With the aging of the population, the prevalence of knee osteoarthritis (KOA) is increasing year by year, and at the same time, the number of knee replacements will also increase. The purpose of total knee replacement (TKA) is to relieve pain, improve physical function, and improve the overall quality of life. This surgery is considered the first choice for patients with advanced KOA. Although TKA has achieved effective clinical outcomes in KOA patients, complications such as joint infection and lower extremity venous thrombosis after surgery can easily aggravate the patient’s pain and even cause functional impairment of the affected limb, which can threaten the patient’s life in severe cases. This article reviews the research progress of TKA in the preoperative, intraoperative, and postoperative stages.
Preoperative Prevention
1. Preoperative disinfection of TKA Surgical site infection after TKA is considered one of the most serious postoperative complications. The presence of bacteria at the surgical site is the most important risk factor, so it is crucial to prevent infection through proper preoperative skin preparation. Research results have found that compared with povidone-iodine scrubbing and smearing, povidone-iodine scrubbing followed by chlorhexidine gluconate smearing and chlorhexidine gluconate scrubbing followed by povidone-iodine smearing have better killing effects on natural bacteria. At the same time, studies have shown that the mid-term results of TKA with coated implants and standard implants are similar, and there are no disadvantages to using coated implants in TKA.
2. Psychological counseling for patients before TKA Preoperative depression and anxiety are associated with high pain levels 1 to 2 years after TKA. Preoperative depression is also closely related to the severity of preoperative pain, and psychological stress has a negative impact on functional outcomes. It is of great significance for KOA patients to receive multidisciplinary intensive guidance before TKA, including lectures arranged by orthopedic surgeons, nurses, and physical therapists, covering preoperative and postoperative care, pain management, obtaining sports rehabilitation exercises, basic steps of surgery, and walking with walkers. In short-term evaluation, the differentiated education program of the multidisciplinary team has a positive effect on the functional outcomes, improved range of motion (ROM) and walking ability of patients undergoing TKA. Medical staff should pay attention to patient health education and psychological counseling, increase patients’ self-efficacy and hope level, avoid negative coping styles, and have a positive effect on patients’ postoperative recovery.
Intraoperative Treatment
1. Use of tourniquet during TKA surgery
TKA is the most effective surgical method for the treatment of end-stage knee osteoarthritis. This type of invasive surgical procedure is associated with significant blood loss and may require transfusion intervention in certain circumstances. Therefore, the requirements for operating room efficiency and surgical treatment quality are increasing. Tourniquet placement (TNQ) is an important step in TKA, its function is to reduce intraoperative blood loss and improve the surgical field of view. It is now recognized as a standard approach during TKA. However, the effectiveness and safety of tourniquet use during total knee arthroplasty is highly controversial. Multiple studies have shown that there is no significant difference in the timing of surgery, blood loss, thigh and knee pain, edema, joint range of motion, functional scores, and postoperative complications whether or not a tourniquet is used during surgery. However, quadriceps recovery takes longer after using a tourniquet. Not using a tourniquet can effectively shorten the operation time and improve early postoperative functional results.
2. Intervention of auxiliary robots during TKA surgery
Robotic technology was first introduced into orthopedic surgery in the 1980s to improve the accuracy of implant positioning and prosthetic alignment and to reduce complication rates compared with traditional manual techniques. Robotic-assisted knee osteoarthritis (r-TKA) improves surgeons’ preoperative planning capabilities and intraoperative real-time dynamic reference. Intraoperative real-time kinematic assessment allows comparison of osteoarthritic knees and neoprosthetic knees. However, trust in robotic TKA is limited by the lack of long-term clinical and functional outcomes compared with conventional TKA, and by concerns that robotic assistance in TKA can lead to increased costs and prolonged operative times. Data on robotic technologies continue to emerge, prompting clinicians to carefully and objectively examine their potential benefits. Multiple studies have shown that there is no significant difference in operative time, patient postoperative recovery time, and knee functional outcomes between r-TKA and conventional TKA.
