TKA PRESENTATIONAnthro-arthroneuromuscular training.

Introduction

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

The best results for TKA at 10 – 15 yrs. compare to or surpass the best result of THA.

Indications for Knee ArthroplastyRelieve pain caused by osteoarthritis of

the knee (the most common).Increase motor controlIncrease functional independence and

performance

Contraindications for TKARecent or current knee sepsis.Remote source of ongoing infection.Extensor mechanism discontinuity or severe

dysfunction.Painless, well functioning knee arthrodesis.Poor health or systemic diseases (relative

contraindications).

Anatomy

Medial and lateral condylesConvex, asymmetricMedial larger than lateral

Tibial plateauMedial tibial condyle: concaveLateral tibial condyle: flat or convexMedial 50% larger than lateralArticular cartilage thicker on medial plateau

Knee Anatomy

Patellar ligament and patellar tendon, Collateral ligaments, Cruciate ligaments, Knee rotation: Many muscles.

Epidemiology

Talking Points.Annually there are over 500,000 total knee

replacement (TKR) procedures performed in the US. It is projected that by 2030 the volume of this procedure will increase to over 3.48 million per year due to the aging baby-boomers, increased obesity and indications for TKR that extend to both younger as well as older patients. American Association of Orthopedic Surgeons 2006 Annual Meeting Presentation Future Caseload Kurtz SM

TKR currently represent 8.2% of all Medicare dollars spent. Economic Burden of Total Hip and Knee Arthroplasty in Medicare Enrollees Ong et al 2006

It is estimated that annual hospital charges for TKR will approach 40.8 billion dollars annually by 2015. Kaiser-Permanente March 2007, Future Clinical & Economic Impact of Revision Total Hip & Knee Revision Kurtz, Ong JBJS 2007.

Nationally, for DRG 544 (THA/TKA) the average charge per hospitalization was $38,447 with an average payment of $11,916. Inpatient Hospital Payment Information for Value-Driven Health Care Top 31 DRGs Aug 2008 www.cms.gov.

The National Institutes of Health consensus recommendations.The National Institutes of Health (NIH) convened a consensus

development conference in 2003 and made recommendations/ conclusions in the following areas. TKA outcome is influenced by:

1. Appropriate candidates for the procedure *2. Short term outcomes by functional status and overall health related

quality of life.3. Surgeon case volume, hospital case volume, surgical technique and

choice of prosthesis.4. Periop interventions of pre-op education, antibiotic prophylactic

antibiotics, aggressive pain management, risk assessment, and management of medical conditions.

5. insufficient data to provide recommendation in the following areas: anticoagulation for pulmonary emboli, periop rehab strategies, methods to reduce post-op anemia, postop physical activity and site of post acute care.

NIH recommendationsIndications fall into three categories:PainDisability/ HandicapExtent of local joint damage x-ray

What determines length of stay after total hip and knee arthroplasty? A nationwide study in DenmarkConclusion Nationwide implementation of fast-track THA and TKA

would result in a significant decrease in the needed number of hospital beds with similar or better outcome for the patients. Implementation of updated logistical and clinical features is expected to increase rehabilitation and reduce LOS with similar or improved patient satisfaction. These results support the implementation of fast-track total hip- and knee arthroplasty.

Departments with short hospital stay were characterized by both logistical (homogenous entities, regular staff, high continuity, using more time on and up to date information including expectations on a short stay, functional discharge criteria) and clinical features (multimodal opioidsparing analgesia, early mobilization and discharge when criteria were met) facilitating quick rehabilitation and discharge.

Arch Orthop Trauma Surg (2010) 130:263–268 DOI 10.1007/s00402-009-0940-7

TKA - Indications

• Osteoarthritis• Rheumatoid Arthritis• Post – Traumatic Arthritis• Osteonecrosis• Tumor

Technical Goals - TKAProsthesis parallel to Floor/StanceMechanical Axis/Center of JointCorrect RotationCentralize Quadriceps Tendon

OA Management J Bone Joint Surg Am. 2002;84:1719-1726.Michael J. Archibeck and Richard E. White, Jr.

Mosely et al., in a randomized, doubleblind,placebo-controlled trial of arthroscopic treatment ofosteoarthritis of the knee in 180 patients with two years offollow-up, found equal improvement in the three treatmentgroups (débridement, lavage, and placebo arthroscopy), suggestingthat the improvement was secondary to a placebo effect

Mandelbaum, in a four-year, multicenterstudy of more than 1300 patients who underwentautologous chondrocyte implantation in the knee, reportedclinical improvement in 70% of patients, with the best resultsoccurring in patients with femoral lesions (85% of whom hadimprovement).

OA Management Marti et al.reported on the use of proximal tibial varus (opening-wedge)osteotomy for the treatment of valgus gonarthrosis in a studyof thirty-six patients with proximal tibial deformity and founda good or excellent result in 88% (thirty) of thirty-four

patientsafter a mean duration of follow-up of eleven years1.Kaper et al. found that 54% (twenty-five) of forty-six patientswho had undergone high tibial osteotomy had development ofpatella baja (>10% lowering of patellar height as measuredwith use of the Insall-Salvati ratio) and 61% (twenty-eight)had a loss of posterior tibial slope of >5°.

