(1)
Department of Orthopedic Surgery ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of South Korea
Abstract
Postoperative management of TKA can greatly affect the prognosis of TKA. I have used the term “management” instead of “treatment” because I would like to describe all the relevant factors including the physical, psychological, and social factors.
Postoperative management of TKA can greatly affect the prognosis of TKA. I have used the term “management” instead of “treatment” because I would like to describe all the relevant factors including the physical, psychological, and social factors.
Psychological and physical changes occur postoperatively and these changes vary from patient to patient. Therefore, there should be a standard treatment protocol and the rehabilitation program should be designed so as to meet each patient’s needs as well.
The postoperative management includes recovery from anesthesia after the operation, pain control, wound care, rehabilitation exercises, ambulation, leisure, and occupational training. These management protocols vary according to the length of hospital stay which is somewhat different from country to country due to the socioeconomic circumstances.
Patients should be informed regarding the various problems that they would encounter after discharge from the hospital such as the duration of pain, the type of rehabilitation therapy they must undergo, as well as the activities they can perform and they should not do.
7.1 Postoperative Care
The protocol and contents of postoperative care can vary according to the length of hospital stay, because intensity of rehabilitation is quite different between that at home and at hospital.
The Beth Israel Medical Center divided postoperative care into three phases. Phase I is up to 1 week after operation for restoration of early function. Phase II is between week 2 and week 5 for restoration of progressive function. Phase III is between week 6 and week 8 for restoration of advanced function.
The purpose of Phase I postoperative care is that the patient should be able to get out of bed, regain balance, walk alone using a walker, and achieve more than 90° of flexion. The purpose of Phase II postoperative care is to improve the muscular strength and proprioception in the operated limb, maximize the functions at home, and achieve 0–110° of motion. The purpose of Phase III postoperative care is that the patient should be able to walk without a cane, do household work, and achieve 0–120° of motion.
The Beth Israel Medical Center’s rehabilitation program includes the details regarding the postoperative care, but there are some difficulties in many aspects for adopting this rehabilitation program in Oriental patients because of the differences in the length of hospitalization, rehabilitation facilities, and lifestyle.
Author’s Opinion
I divide the rehabilitation period into early, midterm, and late stages: The early stage is until Hemovac is removed, the midterm stage is until the stitches are removed, and the late stage is until postoperative 3 months.
I prefer this rehabilitation program because careful monitoring is required for ascertaining the patient’s general condition until Hemovac is removed and the wound condition should be carefully observed until the stitches are removed. After the stitches are removed till postoperative 3 months, the patient should self-monitor his/her knee condition.
It is generally accepted that Hemovac should be retained for no longer than 2 days, because the risk of infection increases if it is retained for more than 2 days postoperatively. Therefore, the early stage starts immediately after the operation until the 2nd postoperative day.
Generally, stitch removal is done between postoperative 10 and 14 days. Hence, the midterm stage is generally considered from the third postoperative day until postoperative 2 weeks. Management during the midterm stage may be somewhat different according to the hospitalization period. In the United States where the cost of hospitalization is high, most patients are admitted for only 3–4 days. Whereas patients in some Oriental countries are discharged within a week or even a month after several rehabilitation therapies have been performed since the cost of hospitalization is not very high in these countries. When the length of hospital stay is short, postoperative care is provided by a home care nurse until stitch removal, and patients themselves should be able to self-monitor their own knee condition thereafter.
7.1.1 Early Stage
7.1.1.1 Care in the Recovery Room
Vital Signs
The purpose of immediate postoperative care is to monitor and maintain the patient’s vital signs. After the patient recovers from anesthesia, he/she is transferred to the recovery room. First step is to check the patient’s vital signs and consciousness. If the patient’s vital signs are unstable, an attempt should be made to correct them immediately and an anesthesiologist should be consulted for identifying the cause of the problem. If the patient does not recover from anesthesia, the anesthetic record should be reviewed in order to identify the causes and to determine the next procedure that should be performed. This is done completely by the anesthesiologist.
