MEHMET ERDURAN, Devrim AKSEKİ, Şükrü ARAÇ

Surgical practices in total knee arthroplasty in Turkey

Amaç: Bu çalışmanın amacı Türkiye’de total diz artroplastisi (TDA) cerrahisinde mevcut uygulamaları ve ortopedik cerrahlar arasındaki uygulama farklılıklarını saptamaktı. Çalışma planı: Kesitsel tanımlayıcı tasarıma sahip olan bu çalışmanın verileri, total TDA cerrahisi yapan 76 ortopedik cerrahtan anket tekniği kullanılarak toplandı. Toplam 57 soruyu kapsayan anket formu cerrahın mesleki özelliklerini anlamaya yönelik sorgulamanın yapıldığı, cerrahi öncesi yaklaşımla ile ilgili genel bilgilerin derlendiği, TDA cerrahisi için uygulanan cerrahi teknik ve tekniğe özel cerrahi detaylarla farklı komplikasyon senaryolarına uygulayabilecekleri çözümlerin değerlendirildiği ve cerrahi sonrası yaklaşımın sorgulandığı dört ana başlıktan oluştu. Bulgular: Ülkemizdeki TDA uygulamalarının %39.7’sinin laminar hava akımı ya da HEPA filtresi olmayan ameliyathanelerde yapıldığı, cerrahların beşte birine yakınının profilaksi amacıyla birden fazla antibiyotik kullandığı, %85’inden fazlasının ise profilaksiye 3 günden daha fazla devam ettiği saptandı. Tromboemboli profilaksisi amacıyla en sık kullanılan yöntemin düşük molekül ağırlıklı heparin olduğu gözlendi. Katılımcıların %94.67’si primer TDA’da sadece çimentolu tekniği uyguladıklarını belirtmişlerdir. Cerrahların %44‘ü aynı seansta iki dizde birden artroplasti uyguladığını, %89’u herhangi bir skorlama sistemi kullanmadığını, %72.37’si de sabit insert ve arka çapraz bağ koruyan tip protez kullandıklarını belirtmiştir. Çıkarımlar: TDA cerrahisi konusunda ülkemizde bir standardizasyonun olmadığı, bazı temel konularda önemli eğitim eksikliklerinin olduğu gözlendi.

Türkiye’de total diz artroplastisinde cerrahi uygulamalar

Objective: The aim of this study was to determine the current practices in the total knee arthroplasty (TKA) and the differences of practice among the orthopedic surgeons in Turkey. Methods: Data in this cross-sectional and descriptive study was collected through a questionnaire from 76 orthopaedic surgeons performing TKA. The questionnaire form contained 57 questions under four main headings, covering the professional properties of the surgeon, pre-surgery approach, surgical technique applied for TKA and the surgical details peculiar to the technique with solutions applied for complication scenarios, and finally the postoperative approach. Results: It was determined that 39.7% of the TKA applications were performed in operating theatres without laminar airflow or HEPA filters. Nearly 1/5 of the surgeons used more than one antibiotic for prophylaxis, and more than 85% continued prophylaxis use over 3 days. Low-molecular-weight heparin was the most commonly used method for thromboprophylaxis. 94.67% of the surgeons used only the cemented technique in primary TKA. 44% indicated that they performed simultaneous bilateral arthroplasty, 89% did not use any scoring system and 72.37% preferred fixed-bearing and posterior-cruciate-retaining type prosthesis. Conclusion: Results showed no standardization in TKA surgery among surgeons in Turkey, and important educational deficiencies were noted.

