Knee Replacement In Young Patients
-
Upload
alampallam-venkatachalam -
Category
Health & Medicine
-
view
4.366 -
download
3
description
Transcript of Knee Replacement In Young Patients
![Page 1: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/1.jpg)
Dr.A.K.VenkatachalamMS Orth, DNB Orth, FRCS, M.Ch
OrthConsultant Orthopedic surgeon
Chennaiwww.kneeindia.com
www.kneeindia.com 1
![Page 2: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/2.jpg)
*< 65 years , Better is < 50 years of age.
*Life expectancy of > 20 years
*Family history of longevity
www.kneeindia.com 2
![Page 3: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/3.jpg)
*Numbers increasing in young patients < 55 years
Australian registry
www.kneeindia.com 3
![Page 4: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/4.jpg)
“If the historical growth trajectory of joint replacement surgeries continues, demand for primary THA and TKA among patients less than 65 years old was projected to exceed 50% of THA and TKA patients of all ages by 2011 and 2016, respectively.”
* Steven M. Kurtz PhD, Edmund Lau MS, Kevin Ong PhD, Ke Zhao MA, MS, Michael Kelly MD, Kevin J. Bozic MD, MBA Symposium: ABJS Carl T. Brighton Workshop on Health Policy Issues in Orthopaedic SurgeryVolume 467, Issue 10 / October , 2009
www.kneeindia.com 4
![Page 5: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/5.jpg)
Secondary osteoarthritis from
*Post traumatic arthritis
*Rheumatoid arthritis is the main cause
*Whereas in older patients, Primary OA is the leading cause.
www.kneeindia.com 5
![Page 6: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/6.jpg)
AGE( years)AGE( years) FAILURE RATESFAILURE RATES
< 65 years< 65 years 12%12%
65- 75 years65- 75 years 10%10%
> 75 years> 75 years 4%4%
*Against-
1)Total knees fail more often in young patients
FAILURE RATES AND AGE
Robertsson, Thesis Lund 2000 , Swedish arthroplasty registerwww.kneeindia.com 6
![Page 7: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/7.jpg)
*than their older colleagues
*Wear is proportional to usage.
*Young patients walk on average upto 50% more than older patients.
*Usage leads to increased poly wear
*Poly wear leads to aseptic loosening
Patient agePatient age Average of Average of steps/yearsteps/year
< 60 years< 60 years 1200,001200,00
> 60 years> 60 years 800,00800,00
Age & activity after THR/TKR
www.kneeindia.com 7
![Page 8: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/8.jpg)
*Young people live longer.
*Young people survive their prosthesis.
*Older people die before prosthetic failure.
AGE(years)AGE(years) Expected to Expected to live furtherlive further
50 years50 years 32 years32 years
67 years67 years 18 years18 years
LIFE EXPECTANCY( WOMEN)
www.kneeindia.com 8
![Page 9: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/9.jpg)
*Previous three slides indicates that there is a higher risk of failure in young patients and they may require a revision within 10 years
*Surgeon knows this. He also knows that the revision will be technically a difficult operation than the primary. Result also will be inferior.
www.kneeindia.com 9
![Page 10: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/10.jpg)
He is unwilling to listen and wait.
www.kneeindia.com 10
![Page 11: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/11.jpg)
*severe pain and stiffness in the knee joint,
*Impaired quality of life,
*Failure of previous treatments of the painful hip / knee joint.
*Specially suitable candidate is a young patient with severe impairment of both hip and knee joints eg- Poly arthritis like rheumatoid arthritis / sero-negative arthritis.
www.kneeindia.com 11
![Page 12: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/12.jpg)
*The OS can do a TKR with a prosthesis that wears out slowly.
*Use of materials, techniques, activity modification can lead to better implant survivorship.
www.kneeindia.com 12
![Page 13: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/13.jpg)
*Prolong prosthetic life, preserve bone while providing function.*Search for design, durability of counter-face, poly, technique, best fixation. *Education of patient about permissible activities of daily living and sport.*Explain possibility of a future revision.*Prevent late metastatic infection from a remote source.*Encourage treatment if the patient has fully understood all issues.
www.kneeindia.com 13
![Page 14: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/14.jpg)
*Baby Boomers
*Relatively healthy
*Wanting the best technology
*Are relatively dissatisfied with current outcomes
*Will out live current total knee technology
*The main contributor to knee replacement growth
www.kneeindia.com 14
![Page 15: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/15.jpg)
Patient expectations start rising concomitantly.
