1 / 43

STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT

TAKEDOWN OF A KNEE FUSION LA DISARTRODESI DI GINOCCHIO III CONGRESSO NAZIONALE AIR ROMA, 24-26 SETTEMBRE 2009. STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT IIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE Chief : STEFANO ZANASI M.D.

elani
Download Presentation

STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. TAKEDOWN OF A KNEE FUSION LA DISARTRODESI DI GINOCCHIO III CONGRESSO NAZIONALE AIR ROMA, 24-26 SETTEMBRE 2009 STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT IIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE Chief: STEFANO ZANASI M.D.

  2. A solid fusion of a knee is still considered • the most successful treatment for • infected intractable yet revised TKA • An ankylosed or formally fused knee • has been considered a contraindication for TKA by many • and therefore conversion to TKA • has been infrequently performed.

  3. The reasons for takedown ofknee fusion is generally that • all patients disliked it andfelt disabled by it. • A successful fusion does not guaranteea satisfactory result: • the excessive hiking of ipsilateral hipduring walking • requires more energy than normal, • limitsthe patient’s endurance • and causes low back pain. • Theipsilateral hip may be damaged by the direct impact withoutbuffering effect of the fused knee. • Besides, the abilityto walk and sit in a normal fashion • is important to thepatient’s overall sense of well-being • and has an importantsocio-psychological effect.

  4. From a position of ankylosis in flexion, conversion to a TKA, we perform with a condylar constrained implant, achieve a high degree of patient acceptance and improvement in ambulation, but is often complicated by a high complication rate. • The indications for knee joint arthroplasty following solid fusion are certainly few and • the procedure oftotal knee arthroplasty (TKA) in fused knee • is technical demanding and high-risk of • postoperative complications.

  5. INDICATIONS Indications for takedown of fused knee arecomplex, -patient’s motivation, -presence of sufficient musculoskeletaland neurovascular structure -and surgeon’sexperience are very important.

  6. CASISTICA E RISULTATI • There were 8 patients with ankylosed knees who underwent total knee replacement with a condylar constrained prosthesis: ankylosed knee have been caused by ankylosingspondylitis in 1 case, septic arthritis with bony ankylosis in 4 cases, and rheumatoid arthritis in 2 cases, osteoblastoma in 1 case • Their mean age was 41.9 years (23 to 60) and • the mean follow-up was for 1.5 years (6 to 44 ms). • Pre- and post-operative data included the Hospital for Special Surgery (HSS), the Knee Society (KS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) scores. • Before the operation joint activity was 0 degrees , Knee Society score (KSS) was 42 (11 - 63), and the function score was 17.

  7. CASISTICA E RISULTATI • Follow-up showed that the average joint activity was raised to 83 degrees (60 degrees - 110 degrees ), • KSS score to 85 (64 - 91) points, and • function score to 77 points. • No infectious case was found. • The mean HSS, and WOMAC scores improved from 60, and 79 pre-operatively to 81, and 37 at follow-up. • -These improvements were statistically very significant (p = 0.018, 0.001 and 0.014 respectively). • -The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). • -The mean satisfaction score was 8.5 (SD 1.5).

