Total Knee Arthroplasty and Parkinson Disease:
Enhancing Outcomes and Avoiding Complications
Macaulay W, Geller JA, Brown AR, Cote LJ, Kiernan HA
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 > 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
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
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 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
TKA and Parkinson Disease
Recurring Themes
✚ Extensor mechanism problems
✚ Wound necrosis
✚ Post-operative confusion
✚ Limited functional improvement
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
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 patient’s neurologist regarding recommencement of PD medications
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
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 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 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
Author’s recommendation based on severity of flexion deformity
and rigidity
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)
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
Summary I
Limited data to aid and predict outcome following TKR in PD patients
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 >25°
✚No response to preoperative diagnostic bupivacaine hydrochloride injection
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