From the Guidelines
I strongly recommend approving this 45-year-old male patient for right total knee arthroplasty. The patient has demonstrated significant improvement in his BMI, decreasing from 41 to 33, addressing the primary concern that led to the postponement of his surgery on 7/10/2023. He has exhausted all conservative treatment options including NSAIDs, acetaminophen, physical therapy, home exercises, activity modification, bracing, and intraarticular injections without relief. His chronic right knee pain of 10 years significantly limits his mobility to walking only 3 blocks and causes difficulty with stairs. The surgeon had previously approved the surgery on 5/3/2023 despite concerns about age and BMI, and the patient understands and accepts the surgical risks. Physical therapy has been thoroughly attempted, with documentation from Westburg PT stating he is no longer benefiting from therapy. Given his persistent symptoms despite comprehensive conservative management, significant functional limitations, documented weight loss efforts, and previous surgical clearance, proceeding with the total knee arthroplasty is appropriate at this time to improve his quality of life and functional status, as supported by the 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons clinical practice guideline for the optimal timing of elective hip or knee arthroplasty 1.
Key Points:
- The patient has tried all conservative treatment options without relief
- Significant improvement in BMI from 41 to 33
- Previous surgical clearance despite concerns about age and BMI
- Patient understands and accepts surgical risks
- Physical therapy has been thoroughly attempted without benefit
- Proceeding with total knee arthroplasty is appropriate to improve quality of life and functional status, as per the latest clinical practice guidelines 1.
Recommendations:
- Approve the patient for right total knee arthroplasty
- Educate the patient on the risks and benefits of the surgery
- Ensure the patient understands and accepts the surgical risks
- Proceed with the surgery as planned to improve the patient's quality of life and functional status, as supported by the clinical practice guidelines 1.
From the Research
Patient Profile
- The patient is a 45-year-old male with a 10-year history of right knee pain, stiffness, and instability.
- The pain is localized in the anterior, medial, and lateral knees and worsens with activity.
- The patient has tried various treatments, including NSAIDs, acetaminophen, physical therapy, and intraarticular injections, without success.
Treatment Options
- The patient has been considered for total knee arthroplasty (TKA), but the surgery was postponed due to a high BMI of 41 2, 3.
- The patient has been losing weight and now has a BMI of 33, making them a more suitable candidate for surgery.
- Studies have shown that TKA can be an effective treatment for end-stage osteoarthritis, with benefits including improved pain management and reduced disability 3.
Pain Management
- The use of intravenous acetaminophen has been shown to be effective in reducing postoperative pain and opioid consumption after TKA 2, 4, 5, 6.
- A systematic review and meta-analysis found that intravenous acetaminophen was not superior to oral acetaminophen in terms of pain scores, but it did reduce the length of hospital stay 5.
- Another study found that intravenous acetaminophen significantly reduced opioid requirements and improved pain scores in patients undergoing TKA 6.
Surgical Considerations
- The patient's age and BMI are important factors to consider when evaluating the risks and benefits of TKA 2, 3.
- The surgeon has approved the surgery, and the patient has been informed of the risks and benefits 2.
- The patient has undergone physical therapy and has been advised to see an orthopedic specialist after the 4/2023 visit 2.