Total knee replacement

[Etomidate]

Any of you ortho residents/attendings know the typical post-op course of a TKA in regards to pain and mobility?

Thanks.

 

[SOUNDMAN]

Well, normally we have them up and walking the next day. CPM machine for 8 hours a day, mostly at night. Try to increase to about 100 degrees by the time they are leaving Acute care which is 3 days. Then most likely acute rehab/transitional/swing bed type place. Some go home. No matter where they go they do PT 3x/week. Return to clinic around 2-3 week mark. staples out. X-ray. Then more PT most likely. RTC 6 weeks post op. And again at 12 weeks post op. Some people follow up to a year.

Should have about 110 degrees by 6 weeks for sure. If not, need to think about why, and if you will manipulate or more PT. Obviously early ROM is important.

 

[Etomidate]

Well, normally we have them up and walking the next day. CPM machine for 8 hours a day, mostly at night. Try to increase to about 100 degrees by the time they are leaving Acute care which is 3 days. Then most likely acute rehab/transitional/swing bed type place. Some go home. No matter where they go they do PT 3x/week. Return to clinic around 2-3 week mark. staples out. X-ray. Then more PT most likely. RTC 6 weeks post op. And again at 12 weeks post op. Some people follow up to a year.

Should have about 110 degrees by 6 weeks for sure. If not, need to think about why, and if you will manipulate or more PT. Obviously early ROM is important.

Thanks for the reply. Glad I was on here when you posted. Do you know what the typical post-op pain control regimen is? i.e. how long do they have a PCA, when do you switch to po pain meds, and how long do they usually continue on po pain meds?

 

[SOUNDMAN]

Thanks for the reply. Glad I was on here when you posted. Do you know what the typical post-op pain control regimen is? i.e. how long do they have a PCA, when do you switch to po pain meds, and how long do they usually continue on po pain meds?

many physicians are different. some here use a spinal with duramorph, gives about 24 hours of pain relief, and transfer them over to PO pain meds. Sometimes they use an epidural after surgery for pain relief as well. Take out at 48 hours. Any sooner, and some get serious rebound pain we've found. Ususally percocet and an anti-inflammatory of some sort for PO stuff.

Some start them on Kadian the night before surgery and continue that through 2 weeks or so of the post operative course, with or without regional pain control.

Some people do use PCA as well, however docs here don't do the continuous, only the patient monitored, with them dosing themselves.

Don't forget that toradol is the best pain medicine out there for orthopedics. We usually stop it before anticoagulation tx starts though.

Every patient is going to be different some need more than others. I think the keys to pain control are:

Early or pre-emptive use. This includes regional as well as pre-surgery narcotic use by anesthesia.
Continuous control of pain, never letting get ahead of you, always stay ahead of the pain, it's easier to control.
Using a variety of targets for your pain control, including anti-inflammatories, narcotics, ice...etc. Hit pain at all of the different levels.
I've seen people on PO narcotics for up to 6-12 weeks. 12 weeks is pushing it though probably. Even 6 weeks is a lot, but every patient is different.

I know I babbled a little, but some general thoughts out there for you.

 

[curious1]

Can orthos make extra money by referring patients over to a rehab center in which they have an ownership stake? or by setting up a new rehab center, hiring some specialists, and kicking all their patients over there?