knee replacement Dr Alpesh

8/7/2019 knee replacement Dr Alpesh

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DrDr AlpeshAlpesh M PatelM PatelM.S. (M.S. (orthoortho))

Trisha Trauma Centre & ICUTrisha Trauma Centre & ICU

TOTAL KNEETOTAL KNEE

ARTHROPLASTYARTHROPLASTY


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Anatomy of the KneeAnatomy of the Knee

Made up of threeMade up of three

bones:bones:

Femur (thigh bone)Femur (thigh bone)

Tibia (lower legTibia (lower leg

bone)bone)

Patella (kneecap)Patella (kneecap)


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KinematicsKinematics

The TRIAXIALThe TRIAXIALmotion of the knee:motion of the knee:

Articular geometryArticular geometry

LigamentousLigamentousrestraintsrestraints


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Causes of Knee PainCauses of Knee Pain

Osteoarthritis (wearOsteoarthritis (wearand tear)and tear)

Rheumatoid arthritisRheumatoid arthritis

PostPost--traumaticarthritistraumaticarthritis

caused by:caused by:

FracturesFractures

Ligament injuriesLigament injuries

Meniscus tearsMeniscus tears


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Osteoarthritis (OA)Osteoarthritis (OA)

OA is theOA is the most common formmost common formof arthritis and the mostof arthritis and the most

common joint diseasecommon joint disease Most of the people who haveMost of the people who have

OA are older than age 45, andOA are older than age 45, andwomen are more commonlywomen are more commonlyaffected than men.affected than men.


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OAOA

OA is a disease of

joints that affects all of

the weight-bearing

components of the

joint:

Articular

cartilage

Menisci

Bone


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Symptoms of Knee ArthritisSymptoms of Knee Arthritis

PainPain During activityDuring activity

At rest or sleepingAt rest or sleeping

Swelling and tightnessSwelling and tightness

Bone spursBone spurs

Grinding sound during movementGrinding sound during movement Stiffness and decreased range ofStiffness and decreased range of

motionmotion


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Diagnosing Knee ArthritisDiagnosing Knee Arthritis

Physical examinationPhysical examination

Medical history reviewMedical history review

XX--RaysRays

Blood testsBlood tests


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Knee JointKnee Joint

Healthy knee joint Arthritic knee joint


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OA Radiographic Diagnosis

Asymmetricaljoint space

narrowing

Periarticular

sclerosis

Osteophytes

Sub-chrondral

bone cysts


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OA Arthroscopic Diagnosis

Normal Articular Cartilage

Ostearthritic degenerated cartilage

with exposed subchondral bone

Arthroscopy allows earlier

diagnosis by demonstrating the

more subtle cartilage changes

that are not visible on x-ray


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How Can My Life ChangeHow Can My Life Change

with Treatment?with Treatment?A return toA return to

mobilitymobility

Regaining a senseRegaining a senseof your formerof your formerlifestylelifestyle

Reduce orReduce oreliminate paineliminate pain


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NonNon--Surgical Treatment OptionsSurgical Treatment Optionsfor Knee Painfor Knee Pain

Modifying activitiesModifying activities

Lose weightLose weight

NSAIDNSAID

Pain MedicationsPain Medications

Glucosamine/Glucosamine/ ChondroitenChondroiten SulfateSulfate

Physical TherapyPhysical Therapy

HyaluronicHyaluronic AcidAcid

SynviscSynvisc,, HyalganHyalgan


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NonNon--Surgical Treatment Options forSurgical Treatment Options for

Knee Pain: Prescription MedicationsKnee Pain: Prescription Medications Biological Response ModifiersBiological Response Modifiers

Treat rheumatoidarthritis;may postpone injury to the jointsTreat rheumatoidarthritis;may postpone injury to the joints

Includes:Includes:InfliximabInfliximab EtanerceptEtanercept

GlucocorticoidsGlucocorticoids or Corticosteroidsor Corticosteroids Treat rheumatoidarthritis; fight inflammationTreat rheumatoidarthritis; fight inflammation

Includes:cortisone, hydrocortisone (Includes:cortisone, hydrocortisone (CortefCortef,, HydrocortoneHydrocortone),),

PrednisolonePrednisolone ((PrelonePrelone))

DMARDSDMARDS Treat rheumatoidarthritis;slow joint destructionTreat rheumatoidarthritis;slow joint destruction

Includes:Includes:methotrexatemethotrexate,, lefumidelefumide,, hydroxychloroquinehydroxychloroquine,, injectableinjectable

gold,,etc.gold,,etc.


