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Treatment of Gonarthrosis by Total Knee Arthroplasty

Article  in  Biotechnology & Biotechnological Equipment · April 2014

DOI: 10.1080/13102818.2006.10817393

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TREATMENT OF GONARTHROSIS BY TOTAL
KNEE ARTHROPLASTY
Z. Golubovic1, M. Mitkovic1, L. Macukanovic-Golubovic1, I. Micic1, P. Stojiljkovic1,
K. Kutlesic-Stojanovic1, A. Lesic2, M. Bumbasirevic2, S. Stamenic1, S. Karalejic1,
M. Todorovic1, A. Visnjic1
Clinic for Orthopaedic Surgery and Traumatology, Clinical Center Nis, Faculty of
Medicine, Nis, Serbia and Montenegro
Institute for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, Belgrade,
Serbia and Montenegro2

ABSTRACT
Gonarthrosis is a progressive chronic arthropatic disease of the knee which includes de-
generative changes of the knee cartilage and hypertrophic changes of the bone tissue
around of the articulare surface. The onset of the disease is insidious and vague. As the
condition progresses, clinical signs became more significant like weakness of musculus
quadriceps, flexion contracture of the knee joint, and valgus or varus deformity of the
knee. Radiological changes of the osteoarthritic knee are narrowing of the joint space,
sclerosis of the subhondral bone, osteophyte formation and in the terminal stadium cystic
degeneration of the subhondral bone. In period from the 30.08.1999 to30.08.2004 year at
the Clinic of the Orthopaedics and Traumatologicy of Clinical Center of the Nis were
treated 10 patients with gonarthrosis by total replacement artrhoplasty of knee joint. In all
patients implant was produced by the company Jonhson-Johnson. After undergone
replacement surgery of the knee joint, patients were relieved from the continous pain, and
had stabile and secure gait with optimal movement of the replace knee joint in all
direction. Excellent and very good results in the treatment of the osteoarthritic knee by
total replacement artrhoplasty were reported in nine patients, and there were
postoperatively infection of the wound only in one patient.
Introduction or valgus position and in the advanced
Gonarthrosis is a progressive chronic ar- stage knee extension and flexion also ap-
thropatic knee disease characterized by pears (2). Pain dominates and also rigidity
knee cartilage degenerative changes and of knee joint in the clinical picture of the
hypertrophic changes of bone tissue around patient with gonarthrosis. Because of its
articular surface. Among all the big joints, mass appearance, sickness duration and
arthropatic changes mostly appear at knee invalidity gonarthrosis therapy is always
joints. Autopsy examinations have showed topic for discussion (3,4).
arthrotic changes of knee in 75% of the In gonarthosis treatment, beside hygienic
cases and of hip in 33% (1). and diet measures, physical therapy, non-
Pathoanatomic changes are first knee steroid anti-rheumatics significant place is left
cartilage degenerative changes and then for surgical treatment and implanting of total
parallel development appear of regressive replacement artrhoplasty of knee joint (5).
and reactive cartilage and bones changes .
Disproportional loss of knee cartilage from Materials and Methods
medial or lateral condil leads to the appea- The aim-objective of our work is to show
rance of secondary deformations in varus the treatment results of ten gonarthrosis

