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TOTAL KNEE ARTHROPLASTY

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Title: TOTAL KNEE ARTHROPLASTY


1
TOTAL KNEE ARTHROPLASTY
  • Richard R. Pelker M.D., Ph.D.Professor Chief,
    Section of Joint Reconstruction
  • Department of Orthopaedics Rehabilitation
  • Yale University School of Medicine

Workers Compensation Conference on
ArthroplastyNovember 14, 2008
2
KNEE ARTHROPLASTY
  • Demographics
  • Indications
  • Alternatives
  • Arthritis Risk Factors
  • Surgical Technique
  • Post Operative Protocol
  • Results Complications
  • Impairment Rating
  • Activity after TKR

3
TOTAL KNEE ARTHROPLASTY
  • 500,000 per year in the U.S.
  • 95 - 98 Success Rate
  • 15 year (? Longer) Longevity
  • ? of Revisions
  • (? Unrealistic) Expectations

THE KNEES ARE THE FIRST THING TO GO!
4
TKR UTILIZATION
5
TKR UTILIZATION
6
INDICATIONS
  • PAIN
  • 2nd Knee Arthritis
  • FUNCTION
  • Also
  • Post Traumatic
  • Deformity

7
ALTERNATIVES
  • Non Operative Rx
  • NSAIDS - Motrin, Advil, Aleve
  • Ambulatory Aids (cane, etc.)
  • Rehab
  • Orthotics Braces
  • Injections
  • Corticosteroids
  • Hyaluronates (Synvisc, etc.)
  • Operative Rx
  • Arthroscopic Debridement
  • Osteotomy
  • Partial Replacement
  • Biologic
  • Cartilage Replacements
  • Allografts

8
? Factors that Increase the Risk for OA
  • SYSTEMIC
  • Heredity
  • Age
  • Gender
  • INTRINSIC
  • Injury
  • Malalignment
  • USE
  • Weight
  • Trauma
  • Repetitive Stress
  • High Impact Sports

Felson Clin Orthop, Volume 427()
Supplement.October 2004.S16-S21
9
Heredity
  • OA Not Hereditary
  • Some Hereditary Disease associated with OA
  • Genetic Predisposition
  • Anatomy
  • Cartilage
  • Etc.
  • Hereditability
  • 50 of Occurrence in Hip and Hand - Hereditable
  • 0 - 30 of Knee

Felson, Arthritis Rheum 4113431355, 1998
10
AGE GENDER
  • Men gt 50 Women gt 40
  • BUT !!!
  • 5 of population 35 - 54 years old have
    radiographic sx of OA

Roos Curr Opin Rheumatol, Volume 17(2).March
2005.195-200
11
Weight
  • BMI gt 27 ? OA KneeAnnals of the Rheumatic
    Diseases 200766158-162
  • BMI gt 30 5 x Radiographic Knee OA

BMI Wt(kg) / Ht2 (m)
BMI Wt(lbs) 703 / Ht2 (in)
12
Weight
  • BMI gt 27 ? OA KneeAnnals of the Rheumatic
    Diseases 200766158-162
  • BMI gt 30 5 x Radiographic Knee OA
  • By age 85 (US) 1/2 All
  • 2/3 Obese

13
TRAUMA
  • FRACTURE
  • Intra-articular
  • Extra-articular - malalignment
  • MENISECTOMY
  • LIGAMENTOUS INJURY / ACL

14
TRAUMA
  • FRACTURE
  • MENISECTOMY
  • Sx Radiographic OA 27 Mensiectomy vs 10
    Control (15 - 22 yrs post surgery) Arthritis
    Rheumatism. 50(9)2811-9, 2004 Sep.
  • 43 xray sx of OA 16 yrs after limited
    Menisectomy (intact ACL)Arthritis Rheumatism.
    482178-87, 2003.
  • LIGAMENTOUS INJURY / ACL