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NonNon--Surgical Treatment Options for KneeSurgical Treatment Options for KneePain: Injection TherapyPain: Injection Therapy

Cortisone InjectionsCortisone Injections

Helps reduce swelling andHelps reduce swelling anddiscomfort from arthritis.discomfort from arthritis.

Temporary pain relief.Temporary pain relief.

Small risk of infection.Small risk of infection.

Hyaluronic Acid (HA)Hyaluronic Acid (HA)

InjectionsInjections Restores lubrication and fluidRestores lubrication and fluid

in the joint.in the joint.

Creates a shock absorberCreates a shock absorber

between the bones.between the bones.


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NonNon--Surgical Treatment OptionsSurgical Treatment Options

for Knee Painfor Knee Pain Lifestyle ChangesLifestyle Changes

Extra weightExtra weight

Exercise important to control weightExercise important to control weight

Know what foods to eatKnow what foods to eat

OrthoticsOrthotics

Assistive devices (Cane, etc)Assistive devices (Cane, etc) WalkingWalking

BathroomsBathrooms

ClimbingClimbing

DressingDressing


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Knee Surgical Treatment OptionsKnee Surgical Treatment Options

ArthroscopyArthroscopy

SynovectomySynovectomy

Tibial osteotomyTibial osteotomy

Total knee replacementTotal knee replacement

UniUni--compartmental replacementcompartmental replacement


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ArthroscopyArthroscopy

Removes damaged soft tissue.Removes damaged soft tissue.

Less invasive surgery, possibly leading toLess invasive surgery, possibly leading toshorter recovery times.shorter recovery times.

Sustained pain relief varies in advancedSustained pain relief varies in advancedosteoarthritis patients.osteoarthritis patients.


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Arthroscopic SurgeryArthroscopic Surgery

Small camera inserted toSmall camera inserted tosee inside the joint.see inside the joint.

Small instrumentsSmall instrumentsremove any debris andremove any debris andsmooth cartilagesmooth cartilage

surfaces.surfaces.


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Arthroscopic Surgery, continuedArthroscopic Surgery, continued

BenefitsBenefits

Outpatient surgeryOutpatient surgery

Less invasiveLess invasive

May reduce recovery timeMay reduce recovery time

DisadvantagesDisadvantages

Pain relief may be temporaryPain relief may be temporary


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SynovectomySynovectomy

Early stages of rheumatoid arthritis.Early stages of rheumatoid arthritis.

Removes inflamed tissue lining.Removes inflamed tissue lining.

Potentially saves joint from furtherPotentially saves joint from furtherdamage.damage.


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Synovectomy SurgerySynovectomy Surgery

Small incision is made.Small incision is made.

Arthroscope is used to inspect the joint.Arthroscope is used to inspect the joint.

Diseased synovium is removed.Diseased synovium is removed.

Physical therapy usually required.Physical therapy usually required.


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Synovectomy, continuedSynovectomy, continued

BenefitsBenefits

Alleviates rheumatoidarthritis pain in theAlleviates rheumatoidarthritis pain in the

jointjoint

Joint may besaved from furtherdamage.Joint may besaved from furtherdamage.

Synoviumcould grow back over timeSynoviumcould grow back over time

DisadvantagesDisadvantages Not a permanent solutionNot a permanent solution


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Tibial OsteotomyTibial Osteotomy Treats a varus orTreats a varus or

bowlegged deformitybowlegged deformity

Candidates have:Candidates have: PainPain

KneecartilagedamageKneecartilagedamage

primarily in onesection.primarily in onesection. Improperly healedImproperly healed

broken knee.broken knee.


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Tibial Osteotomy SurgeryTibial Osteotomy Surgery Incision is made on bothIncision is made on both

the front and side of thethe front and side of the

knee.knee. WedgeWedge--shaped piece ofshaped piece of

bone is removed.bone is removed.

Edge of cut bone is stapledEdge of cut bone is stapledand held by plates andand held by plates andscrews.screws.


