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1. Total Knee Replacement

TOTAL KNEE REPLACEMENT

Oleh Dr. H. Subagyo, Sp.B-Sp.OT.

 

BAB I

PENDAHULUAN

Total Knee Replacement dalam beberapa bentuk telah dipraktekkan selama lebih dari 50 tahun. Complexitas dari sendi lutut baru mulai dipahami 30 tahun yang lalu. Karena itu, total knee replacement awalnya tidak sesukses hip replacement Sir John Charnley's. Namun, kemajuan dramatis dalam pengetahuan mekanika lutut telah menyebabkan desain modifikasi tahan lama.

Kemajuan yang signifikan telah terjadi dalam jenis dan kualitas logam, polyethylene, dan baru-baru ini, keramik digunakan dalam proses manufaktur prosthesis, menyebabkan umur panjang ditingkatkan. Seperti teknik yang paling dalam kedokteran modern, semakin banyak pasien menerima manfaat dari Total Knee Replacement.

Total knee replacement menggantikan sakit sendi lutut dan menghilangkan permukaan bantalan yang rusak yang menyebabkan sakit. Desain implan menawarkan stabilitas diperbaharui dan meminimalkan proses keausan. Secara keseluruhan ada tiga manfaat dari penggantian lutut, yaitu menghilangkan rasa sakit, meningkatkan gerakan, dan meminimumkan pemakaian dan kesengsaraan.

Total knee replacement memberikan kualitas yang terbaik untuk meningkatkan kualitas hidup dari semua operasi. Operasi ini merupakan salah satu dari operasi yang paling sukses dan salah satu hasil terbaik.

Sebelum mempelajari operasi itu sendiri kita perlu tahu dan memahami anatomi sendi lutut dan bagaimana bagian-bagian lutut tersebut saling bekerja sama untuk mempertahankan fungsi normal, seperti yang akan dibahas pada referat ini.

Sendi merupakan suatu engsel penghubung antara ruas tulang yang satu dengan ruas tulang lainnya, sehingga kedua tulang tersebut dapat digerakkan sesuai dengan jenis persendian yang diperantarainya.Sendi lutut ini termasuk dalam jenis sendi engsel , yaitu pergerakan dua condylus femoris diatas condylus tibiae. Jika terjadi gerakan yang melebihi kapasitas sendi maka akan dapat menimbulkan cedera yang antara lain terjadi robekan pada capsul meniscus sendi dan ligamentum di sekitar sendi.

Akhir-akhir ini dalam perkembangannya, total knee replacement mengalami kemajuan dalam teknik operasi dan outcome pasien-pasien yang selesai menjalani operasi tersebut. Para ahli bedah berhasil menemukan cara baru dalam operasi ini yaitu dengan meminimalkan luka dan bekas operasi. Dan jenis operasi itu sering disebut sebagai Mini Total Knee Replacement.

Meskipun sebagian besar outcome pasien yang menjalani operasi total knee replacement menunjukkan hasil yang sangat bagus, tetapi risiko dan komplikasi dapat juga terjadi pada prosedur ini. Yang paling sering ditakuti oleh ahli bedah pada pasien yang menjalani operasi ini adalah deep vein thrombosis atau venous thromboembolism yang bisa mengakibatkan hasil yang fatal pada pasien tersebut. Morbiditas dari komplikasi ini sering menyebabkan kematian yang mendadak. Pada referat ini akan dibahas juga mengenai cara penanganan dan pencegahan sebelum terjadi deep vein thrombosis pada pasien yang telah menjalai operasi total knee replacement.

 

                                    

 

BAB II

ANATOMI

Anatomi Sendi Lutut tidak dibicarakan

 

BAB III

TOTAL KNEE REPLACEMENT

Total knee replacement, juga dapat disebut total knee arthroplasty adalah satu dari prosedur orthopedic yang paling sering dilakukan. Pada tahun 1997, sekitar 300.000 total knee replacement dilakukan tiap tahunnya di Amerika Serikat. Berbagai variasi kondisi patologis yang mempengaruhi lutut dapat diobati dengan cara ini, lebih mudah untuk meringankan rasa sakit, memperbaiki fungsi dan mobilitas.

Fungsi sendi lutut normal sebagai engsel complex yang memberikan pergerakan primer fleksi dan ekstensi, tetapi juga gerakan rotasi dan gerakan yang luwes. Sendi lutut dibentuk dari tiga kompartemen, lateral, medial dan patellofemoral.Kerusakan cartilago pada satu atau lebih kompartemen bisa menyebabkan osteoarthritis (idiopatik atau post traumatic), inflammatory arthritis (rheumatoid, psoriatic, dll), nekrosis avaskular, tumor, atau deformitas congenital. Osteoarthritis dan rheumatoid arthritis adalah penyebab dari mayoritas besar dari total joint arthroplasties.

 

Pengenalan dari “total condylar prosthesis” oleh Insall dan universitas pada 1972 secara umum disetujui sebagai awal dari era prosedur knee replacement yang “modern”. Lulut palsu ini adalah prosedur yang pertama mengganti ketiga kompartemen dari lutut.Ada variasi dari desain asli dan ada peningkatan minat pada parsial (unikompartemental) knee replacement.

Total knee arthrosplasty modern terdiri dari pengangkatan penyakit permukaan articulardari lutut yang diikuti dengan melapisi kembali dengan komponen metal dan polietilen prostetik. Untuk pasien yang dipilih benar, hasil dari prosedur ini secara signifikan menghilangkan rasa nyeri, memperbaiki fungsi dan kualitas hidup.Topik ini meninjauan aspek total knee arthroplasty termasuk pertimbangan pra-operasi, operasi dan pasca operasi. Dan sama dengan prosedur bedah mayor lainnya, komplikasi bisa terjadi selama atau setelah total knee arthroplasty.

 

III. 1 Indikasi

Indikasi utama untuk total knee arthroplasty adalah untuk mengurangi rasa nyeri yang berhubungan dengan arthritits di lutut pada pasien yang gagal dengan terapi non operatif. Sebagai contoh, terapi non operatif untuk pasien dengan osteoarthritis meliputi: modifikasi aktivitas, mengurangi berat badan, menggunakan tongkat, analgesic dan/atau obat-obatan nonsteroid antiinflamasi.

Intervensi nonoperatif pantas dipertimbangkan sebelum arthroplasty pada pasien dengan inflammatory arthritis (co: rheumatoid arthritis dan spondyloarthropathies). Total knee arthroplasty bisa diperlukan pada beberapa pasien dengan osteonecrosis. Meskipun hasil pada beberapa pasien bisa lebih jelek dari pasien yang mengalami osteo- atau inflammatory arthritis.

Pasien sebaiknya mempunyai radiografi yang mendokumentasi mengenai kemajuan perubahan reumatik. Jika rasa sakit di lutut tidak sesuai dengan tampilan radiografi, penyebab lain harus dicari sebelum arthroplasty dilakukan.

Pasien harus memiliki radiografi mendokumentasikan perubahan rematik maju. Jika rasa sakit lutut tampaknya tidak sesuai dengan tampilan radiografi penyebab lain harus dikeluarkan sebelum arthroplasty dikejar.

Koreksi dari deformitas dan memperbaiki fungsi sebaiknya merupakan pertimbangan hasil operasi yang sekunder dan bukan merupakan indikasi primer. Total knee arthroplasty bisa dilakukan pada pasien dari segala umur (kecuali secara skeletal belum matang).

Sendi palsu memiliki keterbatasan seumur hidup dan daya tahan dari alat tersebut tergantung dari faktor yang berhubungan dengan pasien dan arthroplasty. Pertimbangan tersebut antara lain:

  • Umur –angka daya tahan 10 tahun prosthesis dari 11.606 total knee arthroplasty primer yang dilakukan antara tahun 1978 dan 2000 untuk pasien yang berumur kurang dari 55 tahun dengan pasien yang berumur lebih dari 70 tahun sangat signifikan (83% banding 90%, masing-masing).
  • Penyakit penyebab – ketahanan prosthesis menjadi lebih pendek pada pasien dengan osteoarthritis daripada pada pasien dengan rheumatoid arthritis ( angka daya tahan 10 tahun prosthesis 90% banding 95%, masing-masing)
  • Faktor prosthesis dan bedah – tipe prosthesis, teknik fixasi (semen banding bukan semen) dan faktor lain seperti sparing dari cruciate ligament posterior juga mempengaruhi daya tahan prosthesis.

Dengan demikian, dari sudut pandang ketahanan prosthesis kandidat yang ideal dari total knee arthroplasty adalah pasien dengan umur lebih dari 70 tahun dengan rheumatoid arthritis. Namun, dari pertimbangan ketahanan prosthesis harus  seimbang dengan menghilangkan nyeri dan perbaikkan fungsional yang dapat diharapkan dari prosedur pada orang muda.

