Knee Arthroplasty

Total knee replacement in some form has been practiced for over 50 years, but the complexities of the knee joint only began to be understood 30 years ago. Because of this, total knee replacement initially was not as successful as Sir John Charnley's artificial hip. However, dramatic advancements in the knowledge of knee mechanics have led to design modifications that appear to be durable. Definition y Total joint replacement or arthroplasty is a surgical procedure wherein both the femoral and tibial sides of the knee joint are replaced and most commonly fixated with cement. Total joint replacement can be performed on any joint of the body including the hip, knee, ankle, foot, shoulder, elbow, wrist, and fingers. The goal is to provide a long-lasting artificial joint that relieves pain and improves function, while minimizing or avoiding surgical complications. emented joint replacement or arthroplasty is a procedure in which bone cement or polymethylmethacrylate(PMMA) is used to fix the prosthesis in place in the joint. Ingrowth or cementless joint replacement or arthroplasty does not involve bone cement to fix the prosthesis in place. An anatomic or press fit with bone ingrowth into the surface of the prosthesis leads to a stable fixation.

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The most common indications for a total joint replacement are: y Pain. Pain is the principal indication. This includes pain with movement and pain at rest. y Functional limitations. Capsular contractions and joint deformity can cause a decreased range of motion, with subsequent functional restrictions. y Loss of mobility. There are certain patient subgroups in which joint stiffness, without hip pain, is an indication for surgery. y Radiographic indications of intra-articular disease. Although radiographic changes are considered in the decision to operate, the more significant determinant is the severity of symptoms. Of the total joint replacement procedures, the hip and knee total joint replacements are by far the most common. ontraindications Absolute contraindications to total knee replacement include the following: y y y y Knee sepsis A remote source of ongoing infection Extensor mechanism dysfunction Severe vascular disease

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Recurvatum deformity secondary to muscular weakness Presence of a well-functioning knee arthrodesis

Relative contraindications include medical conditions that preclude safe anesthesia and the demands of surgery and rehabilitation. Other relative contraindications include the following: y y y y Skin conditions within the field of surgery (eg, psoriasis) Past history of osteomyelitis around the knee Neuropathic joint Obesity

Types of Knee Arthroplasty Number of Compartments Replaced y Unicompartmental: only medial or lateral joint surfaces replaced y Bicompartmental; entire femoral and tibial surfaces replaced y Tricompartmental; femoral, tibial and patellar surfaces replaced Implant Design y Degree of constraint o Unconstrained: no inherent stability in the implant design; used primarily with unicompartmental arthroplasty o Semiconstrained: provides some degree of stability with little compromise of mobility; most common design used for total knee arthroplasty o Fully constrained: significant congruency of components; most inherent stability but considerable limitation of motion y Fixed bearing or mobile-bearing design y ruciate-retaining- excising/ substituting Surgical Approach y Standard/ traditional or minimally invasive y Quadriceps-splitting or quadriceps-sparing Implant Fixation y Cemented y Uncemented y Hybrid Epidemiology y Widely performed procedure for advanced arthritis of the knee, primarily in older patients (> 70 years of age) with osteoarthritis. y During the decade between 1990 and 2000, the proportion of younger patients increased significantly.

More than 500,000 total joint arthroplasty surgeries of the hip and knee are performed annually, the majority of which are for patients with OA.

Anatomy The knee is the largest and most complex joint in the body. It is considered a "physiologic" joint because it requires the normal functioning of all its parts (bony, ligamentous, and muscular) to simultaneously provide smooth motion, stability in stance, and protection against deterioration over time. The knee joint complex includes three articulating surfaces, which form two distinct joints contained within a single joint capsule: the patellofemoral and tibiofemoral joint. Despite its proximity to the tibiofemoral joint, the patellofemoral joint can be considered as its own entity, in much the same way as the craniovertebral joints are when compared to the rest of the cervical spine. Parts of an Artificial Knee Joint