Unicondylar Knee Arthroplasty Indications:

Younger patients with unicompartmental disease instead of HTO.

Elderly thin patient with unicompartmental disease (shorter rehabilitation, greater ROM)

Contraindications:

Flexion contracture >= 5 degrees.ROM < 90 degrees.Angular deformity >= 15 degrees.Cartilaginous erosion in the weight-bearing

area of the opposite compartment.

Unicompartmental KAPrice et al. found that the ten-year survivorship of theOxford medial unicompartmental knee replacement was 92%in patients who were less than sixty years old compared with96% in patients who were more than sixty years old (p = 0.6).The same group found that the rate of recovery (as determinedby the time needed to achieve straight-leg raising, 70°of flexion, and independent stair-climbing) after unicompartmentalknee replacement performed through a short incisionand without eversion of the patella was two times faster thanthat after open unicompartmental knee replacement andthree times faster than that after total knee replacement, withouta compromise in the radiographic appearance

Alignment in PrimaryTotal Knee ReplacementSurgical technique remains a crucial factor in the success

andlongevity of total knee replacement. Errors in soft-tissue

balancingand component alignment are relatively common. Novotny et

al. Katz et al. Berger et al., Scuderi et al. While there remains

some controversy with regard to the most accurate technique,

relying on one landmark for femoral rotational alignmentmay be inadequate.

Knee Joint Components

Cruciate Retaining

Cruciate substituting

Mobile bearing

Unicondylar

AP and Lateral s/p TKA

Techniques in PrimaryTotal Knee Replacement300 tibial components that were inserted with a “hybrid”

cementingtechnique (insertion of the tray with cement and the tibialkeel without cement) reported a 0.1% rate of failure after amean duration of follow-up of seventy-five months. Wall et al.,110 tibial components and found a 3.6% rate of failure in

their “hybrid” group (insertion of the tibial tray with cement and the tibial stem

without cement) and no failures in the group treated with cemented

tray and stem . Sekundiak.

Surgical ApproachesThe midvastus approach involves an arthrotomy that is performed by dissecting diagonally away from

the superomedial aspect of the patella into the vastus medialis muscle. Dalury et al.11 conducted a prospective randomized study to compare the electromyographic evaluation of the vastus muscle, radiographs, range-of-motion tests, and Knee Society scores for twenty patients undergoing bilateral total knee arthroplasty (with one arthroplasty being performed through a midvastus approach and one being performed through a medial parapatellar approach). At six weeks and at the time of the latest follow-up at twelve weeks, there were no significant differences in any of the measured parameters and there were no electromyographic or nerve-conduction abnormalities in the knees that had the midvastus approach. However, at the six-week follow-up, six of the twenty patients expressed a preference for the total knee implant that had been inserted through the midvastus approach, one had a preference for the implant that had been inserted through the parapatellar approach, and the remainder had no preference. It appears that the midvastus approach is a safe alternative to the parapatellar approach and may offer some early benefits.

The mini-subvastus approach, in which the arthrotomy is extended medially under the vastus medialis muscle, avoids incision of the quadriceps muscle and tendon. Schroer et al.12 retrospectively compared 150 total knee arthroplasties that had been performed through the mini-subvastus approach with 150 total knee arthroplasties that had been performed through the traditional medial parapatellar approach. Both groups of patients had similar characteristics and an identical perioperative management protocol. The authors found that patients who had been managed with the mini-subvastus approach were discharged earlier (3.4 compared with 4.1 days; p < 0.05), exhibited a more rapid recovery of quadriceps strength, were less likely to require inpatient rehabilitation, and had improved knee flexion over a two-year period. Comparison of the groups also showed no differences in terms of the number or severity of complications

(1)Standard anteromedial parapatellar quadriceps incision

(2)Mid vastus incision(3)Subvastus incision(4)Quadriceps-sparing

incision.

Soft-tissue balancing is of paramount importance in theachievement of a successful result after total knee replacementSequences of lateral release and quantified the effect on flexion and

extension gaps in paired cadaveric knees, with the sequence consisting of release of the posterior cruciate ligament, the posterolateral capsule, the iliotibial band, the popliteus tendon, and the lateral collateral ligament producing more symmetric flexion-extension gaps4. Lateral collateral ligament release, independent of the sequence, produced marked gap asymmetry. (Peters et al.)

Similar cadaveric study and found that lateral tightness in extension is well treated with iliotibial band and posterior capsule release and that tightness in flexion is corrected with lateral collateral ligament and popliteus tendon release. In another cadaveric study, (Whiteside et al.)

Indications for simultaneous bilateral total kneereplacement remain controversial.1090 simultaneous bilateral and 958 unilateral total knee

procedures, found greater blood loss and higher rates of transfusion, postoperative ileus, pulmonary complications, cardiac complications, and neurologic complications in patients who were more than eighty years old and underwent simultaneous bilateral total knee replacement (p < 0.05 for all comparisons). (Lombardi et al.,)

Blood loss during total knee replacementFibrin sealant that was sprayed into the wound prior to

tourniquet deflation had reduced drainage (185 compared with 408 mL) (p = 0.002) and higher hemoglobin levels (as indicated by a 28.9% smaller decrease in hemoglobin) (p = 0.005) in comparison with a control group Wang et al.

