Shelbourne Knee Center: Fall 2021 Newsletter

FALL 2021

NEWS

KNEE TREATMENT RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES

BILATERAL TKA:

THE RIGHT OPTION FOR SOME PATIENTS

WHILE MANY ORTHOPEDIC surgeons no longer perform bilateral total knee arthroplasty (TKA), for some patients the procedure is appropriate and beneficial. “Some patients are too anxious or too busy to go through TKA twice. They want to get it over with and move on with their lives,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center.

In carefully selected patients, bilateral TKA is safe and effective.

“My role is to talk about the pluses and minuses of both options,” says

Dr. Benner. “Once we figure out whether bilateral or staged TKA is the best option for that patient, we move forward.”

Good Outcomes With Few Complications A perceived higher risk of major complications is one reason for not performing bilateral TKA. Dr. Benner believes that the risks of bilateral TKA and two unilateral TKAs are similar.

“If you combine two unilateral TKAs, the complication rates are probably more comparable to the

risk of bilateral TKA,” he says.

Surgical advances such as the perioperative use of tranexamic acid have reduced major complications. By minimizing blood loss and the need for transfusion, tranexamic acid also has reduced the number of infections.

While bilateral TKA patients do have more pain initially than staged TKA patients, they only have the pain once. Shelbourne Knee Center’s TKA pain management protocol focuses on minimizing that pain.

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BILATERAL TKA:

THE RIGHT OPTION FOR SOME PATIENTS

“

OUR EXPERIENCE ENABLES US TO SELECT PATIENTS WHO ARE MOST LIKELY TO BE ABLE TO TOLERATE BILATERAL TKA AND PATIENTS FOR WHOM STAGED TKA IS A BETTER OPTION.

Key Criteria for Bilateral TKA • Severe osteoarthritis in both knees • Severe symptoms in both knees • Contraindications: - Cardiovascular risk factors - Diabetes - History of blood clots

”

— Rodney Benner, MD. Dr. Benner performs up to 30 bilateral TKAs each year.

Both bilateral and unilateral TKA patients usually are discharged from the hospital the day after the procedure and recover at the same rate. Few patients require inpatient rehabilitation. The center’s postoperative rehabilitation program, guided for each patient by one of the center’s physical therapists or athletic trainers, is the same whether patients have bilateral or unilateral TKA. “Our bilateral TKA patients do really well,” says Dr. Benner. “Our experience enables us to select patients who are most likely to be able to tolerate bilateral TKA and patients for whom staged TKA is a better option.”

REFERENCES 1. Schwinghammer AJ, Isaacs AN, Benner RW, et al. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother. 2017 Jun;51(6):451-456. doi: 10.1177/1060028017694655. Epub 2017 Feb 1.

NEWS

2 KNEE TREATMENT

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Better Pain Management After TKA Whether patients have unilateral or bilateral TKA, Shelbourne Knee Center’s TKA pain management protocol helps them recover faster and with less pain. Key elements of the protocol are: • • • •

Prevention of postoperative swelling.

Seven days of bed rest.

Use of a continuous passive motion machine.

Use of a Cryo-Cuff.

In the hospital, TKA patients receive a low-dose continuous infusion of Toradol (ketorolac) to control inflammatory pain. A study by Rodney Benner, MD, and colleagues found that post-op ketorolac improved pain control while reducing the use of opioids and adverse effects.1 “We found an 85% reduction in the amount of narcotic pain medication patients needed while in the hospital and statistically significant pain reduction,” says Dr. Benner.

Patients also take Tylenol, and after completing Toradol they take the NSAID Mobic (meloxicam). As needed, they also can take Tramadol or Norco (a combination of acetaminophen and hydrocodone, an opioid). “Very seldom do our patients need IV opioid pain medications,” says Dr. Benner.

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PCL TEARS: SURGERY OFFERS NO BENEFIT

OVERTREATMENT of isolated posterior cruciate ligament (PCL) tears with surgery is becoming increasingly common due to lack of understanding of the natural history of this rare injury and the belief that surgery prevents joint degeneration.

A two-part natural history study by researchers at Shelbourne Knee Center found that: • The PCL heals with nonoperative treatment.

• Some laxity does not reduce activity, strength or range of motion.

• The incidence of moderate to severe osteoarthritis was the same for nonoperative treatment and PCL reconstruction.1,2 “Our research shows that there’s no reason for orthopedic surgeons to operate on PCL tears,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.

Physical Therapy Heals PCLs Researchers followed patients treated non-operatively for isolated PCL injuries at Shelbourne Knee Center for an average of at least 5.4 years after injury in the first study and up to 21 years after injury in the second study. Nonoperative treatment consisted of physical therapy to reduce swelling and then

improve range of motion before strengthening.

