Evaluation of the result of total knee replacement in various arthritic condition of knee

Jaydeep Patel; Rajat Kapoor; Ashutosh Verma; Randheer Chauhan; Sushil Saini; Chandra Prakash Pal

doi:10.4103/jbjd.jbjd_16_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 37 | Issue : 3 | Page : 110-113

Evaluation of the result of total knee replacement in various arthritic condition of knee

Jaydeep Patel, Rajat Kapoor, Ashutosh Verma, Randheer Chauhan, Sushil Saini, Chandra Prakash Pal
Department of Orthopedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India

Date of Submission	09-Aug-2022
Date of Acceptance	22-Oct-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Chandra Prakash Pal
Department of Orthopedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_16_22

Abstract

Introduction: Osteoarthritis is the most common form of the arthritis and is a leading cause of disability in older adults. The management of knee arthritis depends upon severity of arthritis. It starts from conservative management in earlier stage and goes upto the total knee replacement (TKR) in severely advance stage. TKR is an operation to restore pain-free motion to a joint, muscle, ligament, and other soft tissue structures that control joint. The goal of total knee arthroplasty is as simple as to relieve pain, provide motion, maintain stability, and simultaneously correcting deformity. The purpose of this study is to evaluate pain, mobility, stability after TKR in arthritis and to evaluate functional outcome. Materials and Methods: The case material for present study was selected from the out patient Department of Orthopaedics, S.N. Medical College and Hospital, Agra. Each patient would be subjected to detailed clinical history and examination and necessary radiological and pathological investigation. Data was collected by interviews, observation of clinical and radiological findings and assessment of function done using knee society knee score (having 100 points). Results: In this study, evaluation of 10 total knee arthroplasty was performed in S.N. Medical College and Hospital, Agra. In our study most of cases (70%) have age ≥60 years and most of (70%) cases are female in whom TKR was performed. The pre-operative ROM at knee were between 51⁰ and 80⁰ in all the cases (100%). But post-operative after 6 months all the cases have their range of motion between 91⁰ and 110⁰. Maximum number of the cases (80%) have moderate continuous pain at knee before the operation and rest 20% have moderate occasional pain at their knee preoperatively. After the operation, maximum number of cases (90%) have no pain or mild occasional pain after the operation. Maximum number of cases (90%) have ≥30⁰ increase in their range of motion, after operation. Similarly after TKR, there is an increase in post-operative functional knee scores at 6 months (86.5%) as compared preoperative scores (21%). Though there is an initial fall (16.5%) in the functional score in initial 15 days after operation, it then starts increasing at 1 month and ultimately at 6 month. Conclusions: Total knee arthroplasty should definitely be performed over 60 years of age having pain at knee not responding to analgesics with or without any significant deformity at knee. As we found that is no or occasional pain with good range of movement after 6 month of operation so that patient satisfaction level is very high. But large number of patient and ling follow-up is required for long-term result.

Keywords: Knee, OA, TKR

How to cite this article:
Patel J, Kapoor R, Verma A, Chauhan R, Saini S, Pal CP. Evaluation of the result of total knee replacement in various arthritic condition of knee. J Bone Joint Dis 2022;37:110-3

How to cite this URL:
Patel J, Kapoor R, Verma A, Chauhan R, Saini S, Pal CP. Evaluation of the result of total knee replacement in various arthritic condition of knee. J Bone Joint Dis [serial online] 2022 [cited 2023 May 27];37:110-3. Available from: http://www.jbjd.in/text.asp?2022/37/3/110/363845

Introduction

Knee osteoarthritis (OA is now recognized to be multifactorial, resulting from the interaction of a variety of systemic and local factors, including age, genetic predisposition, obesity, trauma, and mechanical properties of the synovial joint. It is often considered as an inevitable consequence of growing old. However, in spite of intensive research over the past 20 years, very little is known about the onset and progression of the disease. OA diseases are a result of both mechanical and biological events that destabilize the normal coupling of degradation and synthesis of articular cartilage chondrocytes and extracellular matrix, and subchondral bone. Knee arthritis attributes approximately 10% of the prevalence among musculoskeletal complaints.^{[1],[2],[3],[4]}

The management of knee arthritis depends on the severity of the arthritis. It starts from conservative management in an earlier stage and goes up to total knee replacement in a severely advanced stage. Arthroplasty comes as a boon for patients who have end-stage arthritis. Arthroplasty is an operation to restore pain-free motion to a joint, muscle, ligament, and other soft-tissue structures that control the joint. The goal of total knee arthroplasty is simple to relieve pain, provide motion while maintaining stability, and simultaneously correct the deformity.