Greater total blood loss (1792 compared with 1499 mL) in patients undergoing total knee replacement when a tourniquet was used (p = 0.02). Tetro et al.

Postoperative pain controlSixty-nine patients, found that the use of intra-articular morphine

and bupivacaine following total knee replacement improved pain scores and reduced the need for systemic analgesics, with a greater effect in patients with rheumatoid arthritis. Tanaka et al.,

Better anesthesia techniques have improved pain control, which allows the patient to reach range-of-motion goals sooner and lessens the need for post operative knee manipulation. Now, femoral and sciatic nerve catheters can be used for continuous application of local anesthetic agents and are usually left in place until the third postoperative day. Longacting anesthetics in the knee capsule, long-acting opiates, and nonsteroidal antiinflammatory drugs have also promoted quicker recovery and minimized the amount of physical therapy needed.

16 Vol. 57, No. 3 2006 Northeast Florida Medicine Maxwell W. Steel, MD

PCL or not PCLThe debate regarding the superiority of posterior cruciate

ligament-retaining or posterior cruciate ligament-substituting total knee replacements continues.

Seventy-four matched pairs of posterior cruciate ligamentsacrificing

\ and posterior cruciate ligament-substituting knee replacements and found that the cruciate-substituting design was associated with better results in terms of range of motion, stair function, anterior knee pain, and walking ability. Title et al.

Randomized, prospective study, compared proprioception, balance, and quadriceps activity in patients with posterior cruciate ligament-retaining and posterior cruciate ligament-substituting total knee replacements and found an improved sense of joint position in the posterior stabilized group, with no difference in the other parameters. Swanik et al.

Patellar Complications PS TKR1. Clunk

2. Synovial Hyperplasia (entrapment)

Grating, crepitation, pain

3. Related to prosthetic design

AMK Congruency 13.5%

PFC Sigma 0%

4. Proximally positioned or wide

femoral box Pollock DC, et al: JBJS 84A: 2174, 2003

PCL or NOT PCL• Cruciate substituting (posterior stabilized)

– More reliable stability (predictable kinematics)– Eliminates possibility of over-tensioning PCL (and the

potential for subsequent rupture)– More constrained– Potential for wear on the tibial spine– Possible dislocation

• Cruciate retaining (PCL intact)– Less conformity– Allows natural femoral rollback– Requires good ligament balancing– Proprioception

Survivorship110 cruciate-retaining total knee replacements (Genesis I;Smith and Nephew, Memphis, Tennessee), reported a 97%survivorship at ten years and a 97% rate of good and

excellentResults Chen et al.,282 consecutive cruciateretaining total knee replacements

that were followed for a minimum of fifteen years, reported a survivorship of 97.9%, 96.2%, and 82.5% at seventeen, nineteen, and twenty-two years, respectively7. Gill and Joshi.

The wear mechanisms of posterior stabilized total knee replacements2.9% rate of revision for loosening and osteolysis in a study of

557 posterior-cruciate-substituting total knee replacements after a mean duration of follow-up of fifty-six months. All failures were associated with polyethylene post damage and backside wear. Mikulak et al

Puloski et al. examined the wear patterns on twenty-three retrieved cruciate-substituting tibial inserts and found wear of the post in all twenty-three, with seven (30%) demonstrating “severe” wear.

The optimal fixation technique for total knee replacement remains controversial.Schroder et al., in a study of 114 consecutive ACG 2000 (Biomet,

Warsaw, Indiana) cementless total knee replacements, reported one case of tibial osteolysis and two cases of aseptic loosening of the tibial component. The ten-year survivorship was 97%.

Berger et al. reported on 129 cementless total knee replacements (Miller-Galante I; Zimmer, Warsaw, Indiana) after a mean duration of followup of twelve years and found excellent femoral component fixation, a 34% rate of revision of the metal-backed patellar component, a 5% rate of aseptic loosening of the tibial component and a 10% rate of tibial osteolysis.

Khaw et al. conducted a prospective, randomized trial of 224 cementless and 277 cemented total knee replacements (Press-Fit Condylar; Johnson and Johnson), with no significant difference in tenyear survivorship between the groups (96.6% and 96.5%, respectively).

Etiology of failure of total knee replacementsFehring et al. reviewed 281 total knee replacements that

were revised within five years after implantation and found that the causes of revision included infection (37%), instability (26%), failure of bone growth into cementless components (13%), patellofemoral problems (8%), and wear or osteolysis (7%)

Sharkey et al. reviewed 215 revision total knee replacements and found that the causes of failure included instability (27%), loosening (25%), polyethylene wear (22%), infection (17%), arthrofibrosis (13%), patellar complications (7%), a deficient extensor mechanism (6%), pain from an unknown source (6%), malalignment (5%), and other factors (6%).

