KNEE REPLACEMENT IN RECURVATUM KNEE.pptx

Knee replacement in a recurvatum deformity is one of the most challenging scenarios. This uncommon surgery is based on a few simple principles which are explained in this ppt. Hyperextension can be a part of neurological disorder, primary ligament laxity, mal-alignment around the joint, post traumatic conditions etc. a careful dissection and minimal bone cuts are essential points in this surgery. Contrary to regular principle we end up stuffing the joint to balance the posterior capsular hammock.
Hope this ppt helps you with your surgery planning.

1. TKR in GENU-RECURVATUM Dr. Vignesh karthik RM MBBS., D.Orth ., DNB Orth FIJR - AJRI, SIAA Consultant Orthopaedic & Joint Reconstruction Surgeon SPMM Hospital, Salem

2. Genu Recurvatum Tibio-femoral joint extension beyond the 0 degree Incidence of >5 o hyperextension in patients presenting for TKA is 0.5-1%

3. Factors Causing Genu Recurvatum Laxity of the knee ligaments Muscle Weakness Biceps femoris muscle Hip extensor muscles Gastrocnemius muscle Popliteus muscle weakness Malalignment of the tibia and femur as in malunion Instability of the knee joint due to ligaments and joint capsule injuries Deficit in joint proprioception Lower limb length discrepancy

4. Conditions Associated With Knee Recurvatum Neurological Spastic lesions Lower motor neuron lesions like Polio Cerebral palsy Multiple sclerosis Congenital Congenital genu recurvatum Muscular dystrophy Arthrogryposis multiplex congenita Congenital knee dislocation Connective tissue disorders Marfan syndrome Ehlers-Danlos syndrome Benign hypermobile joint syndrome Osteogenesis imperfecta disease

5. Conditions Associated With Knee Recurvatum Non- neurological Rheumatoid arthritis Osteoarthritis Failed High tibial Osteotomy Post traumatic Osgood-Schlatter disease Tibial proximal growth plate injury Early tibial physeal closure Plantar flexion contracture Lower Limb length discrepancy Mullaji A, Lingaraju AP, Shetty GM. Computer-assisted total knee replacement in patients with arthritis and a recurvatum deformity. J Bone Joint Surg [Br] 2012;94- B:642–647.

6. Pathoanatomy

7. PATHO ANATOMY Soft tissue: The posterior capsule is usually overstretched Attenuation of the cruciate and collateral ligaments. Posterior soft-tissue structures of the knee joint into a “hammock”

8. With the collateral ligaments intact The distance ‘a’ from ligamentous attachments to the joint surface is shorter than the posterior femoral distance ‘b’. This allows the tibia to pass the midline into hyperextension before the collateral ligaments and posterior capsule are tightened

9. PATHOANATOMY Valgus Deformity SOFT TISSUE IT band :Contracture, anterior placement Cruciate and collateral laxity BONE Hypoplastic lateral femoral condyle

10. PATHOANATOMY Varus deformity Wear starts in antero-medial tibia, With rupture of ACL the femur loads on the postero-medial tibial plateau Gradually leading to hyper extension deformity

11. PATHOANATOMY C Failed HTO BONE Non union / malunion Anterior collapse at the osteotomy Anterior slope of Tibia

12. Quadriceps avoidance gait Chronic patellar pain /previous patellectomy/ obese patients/ nm disorder May adopt a stiff legged gait Pushing the knee backwards during walking to avoid an excessive load on patella Hence stretching the posterior capsule and creating progressive hyperextension

13. NEUROLOGICAL CAUSE Eg: Polio Quadriceps weakness Hand to knee gait Preferential locking of knee in hyper-extension Posterior capsule and ligament stretching Compensatory - hip extension and plantar flexion deformity accentuate the problem.

14. Problems To be Dealt with LARGE EXTENSION GAP Vs Small flexion gap

15. PER OPERATIVE PLANNING

16. PER OPERATIVE PLANNING Pain Expected function Life expectancy Degree of OA Risk of complications

17. Understanding the cause is paramount in treating successfully. Planning should include: Gait analysis( leg length discrepancy, status of adjacent joint, equines of ankle or foot) Radiological examination - AP/LAT scanogram + regular X-rays Degree of recurvatum is assessed & whether combined with medial / lateral instability. contd….

