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STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT IIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE Chief: STEFANO ZANASI M.D. TAKEDOWN OF.

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Presentation on theme: "STEFANO ZANASI VILLA ERBOSA HOSPITAL ORTHOPAEDICS DEPARTMENT IIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE Chief: STEFANO ZANASI M.D. TAKEDOWN OF."— Presentation transcript:

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

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 of knee fusion is generally that all patients disliked it and felt disabled by it. A successful fusion does not guarantee a satisfactory result: the excessive hiking of ipsilateral hip during walking requires more energy than normal, limits the patients endurance and causes low back pain. The ipsilateral hip may be damaged by the direct impact without buffering effect of the fused knee. Besides, the ability to walk and sit in a normal fashion is important to the patients overall sense of well-being and has an important socio-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 of total knee arthroplasty (TKA) in fused knee is technical demanding and high-risk of postoperative complications.

5 INDICATIONS Indications for takedown of fused knee are complex, -patients motivation, -presence of sufficient musculoskeletal and neurovascular structure -and surgeons experience 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 ankylosing spondylitis in 1 case, septic arthritis with bony ankylosis in 4 cases, and rheumatoid arthritis in 2 cases, osteoblastoma in 1 caseankylosing spondylitisseptic arthritisrheumatoid arthritis 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 ( ), and the function score was 17.joint

7 CASISTICA E RISULTATI -Follow-up showed that the average joint activity was raised to 83 degrees (60 degrees degrees ), - KSS score to 85 ( ) 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, and respectively). -The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = and p < respectively). -The mean satisfaction score was 8.5 (SD 1.5).

8 L.B. m. 72 yrs. Old - 13/07/2006 Knee fusion after ostemyelitys sequelae on 3/1953

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

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

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17 B.E. f. 40yrs. old Knee fusion after osteoblastoma resection on 1984 DSM -2.5 cm

18 B.E. f. 40yrs. old

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26 B.E. f. 40yrs. old

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

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31 PITFALLS -Surgical approach of fused knee is important. -Patellar exposure with tibial tubercle osteotomy is a standard procedure to let the extensor apparatus patent. -Identification of fusion site and preservation of bone stock is important too. -Precise tibial cutting and separation of fusion site without takedown of any bony stock: removal of a bone stock with a power saw to separate the fusion is reported in our experience and in most articles. - It is not necessary to lengthen the extensor apparatus despite of easy to free it, the initial ROM is only 35° to 45°, and the ROM improved slowly over the first year

32 PITFALLS -Aglietti et al. recommended quadricepsplasty and performed it early because of risk of avulsing the patella tendon during operation. -Kim et al. believe that aggressive postoperative physical therapy without having quadricepsplasty may not be used effectively to stretch and rehabilitate the contracted extensor muscle -Extensively release of capsule and soft tissue during operation -to perform V-Y quadricepsplasty to increase ROM and to match patello-femoral tracking -mismatch of patello-femoral tracking despite of lateral release -aggressive rehabilitation postoperatively.

33 COMPLICATIONS following operation are significantly high and all are related to the soft tissue problems, such as - skin necrosis, - extensor mechanism contracture, - extensor mechanism rupture, - adhesion and arthrofibrosis with remarkable loss of ROM - insufficient collateral 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%.

34 TREATMENT OF POSTOPERATIVE COMPLICATIONS includes -for adhesion and arthrofibrosis (1) manipulation under anesthesia (2) arthroscopic arthrolysis, (3) open arthrolysis

35 TREATMENT OF POSTOPERATIVE COMPLICATIONS for insufficient extensor mechanism (1) reconstruction by allograft (2) reconstruction by LARS artificial tendon (3) quadricepsplasty

36 TREATMENT OF POSTOPERATIVE COMPLICATIONS -for skin necrosis (1) rotational skin flap (2) muscle island pedicled flap (3) microsurgical free muscle(-cutaneous) flap

37 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, and respectively). The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = and p < respectively). The mean satisfaction score was 8.5 (SD 1.5). Total knee replacement gives good mid-term results in patients with ankylosed knees.

38 Four patients with 7 ankylosed knees, caused by ankylosing spondylitis 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 ( ), and the function score was 17. Follow-up was conducted for months. RESULTS: Follow-up showed that the average joint activity was raised to 83 degrees (60 degrees degrees ), KSS score to 83 ( ) points, and function score to 77 points. No infectious case was found. CONCLUSION: Total knee arthroplasty has a satisfactory effect in treatment of ankylosed knee.kneesankylosing spondylitisseptic arthritisankylosis rheumatoid arthritisknee replacementjointKneeaveragejointknee arthroplastyknee

39 . 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: Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty 2000;4: Kim YH. Total knee arthroplasty for tuberculous arthritis. J Bone Joint Surg Am 1988;70: Holden DL, Jackson DW. Consideration in total arthroplasty following previous knee fusion. Clin Orthop 1988;227: Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty 1996;6: Schurman JR, Wilde AH. Total knee replacement after spontaneous osseous ankylosis: a report of three cases. J Bone Joint Surg Am 1990;72: Bradley GW, Freeman MA, Albrektsson BE. Total prosthetic replacement of ankylosed knees. J Arthroplasty 1987;2: Aglietti P, Windsor RE, Buzzi R, Insall JN. Arthroplasty for the stiff or ankylosed knee. J Arthroplasty 1989;4: 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: Cameron HU. Role of total knee replacement in failed knee fusions. Can J Surg 1987;30:25-27.

40 Current Opinion in Orthopaedics: February Volume 17 - Issue 1 - pp doi: /01.bco c 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 been performed 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 73 o to 91 o. 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.

41 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, and respectively). The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = and p < 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, Ewha Womans University School of Medicine, MokDung Hospital, MokDung, YangChun-Ku, Seoul , 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

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