Beverland D. Surgical Factors Influencing Rom
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Beverland D. Surgical Factors Influencing Rom

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    Beverland D. Surgical Factors Influencing Rom Beverland D. Surgical Factors Influencing Rom Presentation Transcript

    • Surgical factors influencing range of motion
      • David Beverland
      • Belfast N Ireland
      • PROGRAM VOCA LUSTRUM CONGRESS KNEE ARTHROPLASTY
      • SEPTEMBER 15 th – HUIS TER DUIN – NOORDWIJK AAN ZEE
    • Factors influencing ROM
      • Implant design
      • MIS?
      • Surgical technique
      • Rehabilitation
      • Patient factors
      • Post-operative complications
    • Factors influencing ROM Surgical Technique
      • Clearing all osteophytes
      • Stripping the posterior capsule from back of the femur traditional method of correcting fixed flexion
      • Stripping the posterior capsule from back of the femur also described for increasing flexion
      • Severe varus knee – 30 degrees
      • MCL tented over osteophytes
      Usually also severe fixed flexion
    • Stripping the Posterior Capsule
    •  
    • Postero-medial capsulotomy Corrects FFD BUT also Corrects varus deformity Fixed flexion with varus deformity Lateral Medial Medial Lateral Do not release the Supficial MCL in a Varus knee
    • Stripping the Posterior Capsule To improve flexion
    • Prospective RCT in Belfast
      • 50 patients in each group
      • One group with stripping of the posterior capsule the other without
      • No difference between passive or forced ROM at the end of surgery
      • No difference in ROM at 3 months or one year
    • Factors influencing ROM Surgical Technique
      • Importance of restoring joint line
      • Concept of posterior condylar offset
      Bellemans J et al JBJS (Br) 2002
    • 9 mm resection 11 mm resection 10 mm Insert LCS Rotating Platform Normal Raised Lowered PCO Restoring the Joint Line Bellemans J et al JBJS (Br) 2002 Hanratty et al JBJS (Br) 2007 Posterior stabilised knee
    • 11 mm resection 11 mm resection 14 mm resection 14 mm resection 15 mm insert 15 mm insert Common causes of a decreased PCO Normal Lowered Raised Raising joint line on tibia leads to fixed flexion
    • Factors influencing ROM Surgical Technique – cont’d
      • Increased patellar thickness – over stuffing of the patello-femoral joint
      • Closing the wound in flexion?
      • V-Y Plasty ( Scott and Siliski (1985) - no control group
      • Internal rotation of the femoral component – definite link with arthrofibrosis as reported by the Schulthess clinic in Zurich
    • One cause of internal rotation of femoral component Release of Sup MCL
        • Internal rotation of femoral component
        • Trapezoidal flexion gap
        • Raised flexion joint line
        • Femur externally rotates
    • 11 mm resection 15 mm insert 9 mm resection
      • Varus knee
      • Over release MCL
      Raised joint line just on the tibia Normal Raised Lowered PCO So raising the joint line in flexion either on the femur or tibia is not good Raising joint line on tibia leads to fixed flexion
    • Factors influencing ROM Rehabilitation
      • Early flexion on CPM - range 70 - 120 degrees?
      • Routine CPM - no advantage beyond 3 months
      • Post-operative pain?
      • Excessive bleeding after tourniquet release?
      • Post-operative swelling - foot pumps?
      • Intense post-operative physio? – Japan 6 weeks in hospital
      • Routine post-op physio? – Must work!!
    • Outpatient Physio vs no Physio
      • Prospective randomised control trial in Belfast
      • Physio (n=71) No Physio (n=72)
      • Pre-op passive ROM 98.3 ˚ Physio group
      • Pre-op passive ROM 100.2 ˚ No physio group
      • ONE YEAR
      • Post-op passive ROM 108.6 Physio group
      • Post-op passive ROM 108.1 No physio group
    • Results
      • At one year no significant difference in the range of knee motion
      • All other outcomes no difference.
      Now finally accepted by Journal of Arthroplasty Initially submitted to JBJS Br BUT reviewer said it was unthinkable that TKAs would not have outpatient physio and therefore it should not be published!
