Surgical factors Surgical factors influencing range of influencing range of

motionmotion David BeverlandBelfast N Ireland

PROGRAM VOCA LUSTRUM CONGRESS KNEE ARTHROPLASTY

SEPTEMBER 15th – HUIS TER DUIN – NOORDWIJK AAN ZEE

Factors influencing ROMFactors influencing ROM• Implant design

• MIS?

• Surgical technique

• Rehabilitation

• Patient factors

• Post-operative complications

Factors influencing ROMFactors influencing ROM

Surgical TechniqueSurgical Technique

• Clearing all osteophytes

• Stripping the posterior capsule from back of the femur traditional method of correcting fixed flexion

• Stripping the posterior capsule from back of the femur also described for increasing flexion

• Severe varus knee – 30 degrees

• MCL tented over osteophytes

Usually also severe

fixed flexion

Stripping the Posterior Capsule

Postero-medial capsulotomyCorrects FFD BUT also

Corrects varus deformity

Fixed flexion with varus deformity

Lateral Medial MedialLateral

Do not releasethe Supficial MCL in

a Varus knee

Stripping the Posterior CapsuleTo improve flexion

Prospective RCT in BelfastProspective RCT in Belfast

• 50 patients in each group• One group with stripping of the posterior

capsule the other without• No difference between passive or forced

ROM at the end of surgery• No difference in ROM at 3 months or one

year

Factors influencing ROMFactors influencing ROM

Surgical TechniqueSurgical Technique

• Importance of restoring joint line

• Concept of posterior condylar offset

Bellemans J et al JBJS (Br) 2002

9mm resection

11mm resection

10mm Insert

LCS Rotating PlatformNormal Raised Lowered

PCO

Restoring the Joint Line

Bellemans J et al JBJS (Br) 2002Hanratty et al JBJS (Br) 2007

Posterior stabilised knee

11mm resection11mm resection

14mm resection 14mm resection

15mm insert 15mm insert

Common causes of a decreased PCO

Normal LoweredRaised

Raising joint line on tibia leads to fixed flexion

Factors influencing ROMFactors influencing ROM

Surgical Technique Surgical Technique – cont’d – cont’d

• Increased patellar thickness – over stuffing of the patello-femoral joint• Closing the wound in flexion? • V-Y Plasty (Scott and Siliski (1985) - no control

group• Internal rotation of the femoral component – definite

link with arthrofibrosis as reported by the Schulthess clinic in Zurich

One cause of internal rotation of femoral component

Release of Sup MCL

Internal rotation of femoral component

Trapezoidal flexion gap

Raised flexion joint line

Femur externally rotates

11mm resection15mm insert

9mm resection

Varus knee• Over release MCL

Raised joint line just on the tibia

Normal Raised Lowered

PCO

So raising the joint line in flexion either on the

femur or tibia is not good

Raising joint line on tibia leads to fixed flexion

Factors influencing ROMFactors influencing ROM

RehabilitationRehabilitation

• Early flexion on CPM - range 70 - 120 degrees?• Routine CPM - no advantage beyond 3 months• Post-operative pain?• Excessive bleeding after tourniquet release?• Post-operative swelling - foot pumps?• Intense post-operative physio? – Japan 6 weeks in hospital

• Routine post-op physio? – Must work!!

Outpatient Physio vs no PhysioOutpatient Physio vs no Physio

• Prospective randomised control trial in Belfast• Physio (n=71) No Physio (n=72)• Pre-op passive ROM 98.3˚ Physio group• Pre-op passive ROM 100.2˚ No physio group

ONE YEAR• Post-op passive ROM 108.6 Physio group• Post-op passive ROM 108.1 No physio group

ResultsResults• At one year no significant difference

in the range of knee motion

• All other outcomes no difference.

Now finally accepted byJournal of Arthroplasty

Initially submitted to JBJS Br BUT reviewer said

it was unthinkable that TKAs would not have outpatient physio and therefore it should not be published!

Factors influencing ROMFactors influencing ROM

Patient FactorsPatient Factors

• Obesity• Diagnosis - some evidence that RA patients

improve more than OA? Ritter and Stringer (1979)

• Previous surgery - for example High Tibial Osteotomy?

• Motivation?

