cankaya ortopedi · 2016. 7. 2. · • julinj. acta orthop. 2010;81:413–419. § swedishregistry...

Dr. N. Reha Tandoğan

HowtoidentifytheoptimalsurgicalinterventionforyourosteoarthriticpatientRoleofthepatient

Prof. Dr. N. Reha TandoğanOrtoklinik / Çankaya Ortopedi Grubu, Ankara

Dr. Asım Kayaalp Dr. Mümtaz AlpaslanDr. Mahmut Kış Dr. Kürşat Teker Dr. Uğur Gönç Dr. Altuğ TanrıöverDr. Uğur Şaylı Dr. Gürkan ErkulaDr. Şenol Bekmez Dr. Metin PolatDr. Mazhar Tokgözoğlu Dr. Bülent AtillaDr. Muharrem Yazıcı Fzt. İpek İkizCank

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HTO

§ Advantages§ Preservation ofbonestock§ Allowshigh activity level§ Naturalfeeling knee§ Possibility to add cartilage &meniscal procedures

§ Disadvantages§ Longer rehab§ Inferior pain control

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Uni

§ Advantages§ Preservation ofbonestock§ Easier rehab/cosmesis§ Higher rateofforgotten knee§ Good function§ Lowmorbidity

§ Disadvantages§ Disease progression§ Learningcurve /more things cangowrong

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TKA

§ Advantages§ Reproducible technique§ Predictable results§ Inflammatory arthritis,P-Farthritis,Ligament laxity,lateralcompartmentdisease isnotanissue

§ Disadvantages§ Low rateofforgotten joint§ Pain control and ROMnotasgood asthepatient’s expectations

§ Loss ofbonestock makes revision harderCank

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Patient factors inselection oftreatment

§ Age§ Activitylevel§ BMI§ Physcosocial factors§ Disease etiology§ Knee ROM§ Social habits

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AGE

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HTOinyounger patients

§ 20-30%better results with moderntechniquescompared to the 90’ies.

§ 80-94%good results at10years§ 65-90%good results at15-20years

§ SaitoT:Bone JointJ.2014;96-B(3):339-44.§ HarrisJD:Knee.2013;20(3):154-61.§ Spahn D:KneeSurg SportsTraumatol Arthrosc.2013;21(1):96§ Hui C.AmJSportsMed.2011;39(1):64-70§ GstöttnerM,Arch Orthop Trauma Surg 2008;128(1):111–115.§ Sprenger TR, JBoneJointSurg Am 2003;85-A:469–474.§ Akizuki S. JBoneJoint Surg Br 2008;90(5):592–596.

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Uni inyounger patients§ 95%good results insingle series over 10years

§ Faour-MartinO.Acta Orthop Belg.2015Jun;81(2):283-8

§ BiswasD.JArthroplasty.2014Jan;29(1):101-5.

§ Dalury D.JKneeSurg.2013Apr;26(2):133-7.

§ Post-oppain scores higher inyounger patients

§ 10year survival inferior to TKAinregistries:85-86%§ Liddle AD. OsteoarthritisCartilage.2014; 22(9):1241-50.

§ Results ofuni in70(+)years superior to younger patients§ Sebilo A.Orthop Traumatol Surg Res.2013;99(4Suppl):S227-34.

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TKAinyounger patients

§ Finnish Registry 32,019patients 5year survival§ 55years (-):%92§ 55-65years :%95§ 65years(+):%97

• Julin J.Acta Orthop.2010;81:413–419.

§ Swedish Registry :65,661patients§ Cumulative rateofrevision increased by 9%inpatientsunder 55• W-DahlA.Acta Orthop.2010Apr;81(2):161-4.

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Age

§ Considering survival &riskofrevision

1. HTO2. TKA3. Uni

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OBESITY

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Obesity

§ 32%ofmen&36%ofwomen are obese inU.S.A.§ OdumSM. JArthroplasty.2013Sep;28(8Suppl):148-51.

§ WHOcriteria§ Obese:BMI30kg/m2 (+)

§ Super obese:BMI45-50kg/m2(+)

§ Riskoftricompartmental OAishigher and becomessymptomatic atanearlier age inobese patients.§ Guenther J. WorldJOrthop.2015,18;6(1):137-44.Ca

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Obesity &HTO

§ Obesity adversely affects the results ofHTO§ Floerkemeier S.Int Orthop.2014Jan;38(1):55-60.§ Matthews LS.Clin Orthop Relat Res.1988Apr;(229):193-200.

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Obesity &Uni

§ Increased riskofearly revision (x2)§ KandilA. JArthroplasty.2014Oct25.pii:S0883-5403(14)00791-8.

§ Relative riskofrevision at10years 0.387,(butnotstatistically significant)§ Cavaignac E.BoneJointJ.2013Aug;95-B(8):1064-8.

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Obesity &TKA

§ Increased riskofpost-opcomplications andinfection§ Namba RS. JArthroplasty.2005Oct;20(7Suppl 3):46-50.§ SchwarzkopfR.JArthroplasty.2012Mar;27(3):397-401.§ Werner BC. JArthroplasty.2014Dec19.pii:S0883-5403(14)00947-4§ IssaK.JKneeSurg.2013Apr;26(2):89-94.

§ Noeffect oncomplications and post-opmorbidity§ Suleiman LI. JSurg Res.2012May1;174(1):7-11.§ Napier RJ. Knee.2014Jun;21(3):784-8.

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Obesity§ Considering the riskofdegeneration inthe contra-lateralcompartment and disease progression

§ 1.TKA§ 2.Uni§ 3.HTO

§ Patients donotlose weight after TKA,some evengain weight§ KandilA.PhysSportsmed.2013May;41(2):34-7.

