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Total Knee Arthroplasty | Knee Replacement | South Windsor, Rocky Hill, Glastonbury CT
- 1. Total Knee Arthroplasty JAMES T MAZZARA, MD ORTHOPEDIC ASSOCIATES OF HARTFORD CONNECTICUT JOINT REPLACEMENT SURGEONS, LLC CONNECTICUT JOINT REPLACEMENT INSTITUTE BONE AND JOINT INSTITUTE EASTERN CONNECTICUT HEALTH NETWORK
- 2. Contact Information James T Mazzara, MD Orthopedic Associates of Hartford, PC 29 Haynes Street Manchester, CT 06040 _________________ 150 Enterprise Drive Rocky Hill, CT 06067 860-649-2267 www.HartfordSportsOrthopedics.com
- 3. Anatomy
- 4. Anatomy
- 5. Anatomy Normal patella position Lateral patellar tracking, Osteoarthritis
- 6. Meniscus
- 7. Meniscus
- 8. Bursa
- 12. Nerves
- 13. Arterial Supply
- 14. Normal Articular Cartilage Functions to decrease friction and distribute load Structurally designed to stress shield High water content when normal 65-80% Decreases with aging But increases w OA Increased permeability Decreased strength Decreased elasticity
- 15. Normal Articular Cartilage Aneural Subchondral bone is richly innervated Avascular No intrinsic healing potential without blood from subchondral bone Injured cartilage Load is borne by shoulder of defect Progressive enlargement of defect Breakdown products include enzymes and particulate debris Cause effusions, synovitis, mechanical pain
- 16. Articular Cartilage Trauma Onset of symptoms: Traumatic = Acute Athletic activity most commonly reported cause 5-10% of acute hemarthrosis have acute chondral injury High grade lesions (III, IV) Under 40 yo: 5-11% 40-65 yo: up to 60% No spontaneous healing potential Worsen over time
- 17. Articular Cartilage Trauma Due to Shear forces related to ACL tear Impaction or non ACL related shear stresses Blunt injury resulting in chondrocyte death Knee impact Contusion
- 18. Meniscus Cushion, shock absorber, stabilizer Compression results in hoop (circumferential) stress Laterally 70% load transmitted Medially 50% load transmitted
- 19. Meniscectomy Medial meniscectomy 50-70% reduction in femoral condyle contact w/ meniscus 100% increase in contact stress Lateral meniscectomy Total meniscectomy: 40-50% decrease in contact area Increased contact stresses in lateral compartment 200- 300% Contributes to articular cartilage damage and degeneration Grood ES: Adv Orthop Surg 7:193,1984.
- 20. Meniscectomy and Laxity In ACLR, additional MM resection increased whereas MM repair preserved knee laxity in comparison with the ACLR knee with intact menisci. Neither LM resection or LM repair showed a significant effect on knee laxity. Surgeons should make every effort to repair the meniscus whenever possible to avoid the residual postoperative laxity present in the meniscus-deficient knee. Medial Meniscus Resection Increases and Medial Meniscus Repair Preserves Anterior Knee Laxity: A Cohort Study of 4497 Patients With Primary Anterior Cruciate Ligament Reconstruction Riccardo Cristiani, MD*, Erik Rönnblad, MD, Björn Engström, MD, PhD, ... First Published October 24, 2017
- 21. Aging & Arthritic Articular Cartilage Aging Arthritis Water Decreased Increased Stiffness Decreased elasticity Increased elasticity Chondrocytes (Cells) Fewer. Increased size Cells cluster Glycosaminoglycans Increased keratan sulfate/chondroitin 4 sulfate ratio Increased chondroitin 4 sulfate / keratan sulfate ratio Proteoglycans Decreased proteoglycan size Proteoglycans unbound from hyaluronate Collagen Increased collagen crosslinking brittleness Collagen disorganized Advanced Glycosylation End products (AGE) Increased Increased
- 22. Prevalence of OA Framingham OA Study Age and prevalence of OA are correlated 11.5% over 70 yo 19.4% over 80 yo Severe radiographic evidence of OA Less than 50% have symptoms
- 23. Osteoarthritis Most common type of arthritis 21 million Americans 10-13% Americans over 60 yo have OA Incidence increases with aging population and obesity Exact pathology is unknown Disease of the entire joint due to Local mechanical factors Prior trauma (years prior) Surgery