After this, the amount of blood drained into Hemovac should be checked. If it exceeds 200 cc per hour for several hours, the first step is to lock Hemovac and the elastic bandage is applied more tightly. The knee joint is flexed to 30° and any evidence of vascular compromise should be looked for. The elastic bandage should be released if there is severe pain due to excessive compression or there are signs of compartment syndrome. If the amount of bleeding does not decrease and the vital signs drop, transfusion should be initiated and the use of a hemostatic agent should be considered. If the amount of bleeding exceeds 400 cc per hour, an angiography should be performed for preparation of the revision surgery. However, angiography may be skipped in emergent cases in the hospital where angiography takes a long time.
Neurovascular Assessment
Once the patient recovers from anesthesia, he/she should be asked to move the great toe for checking the peroneal nerve function. This is a very important step for differentiating between intraoperative peroneal injury and pressure palsy which develop postoperatively. If a peroneal nerve palsy is detected, it should be reviewed whether any surgical procedure was performed that may have damaged the peroneal nerve. This is very rare in usual TKA, but in cases of a severe valgus deformity, flexion contracture, or ankylotic knee, an exploration can be considered in case of any doubt.
Peroneal nerve palsy that is noticed immediately after the operation is likely to be related to the surgical trauma, but pressure nerve palsy may also develop in the knee that was operated first, due to the tight elastic bandaging or incorrect posture during the second operation in case a simultaneous operation is performed.
If there are signs of multiple nerve palsies, tourniquet palsy or compartment syndrome due to excessive bleeding should be suspected.
7.1.1.2 Care in the Ward
General Care
Once the patient returns to the ward, he or she is placed in the correct position with special care taken for the operated knee. The patient is comfortably laid with the neck in the extended position to keep the airway open. It is recommended to support the ankles with water bags so that the knees are not bent too much, thereby preventing a flexion contracture. The use of an air mattress or water mattress is recommended to prevent bedsores if the patient is obese, is not willing to move, or has history of steroid abuse.
The first step is to recheck the vital signs to confirm that patient’s general condition is stable. It should also be checked whether the lines and attachments such as the IV route, Foley catheter, and Hemovac are working properly.
The peroneal nerve function is checked once again. In fact, a tight elastic bandage or incorrect posture could be the most common cause of peroneal nerve palsy when the patient is not fully conscious. Hence, the condition of the peroneal nerve should be checked from time to time in the ward especially in the early stage. If peroneal nerve palsy occurs, the elastic bandage is released without exposing the wound and the knee should be bent at 30°–60°. Pressure palsy may recover normally in a few days to several weeks. The recovery time seems to be related to the duration of compression. Exploration is not needed in most of the cases.
Hydration is very important especially in aged patients. Hence, the intake and output should be checked strictly in order to prevent pulmonary edema or dehydration due to excessive or insufficient fluid administration respectively.
It is also necessary to remove the sputum by coughing to prevent atelectasis or pneumonia. Deep breathing is encouraged and an inspirometer is useful for the patients.
Oral intake can be started from wetting the lips with a damp gauze when the patient is willing to start oral intake.
Blood Management
Maintaining an adequate postoperative hemoglobin (Hb) level is necessary for improving the patient’s general condition, for preventing medical comorbidity and for promoting wound healing.
Stulberg and Zadzilka suggested that the blood management program should be based on patient-specific strategy (PSS) and can vary from surgeon to surgeon or from hospital to hospital.
Keating and Ritter found that the Hb level drops by an average of 3.9 g/dl in case of single knee arthroplasty and by an average of 5.4 g/dl in case of simultaneous knee arthroplasty, and about half of the patients need transfusion after TKA.
The blood management protocol is divided into three stages: preoperative, intraoperative, and postoperative stage.
