My Orthopedic Surgery

The Knee Society rating system was first promulgated during the late 1980's and has become the standard clinical evaluation system for reporting results for patients undergoing Total Knee Replacement. Most major journals strongly encourage that total knee manuscripts include Knee Society rating scores as part of the result section. The Knee Society System was a logical outgrowth of the Hospital for Special Surgery (HSS) Rating system of the 1970's. The HSS system, although widely used, combined an evaluation of both the operated knee and the patient's general function in one score. This at times was problematic. If a patient had no pain and excellent range of motion, however could not walk because of arthritis in the other leg, or from a chronic medical problem, the total score was artificially low. The Knee Society System separates findings in the operated knee with findings in the patient's function. As such the Knee Score is not artificially affected by comorbid conditions. The Knee Score consists of points given for pain, range of motion, and stability in both the coronal and sagittal planes, with deductions for fixed deformity, and extensor lag. The Function Score consists of points given for the ability to walk on level surfaces, and the ability to ascend and descend stairs, with deductions for the use of external supporting devices. The Knee Society Score is usually reported as the two scores, Knee Score and Function Score, rather than a summation score. There is, as well, a Knee Society Radiographic Evaluation system, however discrete points are not given for individual parameters on X Rays. Richard S. Laskin, MD

Edward T. Habermann, MD, Lester S. Borden, MD, FACS Anthony K. Hedley, MD, FRCS, David S. Hungerford, MD Kenneth A. Krackow, MD
Abstract: This retrospective study reviewed the results of 3,218 total knee arthroplasty cases using one total knee replacement system at five centers from July 1991 to October 1997. Cases were reviewed to determine the occurrence of patellar related complications post-operatively. Events reported included patellar dislocation/subluxation, patellar fracture, component loosening and tendon rupture. The rates were noted to be low in comparison to literature reports of other series. The overall patellar related complication rate was 0.3% (11/3218) for the cases reviewed. Given the historically high rates of patellofemoral complications reported in the literature, this review has shown that good design of the implant helps reduce patellar related problems in total knee arthroplasty patients.

Archive Copy - 1999 Annual Meeting Scientific Program. Avoidance and Treatment of Complications Primary and Revision Total Knee Arthroplasty
The following outlines cover the subjects of preoperative planning, managing skin and wound complications, fractures, extensor mechanism problems, and the management of stiffness.

This chapter presents aspects of the anatomy and kinematics of the knee as they specifically relate to total knee arthroplasty. It is not intended to be an encyclopedic presentation replacing various anatomy texts or other articles on these topics. In fact, it is suggested that this material be read while simultaneously reviewing a standard anatomy text or atlas (2, 8). The anatomic features are discussed as they relate to surgical exposure, and as they define certain features of rotational alignment. In addition, structures involved in soft tissue balancing when correcting varus or valgus deformity are discussed, and the implications of extraordinary bone cuts on subsequent ligament balance are addressed. Last, the fine details of normal joint contours are presented followed by descriptions of the complex kinematic patterns of the normal bone.

Aspirin may be the most effective choice to prevent pulmonary embolism (PE) and venous thromboembolism (VTE) in patients undergoing orthopaedic surgery, according to a new study examining a potential role for aspirin in these patients. Aspirin is not currently recommended by the American College of Chest Physicians to help prevent deep vein thrombosis (DVT) after surgery. The American Academy of Orthopaedic Surgeons (AAOS), however, has developed separate guidelines to prevent PE and VTE that are more clinically relevant to orthopaedic surgeons. The AAOS guidelines recommend aspirin to prevent PE and VTE in patients with a low risk of DVT or a higher risk of bleeding.

Study Objectives. To compare opioid requirements in opioid-tolerant and opioid-naïve patients after total knee arthroplasty, and to compare pain scores, sedation scores, and adverse effects between the groups.
Conclusion. After total knee arthroplasty, patients tolerant to opioids required significantly more opioids in the PACU and up to 48 hours after discharge from the PACU than did opioid-naïve patients. Opioid-tolerant patients also experienced greater pain during the first 24 hours after discharge from the PACU; however, sedation scores and adverse effects did not appear to be significantly different at any of the time periods studied. Clinicians need to be aggressive with pain management immediately after surgery and ensure that patients restart any opioid treatment at home as soon as possible.
Asad E. Patanwala, Pharm.D.; Donna L. Jarzyna, R.N., M.S.; Michael D. Miller, M.D.; Brian L. Erstad, Pharm.D Pharmacotherapy. 2008;28(12):1453-1460.