III. 2 Kontraindikasi

Total knee replacement sebaiknya tidak digunakan pada keadaan klinis seperti dibawah ini:

  • Infeksi yang aktif pada lutut atau diseluruh tubuh
  • Mekanisme ekstensor yang tidak berfungsi
  • Sirkulasi atau vaskularisasi ekstremitas yang jelek
  • Penyakit neurologis yang berpengaruh pada ekstremitas

 

III.3 Mortalitas

Secara garis besar angka 30 hari mortalitas dari total knee dan total hip arthroplasty adalah sama. Pada satu penelitian pada komunitas besar untuk arthroplasty di rumah sakit Veterans Amerika Serikat, 12.108 pasien dengan knee arthroplasty dan rata-rata angka 30 hari mortalitas adalah 0,6 persen dan tidak dipengaruhi ras dan etnik. Rata-rata angka 30 hari mortalitas untuk hip arthroplasty adalah 0,7 persen.

III. 4 Evaluasi pra operasi

Evaluasi pra operasi yang hati-hati harus dilakukan untuk menentukan diagnosa yang tepat, mengidentifikasi kebutuhan untuk operasi, membantu perencanaan operasi dan mencegah komplikasi pada periode perioperatif.Sebuah evaluasi pra operatif yang menyeluruh meliputi:

  • Riwayat penyakit
  • Pemeriksaan fisik
  • Pemeriksaan radiologi
  • Pemeriksaan laboratorium
  • Riwayat pengobatan alternative
  • Diskusi mengenai risiko dan keuntungan dari prosedur yang akan dilakukan
  • Pertimbangan untuk adanya donor darah

III.4.1 Riwayat penyakit

Gejala-gejala pasien harus didokumentasikan.Sangat penting untuk mendokumentasikan dan menyelidiki setiap riwayat penyakit punggung yang bersamaan (sering digambarkan sebagai nyeri pinggul oleh pasien), nyeri pinggul (seringkali digambarkan sebagai nyeri pangkal paha oleh pasien), atau mati rasa / baal, paresthesia atau sakit di kaki.Timbulnya gejala-gejala pada punggung dan panggul mungkin menandakan bahwa nyeri lutut akibat dari sakit di daerah tersebut, sedangkan keluhan neurologis mungkin timbul dari kelainan saraf tepi, root atau sistem saraf pusat. Pemeriksa juga harus menanyakan tentang nyeri betis / claudication yang dapat menandakan penyakit pembuluh darah tepi.

  • Onset – Jika pasien memiliki nyeri lutut, penting untuk didokumentasikan tanggal onsetnya. Perlu dicatat apakah rasa sakit pada saat onset itu bertahap atau jika timbul pada waktu terjadi traumatic yang spesifik.
  • Lokasi – Lokasi nyeri sebaiknya dijelaskan (contoh: medial, lateral, atau patellofemoral). Seringkali pasien akan menggambarkan lokasi-lokasi tersebut seperti didalam lutut, diluar lutut, atau dibalik tempurung lutut. Perlu diperhatikan jika sakitnya unilateral atau bilateral, dan jika bilateral sisi mana yang lebih sakit.
  • Keparahan dan efek fungsional – Tingkat keparahan rasa sakit dan bagaimana hal tersebut mempengaruhi aktivitas pasien sehari-hari dan kualitas hidup harus didokumentasikan. Aktivitas yang memberikan rasa sakit sebaiknya diketahui ( seperti naik turun tangga, terutama turun tangga sering mengakibatkan rasa sakit di daerah patellofemoral).
  • Terapi sebelumnya – catat semua terapi yang pernah pasien lakukan sebelumnya untuk nyeri lutut dan pengobatannya (NSAIDS, injeksi steroid, terapi fisik, terapi alternative, tindakan bedah)

Obat-obatan – obat-obatan pasien saat ini, termasuk semua dosis harus dicatat.Pada pasien yang menjalani total knee arthroplasty, perhatian khusus harus diberikan untuk obat-obatan berikutnya.

  • Aspirin dan non-steroid anti-inflamasi drugs (NSAIDS) – memberikan pengaruh pada perdarahan perioperatif. Disarankan untuk menghentikan obat-obatan ini sedikitnya satu minggu menjelang operasi.
  • COX- 2 inhibitor – Literatur memperdebatkan apakah COX-2 inhibitor mempunyai efek klinis yang signifikan untuk sistem koagulasi atau tidak. Salah satu penelitian prospektif dari 100 pasien yang menjalani total knee replacement dengan acak menerima rofecoxib atau placebo menunjukkan tidak ada perbedaan yang signifikan pada perdarahan perioperatif atau international normalized nation (INR) diantara kedua kelompok tersebut. Rofecoxib kemudian telah ditarik dari pasaran di seluruh dunia karena meningkatkan risiko yang serius kejadian kardiovaskular yang merugikan.

 

Penelitian lain menunjukkan adanya interaksi antara COX-2 inhibitor dan warfarin meskipun dalam berbagai tingkat dan dengan obat yang berbeda.

Keputusan akhir harus berbohong pada ahli bedah. Beberapa dokter bedah meresepkan selektif COX-2 inhibitoruntuk membantu untuk mengatasi nyeri post operasi, jadi lebih cepat harus dipelajari mengenai topic ini.

  • Antikoagulan -  Sebelum menjalani arthroplasty total lutut, pasien harus memiliki waktu prothrombin normal (PT) dan rasio normalisasi internasional (INR). Ini biasanya memerlukan penghentian warfarin minimal 3 sampai 5 hari sebelum operasi. Untuk pasien risiko tinggi (misalnya, pasien dengan katup jantung mekanik), pasien harus mengakui sebelum operasi. Heparin harus dihentikan 6 jam sebelum operasi dan waktu tromboplastin parsial harus diperiksa.
  • Antibiotik - Seperti disebutkan sebelumnya, arthritis septik aktif adalah kontraindikasi untuk total knee arthroplasty. Pasien dengan infeksi harus diselesaikan dari antibiotik setidaknya 48 jam sebelum operasi.
  • Insulin / obat hipoglikemik oral – insulin harus dikurangi atau diberikan dosis rendah tergantung jadwal operasi. Obat hipoglikemi oral harus tetap diberikan pada hari dilaksanakan operasi.
  • Glukokortikoid - Glukokortikoid idealnya diturunkan pada dosis serendah mungkin untuk mengurangi tekanan terhadap sistem kekebalan dan mengurangi risiko mengganggu penyembuhan luka. Tergantung pada dosis normal pasien, pasien terkadang diberikan steroid "stres dosis" pada periode perioperatif untuk menghindari kemungkinan yang timbul dari insufisiensi adrenal.
  • Anticytokin – Mempunyai hubungan antara terapi anti tumor nekrosis faktor alpha (TNF alpha) dan infeksi.

Alergi – alergi sebelumnya terhadap antibiotic dan jenis reaksinya (misalnya: ruam, sesak nafas, anafilaksis) harus secara jelas diketahui. Selain itu, pemakaian pasien dan toleransi atau intolerasi pada analgetik opioid harus diselidiki. Ketepatan dokumentasi akan mencegah kesalahan dalam periode perioperatif.

III.4.2 Pemeriksaan fisik

Pasien yang direncanakan mendapatkan total knee replacement perlu dilakukan pemeriksaan muskuloskeletal.Pemeriksaan yang tepat mengenai lutut ini meliputi observasi, palpasi dan penilaian dengan menggunakan test manual tertentu.

Observasi, mengobservasi gaya berjalan pasien dan bagaimana kulit pasien merupakan bagian yang penting dari pemeriksaan fisik.

  • Gaya berjalan
    • Antalgic gait

Pasien dengan artritis lutut sering berjalan dengan gaya ini, dimana pasien menjadi pincang karena menghindari nyeri karena menahan beban. Di tandai dengan fase berdiri yang sangat singkat.

(Dorland W.A. Dorland’s illustrated medical dictionary, penerjemah ; Huriawati Hartanto, dkk, editor. Philadelphia; 2000. )

  • Knee thrust

Gerakan abnormal dari lutut ke arah medial atau lateral ketika berjalan dapat mengindikasikan ketidakstabilan dari ligamentum.

  • Trendelenburg gait

Gaya berjalan pasien menjadi miring ke arah pinggul yang menderita sehingga mengurangi beban pada pinggul dan mengurangi nyeri.Hal ini dapat menunjukkan adanya kelainan pada sendi pinggul dan/atau kelemanahan pada m. Gluteus medius.

