Download Total Knee arthroplasty in young Adults

Total Knee Arthroplasty in young
Adults
H. Makhmalbaf MD
Consultant Orthopedic & Knee Surgeon
Ghaem Hospital Medical Center
Mashhad IRAN
17th Oct 2011 Tehran
Introduction
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The percentage of patients decreased
Improvement in medical treatment
The backlog of patients has been operated
Training of residents and fellows
TKR in JRI
David Palmer et al
JBJS July 2005
8 pts, 15 knees, average age 16.8 yrs
Evaluation of pain, ROM, walking, X-ray find.
Follow up, 16.5 yrs, pain & functional limit.
Before surgery, 7 of 8 on wheelchair
3 revisions, all pain free, 6 able to walk
Mean ROM from 37°
79°
Good results, pain & function
Causes of OA in young
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Rheumatoid arthritis
Post trauma
Hemophilia
Post infection
Septic arthritis
TB
Osteonecrosis
Ipsilateral hip involvement
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More frequent in RA than OA
Evaluate the hip thoroughly
Operate on the hip 1st
Referral knee pain from the hip
Hip surgery is easier, patient accepts TKR
THR before TKR
• Exercising a hip is easier over a painful knee
• Resolve tension of muscles which cross both
hip & knee
• Correction of knee deformity during THR
• It avoids twisting a well balanced a TKR during
dislocating a stiff hip for THR
Flexion contracture
• FC are more prevalent in RA than OA
• Contracture is mainly because of inflammation
in oft tissues
• If FC is<15 normal distal cut+ posterior release
• If FC is 15-45 cut 2mm more for every 15
• If FC is 45-60 pre op MUA & casting & a PS kn
• For FC >60 pre op MUA & casting&
constrained knee to avoid flexion gap laxity
Rheumatiod cyst
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Cysts are more common in RA
Large cysts
Curett & fill with cancellus bone
Large central cysts need impaction bone
grafting
Patellar resurfacing
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Resurface or not?
Its different from OA
Resurface in all RA patients ?
Some do well without
Chance of recurrence of synovitis if not
Synovectomy & recurrent active
rheumatoid synovitis
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Its possible the RA synovitis to recur after TKA
If patella is not resurfaced or cartilage left
Even if patella is resurfaced syn. Is seen
If acute presentation, large effusion
Synovectomy & recurrent active
rheumatoid synovitis
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Dif. Diagnosis is infection
Aspiration for cell count & culture
If multiple joints involved medical treatment
Initial synovectomy at TKR if
Risk for infection
• The risk of periop & metastatic infection is
higher in RA than OA
• Later metastatic infection is more common
• Because of immune compromised pat.
• the sources are: foot, lower leg & olecranon
bursa
Need for adequate knee flexion
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The RA patients need more flexion than OA
To have satisfactory function
60-70 flexion for walking
90 deg. For ascending stairs
100 deg for descending & sitting up from chair
Involvement of other joints
Use of crutches
Osteopenia
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Can present difficulties during TKA
Notching & postoperative fracture
If so, put long stem femoral component
If between two sizes cut not for smaller
fracture during preparation for surgery
If the hip is stiff there is more chance
Post TKA fracture during MUA for stiffness
Osteopenia
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Patella fracture during MUA
Avulsion of MCL during TKA
Fix with a cancellus screw & washer
Intraoperative frac. Of patella
Cemented component In osteopenic bone
Anesthetic consideration
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Because involvement of C-spine
Preoperative consultation with
Anesthesiologist
Lateral c-spine X-rays in flx. & ext
Regional anesthesia is preferred over GA.
Prepare for GA in case it is needed
PCL preservation v
substitution
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PCL retaining or sacrificed
CR does well in most RA patients
PCL might stretch over the time
Instability & hyperextension
Put the insert tight during TKA
Minimal bone cut
Check PCL before opening prosthesis
Summary
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Management difficulties
Ipsilateral Hip involvement
Bilaterality , anticoagulation needs
Flexion contractures, rheumatoid cysts
Patella resurfacing, synovectomy
More chance of infections
Adequate flexion for daily living & spare uppe
Osteopenia & fractures
Thank you
Indications
• Pain
• Instability
• Limitation of ROM
–Conversion to a:
• Stable
• Pain free
• Mobile joints
Symptoms
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Pain
Limitation of ROM
Stiffness , ankylosed knee
Instability
Limitation of extension & Fixed deformity
Combination of these
Important factors
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Fixed deformity
Mal alignment
Leg length discrepancy
Bone loss
Bone Stock
Bone Quality
Important factors
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Patients expectations
Socio economic condition
Chance of failure
Consult the patients
Need for revision
Knee score
Deformities
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Varus
Valgus
Recurvatum
Leg length
Intra articular deformity
Extra articular deformity
Pre op evaluation: Medications
Steroids
NSAID
Anti TB
Coagulation factors
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Pre op evaluation: Imaging
Standing X-ray
AP & Lateral
Alignment view
MRI
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Pre op evaluation: Laboratory
ESR
CBC
CRP
RF
Factor IIIV
Tuberculin test
Urinalysis
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Intra operative
Examination of the patient
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Range of movement of the knee
Previous scars
Sinus tract
Skin condition
NV status
Ligament deficiency or Laxity
Other joints conditions
Deformities & Length of the leg
Quadriceps working
Pre op considerations
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Pre op physiotherapy
Medications
Timing of surgery
Prosthesis selection & availability & cost
Metal augments & wedges
Allograft & bone substitutes
Simultaneous bilateral TKR?
Intra operative problems
Approach
Patella reflection & exposure
Arthrofibrosis release
Release of contractures
Bone defects management
Protect bone because of osteoporosis
TT osteotomy or quadriceps snip
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Intra operative problems
Soft tissue balance
Ligament deficiency
Knee dislocation or subluxation
PS or more constrained prosthesis (CCK)
Patella tracking in valgus knee
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Medications
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Antibiotics
DVT prophylaxis
NSIAD
Other medications
Post operative management
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Bandage and dressing
Knee supports
Mobilizing the patient
Physiotherapy
Complications :
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Intra operative
Early post operative
Late post operative
Medical complications
Mechanical complications
Intra operative complications
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Inadequate exposure
Fractures
Tendon injuries
NV injuries
Bleedings
Anesthetic complication
Early post op
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Wound dehiscence
Infection , superficial or deep
MI, cardiac arrest
Need for blood transfusion
Quadriceps rupture
Late complications
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Pain, stiffness, limitation of ROM
Infection , reactivation of TB
Ligament insufficiency , subluxation or disloc.
Fractures around the prosthesis
Loosening
Implant wear
PF complications