2. Review of the literature
2.3 Hip and knee replacement operation
2.3.1 Indications
Lower extremity joint replacement operations are a treatment option for chronic arthritis, primary osteoarthritis being the most common indication. TJA is indicated
24
2.2.3 Epidemiology
In European general population, it is estimated that the prevalence of CKD is 6% in general adult population (So et al., 2015). In older patients, the prevalence of CKD is increased; in patients over 60 years of age prevalence of CKD is 17% whereas in patients older than 75 years of age the prevalence is 34%. (Browne et al., 2012; Levey, Andrew S. et al., 2003; Tomonaga et al., 2013).
2.2.4 Impact on life expectancy and morbidity
Patients with CKD are at increased risk for various diseases such as cardiovascular diseases, anemia, and endocrine disorders (Carney, 2020; Kuczera et al., 2015; Shaikh
& Aeddula, 2020). The most common cause of death in CKD patients is cardiovascular diseases. Due to increased plasma volume, CKD elevates blood pressure. It also increases the amount of circulating atherogenic low density
lipoprotein, causes chronic inflammation, and causes hyperphosphatemia, all of which increase vascular calcification. Calcification alongside increased plasma volume causes left ventricular hypertrophy. CKD, alongside functional kidney tissue due to fibrosis, decreases the formation of erythropoietin, leading to anemia. Also, renal failure (CKD stage 5) usually leads to uremia which without dialysis, is fatal. (Afsar et al., 2014;
Carney, 2020; Heaf & Mortensen, 2011; Kuczera et al., 2015; Shaikh & Aeddula, 2020;
Temgoua et al., 2017)
In general population, life expectancy decreases as CKD stage progresses (Turin et al., 2012). Co-presence of proteinuria with decreased eGFR is associated with poorer life expectancy (Hemmelgarn et al., 2010).
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2.2.5 Acute kidney injury
In AKI, glomerular filtration rate suddenly decreases leading to a decrease in urine output, electrolyte disorders and fluid retention. Major causes for AKI are ischemia (lack of blood supply), inflammation (cytokines and other pro-inflammatory
mediators) and rhabdomyolysis (Persson, 2013). Surgery related AKI is a multifactorial problem and many different surgery related factors contribute to AKI. These include anesthesia and fasting induced hypoperfusion, surgery induced mediators that lead to apoptosis and fluid retention, and nephrotoxins that all lead eventually in a decrease in the glomerular filtration rate temporarily or terminally (Gameiro et al., 2018). Also, inappropriate combination of medication such as antihypertensive medication, NSAID´s and diuretics can induce AKI (Fournier et al., 2014).
There are many definitions for AKI, but the most widely used is the risk injury failure loss and end stage (RIFLE) criteria. These define AKI incrementally in postoperative serum creatinine compared to the preoperative value. Postoperatively risk-stage patients have a 50%, injury patients have a 100% and failure patients a 200% increase in SCr from the preoperative value. Loss-stage patients have complete loss of renal function for over four weeks but under three months. End-stage patients have loss of renal function for over three months (Bellomo et al., 2007).
2.3 Hip and knee replacement operation
2.3.1 Indications
Lower extremity joint replacement operations are a treatment option for chronic arthritis, primary osteoarthritis being the most common indication. TJA is indicated
26
when a patient has pain and constricted range of motion in the joint during motion and rest that causes difficulties in daily living, along with radiological findings. Before proceeding to surgery, attempts at conservative treatment should been undergone first. These include weight loss, increased exercise, and analgesics. As there are no established cut off points in any of these indications, the decision to operate is made individually for every patient taking into account that patient’s characteristics.
(Gademan et al., 2016; Pivec et al., 2012; Price et al., 2018)
2.3.2 Operation techniques and perioperative care
In joint replacement operations, the damaged articulating surfaces are removed and replaced by a prosthesis. In hip replacement, the posterior approach is used most commonly to access the joint (Chechik et al., 2013; Varacallo et al., 2020a). With the posterior approach, the joint is reached through the gluteus maximus muscle and the distal fascia lata, from the posterior side of the gluteus medius muscle. The hip abductors are retained, but part of the external rotator muscles of the hip are cut through near the femur (Jolles & Bogoch, 2006). Then, the joint capsule is opened and the joint is revealed. Next, femoral head is cut and removed. The acetabular labrum is then removed and the sclerotic acetabular cup is reamed until healthy bone is reached.