  • Kulit

Kulit pada kedua extremitas bawah diperhatikan apakah adanya abrasi, ulserasi, bengkak, merah, perubahan vaskular atau infeksi.Adanya infeki yang aktif merupakan kontraindikasi dilakukan bedah implant.Adanya luka lama atau sikatrik pada lutut perlu diperhatikan. Adanya deformitas yang kelihatan (contohnya : varus, valgus, rekurvatum, kontraktur fleksi) perlu diperhatikan. Adanya deformitas ini perlu dilakukan penilaian secara radiografi.

Palpasi, apabila terdapat efusi pada lutut maka dilakukan palpasi.Krepitus patellofemoral dapat dideteksi dengan menaruh tangan pada lutut dan secara pasif menggerakkan kaki.Adanya nyeri pada sendi bagian medial and lateral sering didapati pada artritis tetapi juga dapat mengindikasi adanya kelainan meniskus.Pulsasi distal, termasuk a. Dorsalis pedis dan a. Posterior tibialis, harus dinilai.

Penilaian dengan menggunakan test manual tertentu, ada berbagai manuver yang dilakukan  untuk penilaian preoperative, yaitu :

  • Range of motion

Menilai fleksi dan ekstensi maksimal lutut secara aktif maupun pasif.

  • Pemeriksaan otot

Kekuatan motorik diperiksa pada ekstremitas bawah secara menyeluruh dengan perhatian khusus pada mekanisme ekstensor / quadriceps.

  • Pemeriksaan saraf

Dilakukan pemeriksaan pada sensoris dan refleks deep tendon (patella dan ankle)

  • Pemeriksaan ligamen

Lateral collateral ligament (LCL) dan Medial collateral ligament (MCL) merupakan struktur yang sangat penting pada total knee replacement. Penting untuk melakukan penilaian preoperatif mengenai stabilitas atau derajat kontraktur dari ligamen-ligamen ini.

  • Collateral ligaments

Pemeriksaan LCL dan MCL dilakukan dengan memfleksikan lutut 30o pada posisi varus dan valgus masing-masing.  Pada posisi varus, LCL  menjadi lemah sedangkan MCL kontraksi. Pada posisi valgus, LCL kontraksi dan MCl yang lemah.Adanya MCL yang inkompeten menandakan bahwa diperlukannya koreksi yang lebih.

  • Cruciate ligaments

Anterior cruciate ligament (ACL) dikorbankan pada kebanyakan total knee replacement sehingga penilaiannya tidak krusial.Posterior cruciate ligament (PCL) dapat juga dikorbankan pada saat operasi.Penilaiannya dapat dilakukan dengan test posterior drawer dengan memfleksikan lutut 90o dan penekanan pada tibia posterior.

  • Pemeriksaan meniskus

Apabila pasien mempunyai gejala mekanik yang jelas seperti locking atau catching pada lutut dimungkinkan adanya robekan meniskus.Penggunaan arthroscopy yang sedikit invasif dapat menjadi suatu keuntungan pada pasien ini.Pemeriksaan meniskus dapat dilakukan dengan tes Mcmurray dan the Apley Compression test.

  • Pemeriksaan panggul dan tulang belakang

Penting untuk mengeksklusi nyeri menjalar dengan nyeri lutut yang berasal dari panggul dan tulang belakang.Perangsangan nyeri pada lutut dengan mengangkat tungkai yang diluruskan atau dengan menggerakkan panggul (terutama rotasi internal), dapat meningkatkan kecurigaan adanya kerterlibatan tulang belakang lumbar, panggul atau keduanya, sehingga memerlukan pemeriksaan imaging lebih lanjut.

III.4.3 Pemeriksaan radiologi

Berbagai model imaging dapat digunakan untuk membantu penatalaksanaan lutut yang sakit, yaitu:

  • Rontgen polos

Rontgen polos ini merupakan kunci diagnosa, perencanaan preoperatif dan penialaian postoperatif dari artritis dan total knee arthropalsty.Pemeriksaan minimum 3 posisi (foto anteroposterior, foto lateral dan patella sudut tangensial) lebih baik dilakukan.

  • Foto posisi Anteroposterior

Pasien berdiri dengan posisi yang paling nyaman agar tidak terbebandi sendi.Dilakukan penilaian pada ruang sendi medial dan lateral, apakah ada penyempitan atau tidak.

  • Posisi Lateral

Posisi ini dilakukan untuk menilai sendi paletofemoral dan posisi dari patella (contohnya patella baja, patellaalta)

  • Posisi patella sudut tangensial

Ruang sendi paletofemoral dapat dinilai pada posisi ini (‘sunrise’, ‘skyline’, atau merchant view)

Posisi lainnya juga kadang berguna. Posisi posteroanterior sudut 45o dilakukan agar pemeriksaan menjadi lebih akurat untuk melihat adanya penyempitan pada ruang sendi baik pada sisi lateral maupun medial. Film yang memotong 3 sendi dilakukan untuk dapat melihat kesinambungan dari tungkai secara struktur dan anatomis (contohnya varus, valgus) dan hal ini dapat membantu dalam perencanaan preoperatif.

  • MRI

Pada penilaian arthritis pemeriksaan MRI kurang begitu peka.Walau lebih sensitif dibandingakan dengan rontgen polos dalam menilai cartilago, seringkali hal itu disalahartikan dengan adanya kerusakan. MRI ini membantu dalam mengevaluasi meniskus dan kelainan ligamen yang dikarenakan proses degeneratif lanjut yang tidak dapat dilihat dalam rontgen polos.

  • Modal yang lain

CT dan bone scan dapat membantu dalam mengevaluasi postoperatif implant tetapi tidak menunjukan peran dalam evaluasi preoperatif arthritis.

 

III.4.4 Pemeriksaan Laboratorium

Laboratorium preoperatif dapat berbeda-beda tergantung dari keadaan pasien dan keperluannya, tetapi biasanya meliputi pemeriksaan darah rutin, kimia dasar dan koagulasi tes (protombine time, INR dan partial thromboplastine time).Pemeriksaan EKG dan rontgen toraks dilakukan tergantung pada umur pasien dan kebijakan anestesi. Urinalisis dan kultur urin juga dilakukan.

 

III.4.5 Risiko dan keuntungannya

Pasien harus mengerti benar mengenai risiko dan hasil yang berhubungan dengan operasi.Kesimpulan dari informasi ini diberikan secara tertulis untuk pasien.

Risiko

  • Anestesi dan kejadian intraoperatif

Seperti pada umumnya operasi mayor, ada risiko yang berhubungan dengan penggunaan anestesi dan kesalahan intraoperatif.

  • Tromboemboli

Deep venous thrombosis dan venous thromboembolism adalah komplikasi yang poten dan kadang-kadang mematikan.Risiko trombosis vena proksimal akibat operasi lutut dapat dikurangi dengan penggunaan antikoagulan, tetapi dapat juga timbul pada penggunaan dosis profilaxis warfarin, berat molekul rendah atau unfractioned heparin. Adanya clot pada vena proksimal didapati pada 7 – 10% pasien operasi lutut yang menggunakan obat-obatan profilaxis.

  • Infeksi

Komplikasi infeksi jarang tetapi serius.Infeksi sendi prostetik dapat disebabkan karena tinggal di rumah sakit yang lama, sehingga dibutuhkan pemindahan infeksi tersebut, pemberian antibiotik yang lebih lama dan diikuti dengan reimplantasi.

  • Kelainan paletofemoral

Berbagai kelainan pada sendi sekitar patelofemoral dan mekanisme ekstensor dapat terjadi, termasuk : subluksasi patella dan dislokasi, adanya komponen yang renggang, fracture, ‘clunk phenomenon’ dan ruptur dari mekanisme ekstensor (quadriceps atau ruptur tendon patella).

  • Kerusakan saraf

Kerusakan intraoperatif atau pascaoperatif pada saraf peroneal dapat terjadi dan mengakibatkan kelemahan muskulus tibialis anterios (drop foot) dan kehilangan sensorik.

  • Kerusakan arterial

Kerusakan pada a. Poplitea atau yang lain dapat menimbulkan peningkatan perdarahan dan membutuhkan perbaikan arteri. Arterial thrombosis dan / atau embolisasi perifer dapat timbul.

  • Fracture sekitar prostetik

Fracture proksimal sampai pada komponen femoral (fracture suprakondilar) atau distal sampai implant tibial dapat terjadi.

  • Masalah pada proses penyembuhan luka

Proses penyembuhan yang meningkat dapat meningkatkan risiko infeksi sendi sekitar dan membutuhkan bedah plastik untuk mencapai penyembuhan yang adekuat dari insisi dan fungsi dari pergerakan lutut tersebut.

