1. M. Mardani Kivi MD. Guilan University of Medical Sciences 2.

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In the name of GOD

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Kneeling ability after total knee replacement in patients

with osteoarthritis of the knee

M. Mardani Kivi MD.Guilan University of Medical Sciences

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RASHT

KISH ISLAND

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Poursina Hospital

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40% of the population over 70 years of age suffers from osteoarthritis of the knee and by the year 2020 this figure is expected to rise by 66-100%.

Osteoarthritis

Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology 2007; 46: 1445-9.

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over 500,000 TKAs being performed, on average, in the United States annually.

Total Knee Arthroplasty

a major advance in the treatment of DJD

excellent restoration of joint function

pain relief

low perioperative morbidity

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In 2001, 171,335 primary TKAs were performed.

Demand for primary TKA is projected to grow in the USA to 3.48 million procedures by 2030.

By 2015, medical expenses for this procedure in the United States are calculated to increase to a staggering $40.8 billion.

Total Knee Arthroplasty

Kurtz S, Ong K, Lau E et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780–785.

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Kneeling

May cause Increased prostheses

wearing

May cause increased functional

outcome after TKA

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Most of the functional scoring systems quoted in literature use pain, the ability to walk or to ascend and descend stairs, the use of a walking aid, etc. as measurements of outcome. The ability to kneel is often ignored.

Kneeling

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The lack of literature addressing the specific concerns of a large percentage of our Iranian patients with their particular cultural habits, regarding the capacity to which they will be able to kneel post-operatively, has motivated us to investigate: “kneeling ability after TKA in patients with OA of the knee.”

Aim of the Study

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Methods and Materials:

Exclusion criteria: simultaneous OA of the hip and/or lumbar spine, Incomplete patient charts and/or

questionnaires, and TKA performed by other surgeons

Inclusion criteria: clinical diagnose of Ant-lat impingement synd. ,

Design: cross-sectional longitudinal study

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Methods and Materials:prostheses type: Zimmer(NexGen) or Stryker (Scorpio NRG)

Approach: midline

Medial parapatellar arthrotomy

No resurfacing of the patella

PCL substituting prosthesis

Femoral cut: in 3° of ext. rotation

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Variables:

Knee Society Score (KSS)

Functional Knee Score (FKS)

Visual Analogue Scale (VAS)

Kneeling ability: to kneel on a soft flat surface

Variables were assessed 3 times: pre-op, one year post-op, and during the final follow-up visit.

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Kneeling

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Kneeling

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Post operatively along with Physiotherapy, which included a special program for knee flexion, patients were also encouraged to kneel vigorously and frequently.

Post-op Rehabilitation

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Group A and B were analyzed for changes in kneeling ability.

Pre-op Kneeling ability :

Group (A): patients without pain or with mild pain (VAS: 0-4).

Group (B): patients that because of severe knee pain could not kneel (VAS: 5-10).

Group (C): patients that because of non-related knee pain, could not kneel.

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Total patient population:144114 were possible to follow-up

Mean age: 67.9±6.2 years (range:52 to 81) Sex: 69 female (60.5%), 45 male (39.5%) Mean follow-up length: 26.7±2.4 months

(Range:14 to 44)

Results:

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Scoring:

Score Pre-op 1-year f/up Final f/up P-value

VAS 9.24 ± 0.7 1.82 ± 1.04 2.01 ± 1.19 p<0.0001

KSS 59.79 ± 4.54 89.07 ± 5.63 89.82 ± 5.11 p<0.0001

FKS 59.57 ± 4.48 87.72 ± 5.21 88.23 ± 5.36 p<0.0001

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Kneeling results:

Total patient population

N=114

Pt's able to kneel pre-op: 38 (33.3%) Pt's unable to kneel

pre-op: 76 (66.7%)

Due to knee related problem: 59 (77.6%)

Able to kneel at final f/up: 43 (71.2%)

Unable to kneel at final f/up: 17 (28.8%)

Due to non-related knee problem:17 (22.4%)