Total knee arthroplasty is surgery of soft-tissue balancing to restore mechanical axis, joint line, and patellofemoral alignment. The implants used in total knee replacement (TKR) and their designs are highly sophisticated and are meant to provide a biomechanically advantageous and long-life span with minimal wear and tear. They are made from materials, which are biologically inserted and compatible with the human body as well as each other.

Materials and Methods

This study was carried out to evaluate the results of total knee replacement in various arthritic conditions of the knee in the Departmental of Orthopaedics, S.N. Medical College and Hospital, Agra. The case material for this study was selected from the outpatient Department of Orthopaedics, S.N. Medical College and Hospital, Agra. Each patient would be subjected to detailed clinical history and examination and necessary radiological and pathological investigation. Follow-up after first week of stitch removal and the subsequent visits after every 4 weeks for 3 months, after that on 6 and 12 months, and then yearly. The following table shows the criteria for assessment of results based on knee society knee score (having 100 points).

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Result

In this study, the evaluation of 10 total knee arthroplasties was performed in S.N. Medical College and Hospital, Agra. Most of the cases (70%) belonged to the 60 years or above in age, followed by the 40–49 years of age group in which 30% of cases came. None of the patients belonged to 40 years or below in age, showing that total knee arthroplasty is seldom performed in such an age group. Female patients comprise 70% of the total cases. OA was responsible for the maximum number of cases for which TKR was performed constituting 70% of total cases, and rheumatoid arthritis was responsible for the remaining 30% of cases.

It was primary (idiopathic) OA, which was responsible for all the cases of OA in which TKR was performed. The maximum number of cases belonged to the upper class, comprising 60% of cases. Rest 40% of the cases belong to the upper middle class. Approximately 70% of cases had varus deformity of the knee for which TKR was performed and all of them (100%) had OA. Approximately 10% of cases had a valgus deformity of the knee (100%) had rheumatoid arthritis as their diagnosis. Normal alignment (5–10 valgus) is presented in 20% of cases and all of them (100%) belong to the rheumatoid patient. The percentage of case who took >15 years to get operate; from the initiation of symptoms were 40%. Approximately 60% of cases took between 10 and 14 years to get operated. All of the cases, that is, 10 cases, fell into the group of 51°–80° range of motion (ROM). This shows that the maximum number of patients who came for TKR have their knee stiff with ROM restricted between 50° and 80°.

Approximately eight cases, that is, 80%, had moderate continuous pain in their knee, whereas the remaining two cases had moderate occasional pain. Therefore, pain is a very important cause for which TKR is performed. Postoperatively after 6 months, the maximum number of patients, that is, 80% of cases had their ROM at the knee between 101° and 110°. The majority (70%) of our cases had no pain in their knee 6 months after TKR. Only 20% of cases have mild occasional pain. This relief of pain is the most important factor that is responsible for patient satisfaction postoperatively. Approximately 30% of cases had ≥40º increase in their range of motion knee after TKR. Approximately 60% of cases had their increase in range of motion between 30° and 39º.

There was only one case (10%), who had an increase in range of motion between 20° and 29º. Approximately 50% of cases had an increment in pain score ≥40, that is, the maximum number of increments. Although approximately 50% of cases had their increment in pain score between 30 and 39, the maximum number of cases 60% had flexion contracture between 11° and 15º preoperatively and a majority of the cases 70% had no postoperative contracture at 6 months. Approximately 70% have varus alignment preoperatively, whereas all the patients have normal alignment postoperatively.

Majority of the cases were unable to stair climb or move with rail and unable to downstairs preoperatively. But after the operation, the majority of the cases stair climb normally and down with rail. Definite increase in knee score after the operation and the maximum increase is seen just after the operation. Though there is an increase in knee score postoperative) even up to 6 months, the rate goes on decreasing with time. Initially, there is a drop in functional knee score on the 15th postoperative day, but the score slowly increases at 1 month and by 6 months there is a significant increase in functional knee score in comparison to preoperative knee score. In approximately 80% of cases, there is no complication; one case has a superficial infection and delayed wound healing which quickly responds to antibiotics and dressing so if proper precaution is taken then infection cannot be as much concern.

