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Knee osteoarthritis basics to reconstruction to replacement dr.sandeep c agrawal agraesn hospital gondia india


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Knee Osteoarthritis, a common cause of knee pain and treatment ranges from exercises,tablets,arthroscopy,deformity correction to total knee replacement (TKR).
Complications after surgery can even be corrected if occurs by proper evaluation,planning and execution of the Revision Surgery.
Knee osteoarthritis basics to reconstruction to replacement dr.sandeep c agrawal agraesn hospital gondia india

Published in: Health & Medicine

Knee osteoarthritis basics to reconstruction to replacement dr.sandeep c agrawal agraesn hospital gondia india

  1. 1. Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India 09960122234 Knee Osteoarthritis: Basics to Reconstruction to Replacement
  2. 2. Clinical evaluation Pain, functional decline : walking, climbing stairs, arising from low chair. Deformity Detailed history Major source of failure : inability to live up to unreasonable patient expectation, documentation. General health assessment questionnaires
  3. 3. Radiographic evaluation AP, 45 weight-bearing, lateral, Merchant views Three joints standing film (split scanogram): define the mechanical and anatomical axis. Common mistake : supine image of knee, MRI (not specific for articular cartilage abnormality). MRI for cartilage : T1-weight, fat suppressed three-dimensional, spoiled gradient echo technique, T2-weighted fast spin-echo technique
  4. 4. Knee : supine AP view
  5. 5. Knee : lateral view
  6. 6. Knee : tunnel view
  7. 7. Nonsurgical care Cane : resting and unloading the joint. Brace : Medication Rehab : muscle power training
  8. 8. Joint-Preserving surgical Procedures Arthroscopy Osteotomy : for younger and more active patient, disease affects predominantly one compartment – Valgus-producing tibial osteotomy – Varus producing femoral osteotomy
  9. 9. Arthroscopy Role of arthroscopic surgery in the treatment of OA knee : controversy Success in the treatment of OA knee : proportional to the degree of mechanical symptoms (loose bodies, meniscal tears, unstable cartilage flaps), inversely proportional to the severity of the underlying arthritis (malalignment)
  10. 10. Valgus-Producing Tibia Osteotomy Ideal patient : age younger than 50 and active, with high functional demands, involvement mainly on medial side. Contraindications : inflammatory arthritis, poor flexion(<90o), flexion contracture, ligament instability, tricompartmental arthritis Less successful in smokers, patients age more than 60 y/o, degree of deformity beyond 10o
  11. 11. Valgus-Producing Tibia Osteotomy Medial lengthening but not lateral shortening (open wedge). Advantage : more anatomic restoration with resultant ligament stability, ability to more fine tuning the correction. Disadvantage : risk of nonunion and loss of correction.
  12. 12. Varus-Producing Femoral Osteotomy For younger, active patients with involvement isolated in lateral compartment. Deformity should be less than 15o, without flexion contracture or inflammatory disease. Correction to physiologic valgus (4o to 6o)
  13. 13. Total Knee Arthroplasty Advanced disease resulting in failure of the joint to functional satisfactorily Key elements – Debilitating symptoms – Failure of such symptoms to respond to less invasive treatment – Medical suitability of the patient to respond to surgery
  14. 14. Factors Affecting Outcome TKA : survivorship exceeding 90% at 10 years, 80% at 15 years, 75% at 20 years. Age, gender, primary diagnosis, prosthetic design. Positive factors : age of 70 or older, RA, cemented fixation. Adverse factors : younger than 55 y/o, male, OA.
  15. 15. Factors Affecting Outcome Obesity : – Difficulties of exposure – Well-aligned, well-fixed implants fare as well in the heavy patients as in the general population – Wound complications are more common
  16. 16. Factors Affecting Outcome Juvenile Rheumatoid Arthritis – Severe joint destruction and need for reconstructive surgery at a very young age. – High rate of infection – Post-operative stiffness
  17. 17. Factors Affecting Outcome Hemophilic Arthropathy – Repeat hemarthrosis secondary to coagulopathy – Most commonly affects the knee – Young and immunodeficiency, high rate of infection – At least 10% failing within 5 years
  18. 18. Factors Affecting Outcome Osteonecrosis – Secondary to steroid or alcohol usage in younger patients, spontaneous occurrence in older patients – Preoperative MRI can assist in determining the amount of periarticular bone involvement
  19. 19. Factors Affecting Outcome Patellofemoral Arthritis – Isolated PF OA that is calcitrant to treatment can be successfully managed with TKA in older patients – Functional results of TKA are superior to patellectomy or patellofemoral arhtroplasty and are equal to TKA for 3 compartmental arthritis
  20. 20. Impact of Prior Surgery on Subsequent TKA Higher complication and higher revision rates and less satisfactory outcomes than primary TKA Previous scar should be incorporated whenever possible or standard incision with optimal skin bridge If hardware is extensive : consider staged procedure.