Operative Procedure 1. The knee is flexed and osteophytes, menisci and the ACL are resected. If a posterior cruciate-substituting prosthesis is to be implanted, the PCL is also excised 2. Small portions of the distal femur and proximal tibia are removed and prepared for the implants. 3. If a patellar implant is indicated, the patellar surface is also prepared and the prosthesis inserted. 4. After trial components are inserted, soft tissue tension, collateral ligament balance, ROM and patellar tracking are checked. 5. Lateral retinaculum may be released to improve patellar tracking. 6. Permanent components are inserted and the capsule and other soft tissues are repaired. 7. The area is thoroughly irrigated and the wound is closed with the knee extended or in 90 of flexion and with a small suction drain in place. 8. A sterile dressing is placed over the incision and the area is covered from foot to thigh with a compression wrap. . Features of Standard and Minimally Invasive Surgical Approaches for Knee Arthroplasty Standard Approach y Anteromedial parapatellar vertical or curved incision from the distal aspect of the femoral shaft, running medial of the patella to just medial of the tibial tubercle, ranging from 8-12 cm or 13-15 cm in length y Necessary soft tissue releases prior to eversion of the patella y Anterior capsule release y Dislocation of the tibiofemoral joint prior to bone cuts and implantation of components Minimally Invasive Approach y Reduced length of anteromedial skin incision 6-9 cm in length y No patellar eversion y Anterior capsule release y No tibiofemoral dislocation y In situ bone cuts y In situ Implantation of components Common Complications y Dislocation y Infection -Staphylococcus epidermis, Staphylococcus aureus, Streptococcus, E. coli, Proteus, and Pseudomonas -Stages  Stage I acute postoperative-characterized by erythematous, draining, swollen wounds in the early postoperative period

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 Stage II deep delayed- acute, dramatic process or a more subtle indolent infection  Stage III late hematogenous- characterized by joint pain and dysfunction in a previously healthy joint Heterotropic Ossification (bone deposition in soft-tissue structures) Peripheral Nerve Injuries - Sciatic nerve, particularly the peroneal division, is most frequently involved Thromboembolic disease

Pharmacological Treatment (Pain management) y Anti-inflammatory drugs (NSAIDS) y Narcotics Prognosis The short-term outlook for total knee replacement is excellent. Most individuals can stand the morning after surgery and begin to exercise that day. With the support of walkers or crutches, individuals can walk with confidence, climb stairs, and ride in a car by the time they leave the hospital. Some swelling, aching, and numbing are normal during post-operatively. Most individuals are able to return to their normal activities within 6 weeks after surgery. The long-term outlook after total knee replacement is also very good. One group of findings suggests that individuals with well-performed knee replacements can expect a 91% to 96% chance that their knee replacement will be in place and functioning at 14 to 15 years (Palmer). Individuals can influence these odds by maintaining an ideal weight, exercising, protecting against infection, and avoiding impact sports. Alternatives to Knee Replacement y Knee bracing or shoe inserts y Injections, either with a cortisone-like drug or a hyaluronan derivative y Physical therapy and medicine y Arthroscopy y Osteotomy Rehabilitation Preoperative exercise y Aerobic exercise y Strengthening- focus on quadriceps specifically vastus medialis oblique y Joint protection techniques such as use of high stools in lieu of prolonged standing, avoiding high-impact activity, and using adaptive equipment y Energy conservation principles y Weight loss y Limiting squatting and stair climbing

Preoperative education y Patient empowerment y Disease self-management Early postoperative Rehabilitation y Use of continuous passive motion y Ankle pumping exercises y Deep breathing exercises Postoperative exercise prescription Goals o To obtain and maintain rapid recovery of knee ROM o To develop knee and hip muscle strength o To obtain functional independence y Active assisted ROM while sitting by postoperative day 2, y Progressing to isotonic and isometric knee and hip muscle strengthening, particularly of the VMO, by postoperative day 4. y Active knee extensions are performed supine. y Gait training preferably with crutches y If the patient exhibits a stiff knee gait, he or she is asked to exaggerate knee flexion and extension during the gait cycle y Manual joint mobilization can be employed to increase active knee flexion y Proprioceptive retraining Prepared by: Alethia S. Andaleon BSPT, UB 4th year Referrences: O Sullivan Kisner Dutton DeLisa