TKA complication analysisComplications are relatively low for TKA population. In a

large study of Medicare patients who had a primary TKR (n = 124,986), complication rates tracked 90 days following the procedure were as follows:

1. 0.7% death2. 0.8% acute myocardial infarction3. 0.8% pulmonary embolus4. 0.4% wound infection5. 0.9% readmission6. 1.4% pneumonia requiring hospitalization7. 1.3% manipulation under anesthesiaEpidemiology of Total Knee Replacement in the United States

Medicare Population JBJS 2005

DVT or not DVTDVT prophylaxis compliance is still an issue

especially when patients were asked to selfadminister the injections.

Thromboembolism is the one of the most common complication following a total hip or knee replacement and is associated with significant morbidity and in some cases mortality.

The Online Journal of Clinical Audits. 2010; Vol 2(2);p2-10. Published May 2010

Degrees of Freedom

Constrained Prostheses

Non-constrained Prostheses

Intermediated Prostheses

Constrained ProsthesesOne degree of freedom.

Non-constrained Prostheses

•Ideal implants.

•5 degrees of freedom.

•Intact ligamentous system.

Intermediated Prostheses

The Least to the Most Constrained

Cruciate-retaining Cruciate-substituting Varus-valgus Constrained

Hinged

Alignment. Alignment.Alignment

1. Tibial components are implanted perpendicular to the mechanical axis

2. Femoral component is implanted in 5 – 6 degrees of valgus.

General Balancing

Varus Deformity

1st Osteophytes must be removed.

2nd Release the deep MCL.

3rd Release semimembranosus and pes anserinus insertion.

4th release posterior capsule and PCL.

Valgus Deformity

1st Osteophytes must be removed.

2nd Release lateral capsule.

3rd Lesser deformity: release Iliotibial band. Greater deformity: release LCL +/- PCL.Valgus deformity + flexion contracture >> release posterior capsule.

Flexion Contracture

Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule release.

Flexion gap < Extension gap >> larger tibial insert.

Standard Procedure l

Standard Procedure ll

TKA VIDEO

Mobile-Bearing Total Knee ReplacementsMobile-bearing knees have been proposed as a potential

solution with issues related to articular surface and back-side polyethylene wear. Issues limiting the longevity of total knee replacements in younger, more active patients.

Hartford et al., in a report on 139 mobile-bearing knee replacements that were followed for a mean of 7.8 years, found a 93% rate of survivorship and a significantly higher rate of aseptic loosening in association with uncemented components (p = 0.0051)

Clinical and radiological outcomes of fixed- versus mobile-bearing total knee replacement. Meta-analysisControversy exists regarding the clinical and radiological

differences in outcomes between fixed- and mobile-bearing total knee replacements (TKR). The aim of this study was to compare these two TKR designs using a meta-analysis of the electronic databases MEDLINE, EMBASE, CINAHL and AMED in addition to a review of unpublished material. All included papers were critically appraised using a modified PEDro critical appraisal tool. Thirty-three studies were eligible, assessing the outcomes of 3532 TKRs. Analysis suggested that there was no significant difference in clinical or radiological outcomes and complication rates between fixed- and mobile-bearing TKRs.

Knee Surg Sports Traumatol Arthrosc (2010) 18:325–340 DOI 10.1007/s00167-009-0909-7

Total joint replacements in patients with the human immunodeficiency virus (HIV)Norian et al., in a review of fifty total knee replacements that

had been performed in thirty-five patients with hemophilic arthropathy (twenty-six of whom were HIV-positive), reported a ten-year survivorship of 84% and a twenty-year survivorship of 71%.

Lehman et al. evaluated twenty-nine total knee replacements in patients with HIV and/or a history of intravenous drug use and found a 14% rate of infection in the HIV group and a 40% rate of infection among the intravenous drug users who had HIV.

Does same day surgery for bilateral knee arthroplasty increase major complication rates in selected patients? Reflecting accepted clinical practice, there is a tendency for high volume surgeons to

select younger, healthier patients for same day bilateral TKA. Our data suggest that with appropriate patient selection, performing same day bilateral TKA does not materially increase the risk of major peri-operative complications when compared to the cumulative risk of staging the procedures over one year. In these selected patients we conclude that the convenience and cost advantages of bilateral same day surgery are worthwhile. Stefano A. Bini, MD • Monti Khatod, MD • Maria C.S. Inacio, MS • Liz Paxton, MA • Donald C. Fithian, MD From the Kaiser Permanente National Total Joint Replacement Registry

1. Barrett, J.; Baron, J. A.; Losina, E.; Wright, J.; Mahomed, N. N.; and Katz, J. N.: Bilateral total knee replacement: staging and pulmonary embolism. Journal of Bone & Joint Surgery - American Volume, 88(10): 2146-51, 2006.

2. Bullock, D. P.; Sporer, S. M.; and Shirreffs, T. G., Jr.: Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. Journal of Bone & Joint Surgery - American Volume, 85-A(10): 1981-6, 2003.

3. Memtsoudis, S. G.; Gonzalez Della Valle, A.; Besculides, M. C.; Gaber, L.; and Sculco, T. P.: Inhospital complications and mortality of unilateral, bilateral, and revision TKA: based on an estimate of 4,159,661 discharges. Clinical Orthopaedics & Related Research, 466(11): 2617-27, 2008.