  8. L.B. m. 72 yrs. Old - 13/07/2006 Kneefusion afterostemyelityssequelae on 3/1953

  9. L.B. m. 72 yrs. old - 13/07/2006

  10. L.B. m. 72 yrs. old - 13/07/2006

  11. L.B. m. 72 yrs. old - 13/07/2006

  12. L.B. m. 72 yrs. old - 13/07/2006

  13. L.B. m. 72 yrs. old - 13/07/2006

  14. L.B. m. 72 yrs. old - 13/07/2006

  15. L.B. m. 74 yrs. old - 36 ms follow -up

  16. L.B. m. 74 yrs. old - 36 ms follow -up

  17. B.E. f. 40yrs. old - 03-12-2008 Kneefusionafter osteoblastoma resection on 1984 DSM -2.5 cm

  18. B.E. f. 40yrs. old - 03-12-2008

  19. B.E. f. 40yrs. old - 03-12-2008

  20. B.E. f. 40yrs. old - 03-12-2008

  21. B.E. f. 40yrs. old - 03-12-2008

  22. B.E. f. 40yrs. old - 03-12-2008

  23. B.E. f. 40yrs. old - 03-12-2008

  24. B.E. f. 40yrs. old - 03-12-2008

  25. B.E. f. 40yrs. old - 03-03-2009

  26. B.E. f. 40yrs. old - 03-03-2009

  27. B.E. f. 40yrs. old - 03-03-2009

  28. B.E. f. 40yrs. old 6 ms. f.up

  29. B.E. f. 40yrs. old 6 ms. f.up

  30. PITFALLS • -Surgical approach of fused knee is important. • -Patellarexposure with tibial tubercle osteotomy is a standardprocedure to let the extensor apparatus patent. • -Identificationof fusion site and preservation of bone stock is importanttoo. • -Precise tibial cutting and separation offusion site without takedown of any bony stock: removal of a bone stock with a power saw to separatethe fusion is reported in our experience and in most articles. • - It is notnecessary to lengthen the extensor apparatus despite ofeasy to free it, the initial ROM is only 35° to 45°, and theROM improved slowly over the first year

  31. PITFALLS • Aglietti et al. recommended quadricepsplasty and performedit early because of risk of avulsing the patellatendon during operation. • Kim et al. believe that aggressivepostoperative physical therapy without havingquadricepsplasty may not be used effectively to stretch andrehabilitate the contracted extensor muscle • -Extensivelyrelease of capsule and soft tissue during operation • to perform V-Y quadricepsplastyto increase ROM and to match patello-femoral tracking • -mismatch ofpatello-femoral tracking despite of lateral release • aggressive rehabilitation postoperatively.

  32. COMPLICATIONS • following operation are significantlyhigh and all are related to the soft tissue problems, suchas • - skin necrosis, • extensor mechanism contracture, • extensor mechanism rupture, • adhesion and arthrofibrosis with remarkable loss of ROM • insufficientcollateral ligament, • - SPE palsy • and finally, • aseptic failure • infection • Cameron and Hu reported a postoperative complication • rate of 53% and re-operation rate was high. • Legaye et al.reported a complication rate of 86%.

  33. TREATMENT OF POSTOPERATIVE COMPLICATIONS • includes • for adhesion and arthrofibrosis • (1) manipulationunder anesthesia • (2) arthroscopic arthrolysis, • (3) open arthrolysis

  34. TREATMENT OF POSTOPERATIVE COMPLICATIONS • for insufficient extensor mechanism • (1) reconstructionbyallograft • (2) reconstruction by LARS artificial tendon • (3) quadricepsplasty

  35. TREATMENT OF POSTOPERATIVE COMPLICATIONS • -for skin necrosis • (1) rotationalskin flap • (2) muscle island pedicled flap • (3) microsurgical free muscle(-cutaneous) flap

  36. CONCLUSIONS • Previous analysis indicates that although success in reconstructing a previously ankylosed or arthrodesed knee is possible, the lack of consistent adequate motion and the complication rate may suggest that the surgeon reconsider the risks and benefits of this difficult procedure. • Now a day total knee arthroplasty has a satisfactory effect • in treatment of ankylosed knee. • Individualized and directed rehabilitation are a pivotal factor. • The improvements occurred in our data were statistically significant • (p = 0.018, 0.001 and 0.014 respectively). • The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). • The mean satisfaction score was 8.5 (SD 1.5). • Total knee replacement gives good mid-term results in patients • with ankylosed knees.

  37. Four patients with 7 ankylosedknees, caused by ankylosingspondylitis in 1 case, septic arthritis with bony ankylosis in 1 case, and rheumatoid arthritis in 2 cases, underwent artificial knee replacement. Before the operation joint activity was 0 degrees , Knee Society score (KSS) was 42 (11 - 63), and the function score was 17. Follow-up was conducted for 5 - 27 months. RESULTS: Follow-up showed that the averagejoint activity was raised to 83 degrees (60 degrees - 110 degrees ), KSS score to 83 (64 - 91) points, and function score to 77 points. No infectious case was found. CONCLUSION: Total kneearthroplasty has a satisfactory effect in treatment of ankylosedknee.

