1. ΠΑΘΗΣΕΙΣ ΓΟΝΑΤΟΣ ΚΑΡΑΜΠΙΝΑΣ ΠΑΝΑΓΙΩΤΗΣ MD, MSc, PhD ΟΡΘΟΠΑΙΔΙΚΟΣ ΧΕΙΡΟΥΡΓΟΣ Επιστημονικός Συνεργάτης Γ’ ΠΑΝ/ΟΡΘ ΕΚΠΑ, ΚΑΤ

2. Knee Arthritis Assessment Patient assessment of knee pain includes a physical examination and diagnostic radiographic modalities

3. CLINICAL PRESENTATION A. Pain with weight bearing Aggravated by stairs, hills, sit to stand B. Bowing deformity and instability Seen later in presentation

4. IMAGING STUDIES A. Radiographs are still the standard for initial evaluation. Images should include 1. Weight-bearing anteroposterior and lateral 2. Weight-bearing 45-degree bent knee, imaged posterior to anterior X-ray plate is positioned parallel to tibia. 3. Sunrise view (i.e., merchant view) 4. Extension and flexion lateral

5. IMAGING STUDIES B. MRI 1. Grossly overused in the arthritic patient population 2. If the joint space is significantly narrowed on radiograph, then MRI is not indicated. 3. Used when osteonecrosis is suspected

6. IMAGING STUDIES C. CT scan 1. Three-dimensional CT with remodeling used for preoperative planning for reconstruction associated with dysplasia planning, post-trauma planning, and complex total knee arthroplasty (TKA) planning

7. Knee Arthritis Treatment I. NONOPERATIVE A. Activity modification 1. Reduce impact-loading exercises 2. Reduce weight 3. Avoid stairs, inclines, squatting

8. Knee Arthritis Treatment B. Nonsteroidal anti-inflammatory drugs 1. Cyclooxygenase-2 inhibition C. Joint injections 1. Corticosteroid–anti-inflammatory treatment 2. Hyaluronate Backbone of proteoglycan chain of articular cartilage Improves joint rheology

9. Knee Arthritis Treatment D. Unloading brace 1. Helpful but compliance low 2. Best suited for exercise activity E. Assist device (cane or crutch) 1. Opposite hand of affected knee

10. Knee Arthritis Treatment II. OPERATIVE A. Arthroscopy 1. Palliative treatment only 2. Use selectively Overaggressive articular shaving accelerates natural course of degeneration. 3. Success directly related to degree of mechanical symptoms noted preoperatively Meniscal tears with catching and locking Loose bodies Unstable cartilaginous flaps 4. Success inversely related to the severity of arthritis Not helpful in moderate to advanced disease Will not take away toothache pain caused by reactive bone edema from mechanical overload 5. Palliative results less effective in the presence of knee malalignment (varus or excess valgus) Malalignment causes mechanical overload and bone pain.

11. Knee Arthritis Treatment B. Osteotomy 1. Best indication Young active patient generally under the age of 50 years Most likely to succeed when disease affects predominantly one compartment For valgus knee malalignment Treatment is varus-producing supracondylar femoral osteotomy. Osteotomy goal—Maintain joint line of knee perpendicular to the mechanical axis of the leg. For varus knee malalignment Treatment is valgus-producing proximal tibial osteotomy. Osteotomy goal—Maintain joint line of knee perpendicular to the mechanical axis of the leg. Mechanical axis of leg defined as center of hip through center of knee to center of ankle

12. Knee Arthritis Treatment Contraindications Inflammatory arthritis Prior medial meniscectomy Deformity over 15 degrees valgus There is just not enough bone to remove to correct deformity. Flexion contracture over 10 degrees

13. Knee Arthritis Treatment C. Unicompartmental arthroplasty Used for patients in whom arthritis predominantly affects one compartment Most common is medial compartment replacement. Advantage Quicker recovery compared to TKA and osteotomy Fewer short-term complications Better knee function Anterior cruciate ligament (ACL) is not sacrificed as it is in TKA. Smaller incision Shorter hospital stay with less postoperative pain However, long-term survivorship is not comparable to TKA when measured by revision rates.

14. Knee Arthritis Treatment Contraindications Inflammatory arthritis Significant fixed deformity Must be able to correct deformity on clinical examination (e.g., must correct resting varus attitude to normal valgus) Previous meniscectomy in opposite compartment ACL deficiency—key ACL deficiency is an absolute contraindication for a mobile-bearing unicompartmental replacement. Flexion contracture greater than 10 degrees Tricompartmental arthritis

15. Knee Arthritis Treatment D. Isolated patellofemoral arthritis TKA (not patellofemoral arthroplasty) is recommended choice in older patients. Superior functional results compared to patellectomy or patellofemoral arthroplasty. Lateral retinacular release commonly seen with isolated patellofemoral arthritis. Maltracking is usually the cause of isolated patellofemoral arthritis. Must restore a patellofemoral alignment to a normal Q angle

16. Τotal Knee Arthroplasty-TKA I. INDICATIONS A. Debilitating pain affecting activities of daily living B. Pain not well controlled by conservative measures C. Medically fit for surgery D. No active infection—anywhere

17. ΤΚΑ II. TKA SURVIVAL A. Best survival 1. Well-balanced knee 2. Neutral mechanical alignment B. Decreased survivorship 1. Young age—55 years or less 2. Osteoarthritis 3. Reason—high activity level C. Increased survivorship 1. Old age—70 years or older 2. Rheumatoid arthritis 3. Cemented fixation (all components) 4. Reason—low activity level

18. ΤΚΑ III. TECHNICAL GOALS OF TKA A. Restore neutral mechanical alignment of limb B. Restore joint line C. Balanced ligaments D. Normal Q angle

19. ΤΚΑ IV. PREOPERATIVE PLANNING FOR TKA A. Preoperative radiographs should include 1. Standing bilateral anteroposterior knees 2. Extension and flexion lateral 3. Sunrise (merchant view) 4. Standing full-length anteroposterior hip to ankle when Bony angular deformity present Very short stature Below 60 inches (152â¯cm) Very tall stature Above 75 inches (190â¯cm)

20. ΤΚΑ B. Radiographic analysis 1. Determine end cuts—femur and tibia. 2. Determine position of femoral canal entry site at the knee. 3. Identify bone defects. 4. Identify joint subluxation. 5. Identify ligament stretch-out. 6. Determine anticipated ligament releases. 7. Anticipate extent of constraint needed from preoperative review of radiographs.

21. TKA

23. ΕΥΧΑΡΙΣΤΩ