4. Morrey, B. F.; Adams, R. A.; Ilstrup, D. M.; and Bryan, R. S.: Complications and mortality associated with bilateral or unilateral total knee arthroplasty. Journal of Bone & Joint Surgery - American Volume,

69(4): 484-8, 1987. 5. Parvizi, J.; Sullivan, T. A.; Trousdale, R. T.; and Lewallen, D. G.: Thirty-day mortality after total knee arthroplasty. Journal of Bone & Joint Surgery -

American Volume, 83-A(8): 1157-61, 2001. 6. Paxton, E.; Inacio, M.; Slipchenko, T.; and Fithian, D.: The Kaiser Permanente National Total Joint Replacement Registry. The Permanente Journal,

12(3): 12-16, 2008. 7. Restrepo, C.; Parvizi, J.; Dietrich, T.; and Einhorn, T. A.: Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. Journal of Bone &

Joint Surgery - American Volume, 89(6): 1220-6, 2007. 8. Reuben, J. D.; Meyers, S. J.; Cox, D. D.; Elliott, M.; Watson, M.; and Shim, S. D.: Cost comparison between bilateral simultaneous, staged, and

unilateral total joint arthroplasty. Journal of Arthroplasty, 13(2): 172-9, 1998. 9. Ritter, M. A.; Harty, L. D.; Davis, K. E.; Meding, J. B.; and Berend, M.: Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty.

A survival analysis. Journal of Bone & Joint Surgery -American Volume, 85-A(8): 1532-7, 2003. 10. Syed, S.; Vanhelder, T.; and Wijeysundera, D.: Does Staging Bilateral Knee

Mechanisms of FailureAseptic LooseningInfectionInstabilityStiffnessFracturePatella Femoral Problems

Prior fractures about the knee complicate total knee replacement.Saleh et al., in a review of fifteen total knee replacements

performed after internal fixation of a tibial plateau fracture, reported an 80% rate of good or excellent clinical results but a high rate of complications, including three infections, two patellar-tendon disruptions, and three manipulations.

Parvizi et al. reported on forty-eight total knee replacements performed after a previous distal femoral fracture nd also found good clinical results but a high rate of complications, including two instances of aseptic loosening and three infections.

Parvizi et al., in a study of thirty total knee replacements in patients with ankylosing spondylitis, reported a 20% prevalence of heterotopic bone, a 10% manipulation rate, and one revision for patellar loosening after a mean duration of follow-up of 11.2 years.

Infection at the Site of Total Knee ReplacementMason et al., in a report on the use of knee aspiration, found that

a white blood-cell count of >2500 cells/mm3 (2.5 × 109/L), with at least 60% polymorphonuclear Polymorphonuclear cells, had a 98% sensitivity and a 95% specificity for the diagnosis of infection.

Peersman et al., in their Insall Award-winning report on 6439 total knee replacements performed with vertical laminar airflow and body-exhaust suits, noted a 0.43% rate of deep infection. Onethird of the infections occurred within the first three months after surgery. Prior open knee procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and smoking were comorbidities that significantly increased the risk of infection (p < 0.05). Revisions and procedures that took longer than 2.5 hours were associated with an increased risk as well (p < 0.001).

The treatment of infection at the site of a total knee replacement.Nazarian et al. reviewed the use of a monolithic antibiotic

spacer for the treatment of 124 infections that occurred at the site of a total knee replacement and found a 90% cure rate and a 66% rate of good or excellent results after an average duration of follow-up of 4.5 years.

Emerson et al. compared static spacer blocks (twenty-six knees) with articulating spacers (twenty-two knees) and found an improved postoperative range of motion in the articulating-spacer group (108° compared with 94°) and no significant difference in the reinfection rate (9% compared with 7.6%).

Complications and Functional Outcomes After Total Hip Arthroplasty and Total Knee Arthroplasty: Results From the Global Orthopaedic Registry (GLORY)The Global Orthopedic Registry (GLORY) was designed to monitor a broad

range of complications and outcomes that occur following total hip arthroplasty (THA) and total knee arthroplasty (TKA). GLORY provides global ‘‘real-world” data, in contrast to the data generated by the controlled conditions of clinical trials. The results to date show an overall incidence of both in-hospital and post-discharge complications of approximately 7% in THA patients and 8% in TKA patients. (TKA 8,325 patients) The most common in-hospital complications in THA patients are fractures (0.6%) and deep vein thrombosis (DVT) (0.6%), whereas in TKA patients DVT (1.4%) and cardiac events (0.8%) are most common. The most common post-discharge complications in both THA and TKA patients are reoperation due to bleeding, wound necrosis, wound infection, or other causes; and DVT. Bleeding complications were less common than other adverse events in both groups (in-hospital rates of 0.48% and 0.83%, respectively). Functional outcomes improved after surgery in both groups, as expected. Younger patients and patients who had been discharged directly to their homes seemed to have the greatest improvement in functional outcome after surgery.

