midterm results shiv

8/6/2019 Midterm Results Shiv

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Presented by: Dr. Shiv Chouksey

Guide : Dr (Prof) Prakash Parekh(Part of the study was presented at Gujarat Orthopedic Association ANNUAL CONFERENCE)5th February, 2010

MID-TERM RESULTS OFKNEE REPLACEMENT SURGERIES AT

DHIRAJ GENERAL HOSPITAL(A RURAL TEACHING SETUP)


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1. To study the clinical (functional) outcome ofknee joint replacement surgery,.

2. To study complication rate after knee jointreplacement .

3. To compare and analyse result with similarpublished data from technologically advancedcentres.


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R etrospective & Prospective studyTotal knees : 51

Institute :Dhiraj General HospitalPeriod of study : April 2007 to August 2010

All cases were operated by aSpecialist Surgeon

with a changing surgical team.


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INCLUSION C R ITER IA :

Primary and secondary osteoarthritisAge > 50 yearsFailed conservative trialSeverely hampered ADL.

EXCLUSION C R ITER IA :

R ecent or active sepsis of the knee.Patients with poor limb perfusion and severeperipheral vascular disease.


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Thorough history, complete physical examination.Subjective assessment of pain on theV isual Analog Scale ( V AS)A standardized system for complete evaluation ofknee and patient function was done using Knee Society Score (KSS)

X-R

ays: Anteroposterior & Lateral radiographs.(Standing Scannograms of both the lower limbs forassessment of anatomical and mechanical axis.)


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Time taken for wound healing .

Subjective decrease in pain perception using VAS.

Quantification of patient and knee function doneusing Knee Society Score, preoperatively and atthe end of one year and during the most recent

follow up.

Xrays : AP & Lateral :(for implant placement and judging any septic oraseptic loosening.)


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Total operated cases : 51Total Knee R eplacements : 43 (84.5%)Out of which 1 3 were Bilateral and half of themwere operated simultaneously.Uni-condylar R eplacements : 8 (15.5%)Follow up : Max- 2yrs 9 months

Min- 3 months(latest)Average : 1yr 3 months


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W ound healing :Average 15 days (11- 18 days). There was not a single case ofwound gaping or necrosis.


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Pain :

The preoperative average VAS score of 9 reduced to an averageof 2 at the most recent follow up.


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Fu nctional Assesment :

Knee Society Score

P reoperatively the mean knee score was 35 and the mean functionscore 45 . Both scores showed significant improvement at theend of one year. At the end of the present study the mean knee

score was 93 and the mean function score of 90 .


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Radiological evaluation :No reported case of loosening whether septic or aseptic,evident on the most recent xenoradiograph taken.Further none of the case reported with periprosthetic fractures.


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There was no reoperation required in any of the cases reported inthis short series with medium term follow up for any cause suchas infection or aseptic loosening etc.

100% of the patient were satisfied with theresults of surgery and

rated it good to excellent on subjective outcomemeasures.


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Infection following knee arthroplasty or in that caseany replacement surgery has been a dreadedcomplication with potentially devastating

consequences . This can be avoided with strict asepsiscode of conduct and proper surgical technique as alsoproved in our study

In the retrospective study conducted by Peersman on a large series of 6489 patients he reported an infection rate of 1.8% though allthe surgeries were performed in theatre with laminar air flow and with surgical team using body exhaust suits. Peersman, G. MD ;Laskin, R . MD; Davis, J. R N; Peterson, Margaret PhD: Infection in Total Knee R eplacement: A R etrospective R eview of 6489 TotalKnee R eplacements. Clinical Orthopaedics and R elated R esearch: November 2001 - Volume 392 - Issue - pp 15-23

In a similar study of 4171 total knee replacement Wilson reported an infection rate of 1.6 % MG Wilson, K Kelley and TS Thornhill :Infection as a complication of total knee-replacement arthroplasty. R isk factors and treatment in sixty-seven cases The Journal ofBone and Joint Surgery, Vol 72, Issue 6 878-883


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We assessed the patients both on subjectivewellness and functional and pain scores(KSSand VAS)Subjective satisfaction among the patientsoperated is the benchmark for a successfuloperation.Our figures are in accordance with any otherstudy in major knee replacement centres

Study by G. M. Woolhead et.al. of 25 patients reported their outcome from Knee replacement as good Outcomes of total kneereplacement:a qualitativestudy R heumatology 2005 44(8):1032-1037Another study by David Heck 2 year follow up of patients showed 88% satisfaction out of the total enrolled . Heck, David A.; R ebeccaL: Patient outcome after knee replacement. Clinical Orthopaedic and related research. 356():93-110, November 1998


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We have use standard comparisons like KneeSociety Knee Score and Visual Analog Scale

Among various knee scores for defining the outcome after total joint replacement surgery, the knee societyscore (KSS) has been found to be valid, reliable and responsive, so the selection of this scoring system in thisstudy for evaluation of results Kreibich, D. N. MD, Vaz M., Bourne, R .B. et. al.: What is the best way of

assessing outcome after total knee replacement? Clinical Orthopaedic and related research: October 1996 volume 331- issue pp 221-221Improvement in Knee Society Score, confirms the role of knee replacement in functional recovery of thepatient. Insall J, Scott WN, R anawat CS. The total condylar knee prosthesis: A report of two hundred andtwenty cases. JBJS (Am) 1979;61:173-80:Insall J, Scott WN, R anawat CS. The total condylar knee replacement:Preliminary report 1976.Clinical Orthopaedic and R elated R esearch july 2001- volume 388- issue-pp 3-6


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After HTO, the joint function declines, leading toaccelerated degeneration t hese degenerated joints finally require Total Knee Arthroplasty.

However TKA in patients with previously doneosteotomies are filled with technical difficultiesand poor mid to long term results than primaryTKA

30% more complication rate in patients who hadrevision of failed tibial osteotomy to total kneereplacement than revision of UKA to total kneearthroplasty.


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Patients with bilateral disease can have both kneesoperated during the same sitting with fullrecovery within three months of surgery following UKAHowever those who undergo bilateral osteotomiesoften have their surgeries spaced from 3 to 6months apart and as much as a year may berequired for full recovery.

RECENT REFERENCE

Kozinn CS, Marx C Unicompartmental knee arthroplasty.

J.B. J.S. 1989;71A:145-150


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High Intial success rate and low complicationrate in UKA than HTO

Meta-analysis comparing clinical outcomes ofhigh tibial osteotomy (HTO ) with UKA fortreatment of medial compartment OA reportedgreater percentage of good or excellent outcomes

and a strong trend towards improved survivorshipover HTO


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Limitation of this study includes a small seriesof patients with a short follow up.

The cost effectiveness of the procedure has notbeen touched upon.


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The finding of the present study confirms that

1. Good results can be replicated in a rural setupif all the aseptic and surgical precaution aretaken care of .

2. The results are not totally dependent on high

end gadgets and technologies such as laminarair flow system or space suits.


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Clinical outcomes in knee replacement surgeryis more surgeon skill dependent rather thantechnology dependent as proven by excellentfunctional scores of our study with all surgeriesbeing performed by one single surgeon.

Knee replacement surgery is a soft tissuesurgery as suggested by late Prof. Dholakia.


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Such a high end surgery in a rural area marksthe era wherein such procedure could bebrought more close to people wherein the heartof India resides.

Following measures as stated may providecomparable results, though at a reasonable rate,and thus helping us restore the function of joint.


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midterm results shiv

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