In the name of God

Patient Selection in Knee Arthroplasty Mohsen Mardani-Kivi, M.D. Orthopedic Department, Guilan University Of Medical Sciences

We’ll discuss… Indications for: Review recent articles TKA UKA Patellar resurfacing Bi-lat TKA Review recent articles

Did you feel the same?!?!

Case 1 Age/Gender/CC: 80/M/ Pain right knee joint History of Present Illness: pain bilateral knee joint ,right knee joint pain more severe than left. Had arthoscopic partial medial menisectomy and lavage about 3years back which gave temporary relief for about 6 months. also had intra articular hyaluronic acid injection, pain in right knee joint has increased severely

Case 1 CABG around 10 years back, present ejection fraction being 40% Ph.Ex: CABG around 10 years back, present ejection fraction being 40% tenderness medial joint line right knee joint. ROM right knee joint5 to 120 degree Diagnosis: Osteoarthritis bilateral knee joint

Case 1

Case 1

Case 1

1) How would you treat this patient's right knee? conservative 17% arthoscopic debridement 5% total knee joint replacement 75% PRP injection 1%

Ready for Another Question?!

2) Should a UKA be performed in 80 years old male with isolated unicompartmental arthritis? Yes 30% No 60% Depends on surgeons skill and patients demands assuming no contraindications do not exists 10%

Lot’s of controversies, huh!!

Introduction TKA is one of the most successful and commonly performed orthopedic surgery.

Increased physical activity Expectations Excellent pain relief Improvements in ADLs Increased physical activity

Indications for TKA Relieve pain caused by osteoarthritis of the knee (the most common). Deformity in patients with variable levels of pain: Flexion contracture > 20 degrees. Severe varus or valgus laxity.

indication for TKA In Campbell's text: The primary indication for TKA is to relieve pain caused by severe arthritis, with or without significant deformity.

Uni-compartmental Knee Arthritis in only 1 compartment of knee Used in either Young or Old patient Ligaments Intact No systemic Disease Weight <200# Occupation

UKA UKA is contraindicated for rheumatoid arthritis or other inflammatory diseases because the bone and cartilage lesions can be expected to spread and eventually the entire knee will be involved

UKA Some believe that this method is contraindicated for patients exceeding 70 kg in weight. In the United States, however, some surgeons use 90 kg as the cutoff value.

UKA A body mass index (BMI) exceeding 25 or 27 is considered to indicate mild obesity and obesity, respectively. It is desirable for this index to be below 25.

Patellar Resurfacing Indication for leaving the patella unresurfaced: Congruent patellofemoral tracking. Normal anatomical patellar shape. No evidence of crystalline or inflammatory arthropathy. Lighter patient.

Patellar Resurfacing Of all the indications for resurfacing, inflammatory arthritis has been the most widely accepted. Most authors have recommended routine resurfacing for all patients with R.A. Lighter patients tending to do well with un-resurfacing patella.

Lets see What's new in literature?

Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

A trial of weight loss with diet and exercise received the highest possible AAOS recommendation. Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

KEY POINTS Total knee arthroplasty is indicated for patients who continue to have knee pain after 6 months of non-operative treatment. Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

the group of younger age and the group with less severe preoperative symptoms were more likely to have better postoperative outcomes.

Role of AGE in patient selection

Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons

Does surgeon selection of appropriate patients is evolving?!?! Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons Does surgeon selection of appropriate patients is evolving?!?! If this is true, we would see: the typical patient undergoing TKA would report less pain and disability at the time of surgery. variation in typical patients across surgeons.

Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons They demonstrated that both the preoperative pain and function (KOOS scores) represent a large degree of pain and disability at the time of TKA. So, The rapid increase in number of patients undergoing TKA cannot be explained fully by clinicians extending surgical indications to patients with less severe symptoms.

The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more In 2011, Clement et. al study showed that despite similar pain relief and functional improvement, compared with a younger group of patients, octogenarian had a higher risk of death, postoperative complications and longer hospital stay after standard TKA Clement ND :The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br2011,93:1265–1270

However, In 2014 Kuo et. al indicated that the ≥80 years group had similar functional results and pain relief of the TKA compared with the young (65-74 y/o) patient group. Octogenarian just had a higher complication rate of blood transfusion.

Bi-lat TKA? The number of annual bilateral TKAs increased by 75%. The average age of patients undergoing bilateral TKA decreased by 2.5 years from 1999 to 2008.

Protocol for patient selection for bilateral TKA

Take op-room massage!!! Do not occupy your op-rooms with senile complicated patients. While younger patients are suffering from knee problems

Any Questions?