The first study included subjective evaluation of 133 patients at a mean of 5.4 years after injury (range, 2.3 to 11.4 years) and objective evaluation of 68 patients. The second study included subjective evaluation of 68 patients at a mean of 14.3 years after injury (range, 10 to 21 years) and objective evaluation of 48 patients.

Subjective evaluation consisted of three annual questionnaires: •M odified Cincinnati Knee Rating System (CKRS).

• I nternational Knee Documentation Committee (IKDC) knee survey.

• Activity level survey.

Objective evaluation consisted of: • Digital radiographs.

• Physical exam.

•M easurement of range of motion.

No Justification for Surgery Justifying the expense and potential morbidity of PCL reconstruction would require it to be significantly better than nonoperative treatment.

“There is no evidence of this,” says Dr. Shelbourne.

Both studies were published in the American Journal of Sports Medicine.1,2 The American Orthopedic Society for Sports Medicine awarded Dr. Shelbourne and his co-authors on the original study a Hughston Award for the most outstanding paper published in the American Journal of Sports Medicine in 1999.

REFERENCES 1. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. May-Jun 1999;27(3):276-83.

2. S helbourne KD, Clark M, Gray T. Minimum 10-Year Follow-up of Patients After an Acute, Isolated Posterior Cruciate Ligament Injury Treated Nonoperatively. Am J Sports Med. 2013;41(7):1526-1533.

Results for 5.4 Years of follow-up1 • No change in laxity from initial injury to follow-up.

• No correlation between radiographic joint space narrowing and laxity grade.

• More laxity did not result in worse subjective scores.

• Regardless of the amount of laxity: - Half of the patients returned to the same sport at the same or a higher level.

- One-third returned to the same sport at a lower level.

- One-sixth did not return to the same sport.

Results for 10+ years of follow-up2 • Mean quadriceps muscle strength - 97% of the noninvolved leg • Normal knee range of motion - 100% of patients • Radiograph grade - Normal: 26 patients (59%) - Nearly normal: 13 patients (30%) - Abnormal: 4 patients (9%) - Severely abnormal: 1 patient (2%) • Osteoarthritis on radiographs - No differences based on PCL laxity grade - Medial joint space narrowing greater than 2 mm: 5 patients (11%) • Mean IKDC subjective scores - 73.4 + 21.7 • Mean modified CKRS subjective scores - 81.3 + 17.4

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NONPROFIT

U.S. POSTAGE PAID Indianapolis, IN

1500 N Ritter Ave #500, Indianapolis, IN 46219

PERMIT #PI-1345

TO CONSULT WITH ONE OF OUR SURGEONS, CALL

888-FIX-KNEE (317-924-8636) Our orthopedic surgeons, Rodney Benner, MD, and K. Donald Shelbourne, MD, founder of Shelbourne Knee Center.

MEET OUR TEAM ORTHOPEDIC SURGEONS K. Donald Shelbourne, MD n Rodney Benner, MD n

Sharing Our Rare Knee Injury Expertise RARE KNEE INJURIES often have devastating consequences. Yet their low incidence rate makes determining optimal treatment difficult. Because we specialize only in knees, Shelbourne Knee Center sees more rare knee injuries than most orthopedic practices, and we welcome the

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opportunity to discuss these cases with our colleagues.

Through our Rare Knee Injury Research Program, we’ve begun to identify outcomes and factors related to those outcomes for the following injuries: n Arthrofibrosis

n Chronic

patella tendonosis n Failed

ACL surgery n Knee

dislocations n Patellar

tendon rupture n Patellar

femoral instability n Quadriceps

tendon rupture.

Whether you would like to discuss a case or make a referral, patients will benefit from our research-backed treatment protocols. Referrals enable us to expand our research to further improve treatment for rare knee injuries.

To discuss a rare knee injury or other case with one of our orthopedic surgeons, email skckneecare@ecommunity.com or call 888-FIX-KNEE (317-924-8636).

CLINICAL TEAM n Jean Fouts, RN, BSN n Lee Linenberg n Sara Hopkins, NP PHYSICAL THERAPISTS AND ATHLETIC TRAINERS n Bill Claussen, MPT n Emma Sterrett, LAT, ATC n Laura Bray-Prescott, PT/LATC n Scot Bauman, PT, DPT n Darla Baker, PT, DPT ATC/L n Sarah Eaton, PT, DPT, ATC, LAT n Jennifer Christy, PT n Rachel Slaven, PT, DPT n Alana Gillenwater, PT, DPT RESEARCH TEAM n Adam Norris n Tinker Gray, MA, ELS n Heather Garrison n Diane Davidson

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