    • Factors influencing ROM Patient Factors
      • Obesity
      • Diagnosis - some evidence that RA patients improve more than OA? Ritter and Stringer (1979)
      • Previous surgery - for example High Tibial Osteotomy?
      • Motivation?
      • Pre-operative ROM
      - single most important factor Neville Thompson Mphil thesis - 2003
    • Management of the stiff knee after TKA My definition
      • A patient whose post-operative range of ACTIVE knee motion compromises their ability to perform everyday functions
    • Management of the stiff knee ROM for Everyday Functions
      • Swing phase of gait (67° flexion)
      • Climbing stairs (83° flexion)
      • Descending stairs (90-93° flexion)
      • Rising from a chair (93-106° flexion)
      • Tying a shoe lace (106° flexion)
      • Kettelkamp et al. 1970; Laubenthal et al. 1972
      Cultural Differences
    • SEIZA Japanese sitting style (pronounced SAY-ZA) Cultural differences
    • Management of the stiff knee Definition
      • My definition for my patients
      • A patient who has <70 degrees of flexion as this will impair walking
      • Although need 93 for stairs – 13% of my patients have <93 degrees!
    • Management of the stiff knee Prevention
      • Surgery is for pain not stiffness
      • Important that the patient knows that!
      • Avoid comment post-op “If I had known my knee would still have been stiff I would not have had surgery”
      • Patient with a stiff knee pre-op must be warned
      • Otherwise it becomes a complication
      Pre-operative Education Make sure you record the Pre-op ROM!
    • Management of the stiff knee Prevention
      • Probably biggest preventable cause of the stiff knee!
      • In summary remove all osteophytes and try and put things back where they where!
      Surgical technique
    • Management of the stiff knee Investigation
      • Examine knee and hip - a stiff hip inhibits knee flexion and vice versa!
      • Accurately record ROM with a goniometer
      • Any wound problems or knee effusion? - if yes aspirate
      • Routine bloods and x-rays including skyline
      • Exclude mechanical problems such as spinout
      • May consider a CT scan to measure femoral rotation
    • Management of the stiff knee Treatment
      • Who do I treat
      • Patients who at 3 months post-op have less than 75 degrees of flexion providing that they had at least 30 degrees more flexion before surgery
      • Between 1st Apr 2000 to 31 st May 2007 I did 2762 TKAs
      • 30 MUAs during that time – 1.086%
    • Management of the stiff knee Treatment - 30 Patients with MUA (1.086%) All improved except one Average flexion pre MUA = 53 Average flexion post MUA = 85
    • If these patients hadn't an MUA what would their ROM have been at 12 months?
      • One patient with a pre-op ROM of 0-130 had 25-70 at 12 weeks and refused MUA
      @ 12 months they had 5-120!
    • Management of the stiff knee Treatment
      • MUA
      • GA or spinal anaesthesia with peripheral nerve blocks – femoral and sciatic
      • At MUA does it give easily or is it like a lead pipe?
      • Record pre MUA range then post MUA passive and forced flexion
      • Straight on to CPM with active excercises as well
      • Home when active flexion >70 - usually Day 2
      • Outpatient phsiotherapy
      • Many reports on MUA are up to 10% of all primaries
    • Management of the stiff knee Treatment
      • Options other than MUA
      • Serial splinting - I have tried this once for fixed flexion
      • Arthrolysis open or arthroscopic
      • Revision with no aim
      • Revision to correct internal rotation of femur
      • Quadriceps plasty and or excision of HO
      • Arthrodesis
      • I don’t think any of them work!
      Hutchinson JRM, Parish EN, Cross MJ Results of open arthrolysis for the treatment of stiffness after total knee replacement. J Bone Joint Surg Br. 2005 Oct;87(10):1357-60
    • Follow-up study running at Schulthess Clinic in Zurich
      • Group of patients with arthrofibrosis
      • Proven to have internal rotation of the femoral component on CT scanning
      • Are offered revision of their femoral component
      • 4 out of 5 patients improve
      • These data are preliminary and are not published
      • Based on personal communication with Schulthess Clinic via Jens Bolt
    • In Conclusion Factors influencing ROM
      • Implant design
      • MIS?
      • Surgical technique
      • Rehabilitation
      • Patient factors
      • Post-operative complications
      Pre-operative Range of Motion
    • Thank you