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Alimov Aziz Pulatovich, Azizov Mirhakim Javharovich, Scientific Research Institute of Traumatology and orthopedics, Ministry of Health of the Republic of Uzbekistan E-mail: [email protected]
Endoprosthesis of the knee joint without use of metallic modular blocks in the elderly patients with axial deformations
Abstract: The purpose of this research was to evaluate the results of endoprosthesis of the knee joint without use of modular metal blocks in the elderly patients. It was determined that in the endoprosthesis of the knee joint with defects of the tibial plateau condyles with use of metal modular blocks the positive results may be achieved after endoprosthesis in minor and middle defects of the tibia. In the elderly patients (75-84 years) the cement replacement was preferable, and at the more younger age (61-74 years) the bone autoplasty with additional osteotropic therapy is more rational.
Keywords: knee joint, endoprosthesis, tibial condyle, scales, elderly patients.
Introduction
Stable pain in the knee joint with presence of accompanied diseases at the aged age is the indication to the endoprosthesis, ignoring the principles of the further revision interventions [4; 8].
The use of modular metallic blocks resulted in significant improvement of the knee joint endoprosthesis in the axial deformations. However, use of these constructions in the patients with accompanying osteoporotic bone tissue leads to the early instability of the tibial component. The efforts of the surgeons to save the osseous mass for further revision intervention do not always prove their value, and, on the contrary, shorten the time for early intervention in the elderly patients with this pathology [2; 5; 9; 12; 13; 14; 16; 17; 19].
Introduction of the principle of resection of the tibial plateau along "the bottom of defect" with insertion of the polyethylene inset of the more size at this age resulted in significant improvement of the outcomes of endoprosthesis of the knee joint in this category of patients. At large defects the use of bone plasty taking into account the bone mineral density showed also satisfactory clinical-functional outcomes of the endoprosthesis of the knee joint [1; 5; 8; 10; 20].
The prior type of fixation in the endoprosthesis of the knee joint is cement, which was required for biomechanics of the joint when mutual pulling out of the joint components occurs under the effect of force of the antagonistic muscles [1; 13; 15].
In the elderly age the bone mineral density reduces and use of the endoprosthesis with modular metal blocks induced doubts of fixing stability of the endoprosthesis components.
Purpose ofthis research is the assessment ofthe results ofendo-prosthesis of the knee joint without use of modular metal blocks in the elderly patients with axial deformation of the knee joint.
Materials and methods
In the department of adult orthopedics of the Scientific Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Republic of Uzbekistan in 45 patients (29 women, 16 men; of the minimal age 61 years old, maximal age 84 years old, and average age 67 years old) with axial deformations and defects of the condyles of tibia there were performed endoprosthesis of a knee joint: with autobone plasty in 15, and with cement filling in 30 patients.
The operative intervention was performed by the standard methods. Parapatellar approach was used for dissection of the joint, the pathological changed tissues were removed. After proximal resection of the tibial plateau in determination of the large defect the autograft was created from the intercondylar zone for autograft plasty during figured osteotomy of the distal femur, which after giving the form appropriate to the bed of defect was implanted and fixed with the screw then the endoprosthesis of the joint with cement fixation was carried out. In cases of noted insignificant defect of the condyle after osteotomy of tibial plateau there was made bonesaw-line of the tibial plateau on the bottom of defect. If the defect of condyle still remained, the defect was filling with cement during implantation of the total endoprosthesis of the knee joint after preliminary formation of the anchor holes, in some cases there was performed reinforcement with the screw, then cementation and implantation of the total endoprosthesis was made.
All patient were implanted the total endoprosthesis of the knee joint of firm ("DePuy" and "Zimmer", manufacture of USA) with the posterior stabilizer.
All patients before operative intervention were carried out clinical-roentgenological, laboratory and instrumental methods of research (densitometry, dopplerography).
The clinical examination of the patients was performed by the following estimated scales for a knee joint: Bristol Knee Score [11], Lysholm Knee Scoring Scale [18], Knee-Rating Scale [6; 7]. At performance of researches we used principles of evidence-based medicine.
Results and discussion. The clinical examinations of the patients in 6 months after operation were performed on the basis of
the above-stated estimated scales for a knee joint depending on a kind of replacement of defect.
In a scale Bristol Knee Score 4 categories of parameters — function, pain, amplitude of movements, deformation are estimated. Performance of estimation on this scale is very simple and convenient. At autograft plasty in 9 patients the good outcome (36-40 numbers) was marked, the satisfactory outcome (30-35 numbers) was received in 6 patients. At cement replacement the good outcome on this scale was noted in 19 patients, the satisfactory result was found in 11 patients. The unsatisfactory results were not marked (tab. 1).
At use of Lysholm Knee Scoring Scale 8 categories of parameters — lameness, additional means, blocking of a joint, instability of a joint, pain, slight swelling, walking upstairs, squatting position are estimated.
The researches have shown, that at autografting plasty in 2 patients there was noted excellent outcome (86-100 numbers), in 7 good outcome (71-85 numbers), the satisfactory outcome (30-35 numbers) was received in 5 patients (tab. 2). In the cement plasty excellent result was received in 1 patient good result in 16, satisfactory result in 13 patients, unsatisfactory results were not registered.
Use of Knee-Rating Scale means evaluation of a state of knee joint by 6 categories of parameters — pain, function of legs, amplitude of movements, muscular force, restriction of flexion, instability in a joint.
At autografting plasty in 1patient excellent result was received (85-100 numbers) by this estimated scale, in 8 patients — good results (70-84 numbers), and in 15 patients satisfactory outcome (60-69 numbers). The unsatisfactory results were not noted (tab. 3).
