Transcript Slide 1
1 M. Mardani Kivi MD. Guilan University of Medical Sciences 2 3 4 40% of the population over 70 years of age suffers from osteoarthritis of the knee and by the year 2020 this figure is expected to rise by 66-100%. Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology 2007; 46: 1445-9. 5 a major advance in the treatment of DJD excellent restoration of joint function pain relief low perioperative morbidity over 500,000 TKAs being performed, on average, in the United States annually. 6 In 2001, 171,335 primary TKAs were performed. Demand for primary TKA is projected to grow in the USA to 3.48 million procedures by 2030. By 2015, medical expenses for this procedure in the United States are calculated to increase to a staggering $40.8 billion. Kurtz S, Ong K, Lau E et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780–785. 7 May cause May cause Increased increased prostheses functional wearing outcome after TKA 8 Most of the functional scoring systems quoted in literature use pain, the ability to walk or to ascend and descend stairs, the use of a walking aid, etc. as measurements of outcome. The ability to kneel is often ignored. 9 The lack of literature addressing the specific concerns of a large percentage of our Iranian patients with their particular cultural habits, regarding the capacity to which they will be able to kneel post-operatively, has motivated us to investigate: “kneeling ability after TKA in patients with OA of the knee.” 10 Design: cross-sectional longitudinal study Inclusion criteria: clinical diagnose of Ant-lat impingement synd. , Exclusion criteria: simultaneous OA of the hip and/or lumbar spine, Incomplete patient charts and/or questionnaires, and TKA performed by other surgeons 11 prostheses type: Zimmer(NexGen) or Stryker (Scorpio NRG) Approach: midline Medial parapatellar arthrotomy No resurfacing of the patella PCL substituting prosthesis Femoral cut: in 3° of ext. rotation 12 Variables: Knee Society Score (KSS) Functional Knee Score (FKS) Visual Analogue Scale (VAS) Kneeling ability: to kneel on a soft flat surface Variables were assessed 3 times: pre-op, one year post-op, and during the final follow-up visit. 13 14 15 Post operatively along with Physiotherapy, which included a special program for knee flexion, patients were also encouraged to kneel vigorously and frequently. 16 Pre-op Kneeling ability : Group (A): patients without pain or with mild pain (VAS: 0-4). Group (B): patients that because of severe knee pain could not kneel (VAS: 5-10). Group (C): patients that because of non-related knee pain, could not kneel. Group A and B were analyzed for changes in kneeling ability. 17 Total patient population:144114 were possible to follow-up Mean age: 67.9±6.2 years (range:52 to 81) Sex: 69 female (60.5%), 45 male (39.5%) Mean follow-up length: 26.7±2.4 months (Range:14 to 44) 18 Score Pre-op 1-year f/up Final f/up P-value VAS 9.24 ± 0.7 1.82 ± 1.04 2.01 ± 1.19 p<0.0001 KSS 59.79 ± 4.54 89.07 ± 5.63 89.82 ± 5.11 p<0.0001 FKS 59.57 ± 4.48 87.72 ± 5.21 88.23 ± 5.36 p<0.0001 19 Total patient population N=114 Pre-op Pt's able to kneel pre-op: 38 (33.3%) Post-op Pt's unable to kneel pre-op: 76 (66.7%) Due to knee related problem: 59 (77.6%) Able to kneel at final f/up: 43 (71.2%) Due to non-related knee problem:17 (22.4%) Unable to kneel at final f/up: 17 (28.8%) 20 No surgical complications • such as infection, wound dehiscence, loosening of the skin around prosthesis, etc No revision required at the final f/up 21 Similar to other studies, Our study showed a statistically significant improvement in functional outcome (KSS, FKS) and pain relief (VAS) after TKA. ◦ Ahmad Hafiz et al, 2011 ◦ Tahmasebi et al, 2009 ◦ Dierick et al, 2004 Dierick F, Avenière T, Cossement M, Poilvache P, Lobet S, Detrembleur C. Outcome assessment in osteoarthritic patients undergoing total knee arthroplasty. Acta Orthop. Belg 2004; 70: 38-45. Tahmasebi MN, Motaghi A, Shahrezaee M. Total Knee Arthroplasty in patients with osteoarthritis: Results of 34 operations. Tehran university medical Journal 2009; 67(2): 146-150. Ahmad Hafiz Z, Masbah O, Ruslan G. Total Knee Replacement: 12 Years Retrospective Review and Experience. Malaysian Orthopaedic Journal 2011; 5 (1):34-9. 22 Cultural differences Prosthesis type Surgical technique OA or RA Kneeling after TKA misinformation about kneeling 23 A meta-analysis using results from 130 studies: a PCL retaining prosthesis 107° knee flexion after TKA a PCL substituting prosthesis 103° Although more recent studies have shown data to be more in favor of PCL substituting prostheses. Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tri-compartmental total knee replacement. A meta-analysis. JAMA 1994; 271:1349–57. 24 Factors that may negatively influence a patient’s ability to kneel after TKA Tightness of the retained PCL Elevation of the joint line Increase in patellar thickness Trapezoidal flexion gap Chiu KY, Ng TP, Tang WM, Yau WP. Review article: Knee flexion after total knee arthroplasty. Journal of Orthopaedic Surgery 2002: 10(2): 194–202. 25 Yoshino et al. : The ‘unintentional’ passive flexion exercise imparted by the Japanese sitting-style appears to be important in achieving and maintaining full knee flexion after TKA. In Iran: eating traditionally on the ground and praying Yoshino S, Nakamura H, Shiga H, Ishiuchi N. Recovery of full flexion after total knee replacement in rheumatoid arthritis—a follow-up study. Int Orthop 1997;21:98–100. 26 No study has supported that kneeling repetitively may damage knee prostheses. Palmer et al. (2002) Palmer SH, Servant CT, Maguire J, Parish EN, Cross MJ. Ability to kneel after total knee replacement. J Bone Joint Surg [Br] 2002; 84-B: 220-2. 27 Radiographic study has shown that forces exerted from the femur to knee joint: At the time of kneeling While normal standing or during walking Palmer SH, Servant CT, Maguire J, Parish EN, Cross MJ. Ability to kneel after total knee replacement. J Bone Joint Surg [Br] 2002; 84-B: 220-2. 28 Schai et al. and Palmer et al. showed that kneeling ability, when measured objectively, is greater than when measured subjectively after TKA. Schai PA, Gibbbon AJ, Scott RD. Kneeling ability after total knee arthroplasty. Clin Orthop 1999; 367:195-200. Palmer SH, Servant CT, Maguire J, Parish EN, Cross MJ. Ability to kneel after total knee replacement. J Bone Joint Surg [Br] 2002; 84-B: 220-2. 29 Jenkins et al. (2008) a single-blind randomized controlled trial The improvement in patient-reported kneeling ability was thought to be due to the kneeling intervention provided and not to any of the previously reported barriers to kneeling such as scar position, numbness, range of flexion, involvement of other joints, and pain. Jenkins C, Barker KL, Pandit H, Dodd CAF, Murray DW. After partial knee replacement, patients can kneel, but they need to be taught to do so: A single-blind randomized controlled trial. Phys Ther 2008; 88: 1012–21. 30 A 68 Y/O Female DJD 31 32 33 34 35 36 37