Internet savvyWant only broken part to be fixedAs small scar as possibleNo painWant to dance, participate in sportsWant alignment perfect, stability
*Surgical outcomes ≥ Expectations
www.kneeindia.com 15
![Page 16: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/16.jpg)
www.kneeindia.com 16
![Page 17: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/17.jpg)
*Cycling
*Calisthenics
*Swimming
*Low-resistance rowing
*Skiing machines
*Walking & Hiking
*Low-resistance weightlifting
Knee society
www.kneeindia.com 17
![Page 18: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/18.jpg)
*Baseball *Basketball *Football *Hockey *Soccer *High-impact aerobics *Gymnastics *Jogging *Power lifting
Knee society
www.kneeindia.com 18
![Page 19: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/19.jpg)
Wear is an issue. Steps to reduce wear *Bearings- alternate bearings like oxidized zirconium, ceramic*Poly ethylene X3 poly, anti oxidants, thickness.*Cemented vs cementless fixation*Accuracy of component placement- ? Navigated surgery*Fixed vs mobile bearing components*Single radius vs multi radii designs.
www.kneeindia.com 19
![Page 20: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/20.jpg)
Wear in TKR’s
Patient
Polyethylene
DesignTechnique
Counter face
www.kneeindia.com 20
![Page 21: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/21.jpg)
*Change femoral counterface ( Oxidized zirconium, Ceramic)
*Change Poly insert
( XLPE)
*Change design*Mobile vs fixed bearing
*CR vs PS
*Single vs multiple radius curve
*Locking mechanism
www.kneeindia.com 21
![Page 22: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/22.jpg)
*X linked polyethylene seem to be advantageous at least from the hip side.
*Proved lowering of long term wear rates
www.kneeindia.com 22
![Page 23: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/23.jpg)
THR TKR
Contact stresses low High
Wear abrasive/ adhesive fatigue
Crack propagation Less important Important
Highly cross linked polyethylene is advantageous in the knee also.
www.kneeindia.com 23
![Page 24: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/24.jpg)
*Behaves differently in clean and abraded environments
*Wear increases in abraded environment with cobalt chrome for both polys
*Hence highly cross linked poly may not be the best material in the altered environment -10
0
10
20
30
40
50
60
Clean Abraded
CoCr/CPE
CoCr/XPE
Wear rate mm3/MC
www.kneeindia.com 24
![Page 25: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/25.jpg)
*Sequentially irradiated and annealed ( not melted polyethylene)
*Significant wear reduction
*No mechanical changes
*Same poly used for hips and knees
www.kneeindia.com 25
![Page 26: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/26.jpg)
*Scratches are bad - Ideally try to eliminate
www.kneeindia.com 26
![Page 27: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/27.jpg)
*Conventional cobalt chrome is used for femoral and titanium or highly polished cobalt chrome used for tibial base plate. Polishing of tibial tray reduces back side wear.
*Pure Ceramics
*Oxidized zirconium
www.kneeindia.com 27
![Page 28: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/28.jpg)
*Femoral *Cobalt Chrome
* scratching is common
*From cement and poly
*Care to remove cement after TKR.
www.kneeindia.com 28
![Page 29: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/29.jpg)
*Meet requirments for ideal TKR
*Smoother
*↓ Coefficient of friction
*More scratch resistant
*Less wear against both conventional and highly cross linked poly ethylene.
www.kneeindia.com 29
![Page 30: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/30.jpg)
*Polyethylene wear performance of oxidized zirconium and cobalt chromium knee components under abrasive conditions
* ( Ries MD, Salehi A, Widding.K, Hunter G.,JBJS ( Am) 2002)
Oxidized Zirconium femoral components reduce polyethylene wear in a knee wear simulator.