Total knee replacement has become an acceptable method of treating severe arthritis of the knee. The operative procedure must be performed with precise skill and accuracy. Meticulous alignment of the prosthetic components can reduce many of the complications.
Fine attention to general operating technique with adroit handling of tissues and efficient teamwork can reduce operating time to a minimum and thus avoid exposing the wound for an inordinate amount of time. An experienced efficient technique also aids in preventing deep venous thrombosis, unnecessary scarring, and decreases many of the complications that are associated with total knee arthroplasty.
Complications can be classified as those specific to the operation, general complications of the anesthetic (perioperative complications), and other medical complications (postoperative complications).
Synonyms and related keywords: total knee replacement, knee arthritis, deep venous thrombosis, deep vein thrombosis, DVT, knee infection
Author: Mervyn J Cross, MBBS, FRACS 2004

Comprehensive surgeon/author interview Advantages and disadvantages of bone grafts in total knee arthroplasty Conservative treatment: benefits and risks Indications and contraindications Goal for filling tibial and femoral bone defects Consequence of bone loss on the femur Neural and vascular anatomic review Cemented, cementless and hybrid fixation options Selecting the appropriate stem length Postoperative protocol Review of complications

Intrathecal (IT) morphine provides excellent post-operative analgesia, but causes multiple side effects including nausea and vomiting (PONV), pruritus and respiratory depression, particularly at higher doses. The lowest effective dose of spinal morphine in patients undergoing total knee arthroplasty is not known.
We evaluated the analgesic efficacy and side effect profile of 100 - 300mcg IT morphine in patients undergoing elective total knee replacement in this prospective, randomized, controlled, double-blind study.
Both 200mcg and 300mcg provided comparable postoperative analgesia, which was superior to that provided by 100mcg IT morphine in patients undergoing total knee arthroplasty. Based on these findings, we recommend that 200mcg IT morphine be used in these patients.
Patrick Hassett , Bilal Ansari , Pachaimuthu Gnanamoorthy , Brian Kinirons and John G Laffey BMC Anesthesiology 2008, 8:5 Full text available

Clinical Follow up and survivorship analysis from the Royal Orthopaedic Hospital, Stanmore, UK Full Text JBJS B 69: 2; 276

Surgical Technique Monograph
This publication sets forth procedural highlights for using Howmedica devices and instruments. It offers guidance that you should heed, but, as with any such technical guide, each surgeon must consider the particular needs of each patient and make appropriate adjustments when and as required. The surgeon can refer to other Duracon publications for a more detailed description of the surgical technique.

by D.W. LENNOX, L.H. RILEY Jr, D.S. HUNGERFORD, M.A. JACOBS, Th. JUDET and K.A. KRACKOW In: Atlas of Orthopaedic Surgery Volume 3 1991
Procedures covered include Synovectomy of the knee, Total Knee Replacement (TKR), Revision Knee Arthroplasty, Distraction Arthroplasty, Arthrodesis of the knee,

Presentation by D Hungerford

In reconstructing historical data, I have tried to clarify as much as possible the issues where no published data exists, or the contributors themselves are unable to verify the information. Wherever appropriate, references are provided for the reader’s edification. In formulating this history, I am aware that issues or persons may conceivably have been omitted. Perhaps I was not given the information; or I could not confirm the information in the literature; or the information was controversial. In the end, however, I, as narrator and compiler, must assume all responsibility for the contents herein, and I apologize for any errors or omissions. Each topic is listed with the significant contributors, design features, and year of contribution, acknowledging, whenever possible, unpublished documentation and records.
Chitranjan S. Ranawat, M.D. Lenox Hill Hospital Center for Total Joint Replacement New York, NY 10021

Abstract Yong et al Annals of Rheumatic Diseases 2004