145 Biotechnol. & Biotechnol. Eq. 20/2006/3

patients at the Clinic of the Orthopaedics After the test done with the placement of
and Traumatology of Medical faculty of temporary joint complements at the pre-
Nis with the total arthroplasty replacement pared treated surfaces of femur and tibia,
produced by Johnson-Johnson orthopaedics the adequacy of selected surfaces of com-
limited. ponents and stability of knee joint is esti-
In order to realize the determined objec- mated. Test components are removed. Mar-
tive, retrospective analyses of the patients row cement is used and it is placed over the
with gonarthrosis were made. The patients prepared layers as well as over certain parts
were from the group treated at Clinic of the of endoprotesis and its definite implanting
Orthopaedics and Traumatology of Medi- is also done. It takes about 10 to 12 minu-
cal faculty of Nis in the period from tes to cement firming and also reposition is
August 30 1999 to August 30 2004. They done. Joint stitch through layers. Drainage.
were treated with total replacement ar- Surgical procedure was done with turnikea.
trhoplasty of knee joint of Johnson and
Johnson orthopaedics limited. In the stated Results and Discussion
period 10 patients were treated with the In the period from August 30 1999 to
total replacement artrhoplasty of knee joint. August 30 2004 10 patients with gonar-
With this work analyses the patients who throsis were treated with the total replace-
had had total replacement artrhoplasty of ment of arthroplasty by Johnson – Johnson
knee joint done for the rheumatoid arthritis orthopedics limited. There were 8 females
were not taken into account. and 2 males in the analyzed group. The
The final result of gonarthrosis treatment average age limit is 62,5 (tab 1). The
with total replacement artrhoplasty of knee youngest patient is 53 and the oldest 72
joints was estimated by using scale of asso- years old. Gonarthrosis incidence was a the
ciation for knee (Knee society scores) (6). result of joint fracture of thigh bone in the
Surgical tehnic: The incision of the skin case of two patients.
is frontal – along type and starts at about 10 The total replacement artrhoplasty of
centimeters from upper patella and distally knee joint in five patients was done in ge-
goes to tuberosiatis tibia. The knee joint is neral anesthesia and also in the case of five
opened with medial parapatelar incision. patients in spinal anesthesia.
Patella laterally everts with the knee in ex- The average surgical intervention length
tension. Knee is flectured to 90 % and me- of total replacement artrhoplasty of knee
niscetomia and excision of LCA are done. joint was two and half hours long. The
Distal resection of joint femur surfaces is longest duration of surgical operation was
done and then, with the usage of appropri- three hours long and the shortest was two
ate instruments the frontal, lateral and hours long.
sidelong recession of femur condila is done Intraoperative there were no blood losses
as well as the recession of condilar part. since the operations were done with turni-
Then we deal with joint surface of tibia kea. Post surgical blood loss, followed by
with using instruments for determination of wound drainage in average was 470 ml of
the angle or joint tibia surface as well as blood. Maximal loss of blood was 800 ml
the thickness of marrow –joint part and and minimal loss was 250 ml of blood.
resection through certain slots is done. All Average loss of the first post-operative day
recessions are done with oscillatory saw. 400 ml of blood, and minimal blood loss
When the beds for femur and tibia are was equal to zero.
treated then the beds on patella are treated By analyzing blood compensation in the
also. After the trial test the bed is implanted patients with total replacement artrhoplasty
which goes into tibia methaphyses. of knee joint, it has been determined that

Biotechnol. & Biotechnol. Eq. 20/2006/3 146

 TABLE
sex/age 51-60 61-70 71-80 total
men / 2 (20%) / 2 (20%)
female 3 (30%) 40 (40%) 1 (10%) 8 (80%)
total 3 (30%) 6 (60%) 1 (10%) 10 (100%)

Fig. 1. Fig. 2.

three patients got per two units of washed dure was done, including reposition and
erythrocytes (2*350 ml) and also three pa- osteosynthesis of fracture. During post op-
tients received plasma expander (Haemacel erative procedure, physical therapy had
500 ml). Control hematocrites were in the been implemented and after the union of
range between 0,24 to 0,40 (in average fractur osteosythesis material was removed.
0,35). Ten years after the injury and post opera-
From early post-operative complications tive treatment of the patient there was an
in the patients we registered tromboflebitis incidence of pain and limit of moving ac-
of lower leg which was successfully solved tivities in the right knee joint. In the made x
by transferring from low molecular heparin -ray pictures one can see the narrowing of
(Fraxarin) to oral anticoagulans (Sintrom) joint space, border osteofits, come to head
with the value control of INR. intracondial eminence and border sclerosis
We registered post-operative wound in- (Fig. 1).
fection in one of the patients. With regular After the complete post-operative prepa-
strangulation and antibiotic therapy it came ration, surgical action of implantation of
to subsidence state. total endoprotesis of right knee joint was
In all the patients we registered excellent made. In the x-ray pictures of knee joint we
and good results in the treatment of os- can see the state after the endoprotesis im-
teoarthritis of the knee by total arthroplasty plantation (Fig. 2).
replacement. Knee joint is very often in the process of
Patient description: A patient, 58, ten gonarthrosis after the 4th decade of human
years ago got hard intra-articular trans- life. Causal factor of gonarthrosis appea-
condylar femur fracture.Operative proce- rance can be general or local. From local

