1. Total Knee Arthroplasty in young Adults H. Makhmalbaf MD Consultant Orthopedic & Knee Surgeon Ghaem Hospital Medical Center Mashhad IRAN 17 th Oct 2011 Tehran

2. Introduction The percentage of patients decreased Improvement in medical treatment The backlog of patients has been operated Training of residents and fellows

3. TKR in JRI David Palmer et al JBJS July 2005 8 pts, 15 knees, average age 16.8 yrs Evaluation of pain, ROM, walking, X-ray find. Follow up, 16.5 yrs, pain & functional limit. Before surgery, 7 of 8 on wheelchair 3 revisions, all pain free, 6 able to walk Mean ROM from 37° 79° Good results, pain & function

4. Causes of OA in young Rheumatoid arthritis Post trauma Hemophilia Post infection Septic arthritis TB Osteonecrosis

5. Ipsilateral hip involvement More frequent in RA than OA Evaluate the hip thoroughly Operate on the hip 1 st Referral knee pain from the hip Hip surgery is easier, patient accepts TKR

6. THR before TKR Exercising a hip is easier over a painful knee Resolve tension of muscles which cross both hip & knee Correction of knee deformity during THR It avoids twisting a well balanced a TKR during dislocating a stiff hip for THR

7. Flexion contracture FC are more prevalent in RA than OA Contracture is mainly because of inflammation in oft tissues If FC is<15 normal distal cut+ posterior release If FC is 15-45 cut 2mm more for every 15 If FC is 45-60 pre op MUA & casting & a PS kn For FC >60 pre op MUA & casting& constrained knee to avoid flexion gap laxity

9. Rheumatiod cyst Cysts are more common in RA Large cysts Curett & fill with cancellus bone Large central cysts need impaction bone grafting

10. Patellar resurfacing Resurface or not? Its different from OA Resurface in all RA patients ? Some do well without Chance of recurrence of synovitis if not

11. Synovectomy & recurrent active rheumatoid synovitis Its possible the RA synovitis to recur after TKA If patella is not resurfaced or cartilage left Even if patella is resurfaced syn. Is seen If acute presentation, large effusion

12. Synovectomy & recurrent active rheumatoid synovitis Dif. Diagnosis is infection Aspiration for cell count & culture If multiple joints involved medical treatment Initial synovectomy at TKR if

13. Risk for infection The risk of periop & metastatic infection is higher in RA than OA Later metastatic infection is more common Because of immune compromised pat. the sources are: foot, lower leg & olecranon bursa

15. Need for adequate knee flexion The RA patients need more flexion than OA To have satisfactory function 60-70 flexion for walking 90 deg. For ascending stairs 100 deg for descending & sitting up from chair Involvement of other joints Use of crutches

16. Osteopenia Can present difficulties during TKA Notching & postoperative fracture If so, put long stem femoral component If between two sizes cut not for smaller fracture during preparation for surgery If the hip is stiff there is more chance Post TKA fracture during MUA for stiffness

17. Osteopenia Patella fracture during MUA Avulsion of MCL during TKA Fix with a cancellus screw & washer Intraoperative frac. Of patella Cemented component In osteopenic bone

18. Anesthetic consideration Because involvement of C-spine Preoperative consultation with Anesthesiologist Lateral c-spine X-rays in flx. & ext Regional anesthesia is preferred over GA. Prepare for GA in case it is needed

19. PCL preservation v substitution PCL retaining or sacrificed CR does well in most RA patients PCL might stretch over the time Instability & hyperextension Put the insert tight during TKA Minimal bone cut Check PCL before opening prosthesis

22. Summary Management difficulties Ipsilateral Hip involvement Bilaterality, anticoagulation needs Flexion contractures, rheumatoid cysts Patella resurfacing, synovectomy More chance of infections Adequate flexion for daily living & spare uppe Osteopenia & fractures

25. Thank you

26. Indications Pain Instability Limitation of ROM – Conversion to a: Stable Pain free Mobile joints

27. Symptoms Pain Limitation of ROM Stiffness, ankylosed knee Instability Limitation of extension & Fixed deformity Combination of these

28. Important factors Fixed deformity Mal alignment Leg length discrepancy Bone loss Bone Stock Bone Quality

29. Important factors Patients expectations Socio economic condition Chance of failure Consult the patients Need for revision Knee score

30. Deformities Varus Valgus Recurvatum Leg length Intra articular deformity Extra articular deformity

31. Pre op evaluation: Medications Steroids NSAID Anti TB Coagulation factors

32. Pre op evaluation: Imaging Standing X-ray AP & Lateral Alignment view MRI

33. Pre op evaluation: Laboratory ESR CBC CRP RF Factor IIIV Tuberculin test Urinalysis

34. Intra operative

35. Examination of the patient Range of movement of the knee Previous scars Sinus tract Skin condition NV status Ligament deficiency or Laxity Other joints conditions Deformities & Length of the leg Quadriceps working

36. Pre op considerations Pre op physiotherapy Medications Timing of surgery Prosthesis selection & availability & cost Metal augments & wedges Allograft & bone substitutes Simultaneous bilateral TKR?

37. Intra operative problems Approach Patella reflection & exposure Arthrofibrosis release Release of contractures Bone defects management Protect bone because of osteoporosis TT osteotomy or quadriceps snip

38. Intra operative problems Soft tissue balance Ligament deficiency Knee dislocation or subluxation PS or more constrained prosthesis (CCK) Patella tracking in valgus knee

39. Medications Antibiotics DVT prophylaxis NSIAD Other medications

40. Post operative management Bandage and dressing Knee supports Mobilizing the patient Physiotherapy

41. Complications : Intra operative Early post operative Late post operative Medical complications Mechanical complications

42. Intra operative complications Inadequate exposure Fractures Tendon injuries NV injuries Bleedings Anesthetic complication

43. Early post op Wound dehiscence Infection, superficial or deep MI, cardiac arrest Need for blood transfusion Quadriceps rupture

44. Late complications Pain, stiffness, limitation of ROM Infection, reactivation of TB Ligament insufficiency, subluxation or disloc. Fractures around the prosthesis Loosening Implant wear PF complications