( Ezzel KA, Hermida JC,Colwell CW Jr,D’Lima DD, CORR, Nov 2004)
www.kneeindia.com 30
![Page 31: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/31.jpg)
*Zirconium- metallic element
*Zirconia- ceramic
*Zr-2.5 Nb Metallic alloy
*Super heating zirconium to 500+°C in Oxygen presence
*Surface transformation into zirconia ( ceramic oxide)
*Chemically bonded ceramic oxide surface 5μ thick Ceramic Oxide
Original Surface
Air
500oCOxygenDiffusion
Oxygen Enriched Metal
Metal Substrate
www.kneeindia.com 31
![Page 32: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/32.jpg)
*It is a metal component*Thin layer of ceramic like material that is part
of its innate structure. This is not a coating. *Ceramic oxide is 5 μ thick*Biocompatibility is excellent, matches titanium*Very low coefficient of friction vs Cobalt
chrome.*Extremely abrasion resistant. *Hard like ceramic*Equivalent strength properties to Cobalt
chrome.*Adverse to chipping that can occur at insertion
and over time.*Lack of Nickel allergy.
www.kneeindia.com 32
![Page 33: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/33.jpg)
*Equivalent to Cobalt Chrome
*1000 pounds
*10 x 106 Cycles
www.kneeindia.com 33
![Page 34: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/34.jpg)
*Oxdized zirconium produces fewer PE particles when compared to Cobalt chromium
www.kneeindia.com 34
![Page 35: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/35.jpg)
*Oxidized zirconium reduces volumetric wear by upto 89% in an abraded environment when compared to Cobalt Chrome
www.kneeindia.com 35
![Page 36: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/36.jpg)
www.kneeindia.com 36
![Page 37: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/37.jpg)
www.kneeindia.com 37
![Page 38: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/38.jpg)
*Strength of Cobalt chrome
*Low coefficient and scratch resistance of ceramic
*Non brittle as the ceramic layer is part of the innate structure.
*Decrease wear is the main advantage.4900 less volumetric wear.
*160 times smoother.
www.kneeindia.com 38
![Page 39: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/39.jpg)
*Many variables*Articular congruity*CR vs PS*Fixed vs mobile bearing*Single radius vs multi radii*Locking mechanism
*All have in- vitro/theoretical evidence of benefits.
www.kneeindia.com 39
![Page 40: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/40.jpg)
*Cemented TKR is the gold standard at present*However Cement constitutes a third body
wear.*Best fixation is biologic with bone ingrowth
into prosthesis.*Examples of hips – Uncemented hips are
standard in young patients. *Cementation leads to extra operative time*Part results of poor cemenless fixation stem
from metal backed patellas.*Cementless fixation will be the preferred
method in future.
www.kneeindia.com 40
![Page 41: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/41.jpg)
*16 knees from 2007 to 2009 in patients ≤55 years*Cobalt chromium femoral components in 8 and Oxidized zirconium in 8 knees.*CR- 6 knees, PS- 10 *Diagnoses- Post traumatic arthritis-2 Rheumatoid arthritis- 6 Osteoarthritis- 8
www.kneeindia.com 41
![Page 42: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/42.jpg)
*Knee scores improved in all.
*Range of movement from 95 degrees to 140 degrees.
*No loosening
*1 patient with bilateral TKR has anterior knee pain, had patellar component revision
www.kneeindia.com 42
![Page 43: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/43.jpg)
*Skin incisions 4- 6 inches long.
*Midvastus, sub vastus, minimally invasive quad splitting.
www.kneeindia.com 43
![Page 44: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/44.jpg)
*46 year old Indian housewife.
*Left gender specific high flex knee replacement
www.kneeindia.com 44
![Page 45: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/45.jpg)
www.kneeindia.com 45
![Page 46: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/46.jpg)
*Zero error Component placement
*Extra articular deformities- one stage replacement
www.kneeindia.com 46
![Page 47: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/47.jpg)
*Patient specific instrumentation
*Requires MRI scan & Standing x rays
*Eliminates 23 steps from TKR.
*For distal femoral cut & proximal tibial cut.
www.kneeindia.com 47
![Page 48: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/48.jpg)
Rheumatoid arthritis 38 year old patient
www.kneeindia.com 48
![Page 49: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/49.jpg)
www.kneeindia.com 49
![Page 50: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/50.jpg)
www.kneeindia.com 50
![Page 51: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/51.jpg)
www.kneeindia.com 51
![Page 52: Knee Replacement In Young Patients](https://reader038.fdocuments.us/reader038/viewer/2022102805/556c9329d8b42a7a738b4fc4/html5/thumbnails/52.jpg)
*Durable materials like Oxidized zirconium, cross linked poly, highly polished tibial base plate
*Single radius femoral prosthesis
*Computer assisted knee replacement
*Patient specific instrumentation( custom fit surgery)
*Minimally invasive approaches
www.kneeindia.com 52