- 24. Osteoarthritis Systemic vulnerability Genetics Age Ethnicity Nutritional / metabolic status Female gender Consequence of bipedal gait Joint biomechanics Hip – Knee – Ankle alignment Medial compartment bears 60-70% of force Patella tracking
- 25. Osteoarthritis and Aging Mechanical forces at the knee are 3-5 time body weight Muscle strength, reaction time, proprioception deteriorate with age Aging results in increased risk to injury of cartilage Effects of aging and abnormal joint loading are synergistic Cartilage loses resiliency due to biochemical changes Increased stiffness of cartilage with age
- 26. Inflammatory Arthritis Rheumatoid arthritis Systemic autoimmune disease Bilaterally symmetric joints affected Psoriatic Arthritis Hemophilic Arthropathy Chronic recurrent hemarthrosis
- 27. Crystal Deposition Arthropathy Calcium pyrophosphate dihydrate crystal deposition disease (CPPD) Pseudogout Increases with age 50% of patients over 80 yo have CPPD Chondrocalcinosis Calcific deposits in menisci and joint cartilage
- 28. Crystal Deposition Arthropathy Gout Systemic elevation serum urate levels Uric acid crystal result in acute gouty attacks Gouty deposits called tophi More common in men (20:1) 5th to 7th decade Knee and foot more common than hand and elbow involvement
- 29. Osteonecrosis Spontaneous Secondary Post operative / post arthroscopy Subchondral insufficiency fractures Bone infarction Medial femoral condyle most common
- 30. Incidence Begins in second and third decades of life although asymptomatic Primary OA Inflammatory arthritis Secondary arthritis Post traumatic Post meniscectomy
- 31. Etiology of OA Unknown in Primary OA Result of mechanical, biochemical, biologic changes Anything that changes the microenvironment of the chondrocyte Congenital joint abnormalities Infection Autoimmune changes Acute and chronic trauma
- 32. Etiology of Secondary OA Joint injury Previous infection Rheumatoid arthritis Deformity Obesity Hyperthyroidism
- 33. Risk factors Obesity, especially for knee OA Abnormal mechanical loading of the joint Post meniscectomy Instability Inherited collagen defects Occupations (farmers) Infection Heredity
- 34. Symptoms and Signs of OA Initially, gradual onset, mechanical crepitus Pain usually the first symptom Increased with activity Joint swelling Stiffness after immobilization or rest, diminished after activity Acute synovitis can occur with vigorous or even routine activity Acute synovitis also seen in gout and pseudogout Lyme disease can cause acute pain & effusion months after exposure Can appear to be osteoarthritis
- 35. Joint Changes Joint enlargement due to cartilage degeneration, bone and ligament, joint capsule hypertrophy & chronic synovial hypertrophy from inflammation Increased ligamentous laxity Progressive muscular weakness and deconditioning
- 36. Joint changes Cartilage erosion on weight bearing surfaces Fibrillation, softening, splitting, fragmentation & delamination of cartilage Bone surfaces become sclerotic ( more dense), more brittle and prone to microfracture resulting in non healing (subchondral) fractures in the bone and bone cysts Bone becomes deformed from bone spurs and progressive bone loss Synovial lining becomes hypertrophied (thickened) Synovial fluid decreases resulting on loss of nutrition and lubrication of joint surface
- 37. More joint changes Ligaments and tendons Undergo degenerative changes Low grade chronic inflammation related to tendinosis or progressive microscopic tearing of these structures Muscles Atrophy due to disuse
- 38. Examination Tenderness on palpation Pain on passive motion Limited joint motion due to joint contracture Mechanical deformities and subluxation Subchondral bone collapse Osteophytes (bone spurs) Muscle atrophy Bone cysts, ganglion cysts (Bakers cyst)
- 39. Radiography
- 40. Diagnosis Signs and symptoms X-rays Lab data: Inflammatory arthritis
- 41. Prevention and Treatment Goal is to relieve pain, improve function & prevent disability Patient education Most modifiable risk factor is obesity What kind of 80 year old do you want to be?
