Connections: Backing strong science in total joint replacement | Fall 2018

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From OHSU Orthopaedics and Rehabilitation

Dr. Ryland Kagen - total joint surgeon

Ryland Kagan, M.D.

Dr. Kagan is an orthopaedic surgeon with fellowship training in adult reconstruction (hip and knee replacement) and hip preservation. His areas of clinical interest include evaluation of patient engagement platforms including telemedicine as well as evaluation of Patient Reported Outcomes with a focus on quality and value in joint replacement surgery.

With an anticipated wave of elective joint replacement surgeries on the horizon, technologies and techniques are changing rapidly. However, not everything new has clinical evidence to support it. Here are the most compelling differentiators for positive outcomes of total joint replacement based on a large body of scientific evidence:

  • Selection of the least invasive procedure options for knee and hip.
  • Rapid recovery protocols that minimize or eliminate narcotics.
  • Surgical expertise in a high-volume center of excellence.
  • Advanced imaging and computer guidance.

Less is more in replacement procedures

For knees, a partial replacement is an excellent option for patients with isolated disease affecting only one portion of the knee. Numerous studies report fewer complications and improved patient-reported outcomes in terms of function and pain. By preserving the ligaments, the procedure restores the native anatomy, giving the patients a more “normal” feeling knee.

For total hip arthroplasty, surgeons have a choice of minimally invasive options, influenced by patient selection, implants used and surgeon’s preference. Some surgeons, like me, prefer the direct anterior approach. Others prefer the mini-posterior. Both approaches achieve the desired results with fewer complications than traditional hip replacement. Outcomes are tied less to the surgical approach than to the experience of the surgeon in that technique.

Expedited recovery through multimodal pain therapies

Perhaps the most significant factor in positive outcomes in joint replacement is a holistic perioperative plan from preoperative education to postoperative rehabilitation. A critical component is the use of multimodal pain strategies (including selective nerve blocks and intraoperative injections) to minimize or eliminate the need for narcotics. Then, immediately mobilizing the patients after surgery. Scientific evidence supports that using these rapid recovery protocols can lower the risk of complications (such as deep vein thrombosis or pulmonary embolism), avoid narcotic usage and get patients back to their lives quicker.

Expertise and experience matter

The literature is clear that outcomes are more positive in high-volume centers of distinction with sub-specialty-trained surgeons who can apply the appropriate techniques.

Computers, images and robots

In some cases, technology is evolving faster than the evidence to prove its effectiveness. At OHSU, we focus on using technology shown to make a clinical difference in outcomes without adding a cost burden to the care. One method with good science behind it is intraoperative imaging. For example, evidence supports digital fluoroscopic technology for improving component placement and restoration of anatomy. Computer and robotic assistance technology are still evolving and not all the evidence is persuasive. At OHSU, we use intraoperative computer guidance and patient-specific instrumentation for component alignment.

Better solutions make recovery quick and restriction-free

Many patients can have total joint replacement and leave the hospital the same day. Others may need an overnight visit. By the end of their therapy, there are generally no restrictions on activities, and they can return to their favorite pastimes such as golf, tennis, hiking, skiing and more. Our only precaution is for avid runners, as theoretically, the implant may wear faster under frequent impact.

When to refer or consult:

  • Any patient with clinical and radiographic evidence of osteoarthritis to discuss options.
  • Any patient with hip dysplasia or other congenital hip abnormalities to discuss options.

Contact us

Our orthopaedic surgeons at OHSU are available to answer questions about total joint replacement or revision surgeries.

If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567. 

Prevention via hip preservation

OHSU Department of Orthopaedic Surgery and Rehabilitation provides the only comprehensive care in the region for patients with any hip disorder. These conditions include hip dysplasia, slipped capital femoral epiphysis, femoral acetabular impingement, Perthes disease and arthritis. We can see pediatric, adolescent, adult and geriatric patients. If we can treat these disorders early, it may be possible to preserve the hip and the patient can avoid cartilage breakdown and long-term issues. We provide non-operative management, injections, pain management guidance, arthroscopy surgery and osteotomy surgeries, such as the Bernese periacetabular osteotomy surgery.