Correspondence
Minimally Invasive Total Knee Arthroplasty
N Engl J Med 2009; 361:633-634August 6, 2009
- Article
To the Editor:
In the Clinical Therapeutics article on minimally invasive total knee arthroplasty for osteoarthritis, Leopold (April 23 issue)1 does not offer advice regarding weight reduction to ideal levels as part of his recommendations for a female patient with a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 26.6. Overweight and obesity are potent risk factors for knee osteoarthritis. They are stronger risk factors for knee osteoarthritis in women than in men. In women, the risk of knee osteoarthritis with weight gain is linear.2 A patient who has a BMI of 25.0 to 26.9 with coexisting conditions should be treated with diet, exercise, behavior therapy, or pharmacotherapy according to present guidelines.3
3 ReferencesAjit Singh Kashyap, M.D.
Army Hospital, New Delhi, IndiaKuldip Parkash Anand, M.D.
Pravara Institute of Medical Sciences, Loni, IndiaSurekha Kashyap, M.D.
Base Hospital Delhi Cantt, New Delhi, India
surekhakashyapdr@gmail.com 1
Leopold SS . Minimally invasive total knee arthroplasty for osteoarthritis. N Engl J Med 2009;360:1749-1758
Full Text | Web of Science | Medline2
Felson DT. Osteoarthritis. In: Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison's principles of internal medicine. 17th ed. New York: McGraw-Hill, 2008:2158-75.
3
Kushner RF. Evaluation and management of obesity. In: Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison's principles of internal medicine. 17th ed. New York: McGraw-Hill, 2008:468-77.
To the Editor:
We would like to add to the discussion regarding the most appropriate method of anesthesia and analgesia in patients undergoing minimally invasive total knee arthroplasty for osteoarthritis. As Leopold suggests, insufficient postoperative analgesia delays rehabilitation and recuperation. Therefore, the anesthetic technique that is most likely to result in the least postoperative pain, without compromising mobility, should be used.
A recent systematic review and meta-analysis of major knee surgery by Fowler et al.1 concluded that femoral-nerve blockade provided postoperative pain control that was similar to lumbar epidural analgesia. This meta-analysis included a study by Chelly et al.,2 who compared three different approaches to analgesia in 92 patients. Patients who received a peripheral-nerve block had improved pain control and less postoperative nausea and vomiting.
We suggest that a femoral-nerve block be considered as part of a multimodal approach to minimally invasive total knee replacement, particularly since the objective is to accelerate rehabilitation and recovery. We look forward to studies that compare the different anesthetic and analgesic methods when they are used with this new surgical technique.
2 ReferencesMichael J. Moneypenny, F.R.C.A.
Royal Liverpool University Hospital, Liverpool, United Kingdom
michaelmoneypenny@mac.com Simon J. Mercer, F.R.C.A.
University Hospital Aintree, Liverpool, United Kingdom1
Fowler SJ ,Symons J ,Sabato S ,Myles PS . Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth 2008;100:154-164
CrossRef | Web of Science | Medline2
Chelly JE ,Greger J ,Gebhard R , et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty 2001;16:436-445
CrossRef | Web of Science | Medline
To the Editor:
Leopold clearly highlights the point that the minimally invasive approach for total knee arthroplasty should be performed only by surgeons with considerable expertise and experience.
He states that contraindications to the minimally invasive approach include “previous open knee surgery, severe osteoporosis or rheumatoid arthritis, obesity or increased limb girth, and severe joint deformity.” Other contraindications should be considered when determining which patients should undergo this procedure, since not every knee is a good candidate for the minimally invasive approach.
We also discourage the minimally invasive approach in patients with a patella infera (Caton index,1 <0.6; normal range, 0.8 to 1.2, with scores higher than 1.2 indicating patella alta), previous tibial tubercle–transfer procedures (because of the resulting distortion of the anatomy), a chronically dislocated patella (because it usually requires extensive mobilization of the extensor mechanism), previous lateral closing-wedge high tibial osteotomies (since the extensor mechanism has typically lost extensibility), and a knee with limited mobility.2 The minimally invasive approach is appropriate for most but not all knees.