  21. 21. Impact of Prior Surgery on Subsequent TKA Patella baja is common following tibial osteotomy, lead to increased tension on the tendon insertion during exposure TKA after femoral osteotomy : relative post-opertive varus of the femoral component, can be reduced with the use of EM alignment guide Conversion of fused knee to TKA : hinged or constrained prosthesis are recommended
  22. 22. Surgical Technique Optimal success of TKA – Accurate restoration of the mechanical axis : intra and extra medullary guide. – Good fit and fixation of the implant to host bone – Careful attention to soft-tissue balance : equal tibiofemoral space in both flexion and extension, proper femoral rotation. Too tight : flexion contracture Excessive release : instability.
  23. 23. Design issues Fixation Posterior Cruciate Ligament Modularity Mobile bearing
  24. 24. Design issues Fixation – Methacrylate cement fixation Early loosening is more common with cementless fixation Cementing only the metaphyseal surface of the tibial component and press fitting the stem or keel has higher early loosening rate than full cementing the tibial component – Biologic fixation
  25. 25. Design issues Posterior Curciate Ligament – Retention : Advantage :more physiologic femoral roll back, accurate joint line restoration, bone preservation, proprioceptive role of the ligament. PCL too tight : posterior femoral subluxation, asymmetric posterior polyethylene wear, osteolysis, release too much may lead to late failure – Sacrifice – Substitution : cam and post mechanism, increasing the anterior lip of a conforming tibial polyethylene, risk of dislocation, polyethylene wear debris from cam and post.
  26. 26. Design Issues Modularity – Standard design feature of metal- backed tibial component. – Advantage : greater intraoperative flexibility and the potential for simple revision of a worn PE – Disadvantage : motion between the tibial plate and PE back-side wear
  27. 27. Design Issues Mobile Bearing Design – Allow mobile bearing to rotate, increased articular conformity, advantage has yet to be demonstrated, durable well into 2nd decade. – Wear and osteolysis – Unique problems : baring fracture and dislocation.
  28. 28. Patellar Resurfacing Controversial Patellar complications remain one of the most common sources of problems after TKA Revision rates are either equivalent or higher following knees without patellar resurfacing Consensus : knees without patellar resurfacing are at a somewhat increased risk for anterior knee pain, but are at a decreased risk for serious patellar complications
  29. 29. Unicompartmental Arthroplasty Alternative to TKA or osteotomy for one compartment disease. Survivorship of greater than 90% at 10 years has been documented. Patient selection and surgical technique are the key elements. Contraindications : – Inflammatory arthritis – Severe fixed deformity – Previous opposite compartment menisectomy – Tricompartmental arthritis
  30. 30. Unicompartmental Arthroplasty Recommended correction: 1o to 5o of postoperative valgus. Advantage : quicker recovery, fewer short-term complications, better functional outcome. Causes of failure : implant wear, loosening or subsidence, progression of symptomatic arthritis in the lateral or patellar compartments. Revision of uni-knee is less complex than revision TKR. Incision size should not be the dominant outcome measure of this technique.
  31. 31. Unicompartment Arthroplsty
  32. 32. Complications Infection Thromboembolic disease Medial collateral ligament injury Extensor mechanism failure Arthrofibrosis Periprosthetic fracture
  33. 33. Infection Attention to careful surgical technique and soft tissue handling. Laminar air flow and prophylactic antibiotics : reduce infection. Risk factors : immunosuppression, diabetes, smoking, prior surgery, obesity. Antibiotic-cementing : lower incidence of infection, may considered for high risk patients.
  34. 34. Infection : staged surgery
  35. 35. Thromboembolic disease Absence of effective prevention : historical data, 50% Controversy remains regarding the optimal prophylaxis regimen. Physical modality : useful adjunct – compression stocking, pneumatic compression devices, continuous passive motion machines, early mobilization. Two agents commonly used – Low molecular weight heparin Lower rate of DVT but higher bleeding rate – Coumadin
  36. 36. Medial collateral ligament injury Conversion to a prosthesis that provides varus/valgus restraint Repair of reattachment : equally viable alternative, wear braces for 6 weeks but are allowed full ROM Knee scores and ROM at F/U are equivalent to knees without this complication
  37. 37. Extensor mechanism failure Rupture of patellar tendon : compromise in functional outcomes. – Achilles tendon allograft, technique demanding, needs good fixation methods. Fracture of the patella : compromised circulation, overaggressive resection, maltracking, overt trauma. – Incidence less than 1% – Surgical treatment : marked extensor mechanism disruption, gross patellar loosening.