  • Pemakaian prostetik dan kegagalannya

Pemakaian polyethylene dapat memprovokasi respon inflamasi dan kadang dapat menimbulkan kerenggangan prostetik.Apabila hal ini menyebabkan kegagalan lutut prostetik, revisi arthroplasty mungkin dibutuhkan.

Keuntungan

Keuntungan dari total knee arthroplasty ini adalah rasa sakit yang berkurang, pengembalian fungsi dan mobilitas.Perbaikan dari varus dan valgus dapat tercapai.Pada flexion contracture lebih sulit mengalami perbaikan.

  • Rasa sakit yang berkurang

Rasa sakit yang berkurang yang mengikuti penyembuhan dari total knee arthroplasty ini sangat bagus. Sebagai contohnya, dalam salah satu studi retrospektif dari 233 pasien dengan osteoarthritis posterior cruciate ligament, 91 % dari pasien tersebut dilaporkan hasil klinis yang baik. Keuntungan maksimal membutuhkan waktu untuk didapat. Hal ini diilustrasikan pada studi pasien yang mengalami total hip atau knee replacement. Kebanyakan pasien dengan total hip atau knee artheroplasty yang dikarenakan menderita osteoarhtristis yang parah mengalami perbaikan dalam nyeri dimana diperlukan satu tahun atau lebih untuk mencapai efek maksimal. Perbaikan dapat dicapai rata-rata berkisar sekitar tiga tahun.

  • Perbaikan fungsional

Ketika menjalankan aktivitas sehari-hari secara umum menjadi lebih mudah yang dikarenakan berkurangnya rasa sakit pada lutut setelah total knee arthroplasty, pemeriksaan fungsi lutut secara objektif (contohnya range of motion) sedikit mengalami perbaikan. Pada studi yang sudah disebutkan di atas, hanya 23 % lutut yang didapati memiliki fungsi lutut yang bagus ketika di follow up sekitar 17 tahun setelah operasi pertama. Hasil dari pascaoperasi yang diharapkan sangat tergantung dengan preoperatif.

  • Koreksi deformitas

Teknik bedah dapat membuat normal atau mendekati normal lutut posisi valgus.Knee flexion contractures dapat dikurangi pada sebagian besar kasus dengan seleksi komponen yang paling pas dan pelepasan jaringan lunak. Sebagai contohnya, pada satu studi retrospektif 542 arthroplasty lutut pada lutut yang mengalami flexion contractures, 95 % mengalami residual flexion deformities derajat 3 atau kurang, deformitas yang parah dapat kurang responsif dengan total knee arthroplasty.

III.5 Management postoperatif

Management postoperatif ini meliputi profilaxis melawan infeksi, vena tromboemboli dan terapi fisik yang paling cocok agar mendapatkan pergerakan lutut yang paling baik dan rehabilitasi yang aman yang dapat dipraktekkan.

  • Sekurangnya 24 jam setelah post opertative diberikan antibiotik profilaxis.
  • Profilaxis primer untuk trombosis vena dimulai. Penggunaan antikoagulasi sistemik heparin berat molekur rendah atau warfarin dengan dosis yang disesuaikan dapat digunakan kecuali pada keadaan kontraindikasi. Penulis menganjurkan dosis warfarin disesuaikan dengan target INR 1,8 – 2,2. Penanganan secara farmakologis dapat diikuti dengan compression stockings, alat / benda yang gunanya mengkompresi secra mekanik, dan mobilisasi awal.
  • Penanganan nyeri postoperatif yang pertama adalah dengan mendapatkan indwelling epidural catheter atau pasien mendapatkan analgesik yang terkontrol. Analgesik opioid oral dapat digunakan.
  • Tindakan pasien yang kooperatif saat mengikuti program rehabilitasi postoperative juga berperan dalam outcome yang sukses setelah total knee arthroplasty.  Intervensi yang diusahakan dalam menjaga pergerakan dari lutut dengan menggunakan immobilizer lutut dan bantal di bawah kaki yang mengalami operasi dapat menghindarkan dari flexion contracture. Latihan range of motion yang disupervisi oleh terapi fisik harus dimulai sesegera mungkin. Pada studi meta analisis 2007 mengenai lima trial secara random menyimpulkan pasien yang keluar dari rumah sakit dengan mengikuti program pelatihan fungsional yang disupervisi oleh terapis fisik mengalami kemajuan fungsi lutut dan pergerakan dalam jangka waktu yang pendek dibandingkan dengan routin care.

Penggunaan alat Continuous Passive Motion (CPM) cukup sering di berbagai institusi. CPM ini dipercaya dapat membantu penyembuhan lutut setelah operasi dengan cepat. Program dari terapis fisik yang terstruktur dengan baik termasuk range of motion, training gaya berjalan, membuat kuat m. Quadriceps dan training aktifitas sehari-hari merupakan komponen yang penting dalam proses rehabilitasi. Pada tahun 2004 studi meta analisis meliputi 14 studi yang membandingkan CPM ditambahkan terapis fisik dengan program terapis fisik saja, menyimpulkan bahwa pada kombinasi CPM dengan terapis memberikan hasil yang bagus dimana lutut aktif, mengurangi penggunaan analgesik, pengurangan lama tinggal di rumah sakit dan mengurangi kebutuhan untuk manipulasi lutut.

 

BAB IV

TEKNIK OPERASI

 

IV.1 PEMBUKAAN KULIT


Berbagai pembukaan bisa diterapkan pada knee arthroplasty, tetapi yang paling sering dipakai adalah pendekatan straight midline anterior. Insisi lurus mulai dari sekitar 6 cm diatas patella, dan diperpanjang kebawah melewati patella dan berhenti pada tibial tubercle. Menggunakan handuk lembut, kulit dibelah dan dipastikan bahwa sebagian besar jaringan dibawah kulit tetap tertahan dengan kulit.

          

Lalu pisau dalam dipakai dan tendon quadriceps dipotong ditengah-tengah dan insisi diperpanjang sampai permukaan atas patella. Sekali lagi dari batas bawah patella sampai tibial tuberosity insisi dibuat. Dua insisi tersebut digabung pada sisi medial menyusuri sepanjang batas medial  dari lutut. Dengan menggunakan kain kasa besar, patella ditahan antara ibu jari operator dengan jari telunjuk dan membalik keluar ke arah lateral sambil lutut difleksikan. Hal ini akan melenturkan patella secara lateral dan memberikan pandangan yang jelas interior dari lutut. Harus benar-benar hati-hati dalam langkah ini dan memastikan memberikan jarak di atas dan di bawah patella.

 
IV.2 TEKNIK JARINGAN LUNAK

 

Ketika ruang dalam dari lutut terlihat proses dari metode jaringan lunak untuk mencapai hal-hal berikut:

  1. Memberikan visualisasi yang jelas bagian dalam dari lutut
  2. Melepaskan struktur yang kontraksi dan mencapai keseimbangan jaringan lunak
  3. Untuk melepas peri capsular dari permukaan yang adekuat distal femoral dan upper tibial untuk mendapatkan translasi anterior-posterior dari femur melewati tibia dan sebaliknya.
  4. Jarak yang adekuat dari Osteophytes untuk visualisasi yang penuh dari permukaan articular.
  5. Melepas jaringan lunak untuk memungkinkan akomodasi dari semua jig dan alat-alat.

 

Semua perdarahan dihentikan dan dikoagulasi.Menggunakan cutting diathermy, bagian lemak patella dipotong untuk memungkinkan visualisasi yang lebih baik.Anterior cruciate dipotong untuk memungkinkan translasi anterior dari tibia melewati femur. Kedua menisci dibuang. Menggunakan nibbler, semua osteophyte dibuang dari sekeliling femur distal, tibia proximal dan patella. Lutut diluruskan dan dilihat apakah ada fixed varus, fleksi varus atau deformitas recurvatum. Jika hal-hal tersebut ada, langkah-langkah lebih lanjut akan dilakukan untuk mendapatkan keseimbangan dan lutut yang lurus pada 5 sampai 7 derajat dari valgus.

 

 IV.3 PEMOTONGAN FEMORAL DISTAL

 

 

Menggunakan drill bit 8mm dibuat lubang hanya pada anterior sampai insersi dari ligament anterior cruciate. Melewati lubang ini intra medullary rod dimasukkan. Distal femoris cutting guide dimasukkan kedalam ke dalam rod ini. Petunjuk dan operasinya tergantung dari tipe instrument yang dipakai. Beberapa petunjuk mengikuti untuk memilih pemotongan valgus dari rectus sampai 9 derajat dengan tambahan dua sampai tiga derajat.

 

 

Sistem lain bisa memilki fixed jig yang hanya pada 1 sudut saja. Terlepas dari sistem yang dipakai, satu yang harus dipastikan bahwa pemotongan distal femoral secara tepat parallel dengan dasar/lantai di depan axis belakang dan dalam beberapa derajat dari
valgus dari satu sisi

ke sisi lainnya.

