MID-TERM RESULTS OF

KNEE REPLACEMENT SURGERIES AT

DHIRAJ GENERAL HOSPITAL
(A RURAL TEACHING SETUP)
 

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
 AIMS AND OBJECTIVES

 1. To study the clinical (functional) outcome of

knee joint replacement surgery,.

 2. To study complication rate after knee joint

replacement .

 3. To compare and analyse result with similar

published data from technologically advanced
centres.
 MATERIALS AND METHODS
 Retrospective & Prospective study
 Total knees : 51
 Institute :Dhiraj General Hospital
 Period of study : April 2007 to August 2010

All cases were operated by a

Specialist Surgeon
with a changing surgical team.
INCLUSION CRITERIA :

• Primary and secondary osteoarthritis

• Age > 50 years
• Failed conservative trial
• Severely hampered ADL.

EXCLUSION CRITERIA :

• Recent or active sepsis of the knee.

• Patients with poor limb perfusion and severe
peripheral vascular disease.
PREOPERATIVE EVALUATION
 Thorough history, complete physical examination.
 Subjective assessment of pain on the
Visual Analog Scale (VAS)
 A standardized system for complete evaluation
of knee and patient function was done using
Knee Society Score (KSS)
 X-Rays: Anteroposterior & Lateral radiographs.
(Standing Scannograms of both the lower limbs
for assessment of anatomical and mechanical
axis.)
POST OPERATIVE EVALUATION
 Time taken for wound healing .

 Subjective decrease in pain perception using VAS.

 Quantification of patient and knee function done

using Knee Society Score, preoperatively and at the
end of one year and during the most recent follow up.

 Xrays : AP & Lateral :

(for implant placement and judging any septic or
aseptic loosening.)
 RESULTS
 Total operated cases : 51
 Total Knee Replacements : 43 (84.5%)
Out of which 13 were Bilateral and half of them
were operated simultaneously.
 Uni-condylar Replacements : 8 (15.5%)
 Follow up : Max-2yrs 9 months
Min- 3 months(latest)
Average : 1yr 3 months
Wound healing :
Average 15 days (11- 18 days). There was not a single case of
wound gaping or necrosis.
Pain:
The preoperative average VAS score of 9 reduced to an average
of 2 at the most recent follow up.
Functional Assesment:
Knee Society Score

Preoperatively the mean knee score was 35 and the mean function
score 45. Both scores showed significant improvement at the
end of one year. At the end of the present study the mean knee
score was 93 and the mean function score of 90.
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.
 There was no reoperation required in any of the cases reported in
this short series with medium term follow up for any cause such
as infection or aseptic loosening etc.

100% of the patient were satisfied with the

results of surgery and
rated it good to excellent on subjective outcome
measures.
 DISCUSSION
 Infection following knee arthroplasty or in that case
any replacement surgery has been a dreaded
complication with potentially devastating
consequences . This can be avoided with strict asepsis
code of conduct and proper surgical technique as also
proved 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 all
the 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. RN; Peterson, Margaret PhD: Infection in Total Knee Replacement: A Retrospective Review of 6489 Total
Knee Replacements. Clinical Orthopaedics and Related Research: 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. Risk factors and treatment in sixty-seven cases The Journal of Bone
and Joint Surgery, Vol 72, Issue 6 878-883
 Comparison with other centres
 We assessed the patients both on subjective
wellness and functional and pain scores(KSS
and VAS)
 Subjective satisfaction among the patients
operated is the benchmark for a successful
operation.
 Our figures are in accordance with any other
study 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 knee
replacement: a qualitative study Rheumatology 2005 44(8):1032-1037
 Another study by David Heck 2 year follow up of patients showed 88% satisfaction out of the total enrolled. Heck, David A.; Rebecca
L: Patient outcome after knee replacement. Clinical Orthopaedic and related research. 356():93-110, November 1998
 Comparison with other centres
 We have use standard comparisons like Knee
Society Knee Score and Visual Analog Scale

 Among various knee scores for defining the outcome after total joint replacement surgery, the knee society
score (KSS) has been found to be valid, reliable and responsive, so the selection of this scoring system in this
study 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 221-221
 Improvement in Knee Society Score, confirms the role of knee replacement in functional recovery of the
patient.Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis: A report of two hundred and
twenty cases. JBJS (Am) 1979;61:173-80:Insall J, Scott WN, Ranawat CS. The total condylar knee replacement:
Preliminary report 1976. Clinical Orthopaedic and Related Research july 2001- volume 388- issue-pp 3-6
 UKA versus TIBIAL OSTEOTOMIES
 After HTO, the joint function declines, leading to
accelerated degeneration these degenerated
joints finally require Total Knee Arthroplasty.
 However TKA in patients with previously done
osteotomies are filled with technical difficulties
and poor mid to long term results than primary
TKA
 30% more complication rate in patients who had
revision of failed tibial osteotomy to total knee
replacement than revision of UKA to total knee
arthroplasty.
 UKA versus TIBIAL OSTEOTOMIES
 Patients with bilateral disease can have both knees
operated during the same sitting with full
recovery within three months of surgery following
UKA
 However those who undergo bilateral osteotomies
often have their surgeries spaced from 3 to 6
months apart and as much as a year may be
required for full recovery.

RECENT REFERENCE
Kozinn CS, Marx C Unicompartmental knee arthroplasty.
J.B.J.S. 1989;71A:145-150
 UKA versus TIBIAL OSTEOTOMIES

 High Intial success rate and low complication

rate in UKA than HTO
 Meta-analysis comparing clinical outcomes of
high tibial osteotomy (HTO ) with UKA for
treatment of medial compartment OA reported
greater percentage of good or excellent outcomes
and a strong trend towards improved survivorship
over HTO
 DRAWBACK OF THE STUDY
 Limitation of this study includes a small series
of patients with a short follow up.

 The cost effectiveness of the procedure has not

been touched upon.
 CONCLUSION
 The finding of the present study confirms  that

1. Good results can be replicated in a rural setup

if all the aseptic and surgical precaution are
taken care of .
2. The results are not totally dependent on high
end gadgets and technologies such as laminar
air flow system or space suits.
 Clinical outcomes in knee replacement surgery
is more surgeon skill dependent rather than
technology dependent as proven by excellent
functional scores of our study with all surgeries
being performed by one single surgeon.

Knee replacement surgery is a soft tissue

surgery as suggested by late Prof. Dholakia.
 Such a high end surgery in a rural area marks
the era wherein such procedure could be
brought more close to people wherein the heart
of India resides.

 Following measures as stated may provide

comparable results, though at a reasonable
rate, and thus helping us restore the function of
joint.
THANK YOU