Discussion

A total of 10 arthroplasties was done. Maximum eight cases have bilateral total knee arthroplasty in the staged or simultaneous procedure. Total knee arthroplasty is generally performed in patients of age 60 years or above, especially in OA. This age group constitutes a maximum number of seven cases in our study. Rheumatoid arthritis patients require replacement surgery of the knee. Total knee arthroplasty is generally more frequently performed in women as compared to men because degeneration/inflammatory joint disease like rheumatoid arthritis is more common in females than males.^[5],[6],[7]

In our study, women constitute 70% of cases. Generally, total knee arthroplasty is performed for degenerative joint disease of the knee like OA. We found that OA knee has the largest number of group (70%) of the patient for which total knee arthroplasty is done. Among the OA knee, primary/idiopathic OA is responsible for all of cases for which total knee arthroplasty is performed. Total knee arthroplasty is an expensive operation because of the cost of the implant. We found that 60% of cases belong to the upper socioeconomic category, and rest 40% belong to the upper middle category.^[8],[9]

We found that deformity at the knee was varus in all the patients with OA and valgus/normal in all patients with rheumatoid. Usually, patients try to neglect their knee for 10–15 years by taking analgesics and other local measures and it is only through the failure of this modality of treatment that they ultimately agree to total knee replacement. In our eight cases were bilateral total knee arthroplasty, 4 patient whose both knee were successfully replaced. Although the remaining two cases it was the right knee on which total knee arthroplasty done. So we see that the disease of knee for with total knee arthroplasty was performed are, bilateral usually affecting right knee earlier than the left side. Right side being the dominant side is affected fist as the patient subconsciously use the right knee more than left.[10]

The preoperative ROM at the knee was between 51° and 80º in all the cases (100%). But after 6 months postoperatively, all the cases have their range of motion between 91° and 110º. Maximum number of the cases (80%) have moderate continuous pain at the knee before the operation and rest 20% have moderate occasional pain at their knee preoperatively so knee pain is the very important cause for which total knee arthroplasty was performed. Maximum number of cases (90%) have ≥30º increase in their range of motion, after operation, which is a very significant finding. After the operation, maximum number of cases (90%) have no pain or mild occasional pain after operation so pain relief is the most important factor responsible for patient satisfaction postoperatively. The most important cause or morbidity of the patient preoperatively is pain and not deformity or range of motion at the knee. Normal knee pain constitutes 50% of the knee score, so the fall or knee score is maximum contributed by the pain score fall of 78%. After the operation, there is a definition increase in the postoperative knee score which goes on increasing with time. But the rate of increase is maximum just after the operation (initial) 15 days (26.4%).

Similarly, after total knee replacement, there is an increase in postoperative functional knee scores at 6 months (86.5) as compared to preoperative scores (21%). Though there is an initial fall (16.5%) in the functional score in the initial 15 days after the operation, it then starts increasing at 1 month and ultimately at 6 months.

Conclusion

The final conclusion is that total knee arthroplasty should definitely be performed over 60 years of age having pain in the knee not responding to analgesics with or without any significant deformity at the knee. As we found that is no or occasional pain with good range of movement after 6 month of operation so that patient satisfaction level is very high. But a large number of patient and ling follow up is required for long-term result.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

References

1.	Abott LC and Carpenter WF Surgical approach to knee joint. Bone Joint Surg 1945;47A:277-310.
2.	Aglectti P, Buzzi A Posteriorly stabilized total condylar knee replacement. J Bone and Joint Surg 1988;70:211-6.
3.	Andriacchi TP, Galante JO Influence of knee replacement design on walking and stair climbing. J Bone Joint Surg 1982;64A:1328.
4.	Bartel DL, Bicknell VL, Wright TM The effect of conformity, thickness, and materials on stress in ultrahigh molecular weight components for total joint replacement. J Bone Joint Surg 1986;68-A;1041-51,.
5.	Bostrom MP, Bennett AP, Rimnac CM, Wright TM Natural history of ultrahigh molecular weight polyethylene. Clin Orthop 1994;309:20-8.
6.	Bourne MH, Rand JA, Illustrup DM Poseterior cruciate condylat total knee arthroplasty. Clin Orthop 1988;234: 129-36.
7.	Buechel FF, Pappas MJ New Jersey low contact stress knee replacement system: Ten Year evaluation of meniscal bearings. Orthop Clinic North Am 1989;20:147.
8.	Cambell WC Arthroplasty of the knee, a report of cases. J Arthop Surg 1921;9:430.
9.	Catani F, Benedetti MG, De Felice R, Buzzi R, Giannini S, Aglietti P Mobile and fixed bearing total knee prosthesis functional comparison during stair climbing. Clin Biomech (Bristol, Avon) 2003;18:410-8.
10.	Daluga D, Lombardi AV, Mallory TH, Varghan BK Knee manipulation following total knee replacement. J Arthroplasty 1991;6:119.