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Tibial OsteotomyTibial OsteotomyBenefitsBenefits

Restore knee functionRestore knee function

Reduce osteoarthritis painReduce osteoarthritis pain May even stimulate growth of new cartilageMay even stimulate growth of new cartilage

DisadvantagesDisadvantages

Results may be temporaryResults may be temporary Cosmetic difference between kneesCosmetic difference between knees


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When is Knee ReplacementWhen is Knee Replacement

Surgery Right for You?Surgery Right for You?

Experience significant pain.Experience significant pain.

Knee function and mobilityKnee function and mobilitydecreases.decreases.


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UniUni--compartmental Kneecompartmental Knee

ReplacementReplacement Minimally invasive surgeryMinimally invasive surgery

Removes damagedRemoves damagedarticular cartilage in singlearticular cartilage in single

area of the kneearea of the knee Replaces damagedReplaces damaged

component with prosthesiscomponent with prosthesis

Goal is quick:Goal is quick:

Return to normal activities.Return to normal activities. Pain reliefPain relief


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Benefits of a UniBenefits of a Uni--compartmentalcompartmental

Knee ReplacementKnee Replacement

Resolves arthritis painResolves arthritis pain

Maintains twoMaintains two--thirds of thethirds of thenatural kneenatural knee

Minimally invasive procedureMinimally invasive procedure

Proven procedureProven procedure


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Unicondylar Knee ArthroplastyUnicondylar Knee Arthroplasty Indications:Indications:

Younger patientsYounger patientswithwithunicompartmentalunicompartmentaldisease instead ofdisease instead ofHTO.HTO.

Elderly thin patientElderly thin patientwithwithunicompartmentalunicompartmentaldisease (shorterdisease (shorterrehabilitation,rehabilitation,

greater ROM)greater ROM)

Contraindications:Contraindications:

Flexion contractureFlexion contracture>= 5 degrees.>= 5 degrees.

ROM < 90 degrees.ROM < 90 degrees.

Angular deformityAngular deformity>= 15 degrees.>= 15 degrees.

Cartilaginous erosionCartilaginous erosionin the weightin the weight--bearingbearingarea of the oppositearea of the oppositecompartment.compartment.


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Total Knee Replacement ComponentsTotal Knee Replacement Components

FemoralFemoral-- replaces arthriticreplaces arthriticportion of thigh boneportion of thigh bone

TibialTibial-- replaces arthriticreplaces arthriticportion of shin boneportion of shin bone

Tibial insertTibial insert-- replacesreplacescartilage and acts as shockcartilage and acts as shockabsorberabsorber

PatellaPatella-- replaces knee capreplaces knee cap


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1- Cruciate

retaining

2- Cruciate

substituting

3- Mobile bearing

4- Unicondylar

ClassificationClassification

1

2

3

4


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The ends of the femur, tibia, and patella are shaped to accept

the artificial surfaces.

The end result is that all moving surfaces of the knee aremetal against plastic

Total Knee Replacement


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Total Knee Replacement:Total Knee Replacement:

Cemented or CementlessCemented or Cementless Cemented implant is held in place by aCemented implant is held in place by a

type of epoxy cement that attaches thetype of epoxy cement that attaches the

metal to the bone.metal to the bone. Uncemented implant has a fine mesh ofUncemented implant has a fine mesh of

holes on surface allowing tissue to growholes on surface allowing tissue to growinto.into.


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Total Knee ReplacementTotal Knee Replacement Two major types of total kneeTwo major types of total knee

replacement systems:replacement systems:

Fixed BearingFixed Bearing-- does not allow full range ofdoes not allow full range ofmotionmotion

Rotating Platform BearingRotating Platform Bearing-- closelyclosely

simulates the action of the normalsimulates the action of the normalknee jointknee joint


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Potential Benefits ofPotential Benefits of Fixed BearingFixed Bearing

Total Knee ReplacementTotal Knee Replacement

Provides pain relief.Provides pain relief.

Restores the motion ofRestores the motion ofyour knee.your knee.

Improves quality ofImproves quality oflife.life.

Good results inGood results inappropriate patients.appropriate patients.


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Potential Benefits ofPotential Benefits of RotatingRotating

PlatformPlatform Total Knee ReplacementTotal Knee Replacement Provides pain relief.Provides pain relief.