 

IV.4 PEMOTONGAN TIBIAL ATAS

Berbagai macam jig tersedia untuk pemotongan ini dan hal ini bisa menjadi intramedular yang sama baiknya dengan ekstramedular. Tidak seperti femur yang yang
dilindungi oleh otot paha yang besar, aspek medial dari tibial yang memiliki subkutaneus yang banyak atau sedikit yang melewati garis tersebut dan tidak menjadi masalah apakah menggunakan petunjuk intra atau ekstra medular.

 

Kebanyakan petunjuk mempunyai ketetapan untuk beberapa derajat lekukan posterior dan pemotongan tibial atas harus tepat parallel dengan dasar lantai / dasar pada axis side to side dan dimiringkan ke posterior di depan axis belakang. Sekali potongan ini dibuat, lutut diluruskan dan diperiksa untuk koreksi yang lengap dari semua deformitas.

 

IV.5 PEMOTONGAN FEMORAL ANTERIOR DAN POSTERIOR DAN CHAMPERS


Menggunakan cutting guide yang tepat ukurannya, pemotongan anterior dan posterior dibuat. Potongan ini sebaiknya parallel dengan yang lain dan kedua permukaan harus paralel pada rotasi eksternal. Hal ini akan member tracking patella yang lebih baik. Potongan pada permukaan ini, dimana posisi komponen femoral pada rotasi internal adalah suatu bencana dan harus dengan teliti dihindari.

 

 IV.6 PEMOTONGAN PATELLA DAN PERSIAPAN

Menggunakan alat yang tepat, patella dipotong melewati setengah dari ketebalannya. Hal ini adalah dasar bahwa tulang yang secukupnya dipotong sehingga setelah memasukkan patellar prosthesis, ketebalan dari sisa patella ditambah dengan prosthesis harus sama dengan ketebalan patella sebelum dipotong.

 

IV.7 PERCOBAAN KOMPONEN DAN PERCOBAAN REDUKSI

Hole slot yang tepat dan tanda-tanda dibuat diatas permukaan potongan dari femur, tibia, dan patella. Metode dan sistem yang tepat adalah instrument dependent dan berbagai macam variasi dari desain ke desain lainnya. Komponen uji coba dimasukkan dan lutut diletakkan melewati jarak penuh dari pergerakkan lutut.

 

Tips-tips ini berguna terlepas dari sistem yang digunakan:

  • Jika lutut dapat ekstensi penuh dan goyang pada pergerakkan side-to-side, berarti salah satu menggunakan komponen tibia yang lebih tipis. Gunakan nomor diatasnya sampai lutut stabil di axis side-to-side pada ekstensi penuh.
  • Jika lutut tidak bisa diekstensi penuh, kemungkinan pelepasan bagian posterior tidak dilakukan atau ketebalan tibia terlalu tebal dan ketebalan satu nomor lebih kecil perlu digunakan.

 

  • Jika lempeng dasar tibia tidak terletak secara melingkar diatas tulang cortical dipermukaan pemotongan tibia atas atau jika lempeng tersebut berlebihan dengan komponen tibia yang menonjol melebihi tulang, pengukuran ulang tibia perlu dilakukan.
  • Jika patella tidak terletak pada femoral groove atau jika diperlukan menggunakan jari untuk menjaga patellar tracking kemudian pelepasan lateral merupakan kewajiban.

 

 IV.8 PROSTHESIS FINAL DAN FIXASI

Setelah uji coba reduksi sempurna, implant yang tepat dengan ukuran yang benar dikeluarkan dari bungkus steril dan dimasukkan tanpa semen. Reduksi uji coba dilakukan kembali karena perhatian ditujukan pada deformitas, laxities, dan patellar tracking. Setelah semuanya bagus, implant difixasi dengan atau tanpa semen tergantung dari desain implant dan metode dari fixasi itu sendiri.

 

IV.9 DRAINASE DAN PENUTUPAN

Luka dicuci dan dilihat untuk perdarahan-perdarahan yang masih terjadi. Semua titik perdarahan dicauter dan diligasi dan terlihat bahwa implant pada posisi yang benar. Tendon patella dibelokkan kembali ke medial. Dua buah drain digunakan yang tipenya bisa disambungkan dengan ke sistem suction yang tertutup.

Menggunakan benang sintetik tebal seperti Daxone atau vicryl (nomor 1), tendon patella ditutup. Jahitan subkutaneus dilakukan menggunakan vicryl 1,0. Kulit dijahit menggunakan nylon atau prolene nomor 1. Biasanya menggunakan jahitan continues.

 

BAB V

Minimally Invasive Total Knee Replacement

Adalah salah satu dari knee replacement invasive yang terakhir yang bisa digunakan akhir-akhir ini, dan didesain untuk membuat operasi dan rehabilitasi menjadi lebih mudah. Ini adalah teknik pertama yang secara spesifik didesain untuk memungkinkan ahli bedah melakukan operasi total knee replacement tanpa manipulasi atau sayatan pada tendon dan otot quadriceps yang mengontrol kelenturan dari lutut. MIS Quad-Sparing TKA meredakan sakit lutut dan memungkinkan beberapa pasien untuk pulih dan kembali pada pekerjaan dan kegiatan sehari-hari lebih cepat daripada mereka melakukan operasi knee replacement tradisional.

 

Gambar insisi Mini Total Knee Replacement

Operasi knee replacement tradisional sudah terbukti sangat sukses dalam meringankan rasa sakit dan mengembalikan mobilitas.Akan tetapi, rehabilitasi setelah operasi tradisional membutuhkan waktu yang lama dan menyakitkan.Orang sering menunda knee replacement karena tidak mau meninggalkan pekerjaan dan aktifitas sehari-hari selama beberapa bulan. Selain itu beberapa memperhatikan tentang lamanya bekas luka operasi.

Akhir-akhir ini alternatif baru mucul – Zimmer Minimally Invasive Solution TM (MISTM) Quad-Sparing TM total knee arthroplasty (TKA), sering disebut sebagai “mini total knee replacement”. Teknik ini menggunakan implant yang sama dengan total knee replacement tradisional tetapi invasinya lebih sedikit.

V.1 Keuntungan dari Zimmer MIS Quad Sparing Total Knee

  • Lebih sedikit trauma pada otot dan tendon-tendon dan otot quadriceps dapat dihindarkan dari pemotongan atau manipulasi.
  • Lebih kecil, insisi yang tidak terlalu kelihatan – 3 sampai 5 inci vs. 8 sampai 12 inci.
  • Total rehabilitasi lebih cepat
  • Lebih sedikit kehilangan darah
  • Lebih tidak menyakitkan
  • Lebih singkat waktu tinggal di rumah sakit

Sama seperti setiap operasi, hasil dari “mini total knee replacement” tergantung dari keadaan perorangan pasien, termasuk faktor-faktor yang bervariasi seperti tinggi badan, tingkat aktivitas, kualitas tulang, dan kesediaan pasien mengikuti program terapi fisik.

 

V.2 The Zimmer MIS Quad-Sparing TKA

Sebelum operasi, pasien mungkin membutuhkan satu atau dua unit darah.Meskipun prosedur mini total knee secara umum sedikit kehilangan darah dibandingkan dengan knee replacement tradisional, transfusi darah mungkin masih dibutuhkan selama operasi.Pasien harus dijelaskan juga oleh dokter keluarga atau dokter internisnya.

Operasi dilakukan dalam anastesi umum atau anestesi epidural regional, dimana membius setengah badan bawah dari pasien. Petunjuk dan alat khusus memungkinkan prosedur tersebut dilakukan dengan insisi yang lebih kecil yag telah dibahas sebelumnya. Kerusakan pada permukaan lutut telah dibuang dan ujung dari tulang dibentuk ulang untuk memungkinkan peletakkan implant. Implant tersebut aman untuk tulang dan jika diperlukan operator menyesuaikan ligament yang berada di sekeliling lutut untuk melindungi fungsi lutut yang tidak rusak. Sewaktu operator selesai dengan prosedur ini, insisi ditutup.

Operasi biasanya memakan waktu antara satu sampai tiga jam. Drain dimasukkan kedalam luka untuk mengurangi cairan yang terkumpul di daerah operasi, kemudian insisi dibungkus dengan perban yang steril.

