Transcript dealto-clinical-problem-solving-i-presentation

Risk of Developing
Osteoporosis after a
Total Knee Arthroplasty
Samantha DeAlto
November 7th, 2015
Clinical Problem Solving I
Objectives

Describe the patient management of the
demographic of interest

Examine the evidence for the likelihood
of developing osteoporosis for patients
status-post total knee arthroplasty.

To evaluate the likelihood of the patient
of interest in developing osteoporosis
Patient X
Demographics
◦ 65-year old, 5'7", 150lbs
Caucasian female
◦ lives with partner; no
children
◦ medications during
treatment: xarelto (DVT)
and Topamax (migraines)
◦ PTA: independent, retired
◦ DME: none
Procedure
◦ R total knee arthroplasty
(general with Block) due to
OA
PT Evaluation
Previous Surgeries
◦ Low back surgery (1987)
PMH
◦ OA/arthritis
◦ cancer (melanoma 2013)
◦ migraines
◦ Diverticulitis
Risk of Osteoporosis
◦ Unknown
PT Examination
Evaluation
(day 1 post op)
AM
PM
D/C
(day 2 post op)
AM
PM
AAROM (R knee
flexion/extension)
120 flex*
9 ext*
NT
101 flex
6 ext
D/C
Pain at rest (VAS)
0/10*
NT
6/10
D/C
Sensation
( *on-Q)
Numb (top NT
foot and
back of
knee)
R LE
Sensation
intact
D/C
Transfers (sit/stand/sit)
CG x2
NT
CGx2
D/C
Gait (use RW)
30 ft
NT
80 ft
D/C
Stairs (use RW)
NT
NT
4 stairs
D/C
Therapeutic Exercise/HEP per protocol
Exercise
Sets
Reps
Active
Ankle Pumps 1-2
10
x
Quad Sets
1-2
10
x
Hamstring
Sets
1-2
10
Heel Slides
1-2
10
SLR
1-2
10
Active
Assistive
x
x
x
Goals
Patient goal

To return to private residence and be independent again
PT's goals

Pt. will perform home exercise program per protocol with
modified independence within 4 days

Pt. will ascend/descend 3 stairs with 1 handrail(s) with
minimal assistance/CG assist within 4 days

Pt. will ambulate with modified independence 150 ft with the
least restrictive device within 4 days

Patient will demonstrate AROM 0-90 degrees in operative
joint within 4 days
Clinical Question
For a 65 yo female status-post total knee
arthroplasty, what is the likelihood of
developing osteoporosis?
Periprosthetic femoral bone loss after
total knee arthroplasty: 1-year follow-up
study of 69 patients
Tarja A. Soininvaara, Hannu J.A. Miettinen, Jukka S. Jurvelin, Olavi
T. Suomalainen, Esko M. Alhava, Heikki P.J. Kroger
Study Design: prospective cohort study
Purpose: to measure the quantitative changes in
BMD in the distal femur 1-year after a cemented TKA
Subject Characteristics




69 subjects (49 female, 20 male)
Mean age: 67 at time of operation
Mean weight: 80 kg
Patients recruited from same orthopedic department
operated by senior surgeons from May 1997 and May
2000
◦ Hardware: Cemented TKA using modular prosthesis from
one of following:
 Duracon (n=37), Nexgen (n=23), or AMK (n=9)
Exclusion Criteria


Previous joint replacement of either knee
Free from diseases and all medications known to
influence BMD
Methods
FWB was allowed immediately after
operation
 All patients received prophylactic
antibiotic and antithrombotic medication

◦ two patients received further antibiotics for
wound irritation
No complications were encountered
 All patients attended scheduled f/u