2 ReferencesUmile Giuseppe Longo, M.D.
Campus Bio-Medico University, Rome, ItalyNicola Maffulli, M.D., Ph.D.
Queen Mary University of London, London, United Kingdom
n.maffulli@qmul. ac. uk Vincenzo Denaro, M.D.
Campus Bio-Medico University, Rome, ItalyAuthor/Editor Response
I am in general concurrence with the authors of these letters. Decreasing postoperative pain, as Moneypenny and Mercer suggest, is the driving reason to consider less invasive approaches to total knee arthroplasty and is at the foundation of my own clinical interest in the topic. That said, the subject of the optimal anesthetic and analgesic approach remains an area of some controversy. Femoral-nerve blocks are one reasonable (and widely used) approach. But a Medline search of the terms “analgesia total knee arthroplasty” with the use of “randomized controlled trial” as a limiting function returned listings of more than 100 randomized, controlled trials since 2002; literally dozens of anesthesia and pain protocols have been described. More important even than coming up with the single best approach — which might or might not exist — is the dramatic and appropriate increase in interest among clinician-scientists in minimizing patients' pain after this kind of surgery. Effective analgesia after knee replacement is critical to achieving the best possible clinical result, and is, not insignificantly, the humane thing to do.
As stated in my article, I agree that minimally invasive approaches to total knee arthroplasty are not necessarily for every patient, and they definitely are not for every surgeon. Both patient factors, such as the ones cited (among others), and surgeon factors, including previous training, experience, and the learning curve,1 may come into play. It would be most important for each surgeon who is considering this approach to have a realistic idea of what is and what is not possible for him or her to achieve safely and accurately using minimally invasive approaches to total knee arthroplasty. I commend Longo et al. for keeping this important issue an explicit part of their surgical decision making.
Finally, I agree that there is strong evidence in the literature correlating obesity with the development of knee osteoarthritis. I also agree that patients should be counseled to maintain an ideal BMI in order to decrease the risk of the development of knee arthritis. What is less clear is whether very small reductions in body weight (such as the reduction from a BMI of 26.6, as in the case study, to less than 25.0, which would be within the “normal” range) would have any meaningful clinical effect in a patient who already has severe arthritis and activity-limiting symptoms. Still, the suggestions of Kashyap et al. are, of course, relevant to the population at large.
1 ReferencesSeth S. Leopold, M.D.
University of Washington School of Medicine, Seattle, WA
leopold@u.washington. edu 1
King J ,Stamper DL ,Schaad DC ,Leopold SS . Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty: assessment of the learning curve and the postoperative recuperative period. J Bone Joint Surg Am 2007;89:1497-1503
CrossRef | Web of Science | Medline
- Citing Articles (4)
Citing Articles
1
Umile Giuseppe Longo, Mattia Loppini, Alessandra Berton, Filippo Spiezia, Nicola Maffulli, Vincenzo Denaro. (2012) Tissue Engineered Strategies for Skeletal Muscle Injury. Stem Cells International 2012, 1-13
CrossRef2
Umile Giuseppe Longo, Stefano Campi, Giovanni Romeo, Filippo Spiezia, Nicola Maffulli, Vincenzo Denaro. (2012) Biological Strategies to Enhance Healing of the Avascular Area of the Meniscus. Stem Cells International 2012, 1-11
CrossRef3
Umile Giuseppe Longo, Stefano Petrillo, Edoardo Franceschetti, Nicola Maffulli, Vincenzo Denaro. (2012) Growth Factors and Anticatabolic Substances for Prevention and Management of Intervertebral Disc Degeneration. Stem Cells International 2012, 1-12
CrossRef4
N. Maffulli, U. G. Longo, A. Marinozzi, V. Denaro. (2011) Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. British Medical Bulletin 97:1, 149-167
CrossRef
