Johnson Dp. Mis Knee Replacement. What Are The Functional Benefits. Slide 19 36


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  • Assessing function following knee replacement has always been difficult. Scoring systems were designed in the 1980’s. These scores variously included points for knee flexion, and walking distance. Negative scores were added for fixed flexion deformity, malalignment, residual pain and walking aids. However these scores were developed when residual pain, malalignment and instability were commonplace and the function expectations was to undertake shopping and ADL. These indirect parameters of function are less relevant to the current situation where patients expectations are much greater and sport, recreation, work and longevity are the patients criteria. What is the real measure of function following knee replacement? This must address the functional demands of the relevant population and include parameters for walking speed, walking endurance, standing endurance, stair climbing ability and perhaps extensor muscle strength. There is no such score or assessment. However we can estimate such function crudely and indirectly by the range of motion, and knee score. The early function can reasonably be estimated by the range of early knee flexion, time of hospital discharge and post-op analgesia requirement. However we must be cognisant of the fact that this is a crude low level assessment. Function on stairs, endurance or sports is a current expectation and possibility with a successful knee replacement and these parameters would be a better outcome measure for today's patient. Holistic and satisfaction assessment can be measured by the SF36 or WOMAC scores but again this does not really relate to objective function of the knee. However these are the tools we have.
  • Johnson Dp. Mis Knee Replacement. What Are The Functional Benefits. Slide 19 36

    1. 1. Functional Outcome of Knee Replacement <ul><li>Patient orientated function </li></ul><ul><ul><li>Self care, sticks, stability, ADL, walking </li></ul></ul><ul><ul><li>Stairs, work, sport, longevity </li></ul></ul><ul><li>Objective function </li></ul><ul><ul><li>Speed, quadriceps power, endurance </li></ul></ul><ul><li>Expectations </li></ul><ul><li>Age </li></ul><ul><li>Pain </li></ul><ul><li>Flexion </li></ul><ul><li>Fixed Flexion </li></ul>
    2. 2. Functional Outcome <ul><li>McClelland et al Knee 2007 </li></ul><ul><li>Gait analysis of patients following total knee replacement. </li></ul><ul><ul><li>Post TKA gait is not normal </li></ul></ul><ul><ul><li>Less flexion </li></ul></ul><ul><ul><li>Quads avoidance </li></ul></ul>
    3. 3. MIS – TKA elderly <ul><li>72 years old 36 hours post-op </li></ul><ul><li>0-100 ° 1 stick </li></ul><ul><li>Cuckler JM: CORR 2007: “ The ugly underbelly of the MIS movement” </li></ul>
    4. 4. MIS Knee Replacement: What are the functional benefits ? David P. Johnson MB ChB FRCS FRCS(ORTH) MD The Bristol Orthopaedic and Sports Injury Clinic
    5. 5. Minimally Invasive Surgery <ul><li>Arthroscopy 1975 </li></ul><ul><li>Power arthroscopic instruments 1985 </li></ul><ul><li>Arthroscopic carpal tunnel release 1992 </li></ul><ul><li>Total hip replacement 2001 </li></ul><ul><li>Uni-compartmental knee replacement 2002 </li></ul><ul><li>Total knee replacement 2004 </li></ul>
    6. 6. Management of Postoperative Pain <ul><li>Nuelle DG, J Arthroplasty. 2007 Minimal incision protocols for anesthesia, pain management, and physical therapy with standard incisions in hip and knee arthroplasties </li></ul>
    7. 7. MIS – Medial collateral ligament <ul><li>MCL at risk </li></ul>
    8. 8. Wound closure <ul><li>1 Drain </li></ul><ul><li>Vicryl in layers </li></ul><ul><li>Clips to skin </li></ul><ul><li>Dressings </li></ul>
    9. 9. MIS – Total Knee Replacement <ul><li>Advancements in minimally invasive total knee arthroplasty. Tria AJ Jr Orthopedics. 2003 Aug;26(8 Suppl):s859-63 </li></ul><ul><li>Minimal incision total knee arthroplasty: early experience. Tria AJ Jr, Coon TM Clin Orthop Relat Res. 2003 Nov;(416):185-90 </li></ul>
    10. 10. MIS - Skin incision <ul><li>Mark skin </li></ul><ul><ul><li>Medial boarder of tibial tuberosity </li></ul></ul><ul><ul><li>Medial boarder of patella </li></ul></ul><ul><ul><li>Upper margin of patella </li></ul></ul>
    11. 11. Modified sub-vastus incision
    12. 12. Computer Assisted Navigation in MIS <ul><li>Keene G .et al 2006 </li></ul><ul><ul><li>Alignment improved 2.8 ° cv 0.9 ° </li></ul></ul><ul><ul><li>+/- 2 ° improved from 60% to 87% </li></ul></ul><ul><li>Kim YH. JBJS Br 2007 </li></ul><ul><ul><li>CAN made no difference to alignment </li></ul></ul><ul><li>Bauwens K JBJS AM 2007 </li></ul><ul><ul><li>23% longer surgery </li></ul></ul><ul><ul><li>CAN fewer outliers </li></ul></ul><ul><ul><li>No functional difference. </li></ul></ul>
    13. 13. General discrediting <ul><li>Cuckler JM: 2007: “ The ugly underbelly of the MIS movement” </li></ul><ul><li>Hungerford DS: “Smaller is not necessarily better and, when it is worse, it will be the &quot;smaller&quot; that is held accountable .” </li></ul>
    14. 14. MIS – Anatomy of the medial retinaculum <ul><li>Pegnamo NW. CORR 2006 </li></ul><ul><ul><li>The VMO inserts to the midpole of the medial patella. </li></ul></ul><ul><ul><li>The VMO inserts at an angle of 50 ° </li></ul></ul>
    15. 15. MIS – Uni - Compartmental Knee <ul><li>Kort et al: 2007 </li></ul><ul><ul><li>11% revision @ 2-7 years </li></ul></ul><ul><li>Hamilton WG et al J Arthroplasty 2006 </li></ul><ul><ul><li>Aseptic loosening 3.7% cv 1% </li></ul></ul><ul><ul><li>Reoperation 11.3% cv 8.6% </li></ul></ul>
    16. 17. Preservation of the Supra-patellar pouch <ul><li>Sub-vastus release </li></ul>
    17. 18. Management of Postoperative Pain <ul><li>Principles of pain management: </li></ul><ul><ul><li>Reduce “sundowning” </li></ul></ul><ul><ul><li>Improve daytime sensorium to speed rehabilitation </li></ul></ul><ul><ul><li>Reduce effects of pain stress, i.e., chest pain </li></ul></ul><ul><ul><li>Reduce side effects: respiratory depression, constipation, urinary retention, pressure sores, etc. </li></ul></ul>