  38. REFERENCES 1. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prosthesis. J Bone Joint Surg Am 1976;58:754-765. 2. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty 2000;4:453-460. 3. Kim YH. Total knee arthroplasty for tuberculous arthritis. J Bone Joint Surg Am 1988;70:1322-1330. 4. Holden DL, Jackson DW. Consideration in total arthroplasty following previous knee fusion. ClinOrthop 1988;227:223-228. 5. Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty 1996;6:732-737. 6. Schurman JR, Wilde AH. Total knee replacement after spontaneous osseous ankylosis: a report of three cases. J Bone Joint Surg Am 1990;72:455-459. 7. Bradley GW, Freeman MA, Albrektsson BE. Total prosthetic replacement of ankylosed knees. J Arthroplasty 1987;2:179-183. 8. Aglietti P, Windsor RE, Buzzi R, Insall JN. Arthroplasty for the stiff or ankylosed knee. J Arthroplasty 1989;4:1-5. 9. Henkel TR, Boldt JG, Drobny TK, Munzinger UK. Total knee arthroplasty after formal knee fusion using unconstrained and semiconstrained components: a report of 7 cases. J Arthroplasty 2001;16:768-776. 10. Cameron HU. Role of total knee replacement in failed knee fusions. Can J Surg 1987;30:25-27. • .

  39. Current Opinion in Orthopaedics: February 2006 - Volume 17 - Issue 1 - pp 56-59 doi: 10.1097/01.bco.0000192522.56034.7c Knee reconstruction Conversion of a fused or ankylosed knee to a total-knee arthroplasty Sterling, Robert S. Abstract Purpose of review: Recent reports have revisited the issue of conversion of an ankylosed knee to total-knee arthroplasty (TKA). Here, recent studies are reviewed and placed within the context of previous reports. Recent findings: An ankylosed or formally fused knee has been considered a contraindication for TKA by many and therefore conversion to TKA has been infrequently performed. From a position of ankylosis in flexion, conversion to a TKA achieved a high degree of patient acceptance and improvement in ambulation, but was complicated by a high wound complication rate. While the majority of conversions had most often beenperformed with a condylar constrained implant, a posterior stabilized implant without condylar constraint achieved equivalent results in the largest series to date (36 patients) without complications due to instability. An extensile approach with a V-Y quadricepsplasty or tibial tubercle osteotomy is recommended with an anticipated mild postoperative extensor lag and prolonged rehabilitation period required. The postoperative flexion arc ranged from 73o to 91o. Wound healing problems occur in up to 50% of cases and careful preoperative assessment of the soft-tissue envelope is imperative. Preoperative soft-tissue expansion has been suggested as one possible solution to this problem, but has not yet been reported upon. Summary: Conversion of a bony ankylosis or fusion to TKA can yield acceptable results; there is, however, a high complication rate and long-term outcomes are lacking. Patients must be carefully advised about expected outcomes and complications with specific attention to potential wound complications.

  40. Total knee replacement for patients with ankylosed knees. Full Abstract The purpose of this study was to determine objectively the outcome of total knee replacement in patients with ankylosed knees. There were 82 patients (99 knees) with ankylosed knees who underwent total knee replacement with a condylar constrained or a posterior stabilised prosthesis. Their mean age was 41.9 years (23 to 60) and the mean follow-up was for 8.9 years (6.6 to 14). Pre- and post-operative data included the Hospital for Special Surgery (HSS), the Knee Society (KS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) scores. The mean HSS, KS and WOMAC scores improved from 60, 53, and 79 pre-operatively to 81, 85, and 37 at follow-up. These improvements were statistically significant (p = 0.018, 0.001 and 0.014 respectively). The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). The mean satisfaction score was 8.5 (SD 1.5). Total knee replacement gives good mid-term results in patients with ankylosed knees. Author/s: Kim, Y-H (YH); Kim, J-S (JS); Affiliation: The Joint Replacement Center of Korea, EwhaWomans University School of Medicine, MokDung Hospital, MokDung, YangChun-Ku, Seoul 110-783, Korea. younghookim(-atsign-)ewha.ac.kr Journal and publication information Publication Type: Journal Article Journal: The Journal of bone and joint surgery. British volume (J Bone Joint Surg Br), published in England. (Language: eng) Reference: 2008-Oct; vol 90 (issue 10) : pp 1311-6

More Related