Then the femur is prepared for the implants. Implant sizes are tested until the length, motion, and stability of the joint are appropriate. The femoral head is typically ceramic or made of metallic alloy, while the acetabular counterpart is typically made of
polyethene. Implants are placed either using bone cement or press-fitted. Cementless fixation of the prothesis components is mainly recommended in younger patients, while cemented fixation is more recommended for use among elderly patients (Jämsen et al., 2014; Stea et al., 2014). The joint capsule and external rotator muscles are sutured in place. In the more superficial layer, the gluteus maximus and fascia lata are closed, then the subcutaneous layer followed by skin. (Varacallo et al., 2020a)
27
In total knee replacement, a medial parapatellar approach is the standard technique (Peng et al., 2015). In this approach, the joint is accessed medially by dividing the lower aspect of the quadriceps tendon, the joint capsule medial to the patella extending near the patellar tendon distally. The medial and lateral meniscus are removed. Then, with guiding instrumentation, tibial and femoral surfaces are shaped to match the implants. The implant sizes are tested and implants selected. Femoral and tibial components are made of metallic alloys and there is a polyethene liner between the components. Sometimes the patella is resurfaced. Most implants are cemented in place (Prudhon & Verdier, 2017). Bone cement is often impregnated with antibiotic agents to reduce the risk of infection (Martínez-Moreno et al., 2017).
Perioperatively, insertion of bone cement has a rare but possibly lethal consequence known as bone cement implantation syndrome (BCIS), manifesting as hypoxia, hypotension or both (Khanna & Cernovsky, 2012). The incidence of lethal BCIS is 0.1% (Ereth et al., 1992). After bone cement implantation, the wounds are closed in three layers. (Varacallo et al., 2020b)
Besides the antibiotic agents in bone cement, most patients also receive intravenous antibiotic prophylaxis prior to surgery (de Beer et al., 2009; Jämsen, Peltola et al., 2013a; Siddiqi et al., 2019). On average, TJA is a 60 to 90 min operation with
transfusion rates of 13 to 16% (Carling et al., 2015; Jämsen et al., 2015). A tourniquet is traditionally used in knee replacement minimizing blood loss (Palanne et al., 2020) and operating time (Zhang et al., 2014). Although with modern fast-track surgical protocols, usage of tourniquet has decreased as earlier it was standard care in knee replacements (Tai et al., 2010). Most joint replacement procedures are made under spinal anesthesia but general anesthesia is also used (Perlas et al., 2016).
26
when a patient has pain and constricted range of motion in the joint during motion and rest that causes difficulties in daily living, along with radiological findings. Before proceeding to surgery, attempts at conservative treatment should been undergone first. These include weight loss, increased exercise, and analgesics. As there are no established cut off points in any of these indications, the decision to operate is made individually for every patient taking into account that patient’s characteristics.
(Gademan et al., 2016; Pivec et al., 2012; Price et al., 2018)
2.3.2 Operation techniques and perioperative care
In joint replacement operations, the damaged articulating surfaces are removed and replaced by a prosthesis. In hip replacement, the posterior approach is used most commonly to access the joint (Chechik et al., 2013; Varacallo et al., 2020a). With the posterior approach, the joint is reached through the gluteus maximus muscle and the distal fascia lata, from the posterior side of the gluteus medius muscle. The hip abductors are retained, but part of the external rotator muscles of the hip are cut through near the femur (Jolles & Bogoch, 2006). Then, the joint capsule is opened and the joint is revealed. Next, femoral head is cut and removed. The acetabular labrum is then removed and the sclerotic acetabular cup is reamed until healthy bone is reached.
Then the femur is prepared for the implants. Implant sizes are tested until the length, motion, and stability of the joint are appropriate. The femoral head is typically ceramic or made of metallic alloy, while the acetabular counterpart is typically made of
polyethene. Implants are placed either using bone cement or press-fitted. Cementless fixation of the prothesis components is mainly recommended in younger patients, while cemented fixation is more recommended for use among elderly patients (Jämsen et al., 2014; Stea et al., 2014). The joint capsule and external rotator muscles are sutured in place. In the more superficial layer, the gluteus maximus and fascia lata are closed, then the subcutaneous layer followed by skin. (Varacallo et al., 2020a)
27
In total knee replacement, a medial parapatellar approach is the standard technique (Peng et al., 2015). In this approach, the joint is accessed medially by dividing the lower aspect of the quadriceps tendon, the joint capsule medial to the patella extending near the patellar tendon distally. The medial and lateral meniscus are removed. Then, with guiding instrumentation, tibial and femoral surfaces are shaped to match the implants. The implant sizes are tested and implants selected. Femoral and tibial components are made of metallic alloys and there is a polyethene liner between the components. Sometimes the patella is resurfaced. Most implants are cemented in place (Prudhon & Verdier, 2017). Bone cement is often impregnated with antibiotic agents to reduce the risk of infection (Martínez-Moreno et al., 2017).