Post-operasi lutut akan tetap membengkak dan nyeri untuk beberapa hari. Program rehabilitasi dimulai di rumah sakit sesegera mungkin setelah operasi. Sekitar empat sampai enam jam setelah operasi, pasien dibantu untuk berdiri, dalam 24 jam pertama pasien mulai bisa berjalan, biasanya menggunakan alat bantu. Sesegera setelah fisikal terapis memastikan pasien dapat berjalan dan dapat memanjangkan lutut dengan leluasa, pasien diperbolehkan pulang. Ini biasanya terjadi dalam 24 sampai 48 jam dari waktu operasi. Kemudian pasien akan diberikan program latihan di rumah dan fisikal terapi. Kunjungan oleh operator dalam satu sampai dua minggu setelah operasi.

Dalam minggu-minggu selanjutnya, kebanyakan pasien akan dapat berjalan menggunakan tongkat atau tanpa bantuan apapun. Beberapa pasien bahkan dapat kembali melakukan rutinitas kembali dalam tujuh sampai sepuluh hari setelah operasi. Tentu saja waktu pemulihan akan berbada tergantung individu masing-masing.

Tujuan dari total knee replacement adalah untuk mengurangi rasa sakit dan kekakuan dan memungkinkan untuk kembali beraktifitas seperti biasa. Tetapi tentu saja masih ada beberapa larangan seperti olah raga yang berat atau aktifitas yang mengakibatkan lutut menegang secara berlebihan tidak diperbolehkan.Operator dan para staf memberikan panduan yang jelas kepada setiap pasien, dan mengikutinya untuk kepentingan terbaik pasien. Perbaikan dari prosedur total knee dapat diterapkan, tetapi biasanya operasi yang kedua tidak seefektif yang pertama.

V.3 Perbandingan Prosedur Knee Replacement

MIS Quad-Sparing TKA vs. Traditional Total Knee Replacement

 

  Insisi Jaringan yang trauma
Zimmer MIS Quad-Sparing TKA 3 sampai 5 inci Tendon dan otot quadriceps tendon and muscles dihindari
Traditional Knee Replacement 8 sampai 12 inci Tendon dan otot quadriceps dipotong atau dimanipulasi

 

BAB VI

UNICONDYLAR  KNEE REPLACEMENT

Ketika cartilago pada satu bagian lutut mengalami kerusakan, ahli bedah mungkin dapat mengganti hanya bagian yang rusak dari sendi tersebut. Prosedur ini disebut partial atau unicompartmental atau unicondylar knee replacement.

Implant untuk operasi unicondylar knee replacement meningkat pesat sejak awal tahun 1970an, ketika bagian bedah mulai memperkenalkan. Hasilnya, operasi partial knee replacement menjadi popular.Sekitar 7500 unicondylar knee replacement dilakukan setiap tahunnya di Amerika Serikat.

Meskipun insisinya lebih kecil dengan unicondylar knee replacement dan perawatan biasanya hanya 1 hari, hasil jangka panjang mungkin tidak sebagus total knee replacement. Sebagai tambahan, prosedur operasi kedepan mungkin lebih susah ketika sudah melakukan operasi partial replacement. Pasien yang ideal untuk operasi partial knee replacement adalah seseorang yang mempunyai arthritis hanya pada satu bagian dari lutut dan tidak lebih. Pasien dengan usia dibawah 60 tahun dengan gaya hidup terlalu lama duduk bisa menjadi kandidat.

 

VI.1 Teknik Operasi

  • Pada prosedur ini hanya bagian yang rusak dari sendi lutut yang diganti melalui insisi yang lebih kecil daripada total knee replacement normal yang biasa digunakan.
  • Operator membuat insisi kecil sepanjang lutut yang luka untuk membuka sendi lutut.
  • Sebagian kecil tulang dapat dilepas untuk membuat ruangan untuk komponen tibia yang baru.
  • Meniscus yang rusak dilepas dan terkadang sedikit tulang juga dapat dilepas untuk menyesuaikan komponen plastic yang baru.
  • Komponen plastic dimasukkan ke area yang disediakan. Dapat dilakukan penekanan atau semen dapat digunakan untuk memfixasi pada tempatnya.
  • Operator berkonsentrasi pada femur dan luka pada femur dibuang.

  • Condylus femoral dipersiapkan dengsn membuang bagian yang rusak. Bagian dari tulang juga bisa dibuang untuk membuar jalan untuk komponen femoral yang baru.

  • Komponen dari metal yang baru dipasang pada tempatnya. Semen bisa ditambahkan untuk memfixasi komponen tersebut.
  • Komponen femoral dan tibial difixasi pada tempatnya dan lutut ditaruh pada batas pergerakan.

 

 

 

 

 

  • Otot dan tendon kemudian diperiksa kembali.
  • Drain dapat diletakkan ditempatnya.

VI.2 Risiko dan komplikasi

Komplikasi dapat medikal (general) atau komplikasi lokal yang spesisfik pada lutut itu sendiri.

Komplikasi medikal, termasuk segi anestesi. Hampir semua kondisi medis dapat timbul, komplikasi itu adalah :

  • Reaksi alergi terhadap medikasi
  • Perdarahan yang memerlukan transfusi
  • Heart Attack, stroke, gagal ginjal, pneumonia, ada infeksi kandung kemih.
  • Komplikasi dari saraf, contohnya : adanya infeksi atau kerusakan saraf.
  • Masalah medis yang serius dapat menjadi masalah kesehatan yang perlu diperhatikan, hospitalisasi yg lebih lama.

Komplikasi lokal

  • Kekakuan pada lutut

Idealnya lutut kita dapat fleksi hingga melebihi 100◦ tetapi pada kondisi tertentu, lutut tidak dapat di fleksikan.

  • Iritasi pada luka

Pada saat operasi, terjadi pemotokan saraf kulit sehingga terdapat rasa kesemutan pada luka tersebut.Hal ini tidak mempengaruhi fungsi dari sendi lutut tersebut.Dapat juga dirasakan nyeri pada luka. Pemberian vitamin E cream dan pijat dapat mengurangi hal ini. Pemberian antibiotik atau bedah lebih lanjut dialkukan apabiala ada reaksi pada jaringan luka.

  • Infeksi

Infeksi yang terjadi dapat secara superficial atau dalam. Jikalau timbul, dapat ditangani dengan antibiotika atau bedah lanjut,

  • Blood clot (deep venous trombosis)

Gumpalan ini terbentuk pada betis dan dapat berjalan ke paru (emboli paru).Hal ini dapat menjadi suatu hal yang serius dan dapat membahayakan jiwa.Apabila adanya nyeri pada bagian betis atau sesak napas segera hubungi dokter bedah yang menangani anda.

  • Kerusakan pada saraf atau pembuluh darah

Hal ini jarang tetapi dapat menjadu kelemahan atau hilangnya sesasi pada sebagian tungkai bawah.Kerusakan pada pembuluh darah apabila terdapat perdarahan terus menerus, maka diperlukan operasi lanjutan.

  • Wear (tutup / cover)

Plastic liner seringkali digunakan lebih dari batas waktu, biasanya dalam 10-15 tahun, penutup tersebut perlu diganti.

  • Penampilan / kosmetik

Lutut dapat terlihat berbeda dari sebelumnya.

  • Dislokasi

Kondisi yang sangat jarang dimana akhir dari sendi lutut tersebut tidak saling menyambung atau platik buatan tidak menyambung dengan tibia (shinbone) atau pada femur (thigh bone).

  • Masalah patella

          Pada patella dapat terjadi dislokasi. Apabila berubah tempat dari yang seharusnya, maka dapat menjadi kendor atau patah.

  • Luka pada ligamen

          Ligamen-ligamen yang ada di sekeliling lutut dapat robek karena operasi atau tertarik. Dokter bedah harus memperbaiki masalah ini.

  • Fracture

          Dapat terjadi selama operasi berlangsung atau saat kita jatuh. Untuk memperbaiki ini perlu dokter bedah.

 

BAB VII

VENOUS THROMBOEMBOLISM

Venous thromboembolism (VTE) terjadi karena pembentukan bekuan darah yang tersumbat di dalam vena, membatasi aliran darah yang melewati vena.Hal ini paling sering terlihat pada vena profunda pada tungkai bawah, femoral atau pelvis (deep vein thrombosis, DVT).Terkadang, bagian dari bekuan lepas, berjalan melewati sistem vena, dan tersangkut pada bagian tubuh lainnya.Ketika bekuan tersebut tersumbat di paru-paru (pulmonary embolism, PE), dapat menjadi fatal.Di seluruh dunia, VTE menimbulkan angka morbiditas, angka mortalitas serta angka pengeluaran yang tinggi.

Di Amerika Serikat, insiden dari VTE yang pertama kali sekitar 120 dari 100.000 orang per tahun. Insiden ini sangat bervariasi tergantung dari usia dan jenis kelamin penderita. Pada anak-anak umur 14 tahun atau lebih muda, insidennya adalah 1 dari 100.000 orang per tahun, dan pada dewasa umur 85 tahun keatas, hampir 1000 dari 100.000 orang pertahunnya.