Restores the motion ofRestores the motion of

your knee.your knee. Rotation similar to aRotation similar to a

normal knee.normal knee.

Reduces potential of earlyReduces potential of early

wear and loosening.wear and loosening.

Improves quality of life.Improves quality of life.


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Surgical ProcedureSurgical Procedure Patient is anesthetized.Patient is anesthetized.

Incision is made.Incision is made.

Arthritic surface at the end of the thighArthritic surface at the end of the thighbone or femur is removed.bone or femur is removed.

Bone is prepared for a new covering.Bone is prepared for a new covering.

Femoral component is attached.Femoral component is attached.


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Surgical ProcedureSurgical ProcedureArthritic surface on top ofArthritic surface on top of

the shin bone is removed.the shin bone is removed.

A metal tray (tibial tray) isA metal tray (tibial tray) isplaced on top ofplaced on top ofremaining bone.remaining bone.

Tibial insert locked intoTibial insert locked intotray.tray.

Incision is closed.Incision is closed.


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Preoperative X rayPreoperative X ray


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After SurgeryAfter Surgery Postoperative Pain control achieved byPostoperative Pain control achieved by

Epidural anesthesia, femoral block,Epidural anesthesia, femoral block,

opiodopiod analgesicanalgesic Movement of knee determined byMovement of knee determined by

doctor.doctor.

Physical therapy is very important toPhysical therapy is very important toregain mobility and strength.regain mobility and strength.


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After SurgeryAfter Surgery Static and active quadriceps kneeStatic and active quadriceps knee

exercise started after 24 hoursexercise started after 24 hours

Walking with supportWalking with support

Drains removed after 48 hoursDrains removed after 48 hours

Patient can be dischargedPatient can be discharged betwweenbetwween 55--

7 days.7 days.


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Recovery in theFirst WeekRecovery in theFirst Week

Continued use of your walker or crutchesContinued use of your walker or crutchesis required.is required.

With a cemented procedure, increaseWith a cemented procedure, increaseweight on sore leg as comfortable.weight on sore leg as comfortable.

With a cementless procedure, place onlyWith a cementless procedure, place only

the toes down until a followthe toes down until a follow--up xup x--ray.ray.


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Recovery in theFirst MonthRecovery in theFirst Month

Sutures or staples usually taken out 10Sutures or staples usually taken out 10--1414days after surgery.days after surgery.

Do not shower or bathe until the suturesDo not shower or bathe until the suturesor staples are removed.or staples are removed.

Motion exercises should be progressing.Motion exercises should be progressing.


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Recovery After Six WeeksRecovery After Six Weeks Swelling normal for first three to six monthsSwelling normal for first three to six months

Elevate leg slightly and apply ice.Elevate leg slightly and apply ice.

DrivingDriving 1 to 2 weeks1 to 2 weeks-- Left knee replaced and automaticLeft knee replaced and automatic

transmission.transmission.

6 to 8 weeks6 to 8 weeks-- Right knee replaced.Right knee replaced.

Return to work in 6 to 8 weeks dependingReturn to work in 6 to 8 weeks dependingon type of work.on type of work.


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Complications(Complications( IntraoperativeIntraoperative)) FractureFracture

MalalignmentMalalignment

Anesthetic complicationsAnesthetic complications


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Complications(PostComplications(Post--operative)operative) InfectionInfection

Deep vein thrombosisDeep vein thrombosis

Fractures (common supraFractures (common supra condylarcondylar femur)femur) Spin outSpin out

Patellar clunkPatellar clunk

DislocationDislocation Plastic wearPlastic wear


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Common question from PatientCommon question from Patient

What is theWhat is the

success ratio ?success ratio ?


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What is theWhat is the

Life of the jointLife of the joint


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Type of jointType of jointTest us and confuse themselvesTest us and confuse themselves


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SummarySummary Knee replacement is a elective surgeryKnee replacement is a elective surgery

and patient needs to be mentallyand patient needs to be mentally

prepared and understand itprepared and understand it Realistic expectation that TKR canRealistic expectation that TKR can

improve knee range movement andimprove knee range movement and

cant make a old horse runcant make a old horse run


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Questions?

Questions?


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Thank YouThank You

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knee replacement Dr Alpesh