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Total Knee A rthroplasty in young Adults

Total Knee A rthroplasty in young Adults. H. Makhmalbaf MD Consultant Orthopedic & Knee Surgeon Ghaem Hospital Medical Center Mashhad IRAN. 17 th Oct 2011 Tehran. Introduction . The percentage of patients decreased Improvement in medical treatment

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Total Knee A rthroplasty in young Adults

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  1. Total Knee Arthroplastyin young Adults H. Makhmalbaf MD Consultant Orthopedic & Knee Surgeon Ghaem Hospital Medical Center Mashhad IRAN 17th Oct 2011 Tehran

  2. Introduction • The percentage of patients decreased • Improvement in medical treatment • The backlog of patients has been operated • Training of residents and fellows

  3. 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

  4. Causes of OA in young • Rheumatoid arthritis • Post trauma • Hemophilia • Post infection • Septic arthritis • TB • Osteonecrosis

  5. Ipsilateral hip involvement • 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

  6. 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

  7. 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

  8. Rheumatiod cyst • Cysts are more common in RA • Large cysts • Curett & fill with cancellus bone • Large central cysts need impaction bone grafting

  9. Patellar resurfacing • Resurface or not? • Its different from OA • Resurface in all RA patients ? • Some do well without • Chance of recurrence of synovitis if not

  10. Synovectomy & recurrent active rheumatoid synovitis • 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

  11. Synovectomy & recurrent active rheumatoid synovitis • Dif. Diagnosis is infection • Aspiration for cell count & culture • If multiple joints involved medical treatment • Initial synovectomy at TKR if

  12. 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

  13. Need for adequate knee flexion • 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

  14. Osteopenia • 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

  15. Osteopenia • Patella fracture during MUA • Avulsion of MCL during TKA • Fix with a cancellus screw & washer • Intraoperativefrac. Of patella • Cemented component In osteopenic bone

  16. Anesthetic consideration • 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

  17. PCL preservation v substitution • 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

  18. Summary • 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

  19. Thank you

  20. Indications • Pain • Instability • Limitation of ROM • Conversion to a: • Stable • Pain free • Mobile joints

  21. Symptoms • Pain • Limitation of ROM • Stiffness , ankylosed knee • Instability • Limitation of extension & Fixed deformity • Combination of these

  22. Important factors • Fixed deformity • Mal alignment • Leg length discrepancy • Bone loss • Bone Stock • Bone Quality

  23. Important factors • Patients expectations • Socio economic condition • Chance of failure • Consult the patients • Need for revision • Knee score

  24. Deformities • Varus • Valgus • Recurvatum • Leg length • Intra articular deformity • Extra articular deformity

  25. Pre op evaluation: Medications • Steroids • NSAID • Anti TB • Coagulation factors

  26. Pre op evaluation: Imaging • Standing X-ray • AP & Lateral • Alignment view • MRI

  27. Pre op evaluation: Laboratory • ESR • CBC • CRP • RF • Factor IIIV • Tuberculin test • Urinalysis

  28. Intra operative

  29. Examination of the patient • 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

  30. Pre op considerations • Pre op physiotherapy • Medications • Timing of surgery • Prosthesis selection & availability & cost • Metal augments & wedges • Allograft & bone substitutes • Simultaneous bilateral TKR?

  31. 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

  32. Intra operative problems • Soft tissue balance • Ligament deficiency • Knee dislocation or subluxation • PS or more constrained prosthesis (CCK) • Patella tracking in valgus knee

  33. Medications • Antibiotics • DVT prophylaxis • NSIAD • Other medications

  34. Post operative management • Bandage and dressing • Knee supports • Mobilizing the patient • Physiotherapy

  35. Complications : • Intra operative • Early post operative • Late post operative • Medical complications • Mechanical complications

  36. Intra operative complications • Inadequate exposure • Fractures • Tendon injuries • NV injuries • Bleedings • Anesthetic complication

  37. Early post op • Wound dehiscence • Infection , superficial or deep • MI, cardiac arrest • Need for blood transfusion • Quadriceps rupture

  38. Late complications • Pain, stiffness, limitation of ROM • Infection , reactivation of TB • Ligament insufficiency , subluxation or disloc. • Fractures around the prosthesis • Loosening • Implant wear • PF complications

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