• Pre-operative ROM- single most important factor- single most important factor

Neville Thompson Mphil thesis - 2003

Management of the stiff knee after TKAManagement of the stiff knee after TKA

My definitionMy definition

•A patient whose post-operative range of ACTIVE knee motion compromises their ability to perform everyday functions

Management of the stiff kneeManagement of the stiff knee

ROM for Everyday FunctionsROM for Everyday Functions

• Swing phase of gait (67° flexion)

• Climbing stairs (83° flexion)

• Descending stairs (90-93° flexion)

• Rising from a chair (93-106° flexion)

• Tying a shoe lace (106° flexion)Kettelkamp et al. 1970; Laubenthal et al. 1972

Cultural DifferencesCultural Differences

SEIZA Japanese sitting style (pronounced SAY-ZA)

Cultural differences

Management of the stiff kneeManagement of the stiff knee

DefinitionDefinitionMy definition for my patients

• A patient who has <70 degrees of flexion as this will impair walking

• Although need 93 for stairs – 13% of my patients have <93 degrees!

Management of the stiff kneeManagement of the stiff knee

PreventionPrevention

• Surgery is for pain not stiffness

• Important that the patient knows that!

• Avoid comment post-op “If I had known my knee would still have been stiff I would not have had surgery”

• Patient with a stiff knee pre-op must be warned

• Otherwise it becomes a complication

Pre-operative Education

Make sure you Make sure you record the record the

Pre-op ROM!Pre-op ROM!

Management of the stiff kneeManagement of the stiff knee

PreventionPrevention

Probably biggest preventable cause of the stiff knee!

• In summary remove all osteophytes and try and put things back where they where!

Surgical technique

Management of the stiff kneeManagement of the stiff knee

InvestigationInvestigation

• Examine knee and hip - a stiff hip inhibits knee flexion and vice versa!

• Accurately record ROM with a goniometer

• Any wound problems or knee effusion? - if yes aspirate

• Routine bloods and x-rays including skyline

• Exclude mechanical problems such as spinout

• May consider a CT scan to measure femoral rotation

Management of the stiff kneeManagement of the stiff knee

TreatmentTreatmentWho do I treat

• Patients who at 3 months post-op have less than 75 degrees of flexion providing that they had at least 30 degrees more flexion before surgery

• Between 1st Apr 2000 to 31st May 2007 I did 2762 TKAs

• 30 MUAs during that time – 1.086%

WeeksFlexion

Pre MUAFlexion post MUA @ 1yr

14 60 11214 70 907 45 10015 45 1009 65 9014 80 9015 40 10012 20 6014 45 957 60 10018 70 9012 9814 55 10010 70 1159 50 789 50 10517 70 10016 55 NR7 60 8529 55 704 49 7420 50 8016 60 11015 65 5015 58 8012 56 8522 45 4513 35 856 32 NR16 40 NR

Management of the stiff knee

Treatment - 30 Patients with MUA (1.086%)

All improved except one

Average flexion pre MUA = 53

Average flexion post MUA = 85

If these patients hadn't an If these patients hadn't an MUA what would their ROM MUA what would their ROM

have been at 12 months?have been at 12 months?

One patient with a pre-op ROM of 0-130 had 25-70 at 12 weeks and refused MUA

@ 12 months they had 5-120!

Management of the stiff kneeManagement of the stiff knee

TreatmentTreatmentMUA

• GA or spinal anaesthesia with peripheral nerve blocks – femoral and sciatic• At MUA does it give easily or is it like a lead pipe?• Record pre MUA range then post MUA passive and forced flexion• Straight on to CPM with active excercises as well• Home when active flexion >70 - usually Day 2• Outpatient phsiotherapy• Many reports on MUA are up to 10% of all primaries

Management of the stiff kneeManagement of the stiff knee

TreatmentTreatmentOptions other than MUA

• Serial splinting - I have tried this once for fixed flexion• Arthrolysis open or arthroscopicArthrolysis open or arthroscopic• Revision with no aimRevision with no aim• Revision to correct internal rotation of femurRevision to correct internal rotation of femur• Quadriceps plasty and or excision of HOQuadriceps plasty and or excision of HO• ArthrodesisArthrodesis

I don’t think any of them work!I don’t think any of them work!Hutchinson JRM, Parish EN, Cross MJ

Results of open arthrolysis for the treatment of stiffness after total knee replacement.

J Bone Joint Surg Br. 2005 Oct;87(10):1357-60

Follow-up study running at Follow-up study running at Schulthess Clinic in ZurichSchulthess Clinic in Zurich

• Group of patients with arthrofibrosis • Proven to have internal rotation of the femoral

component on CT scanning• Are offered revision of their femoral component• 4 out of 5 patients improve • These data are preliminary and are not published• Based on personal communication with Schulthess

Clinic via Jens Bolt

In ConclusionIn ConclusionFactors influencing ROMFactors influencing ROM

• Implant design

• MIS?

• Surgical technique

• Rehabilitation

• Patient factors

• Post-operative complications

Pre-operativeRange of Motion

Thank youThank you