1. In the name of God

2. Patient Selection in Knee Arthroplasty
Mohsen Mardani-Kivi, M.D.
Orthopedic Department, Guilan University Of Medical Sciences

3. We’ll discuss… Indications for: Review recent articles TKA UKA
Patellar resurfacing
Bi-lat TKA
Review recent articles

4. Did you feel the same?!?!

5. Case 1 Age/Gender/CC: 80/M/ Pain right knee joint
History of Present Illness: pain bilateral knee joint ,right knee joint pain more severe than left. Had arthoscopic partial medial menisectomy and lavage about 3years back which gave temporary relief for about 6 months. also had intra articular hyaluronic acid injection, pain in right knee joint has increased severely

6. Case 1 CABG around 10 years back, present ejection fraction being 40%
Ph.Ex:
CABG around 10 years back, present ejection fraction being 40%
tenderness medial joint line right knee joint. ROM right knee joint5 to 120 degree
Diagnosis:
Osteoarthritis bilateral knee joint

7. Case 1

8. Case 1

9. Case 1

10. 1) How would you treat this patient's right knee?
conservative
17%
arthoscopic debridement 5%
total knee joint replacement
75%
PRP injection 1%

11. Ready for Another Question?!

12. 2) Should a UKA be performed in 80 years old male with isolated unicompartmental arthritis?
Yes
30% No
60%
Depends on surgeons skill and patients demands assuming no contraindications do not exists
10%

13. Lot’s of controversies, huh!!

14. Introduction
TKA is one of the most successful and commonly performed orthopedic surgery.

15. Increased physical activity
Expectations
Excellent pain relief
Improvements in ADLs
Increased physical activity

16. Indications for TKA
Relieve pain caused by osteoarthritis of the knee (the most common).
Deformity in patients with variable levels of pain:
Flexion contracture > 20 degrees.
Severe varus or valgus laxity.

17. indication for TKA In Campbell's text:
The primary indication for TKA is to relieve pain caused by severe arthritis, with or without significant deformity.

18. Uni-compartmental Knee
Arthritis in only 1 compartment of knee
Used in either Young or Old patient
Ligaments Intact
No systemic Disease
Weight <200#
Occupation

19. UKA
UKA is contraindicated for rheumatoid arthritis or other inflammatory diseases because the bone and cartilage lesions can be expected to spread and eventually the entire knee will be involved

20. UKA
Some believe that this method is contraindicated for patients exceeding 70 kg in weight. In the United States, however, some surgeons use 90 kg as the cutoff value.

21. UKA
A body mass index (BMI) exceeding 25 or 27 is considered to indicate mild obesity and obesity, respectively. It is desirable for this index to be below 25.

22. Patellar Resurfacing Indication for leaving the patella unresurfaced:
Congruent patellofemoral tracking.
Normal anatomical patellar shape.
No evidence of crystalline or inflammatory arthropathy.
Lighter patient.

23. Patellar Resurfacing
Of all the indications for resurfacing, inflammatory arthritis has been the most widely accepted. Most authors have recommended routine resurfacing for all patients with R.A.
Lighter patients tending to do well with un-resurfacing patella.

24. Lets see What's new in literature?

26. Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

27. A trial of weight loss with diet and exercise received the highest possible AAOS recommendation.
Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

28. KEY POINTS
Total knee arthroplasty is indicated for patients who continue to have knee pain after 6 months of non-operative treatment.
Van Manen MD, et. al. Management of Primary Knee Osteoarthritis and Indications for Total Knee Arthroplasty for General Practitioners. JAOA. 2012:709-15

29. the group of younger age and the group with less severe preoperative symptoms were more likely to have better postoperative outcomes.

30. Role of AGE in patient selection

31. Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons

32. Does surgeon selection of appropriate patients is evolving?!?!
Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons
Does surgeon selection of appropriate patients is evolving?!?!
If this is true, we would see:
the typical patient undergoing TKA would report less pain and disability at the time of surgery.
variation in typical patients across surgeons.

33. Preoperative Pain and Function Profiles Reflect Consistent TKA Patient Selection Among US Surgeons
They demonstrated that both the preoperative pain and function (KOOS scores) represent a large degree of pain and disability at the time of TKA.
So,
The rapid increase in number of patients undergoing TKA cannot be explained fully by clinicians extending surgical indications to patients with less severe symptoms.

34. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more
In 2011, Clement et. al study showed that despite similar pain relief and functional improvement, compared with a younger group of patients, octogenarian had a higher risk of death, postoperative complications and longer hospital stay after standard TKA
Clement ND :The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br2011,93:1265–1270

35. However,
In 2014 Kuo et. al indicated that the ≥80 years group had similar functional results and pain relief of the TKA compared with the young (65-74 y/o) patient group.
Octogenarian just had a higher complication rate of blood transfusion.

36. Bi-lat TKA? The number of annual bilateral TKAs increased by 75%.
The average age of patients undergoing bilateral TKA decreased by 2.5 years from 1999 to 2008.

37. Protocol for patient selection for bilateral TKA

38. Take op-room massage!!!
Do not occupy your op-rooms with senile complicated patients. While younger patients are suffering from knee problems

39. Any Questions?