Adolph V. Lombardi Jr, MD, FACS

AAOS Now

Published 8/31/2019
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Kerri Fitzgerald

JAMM Course Director Details the Latest Trends in Total Hip and Total Knee Arthroplasty

The 2020 Joint Arthroplasty Mountain Meeting (JAMM)® will take place Feb. 2–5, 2020, in Park City, Utah, offering strategies to improve operative performance and patient outcomes for total hip arthroplasty (THA) and total knee arthroplasty (TKA). JAMM Course Director Adolph V. Lombardi Jr, MD, FACS, spoke with AAOS Now about the latest research and updates in joint arthroplasty.

AAOS Now: What are the current hot topics and challenges in joint arthroplasty?

Dr. Lombardi: My colleagues and I are still very concerned about preparing patients for surgical intervention. There are many things we consider as modifiable risk factors, such as smoking status, prior deep vein thrombosis, preoperative anemia, malnutrition, and obesity. I think these things need to be discussed and vetted.

In the knee arena, there is continued discussion on whether a patient is a candidate for a partial knee replacement: Should we do a medial unicompartmental? When is it indicated? What are the results, and who should do the medial unicompartmental? Are there indications for lateral unicompartmentals? In the partial knee area, is there a place for robotic surgery, and does this intervention actually enhance or improve the results of partial knee replacement?

There is also an ongoing discussion on whether to consider a patellofemoral replacement in certain patients: Should we be doing compartmental knee surgery or total knee replacement (TKR)?

In the arena of TKR, we’re seeing a greater enthusiasm for multiple types of bearings. Should we use a standard cruciate retaining bearing, a medial congruent bearing, a lateral congruent bearing, or an ultracongruent bearing?

There’s also ongoing and increasing enthusiasm for cementless knee arthroplasty. Things to think about are whether this is really the future, what type of cementless interface we are looking for, what has been successful to date, and what we will see happen in the future.

In the hip arena, a top issue is whether to consider cemented fixation of the femoral stem in older, osteopenic female patients or whether to continue to try to use the cementless implants. There is some information on an increasing number of periprosthetic fractures in the older female population with cementless devices. Can we change that by actually changing our mindsets?

There are growing enthusiasm and concern regarding THA patients who have had previous spine surgery. Is there a need to evaluate the spine in sitting and standing positions preoperatively? Do we just need to consider using dual mobility in all of those patients, or are we increasing the use of dual mobility too rapidly without a lot of good data? With dual mobility, is it something that we should be doing in the patients who present with acute subcapital hip fracture? I think tightening the indications for when to do dual mobility is important.

There is a growing interest in outpatient surgery right now. As we approach 2020, it will be interesting to learn the final decision from the Centers for Medicare & Medicaid Services (CMS). Will CMS remove THA from the inpatient-only category? It appears that they will allow TKA in an ambulatory surgery center. With these changes, will we see more patients moving from inpatient to outpatient facilities? What do we need to do to allow that to happen safely for the patient? Are there preoperative parameters we need to develop and establish?

There is still an ongoing concern about metal-on-metal failure and issues with the taper or trunnion in metal in our basic THAs. Should we be doing ceramic femoral heads in all patients? Is there still a place for chrome cobalt heads?

Another debate will be on the opioid epidemic and what we as surgeons are doing to decrease opioid use in our patients. How do we effectively approach the patients—do we set up contracts for postoperative opioid use? How do we deal with patients who have used opioids preoperatively? How do we get patients to understand that we cannot continue to supply them with more opioids postoperatively?

What is your approach for managing opioids in your post-surgical patient population?

Dr. Lombardi: Managing opioids has indeed become very important and timely in our practice. We are carefully interviewing patients preoperatively to assess opioid usage. If there is significant opioid usage, we have a thorough discussion with the patient on the implications of opioid usage and techniques to reduce opioids pre- and postoperatively. We thoroughly embrace the multimodal pain-management approach to include a number of preoperative medica­tions such as corticosteroids to reduce inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen. Postoperatively, we are advocating the use of NSAIDs and acetaminophen. As a practice, we are moving away from extended utilization of oxycodone and recommending usage of tramadol. We attempt to discontinue prescribing narcotics by 10 to 14 days postoperatively. 

Can you talk about the use of robots in unicompartmental, partial, and TKR?

Dr. Lombardi: The success of partial knee replacement and TKR is a combination of appropriate boney resections to accomplish appropriate alignment and accurate soft-tissue balance. Over the past decade, smart tools have been introduced to assist surgeons in both implantation and balancing of soft tissues in knee arthroplasty. The robot is the most sophisticated extension of this smart-tool technology and allows for the most accurate placement of the components and can give the surgeon feedback on the gaps created in both flexion and extension, which is a secondary indicator of soft-tissue balance. This phase will only continue to grow and enhance total joint arthroplasty.

How are registry data impacting joint arthroplasty research and best practices?

Dr. Lombardi: The usefulness of registry data lies in the fact that they give us rapid access to multiple data points. As surgeons, we can understand quickly what our colleagues across the country are doing by utilizing national benchmarks and patient outcomes. There is some very interesting information coming from registries, such as the number of patients receiving a cemented femoral versus cementless component THA, the number of fractures in cemented versus cementless THA, which bearings are being utilized in TKA, and the percentage of patients receiving partial knee arthroplasty. The American Joint Replacement Registry (AJRR) is just beginning to give U.S. surgeons this type of information. It certainly will have a great impact on how we proceed with care and treatment in our arthroplasty patients.

More about JAMM 2020

The 2020 Joint Arthroplasty Mountain Meeting (JAMM)® is presented in a small-group, roundtable format in partnership by The Hip Society and The Knee Society, as well as AAOS, and includes case discussions, keynote addresses, symposia, and point-counterpoint debates on treatment decision-making.

“The format of this meeting is very unique,” said JAMM Course Director Adolph V. Lombardi Jr, MD, FACS. “JAMM is an interactive experience. Session topics will include whether to do outpatient total joint surgery, whether to do bilateral knees together or stage them, whether you need to do formal postoperative physical therapy in all patients, and the role of new devices that have been brought to the market to help monitor patients postoperatively. The content is presented in multiple formats, so it’s never boring. The style and format are always changing, so no two sessions are exactly the same.”

Attendees will have the opportunity to be involved and engage with the faculty, as there is ample time built into the schedule for question-and-answer sessions with panelists and speakers. “Attendees can also present their solutions to particular case discussions and receive direct input from faculty on whether they think the solutions are correct or how they would proceed,” said Dr. Lombardi.

Visit www.hipsoc.org to learn more and register for the meeting. For more information on AJRR, visit www.aaos.org/ajrr.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.