147 Biotechnol. & Biotechnol. Eq. 20/2006/3

factors important are: wrong static relations of body weight, anati-inflamatory drugs,
of pressure, functional over-pressure disburden of joint (usage of walking stick).
(sportsmen, physical workers), overweight, Operative treatment is about osteotomia to
stronger equally measured or frequent inju- correct lower and upper leg part deformi-
ries, inflammatory processes that harm ties and malting the relations in joint and
joint gristle. From general factors important total artroplastic of knee joint (13, 14, 15).
are aging of organism, metabolic and hor- With total replacement artrhoplasty of
monal disorders (7, 8, 9). knee joint a patient is relieved of constant
The beginning of the disease is insidious pains, stabile and secure walk is provided
and latent. In the beginning a patient feels for him as well as good range movements
stiffness in the joint that further goes to in operated knee (16, 17, 18).
pain during knee movements. Pain is get-
ting stronger during longer physical activity Conclusions
and weaker in stillness periods. With the Arthrotic changes are most frequent in
disease improvement, pains grow stronger knee joint if you consider all big human
and one moderate, in rare cases – stronger, joints. Gonarthrosis is three times more
hypotonia of four-headed muscle of upper frequent in females that in males. Causes
leg is developing, mostly for the pains and for gonarthrosis appearance can be local
during activities. We can find thicker joint and general. From general factors there are:
capsule with palpation. During the move- the state of the organism, metabolic distur-
ments of flexia and extensions we can hear bances and climacterium. From local
more or less emphasized crepitacions. Dif- causing factors important are wrong static
fused crepitacions, like crunching sounds pressure, functional over-pressure (sports-
of dry snow, appear in the whole joint area. men, physical workers), over-weight,
Pathoanatomic changes are always first of trauma (intra-articular fracture), frequent
all degenerative gristle changes and then minor injuries of joint (micro-trauma), in-
regressive and reactive changes of gristle flammatory joint processes, giht and gout
and bones have parallel development. In and hemofilia.
late period of gonarthrosis atrophy of four In the treatment of gonarthrosis beside
headed upper leg muscle, flexion contrac- hygene –diet measures, physical therapy,
ture and valgus or varus knee deformity. non-steroid antirheumatics operative treat-
Mobility of patella is also reduced (10,11). ment takes significant place and total re-
In the stadium of exarbation hydrops and placement arthroplasty of knee joint.
hypertremia of knee. Subjective distur- In the period from 30th August 1999 to
bances are increased during the weather 30th August 2004 ten patients were treated
changes. General state is not damaged and with total replacement artrhoplasty of knee
erythrocyte sedimentation is not increased. joint of Johnson and Johnson orthopaedics
In radiographic way we find ridged inter- limited at our clinic. Average duration of
condilal eminence incidence, bigger or surgery was two and half hours. Intraop-
smaller marginal osteofites, narrow joint erativelly there were no blood losses (op-
interstice, faset joint surfaces and in later erations were done with turnikea) while
stage subhondral sclerosis and degenerative post-operative blood loss (followed over
cysts (12). drainage of the wound ) in average was
Treatment of gonarthrosis can be of not about 470 ml. Three patients in post-opera-
operative type and operative too. Not-ope- tive state got per two units of washed ery-
rative procedure treatment includes limiting trocites and three patients got plasmaex-
of activities (avoiding walking down and pander.
up the stairs and slant surfaces), reduction Excellent and good results in gonarthro-

Biotechnol. & Biotechnol. Eq. 20/2006/3 148

 sis treatment with total arthroplasty re- 7. Elkus M., Ranawat C.S., Rasquinha V.J.,
placement of Johnson and Johnson type Babhulkar S., Rossi R., Ranawat A.S. (2004) J.
were registered in all operated patients. Bone Joint Surg. Am., 86, 2671-2676.
From post-operative complication we 8. Kimm W.Y., Richards J., Jones R.K., Hegab
have one operative wound infection of the A. (2004) Knee., 11, 225-231.
which with the help of constant wound 9. Haidukewych G.J., Springer B.D., Jacofsky
dressing and antibiotic therapy subsided. D.J., Berry D.J. (2005) J. Arthroplasty., 20, 344-
349.
We have also registered in patient trombo-
10. Jajic I. (1981) Klinicka reumatologija, Skolska
flebitis of lower leg segment that was suc- knjiga, Zagreb,123-129.
cessfully solved. The patient was further 11. Ritter M.A., Thong A.E., Davis K.E., Berend
treated with low-molecular heparin (Frax- M.E., Meding J.B., Faris P.M. (2004) J. Bone Joint
arin) and he was transferred to oral antico- Surg. Br., 86, 438-442.
agulants (Sintrom)with INR control. 12. Davies A.P., Glasgow M.M. (2000) Knee., 7,
139-143.
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