15
TRAUMA
  • FRACTURE
  • MENISECTOMY
  • LIGAMENTOUS INJURY / ACL
  • Little evidence that ACL repair lessens incidence
    of OA
  • Especially with concomitant meniscus injury

16
INJURY
Roos Curr Opin Rheumatol, Volume 17(2).March
2005.195-200
17
OA ACTIVITY? INJURY vs USE
  • SPORTS
  • RUNNING
  • OCCUPATIONAL
  • INCREASED LOADING
  • REPETITION

18
Running OA
  • Table 1. Studies on Knee Osteoarthritis in
    Runners vs. Non Runner Controls
  • From Felson Clin Orthop, Volume 427()
    Supplement.October 2004.S16-S21

19
OCCUPATION
  • Increased Prevalence in Jobs
  • Repetitive Bending Strenuous Activity
  • Heavy Lifting
  • Squatting
  • Knee Bending
  • Kneeling
  • ? Causal or Injury

20
GOALS of TKR
  • DECREASE PAIN
  • RESTORE
  • Anatomy
  • Function
  • RESTORE
  • Mechanical Axis
  • ROM
  • Stability

21
PREOPERATIVE ASSESMENT
  • Hx PE
  • Radiographs
  • Medical Clearance

22
ANATOMYBONES
  • FEMUR
  • TIBIA
  • PATELLA

23
ANATOMYLIGAMENTS
  • ACL
  • PCL
  • MCL
  • LCL

24
ANATOMYMUSCLES
  • EXTENSORS
  • Quadriceps
  • FLEXORS

25
SURGERY
  • Exposure
  • Bone Cuts
  • Alignment Measurement Jigs
  • Soft Tissue Balance
  • Insertion of Prosthesis
  • Femur
  • Tibia Trey
  • Polyethylene Insert
  • Patella

26
Exposure
  • Skin Incision
  • Split Muscle
  • Expose bone

SNR SURG TECH
27
Prepare Femur
  • Drill Guide Hole in Femur
  • Insert Rod and Alignment Block

SNR SURG TECH
28
Prepare Femur
  • Measure Size of Femur
  • Place Cutting Block on Femur

SNR SURG TECH
29
Prepare Femur
  • Make Femoral Bone Cuts

SNR SURG TECH
30
Prepare Tibia
  • Drill Guide Hole in Tibia
  • Place Alignment Jig in Tibia
  • Make Tibial Cuts

SNR SURG TECH
31
Prepare Patella
  • Measure Patella Size Thickness
  • Place Cutting Guide on Patella
  • Make Patella Cuts

SNR SURG TECH
32
Insert Trials
  • Insert Femoral, Tibial, Patella Insert Trial
  • Asses Alignment, ROM, Ligament Balance

SNR SURG TECH
33
Insert Components
  • Clean Bone
  • Cement in Components
  • Reassess
  • Soft Tissue Closure

SNR SURG TECH
34
PROSTHETIC CHOICES
  • MATERIALS
  • Metals
  • Cobalt Chrome
  • Titanium
  • Polyethylene
  • Ceramics
  • BEARING SURFACES
  • Metal - Polyethylene
  • Zirconium - Polyethylene
  • DESIGN
  • Constraint
  • Crux Retaining
  • Crux Replacing
  • Constrained
  • Hinged
  • Mobile Bearing
  • SURGERY
  • Mini Incision
  • Computer Navigation

35
TIME
  • SURGERY Hour
  • HOSPITAL 1-3 Days
  • REHABILITATION 1-6 Months

36
Rehabilitation
  • PT, HEP, CPM
  • Motion
  • Strength
  • Balance

37
Rehabilitation
  • 24o
  • Ambulation
  • Motion - CPM
  • 1 Week
  • Stairs
  • Independent
  • 1 Month
  • Drive

38
Average Post Op Protocol AAHKS Survey
  • Bending 4th week
  • Driving 5th week
  • Sitting _at_ office desk 6th week
  • Carry brief case 7th week
  • Climb ladder 9th week
  • Work on hands knees 11th week