- 42. Medications Topical agents: Capsaicin, Topical non-steroidal anti- inflammatory Oral medications: NSAIDS, analgesics Glucosamine & chondroitin Injection of corticosteroids Injection of hyaluronic acid PRP, Stem Cells Exercise as medication
- 43. Non operative Treatments Medications Injections Steroid injection Hyaluronic acid injection Lateral heel wedges Bracing: OTC & unloader braces Therapy
- 44. Surgical treatments Knee arthroscopy Meniscectomy Debridement Lavage Osteotomy Partial Knee Arthroplasty Total Knee Arthroplasty
- 45. About TKR Economic analysis indicates TKR is highly cost effective Projected demand in US will increase to 3.5 million cases per year by 2030 673% increase over current usage Aging population Obesity epidemic Younger patients (<65 yo)
- 46. Who gets a TKR Arthritis in at least one compartment Failed non operative treatment Expectation Primary pain relief Secondary improved function Restoration of active lifestyle Surgeon considerations Age Severity of arthritis Knee examination and appearance of knee Patient expectations
- 47. Who gets a TKR Severity and extent of OA One or more knee compartments Malalignment of limb Clinical symptoms and exam General pain or variable pain location Stiffness in flexion or extension or malalignment Patient Expectations High impact activities in younger patients may lead to early failure Age Not as much a factor <40yo: Consider partial knee replacement or other alternative
- 48. Total Knee Arthroplasty Indications Pain from arthritis Loss of function and disabling Significant impairment in quality of life Deformity and loss of range of motion of alignment deformity
- 49. TKR Contraindications Knee infection Remote active infection Extensor mechanism dysfunction Severe vascular disease Well functioning knee arthrodesis (fusion) Relative contraindications Local skin condition (psoriasis) Past history of knee osteomyelitis Neuropathic joint (insensate) Obesity
- 50. Anesthesia Regional anesthesia Nerve blocks General Anesthesia Intubation, LMA Spinal Anesthesia Factors in selecting Medical comorbidities Expertise of anesthesiologists
- 51. Pre operative Planning Medical evaluation Orthopedic evaluation Previous treatment Imaging Total knee Prehab
- 52. Perioperative Planning Antibiotics within 30 minutes of incision Mechanical anti thromboembolic devices
- 54. Minimally Invasive TKR This is a dream My Opinion Limited Skin Incision Ideal candidate Minimal knee deformity (<15 degrees varus, <20 degrees valgus, <10 degree flexion contracture) Good preoperative range of motion (minimum 90 degrees flexion) Small to average stature (Short thin females, low BMI) Non diabetic Low BMI No rheumatoid or inflammatory arthritis
- 55. TKR Procedure Bone resection based on bone landmarks in flexion and extension Ligaments released incrementally to obtain equal medial and lateral balance
- 56. TKR Procedure
- 57. TKR Procedure Patella Patellar resurfacing Optional May try to avoid in younger patients who kneel at work Up to 15% may need resurfacing later on
- 59. Patella failure Periprosthetic patella fracture 0.5% to 5.2% in resurfaced patella 0.05% in unresurfaced patella Patella implant wear and loosening 0.6 to 4.8%. May be asymptomatic Component wear Increases with ROM, BMI, longevity of implant Patellar instability Maltracking, Dislocation Extensor mechanism disruption Patellar tendon rupture 0.22.to 2.5% Quadriceps tendon rupture 0.1%
- 60. Results of TKR 90% good to excellent results 93% survivorship at 15 years
- 61. Complications of TKR In hospital mortality Bilateral TKR 0.5% Unicompartmental Knee 0.3% In hospital complication BTKR 12.2% UKR 8.2%
- 62. Complications of TKR DVT, in absence of prophylaxis 50% of unilateral cases 75% of bilateral cases Pulmonary embolism w/o prophylaxis 1 to 28% Fatal Pulmonary embolism w/o prophylaxis 0.1 to 2%
- 63. Complications of TKR Wound healing problems related to previous surgical incisions Hematoma Wound drainage Arterial complications Injury to popliteal artery Acute arterial obstruction Nerve palsy Peroneal nerve palsy 0.01% Metal allergies Nickel
- 64. Mechanical Complications of TKR Instability 10-22% of failures requiring revision Early laxity due to alignment, balance, rupture of MCL, intrinsic laxity Late instability due to polyethylene wear, ligament elongation or attenuation
- 65. Failure modes in TKR Review of 440 TKR revisions 63% revised within 5 years of index procedure Infection 37% Instability 26% Failure of cementless fixation 13% Aseptic loosening of cemented implant 3%
- 66. Computer-Assisted Knee Replacement Hypothesis Improves neutral mechanical axis Minimizes eccentric stresses on load-bearing surfaces Decrease shear stresses on bone- prosthesis interface Mechanical axis malalignment in up to 30% of TKR Increased likelihood of failure
- 67. Computer-Assisted TKR Computer-assisted Navigation Digital mapping of anatomic landmarks Computer constructs 3D model of the knee Either based on pre op imaging or intraoperative sensor placement Results Improved position of components Improved ability to establish neutral mechanical axis Best for patients with extra-articular joint deformity and obese