Preoperative management includes administration of erythropoietic agent and autotransfusion. Currently, the most popular erythropoietic agent is epoetin alfa (recombinant human erythropoietin). If the Hb level is between 10 and 13 g/dl, 40,000 units can be injected subcutaneously at 3 weeks, 2 weeks, and 1 week prior to the operation. It is recommended to give epoetin alfa concomitantly with 200–300 mg of iron and 1 mg of folic acid daily to prevent iron deficiency disorder caused by the erythropoietic activity.
Autotransfusion, the technique in which the patient’s blood is harvested preoperatively for transfusion, can also be used. However, this method has many limitations and its effect is controversial. If the patient has anemia before the operation, harvesting the blood can worsen the anemia. Hatzidakis et al. did not recommend autotransfusion if the Hb level was below 13 g/dl. Since the erythropoietic activity after blood harvesting is not as active as expected, the preoperative Hb level decreases. Fred emphasized that not more than 2 units of blood should be harvested. Also, autotransfusion activates the immune reaction, thereby increasing the risks of allogeneic transfusion reaction, and the autotransfusion process is inconvenient for the patient.
Another drawback of autotransfusion is that the blood is harvested 3–5 weeks prior to the operation during which the number of red blood cells can decrease. Also, the patients should be asked to stop taking any medications which can give rise to a bleeding tendency.
Intraoperative methods include hypotensive anesthesia, blood salvage and hemodilution, and use of a topical hemostatic agent or specialized cautery. Hypotensive anesthesia can cause hypoxia in the tissues, which can lead to the development of complications. It increases the risks of cardiovascular and cerebrovascular complications, and it also increases the incidence of deep vein thrombosis. Mild acute normovolemic (isovolemic) hemodilution is a method in which more than 1,000 cc of blood is collected preoperatively and the ECF is temporarily substituted with crystalloid or colloid fluids. It is indicated in patients whose Hb level is higher than 10 g/dl and when the operation is expected to last for a longer time and more than 1,000 cc of blood loss is likely.
Topical hemostatic agents include thrombin, collagen and fibrin glue, or antifibrinolytic agents such as aprotinin. However, there are reports that the use of these agents increases the incidence of deep vein thrombosis. Cho et al. reported that the initial bleeding can be reduced by synovial injection of norepinephrine.
Administration of tranexamic acid can reduce the blood loss and blood transfusion requirement. Tranexamic acid reduces postoperative bleeding by maintaining fibrin activity through the bonding with plasminogen which is related to thrombolysis. Clinically, it is effective when an antithrombotic agent is used or in hemophilia patients in whom there is a deficiency of fibrin formation. It is administered just before the operation or before deflation of the tourniquet. It cannot reduce the bleeding if it is administered after postoperative 24 h. Lin et al. reported that they could reduce the blood loss after minimally invasive TKA by single intraoperative injection of tranexamic acid.
Postoperative management includes either no use or modification in the usage of Hemovac, allogeneic transfusion, and reinfusion of drained blood.
The insertion of Hemovac is closely related to the amount of bleeding. Parker et al. and Song et al. reported that the amount of bleeding and transfusion could be decreased by not using Hemovac, and Shen et al. also stated that clamping Hemovac during the first 4 postoperative hours reduced the amount of bleeding and the need for transfusion.
The most widely used method is allogeneic transfusion. However, allogeneic transfusion has a number of potential adverse effects such as disease transmission, allergic reactions, fluid overload, infection, or immunosuppression. The most important factor in the prediction of blood transfusion requirement is the preoperative Hb level; the lower the preoperative Hb level, the more the need for blood transfusion. Generally, transfusion requirement and amount of blood are determined in relation with the amount of bleeding and Hb level. If the Hb level drops below 10 g/dl or the amount of bleeding exceeds 1,000 cc, blood transfusion is required. When blood transfusion is to be done, packed cells are the best choice. It is known that one pint transfusion is meaningless, and therefore transfusion of at least 2 pints is recommended. However in practice, only 1 pint is given in many cases. Some authors suggest platelet-rich plasma transfusion for decreasing the postoperative bleeding.
