What is the diagnosis and treatment for Total Knee Replacement (TKR)?

From the Guidelines

Total Knee Replacement (TKR) is recommended for patients with symptomatic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy is ineffective, and the decision to proceed with surgery should be made through a shared decision-making process between the physician and patient. When considering TKR, it is essential to evaluate the patient's medical comorbidities and prior nonoperative treatments 1. The treatment approach for TKR involves a comprehensive evaluation of the patient's overall health, including factors such as obesity, diabetes mellitus, and nicotine dependence 1. For patients with obesity, surgery should not be delayed to meet a rigid weight or body mass index threshold, but rather patients should be educated on the increased risk of medical and surgical complications due to their obesity 1. In contrast, for patients with diabetes mellitus, surgery should be delayed to allow for improved glycemic control 1. Additionally, for patients with nicotine dependence, surgery should be delayed to achieve nicotine cessation or decreased use of nicotine products 1. The rehabilitation protocol after TKR typically includes range-of-motion exercises, progressive weight-bearing activities, and strengthening exercises, with the goal of achieving significant pain relief and improved mobility 1. Some key points to consider when evaluating a patient for TKR include:

• The patient's overall health and medical comorbidities
• The effectiveness of prior nonoperative treatments
• The presence of risk factors such as obesity, diabetes mellitus, and nicotine dependence
• The importance of shared decision-making between the physician and patient
• The need for a comprehensive rehabilitation protocol after surgery It is crucial to prioritize the patient's quality of life, morbidity, and mortality when making decisions about TKR, and to base these decisions on the most recent and highest-quality evidence available 1.

From the Research

Diagnosis of Total Knee Replacement (TKR)

• The diagnosis of TKR is typically made for patients with severe osteoarthritis (OA) of the knee, which is a top cause of disability among the elderly 2.
• The decision-making process for TKR surgery is complex and involves weighing numerous considerations, including social and cultural categories of aging, the role of healthcare professionals, coping strategies, and life context 3.

Treatment Options for TKR

• Total knee replacement (TKR) is an effective and definite surgical method to treat severe OA of the knee, but it is a significant procedure with potential risks for serious complications and high costs 2.
• Alternative lower-risk therapies, such as hyaluronic acid (HA) injections, can delay or obviate the need for TKR and are a safe and effective treatment to improve pain, function, and longevity of the knee 2.
• Multimodal analgesia, including regional anesthesia techniques, can provide good acute pain control after TKR, which is essential to prevent the development of chronic pain 4.
• Postoperative pain management after TKR can also be managed with pharmacological and non-pharmacological techniques, such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, and complementary or psychological therapies 4.
• Physical therapy (PT) is a common intervention after TKR, but the content, dose, and progression of PT services can vary widely, and evidence-based interventions may be underutilized 5.

Factors Influencing TKR Outcomes

• The role of healthcare professionals is a strong theme in the decision-making process for TKR surgery, and their involvement can shape patients' expectations of treatment options 3.
• Coping strategies and life context can determine short and longer-term outcomes of TKR, and patients' individual characteristics and circumstances should be taken into account when making decisions about surgery 3.
• The use of evidence-based interventions, such as closed chain exercises, and the progression of these exercises can be associated with better functional outcomes after TKR 5.