Perioperatively, insertion of bone cement has a rare but possibly lethal consequence known as bone cement implantation syndrome (BCIS), manifesting as hypoxia, hypotension or both (Khanna & Cernovsky, 2012). The incidence of lethal BCIS is 0.1% (Ereth et al., 1992). After bone cement implantation, the wounds are closed in three layers. (Varacallo et al., 2020b)
Besides the antibiotic agents in bone cement, most patients also receive intravenous antibiotic prophylaxis prior to surgery (de Beer et al., 2009; Jämsen, Peltola et al., 2013a; Siddiqi et al., 2019). On average, TJA is a 60 to 90 min operation with
transfusion rates of 13 to 16% (Carling et al., 2015; Jämsen et al., 2015). A tourniquet is traditionally used in knee replacement minimizing blood loss (Palanne et al., 2020) and operating time (Zhang et al., 2014). Although with modern fast-track surgical protocols, usage of tourniquet has decreased as earlier it was standard care in knee replacements (Tai et al., 2010). Most joint replacement procedures are made under spinal anesthesia but general anesthesia is also used (Perlas et al., 2016).
28
2.3.3 Outcomes
2.3.3.1 Clinical outcomes
In the treatment of osteoarthritis, hip and knee replacement operations successfully relieve symptoms and are cost-effective (Chang et al., 1996; Elmallah et al., 2017;
Walker et al., 2002). One quality-adjusted life year costs about 6,700 euros (Räsänen et al., 2007). Hip replacement patients are more satisfied with their one-year
postoperative outcomes than are knee replacement patients (Weber et al., 2018).
Better postoperative clinical outcome was found among patients with greater preoperative greater pain or disability, osteoarthritis (over otherindications), fewer comorbidities and fewer arthritic joints (Hawker et al., 2013; Niemeläinen, M. et al., 2019).
2.3.3.2 Postoperative complications, adverse events, and mortality
Postoperative complications in joint replacement operations are the same as in any surgical operations (bleeding, wound healing problems, infectious complications, neural deficits, and vascular injuries) but there are also operation specific
complications such as dislocations, implant fractures, and periprosthetic fractures (Healy et al., 2016). Joint replacement recipients are also at risk for various adverse events such as pneumonia, AKI, myocardial infarction, cerebrovascular event, deep vein thrombosis, pulmonary embolism, gastrointestinal ulcers, urinary retention and constipation (Berg et al., 2018). Readmission within 90 postoperative days due to adverse events is needed in about 4 to 7% of TJA operations (Berg et al., 2018;
Middleton et al., 2017). Diabetes and CKD increase the likelihood of surgical complications and morbidity after TJA, and there is no clear consensus about heart
29
disease, hypertension, liver disease and lung disease (Ackland et al., 2011; Podmore et al., 2018).
In the 90-day postoperative period, TJA recipients are at increased risk for ischemic heart disease, deaths due to malfunction of the digestive system and pulmonary embolism, which are the three major single causes of death (Hunt et al., 2017).
Increased risk for mortality after joint replacement plateaus at 90 days postoperatively (Berstock, J. R. et al., 2014; Berstock, James R. et al., 2018) and the 90-day mortality rate varies between 0.2 and 0.5% (Hunt et al., 2013; Middleton et al., 2017). In the long term, joint replacement operation reduces the risk of death postoperatively by approximately eight years, but patients have a higher mortality rate thereafter than in general population. (Gordon et al., 2016; Maradit-Kremers et al., 2016). A suggested etiology for this is cardiovascular events caused by a long-term inflammatory process (Gordon et al., 2016). Long-term mortality is caused by malignant neoplasms in about one third, circulatory disorders in one third and respiratory disorders in 10% of patients (Hunt et al., 2017). Risk factors for postoperative death include CHF, cardiovascular disease, anemia, diabetes and frailty (Bellamy et al., 2017; Bozic et al., 2012a; Hunt et al., 2013; Jämsen et al., 2013b).