Reinfusion of drained blood or cell salvage method is also available and the methods for reinfusion vary according to the filtering mechanism. The drained blood contains bone and soft tissue debris, bone marrow, activated coagulation factors, etc. The small particles less than 40 μm can pass the filter and enter into the blood stream. As a result, complications such as febrile episodes and coagulation deficiency can occur. Reinfusion within 6 h can minimize these complications. The known problem associated with reinfusion is the defect in the anticoagulation factor, but Jensen et al. reported that the amount of allogeneic transfusion could be decreased by reinfusion of the blood from Hemovac and there was no defect in the anticoagulation factor.
Kourtzis et al. introduced the Aegion protocol, which comprised of a combination of these pre- and postoperative methods depending on the hemoglobin level and expected blood loss. With this method, allogeneic transfusion requirement could be reduced by 94 % without any adverse effect during postoperative care of TKA. Slappendel and Dirksen also reported that allogeneic transfusion requirement could be reduced by 80 % using a similar method.
Pain Management
Epidural block or PCA (patient-controlled analgesia) is the most frequently used method for pain control; however, the problem with PCA is that it may cause dyspnea, lethargy, urinary dysfunction, or nausea. It is important to use strong analgesics to relieve pain as much as possible. Hartrick et al. used a single epidural norepinephrine infusion to relieve the pain, whereas Szczukowski et al. and Hunt et al. reported that they could relieve the pain and decrease the amount of narcotic use by blocking the femoral or sciatic nerve.
Local anesthetic agents have also been tried intraoperatively; Vendittoli et al., Busch et al., and Cho et al. found that the initial pain could be reduced by injecting local anesthetics around the soft tissues before closure. Some surgeons mix these agents with steroids. Joo et al. compared the effect between intra-articular injection of multimodal drug and a placebo. The cocktail injection contained bupivacaine, morphine, methylprednisolone, and epinephrine. The results revealed that multimodal drug injection did not improve patient satisfaction, range of motion, or blood loss compared with that in the placebo group.
In spite of these trials, the pain will still be severe for the first 2–3 postoperative days. The pain increases when the patient moves or when there is a swelling, and it decreases when the patients elevate the limb, an ice pack is applied, and the movement is restricted. Ice pack has an anti-inflammatory action since the release of prostaglandin E2 is sensitive to temperature. Also decreased blood flow by cryotherapy is not accompanied by decreased oxygen saturation as the metabolic activity is reduced. Hence, pharmaceutical as well as cryo-methods is performed concomitantly to relieve the pain.
Some patients believe that analgesic agents can delay the healing process, and hence, they hesitate to use them; however, there is no supporting evidence for this concept. Since the patients may experience drowsiness, nausea, and lethargy with the use of opioid analgesics, it is necessary to monitor them regularly.
Currently the preemptive pain control method is widely accepted. The basic concept is that it is probably easier to prevent the pain than to eradicate it and prevention of the initial postoperative pain makes the subsequent pain management simpler. Preemptive analgesia limits the sensitization of the nervous system in response to painful stimuli and blocks the transmission of noxious afferent impulses from the peripheral nervous system to the spinal cord and brain. Opioids, nonsteroidal anti-inflammatory drugs, and COX II inhibitors (multimodal) are commonly used before operation.
Close observation is needed when extreme pain is experienced from the first postoperative day (pain from day 1 onwards). It strongly suggests the acute infection.
Other Medications
It is recommended to use anticoagulants for preventing deep vein thrombosis (DVT). It has been reported that thrombosis is not very common among the oriental population. However, when DVT develops, the hospital is legally liable. Therefore anticoagulants should be used in all high-risk patients unless they have coagulopathy. This is further described in Chap. 8.
Prophylactic antibiotics can be used longer than usual in the patients who are at risk of infection; this is also described in Chap. 8.
