Dr.A.K.Venkatachalam               MS Orth, DNB Orth, FRCS, M.Ch Orth                 Consultant Orthopedic surgeon       ...
* < 65 years , Better is < 50 years of age.* Life expectancy of > 20 years* Family history of longevity   www.kneeindia.co...
*Numbers increasing in  young patients < 55  years              Australian registrywww.kneeindia.com                   3
“If the historical growth trajectory of        joint replacement surgeries        continues, demand for primary THA       ...
Secondary osteoarthritis from       * Post traumatic arthritis       * Rheumatoid arthritis is the main cause       * Wher...
* Against-     1)Total knees fail more often in young patients                             FAILURE RATES AND AGE     AGE( ...
*than their older             Age & activity after THR/TKR colleagues*Wear is proportional to usage.                     P...
*Young people live          LIFE EXPECTANCY( WOMEN)  longer.*Young people survive       AGE(years)   Expected to  their pr...
* Previous three slides indicates that there is a         higher risk of failure in young patients and they         may re...
He is unwilling to listen and wait.www.kneeindia.com                  10
* severe pain and stiffness in the knee joint,       * Impaired quality of life,       * Failure of previous treatments of...
* The OS can do a TKR with a prosthesis that         wears out slowly.       * Use of materials, techniques, activity     ...
*Prolong prosthetic life, preserve bone        while providing function.       *Search for design, durability of counter- ...
* Baby Boomers           * Relatively healthy           * Wanting the best technology           * Are relatively dissatisf...
Patient expectations start rising        concomitantly.       Internet savvy       Want only broken part to be fixed    ...
www.kneeindia.com   16
* Cycling       * Calisthenics       * Swimming       * Low-resistance rowing       * Skiing machines       * Walking & Hi...
*Baseball       *Basketball       *Football       *Hockey       *Soccer       *High-impact aerobics       *Gymnastics     ...
Wear is an issue. Steps to reduce wear       *Bearings- alternate bearings like oxidized        zirconium, ceramic       *...
Wear in TKR’s                        Patient     Counter face                                   Polyethylene          Tech...
*Change femoral counterface ( Oxidized zirconium, Ceramic)*Change Poly insert  ( XLPE)*Change design   * Mobile vs fixed b...
* X linked polyethylene seem to be advantageous         at least from the hip side.       * Proved lowering of long term w...
THR            TKR       Contact stresses       low            High       Wear             abrasive/ adhesive   fatigue   ...
*Behaves differently in           60 clean and abraded environments                We 50*Wear increases in abraded   ar 40...
* Sequentially irradiated and annealed ( not         melted polyethylene)       * Significant wear reduction       * No me...
* Scratches are bad -   Ideally try to eliminatewww.kneeindia.com                     26
* Conventional cobalt chrome is used for femoral         and titanium or highly polished cobalt chrome         used for ti...
*Femoral   *Cobalt Chrome   * scratching is common   *From cement and poly   *Care to remove cement     after TKR.www.knee...
* Meet requirments for ideal TKR       * Smoother       * ↓ Coefficient of friction       * More scratch resistant       *...
* Polyethylene wear performance of oxidized         zirconium and cobalt chromium knee components         under abrasive c...
* Zirconium- metallic element* Zirconia- ceramic* Zr-2.5 Nb Metallic alloy* Super heating zirconium to  500+°C in Oxygen p...
* It is a metal component       * Thin layer of ceramic like material that is part of its         innate structure. This i...
*Equivalent to Cobalt  Chrome*1000 pounds*10 x 106 Cycleswww.kneeindia.com       33
*Oxdized zirconium  produces fewer PE  particles when  compared to Cobalt  chromiumwww.kneeindia.com      34
*Oxidized zirconium  reduces volumetric  wear by upto 89% in  an abraded  environment when  compared to Cobalt  Chromewww....
www.kneeindia.com   36
www.kneeindia.com   37
* Strength of Cobalt chrome       * Low coefficient and scratch resistance of ceramic       * Non brittle as the ceramic l...
*Many variables       *Articular congruity       *CR vs PS       *Fixed vs mobile bearing       *Single radius vs multi ra...
* Cemented TKR is the gold standard at present       * However Cement constitutes a third body         wear.       * Best ...