Patellar resurfacing during total knee replacement.Barrack et al., in a prospective, randomized, double-blind study of

118 knees that were treated with or without patellar resurfacing during total knee replacement, found no significant difference between the resurfaced and nonresurfaced groups with regard to the overall Knee Society score or the pain or function subscores after five to seven years of follow-up18. However, 12% of the knees in the nonresurfaced group were subsequently resurfaced because of anterior knee pain.

Boldt et al., in a report on 1777 knees that were treated with the Low Contact Stress mobile-bearing total knee replacement (DePuy) without patellar resurfacing, found a 95% rate of good or excellent results after two to fifteen years of follow-up. Nineteen patients (1.1%) had a reoperation because of patella-related anterior knee pain, but only nine of those patients had improvement.

Patellar fractures after TKAKeating et al., in a review of 4583 total knee replacements,

identified 177 patellar fractures. Both of the fractures that were treated with internal fixation went on to nonunion, and four of the eight patients who were treated with excision of the patellar button had an infection. Those authors concluded that most patellar fractures are best treated nonoperatively

Polyethylene Wear in Total Knee ReplacementWear between the tibial baseplate and the modular polyethylene

insert, also known as backside wear, has been identified in several studies.

Surgical technique and alignment have been shown to have an effect on polyethylene wear as well

D’Lima et al., with use of a finite element model, demonstrated that increasing articular conformity significantly reduced stresses when the knee was well aligned. In the presence of rotational malalignment, increased conformity appeared to be detrimental. The same group of authors compared wear in association with “low intensity” loading, “high intensity” loading, and simulated malalignment (3° varus) and found that the most wear occurred in the malalignment group (as indicated by wear values of 3.1, 7.4, and 9.2 mg/million cycles for the three groups, respectively) (p < 0.01).

Revision Total Knee ReplacementBarrack et al., in a study of 112 revision total knee replacements

performed with cemented components with press-fit stems, found a 9% rate of reoperation and a 2.2% rate of aseptic loosening (defined as revision or radiographic evidence of loosening) after four to eight years of follow-up.

It is generally agreed that the minimal amount of constraint that is required should be used during revision total knee replacement. Determining the amount of constraint that is needed can be difficult.

Beckenbaugh et al., in a report on the fifteen-year results of twenty revision procedures performed with use of a cemented Total Condylar III replacement (Johnson and Johnson), noted that four of the replacements had failed (two because of aseptic loosening and two because of infection) and that the remaining sixteen were radiographically stable.

The Epidemiology of Revision Total Knee Arthroplasty in the United StatesUnderstanding the cause of failure and type of revision total knee

arthroplasty (TKA) procedures performed in the United States is essential in guiding research, implant design, and clinical decision making in TKA. Nationwide Inpatient Sample (NIS) database. Clinical, demographic, and economic data were reviewed and analyzed from 60,355 revision TKA procedures performed in the United States between October 1, 2005 and December 31, 2006.

The most common causes of revision TKA were infection (25.2%) and implant loosening (16.1%), and the most common type of revision TKA procedure reported was all component revision (35.2%). Revision TKA procedures were most commonly performed in large, urban, nonteaching hospitals in Medicare patients ages 65 to 74. The average length of hospital stay (LOS) for all revision TKA procedures was 5.1 days, and the average total charges were $49,360. However, average LOS, average charges, and procedure frequencies varied considerably by census region, hospital type, and procedure performed.

Clin Orthop Relat Res (2010) 468:45–51 DOI 10.1007/s11999-009-0945-0

TKA Revision talking pointsThe incidence of revision is commonly used as a measure of prosthesis

failure, but is not a viable option for direct data submission because of the length of time to capture this event. Revision rate at 10 years is 10% and at 20 years is 20%. NIH Consensus Development Program Conference on Total Knee Replacement- 2003

Reporting a flat rate of the number of revisions done by a medical group is not indicative of treatment failure as there may not be a relationship between the provider who placed the original joint and the provider who performed the revision. Risk factors for revision are age younger than 55 at the time of TKR, male gender, diagnosis of osteoarthritis, obesity and the presence of co-morbid conditions. National Guideline Clearinghouse www.guideline.gov Feb 2004

There is a high level of satisfaction with this procedure. In a multi-center study involving 32 states and over 7,700 patients, 95% report that they are satisfied with their procedure. American Association of Orthopaedic Surgeons 2010 Annual Meeting Presentation C. Ayers

Revision Total Knee Arthroplasty with a Cemented Posterior Stabilized, Condylar Constrained or Fully Constrained Prosthesis: A Minimum 2-year Follow-up AnalysisN= 361998 and 2006.

Cemented posterior stabilized (PS)

Condylar constrained knee (CCK)

Fully constrained rotating hinge knee (RHK)

1. Aseptic loosening (15)

2. Infection (18)3. periprosthetic fx (

3)

8 25 13*extensor mechanism defect (two ruptures of ligamentum patellae and one patellectomy) were managed w/ RHK

The mean KOOS increase from 28 (range, 5 to 43) to 83 (range, 55 to 94) (p < 0.001) the mean Knee Society function score improved from 42 (range, 10 to 66) to 82 (range, 60 to 95), (p < 0.001).

Radiolucent lines were observed in 18% of the knees without progressive osteolysis.

