What’s new in adult reconstructive knee surgery

• Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Increase in both primary and revision TKR*; primary TKR vol. at 313 per 100,000 in 1990-1994, to 634 per • Shifting towards Sub-specialty surgeons • Avg. duration for TKR declined 160min in 1997 to • Morbidities and mortalities also declined in general • Implementation of National Guidelines, clinical *Kutz et al; J Arthroplasty. 2009;24:195-203 • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • AAOS guidelines* • Literature since 1996 shows no significant differences in the rate of symptomatic PE with the use of LMW Heparin, warfarin, or mechanical devices and ASA alone • Bleeding as a serious side effect • The American College of Chest Physicains study concluded that ASA is as affective, but study flaws exist • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Computer Navigation vs. case-specific cutting jigs • Mechanical axis restoration as a predicator of • Computer navigation associated with higher number of knees iethin 3 degrees of a neutral mechanial alignment (88% vs. 61%)** • Increase in surgical time but an average of *Fang etal. J Arthroplasty. 2009;24:39-43 **Choong PF etal. J Arthoplasty. 2009;24:560-9 • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Tendon preserving, muscle preserving, and smaller incision • Increased surgical time, potential of malalignment and wound complications and limited early benefit* • Effect of anterior tibial translation and patellar eversion. No significant difference in early recovery in a randomized • Serum levels (Creat. Phospokinase, myoglobin, aldolase, lact. Dehy., creat.) ; no difference *** • Higher revision rates in unicompartmental **** *Karpman et al. J Arthroplasty. 2009;24-681-8 **Da;ury DF et al. JBJS Am. 2009;91:1339-43 ***Niki et al. J Arthroplasty. 2009;24:499-504 ****Hamilton et al. J Arthroplasty. 2010;25:735-40 • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Pain management: use of nerve blocks after TKR, there is an early post op benefit (up to 24-72 hrs) of decrease in pain and opioid use, but no clinical benefit or improved outcomes beyond this period • Tourniquet down before or after wound *Shum et al. J Arthroplasty. 2009;24:204-9 **Steffin et al. J Arthroplasty. 2009;24:539-42 • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • No significant improvement of range of motion in multiple prospective randomized studies up to 2 years* • Await long term survival results to determine • Rotation may facilitate optimal patellar • Randomized prospective studies of up to 5 years showed no clinical benefit in any of the above Gioe et al. JBJS Am. 2009;91:2104-12 Engh et al. J Arthroplasty. 2009;24:28-32 prospective study of pts. That underwent a cruciate retaining TKR for OA with and with out patellar replacement: no difference in the two groups in terms of ROM, Knee Society Score, anterior knee pain or overall revision; however rate of patellar revision was higher in the unresurfaced group (12% vs. 3%) • 15 yrs f/up of modular posterior stabilized TK • 10 yr f/up of all-polyethylene and metal backed tibial components. Both implants had a survival rate of 97%** • Uncemented trabecular metal tibial component at 3 years follow up shows a consistent stable fixation compared to cemented implants*** *Lachiewicz et al. JBJS Am. 2009;91:1419-23 **Bettinson et al. JBJS Am. 2009;91:1587-94 ***Dunbar et al. JBJS Am. 2009;91:1578-86 • Hospital volume and surgeon volume affect outcome , but studies indicate that hospitals with standardized processes had equal outcomes to high volume hospitals* • Staged vs. simultaneous TKR: no difference in a new study from the New Zealand National Joint Registry** • No support of use of antibiotic cement for primary TKR*** • Outcome and satisfaction may be improved if TKR done at *Manley et al. J Arthroplasty. 2009;24:1061-7. **Hooper et al. J Arthroplasty. 2009;24:1174-7. ***Namba et al. J Arthroplasty. 2009;24(6 suppl):44-7. ****Gandhi et al. J Arthroplasty. 2009;24:716-21 • In the morbid obese, comparing BMI of <30, 30-39 and >39: no difference in outcomes but increase in patellar radiolucency in BMI >39 at a mean f/up of 5.4 years* • Neuropathic arthropathy with mean f/up of 12 years: showed improvements in Knee score. Complications incl. knee dislocation** *Dewan et al. J Arthroplasty. 2009;24:89-94 **Bae et al. J Arthroplasty. 2009;24:1152-6 • Epidemiology • Venous Thromboembolism • Navigation • Minimally Invasive Surgery • Perioperative Care • Outcome Studies • Complications • Infection: rates of .5% for primary and 2% for revision. Risk factors: male, Rheumatoid Arth., Fx about the knee, and use of hinged or constrained • Patients with un-controlled diabetes had higher risk of stroke, UTI, ileus, post-hematoma, transfusion, wound infection and death. Routine Endocrinology consultation is recommended to *Jameson et al. JBJS BR. 2010;92:123-9 **Marchant et al. JBJS Am. 2009;91:1621-9

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