*16 knees from 2007 to 2009 in patients ≤55        years       *Cobalt chromium femoral components in 8        and Oxidize...
* Knee scores improved in all.       * Range of movement from 95 degrees to 140         degrees.       * No loosening     ...
*Skin incisions 4- 6  inches long.*Midvastus, sub vastus,  minimally invasive  quad splitting.www.kneeindia.com         43
*46 year old Indian  housewife.*Left gender specific  high flex knee  replacementwww.kneeindia.com       44
www.kneeindia.com   45
*Zero error Component placement       *Extra articular deformities- one stage         replacementwww.kneeindia.com        ...
*Patient specific  instrumentation*Requires MRI scan &  Standing x rays*Eliminates 23 steps  from TKR.*For distal femoral ...
Rheumatoid arthritis 38 year oldpatient www.kneeindia.com                 48
www.kneeindia.com   49
www.kneeindia.com   50
www.kneeindia.com   51
* Durable materials like Oxidized zirconium,         cross linked poly, highly polished tibial base         plate       * ...
QR code       E mail- drvenkat@kneeindia.comwww.kneeindia.com              53
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Knee Replacement In Young Patients

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Knee replacement in young patients deals with issued involved in choosing the procedure when inevitable. MJRC offers knee replacements for young patients in Chennai, India. Visit www.kneeindia.com

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Knee Replacement In Young Patients

  1. 1. Dr.A.K.Venkatachalam MS Orth, DNB Orth, FRCS, M.Ch Orth Consultant Orthopedic surgeon Chennai www.kneeindia.comwww.kneeindia.com 1
  2. 2. * < 65 years , Better is < 50 years of age.* Life expectancy of > 20 years* Family history of longevity www.kneeindia.com 2
  3. 3. *Numbers increasing in young patients < 55 years Australian registrywww.kneeindia.com 3
  4. 4. “If the historical growth trajectory of joint replacement surgeries continues, demand for primary THA and TKA among patients less than 65 years old was projected to exceed 50% of THA and TKA patients of all ages by 2011 and 2016, respectively.” * Steven M. Kurtz PhD, Edmund Lau MS, Kevin Ong PhD, Ke Zhao MA, MS, Michael Kelly MD, Kevin J. Bozic MD, MBA  Symposium: ABJS Carl T. Brighton Workshop on Health Policy Issues in Orthopaedic Surgery Volume 467, Issue 10 / October , 2009www.kneeindia.com 4
  5. 5. Secondary osteoarthritis from * Post traumatic arthritis * Rheumatoid arthritis is the main cause * Whereas in older patients, Primary OA is the leading cause.www.kneeindia.com 5
  6. 6. * Against- 1)Total knees fail more often in young patients FAILURE RATES AND AGE AGE( years) FAILURE RATES < 65 years 12% 65- 75 years 10% > 75 years 4% Robertsson, Thesis Lund 2000 , Swedish arthroplasty register www.kneeindia.com 6
  7. 7. *than their older Age & activity after THR/TKR colleagues*Wear is proportional to usage. Patient age Average of*Young patients walk on steps/year average upto 50% more < 60 years 1200,00 than older patients.*Usage leads to increased poly wear > 60 years 800,00*Poly wear leads to aseptic looseningwww.kneeindia.com 7
  8. 8. *Young people live LIFE EXPECTANCY( WOMEN) longer.*Young people survive AGE(years) Expected to their prosthesis. live further*Older people die before prosthetic 50 years 32 years failure. 67 years 18 yearswww.kneeindia.com 8
  9. 9. * Previous three slides indicates that there is a higher risk of failure in young patients and they may require a revision within 10 years * Surgeon knows this. He also knows that the revision will be technically a difficult operation than the primary. Result also will be inferior.www.kneeindia.com 9
  10. 10. He is unwilling to listen and wait.www.kneeindia.com 10
  11. 11. * severe pain and stiffness in the knee joint, * Impaired quality of life, * Failure of previous treatments of the painful hip / knee  joint. * Specially suitable candidate is a young patient with severe impairment of both hip and knee joints eg- Poly arthritis like rheumatoid arthritis / sero-negative arthritis.www.kneeindia.com 11