Outcome Measures
• 5 periprosthetic regions of
interest (ROIs) in the distal
femur
• American Knee Society (AKS)
score – used to evaluate knee
status and function during daily
activities
• Postoperative 1-week and at
3-, 6-, and 12-month
• DEXA
Results
Mean (S.D) femoral periprosthetic BMD (g/cm2) values at 0, 3, 6 and 12
months follow up of 69 patients
ROI
1 week post-op
3 months
6 months
12 months
1
1.26 (0.23)
1.12 (0.24)
1.08 (0.26)
1.05 (0.24)*
2
1.41 (0.34)
1.20 (0.34)
1.16 (0.36)
1.10 (0.33)*
3
1.74 (0.31)
1.53 (0.34)
1.52 (0.31)
1.52 (0.31)*
5
1.47 (0.27)
1.28 (0.28)
1.25 (0.29)
1.22 (0.27)*
4
1.36 (0.24)
1.30 (0.25)
1.27 (0.25)
1.25 (0.24)*
*Significant BMD changes during the follow-up
Mean Relative BMD Change (%) in the ROIs in the
Distal Femur with Different Prosthesis Models
Conclusion
The highest decrease in distal femur BMD
occurred during the first 3-months after
cemented TKA most likely due to:




Postoperative stress shielding
Operative trauma
Postoperative immobilization
Altered mechanical situation
There was no correlation between AKS score
and BMD
Study Limitations
Small study (69 participants)
 Study period limited to 1 year
 Baseline BMD was taken only
postoperatively

Changes in Bone Mineral Density of Both
Proximal Femurs after Total Knee
Arthroplasty
Kwang Kyoun Kim, Ye Yeon Won,Youn Moo Heo, Dae Hee Lee,
Jeong Yong Yoon, Won Sub Sung
Study Design: prospective cohort study
Purpose:
 to investigate whether TKA can affect changes in
proximal femur BMD
 to compare changes in BMD of both proximal
femurs after a unilateral TKA in osteoarthritic knee
joints
Subject Characteristics





48 subjects (37 female, 11 male)
Mean age: 63 (range, 53 to 76)
Patients were recruited from the same orthopedic
department between October 2006 and October 2009.
Radiographic Kellgren-Lawrence grade III or greater
Non-operative knee
◦ 40 cases were Kellgren-Lawrence grade II or less
◦ 8 cases had grade III or more, did not feel need to receive TKA
Exclusion Criteria
Contralateral TKA within one year after TKA
 Neurological issues (cerebral infarction, Parkinson’s Disease,
peroneal nerve injury)
 Medications (steroid, osteoporosis drug)

Methods
BMD measured using dual energy X-ray
absorptiometry (DEXA)
 BMD of both proximal femurs measured
at baseline and at 1-, 3-, 6- and 12-month
follow-up

Regions of Interest (ROIs)
Femoral neck, trochanter, and total area of
proximal femur
Results
Study Limitations



Small study (49)
Patients were very compliant
The following were considered in combination:
◦ Exercise restriction due to pain and limited joint
ROM
◦ Degree of OA
◦ Pain scale before operation
◦ Dominant leg
◦ Individual demands in daily life
◦ Discordance between BMD of the L- and R-hip
Gender not compared
 Lack of osteoarthritis severity of both knees

Conclusions
TKA was found to affect BMD in both proximal
femurs during the 1-month and 3-month period
BMD at 12-months after operation was similar to
preoperative levels, but lower
than baseline most likely due to:
 Age related loss
◦ Women 60–75 = 1.43% (Dennison et al.)
 Return to function
There was no significant difference in change of BMD
between the operative and nonoperative side
Significance to Patient X
Patient X criteria
 Female
 Caucasian
 65 yo
 5’7”, 150 lbs = BMI: 23.59 (normal/healthy)
 Knee OA
 Unilateral TKA
 Retired
 Recommended D/C to home health
Prognosis of Patient X
The likelihood of Patient X developing osteoporosis as a result of a TKA is
slightly increased due to type of prosthesis, age, gender, low BMI and
decreased activity level; however other factors such as nutrition and PMH
should be considered.
This verifies the intervention done with the patient and emphasizes the
importance of continued physical therapy
References
Soininvaara, T., Miettinen H., Jurvelin, J.,
Suomalainen, O., Alhava, E., Kroger, H. (2003)
Periprosthetic Femoral Bone Loss after Total
Knee Arthroplasty: 1 Year Follow-Up Study of
69 Patients. The Knee, 11(2004), 297-302.
Kim, K., Won,Y., Heo,Y., Lee, D., Yoon, J., Sung,
W. (2014) Changes in Bone Mineral Density of
Both Proximal Femurs after Total Knee
Arthroplasty. Clinics in Orthopedic Surgery, 6, 4348.
QUESTIONS???