Updated: 6/11/2021

TKA Postoperative Inpatient Management

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  • Introduction
    • Rehabilitation requires coordinated effort from
      • orthopaedic surgeon
      • physical therapist
      • occupational therapist
      • case manager
      • nursing staff
      • patient and patient's family
    • Care can be broken down into different phases including
      • Inpatient management
      • post-operative anemia 
  • Inpatient Management
    • Pain management
      • preoperative
        • NSAIDS and opioids given immediately before procedure reduce postoperative pain
      • intraoperative
        • regional anesthesia (spinal and/or epidural)
          • preferred over general anesthesia
        • peripheral nerve blocks
          • useful adjuvant to decrease postoperative pain
        • periarticular multimodal drug injection
          • decrease postoperative pain with minimal risks
      • postoperative
        • multimodal oral drug therapy
          • gold standard and includes
            • NSAIDs: Inhibit COX-1 and COX-2 ? inhibition of inflammatory mediators ( PGs, TXA, AA)
              opioids
              • Mu agonist leading to neuron hyperpolarization and reduced excitability
            • NSAIDs
              • inhibit COX-1 and COX-2
              • inhibition of inflammatory
              • mediators (PGs, TXA, AA)
            • selective COX-2 inhibitors
              • inhibits transformation of AA to PG precursors
              • minimizes GI effects
              • may inhibit bone healing
            • gabapentin/pregabalin
              • reduce hyper-excitability of voltage dependent Ca2+ channels in activated neurons.
              • pregabalin= better oral bioavailability.
            • SNRIs
              • inhibition of serotonin and noradrenergic reuptake in the CNS
    • Physical therapy
      • therapy should start on the day of surgery
        • reduces length of hospital stay
        • reduced pain and improves function
    • Range of motion
      • requirements
        • swing phase of gait
          • 65° of flexion
        • activities of daily living
          • 90° of flexion
        • stairs
          • 95° of flexion
        • rise from a chair
          • 105° of flexion
    • Continuous passive motion (CPM) machine
      • improve early knee flexion
      • has not been shown to have a long-term benefit
    • Drain Placement
      • has not demonstrated any difference in complications or outcomes
    • Discharge home criteria
      • medically stable
      • 80-90° AROM knee flexion
      • ambulate 75-100 feet
      • ascend or descend stairs
  • Post-Operative Anemia
    • Intra-operative
    • Earlier discharge to rehab from hospital associated with improved outcomes
    • Discharge criteria to home similar to those in hospital

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(OBQ12.225) A 62-year-old female undergoes an uncomplicated primary total knee replacement. Her knee range-of-motion pre-operatively was 0-135 degrees of flexion. Which of the following is true regarding the immediate post-operative use of a continuous passive motion machine in this patient?

QID: 4585
1

Reduced risk of venous thromboembolism

1%

(69/5255)

2

No long-term difference in ROM compared to patients not using CPM

95%

(4970/5255)

3

Increased passive knee flexion at 6 months

3%

(135/5255)

4

Increased length of hospitalization

1%

(39/5255)

5

Decreased risk of surgical site infection

0%

(3/5255)

L 1 B

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(OBQ10.109) Which of the following statements regarding the use of continuous passive motion (CPM) devices following total knee arthroplasty is true?

QID: 3203
1

The use of CPM decreases the incidence of knee flexion contracture at 6 months following surgery.

3%

(101/3043)

2

The use of CPM has been associated with a decreased incidence of secondary surgery for knee manipulation.

2%

(55/3043)

3

The use of CPM has not demonstrated any difference in clinical outcomes at one year following surgery.

92%

(2790/3043)

4

The use of CPM has been associated with increasing analgesic pain requirements in the first 3 days following surgery.

2%

(74/3043)

5

The use of CPM decreases knee flexion at one year following surgery.

0%

(7/3043)

L 1 B

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