Post-op

Pre-op

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Complications:

• such as infection, wound dehiscence, loosening of the skin around prosthesis, etc

No surgical complications

No revision required at the final f/up

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Similar to other studies, Our study showed a statistically significant improvement in functional outcome (KSS, FKS) and pain relief (VAS) after TKA.◦ Ahmad Hafiz et al, 2011◦ Tahmasebi et al, 2009 ◦ Dierick et al, 2004

Discussion:

Dierick F, Avenière T, Cossement M, Poilvache P, Lobet S, Detrembleur C. Outcome assessment in osteoarthritic patients undergoing total knee arthroplasty. Acta Orthop. Belg 2004; 70: 38-45.Tahmasebi MN, Motaghi A, Shahrezaee M. Total Knee Arthroplasty in patients with osteoarthritis: Results of 34 operations. Tehran university medical Journal 2009; 67(2): 146-150.Ahmad Hafiz Z, Masbah O, Ruslan G. Total Knee Replacement: 12 Years Retrospective Review and Experience. Malaysian Orthopaedic Journal 2011; 5 (1):34-9.

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Kneeling after TKA

Surgical technique

Prosthesis type

Cultural differences

OA or RA

misinformation about kneeling

Factors affecting kneeling after TKA:

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A meta-analysis using results from 130 studies:

Although more recent studies have shown data to be more in favor of PCL substituting prostheses.

Kneeling and prosthesis type

knee flexion after TKA

a PCL retaining prosthesis 107°

a PCL substituting prosthesis 103°

Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tri-compartmental total knee replacement. A meta-analysis. JAMA 1994; 271:1349–57.

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Kneeling and surgical techniqueFactors that may negatively influence

a patient’s ability to kneel after TKA

Tightness of the retained PCL

Elevation of the joint line

Increase in patellar thickness

Trapezoidal flexion gap

Chiu KY, Ng TP, Tang WM, Yau WP. Review article: Knee flexion after total knee arthroplasty. Journal of Orthopaedic Surgery 2002: 10(2): 194–202.

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Yoshino et al. : The ‘unintentional’ passive flexion exercise imparted by the Japanese sitting-style appears to be important in achieving and maintaining full knee flexion after TKA.

In Iran: eating traditionally on the ground and praying

Kneeling and cultural differences:

Yoshino S, Nakamura H, Shiga H, Ishiuchi N. Recovery of full flexion after total knee replacement in rheumatoid arthritis—a follow-up study. Int Orthop 1997;21:98–100.

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No study has supported that kneeling repetitively may damage knee prostheses.

Palmer et al. (2002)

Kneeling and misinformation:

Palmer SH, Servant CT, Maguire J, Parish EN, Cross MJ. Ability to kneel after total knee replacement. J Bone Joint Surg [Br] 2002; 84-B: 220-2.

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Radiographic study has shown that forces exerted from the femur to knee joint:


At the time of kneeling

While normal

standing or during walking


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Schai et al. and Palmer et al. showed that kneeling ability, when measured objectively, is greater than when measured subjectively after TKA.


Schai PA, Gibbbon AJ, Scott RD. Kneeling ability after total knee arthroplasty. Clin Orthop 1999; 367:195-200.


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Jenkins et al. (2008) a single-blind randomized controlled trial The improvement in patient-reported kneeling ability was thought to be due to the kneeling intervention provided and not to any of the previously reported barriers to kneeling such as scar position, numbness, range of flexion, involvement of other joints, and pain.


Jenkins C, Barker KL, Pandit H, Dodd CAF, Murray DW. After partial knee replacement, patients can kneel, but they need to be taught to do so: A single-blind randomized controlled trial. Phys Ther 2008; 88: 1012–21.

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A 68 Y/O Female

DJD

Radiographic Shopping

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There is no need to prohibit patients from Kneeling after Total Knee Replacement.

Take home message:

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With Regards

1. M. Mardani Kivi MD. Guilan University of Medical Sciences 2.

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