1. Revision total knee requires a more constrained prosthesis than primary total knee arthroplasty (ligamentous instability and bony defect).

2. Infected cases showed as good a result as those with aseptic loosening through the use of a. antibiotics-impregnated cement beads and b. Proper soft tissue coverage with a medial gastrocnemius flap.

TKA-Critical Pathway Decreasing medical complications for total knee arthroplasty: Effect of

Critical Pathways on OutcomesStudies on critical pathway use have demonstrated decreased length of stay

and cost without compromise in quality of care. However, pathway effectiveness is difficult to determine given methodological flaws, such as small or single center cohorts. Hospitals in four US states that performed total knee replacements. The principal outcome measure was the risk of having one or more postoperative complications. Results: Two hundred ninety five hospitals (73%) responded to the questionnaire, with 201 reporting the use of critical pathways. 9,157 Medicare beneficiaries underwent TKR in these hospitals with a mean age of 74 years (± 5.8). After adjusting for both patient and hospital related variables, patients in hospitals with pathways were 32% less likely to have a postoperative complication compared to patients in hospitals without pathways (OR 0.68, 95% CI 0.50-0.92). Patients managed on a critical pathway had an average length of stay 0.5 days (95% CI 0.3-0.6) shorter than patients not managed on a pathway.

Husni et al. BMC Musculoskeletal Disorders 2010, 11:160 http://www.biomedcentral.com/1471-2474/11/160

Critical Pathway

Insert Word Document

Outcome Measurement Tools

Oxford

WOMAC

The Knee Society Scores

Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0

INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to perform your usual activities.

Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can.

KOOS

The Knee Society Clinical Rating System. Rationale.A total knee rating system developed by The

Knee Society to provide an up-to-date more stringent evaluation form.

Subdivided into a knee score that rates only the knee joint itself and a functional score that rates the patient’s ability to walk and climb stairs.

Knee Score 100 points maximum.

What does literature say in Long term reviews about PT in TKA.Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review

and metaanalysis of randomized controlled trialsBMJ | ONLINE FIRST | bmj.com doi:10.1136/bmj.39311.460093.BE They evaluated the effectiveness of PT exercise * after elective primary total knee arthroplasty in patients with

osteoarthritis. Design Systematic review. Data sources Database searches: AMED, CINAHL, Embase, King’s Fund, Medline,

Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings.

Randomized controlled trials were reviewed if: 1. They included a PT ex. intervention compared with usual or standard physiotherapy care, or compared two types

of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis.

2. Outcome measures Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardized effect sizes, and tests for heterogeneity.

Results Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardized effect size (0.33, 95% confidence interval 0.07 to 0.58) in favor of functional exercise for function three to four months postoperatively.

There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (−1 to 4.3) for quality of life in favor of functional exercise three to four months postoperatively.

Benefits of treatment were no longer evident at one year.

Conclusions Interventions including PT functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty.

CPM– Early effects onROM in acute setting– No effect on ROM long term

Brosseau L et al 2004Brunn-Olsen V et al 2008

Rehabilitation after Total Knee Arthroplasty

Restore mechanical axisRestore joint linePainless ROM for ADL

CPM or PROM long stretch

Rehabilitation Acute Phase (Protection)CPM 0 ° → 30 ° – progress as tolerated.Ankle pumpsIsom → submax Hamstrings and Quad

activationAmbulation trainingClosed kinetic chain trainingStanding terminal knee extensionHeel to toe loading → minisquatsStanding straight Leg raises (control

training)

Rehab TKA Sub-acute Phase (ROM)CPM/R.O.M. as tolerated.Exercises for early return of proprioception.Core Stabilization: Swiss-plyo-ball exercisesClosed Kinetic chain progression:Wall squats (mini), standing terminal extension

with resistance, leg press and balance activitiesOpen chain exercises: Terminal Extension,

CocontractionHamstrings/Quads, short arc exercises

Mobility Activity as needed: Hamstrings and heel cord stretching.

TKA – Functional Summary (Strengthening )Stage I:1. Core Stabilization• Swiss Ball Exercise• Seated Balance with quad sets2. Double Leg Wall Slides Ball Squats3. Leg Press – Closed Kinetic Chain Strengthening

Total Gym – Sub max. based on body weight4. Heel to Toe Loading – mini squats5. STE – Standing Terminal Extension6. Step Lunges

TKA – Functional Summary (Sports)Stage II:1. Single Leg Balance – eyes open2. Single Leg Mini Squat3. Balance Vector ProgramTT 553 – Tri-plane Stabilization4. Eye open/ Eyes Closed balance testing

Voluntary Activation and Decreased Force Production of the Quadriceps Femoris Muscle After Total KneeArthroplastyDiscussion and Conclusion. Considerable quadriceps

femoris muscle inhibition after surgery has several implications for recovery. Rehabilitation programs that focus on volitional exercise alone are unlikely to overcome this pronounced failure of activation. Early interventions focused at improving quadriceps femoris muscle voluntary activation may improve efforts to restore muscle force.

[Mizner RL, Stevens JE, Snyder-Mackler L. Voluntary activation and decreased force production of the quadriceps femoris muscle after total knee arthroplasty. Phys Ther. 2003;83:359 –365.]