Table 1. - Estimation of endoprosthesis outcome in the patients at the patients of elderly age on a scale of Bristol Knee Score
Method of endoprosthesis plasty of the knee joint Excellent 41-50 numbers Good 36-40 numbers Satisfactory 30-35 numbers Unsatisfactory < 30 numbers
Osseous - 9 6 -
Cement - 19 11 -
Table 2. - Estimation of endoprosthesis outcome in the patients of elderly age on Lysholm Knee Scoring Scale
Method of endoprosthesis Excellent Good Satisfactory Unsatisfactory
plasty of the knee joint 86-100 numbers 71-85 numbers 61-70 numbers < 60 numbers
Osseous 2 7 6 -
Cement 1 16 13 -
Table 3. - Estimation of endoprosthesis outcome in the patients of elderly age on Knee-Rating Scale
Method of endoprosthesis Excellent Good Satisfactory Unsatisfactory
plasty of the knee joint 85-100 numbers 70-84 numbers 60-69 numbers < 60 numbers
Osseous 1 8 6 -
Cement 1 14 15 -
At observation of all patients in 1 year after operation the clinical results were evaluated as excellent in 1 patient with bone plasty and in 1 with patient with cement plasty, in the rest cases the good and satisfactory outcomes were marked.
The comparative parameters show, that in relation to informa-tivity and reliability, the values of knee joint after endoprosthesis with regard to simplicity of use, availability and clinical efficiency, obtained by these scales, practically did not differ among themselves. Even by the results received between them the reliable differences did not observe, though some stable results at the same time were received more often while using Bristol Knee Score.
Besides we establish some insignificant features of advantage of the Bristol Knee Score in relation to other scales: firstly, for estimation of a knee joint of the patient not enough time is spent; secondly, the
partial load mode for the patients is chosen at the estimation; thirdly,
the subtracted numbers are absent, which complicate account; in
fourth, the estimated tests are very simple, are accessible, does not require high qualification and special preparation of the doctor.
In this connection, at the estimation of a knee joint after endo-prosthesis we recommend to use all estimated scales, described by us, but preference we give to scale Bristol Knee Score.
The long-term results show, that expressed muscle imbalance was available for 1 patient, which was shown by discomfort in a joint. After physiotherapeutic procedures. The complex of physical exercises for strengthening and relaxation of the muscle groups this feeling has decreased.
On the roentgenogram there was defined osteosclerosis around cement mantle of endoprostesis. On a place of osteoimpactionn
there was present union of the autobone with plateau of the tibia in the patients ofyounger age (61-68 years). In a zone of osteosclerosis there was observed the signs of lysis with displacement of femur component in anterior-posterior and lateral directions to 2.0 mm., of the tibial component in anterior-posterior also up to 2.0 mm., above a zone of cement mantle in the persons of the senior age category (70-84 years). These patients were carried out the course of osteotropic treatment, and then the sensations of discomfort have disappeared.
Densitometric parameters allowed identification of osteopenia in the peripheral segments of a skeleton, and dopplerographic investigations showed decrease in blood flow in the veins of the both ankle joints.
As illustrations we present cases of the successful total endoprosthesis of knee joint.
Patient of 84-year-old has admitted to the clinic with the complaints on pains in both knee joints more on the right side, deformation, damage of the support of the ankle joint. There was revealed bilateral gonarthrosis of the III degree, flexion contracture of the right knee joint, varus deformation. In 2014 there was performed total endoprosthesis of the right knee joint with implants for knee «DePuy», the defect internal condyle was eliminated by sawing of the tibial plateau on the bottom of defect with bone auto-grafting plus screw fixation. The postoperative period was smooth, with wound primary adhesion. The patient was discharged from the clinic in 2 weeks after operation. At discharge there were no pains in the knee joint, the extremity axis is restored, contracture in the knee joint is eliminated, the flexion has increased up to 90°. At survey in 6 months later complaints was absent, the gait was independent (fig. 1).
a b c d
Fig. 1. Roentgenograms of the right knee joint of the patient ^ G. Before treatment (a, b) and after treatment (c, d)
The patient P. M., of 66-year-old, during 15 years suffer from rheumatoid arthritis, has admitted to he clinic with the complaints to sharp pains in both knee joints more on the left side, deformation, damage of the extremity support. There was diagnosed left-hand gonarthrosis of III degree with defect of internal condyle, varus deformation. In 2013 there was made total endoprosthesis of the left knee joint with implant of firm "DePuy" with replacement
of a zone of defect by cement with formation of anchor aperture (fig. 2). Postoperative period was smooth, with the wound of primary adhesion. The patient was discharged in 2 weeks after operation. At discharge the pains were absent in the knee, the axis of extremity was restored, flexion achieved 90°.
At survey in 6 months after the complaints were absent, gait was independent, osteolysis around the cement mantle was not found.
b
Fig. 2. Roentgenograms of the left knee joint of the patient Р. М. Before treatment (a) and after treatment (b, c)
a
c
Conclusions: 3. The cement replacement in minor and middle defective zones
1. In elderly age in endoprosthesis of the knee joint with of condyles provides sufficient stable fixation of implant. defects of tibial plateau condyles without application 4. The bone autoplasty of the tibial plateau resulted in its union of metal modular blocks, the successive positive results with tibial plateau, and in a zone of osteosclerosis there was may be achieved in miner and middle defects of the tibial found lysis of the bone tissue around cement mantle of the condyles. total endoprosthesis of the knee joint.
2. In the patients of elderly age (75-84 years) the cement re- 5. The comparative analysis of the clinical assessment of the replacement is more preferable, in younger age (61-74 years) sults of the endoprosthesis of the knee joint showed that it is the bone autoplasty with additional osteotropic therapy. more preferable to use an estimated scale Bristol Knee Score.
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