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Total Knee Arthroplasty Essay

Etiology and Pathology

The knee functions as a type of biological transmission whose purpose is to accept and transfer range of loads between and among the femur, patella, tibia, and fibula without causing structural or metabolic damage. Arthritic knees are like living transmissions with worn bearings that have limited capacity to safely accept and transmit forces.

Arthritis of the knee can be restricted to a monoarticular clinical manifestation, or it may be a part of an oligo-or polyarticular disease. A careful anamnesis and clinical examination will allow the clinician to classify the clinical presentation of arthritis of the knee into disease groups such as osteoarthritis, rheumatoid arthritis spondyloarthropathy, or miscellaneous arthritic diseases.

Infectious arthritis presents typically as an (sub) acute inflammatory monoarthritic disease. Up to 90 % of infectious arthritis cases present as monoarthritis. The only exception is gonococcal arthritis, which presents more commonly as a migratory polyarthritis. If the condition is unrecognized, joint destruction will occur rapidly.

In confronting the athlete who will undergo the operation it is important for me to discuss a working hypothesis and ultimately critical to arrive to the most likely diagnosis. The clinical history of the patient is to be well studied it is a demanding task and a lot of circumstantial evidence can evolve from a full history of the current problem , past medical conditions, and the family history.

Kinds of Pain

The nature of the pain that he might encounter and the reason he needs to undergo TKA belongs to “the basics”, whether it is mechanical, inflammatory, neuropathic, or poorly defined. Mechanical pain occurs when the joint is used; walking becomes difficult and especially climbing stairs causes problems. On resting, there is less pain. Starting pain and stiffness are very characteristics of a more advanced mechanical pain pattern.

Inflammatory pain typically presents at night. More specifically, the second part of the night become troublesome, and patients need to go out of bed and move. They experience morning stiffness for at least one hour, and this stiffness diminishes progressively as the pain begins to move.

When pain is neuropathic in origin, a typical distribution pattern corresponding to the innervations’ is found. Psychosomatic pain has no typical presentation or distribution. Complaints are always more impressive than the clinical findings.

Consider asking the patient of how long the knee problem has existed, when pain and swelling have been present for less than 6 weeks, the problem is acute. Beyond 6 week’s duration, the term chronic is used and implies that spontaneous healing of the arthritis is unlikely.

It is also important to look for circumstantial evidence. Did the trauma occur just before the knee swelling began? Did the patient have an episode of fever such as angina, gastroenteritis, or arthritis? Does the patient have other clinical conditions that could be linked to the knee arthritis, such as skin problems (psoriasis, erythema nodosum), chronic diarrhea as seen inflammatory bowel disease, and eye problems such as uveitis or scleritis? In this setting a complete familial history can also add useful information.

Advantages of Total Knee Arthroplasty
Consistent reproducible results
Correction of mechanical alignment
Addressing all knee compartments
Long term (greater than 90%) 10 year survivorship

Drawbacks
Postoperative pain which can endure for months
Prolonged recovery sometimes inferior
Patient satisfaction

With extensive exposure required to align and implant the total knee arthroplasty, there is significant damage to the quadriceps muscle both in cutting into the musculature itself as well as damage with eversion of the patella and prolonged stretch to the quadriceps mechanisms intraoperatively. Muscle damage is permanent and can limit postoperative strength and/or function.

Surgical Procedure

Before the surgery is performed usually blood count, electrolytes, APTT and PT to measure blood clotting, chest X-rays, ECG, and blood cross matching for possible transfusion. Accurate X-rays of the knee are needed to measure the size of components which will be needed. Medications such as warfarin and aspirin will be stopped some days before surgery to reduce the amount of bleeding. The athlete may be admitted on the day of surgery if the pre-op work up is done in the pre-anesthetic clinic or may come into hospital one or more days before surgery.

Recent improvements in technology have led to a confusing spectrum of choices for both the patient and surgeon in treating monocompartmental knee arthritis. The obvious need to get the surgery done right, there are now pressures to “do it quickly” and with a minimal scar and reduced disability time. The combination of patient’s demands and expectations with actual surgical possibilities may be challenging. To this end, a logical structuring of options is in this order:
Osteotomies
Unincompartmental knee arthroplasty
Total knee arthroplasty

The indications and more importantly, the contraindications of the surgical procedures often results in overlap of options that must be considered for any given clinical situation. The appropriateness of any of these procedures should be considered in light of their relative indications and problems.

These include patient age, activity level, expected longevity of the procedure, reliability of the procedure to bring about the expected goal, and ease of revision in the event of failure. Of equal importance are the contraindications to the procedures including contracture, deformity, ligament contracture or insufficiency, and bone deficiency.

