1. Case Presentation Son Eui Young 2007313075 Sungkyunkwan University School of Medicine

2. Chief Complaint n 67/F, Both knee pain –Onset : 20YA

3. Present Illness n 20 년전부터 시작된 양슬관절 통증 (Left > Right) n 최근 2 년동안 악화됨 n 평지나 계단 오를 때, 쪼그려 앉거나 일어날 때 통증 호소, 계단 내려가는 것은 아파서 못한다. n Trauma history : 없음

4. Present Illness n 보존적 치료에도 호전 없어 인공관절 수술 결정 n 2012. 02.15 – 수술적 치료 위해 입원

5. Past Medical History n 고혈압 (No) 당뇨병 (No) n 결핵 (No) 간염 (No) n 알레르기 (No) 항생제 알레르기 (No)

6. Review of System n Fever/chill (-/-) n Sore throat/rhinorrhea/sneezing (-/-/-) n Cough/sputum/hemotpysis (-/-/-) n Dyspnea/orthopnea (-/-) n Nausea/vomiting (-/-) n Constipation/diarrhea (-/-) n Hematemesis/melena/hematochezia (-/-/-)

7. Physical Examination n Vital sign (2012-02-15 14:54) –BP135/81 mmHgRR86.0/min –RR18/minBT35.6 ℃ n Knee ROM –FC5/5FF150/150 –Varus5/10PCT+++/+++ –Crepitus +/++

8. Knee X-ray

10. Problem List 1. Both knee pain 2. Knee effusion, Crepitus 3. Asymmetric knee joint narrowing

11. Assessment n Advanced Osteoarthritis knee, bilateral n Rheumatoid arthritis n Knee Fracture

12. Operation n 2012-02-16 : Left TKA n 2012-02-22 : Right TKA

13. Post-op. X-ray

14. Progressive Note n 2012-03-01 (POD 7) –Vital sign stable, Pain tolerable –Wound clear, No immediate complication

15. Case Review n K-L Classification –Estimation of Osteoarthritis Severity n OS – Treatment n Simultaneous bilateral TKA

16. K-L classification n Kellgren-Lawrence grading scale n Grade 1: –doubtful narrowing of joint space and possible osteophytes

17. K-L classification n Grade 2 –definite osteophytes, definite narrowing of joint space

18. K-L classification n Grade 3 –moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour

19. K-L classification n Grade 4 –large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

20. OA – Treatment n Education –Posture, habit, occupation – 지팡이 등의 보조기구 – 체중 감량 초기중기말기 파 스파 스 NSAIDs 스테로이드 주사 Hyaluronic acid 주사 관절경 수술 인공관절 치환수술

21. OA – Treatment n Medication –Oral : NSAIDS, COX-2 inhibitor, Tramadol, Hydrochloride –Injection : Hyaluronan, Glucocorticoid n Surgery –Osteotomy –Arthroplasty, Arthrodesis

22. Simultaneous bilateral TKA n 비용은 58% 정도 저렴 (by campbell’s) n 추가 입원 일 수 증가 (Bi 89%, Uni 45%) n Postop. Thrombocytopenia 증가 n Blood loss 량 증가 n DVT, PE 발생율 증가 n 80 세 이상에서는 cadiovascular 와 neurological complication 증가  Comorbidity 와 physiological age 가 고려되어야 함

23. References n CAMPBELL’s Operative Orthopedics 11 th Ed.