39
RESULTS
  • 95 - 98 good to excellent
  • 80 -90 15 year survival

40
COMPLICATIONS
  • INFECTION
  • DVT - PE (Blood Clots)
  • PAIN
  • LOOSENING / WEAR
  • INSTABLITY
  • NEUROLOGIC
  • VASCULAR

41
Impairment Evaluation
  • Knee Score (100 points)
  • Pain 50 points
  • Motion 25 points
  • Stability 25 points
  • Deductions
  • Function Score (100 points)
  • Walking 50 points
  • Stairs 50 points
  • Deductions

42
Knee Score
  • Pain (50 points)
  • None 50 points
  • Mild or Occasional 45 points Stairs only 40
    points Walking Stairs 30 points
  • Moderate Occasional 20 points Continual 10
    points
  • Severe 0 points

43
Knee Score
  • Motion (25 points)
  • 125 deg 25 point
  • (5 deg 1 point)
  • Stability (25 points)
  • Medial - Lateral
  • lt 5 deg 15 points
  • 6 - 9 deg 10 points
  • 10 - 14 deg 5 points
  • gt 15 deg 0 points
  • Anterior - Posterior
  • lt 5 mm 10 points
  • 5 - 9 mm 5 points
  • gt 9 mm 0 points

44
Deductions
  • Extensor Lag (-15 points)
  • Flexion Contracture (-20 points)
  • Malalignment ( -20 points)

45
Deductions
  • Extensor Lag (-15 points)
  • lt 10 deg -5 points
  • 10 - 20 deg -10 points
  • gt 20 deg -15 points

46
Deductions
  • Flexion Contracture (-20 points)
  • 5 - 9 deg -2 points
  • 10 - 15 deg -5 points
  • 16 - 20 deg -10 points
  • gt 20 deg -20 points

47
Deductions
  • Alignment (-20 points)
  • 0 - 4 deg 0 points
  • 5 - 10 deg -3 points per deg
  • 11 - 15 deg -3 points per deg
  • gt 15 deg -20 points

48
Permanent Physical Impairment
Whole Person (Lower Ext)
  • TKR
  • GOOD (85 - 100 points) 15 (37)
  • FAIR (50 - 84 points) 20 (50)
  • POOR (lt 50 points) 30 (75)

AMA Guide to PPI - 5th ed
49
Permanent Physical Impairment
Whole Person (Lower Ext)
  • TKR
  • GOOD (85 - 100 points) 15 (37)
  • FAIR (50 - 84 points) 20 (50)
  • POOR (lt 50 points) 30 (75)
  • Menisectomy (Med or Lat)
  • Total 3 (7)
  • Cruciate Lig Laxity
  • Severe 10 (25)
  • Arthritis
  • 0 mm cartilage remaining 20 (50)
  • Amputation
  • BKA 28 (70)
  • AKA 32 (80)

AMA Guide to PPI - 5th ed
50
LIFE AFTER TKR
51
FUNCTION
  • ABILITY To Perform A Function VS
  • ADVISABILITY To Perform A Function VS
  • PATINETS Expectations

CONSEQUENSES
52
Physically Able
  • Walk
  • Kneel ???
  • Bend
  • Stairs
  • Drive - 4 weeks post surgery

53
Discouraged Activities KNEE SOCIETY
  • In general, patients who have undergone total
    knee replacement should avoid high-impact
    activities that cause high stress loads on the
    implant and therefore may increase the risk of
    early failure.