The relative value of an osteotomy stands in inverse proportion to the patient’s age. Younger patient’s demands on an implant that will not stand the test of time, with failure due to wear or fixation failure. Considering that the patient is an athlete, athletic activities after the operation such as jumping and running are associated with surface loads in excess of the limits of the polyethylene.

The hazards of heavy or repetitive loading, deep knee bending and the lifting activities that accompany a variety of occupations and activities may loosen or damage prosthesis.

Research Probability on Different methods on Knee Surgery

Long term results of osteotomy show a gradual decline in function and recurrence of deformity. Hungerford et al reported that on ninety-two knees with a good or excellent rating after osteotomy at two years. At ten years only fifty-eight knees (61%) maintained this level 13. Parvizi et al reported on fifty-eight patients with a mean fifteen year follow up. There were only 55% good to excellent results. Twenty-six patients formed subsets that have been reviewed previously. At eight years, there were 73% good to excellent results, declining to 46% at eighteen years.

Technical Problems

Technical problems of total knee arthroplasty after closing wedge osteotomy include: difficulties in gaining exposure, bony deficiencies necessitating grafts or wedges, difficulties in attaining ligament balance, prolonged surgical time and increased blood loss. Lonner et al recommended reserving the procedure for young, active overweight patient only 15.

Justification for the procedure in high demand patients is more difficult. Bellemans and Co author have reported range of motion between 120 and 130 degrees with enhanced functional potential for activities of daily living including stair climbing and transfer function.

Osteotomy has some contraindications including: various deformities greater that 10 degrees, flexion contracture more than 20 degrees, limited range of motion, ligament insufficiency including the anterior cruciate, and patellofemoral (Kurtz, 2004). Unicompartmental arthroplasty shares similar contraindications.

Surgical treatments include tissue repair approaches, arthroscopic lavage and debridement, osteotomy, and unicompartmental and total knee replacement. There is little or no evidence that surgical reconstruction of torn cruciate ligaments or the meniscus prevents the development of the knee OA. It remains to be seen whether cartilage repair procedures prevent or slow down knee OA. The combination of tissue repair, such as the repair of cartilage defects, with an osteotomy, performed on the right patient and by a trained surgeon.

In the case of knees with advanced degenerative arthrosis which undergo joint replacement surgery, the principle of functional restoration may be more properly stated as maximization of the functional capacity of the knee. As effective as current joint replacement techniques are at achieving pain relief and often associated increases in muscle strength and control, knees that have had joint replacement surgery do not replicate the functional status of a healthy, uninjured, adult joint. After the joint replacement the patient should avoid in running marathons or play tackle football.

The structure of the knee is complex, and its behavior can be unpredictable even in the most experienced hands. However, the task of replacing the bone surfaces and balancing the ligaments can be made manageable by following a logical plan based on correct alignment throughout the arc of flexion and ligament release based on the function of each ligament.

Optimal knee function requires correct varus-valgus alignment in all positions of flexion. This requires reliable anatomical landmarks for alignment both in flexion and extension. The long axes of the femur and tibia and the anterior and posterior axis of the femur are highly reliable and provide the guidelines for establishing stable alignment of the joint surfaces by placing the tibia and patellar groove correctly in the median anterior-posterior plane trough the entire arc flexion.

Knowing their function and testing their tension provides the information necessary to release only the ligaments that are excessively tight, leaving those that are performing normally.

Fractional release does not destabilize the knee, because other ligaments are retained, and because the peripheral attachments of the ligament to other soft tissue structures such as the peristeum or synovial capsular tissue allow the released ligament to continue to function. Ligament release does not cause instability.

Failure to align the knee and release the tight ligaments, however, does not cause instability, unreliable function, and excessive wear. With this knowledge, good instruments, and sound implants, the surgeon can align, balance, and stabilize the knee even when severe bone destruction and ligament contracture are present.

CT scanning is an accurate way of measuring the component malrotation. Assessment of the rotatory alignment of the femoral component and the axial rotational relationship of the femoral and tibial components is part of the Perth CT protocol which is used routinely in total knee replacement surgery.

The athlete will have preoperative clinical investigation and a radiological examination with standardized coronal long leg stance X-ray and standard lateral X-rays, adapted from the technique. Intraoperative complications will be recorded. The radiological evaluation was repeated between the 6th and 12th postoperative weeks by an independent observer at each center.

The athlete should perform straight leg raises by the first postoperative day, by the second postoperative day research shows that 90% of patients have straight leg rise which suggest s good control of the quadriceps mechanism. On the third postoperative day the athlete should be able to independently transfer from a bed to a chair and on fourth postoperative day the athlete is able to navigate up and down stairs with assistance, and the mean postoperative discharge is 2.8 days.