2.3.3.3 Durability of joint replacement
Aseptic loosening, dislocation, adverse reactions to metal debris, periprosthetic fractures, infections, pain and wear are the most common reasons for revision joint replacement (Finnish arthroplasty register, 2020; Pivec et al., 2012; Price et al., 2018;
Sadoghi et al., 2013). Survival of hip implants varies from 91 to 95% at 10 years, whereas survival of the knee implants at 10 years is around 93-97% (Australian Orthopaedic Association National Joint Replacement Registry Annual Report 2020;
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2.3.3 Outcomes
2.3.3.1 Clinical outcomes
In the treatment of osteoarthritis, hip and knee replacement operations successfully relieve symptoms and are cost-effective (Chang et al., 1996; Elmallah et al., 2017;
Walker et al., 2002). One quality-adjusted life year costs about 6,700 euros (Räsänen et al., 2007). Hip replacement patients are more satisfied with their one-year
postoperative outcomes than are knee replacement patients (Weber et al., 2018).
Better postoperative clinical outcome was found among patients with greater preoperative greater pain or disability, osteoarthritis (over otherindications), fewer comorbidities and fewer arthritic joints (Hawker et al., 2013; Niemeläinen, M. et al., 2019).
2.3.3.2 Postoperative complications, adverse events, and mortality
Postoperative complications in joint replacement operations are the same as in any surgical operations (bleeding, wound healing problems, infectious complications, neural deficits, and vascular injuries) but there are also operation specific
complications such as dislocations, implant fractures, and periprosthetic fractures (Healy et al., 2016). Joint replacement recipients are also at risk for various adverse events such as pneumonia, AKI, myocardial infarction, cerebrovascular event, deep vein thrombosis, pulmonary embolism, gastrointestinal ulcers, urinary retention and constipation (Berg et al., 2018). Readmission within 90 postoperative days due to adverse events is needed in about 4 to 7% of TJA operations (Berg et al., 2018;
Middleton et al., 2017). Diabetes and CKD increase the likelihood of surgical complications and morbidity after TJA, and there is no clear consensus about heart
29
disease, hypertension, liver disease and lung disease (Ackland et al., 2011; Podmore et al., 2018).
In the 90-day postoperative period, TJA recipients are at increased risk for ischemic heart disease, deaths due to malfunction of the digestive system and pulmonary embolism, which are the three major single causes of death (Hunt et al., 2017).
Increased risk for mortality after joint replacement plateaus at 90 days postoperatively (Berstock, J. R. et al., 2014; Berstock, James R. et al., 2018) and the 90-day mortality rate varies between 0.2 and 0.5% (Hunt et al., 2013; Middleton et al., 2017). In the long term, joint replacement operation reduces the risk of death postoperatively by approximately eight years, but patients have a higher mortality rate thereafter than in general population. (Gordon et al., 2016; Maradit-Kremers et al., 2016). A suggested etiology for this is cardiovascular events caused by a long-term inflammatory process (Gordon et al., 2016). Long-term mortality is caused by malignant neoplasms in about one third, circulatory disorders in one third and respiratory disorders in 10% of patients (Hunt et al., 2017). Risk factors for postoperative death include CHF, cardiovascular disease, anemia, diabetes and frailty (Bellamy et al., 2017; Bozic et al., 2012a; Hunt et al., 2013; Jämsen et al., 2013b).
2.3.3.3 Durability of joint replacement
Aseptic loosening, dislocation, adverse reactions to metal debris, periprosthetic fractures, infections, pain and wear are the most common reasons for revision joint replacement (Finnish arthroplasty register, 2020; Pivec et al., 2012; Price et al., 2018;
Sadoghi et al., 2013). Survival of hip implants varies from 91 to 95% at 10 years, whereas survival of the knee implants at 10 years is around 93-97% (Australian Orthopaedic Association National Joint Replacement Registry Annual Report 2020;
30
Finnish Arthroplasty Register 2020; Jämsen et al., 2013a; Mäkelä et al., 2014;
Norwegian Arthroplasty Register Report 2019; NRJ 15th Annual Report 2015;
Swedish Hip Arthroplasty Register Annual Report 2018). In younger patients, the durability of TJA is poorer and the younger the patients is, the greater risk for lifetime revision operation (Bayliss et al., 2017; Niemeläinen, Mika J. et al., 2020; Norwegian Arthroplasty Register report 2019). Diabetes, CKD, pulmonary disease and cancer have shown little or no impact on the survival of hip or knee implants, whereas depression and psychotic disorders have been associated with poorer outcome (Jämsen et al., 2013a; Podmore et al., 2018).