Scientific associate of the newspaper “My Health“. Articles published: “Knee Arthroplasty 1st Issue”, September 16, 2006, issue No. 11

Lambros S. Hadjimichael, Cert. MTD

Knee arthroplasty

Historical background, epidemiology, economic data, indications, contraindications and results

 Chronology

The first knee arthroplasty was reported in 1861 by Ferguson. However, Verneuil’s arthroplasty was recognized in 1863, when he introduced a membrane sac between the articular surfaces of the knee. Later, other surgeons invented and used materials such as leather, muscle, fat and even the urinary bladder from pigs. But none of these efforts succeeded. In the 1920s and 1930s, Cambell made the use of peritoneal graft popular as an interventional material. This method had limited results in knee anchoring.

In 1940, Cambell reported successful use of a metal insert in the femoral footprint, and soon MNSmith-Petersen, at Massachusetts General Hospital, developed a similar arthroplasty initially to treat patients with rheumatoid arthritis with ankylosing spondylitis. Later in 1953, Macintosh and McKeever reported the use of semi-arthroplasty in the femur.

The new groundbreaking development began when B.Willdius made the first artificial hinge joint in 1951. The “hinge” type corrected several deformations as well as the patient acquired a moving trajectory (with a lower driving trajectory 90).And without pain).

However, the pioneers of the historical period of modern arthroplasty are Gunston and McKenzie.by inserting metal sliding brackets into the femur into the articular joint. In order to secure the underlying bone, clay cement was first used. This arthroplasty was the first to be designed and based on changing the radius of the femoral condyles. The cruciate ligaments were maintained in order to increase joint stability.    

But the most important success came in 1973 with the design of the total knee arthroplasty, which still remains the same.

Experience has now led to the promotion of materials such as metal and plastic materials, the selection and use of titanium, the choice of a fastening method to replace the fastening of materials with cement and finally metal surfaces are manufactured to bring about an internal increase in bone spongy.[ek1] .

Epidemiology

There is not a lot of research on epidemiology for total knee arthroplasty. However, numbers are given about it. In the United States, there are 213,000 total knee arthroplasties performed each year, which are performed on the knee due to osteoarthritis of the knee.

Financial data

The results of a study by Culler and his colleagues showed that each total knee arthroplasty costs an average of $ 11,000, while at the same time it is estimated that 213,000 are made each year, with a total cost of up to $ 5 billion.

The cost for each total knee arthroplasty includes:

a. the operating room,

b. medical and nursing staff,

c. the preoperative entry of the patient in whom antibiotics are administered and various tests are performed,

d. the patient’s postoperative stay and

e. the period of monitoring and rehabilitation (physiotherapy) of the patient.

If we compare the financial costs in relation to the benefit that the patients had from the replacement of their joint, it is comparatively much higher than the corresponding of these patients who undergo open heart surgery or dialysis.

Indications

Surgical rehabilitation is the last option that will be recommended when conservative treatment may not be effective.

The indications for total knee arthroplasty are:

a. severe persistent pain, which can no longer be controlled conservatively (with medication and physical therapy),

b. the great deformation in roughness or roughness,

c. severe osteoarthritis of the knee,

d. the great difficulty in walking and

e. in patients over 65 years of age.

Severe nocturnal pain and pain during movement that makes the patient dysfunctional and unable to cope with their daily activities, even after temporary analgesia is a key indication for surgical rehabilitation and not the reduced range of motion of the joint, imbalance or any pathological findings.

The patient’s age is often an indication or contraindication for surgery. If the patient is under 65 years of age and who suffers from rheumatoid arthritis, joint replacement may be indicated.

In general, total knee arthroplasty, depending on the person’s gender, age and body weight, is indicated in:

a. men 65 years old, while in case their body weight exceeds 255lbs we add another 5 years,

b. women 60 years old, while in case their body weight exceeds 175 lbs we add another 5 years.

The results we have from total knee arthroplasty are:

a. 95% pain relief,

b. improving the trajectory of movement and stability of the knee and

c. improving the patient’s level of activity.

Finally, the orthopedic surgeon should discuss with the patient the surgical procedure and the complications that may occur. It is also important for the patient to talk to his family or a friend before making a decision, as many patients do not feel comfortable making the decision in the doctor’s office.

Contraindications

 Surgery for total knee arthroplasty is a major surgical procedure, often accompanied by a significant number of complications and mortality (1-2%). Therefore, in cases where total arthroplasty is indicated, the general condition of the patient should be evaluated and in particular the functions of the brain, heart, liver, generalized atony (weakness), ie conditions that can be a contraindication for any selected surgery. An emergency medical consultation is always recommended. The number of patients in whom preoperative problems were identified that did not require correction before the patient was admitted to the operating room (eg problems with the cardiovascular, liver, urinary tract, metabolic diseases, etc.) is really impressive.

It has been observed that postoperative complications are more common in patients 80 years of age and older, and for this reason it is advisable to have this last option. Contraindications are also these surgeries for patients who cannot be walked due to serious pre-existing problems.

Other contraindications to total knee joint replacement are:

  • active infection of the knee joint, bladder, skin, chest or any other area,
  • any process that can cause rapid bone destruction (eg generalized osteopenia, local treatment in the knee, local osteoporosis),
  • neurotrophic joint,
  • evolving neurological disease.

Total knee arthroplasty should also not be performed in patients with overt osteopenia. The cause of the disease must first be determined, treatment must be started and it must be ensured that the disease does not develop with the help of a series of radiographic data.

In patients with neurotrophic joints there is extensive bone destruction and significant exotic treatment, there is additional pain but it is not as acute as in the case of massive changes in bone formation. Also, patients with increased erythrocyte sedimentation rate should be investigated for possible infection.­­

Finally, in order for this type of surgery to be performed, there must be a sufficient amount of bone mass that will allow for satisfactory stabilization of the parts of the prosthesis. This is often a serious limiting factor when there are malignant tumors in the area that destroy a significant amount of bone mass.


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