The athlete is discharged to physical therapy which he will perform on his own home. Athlete should be averaging 10 days on a walker, 1 week on a cane, and independent ambulation is averaging approximately 3.5 weeks.

Rehabilitation Protocol

To have the ability to perform physical actions task, and activities related to self-care is improved:
Care is coordinated with patient, family, and other professionals.
Case is managed throughout episode of care
Integumentary integrity is improved
Knowledge of behaviors that foster healthy habits its gained
Placement needs are determined
Risk factors are reduced
Risk of secondary impairments is reduced
ROM is increased
Standing balance is improved, stress is decreased

To achieve this outcome, the appropriate intervention for this patient is determined. This will include coordination, communication, and documentation.

Is there evidence of total contact?

If the person has a pelite liner, total contact maybe checked by putting a little ball of play dough at the end of the socket, the patient stands and bears weight and the displacement of the play dough indicates the extent of total contact, Too little contact may cause may cause distal end skin problems and a stretching pain. Too much may cause excessive pressure at the end of the stump and pressure pain.

Is suspension maintained when patient’s lifts leg off the floor?

Check that there is no excessive movement of the prosthesis away from limb when weight is removed. On weight bearing, make a small pencil mark at the anterior socket brim or, if sleeve or shuttles locks suspension, place lightly at edge of socket. Too much movement between residual limb and socket creates abrasions and may lead to toe drag on swing.

CONCLUSION

Joint replacement surgery is designed to expand the entire envelope of function of symptomatic arthritic knees as safely and predictably as possible. Properly utilized, total knee replacement surgery is capable of substantial increases in the functional capacity of a given arthritic joint, but it is not designed to restore the full physiological function of a normal, uninjured adult knee.

Future developments in the therapeutic management of arthritic knees may eventually involve biological approaches that could result in further improvements in maximizing the post treatment envelope of function over what can be achieved with the current technique of using artificial components. By tracking the loss of osseous homeostasis in knees starting at a time prior to the development of overt radiography identifiable degenerative changes

Most patients can easily readily grasp the concept of the envelope and therefore can have a better understanding of what function is to be expected postoperatively. By this method they can more readily understand the joint replacement surgery is not designed to restore a knee to full, normal physiological function.

Patients have responsibilities, as well to do all they can ( by participating in pre- and post operative physical therapy, for example_ to maximize their envelope and, once3 this is achieved, to not exceed the functional capacity of the joint following surgery by avoiding activities associated with supraphysiological loading.

Cited Literature

Hungerford MW, Mont MA. 2000. Nonoperative treatment of knee arthritis. In Insall JN, Scott NA (ed.). The Knee. CV Mosby, NY.

Robertsson O. 2000. Unicompartmental arthroplasty. Results in Sweden. Orthopade 2000; 29 Suppl 1:S6-8.

Lonner JH, Hershman S, Mont M, Lotke PA, 2000.Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis. Clinical Orthopedic pp. 380:85-90.

Mont MA, Chang MJ, Sheldon MS, Lennon WC, Hungerford DS, 2002. Total knee arthroplasty in patients less than 50 years old. J Arthroplasty 17: pp. 338-343.

Romanowski MR and Repici JA. 2002. Minimally invasive unicondylar arthroplasty. Eight year follow-up. J Knee Surgery 15: pp. 17-22.

Parvizi J, Hanssen AD, Spangehl MJ, 2003. Total knee arthroplasty following a prior proximal tibial osteotomy. A long-term study identifying risk factors for failure. J Bone Joint Surgery (In Press).

Hungerford, D. S. Kenneth A., Krackow, Kenna R.V. 1994. Total Knee Arthroplasty: A Comprehensive Approach. Williams and Wilkins.

Kurtz, S.M. 2004. The UHMPE Handbook Ultra-High Molecular Weight Polyethylene. Academic Press.

Rodriguez, E. C. 2003. The Haemophilic Joints: New Perspective. Blackwell Publishing.

Delloye, C. and Bannister, G. 2004. Impaction Bone Grafting in Revision Arthropplasty.

Published Informa Health Care.

Bono, J.V., Scott, R.D. 2005. Revision Total Knee Athroplasty. Springer.

Dutton, M. 2004. Orthopedic Examination, Evaluation, and Intervention. Mc Graw Hill Professional.

Sculco, T.P., Martucci, E.A., 2001. Knee Arthropplasty. Springer Publising.

Moffat, M. Rosen, E. Rusnak-Smit S., 2006. Muscuskeletal Essentials: Applying the Physical Therapist. SLACK Incorporated.

Callaghan, J.J., 2003. The Adult Knee. Contributor Harry E. Rubash. Lippincott Williams & Wilkins.

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