18. 4. Reducibility of valgus/varus deformity 5. Pre surgical range of movement. 6. Muscle charting of Quadriceps, Hamstring, Gastrocnemius. 7. Patellar tracking 8. Torsional deformity identification

19. Radiographic evaluation Recurvatum + Valgus = hypoplasia of lateral femoral condyle Recurvatum + Varus = anterior tibial wear Sagittal plane : Metaphyseal area of tibia and femur, Tibial slope and tibial tubercle —> often dysplastic. Medullary canal morphology to accept stem. Bony deformity affecting FEMUR/TIBIA

20. Extra articular deformity of proximal tibia with inversion of tibial slope.

21. Surgical Technique

22. SURGICAL TECHNIQUE DESCRIBED TECHNIQUES: INSALL: UNDER RESECTION OF BONE ENDS AND USING A THICKER FEMORAL OR TIBIAL COMPONENT WHITESIDE & MIKHALO: DOWN SIZING FEMORAL COMPONENT, when in-between sizes, which allows for under resection of tibia, improved stability in extension. KRACKOW& WEISS : POSTERIOR CAPSULE PLICATION AND PROXIMAL & POSTERIOR TRANSFER OF COLLATERAL LIGAMENTS Problem : EXCESSIVELY LARGE EXTENSION GAP COMPARED TO FLEXION GAP.

23. FEMORAL SIDE Distal femur cut : Less than the implant thickness Femoral component of the smaller size should be used while in between sizes. After posterior condylar resection, osteophytes should be removed to accommodate deep flexion, POSTERIOR CAPSULE SHOULD NOT BE RELEASED.

24. Under resect the distal femur Over resect the posterior femur - increase flexion space Posterior slope of tibia to enlarge the flexion and narrow the extension

25. TIBIAL SIDE Bone cut should be minimised Slope can be slightly increased to facilitate balance of flexion/ extension gap Sacrificing the PCL will increase the flexion gap An extra articular deformity of proximal tibia with inversion of tibial slope = tibial resection upto 15 0 . If more —> simultaneous corrective osteotomy Wang JW, Chen WS, Lin PC, Hsu CS, Wang CJ. Total knee replacement with intra-articular resection of bone after malunion of a femoral fracture: can sagittal angulation be corrected? J Bone Joint Surg [Br] 2010;92-B:1392–1396.

26. Surgical Technique In severe cases recurvatum >20 degrees Distal femoral augmentation or rotating hinge devices with built in stop to hyperextension are required.

27. Surgical technique Nm disorders/ extensor mech weakness TKR WAS CONTRA-INDICATED If done ->Hinge prosthesis should be used: However these are the patients who can walk with locking their knee and hence joint which allow few degrees of hyperextension should be preferred in those cases. Increased stress transfer to the fixation interface and subsequent loosening With recent rotating hinge prosthesis, more physiological kinematics and better distribution of shearing forces are giving encouraging results.

28. Post operative protocol FWB walking, active knee bending from POD1 Quadriceps strengthening exercises Pillow underneath the knee for 2 weeks to allow tightening of posterior capsule. Cases with severe recurvatum - long leg knee brace while walking for 2 weeks

29. Studies & Observations

30. Study Mending et al: (57 CRtkr, Mean 11 degree, well functioning extensor mechanism) No significant relationship between the pre-op recurvatum and soft tissue release. Joint line was elevated by 0.6mm in 38 knees, 2-5mm in 15 knees and lowered by 2-3mm in 4 knees. Correction was achieved without use of thicker poly insert/ collateral transfer. At average 4.5 years follow up —> only 2 knees had 10 degrees hyper extension deformity. Average extension was 0 degree.

31. Gene recurvatum in total knee arthopalsty + 1 Bayers-Thering, M; 1,2 Krackow KA; 1,2 McGrath; BE; 1,2 Phillips, MJ 1 Kaleida Health, 2 State University of New York at Buffalo [email protected] Used CAS 1201 CONSECUTIVE TKR, Retrospective review 151 cases(12.6%) had recurvatum 0.5 to 30 degree with mean of 5 degree. >/= 5 degree - 33; only 2 patients had pre operative recurvatum 62.3% varus, 36.4% valgus, 2 patients with neutral OA in 92% Study All cases received “ UNDER-RESECTION OF FEMUR AND CORRECTION IN CORONAL PLANE” NO RECURRENCE AT 4 YEARS.

32. Study HYPOTHESIS : recurvatum can be treated by implant positioning without resorting to constrained implants. PROTOCOL : the smaller femoral size was chosen to enlarge the flexion space, allowing under-resection of the tibia to stabilize the knee in extension. The cutting guides were positioned so that 3 to 5 mm less than the distal thickness of the femoral component was removed to stabilize the knee in extension.

33. Study Distal femoral augments not used. Mean ffd at 1 month post op was 6.3+/- 1. Mean ffd at 2 years post op was 0.5+/-0.3 No recurrence of recurvatum. No hinged implants used.