54
Questionable Activities
  • Higher Impact Activities
  • Running
  • Jumping
  • Heavy Lifting

55
ACTIVITIES AFTER TKR
  • Driving 86 after 5th week
  • Climbing Ladder 85 after 9th week
  • Crawling 67 after 11th week
  • 33 never allow
  • Weight Carried
  • 10 lbs 98 after 9 weeks
  • 50 lbs 50 after 14 weeks
  • (Rarely allowed 89 after 10 weeks)

AAHKS Survey 1998
56
ACTIVITIES AFTER TKR
  • Recommended Activities Not recommended
    Activities ?????
  • Low-impact aerobics Racquetball Fencing
  • Stationary bicycling Squash Roller Blade
  • Bowling Rock climbing Inline Skating
  • Golf Soccer Downhill Skiing
  • Dancing Single tennis Weight Lifting
  • Horseback riding Volleyball
  • Croquet Football
  • Walking Gymnastics
  • Swimming Lacrosse
  • Shooting Hockey
  • Shuffleboard Basketball
  • Horseshoes Jogging
  • Road bicycling ) Handball
  • Canoeing )
  • Hiking )
  • Rowing )
  • Cross-country skiing )

experienced patients ()
Healy et al. American Journal of Sports Medicine
200129 377 - 388
57
Knee Society Survey1999 v 2005
  • ALLOWED 1999 2005Bowling ? ?Stationary
    cycling ? ?Ballroom dancing ? ? Golf ? ?
    Horseback riding ? With Experience
    Shuffleboard ? ? Swimming ? ? Walking ? ?
    Canoeing With Experience ? Cycling With
    Experience ? Square dancing NA ? Hiking With
    Experience ? Speed walking With Experience ?

Healy et al., Athletic Activity After Total
Joint ArthroplastyJBJS 2008902245-2252
58
Knee Society Survey1999 v 2005
  • Allowed with Experience 1999 2005Canoeing ? Allow
    ed Cycling ? Allowed Hiking ? Allowed
    Rowing ? ? Ice Skating ? ? Cross-country
    skiing ? ? Stationary skiing ? ? Doubles
    tennis ? ? Speed walking ? Allowed Weight
    Machine ? No Consensus Horseback riding ? ?
    Downhill skiing No Consensus ?

Healy et al., Athletic Activity After Total
Joint ArthroplastyJBJS 2008902245-2252
59
Knee Society Survey1999 v 2005
  • Not Recommended 1999 2005Baseball ? No
    Consensus Basketball ? ?Football ? ?
    Gymnastics ? No Consensus Handball ? No
    Consensus Hockey ? No Consensus Jogging ? ?
    Rock climbing ? No Consensus Soccer ? ?
    Squash / racquetball ? No Consensus Singles
    tennis ? No Consensus Volleyball ? ?

Healy et al., Athletic Activity After Total
Joint ArthroplastyJBJS 2008902245-2252
60
Knee Society Survey1999 v 2005
  • NO CONSENSUS 1999 2005Square dancing ? Allowed
    Fencing ? ?Roller skating ? ? Downhill
    skiing ? With ExpWeightlifting ? ?
    Baseball Not Rec ? Gymnastics Not Rec ?
    Handball Not Rec ? Hockey Not Rec ? Rock
    climbing Not Rec ? Squash / racquetball Not
    Rec ? Singles tennis Not Rec ? Weight
    machine NA ?

Healy et al., Athletic Activity After Total
Joint ArthroplastyJBJS 2008902245-2252
61
? TIME TO RTW
  • ABSOLUTE
  • In patient (hospital rehab)
  • Age
  • Health
  • Previous Activity Level
  • Rehab / PT
  • Transportation
  • Accommodations Work Requirements
  • Sedentery vs. Manual Labor
  • Ambulatory aids on the job
  • Part Time

62
What Does It Cost
63
What Does It Cost
64
Is It Worth It?
  • Society
  • QALY
  • 2.5 yrs
  • 4.2 - 6.7 yrs
  • American College of Rheumatology Boston, Mass
    2007
  • Individual
  • Priceless

If you put the federal government in charge of
the Sahara Desert, in five years there'd be a
shortage of sand. --Milton Freidman
65
SUMMARY ?
  • 95 - 98 Good to Excellent Results
  • Pain Relief
  • Function
  • 15 () years Longevity
  • Increasing Burden
  • Aging population
  • Revisions
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