  12. 12. * The OS can do a TKR with a prosthesis that wears out slowly. * Use of materials, techniques, activity modification can lead to better implant survivorship.www.kneeindia.com 12
  13. 13. *Prolong prosthetic life, preserve bone while providing function. *Search for design, durability of counter- face, poly, technique, best fixation. *Education of patient about permissible activities of daily living and sport. *Explain possibility of a future revision. *Prevent late metastatic infection from a remote source. *Encourage treatment if the patient has fully understood all issues.www.kneeindia.com 13
  14. 14. * Baby Boomers * Relatively healthy * Wanting the best technology * Are relatively dissatisfied with current outcomes * Will out live current total knee technology * The main contributor to knee replacement growthwww.kneeindia.com 14
  15. 15. Patient expectations start rising concomitantly. Internet savvy Want only broken part to be fixed As small scar as possible No pain Want to dance, participate in sports Want alignment perfect, stability * Surgical outcomes ≥ Expectationswww.kneeindia.com 15
  16. 16. www.kneeindia.com 16
  17. 17. * Cycling * Calisthenics * Swimming * Low-resistance rowing * Skiing machines * Walking & Hiking * Low-resistance weightlifting Knee societywww.kneeindia.com 17
  18. 18. *Baseball *Basketball *Football *Hockey *Soccer *High-impact aerobics *Gymnastics *Jogging *Power lifting Knee societywww.kneeindia.com 18
  19. 19. Wear is an issue. Steps to reduce wear *Bearings- alternate bearings like oxidized zirconium, ceramic *Poly ethylene X3 poly, anti oxidants, thickness. *Cemented vs cementless fixation *Accuracy of component placement- ? Navigated surgery *Fixed vs mobile bearing components *Single radius vs multi radii designs.www.kneeindia.com 19
  20. 20. Wear in TKR’s Patient Counter face Polyethylene Technique Designwww.kneeindia.com 20
  21. 21. *Change femoral counterface ( Oxidized zirconium, Ceramic)*Change Poly insert ( XLPE)*Change design * Mobile vs fixed bearing * CR vs PS * Single vs multiple radius curve * Locking mechanismwww.kneeindia.com 21
  22. 22. * X linked polyethylene seem to be advantageous at least from the hip side. * Proved lowering of long term wear rateswww.kneeindia.com 22
  23. 23. THR TKR Contact stresses low High Wear abrasive/ adhesive fatigue Crack propagation Less important Important Highly cross linked polyethylene is advantageous in the knee also.www.kneeindia.com 23
  24. 24. *Behaves differently in 60 clean and abraded environments We 50*Wear increases in abraded ar 40 CoCr/CP environment with cobalt rat e 30 E chrome for both polys m CoCr/XP*Hence highly cross linked m3 20 E poly may not be the best /M C 10 material in the altered environment 0 -10 Clean Abradedwww.kneeindia.com 24
  25. 25. * Sequentially irradiated and annealed ( not melted polyethylene) * Significant wear reduction * No mechanical changes * Same poly used for hips and kneeswww.kneeindia.com 25
  26. 26. * Scratches are bad - Ideally try to eliminatewww.kneeindia.com 26
  27. 27. * Conventional cobalt chrome is used for femoral and titanium or highly polished cobalt chrome used for tibial base plate. Polishing of tibial tray reduces back side wear. * Pure Ceramics * Oxidized zirconiumwww.kneeindia.com 27
  28. 28. *Femoral *Cobalt Chrome * scratching is common *From cement and poly *Care to remove cement after TKR.www.kneeindia.com 28
  29. 29. * Meet requirments for ideal TKR * Smoother * ↓ Coefficient of friction * More scratch resistant * Less wear against both conventional and highly cross linked poly ethylene.www.kneeindia.com 29