___

1. Michael JW, Schlüter-Brust KU, Eysel P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int 2010;107:152-62.
2. Zeni JA Jr, Axe MJ, Snyder-Mackler L. Clinical predictors of elective total joint replacement in persons with end-stage knee osteoarthritis. BMC Musculoskelet Disord 2010;11:86.
3. Roberts VI, Esler CN, Harper WM. A 15-year follow-up study of 4606 primary total knee replacements. J Bone Joint Surg Br 2007;89:1452-6.
4. Dixon MC, Brown RR, Parsch D, Scott RD. Modular fixed- bearing total knee arthroplasty with retention of the posteri- or cruciate ligament. A study of patients followed for a mini- mum of fifteen years. J Bone Joint Surg Am 2005;87:598-603.
5. Parsch D, Krüger M, Moser MT, Geiger F. Follow-up of 11- 16 years after modular fixed-bearing TKA. Int Orthop 2009;33:431-5.
6. Al-Arabi YB. Risk classification for primary knee arthroplas- ty. J Arthroplasty 2009;24:90-5.
7. Bridgman SA, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N. Sub-vastus approach is more effec- tive than a medial parapatellar approach in primary total knee arthroplasty: a randomized controlled trial. Knee 2009;16:216-22.
8. Wajsfisz A, Biau D, Boisrenoult P, Beaufils P. Comparative study of intraoperative knee flexion with three different TKR designs. Orthop Traumatol Surg Res 2010;96:242-8.
9. Lygre SH, Espehaug B, Havelin LI, Vollset SE, Furnes O. Does patella resurfacing really matter? Pain and function in 972 patients after primary total knee arthroplasty. Acta Orthop 2010;81:99-107.
10. Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, et al. Efficacy of continuous passive motion fol- lowing total knee arthroplasty: a metaanalysis. J Rheumatol 2004;31:2251-64.
11. Alkire MR, Swank ML. Use of inpatient continuous passive motion versus no CPM in computer-assisted total knee arthroplasty. Orthop Nurs 2010;29:36-40.
12. Crossett L. Evolution of the low contact stress (LCS) com- plete knee system. Orthopedics 2006;29:S17-22.
13. Arthroplasty of the ankle and knee. In: Canale ST, ed. Campbell’s operative orthopaedics. Vol 1. 10th ed. Philadelphia: Mosby; 2003. p. 243-314.
14. Robertsson O, Bizjajeva S, Fenstad AM, Furnes O, Lidgren L, Mehnert F, et al. Knee arthroplasty in Denmark, Norway and Sweden. Acta Orthop 2010;81:82-9.
15. Sener N, Demirhan M, Yazicioglu O. Total knee arthroplas- ty in specific conditions. [Article in Turkish] Acta Orthop Traumatol Turc 1997;31:58-62.
16. Furnes O, Espehaug B, Lie SA, Vollset SE, Engesaeter LB, Havelin LI. Early failures among 7,174 primary total knee replacements: a follow-up study from the Norwegian Arthroplasty Register 1994-2000. Acta Orthop Scand 2002;73: 117-29.
17. Boscainos PJ, McLardy-Smith P, Jinnah RH. Deep vein thrombosis prophylaxis after total knee arthroplasty. [Article in Turkish] Curr Opin Orthop (Turkish ed.) 2006;1:51-60.
18. Banks SA, Markovich GD, Hodge WA. In vivo kinematics of cruciate-retaining and -substituting knee arthroplasties. J Arthroplasty 1997;12:297-304.
19. Smith TO, Ejtehadi F, Nichols R, Davies L, Donell ST, Hing CB. Clinical and radiological outcomes of fixed- versus mobile-bearing total knee replacement: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2010;18:325-40.
20. Jacobs WC, Clement DJ, Wymenga AB. Retention versus removal of the posterior cruciate ligament in total knee replacement: a systematic literature review within the Cochrane framework. Acta Orthop 2005;76:757-68.
21. Post ZD, Matar WY, van de Leur T, Grossman EL, Austin MS. Mobile-bearing total knee arthroplasty: better than a fixed-bearing? J Arthroplasty 2010;25:998-1003.
22. Knee arthroplasty manual. The techniques in total knee and revision arthroplasty. [Text in Turkish] In: Scuderi Gr, Tria AJ, eds. Istanbul: Hayat T›p Kitapç›l›k; 2007.
23. Jazrawi LM, Bai B, Kummer FJ, Hiebert R, Stuchin SA. The effect of stem modularity and mode of fixation on tibial compo- nent stability in revision total knee arthroplasty. J Arthroplasty 2001;16:759-67.
24. Yoshii I, Whiteside LA, Milliano MT, White SE. The effect of central stem and stem length on micromovement of the tibial tray. J Arthroplasty 1992;7:433-8.
25. Radnay CS, Scuderi GR. Management of bone loss: aug- ments, cones, offset stems. Clin Orthop Relat Res 2006;(446): 83-92.
26. Hersekli MA, Akpinar S, Ozalay M, Ozkoc G, Uysal M, Tandogan RN. A comparison between single- and two- staged bilateral total knee arthroplasty operations in terms of the amount of blood loss and transfusion, perioperative com- plications, hospital stay, and cost-effectiveness. [Article in Turkish] Acta Orthop Traumatol Turc 2004;38:241-6.
27. Altintas F, Gürbüz H, Erdemli B, Atilla B, Ustaoglu RG, Oziç U, et al. Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observation- al study. Acta Orthop Traumatol Turc 2008;42:322-7.
28. Phillips AM, Goddard NJ, Tomlinson JE. Current tech- niques in total knee replacement: results of a national survey. Ann R Coll Surg Engl 1996;78:515-20.
29. Malik MH, Chougle A, Pradhan N, Gambhir AK, Porter ML. Primary total knee replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register. Ann R Coll Surg Engl 2005;87:117-22.
30. de Beer J, Petruccelli D, Rotstein C, Weening B, Royston K, Winemaker M. Antibiotic prophylaxis for total joint replace- ment surgery: results of a survey of Canadian orthopedic sur- geons. Can J Surg 2009;52:E229-34.
31. Lutz MJ, Halliday BR. Survey of current cementing tech- niques in total knee replacement. ANZ J Surg 2002;72:437-9.
32. Wright JG, Coyte P, Hawker G, Bombardier C, Cooke D, Heck D, et al. Variation in orthopedic surgeons' perceptions of the indications for and outcomes of knee replacement. CMAJ 1995;152:687-97.
33. Mesko JW, Brand RA, Iorio R, Gradisar I, Heekin R, Leighton R, et al. Venous thromboembolic disease manage- ment patterns in total hip arthroplasty and total knee arthro- plasty patients: a survey of the AAHKS membership. J Arthroplasty 2001;16:679-88.