Improved Function From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort

Objective. To determine the effectiveness of progressive quadriceps strengthening with or without neuromuscular electrical stimulation (NMES) on quadriceps strength, activation, and functional recovery after total knee arthroplasty (TKA), and to compare progressive strengthening with conventional rehabilitation.

Methods. RCT 2000 to 2005 in OP PT. 200 patients who had undergone primary, unilateral TKA for knee osteoarthritis were randomized to 1 of 2 interventions 4 weeks after surgery, and 41 patients eligible for enrollment who did not participate in the intervention were tested 12 months after surgery (standard of care group). All randomized patients received 6 weeks of outpatient physical therapy 2 or 3 times per week through 1 of 2 intervention protocols: an exercise group (volitional strength training) or an exercise-NMES group (volitional strength training and NMES). Treatment effects were evaluated by a burst superimposition test to assess quadriceps strength and volitional activation 3 and 12 months postoperatively. The Medical Outcomes Study Short Form 36 and Knee Outcome Survey were completed. Knee range of motion, Timed Up and Go, Stair-Climbing Test, and 6-Minute Walk were also measured.

Results. Strength, activation, and function were similar between the exercise and exercise-NMES groups at 3 and 12 months. The standard of care group was weaker and exhibited worse function at 12 months compared with both treatment groups.

Conclusion. Progressive quadriceps strengthening with or without NMES enhances clinical improvement after TKA, achieving similar short- and long-term functional recovery and approaching the functional level of healthy older adults. Conventional rehabilitation does not yield similar outcomes.

Arthritis & Rheumatism (Arthritis Care & Research) Vol. 61, No. 2, February 15, 2009, pp 174–183 DOI 10.1002/art.24167 © 2009, American College of Rheumatology

Impaired step down sit to stand

Additional Testing TUG6 mins Treadmill TestingSLSSit → stand Stairs ↑ ↓

Manual Therapy: How to manage a knee that hurts here and here & here.

Tibio-Femoral AP / PA SupinePatient position– Supine, knee flexed to about 70º with foot resting on

plinthTherapist position– Sitting on plinth with patient’s foot under the thigh

for stabilization.– Thenar eminence of both hands over tibial condyles,

while fingers wrap posteriorly into the popliteal fossa.Mobilization technique– Graded antero=posterior mobilizations produced by

pushing on the proximal tibia (posterior drawer test).– Graded postero-anterior mobilizations produced by

pulling on the proximal tibia (anterior drawer test).

Knee ExtensionPatient position– Supine, knee in extensionTherapist position– Distal hand: Grasp the patient’s ankle, holding the heel a few

inches above the plinth.– Proximal hand: Place heel of hand over the tibial tuberosity,

fingers pointing distally.Mobilization technique– Extension: Apply small-amplitude mobilization into extension

using an AP force with proximal arm.– Extension w/ Varus: Position proximal hand over medial tibial

plateau to impart ext/varus force.– Extension w/ Valgus: Grip ankle with supinated forearm.

Position proximal hand over lateral tibial plateau to impart ext/valgus force.

Patello-Femoral Mobs (Caudal and Cephalad)

Patient position– Supine with knee slightly flexed over your thighTherapist position– Place one knee and leg in a kneeling position on the plinth.– Bottom hand (guide hand): Holds the medial and lateral

patella with the thumb and index finger.– Top hand (mobilizing hand): Cups the inferior or superior

pole of the patella into the heel of hand.Mobilization technique– Use different hand positions to apply graded caudal or

cephalad mobilization (see insets)– Bottom hand can be used to decompress the PF joint

(pincher motion) or add more compression during treatment.

Patello-Femoral Mobs (Caudal with Flexion Progression)Patient position– Sitting on edge of plinth with knee flexed and heel

supported on chair or therapist’s legTherapist position– Bottom hand (guide hand): Holds the medial and lateral

patella with the thumb and index finger.– Top hand (mobilizing hand): Cups the superior pole of

the patella into the heel of hand.Mobilization technique– Apply graded caudal mobilization with the top hand.– Vary amount of knee flexion for progression of technique– Bottom hand can be used to decompress the PF joint

(pincher motion) or add more compression during treatment.

Patello-Femoral Mobs (Medial and Lateral)Patient position– Supine with knee slightly flexed over your thighTherapist position– Medial glides: Both thumb pads on lateral border of

patella; fingers around medial knee.– Lateral glides: Both index fingers on medial border of

patella; thumbs around lateral knee.Mobilization technique– Medial glides: Apply a graded medially directed

mobilization by pushing on the patella with your thumbs.

– Lateral glides: Apply a graded laterally directed mobilization by pulling on the patella with your index fingers.

Fibular Head MobilizationPatient position– Supine with knee flexed Therapist position– Proximal hand: Grasps the posterior proximal tibia

just medial to fibular head. Move soft tissue laterally until 2nd MP joint is against posterior fibular head

– Distal hand: Serves as the movement hand by grasping the distal tibia

Mobilization technique– Rotate the tibia into ER with your movement hand

and take up slack into knee flexion– Engage barrier and apply Grade l Mobilization