  30. 30. * Polyethylene wear performance of oxidized zirconium and cobalt chromium knee components under abrasive conditions * ( Ries MD, Salehi A, Widding.K, Hunter G.,JBJS ( Am) 2002) Oxidized Zirconium femoral components reduce polyethylene wear in a knee wear simulator. ( Ezzel KA, Hermida JC,Colwell CW Jr,D’Lima DD, CORR, Nov 2004)www.kneeindia.com 30
  31. 31. * Zirconium- metallic element* Zirconia- ceramic* Zr-2.5 Nb Metallic alloy* Super heating zirconium to 500+°C in Oxygen presence* Surface transformation into Air 500oC zirconia ( ceramic oxide) Oxygen Diffusion* Chemically bonded ceramic oxide surface 5μ thick Original Surface Ceramic Oxide Oxygen Enriched Metal Metal Substratewww.kneeindia.com 31
  32. 32. * It is a metal component * Thin layer of ceramic like material that is part of its innate structure. This is not a coating. * Ceramic oxide is 5 μ thick * Biocompatibility is excellent, matches titanium * Very low coefficient of friction vs Cobalt chrome. * Extremely abrasion resistant. * Hard like ceramic * Equivalent strength properties to Cobalt chrome. * Adverse to chipping that can occur at insertion and over time. * Lack of Nickel allergy.www.kneeindia.com 32
  33. 33. *Equivalent to Cobalt Chrome*1000 pounds*10 x 106 Cycleswww.kneeindia.com 33
  34. 34. *Oxdized zirconium produces fewer PE particles when compared to Cobalt chromiumwww.kneeindia.com 34
  35. 35. *Oxidized zirconium reduces volumetric wear by upto 89% in an abraded environment when compared to Cobalt Chromewww.kneeindia.com 35
  36. 36. www.kneeindia.com 36
  37. 37. www.kneeindia.com 37
  38. 38. * Strength of Cobalt chrome * Low coefficient and scratch resistance of ceramic * Non brittle as the ceramic layer is part of the innate structure. * Decrease wear is the main advantage.4900 less volumetric wear. * 160 times smoother.www.kneeindia.com 38
  39. 39. *Many variables *Articular congruity *CR vs PS *Fixed vs mobile bearing *Single radius vs multi radii *Locking mechanism *All have in- vitro/theoretical evidence of benefits.www.kneeindia.com 39
  40. 40. * Cemented TKR is the gold standard at present * However Cement constitutes a third body wear. * Best fixation is biologic with bone ingrowth into prosthesis. * Examples of hips – Uncemented hips are standard in young patients. * Cementation leads to extra operative time * Part results of poor cemenless fixation stem from metal backed patellas. * Cementless fixation will be the preferred method in future.www.kneeindia.com 40
  41. 41. *16 knees from 2007 to 2009 in patients ≤55 years *Cobalt chromium femoral components in 8 and Oxidized zirconium in 8 knees. *CR- 6 knees, PS- 10 *Diagnoses- Post traumatic arthritis-2 Rheumatoid arthritis- 6 Osteoarthritis- 8www.kneeindia.com 41
  42. 42. * Knee scores improved in all. * Range of movement from 95 degrees to 140 degrees. * No loosening * 1 patient with bilateral TKR has anterior knee pain, had patellar component revisionwww.kneeindia.com 42
  43. 43. *Skin incisions 4- 6 inches long.*Midvastus, sub vastus, minimally invasive quad splitting.www.kneeindia.com 43
  44. 44. *46 year old Indian housewife.*Left gender specific high flex knee replacementwww.kneeindia.com 44
  45. 45. www.kneeindia.com 45
  46. 46. *Zero error Component placement *Extra articular deformities- one stage replacementwww.kneeindia.com 46
  47. 47. *Patient specific instrumentation*Requires MRI scan & Standing x rays*Eliminates 23 steps from TKR.*For distal femoral cut & proximal tibial cut.www.kneeindia.com 47
  48. 48. Rheumatoid arthritis 38 year oldpatient www.kneeindia.com 48
  49. 49. www.kneeindia.com 49
  50. 50. www.kneeindia.com 50
  51. 51. www.kneeindia.com 51
  52. 52. * Durable materials like Oxidized zirconium, cross linked poly, highly polished tibial base plate * Single radius femoral prosthesis * Computer assisted knee replacement * Patient specific instrumentation( custom fit surgery) * Minimally invasive approacheswww.kneeindia.com 52
  53. 53. QR code E mail- drvenkat@kneeindia.comwww.kneeindia.com 53

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