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

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

Introduction IPD is the second most common neurodegenerative disorder after Alzheimer diseaseUSA Australia World0.3% population1-2% persons ≥ 65 yrs 3-6-4.9% 1.8%4-5% persons > 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)

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.”

Parkinson Disease Pathophysiology

IdiopathicSecondary 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

Parkinson Disease Severity Rating Scales

Unified Parkinson’s Disease Rating Scale mentation, behaviour, mood, motor ability, ADLs, therapy complications

Schwab and England Scale

Modified Hoehn and Yahr Scale

TKA and Parkinson DiseaseTKR 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

TKA and Parkinson DiseaseRecurring Themes

✚ Extensor mechanism problems✚ Wound necrosis✚ Post-operative confusion

✚ Limited functional improvement

Avoiding Early ComplicationsDifficult 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

Medical Management IDecreased 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 patient’s neurologist regarding recommencement of PD medications

Medical Management IIMehta 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 consultationchange in mentation, deterioration in neurological status, pharmacological management

Intraoperative anaesthesia and post-operative analgesiaregional 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

Medical Management IIIKetorolac 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 patient’s 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.

Orthopaedic ManagementCR 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

Author’s recommendation based on severity of flexion deformity and rigidity

Orthopaedic Management IINo 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)

Orthopaedic Management IISeyler 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

Summary ILimited data to aid and predict outcome following TKR in PD patients

Summary IIRecommendations 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 >25°✚No response to preoperative diagnostic bupivacaine hydrochloride injection

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