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ACTIVITYLEVEL

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Activity&sports after HTO§ 76%return to sports atthe same level after HTO+

mosaicplasty inyounger patients§ Minzlaff P. KSSTA 2014Dec7.(Epub)

§ Low impact/short duration sports activity possible in85-90%ofolder patients after HTO

§ Skiing,cycling,jogging,tennis isreasonable

§ Returnto competitive sports unrealistic§ Salzmann GM. AmJSportsMed.2009;37(2):312-8.

§ Saragaglia D. Int Orthop.2014Oct;38(10):2109-14.

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Activity&sports after uni§ Non-impact sports possible (cycling,swimmming)§ Levelofsports inferior and shorter compared to pre-opbut

the patients are still satisfied§ Naal FD.Am JSports Med.2007;35(10):1688-95.

§ Malegender,low BMI,age 65y(-)positive predictors forsports§ Jahnke AInt Orthop.2014Sep26.[Epub aheadofprint]§ Pietschmann MF.Int Orthop.2013;37(1):31-7.

§ Higher rateand shorter timeto return to sports activitycompared to TKA

§ Less pain after sports/activity compared to TKA§ Hopper GP. KneeSurg SportsTraumatol Arthrosc.2008;16(10):973-9.

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Activity&sports after TKA§ Low impact sports advisable

§ Kuster MS.SportsMed.2002;32(7):433-45.

§ Activitylevel does notincrease significantly inmost series§ Positive predictors for sports

§ Younger age,male,pre-ophigh activity,normalBMI§ Noeffect ofprostheticdesign

• WilliamsDH.Clin Orthop Relat Res.2012;470(2):555-61.• Jassim SS. Bone JointJ.2014;96-B(7):923-7.

§ 25%ofthe patients perform high impact sports contrary torecommendations§ Mayr HO. JArthroplasty. 2015Jan;30(1):46-9.

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Activitylevel &sports

§ Higher level ofactivity and sports,no riskofpoly wear or mechanical problems..

1. HTO2. Uni3. TKA

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KneeROM

§ HTObetterthanuni§ FuD:JArthroplasty.2013;28(5):759-65

§ Uni betterthanTKA§ GriffinT.ANZJSurg.2007Apr;77(4):214-21.

§ But…§ ImprovementinROMpossibleonlyafterTKAinstiffknees

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Paincontrol

§ Uni betterthanHTO§ FuD:JArthroplasty.2013;28(5):759-65§ Spahn G:KSSTA2013Jan;21(1):96-112

§ Uni similarorbetterthanTKA§ Lyons MC. Clin Orthop Relat Res.2012;470(1):84-90.§ Liddle AD. Lancet.2014;384(9952):1437-45.

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Centralsensitization&chronicpain

§ AnimportantsubsetofkneeOApatientshavecentralsensitizationandchronicpaindiscordantwiththeseverityofarthritis§ Finan PH.ArthritisRheum.2013;65(2):363-72.§ Fingleton C.Osteoarthritis Cartilage.2015;23(7):1043-56.

§ Sleepdisturbances,paincatastrophizingandcentralsensitizationcontributetochronicpainbeforeandaftersurgery§ CampbellCM.ArthritisCareRes.2015;67(10):1387-96.§ Skou ST,Eur JPain.2014;18(7):1024-31.

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Riskfactors for chronic painfollowing arthroplasty

§ Pre-opsevererestpain§ Bourne RB.Clin Orthop.2010; 468(1):57-63.

§ Younger age,female,pre opanxiety/depression§ Parvizi J.Clin Orthop Relat Res.2014Jan;472(1):133-7.§ O’Connor MI.ClinOrthopRelatRes.2011Jul;469(7):1846-51.§ Bonnin MP. KneeSurg SportsTraumatol Arthrosc.2011;19(9):1411-7.

§ Inadequate pain control after surgery§ Consider gabapentinoids inthemulti-modalpain regimen

• Liu SS. Reg Anesth PainMed.2012;37(4):415-22.

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Physcological distress..

§ Inferioroutcomesinpainandfunctionafterarthroplastysurgeryinpatientswithanxiety/depression§ Hirschmann MT.KSSTA2013;21(10):2405-11.§ Lavernia CJ.Clin Orthop 2015;473(1):159-63.

§ ThesepatientsstillimproveafterTKA,painreliefmaytakelongerthan1year§ BlackburnJ.Knee.2012;19(5):522-4.§ BranderV.Clin Orthop Relat Res.2007;464:21-6.§ Pérez-PrietoD.JArthroplasty.2014Jan;29(1):44-7.Ca

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SocialHabits..

§ Smokingincreasessurgicalsiteinfections,delayedwoundhealing&earlymorbidityandreadmissionrates§ Maradit Kremers H.JArthroplasty. 2015;30(10):1852-4.§ Duchman KR,.J BoneJointSurg Am.2015Jul 1;97(13):1049-58.

§ Alcohol abuse is detrimental§ GGT,MCVscreening

§ Effect ofmoderate/occasional alcohol consumptionunclear§ Lavernia CJ.Clin Orthop Relat Res.2013Jan;471(1):189-94.

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Idealpatients

§ HTO:Young,active,malewithgoodROM,somepreservationofmedialjointspaceandmetaphysealvarus

§ Uni :Sedentaryolderfemalewithbone-onbonemedialOAwithcorrectablevarusduetolossofcartilage

§ TKA:Anypatientwithtricompartmental OAorinflammatoryarthritisCa

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Take homemessage

§ Appropriate surgery forpatients that fitidealindications for eachtechnique

§ Patients without idealparameters§ Surgeon experience§ Patient preference

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Thank you …

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cankaya ortopedi · 2016. 7. 2. · • julinj. acta orthop. 2010;81:413–419. § swedishregistry...

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