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M. Mardani Kivi

Guilan University of Medical Sciences

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

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%.

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Conservative treatment  just for symptomatic relief and delaying the progressive worsening of symptoms The only proven definitive treatment for OA of the knee is total knee joint replacement surgery  expensive but effective and beneficial.

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a major advance in the treatment of DJD excellent restoration of joint function pain relief low perioperative morbidity 

over 500,000 TKA being performed, on average, in the United States annually.

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   In 2001,

171,335

performed. primary TKA were By 2015, medical expenses for this procedure in the United States are calculated to increase to a staggering

$40.8 billion

.

Demand for primary TKA is projected to grow in the USA by 673% to procedures by 2030.

3.48 million

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May be a predisposing factor for OA May preserve kneeling function after TKA 7

 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.

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 The lack of literature addressing the specific concerns of a large percentage of our patients with OA undergoing TKA, regarding the capacity to which they will be able to function post-operatively performing these tasks, has motivated us to investigate:

“kneeling ability after TKA in patients with OA of the knee.”

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Design: cross-sectional longitudinal study Inclusion criteria: all participants with OA who had TKA from the years 2007-10 at Poursina Trauma Center, Rasht, Iran.

Exclusion criteria: simultaneous OA of the hip and/or lumbar. Incomplete patient charts and/or questionnaires, and TKA performed by other surgeons 10

prosthesis type: Zimmer or Stryker Approach: midline Medial parapatellar arthrotomy No resurfacing of the patella PCL substituting prosthesis Femoral incision: in 3° of ext. rotation and in 0° alignment 11

Variables:

Time: 1-preop, 2-one year post-op, 3-during a final follow-up visit. Knee Society Score (KSS) Functional Knee Score (FKS) Visual Analog Score (VAS) Kneeling ability: to kneel on a hard flat surface 12

Kneeling ability : Group (A): patients without pain or with mild pain (VAS: 0-4).

Group (B): patients who, because of severe pain, could not kneel (VAS: 5-10).

Group (C): patients, because of non-knee associated pain, could not kneel.

 Group A and B were analyzed for changes in kneeling ability.

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    Total patient population:144  114 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) 14

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

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Pt's able to kneel pre-op: 38 (33.3%) Total patient population N=114 Pt's unable to kneel pre-op: 76 (66.7%) Due to knee related problem: 59 (77.6%) Due to non-knee related problem:17 (22.4%) Able to kneel at final f/up: 43 (71.2%) Unable to kneel at final f/up: 17 (28.8%) 16

No surgical complications •such as infection, wound dehiscence, loosening of the skin around prosthesis, etc No revision required at the final f/up 17

  With the help of different measurement scales criteria (VAS, KSS, FKS), Our study showed a statistically significant improvement in functional outcome after TKA.

◦ ◦ ◦ Similar to other studies: Ahmad Hafiz et al, 2011 Tahmasebi et al, 2009 Dierick et al, 2004 18

Prosthesis Cultural differences OA or RA Surgical technique Kneeling after TKA misinformation about kneeling 19

 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.

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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 21

  Shoji et al. : The ‘unintentional’ passive flexion exercise after TKA.

imparted by the Japanese sitting-style appears to be important in achieving and maintaining full knee flexion In Iran: eating traditionally on the ground and praying 22

   No study to date has supported that patients will do harm to their prostheses by kneeling repetitively.

Hamai et al. (2008) Palmer et al. (2002) 23

 Radiographic studies have shown that forces exerted from the femur to knee joint: At the time of kneeling While seated or during walking 24

 The most recent studies showed that kneeling ability, when measured objectively, is greater than when measured subjectively after TKA.

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 Jenkins et al. (2008) a single-blind randomized controlled trial

intervention provided

 The improvement in patient-reported kneeling ability was thought to be due to the

kneeling

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.

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