Transcript Technical considerations for successful primary TKR To

Technical considerations
for successful primary TKR
To improve ROM
Lee Beom Koo
Gachon university
Gil hospital.
Advantage of high flexion
•
although the degree of
postoperative knee
flexion did not affect
patient satisfaction, it
did influence fulfillment
of expectations,
functional ability, and
knee perception.
Brandon N. Devers, Michael A. Conditt, Miranda L. Jamieson, Matthew D. Driscoll,
Philip C. Noble, Brian S. Parsley
Does Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee
Arthroplasty?
JA feb 2011 Pages 178-186
Factor for high flexion;
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•
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Pre-operative factor
Intraoperative factor
Post-operative factor
Design
Factor for high flexion;
•
•
•
•
Pre-operative factor
Intraoperative factor
Post-operative factor
Design
Intraoperative factor
Posterior translation
Early
Impingemen
t
Late
Impingemen
t
Need functional PCL or PCL substitution mechanism for
good flexion
Dennis; CORR 464, Nov 2007,53
Philippe Massin J arthroplasty 2006 sept
Adequate PCL. balancing
• Tight posterior
cruciate ligament
result in tightness in
flexion & decreased
flexion
TKA
with Tight PCL
Laskin R: Total knee replacement with posterior cruciate
ligament retention in patients with a fixed varus
deformity. Clin Orthop 331:29, 1996
Lombardi AV, Mallory TH, Fada RA, et al: An algorithm
for the posterior cruciate ligament in total knee
arthroplasty. Clin Orthop 392:75, 2003
PS > CR
• Consistent posterior translation
• Increased flexion gap
•
•
Kurosaka Jarthroplasty 2002
Dennis CORR 464 2007
Impingement
Posterior condylar offset
For every 2mm decrease in condylar offset, the maximum
flexion was reduced by a mean of 12.2
Bellman JBJS (Br) 2002-84-B;50-3
Larger flexion gap
• PCL-substituting prosthesis
can provide a more predictable flexion
gap and a larger flexion angle
Dennis DA, Komistek RD, Stiehl JB, et al: Range of
motion after total knee arthroplasty: the effect of
implant design and weight-bearing conditions. J
Arthroplasty 13:748, 1998
Sagittal Laxity & ROM
•
Laxities of less than 5 mm, irrespective of implant design, were
associated with an impaired range of passive motion and an
increased likelihood of incurring a flexion deformity in excess of
4 degrees.
• It was concluded that anteroposterior laxity in excess of 5 mm
in prosthetic knees is desirable for unimpaired joint function,
although an upper limit of acceptable anteroposterior laxity
could not be identified.
Warren PJ, Olanlokun TK, Walker PS, et al. Laxity
and function in knee replacements. Clin Orthop
1994; 305:200
Sagittal Laxity & ROM in CR
<5
5-10
>10
P value
98.73
112.27
117.66
0.000
extension 2.47
75
-2.93
0.005
Function
score
>80
40%
52%
43%
0.080
Oxford
score
18.5
17.1
18.1
0.045
flexion
Moderate laxity (5-10mm) is likely associated with
1) Significant better functional outcome
2) Minimal hyperextension
Hee-Nee Pang
AAOS 2012
singapore
Sagittal Laxity & ROM
• . Dejour et al compared PCR and posterior stabilised (PSknees
at 3 to 4 years postoperative using clinical examination and
radiological laxity on weightbearing radiographs,
•
more than 10mm of anterior translation had a worse outcome,
as shown by Knee Society Function Scores
Dejour D, Deschamps G, Garotta L, et al. Laxity in
posterior cruciate sparing and posterior stabilized
total knee prostheses. Clin Orthop 1999;364:182
Sagittal laxity & ROM
. Knees with more than 10 mm
of AP laxity at 75° had
significantly less flexion and
lower Knee Society Scores than
knees with 5 to 10 mm of AP
laxity.in PCL retaining TKA
David
JA
P. Gwynne Jones
aug'06 Pages 719-723
Instability & ROM
Y. Matsuda, Y. Ishii, H. Noguchi, and R. Ishii
J Bone Joint Surg Br, Jun 2005; 87-B: 804 - 808.
Trapezoidal flexion gap
• the range of flexion was decreased
and the incidence of medial tibial pain
and zone I radiolucencies in
trapezoidal flexion space
Laskin
The Journal of Arthroplasty Vol. 10 No. 5
1995
Internal rotated femoral component
The femoral component rotation
was more internally rotated in
symptomatic patients (5.5°) than in
controls (1.0°) (P = .04).