Angka ini lebih tinggi pada wanita pada usia subur dan juga pada laki-laki dengan usia 50 tahun ke atas. Hampir sepertiga dari penduduk yang mempunyai riwayat VTE, dapat terjadi kejadian VTE yang kedua pada 10 tahun kedepan.

Angka mortalitas keseluruhan dari VTE adalah 30% dalam tiga bulan di setiap kejadian. Suddent death terjadi hampir 25% pada pasien PE, dengan hampir 40% kematian terjadi dalam tiga bulan.

Di United Kingdom, pulmonary embolism kedua dengan DVT pada pasien rawat inap menyebabkan antara 25.000 sampai 32.000 kematian setiap tahunnya. Sekitar 10% dari semua pasien yang meninggal di rumah sakit, PE merupakan penyebab yang mendadak. Angka ini lebih dari total kombinasi kematian dengan kanker payudara, AIDS, dan kecelakaan lalul lintas. Kurang dari 1 diantara 10 orang PE yang fatal didiagnosis sebelum kematian.Tidak dapat disangkal bahwa VTE merupakan penyakit yang tenang dan sulit untuk diketahui tetapi sangat bisa untuk dicegah.

 Gambar Venous Thromboembolism

VII.1 Pathogenesis

VTE berkembang sebagai hasil dari beberapa faktor yang bersamaan pada waktu operasi.Faktor-faktor yang mempengaruhi thrombosis vena – statis, kerusakan vascular, dan hiperkoagulabilitas – yang digambarkan oleh trias Virchow’s.Dipercaya bahwa operasi besar pada ortopedi, merusak bone marrow, impaksi oleh semen tulang, statis selama prosedur operasi, pencetus kuat dari terbentuknya thrombin secara local dan sistemik dan aktivitas yang menyebabkan terjadinya formasi thrombus pada bagian yang dioperasi atau bagian lain yang resisten (locus minoris resistentia).

Bagian dari sisa-sisa sumsum tulang dan agregat sel dapat menyebabkan keadaan klinis yang parah selama dan segera sesudah operasi, yang mungkin terjadi pada beberapa organ seperti paru-paru, otak dan miokardium. Thrombin berhubungan dengan proses penyembuhan inflamasi dan dapat menempatkan pasien tertentu pada risiko terjadinya tromboemboli vena dan arteri untuk waktu yang lama setelah operasi. Kondisi klinis yang menyebabkan statisnya aliran darah, kerusakan pembuluh darah, atau meningkatkan kecenderungan menuju koagulabilitas, dapat mempengaruhi terjadinya VTE.

 

Table 1 Inherent disorders that predispose to venous thromboembolism

  • Antiphospholipid syndrome
    • Primer, tanpa penyakit autoimun lainnya seperti SLE
    • Sekunder dengan SLE dengan LA (dengan aCL)
    • Sekunder dengan SLE tanpa LA (dengan aCL)
    • Sekunder, dengan penyakit autoimun lainnya atau dikarenakan obat
    • Myeloproliferative disorders – termasuk polisitemia vera, pada daasarnya thrombositosis
    • Hiperhomositenemia – kadar plasma homositein puasa diatas 40 μmol/L pada wanita; 18 μmol/L pada laki-laki
    • Defisiensi antithrombin – Heterozygotic
    • Defisiensi Protein C  – Heterozygotic
    • Defisiensi Protein S  – Heterozygotic
    • Mutasi Factor V Leiden – Heterozygotic
    • Mutasi Factor II  – Heterozygotic
    • Mutasi Factor V or II  – Homozygotic
    • Riwayat venous thromboembolism sebelumnya
      • Proximal saphenous/superficial vein thrombosis
      • Proximal with or without distal deep-vein thrombosis
      • Hanya distal deep vein thrombosis
      • Pulmonary embolism
      • Additional risk caused by clinical idiopathic VTE event
      • Riwayat keuarga adanya venous thromboembolism – pada keluarga pertama, orang tua atau saudara kandung.

aCL: anticardiolipin antibodies; LA: lupus anticoagulant; SD: standard deviation; SLE: systemic lupus erythematosus.

Table 2 faktor risiko umum yang mempengaruhi venous

  • Karakteristik umum pasien
    • Jenis kelamin – laki-laki
    • Umur >40 tahun (risiko meningkat dengan bertambahnya usia, maksimum pada usia lebih dari 70 tahun)
    • Golognan darah / goloongan Non- O
    • Obesitas / BMI > 30 kg/m2
    • Perokok
    • Terapi kontrasepsi oral dengan kombinasi esterogen / progesteron
    • Terapi hormone replacement therapy combined estrogen/ progesterone
    • Menggunakan obat spesifik – dengan protective effects seperti statins, aspirin
    • Kondisi klinis saat ini (kurang dari 3 bulan)
      • Menjalani operasi besar (3 bulan), lebih jika terdapat komplikasi yang berhubugan dengan operasi
      • Myocardial infarction – dalam 3 bulan terahir
      • Ischemic stroke dalam 3 bulan terakhir, mengabaikan paralisis
      • Perjalanan panjang – lebih dari 6 jam
      • Dehidrasi – dehidrasi berat dengan kehilangan berat badab 10%
      • Hematokrit yang meningkat >45% untuk wanita; >50% untuk laki-laki
      • Hyperviscosity ‡ – meningkatnya viscositas darah
      • Kondisi klinis kronik
        • Keganasan
          • Risiko bertambah dengan meningkatnya stage
          • Risiko lebih tinggipada kanker metastatis
          • Risiko bertambah jika terdapat tipe spesifik yaitu pancreatik, gastrointestinal, ovarian, prostatik, pulmonary, malignant glioma (dibanding dengan buka keganasan)
          • Radioterapi
          • Chemotherapy
          • Hormonal therapy
  • Gagal jantung / kelainan jantung (semakin tinggi staging NYHA, semakin tinggi risikonya)
  • Chronic respiratory disease – chronic obstructive pulmonary disease atau emphysema
  • Nephrotic syndrome – sindroma dari proteinuria, hypoalbuminemia dari
  • Kesakitan yang parah dan akut
    • Dengan rawat inap
    • Systemic sepsis (septicemia)
  • Immobilisasi
    • Terkurung dalam tempat tidur atau kursi roda  >3 hari
    • Paralisis tungkai bawah (hemiplegia/paraplegia/ neurological disease)
  • Inflammatory bowel disease – Crohn’s disease dan ulcerative colitis
  • Venous insufficiency
    • Varicose veins, penonjolan vena superficial pada waktu berdiri
    • Pembengkakan tungkai bawah, tidak nyaman
    • Ulcerasi
  • Penyakit arteri pada tungkai bawah – intermittent claudication
  • Diabetes – termasuk kedua tipe 1 dan 2 dari setiap etiologi
  • Meningkatnya tingkat trigliserid
  • Menurunnya tingkat HDL

Normal relative serum viscosity ranges from 1.4–1.8 units; symptoms usually are not seen at viscosities of less than 4 units, and the hyperviscosity syndrome typically requires

a viscosity greater than 4 units; ASA: acetyl salicylic acid; BMI: body mass index; NYHA: New York Heart Association; HDL: High Density Lipoprotein

VII.2 Diagnosis

Diagnosis awal penting untuk mencegah morbiditas dan mortalitas yang berhubungan dengan VTE.Pemeriksaan fisik dan penilaian kemungkinan yang detail memberikan informasi yang berguna untuk kemungkinan antara DVT dan PE.

VII.2.1 Peraturan kemungkinan klinis pada pasien non-bedah

Berdasarkan penilaian kemungkinan pre-test dari VTE, DVT dan PE, ditetapkan keputusan untuk keadan klinis, seperti peraturan kemungkinan Wells, yang sering digunakan.Peraturan ini kombinasi dari berbagai komponen yaitu anamnesa, pemeriksaan dan invetigasi, dan menyederhanakan prosedur diagnostik, meningkatkan akurasi klinis dan mengurangi biaya keseluruhan dari investigasi yang dibutuhkan. Peraturan Wells member hasil yang lebih baik pada pasien yang lebih muda tanpa co-morbiditas atau dengan riwayat VTE,pada pasien yang lebih tua dan pasien dengan co-morbiditas, pemeriksa menyarankan untuk mempercayakan pada pertimbangan pemeriksaan.

VII.2 Diagnosis

Diagnosis awal penting untuk mencegah morbiditas dan mortalitas yang berhubungan dengan VTE.Pemeriksaan fisik dan penilaian kemungkinan yang detail memberikan informasi yang berguna untuk kemungkinan antara DVT dan PE.