Wound Evaluation
It is not necessary to check the wound until Hemovac is removed, and it is also acceptable to check the wound after a day or 2 days after removal of Hemovac. However, it may be necessary to check the wound on the first postoperative day if there is the risk of developing skin necrosis due to tight closure, poor skin condition, or previous operation scar.
If blood is seen on the outside of the gauze, there is a possibility of an increased risk of ascending infection and so the gauze should be changed immediately.
Rehabilitation
If the patient wants to change his/her position, the patient should be allowed to do so and he/she should also be allowed to get on a wheelchair with help.
Even in the early phase, the patient should begin isometric exercises when the pain becomes tolerable. The quadriceps setting exercise or ankle pump can be started in the lying down position to promote blood circulation and to prevent weakening of muscular strength.
7.1.2 Midterm Stage
The focus of management from the time of Hemovac removal until the removal of stitches is monitoring the patient’s general condition, wound care, and rehabilitation.
7.1.2.1 General Condition
Although the most risky period has passed, there are a few risk factors in this stage as well.
The most important risk factor is still the cardiopulmonary problem. If the patient complains of chest pain or dyspnea, it may be due to a fresh episode of angina or myocardial infarction, aggravation of preexisting cardiopulmonary problem, pulmonary edema due to overhydration, or pulmonary embolism. Careful monitoring of the patient is needed immediately to initiate appropriate treatment.
If the patient shows central nervous system symptoms such as disorientation, unconsciousness, or paralysis of limbs, fat embolism or cerebral infarction can be suspected. However, it should be checked first whether the pain control medications are being administered in excess. It is necessary to consult a neurologist and brain CT is ordered if needed. If there is no definite lesion on brain CT, the patient’s condition may return to normal in a week.
Pain management is still important during this stage. Some patients experience more severe pain temporarily after the discontinuation of PCA. If there is swelling over the operated lower limbs and the pain is accompanied by mild fever, the work-up for DVT is needed. In case of thrombosis, a physician is consulted for initiation of heparin treatment.
Routine checkup such as CBC and urinalysis is checked immediate postoperatively and on the 3rd postoperative day or before discharge. Chemical tests are helpful for detecting toxic hepatitis which may have developed due to anesthesia and pain medications.
Other general symptoms are voiding disorders, anorexia, insomnia, mild fever, etc. Voiding disorder is generally temporary, but some patients develop an atonic bladder which requires an insertion of a urinary catheter and a few days of training. Most patients experience anorexia due to pain, lethargy, nausea, or insomnia. As wound healing is closely related to nutrition, it is important to restore the patient’s appetite, although it is not very easy to do so. Antiemetics would be of help in some patients. If anorexia persists, it is sometimes necessary to provide nutrition through the IV route. Anorexia may also be caused due to gastritis, activation of peptic ulcer, or abdominal pain. If the symptoms persist for days, it is recommended to consult a physician.
Insomnia is caused due to postoperative pain, changes in the environment, etc. Since sleep is important for the patient’s psychological and physical condition, hypnotics should be given so that the patient gets sufficient sleep. Hypnotics are also prescribed on discharge as sleeplessness often persists for a long time after discharge.
If the patient has fever, appropriate management should be initiated considering all the possibilities such as absorption fever, drug side effects, reaction to transfusion, thrombosis, pneumonia, urinary infection, ileus, and wound infection.
7.1.2.2 Wound Care
Wound condition is a very critical issue and must not be overlooked. Even if the operation was successful, the wound problem can cause limited ROM and it may progress to deep infection.
Dressing once every 3–4 days is enough unless any special conditions preexist. When performing wound dressing, any sign of infection, skin necrosis, or serous discharge from the incision or Hemovac insertion site should be carefully examined. If there is a wound problem, active treatment should be started to prevent deep infection and to preserve the prosthesis. Delayed management can cause limited ROM and pain even though the prosthesis is saved.
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