Varus laxity in flexion was higher in
symptomatic patients (11.0°) than in
controls (7.0°)
Jose Romero, Thomas Stähelin, Chistoph Binkert, Christian Pfirrmann, Jurg
Hodler and Oliver Kessler
The Clinical Consequences of Flexion Gap Asymmetry in Total
Knee Arthroplasty
Pages 235-240
J A Feb'07
Lateral Laxity in Flexion Increases the Postoperative Flexion
Angle in Cruciate-Retaining Total Knee Arthroplasty
Tatsuya Kobayashi
The Journal of Arthroplasty Vol. 27 No. 2 2012
Geert Van Damme,
J Bone Joint Surg Am. 2005;87(Suppl 2):52–58.
Joint line
–  10 mm.
– > 10 mm.
– 32% flexed > 120°
– 7% flexed > 120°
Maloney Jarthroplasty June‘2002 P 71)
Shoji et al.
Orthopaedics 1990
순천향
Posterior spur
resection
Laskin The Journal of Arthroplasty Suppl. 1 June 2004
Dennis CORR 464 2007
Efficacy of tibia slope
Philippe Massin J arthroplasty 2006 sept.
Increasing tibia slope
• high load in anterior portion of
polyethylene
(Walker CORR262,227;1991)
• Knee unstable in flexion
Hungerford AAOS ICL 96
The Effect of Posterior Tibial Slope on Range of Motion
After posterior cruciate–sacrificing design
Total Knee Arthroplasty (scorpio)
but increasing posterior slope did not
result in a significant increase in ROM or
Hospital for Special Surgery functional
score
J Arthroplasty sept‘2006Pages 809-813
Devanshu Kansara and David C. Marke
Avoid  patellar thickness
–  20% - 26% flexed > 100°
– < 20% - 97% flexed > 100°
Shoji et al.
Orthopaedics 90
– good flexion -  0.8 mm
– poor flexion -  2.6 mm
Ryu et al. Bull Hosp Joint Dis 93
Flexed femoral component
Slightly flexed positining of femoral component &
posteriorly tilted positioning of tibia can create
slightly better range of flexion
Kurosaka JA 2002
Wound closure in flexion
– Wound closed in 90° - 110° of flex
ion
– At 6 months - 2° more flexion
compared with pre-operative range
vs. 4° less flexion with extension
closure
Emerson Jr et al.
Clin Orthop 1996
– No difference in the early post-op.
or the 2- to 3-month follow-up p
arameters
Masri et al.
Clin Orthop 1996
No tourniquet?
– Without tourniquet – significantly better
knee flexion at 1 week
Wakanker et al. JBJS-B 1999
MIS
140
120
Flexion
100
Conv
MIS
80
60
40
1d
3d
5d
7d
2w
3m
Lee Myung chul SNUH
6w
Post-op factor
• Aggressive rehabilitation + adequate
pain control is necessary to optimize
post-op flexion
Sultan CORR 416 2003.
Design aspect for high
flexion
Nexgen LPS-Flex®
• Thick posterior condyle
• PE: deep anterior patella cut
Most E, JBJS(Am), 2004
Scorpio
• single-axis knee
• a relaxed posterior slope of the
tibial polyethyle
•
.
•
a reduced femoral rise, improved collateral
ligament function in deep flexion
Klein J arthroplasty 2004 Dec.
Design for high flexion
• Small femoral radius
large flexion gap
(Kurasaka JA 2002 June)
internal rotation of the tibia
in deep flexion (mobile bearing)
• Another important factor for achieving
deep knee flexion is the need for large
internal rotation of the tibia,
Maximizing Flexion After TKA •
Kurosaka et al. J arthroplasty
June 2002
RPF
Small femoral radius
relaxed posterior slope
of the tibial polyethyle
internal rotation of the tibia
ROM between high flex knee and
standard knee
• high-flexion design and those that had the standard design
were found to have a similar range of motion under both nonweightbearing
• and weight-bearing conditions. Moreover, no significant
difference was found in terms of the other functional outcomes
examined.
Jong Keun Seon,, Eun Kyoo Song, MD, PhD
J. Bone Joint Surg. Am., Mar 2009; 91 (3); 672-679
Young-Hoo Kim,, Jun-Shik Kim, MD
J. Bone Joint Surg. Am., Aug 2009; 91 (8); 1874-1881
High-flexion total knee arthroplasty in
stiff knees( pre-op max flex <100)
• In the LPS-flex group, about half of the
knees (n = 18,44%) could achieve a
maximum flexion of 140 postoperatively,
• but in the LPS group only five knees
(13%) achieved a maximum flexion of
140.
Bum-Sik Lee, Seong-il Bin
Knee Surg Sports Traumatol Arthrosc
(2011) 19:936–942
Summary
TKA후 좋은 굴곡을 얻기 위하여는
• ligament balancing을 잘하는 것 이 가장
중요하다
• 그외에 joint line,patella thickness를 거
의 정상에 가깝게 수술하고 post spur
resection을 해야하며
• MIS, pain control, repair in flexion,은
초기에 굴곡을 더 얻을 수 있다
• High flexion design은 강직이 있는슬관절
에서 굴곡을 얻는 데 도움 이 된 다
Thank you for
your attention