- 68. Computer-Assisted TKR Results Meta analysis of 21 studies, 1,713 knees Slightly improved Knee Society Scores at 3 and 12 months No difference in functional or clinical outcomes at 10 years Cost may outweigh the benefits except for high volume centers
- 71. Computer-Assisted TKR Drawbacks Incorrect positioning of sensors, especially at distal femur Sensors move during surgery in osteoporotic bone Fractures at drilling site
- 72. Post operative care Post anesthesia care unit (PACU) Discharge depends on patient recovery 1-2 days Same day surgery Home the day of surgery Office the next day Selected patients and insurers
- 73. TKR Rehabilitation Immediate rehab Out patient therapy preferred to rehab center Self directed therapy can be as effective as therapist directed PT One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty JBJS: 6 November 2013 - Volume 95 - Issue 21 - p. 1942-1949 Internet-Based Outpatient Telerehabilitation for Patients Following Total Knee Arthroplasty results are comparable to conventional rehab JBJS: 19 January 2011 - Volume 93 - Issue 2 - p. 113-120 JBJS: 15 July 2015 - Volume 97 - Issue 14 - p. 1129-1141 https://healthresearchfunding.org/double-knee- replacement-pros-cons/
- 74. Return to Work factors 94% return to work Mean time out of work 9 weeks Affected by many factors Sense of personal urgency to return to work Female sex Higher physical functional scores Handicapped accessible workplace Negative factors for RTW Less pre op pain More physically demanding job Workers compensation
- 75. Return to Work Considerations Earlier return to sedentary and light work Avoid prolonged sitting (increased leg swelling) Pain medication use (company drug policies) Work release time for rehabilitation
- 76. Total Knee RTW Studies 21 WC patients, 23 knees 16 non WC patients 21 knees Average follow up 4.5 years Same ROM, stability, alignment Improved function and outcomes both groups 100% non WC patients RTW 23% WC patients RTW J Arthroplasty. 2004 Apr;19(3):310-2. 10 patients WC post traumatic OA 10 Patients non work related OA HSS knee rating score Max 100 WC 64.1 Non WC 91.9 Subjective pain and function significantly different Objective indices of ROM, strength, deformity, stability not different Bull Hosp Jt Dis. 1998;57(2):80-3.
- 77. Sport and Activity Restrictions Permitted Bowling, bicycling, dancing, golf, swimming, walking, hiking Permitted with prior experience Rowing, cross country skiing, downhill skiing, doubles tennis, horseback riding No consensus Fencing, roller skating, weight lifting, handball, hockey, rock climbing, squash, racquetball, singles tennis, weight machines Not recommended Basketball, football, soccer, jogging, volleyball Avoid jumping from a height or twisting on the limb Avoid kneeling if patella is resurfaced
- 78. AAOS Guidelines BMI Strong evidence that obese patients have less improvements with TKR Diabetes Moderate evidence of higher risk for complication Chronic pain Moderate evidence of less improvements Cirrhosis/Hepatitis C Limited evidence of increased complications Delayed TKR Moderate evidence that 8mo delay does not worsen outcomes
- 79. AAOS Guidelines Tourniquet use Strong evidence that tourniquet increases short term post op pain Limited evidence that tourniquet use decrease short term post op function Tranexamic acid Strong evidence that TXA reduces blood loss and need for transfusion Bilateral TKR Limited evidence to support BTKR for healthy patients due to fewer complications UKA revisions Moderate support for TKR over UKA to reduce revisions
- 80. AAOS Guidelines CR vs PS implant Strong evidence, no difference in complications Patella resurfacing Strong evidence of no difference in pain or function Patella resurfacing: re operation Moderate evidence that resurfacing could reduce reoperation in 5y Navigation Strong evidence for not using navigation. No difference in outcomes Patient specific Instrumentation Strong evidence for not using PSI. No difference in outcomes
- 81. AAOS Guidelines Drains Strong evidence for not using drains. No outcomes or complications differences CPM Strong evidence that CPM does not improve outcomes Post op mobilization Strong evidence that rehab on day of TKR reduces hospital stay and improves function Post discharge rehab Moderate evidence to support supervised rehab in 2 months post op
- 82. Pain after TKR Excellent results in 98% of patients Malalignment Ligamentous laxity Loosening Infection Neural origin Deep knee pain after TKR 1-3% nerve related Cutaneous nerve trapped in scar Cutaneous neuroma
- 83. Nerve Related Painful TKR Medial and lateral retinacular nerves become adherent to capsule Nerves are stretched through traction with flexion Result is a painful knee Six months of post op pain No other reason for the pain Treated with nerve resection Most patients get some improvement Knee scores improved from mean of 55 to mean of 90.
- 84. Painful Neuromas after TKR Identify the neuroma Resect the end of he nerve Relocate end of nerve to an intramuscular location
- 85. Impairment Rating AMA guides, 6th edition Good result Good position, stable, functional 21 -25% LE Fair result Fair position, mild instability, mild motion deficit 31 – 43% LE Poor result Poor position, moderate to sever instability, moderate to severe motion deficit 59 – 75% LE Poor result, Chronic infection 67 – 83%
- 87. Thank you What kind of 80 year old do you want to be?