  38. 38. Arthrofibrosis Stiff total knee : common source of failure and remains unsolved. Best predictor of post-op ROM : pre- op ROM. Early suspect : manipulation under epidural anesthesia and aggressive physical therapy. Late treatment : unreliable and high rate of failure.
  39. 39. Periprosthetic fracture Prevalence : less than 2% Risk factors : – Osteoporosis, Stress shielding, Femoral notching, Osteonecrosis, Wear-related osteolysis Treatment : maintaining alignment and fracture stability with early ROM Key factors of surgical decision making : fracture displacement, stability of the prosthesis, quality of bone.
  40. 40. Periprosthetic fracture Implant loosening : revision, allograft for bone defect, implant is cemented to the allograft with long stems, preserve collateral ligament but usually needs articular constraint. Displaced fracture : – Intercondylar open : retrograde nail through transarticular approach – Fixed angle device and locked screws : evolving – Flexible IM rod : less rigid
  41. 41. Revision Total Knee Arthroplasty Evaluation of pain Preoperative planning Selective component retention Patellar failure management of bone loss
  42. 42. Evaluation of pain Successful revision of a painful, failed TKA is dependent on accurate evaluation of the cause of failure. Intrinsic (knee related) and extrinsic cause Pain from hip or spine ? Aspiration : negative culture does not exclude infection, white blood cell count higher than 2500 hint chronic low-grade infection, repeat aspiration can increase accuracy.
  43. 43. Preoperative planning Challenge of successful outcome : – Lower level of general patient health – Decreased soft tissue integrity – Bone loss Complication rate : almost 25% Factors compromise outcome: infection, extensor mechanism dysfunction, instability, fixation failure, periprosthetic fracture
  44. 44. Preoperative planning Indications for revision TKR : gross loosening, fracture, instability, infection, malalignment, wear, osteolysis or extensor mechanism disruption. Midline incision is preferred, lateral most incision for multiple old incisions Collateral ligament integrity, gap balancing, joint line restoration(1.5 cm proximal to the tip of fibula)
  45. 45. Preoperative planning Factors impacting the flexion gap : – Tibial resection level – Polyethylene thickness – Tibial slope – AP dimension of the femoral component – AP placement of the femoral component Factors impacting the extension gap: – Tibial resection level – Polyethylene thickness – Distal femoral resection – Posterior capsule
  46. 46. Selective component retention Significant PE wear with osteolysis : may consider change PE only but the failure rate is 30%-40%. Consider any occult reasons that lead to excessive wear of PE – Malalignment – Inadequate soft-tissue balance
  47. 47. Patellar failure One of the most common indication for revision TKR. Revision TKR due to isolated patellar fracture : high rate of failure due to unrecognized malalignment, evolving patellar osteonecrosis, inability to restore bone stock. Patellar bone loss (inadequate bone stock): patellectomy or debridement, extensor lag and weakness due to loss of patellar height.
  48. 48. Management of bone loss Infection and osteolysis can result in significant bone loss, often under-estimated. Metal augment or substitute or bone grafting. Contained defect : morcellized bone with long stem prosthesis. Uncontained defect : structural allograft Metallic mesh : converting uncontained defect into contained, Circumferential defects : allograft prosthesis composite
  49. 49. ThanksPersistence in your presentations, this is one secret to success. After my first presentation, I got up and did it again. Even though I was scared to death, I did it again. So preparation in all areas of life is so vital to your success. Don’t be lazy in preparing; don’t be lazy in laying the groundwork that will make all of the difference in how your life turns out. What you may be lacking in are the strong feelings about what you want and what you want to do. Let these strong feelings help you take a second look at your life. After all, you’ve only got one life, at least on this planet. So why not make it an adventure in achievement? Why not discover what all you can do and what all you can have? Why not now take the Challenge to Succeed! First you need to succeed to survive. We must take the seasons and learn how to use them with the seed, the soil and the rain of opportunity to learn how to sustain ourselves and our family. But then second is to then succeed to flourish in every part of your life today than yesterday, in our speech, our language, our health, everything we can possibility think of.