Total Knee Arthroplasty and Parkinson Disease: Enhancing Outcomes and Avoiding Complications

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Total Knee Arthroplasty and Parkinson Disease
Enhancing Outcomes and Avoiding Complications

• Macaulay W, Geller JA, Brown AR, Cote LJ, Kiernan
  HA

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Introduction I

• PD is the second most common neurodegenerative
  disorder after Alzheimer disease
• USA Australia World
• 0.3 population
• 1-2 persons 65 yrs 3-6-4.9 1.8
• 4-5 persons gt 85 yrs 2.6
• TKR outcome has proved a challenge in PD
• Musculoskeletal Rigidity
• Tremor
• Contracture
• Gait Instability

Chan DK, Dunne M, Wong A, Hu E, Hung WT Beran
RG 2001. Pilot study of prevalence of Parkinsons
disease in Australia. Neuroepidemiology 20
112-7 de Rijk MC et al (2000). Prevalence of
Parkinsons disease in Europe a collaborative
study of population-based cohorts. Neurology
54(Suppl)
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Introduction II

• integrative, systematic, multidisciplinary
  approach to patients with PD undergoing TKR
• the lack of evidence-based medicine and overall
  paucity of published studies severely limits
  review of this topic.

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Parkinson Disease Pathophysiology

• Idiopathic
• Secondary medications, toxins, environmental
  factors
• herbicide/ pesticide/ chemical exposure, FHx,
  smoking, tea drinking, high cholesterol
• Disease optimisation can be difficult due to
  idiopathic nature.
• Loss of dopaminergic neurons in the substantia
  nigra
• no dopamine
• no regulation of excitatory and inhibitory
  outflow from basal ganglia
• disturbance of motor pathways

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Parkinson Disease Severity Rating Scales

• Unified Parkinsons Disease Rating Scale
  mentation, behaviour, mood, motor ability, ADLs,
  therapy complications
• Schwab and England Scale
• Modified Hoehn and Yahr Scale

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TKA and Parkinson Disease

• TKR is less successful in PD than in typical
  patients with OA
• Oni MacKenny (1985)
• 3 patients, 2 ruptured quadriceps tendons, all
  died within 24 weeks.
• Vince et al. (1989)
• 9 patients, 13 TKRs, 4.3 yr follow up, all HK
  1-3.
• Duffy Trousedale (1996)
• 24 patients, 33 TKRs, 33 month follow up,
  achieved pain relief but not functional status
• Erceg Maricevic (2000)
• Case report, recurrent posterior dislocation
  requiring revision
• Shah et al. (2005)
• Case report, diabetic coma, UTI, recalcitrant
  flexion contracture, 2200 U botulinum toxin type
  A into biceps femoris and semitendinosis, and
  subsequently gastrocnaemius, with greatly
  increased ROM

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TKA and Parkinson Disease

• Recurring Themes
• Extensor mechanism problems
• Wound necrosis
• Post-operative confusion
• Limited functional improvement

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Avoiding Early Complications

• Difficult to conclude whether PD is a
  contraindication to TKR.
• Achieving pain relief while minimising
  perioperative complications, may be the target
  goal.
• Multimodal approach required
• Patients expectations and goals need to be
  clearly established

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Medical Management I

• Decreased function may be as a result of OA, or
  PD
• This may be more appropriately addressed with
  physical therapy and botox
• TKR should be considered only after failure of
  these measures, and presence of debilitating
  joint pain.
• Perioperative plan from patients neurologist
  regarding recommencement of PD medications

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Medical Management II

• Mehta et al report that neurological intervention
  preoperatively, or on day of surgery, was the key
  to a good clinical outcome after TKR.
• immediate rather than delayed consultation with
  neurologist perform better (LOS, KS Scores)
• Triggers required for repeat consultation
• change in mentation, deterioration in
  neurological status, pharmacological management
• Intraoperative anaesthesia and post-operative
  analgesia
• regional preferable to general anaesthesia
  (particularly in pts with ongoing
  levodopa/carbidopa therapy)
• general anaesthesia has been shown to mask
  myopotentials and PD symptoms
• Opiod drugs effect dopaminergic pathway, and
  hence mental state and Parkinsonian symptoms

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Medical Management III

• Ketorolac 15 to 30 mg Intramuscularly Q6H for 48
  hrs
• Perioperative risks may outweigh benefits for pts
  no able to tolerate regional anaesthesia or
  non-opiod analgesics
• Interactions between analgesics and patients
  medications should be addressed.
• Almost no data available in the literature.
• PD patients have a high risk of falls, and hence
  nursing vigilance is recommended.

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Orthopaedic Management

• CR and PS prostheses mild disease, normal
  quadriceps and hamstrings function
• Authors prefer CR, condylar-constrained, or
  hinged prostheses, due to the incidence of
  subluxation of PS components
• Hinged prostheses may be the safest option in
  patients with severe disease.
• Activity levels of these patients mitigate the
  concerns of using a fully constrained prosthesis
• Authors recommendation based on severity of
  flexion deformity and rigidity

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Orthopaedic Management II

• No literature recommending particularly surgical
  approach
• Pt should be assessed regularly for
• Surgical site infection
• Intact extensor mechanism
• Flexion contracture serial bracing, splinting,
  casting, (No evidence for CPM)
• Patellar maltracking
• Sialorrhea (PD patients higher risk for silent
  aspiration)

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Orthopaedic Management II

• Seyler et al described the use of botulinum toxin
  type A to improve flexion contractures following
  TKR
• improved and sustained ROM in 9/11 knees at 2
  year follow up
• Orthopaedic/Neurology communication should
  continue post-discharge

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Summary I

• Limited data to aid and predict outcome following
  TKR in PD patients

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Summary II

• Recommendations for TKA
• Only perform TKA after failure of nonsurgical
  measures and in the presence of debilitating
  joint pain
• Use cruciate-retaining, condylar constrained
  kinetic, or hinged-knee devices in patients with
  severe PD
• Do not use isolated femoral blockade, which may
  potentiate the early development of postoperative
  flexion contracture
• Use sciatic blockade or hamstring botulinum toxin
  type A injection
• Do not use CPM
• Use extremely well-padded braces, splints, or
  casts in full extension
• Contraindications to TKA
• Any level of preoperative delirium
• Patient is not a candidate for regional
  anesthesia or it is not achievable (ie, due to
  body habitus) and general anesthesia is the only
  option
• Opiates required postoperatively
• Multidisciplinary team members are not available
  (ie, orthopaedic staff, neurologist, pain service
  staff, highly trained nursing staff, geriatrics
  specialists, physiatrist)
• Hoehn and Yahr rating 3
• Preoperative knee flexion contracture gt25
• No response to preoperative diagnostic
  bupivacaine hydrochloride injection

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Thank you