(A) Applicable target.
First diagnosis of severe knee osteoarthritis (ICD-10:M17)
Total knee arthroplasty (ICD-9-CM-3:81.54)
(B) Diagnostic basis.
According to the Clinical Diagnosis and Treatment Guide-Orthopaedic Division (edited by Chinese Medical Association, People’s Health Publishing House), Osteoarthritis Diagnosis and Treatment Guide (2007 edition), Modern Artificial Joint Surgery (People’s Health Publishing House).
1. Medical history: intermittent knee pain for many years, recently aggravated with limited activity.
2. Physical examination with clear signs: knee swelling, flexion contracture and inversion or valgus deformity, knee mobility limited to varying degrees, and pain during hyperflexion and hyperextension.
3. Adjunctive examinations: weight-bearing x-ray of the knee joint shows obvious patellofemoral joint lesions with significant narrowing or loss of the medial, lateral or bilateral joint space.
(C) Selection and basis of treatment plan.
According to the Clinical Diagnosis and Treatment Guide-Orthopaedic Division (edited by Chinese Medical Association, People’s Health Publishing House), the Guide to the Diagnosis and Treatment of Osteoarthritis (2007 edition), Modern Artificial Joint Surgery (People’s Health Publishing House)
1.No recent systemic or local infection.
2.No serious comorbidities.
3.Preoperative quality of life and activity level assessment.
(D) Standard hospitalization days are 14-20 days.
(V) Entry pathway criteria.
1, The first diagnosis must meet the ICD-10: M17 severe knee osteoarthritis disease code.
2.When suffering from other diseases, but do not require special treatment during hospitalization nor affect the implementation of the clinical pathway process for the first diagnosis, they can enter the pathway.
(F) Preoperative preparation 3-5 days.
1. Required examination items.
(1)Blood routine, urine routine ;
(2)Liver and kidney function, electrolytes, blood glucose, blood lipids;
(3) Blood sedimentation, C-reactive protein;
(4) Coagulation function;
(5) Infectious disease screening (hepatitis B, hepatitis C, AIDS, syphilis, etc.);
(6) Chest X-ray, electrocardiogram;
(7) Bilateral frontal and lateral x-ray of the knee joint and axial patellar film.
2. Depending on the patient’s condition, the following options are available.
(1) Weight-bearing X-ray or full-length film of both lower limbs if necessary;
(2) Echocardiography, blood gas and pulmonary function;
(3) Lumbar or cervical frontal and lateral X-rays, MRI (if history or physical examination suggests spinal lesions);
(4) Preoperative blood distribution;
(5) timely consultation with relevant departments for those with related diseases.
(7) Selection of medication.
Antimicrobial drugs: follow the Guidelines for Clinical Application of Antimicrobial Drugs (Wei-Hai-Fa [2004] No. 285).
(H) The surgery day is the 3rd-5th day of admission.
1.Anesthesia mode: nerve block anesthesia, intralesional anesthesia or general anesthesia.
2. Surgical procedure: total knee arthroplasty.
3. Surgical implants: artificial knee prosthesis, bone cement.
4. Blood transfusion: depending on bleeding after intraoperative relaxation of tourniquet.
(ix) Post-operative hospital recovery 10-14 days.
1.Checkup items that must be reviewed: blood routine, front and side x-ray of both knees.
2.Check coagulation function, hematocrit, CRP, D-Dimer, ultrasound/CTPA of deep veins of both lower limbs if necessary.
3, Postoperative management.
(1)Antimicrobial drugs: follow the Guidelines for Clinical Application of Antimicrobial Drugs (Wei-Hai-Fa [2004] No. 285);
(2) Postoperative treatment of venous thromboembolism prevention: refer to the “Guidelines for the Prevention of Venous Thromboembolism after Major Orthopedic Surgery in China”;
(3) Postoperative rehabilitation: active exercise is the mainstay and passive exercise is supplementary;
(4) Postoperative analgesia: refer to the Expert Recommendations on the Management of Common Pain in Orthopedics.
(J) Discharge criteria.
1, normal body temperature, no significant abnormalities in routine laboratory indicators (except for blood sedimentation and CRP).
2.Good wound healing: drainage tube removed, no signs of infection in the wound (or wound conditions that can be treated in the outpatient clinic), no skin flap necrosis.
3.Knee joint function improved.
4. No complications and/or comorbidities requiring inpatient management.
(XI) Analysis of variants and causes.
1.Medical comorbidities: Patients with advanced severe osteoarthritis are often combined with underlying medical diseases, which require detailed medical examination and consultation with relevant departments during the perioperative period, and the preoperative preparation time needs to be extended; the use of related drugs at the same time will increase the hospitalization cost.
2. Peri-operative complications: Differences in patients’ bone conditions, deformity types, and severity of arthritic lesions may lead to surgery-related complications, such as fracture, ligament injury, neurovascular injury, deep vein thrombosis, infection, etc. The need for prolonged down time and rehabilitation after surgery may result in longer hospital days and increased costs.
3. Choice of artificial knee prosthesis: There are more artificial knee prostheses available for different types of joint lesions, which can lead to differences in hospitalization costs.