after primary TKA, does a fast‐track (FT) early‐mobilization schedule lead to an improved outcome in functional scores and hospitalization time compared to a regular joint care protocol?
  3. In patients after primary TKA, does local cryotherapy have a positive effect on early postoperative parameters compared to protocols without cryotherapy application?

Question 1: In patients scheduled for primary TKA, does preoperative bathing/showering or wiping with antiseptics result in fewer SSIs compared to nonantiseptic preparations?


Rationale


Prosthetic joint infection (PJI) after TKA is among the most frequent indications for revision TKA.1–4 A huge economic burden is associated with the increasing number of (septic) revision TKA.5


Clinical comment


One of the most frequent causes for wound contamination is skin microflora. With the incision made during surgery, micro‐organisms may be able to infect tissue, joint, and/or implant. It is a widely accepted fact that the use of an antiseptic skin wash product can reduce skin microflora. However, there is no consensus whether this leads to a reduced incidence of SSI/PJI.6,7 Knowing the history of the patient, you want to know if bathing/showering with antiseptic skin wash products prior to surgery can help prevent an SSI/PJI.


Available literature and quality of the evidence



  • Level III: our literature search showed 1 meta‐analysis (including 4 retrospective comparative studies with 8787 patients) investigating exclusively TKA patients.8
  • Level III: 1 retrospective comparative study including 2055 TKA patients.9
  • Level I: 1 Cochrane systematic review (including 7 randomized controlled trials [RCTs] with 10 157 patients) investigating SSI of all localizations.10

Findings


The level III meta‐analysis results (total study population) indicate a reduced incidence of SSI when chlorhexidine (the active substance in all investigations) was used in preoperative washing/wiping (risk ratio [RR] = 0.22; 95% confidence interval [CI]: 0.12–0.40; p = 0.000). Furthermore, a reduction of SSI rates in moderate and high risk patients according to the National Healthcare Safety Network (NHSN) risk classification is shown (RR = 0.18; 95% CI: 0.05–0.63; p = 0.007 and RR = 0.13; 95% CI: 0.03–0.67; p = 0.014.8,11


In contrast, the level I systematic review as well as the retrospective comparative study found no benefits in the chlorhexidine groups regarding SSI incidences. A discrimination by risk classification has not been performed in these studies. Insignificant differences in SSI rates are reported in the chlorhexidine and in the placebo groups (RR = 0.60; 95% CI: 0.22–1.60; p = 0.330.8–10


Resolution of clinical scenario



  • Routine use of preoperative chlorhexidine baths/showers or wipes is not recommended for daily clinical practice as it shows no SSI rate reduction in TKA.9,10
  • The SSI risk should be calculated if deemed necessary.11
  • In TKA patients with moderate to high SSI risk profiles chlorhexidine baths/showers or wipes should be considered, especially regarding the low cost and the very rare unwanted side effects. However, the available data do not support a final recommendation.8

Question 2: In patients after primary TKA, does a fast‐track (FT) early‐mobilization schedule lead to an improved outcome in functional scores and hospitalization time compared to a regular joint care protocol?


Rationale


Multidisciplinary perioperative treatment protocols for TKA have been presented and further advanced in recent years, aiming to provide standardized treatment leading to a reduced length of stay, improved clinical outcome, and patient satisfaction.12–14 To achieve this, physicians, anesthesiologists, physiotherapists, and nurses must closely work together and adhere to evidence‐based protocols, known as fast track (or FT).


Clinical comment

Only gold members can continue reading. Log In or Register to continue

Related posts:

Default ThumbnailThe Direct Anterior Approach Default ThumbnailPatient‐Specific Instrumentation in Total Knee Arthroplasty Default ThumbnailReverse Total Shoulder Arthroplasty Default ThumbnailProximal Tibia Fractures Default ThumbnailAnkle Ligament Injuries Spinal Infections

Stay updated, free articles. Join our Telegram channel
Tags:
Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Perioperative Management in Total Knee Arthroplasty

Full access? Get Clinical Tree
Get Clinical Tree app for offline access