Postoperative Recovery
1. Anticoagulation after TKA
The benefits of a successful TKA are significant, enabling pain-free knee motion and the patient’s return to most daily activities. However, massive intraoperative and postoperative blood loss and secondary acute anemia are major concerns for joint surgeons. Studies have shown that in the absence of blood protection measures, the perioperative bleeding volume of TKA can be as high as 2000 mL, and the blood transfusion rate is 10% to 62%. Blood transfusion plays an important role in postoperative complications. How to effectively reduce perioperative bleeding without increasing the risk of thrombosis is a hot topic in current research. Studies have investigated whether the combination of intravenous (IV) and oral tranexamic acid (TXA) during treatment is more effective than intravenous TXA alone in reducing the decline in hemoglobin (Hb) levels. To assess whether the use of additional oral TXA results in an increase in complications such as deep vein thrombosis (DVT) and symptomatic pulmonary embolism (PE). Although the complication rate did not increase, the results showed that continuous use of oral TXA for up to 5 days after intravenous TXA did not reduce the degree of Hb decline. Therefore, based on the research data, the combined use of oral and intravenous TXA is not recommended. Literature results show that short-term intravenous application of TXA after TKA can reduce hidden blood loss, but no increase in the actual incidence of VTE or potential risk of thrombosis has been measured, and administration of TXA after the first 24 hours has no significant effect. Continuous cryotherapy combined with intra-articular injection of TXA has short-term advantages in reducing blood loss, pain, postoperative swelling, and increasing ROM and joint function in the early postoperative period after TKA without increasing any serious complications. Oral TXA in postoperative knee replacement patients did not further improve blood loss compared with patients who received perioperative intravenous TXA before surgery and at wound closure.
2. Analgesia after TKA
Pain after TKA may hinder early recovery and lead to patient dissatisfaction. Therefore, postoperative pain management is crucial for functional recovery, patient return to society, and patient satisfaction after TKA. Results of a study using local infiltration analgesia (LIA) with steroids in TKA showed that steroids in LIA provided additional and long-lasting pain control and recovery benefits after TKA, with no adverse effects noted within 1 year after surgery. Other studies have shown that LIA combined with popliteal block can reduce patient pain levels, reduce opioid consumption, and improve functional outcomes. A study on the effect of butorphanol-assisted ropivacaine adductor canal block on postoperative analgesia in TKA patients found that under ultrasound guidance of butorphanol plus ropivacaine adductor canal block can prolong sensation. The duration of the block can relieve early postoperative pain, improve knee joint mobility, and does not affect the occurrence of postoperative complications.
3. Functional recovery after TKA
Currently, TKA represents an international standard of care, with 1,324,000 total knee replacement and revision surgeries performed in 18 countries around the world, particularly in the aging population. Although significant technical advances have been made in optimizing TKA surgery, a key challenge remains the rehabilitation of mobility impairments, which can impede activities of daily living, reduce social participation, and impact quality of life. The rehabilitation process after TKA is designed to restore the strength and flexibility of the knee joint and improve daily life and activities. However, to date, it is unclear which strength training is most effective in achieving this goal in a rehabilitation regimen. Therefore, rehabilitation guidelines after TKA include strength training/resistance exercise as the main way to restore knee joint function. Unilateral strength training is more effective than bilateral strength training in increasing strength in healthy individuals, and unilateral strength training improves strength and flexibility as well or better than standard bilateral strength training. In the early rehabilitation stage after TKA, combined kinetic chain exercise (CCE) training can serve as the basis for functional gait enhancement, improve patients’ living standards, prevent falls, and reduce fear of walking. Older adults undergoing TKA have limited knee range of motion due to pain and stiffness. Patients use roller massagers for rehabilitation after TKA, which can effectively treat stiffness and pain after TKA. Progressive muscle relaxation (PMR) + standard physical therapy (PT) has better results in both subjective and objective measures during hospitalization in TKA patients. The immediate use of an extended locking splint after TKA is a non-invasive, non-pharmacological, and inexpensive intervention with good results on knee range of motion, short-term functional improvement, and acute postoperative pain management. Resistance band exercises not only improve muscle strength and elasticity, improve efficiency, balance and quality of life, but also reduce the risk of injury.
References for this article: Jin Hongzhen, Wang Yan, Bai Haohao, et al. Research progress in the perioperative period of total knee replacement for the treatment of knee osteoarthritis. Chinese Journal of Integrated Traditional Chinese and Western Medicine Surgery, 2024, 30(1)144-149
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Post time: Aug-23-2024