Michael P. Nett

Postoperative Pain Management

Although the long-term results following traditional total joint arthroplasty are excellent, postoperative pain management has been suboptimal. Under-treatment of pain is a focus of growing concern to the orthopedic community. Poorly controlled postoperative pain leads to undesirable outcomes, including immobility, stiffness, myocardial ischemia, atelectasis, pneumonia, deep venous thrombosis, anxiety, depression, and chronic pain. Over the past decade, the attempt to minimize postoperative complications, combined with the move toward minimally invasive surgery and early postoperative mobilization, has made pain management a critical aspect of joint replacement surgery. Effective protocols are currently available; all include a multimodal approach. Debate continues regarding the ideal approach; however, reliance on narcotic analgesia alone is suboptimal.

Unanswered Questions, Unmet Needs in Venous Thromboprophylaxis

Although significant progress has been made over the past 25 years in preventing thromboembolic disease in patients undergoing total hip and total knee arthroplasty, important questions remain unanswered. Few would debate the need to seek a balance between maximal antithrombotic efficacy and minimal bleeding in choosing a thromboprophylactic strategy, but there is less agreement as to how efficacy should be defined, and whether efficacy and safety (however each is defined) are intrinsic to the thromboprophylactic agent chosen or depend as well on exogenous factors, ranging from the timing of drug administration to surgical technique. Differences between recent guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) illustrate these unanswered questions. The AAOS guidelines focus solely on preventing symptomatic pulmonary embolism and ignores the importance of other acute and chronic manifestations of venous thromboembolic disease. The ACCP, on the other hand, does consider these other manifestations of venous thromboembolic disease, and thus reaches very different conclusions about what constitutes effective thromboprophylaxis. Despite these questions and uncertainties, there are fundamental truths: (1) venous thromboembolism (VTE) is a known and serious complication of total joint arthroplasty, and (2) evidence-based thromboprophylaxis works. Gaps between guideline-recommended and actual orthopedic practice must be reduced.

Blood Loss and Transfusion Rates Following Patellofemoral Arthroplasty

Patellofemoral arthroplasty (PFA) is a viable treatment option of the patient with isolated patellofemoral arthritis. Some of the purported advantages of PFA compared with total knee arthroplasty (TKA) include less invasive approach, less bone resection and tissue destruction, decreased operative time, shorter rehabilitation, better knee kinematics, and decreased blood loss. This study compared the blood loss associated with PFA with that of a cohort of patients with TKA. A proposed benefit of partial knee arthroplasty is less blood loss. Patellofemoral replacement seems not to have this benefit and blood loss prevention initiatives similar to those of TKA should be maintained.

Management of Soft Tissue Defects

Wound complications following total knee arthroplasty (TKA) can be a serious and challenging problem. As the number of TKAs increases annually, the number of complications is expected to rise. Impaired wound healing or soft tissue compromise can lead to more devastating complications, such as extensor mechanism disruption and infections. An organized approach to wound complications includes identification of the lesion, classifying the severity and depth of the defect, and initiating appropriate treatment [1]. Optimal treatment requires a comprehensive interdisciplinary approach with collaboration between orthopedic surgery and plastic surgery. Critical for a successful outcome and implant retention is timely reaction to the appearance of a wound problem and restoration of complete soft tissue coverage [2].