34. Study Mullaji et al 45 tkr , CAS, at 26.4 months follow-up (13-48) PS prosthesis Mean pre op recurvatum 11 degrees, well functioning extensor mechanism. Excellent results with no recurrence of deformity

35. Jordan et al. Largest series on TKA in patients with poliomyelitis. 17 TKAs: 8 semi const, 8 PS, with only one hinge prosthesis Had no loosening or recurrence at mean follow-up of 41.5 months. Just two cases had a muscle power less than 3/5 & 2 =3/5. Study

36. Giori and Lewallen Functional deterioration and recurrence of hyperextension instability occur when quadriceps strength is less than antigravity. Tigani et al. Excellent results using rotating-hinge implants in ten TKAs at a mean follow-up of 4 years. (1-PS; 2- CCK; 7RHK) - One CCK needed revision due to recurrence. The RHK which allowed hyperextension was suitable for treatment of patients with knee OA and polio for loss of quadriceps power Study

37. Hyperextension Deformity (examined under Anaesthesia) Associated RIGID varus/valgus Deformity Associated CORRECTIBLE varus/valgus Deformity UNSTABLE Knee Preliminary medial/lateral soft-tissue Release No release Preliminary medial/lateral soft-tissue Release Preliminary medial/lateral soft-tissue Release No release Preliminary medial/lateral soft-tissue Release Preliminary medial/lateral soft-tissue Release 6-8 mm tibial And femoral Bone resection 6-8 mm tibial And femoral Bone resection 4-6 mm tibial And femoral Bone resection Graduated medial/lateral release with/without epicondylar osteotomy Undersize the femur Or constrained implant

38. Conclusion Genu recurvatum is no more a contraindication for TKA, Etiology should be elucidated. In the absence of neuromuscular disease, hyperextension deformities tend not to recur after surgery, if adequate gap balancing technique is performed. Quadriceps strength is compromised —>rotating- hinge prosthesis (slight hyperex - tension is needed for those who can be able to walk)

39. References Barrack RL. Evolution of the rotating hinge for complex total knee arthroplasty. Clin Orthop . 2001;392:292–9. Giori NJ, Lewallen DG. Total knee arthroplasty in limbs affected by poliomyelitis. J Bone Joint Surg. 2002;84A:1157–61. Insall JN. Surgical techniques and instrumentation in total knee arthroplasty. In: Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P, editors. Surgery of the knee. New York: Churchill Livingstone; 1993. p. 739–804. Insall JN, Haas SB. Complications of total knee arthroplasty. In: Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P, editors. Surgery of the knee. New York: Churchill Livingstone; 1993. p. 891–934 Jordan L, Kligman M, Sculco TP. Total knee arthroplasty in patients with poliomyelitis. J Arthroplasty. 2007;22:543–8. Krackow KA, Weiss AP. Recurvatum deformity complicating performance of total knee arthroplasty: a brief note. J Bone Joint Surg. 1990;72A:268–71. Krackow KA. The technique of total knee arthroplasty. CV Mosby: St Louis; 1990. Lombardi AV, Berend KR. Recurvatum/ exion contracture in total knee arthroplasty. In:Advanced reconstruction knee, vol. 22. Rosemont: AAOS; 2011. p. 189–97.

40. Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME. Total knee replacement in patients with genu recurvatum. Clin Orthop . 2001;393:244–9. Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME. Genu recurvatum in total knee replacement. Clin Orthop . 2003;416:64–7. Mullaji A, Lingaraju AP, Shetty GM. Computer-assisted total knee replacement in patients with arthritis and a recurvatum deformity. J Bone Joint Surg Br. 2012;94-B:642–7. Patterson BM, Insall JN. Surgical management if gonarthrosis in patients with poliomyelitis. J Arthroplasty. 1992;(Suppl)7:419–26. Petrou G, Petrou H, Tilkeridis C, Stavrakis T, Kapetsis T, Kremmidas N, Gavras M. Medium- term results with a primary cemented rotating-hinge total knee replacement. A 7- to15-year follow-up. J Bone Joint Surg Br. 2004;86(6):813–7. Tew M, Forster IW. Effect of knee replacement on exion deformity. J Bone Joint Surg. 1987;69B3:395–9. Tigani D, Fosco M, Amendola L, Boriani L. Total knee arthroplasty in patients with poliomy - elitis . Knee. 2009;16:501–6. Westrich GH, Mollano AV, Sculco TP, Buly RL, Laskin RS, Windsor R. Rotating hinge total knee arthroplasty in severely affected knees. Clin Orthop . 2000;379:195–208. Whiteside LA, Mihalko WM. Surgical procedure for exion contracture and recurvatum in total knee arthroplasty. Clin Orthop Relat Res. 2002;404:189–95. References

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