VII.2.1 Peraturan kemungkinan klinis pada pasien non-bedah

Berdasarkan penilaian kemungkinan pre-test dari VTE, DVT dan PE, ditetapkan keputusan untuk keadan klinis, seperti peraturan kemungkinan Wells, yang sering digunakan.Peraturan ini kombinasi dari berbagai komponen yaitu anamnesa, pemeriksaan dan invetigasi, dan menyederhanakan prosedur diagnostik, meningkatkan akurasi klinis dan mengurangi biaya keseluruhan dari investigasi yang dibutuhkan. Peraturan Wells member hasil yang lebih baik pada pasien yang lebih muda tanpa co-morbiditas atau dengan riwayat VTE,pada pasien yang lebih tua dan pasien dengan co-morbiditas, pemeriksa menyarankan untuk mempercayakan pada pertimbangan pemeriksaan.

VII.2.4 Diagnosis radiologi

Jika hasil pre-test probabilita dari pulmonary embolism adalah intermediet sampai tinggi, pasien disarankan untuk melakukan pemeriksaan diagnostik radiologi. Radiologi ini meliputi ventilation-perfusion (V/Q) scans, multi detector helical computed axial tomography (CT), dan/ atau pulmonary angiography. Saat ini disarankan bahwa CT scan saja tidak cukup sensitive untuk mendeteksi pulmonary embolism pad pasien yang mempunyai pre-test probabilitas yang tinggi pada pulmonary embolism. Saat CT scan negative, direkomendasikan dilakukan pemeriksaan radiologi yang selanjutnya. Yaitu single atau rangkaian penilaian ultrasound pada ekstremitas bawah atau pulmonary angiography.

VII.3  Penyebab penyakit dan rekurensi

Deep vein thrombosis biasanya terjadi pada satu tungkai, tetapi tidak selalu.Pada pasien non-bedah, gejala klasik seringkali tidak jelas, progresif, dan “sensasi tarikan” yang mengganggu pada betis bawah.Setelah itu perasaan ini menjadi lebih berat dan disertai dengan rasa panas, bengkak, dan eritem.Mungkin bisa mnimbulkan nyeri di sepanjang daerah vena yang terlibat dan vena mungkin teraba.Bisa terjadi meningkatnya turgor kulit dan distensi dari vena superficial.Kolateral vena dapat menjadi mencolok.Tanda Homan’s (nyeri yang berhubungan dengan pergerakan dorsofleksi dari sendi ankle) mungkin juga ditemukan.

Pada kasus yang tidak biasa dari thrombosis adalah vena iliaca, femoral, atau politeal, arus balik vena yang dapat dikompromikan, dapat menyebabkan iskemik.Daerah dibawah vena yang tersumbat dapat berwarna biru, bengkak, dan sakit.Hal ini mengarah seperti phlegmasia cerulea dolens. Dengan meningkatnya bekuan dan pembengkakan, vena sama halnya dengan arteri, keduanya bisa terganggua dan meyebabkan kepucatan, phlegmasia cerulea dolens, yang dapat menyebabkan gangrene dan bisa mengarah ke amputasi.

Komplikasi DVT yang sering dan serius adalah pulmonary embolism.Hal ini terjadi ketika bekuan di vena tungkai terlepas dan berjalan menuju ke paru-paru.bekuan bisa sebagian atau seluruhnya menghambat arteri di dalam paru-paru dan menyebabkan nyeri dada atau rasa tidak nyaman, nafas pendek yang tidak bisa dijelaskan, nafas yang cepat pada saat istirahat, batuk darah tiba-tiba, dan detak jantung yang cepat. Embolus yang besar dapat menyebabkan terhambatnya pembuluh darah ke kedua paru-paru dan berakibat fatal; hal ini adalah penyebab yang sering dari kematian mendadak yang tidak terduga.

VII.4 Penanganan dari Venous thromboembolism

VII.4.1 Pencegahan

Profilaxis rata-rata dari VTE sedikit rendah di seluruh dunia.Profilaxis dari VTE, normalnya menggunakan heparin, atau low-molecular-weight heparin (LMWH), dipakai secara luas untuk pasien dengan risiko operasi tetapi kurang sering pada pasien medis yang berisiko. The Epidemiologic International Day untuk penelitian Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) merupakan survey cross-sectional multinational yang menunjukkan bahwa hanya 58,5% dari pasien bedah dan 39,5% dari pasien medis menerima profilaxis untuk VTE. Spencer et al, menemukan bahwa beberapa VTE didiagnosis dalam 3 bulan setelah perawatan daripada yang sedang menjalani perawatan. Hingga kini, rumah sakit yang rutin menggunakan profilaxis dapat mengurangi insiden dari pasien yang terkena VTE.Profilaxis untuk VTE harus dilanjutkan diluar rumah sakit untuk mencegah perkembangan mengarah ke DVT dan gejala DVT.

VII.4.2 Farmakologi dan mekanisme intervensi

Umumnya unfractioned heparin (UFH) dan LMWH efektif untuk mencegah terjadinya VTE.Heparin dan warfarin dipercaya menjadi nilai yang lebih rendah.Meskipun terdapat bukti yang kuat bahwa aspirin mencegah arterial thrombosis, ini berperan dalam mencegah venous thrombosis diragukan.Selain pendekatan farmakologi, kompresi fisik pada vena, mobilisasi awal, dan pencegahan dehidrasi dapat juga menjalankan peran sebagai pencegahan VTE, tetapi intervensi mekanik tidak berarti mngganti profilaxis kimia.

VII.4.3 Profilaxis

Pilihan antikoagulan profilaxis kini membuat sulit bagi dokter maupun pasien. Tantangan yang dihadapi termasuk:

  • Membutuhkan pemberian parenteral
  • Mengganggu pasien
  • Interaksi makanan dan obat
  • Sempitnya terapi
  • Meningkatkan risiko perdarahan
  • Risiko serius lainnya

Beberapa perbedaan langkah pada kaskade koagulasi dapat ditargetkan pada pencarian obat yang baru yang dapat ideal untuk venous thromboprophylaxis. Strategi profilaxis VTE yang ideal dapat mempunyai karakteristik sebagai berikut:

  • Pemberian oral
  • Dapat mengurangi VTE
  • Tidak membutuhkan monitoring koagulasi.

VII.4.4 Pengobatan

Tujuan dari terapi dari VTE adalah untuk membantu thrombolysis, mencegah thrombus berkepanjangan dan PE, dan mengurangi insiden dari berulangnya VTE dan PPS.Tujuan tambahan adalah untuk mencapai pilihan terapi yang menyebabkan minimalnya efek samping dan gangguan pasien.

VII4.4.1 Anticoagulation

Antikoagulasi adalah andalan dari pengobatan VTE. Terapi antikoagulasi untuk PE dan DVT tanpa komplikasi menggunakan obat antikoagulasi yang sama. pengobatan pertama untul VTE adalah dengan heparin untuk lima sampai sepuluh hari. Digunakan secara oral antikoagulan untuk minimum tiga bulan.Terapi rawat jalan dengan LMWH telah diganti dengan pengobatan rawat inap dengan intravena UFH seperti yang paling sering digunakan sebagai obat antikoagulan.

Beberapa penelitian menegaskan bahwa LMWH fixeddose subkutan yang tidak dimonitor paling kurang efektif dan aman sebagai dosis biasa UFH iv untuk mengobati pasien dengan VTE. Dalam penelitian pasien dalam LMWH mempunyai episode yang lebih sedikit perdarahan besar dan juga secara signifikan mengurangi mortalitas selama 3 sampai 6 bulan dalam follow up, dibanding dengan UFH. Monitoring laboratorium yang kontinu tidak diperlukan.Untuk sebagian besar pasien, pasien rawat jalan dengan terapi LMWH sc aman dan efektif.

Meskipun pasien dengan risiko tinggi komplikasi perdarahan, pengobatan awal dengan iv UFH dapat digunakan karena mempunyai waktu paruh yang pendek dan kemungkinan untuk membalikkan efek antikoagulan dengan protamine sulfat. Pengobatan jangka panjang dengan terapi UFH dapat dihubungkan dengan komplikasi seperti heparin induce trombositopenia dan osteoporosis. Komplikasi ini lebih jarang dibanding LMWH.Obat lainnya adalah hirudin, lepirudin dan derivate coumarin (warfarin) lebih jarang dipakai untuk antikoagulan awal.

Durasi dari antikoagulasi tergantung dari setiap pasien.Umur, pribadi, dan riwayat keluarga dari VTE, dan adanya co-morbiditas dan faktor risiko harus perhitungkan sebelum menetukan panjangnya terapi antikoagulasi.Obat yang paling sering digunakan untuk antikoagulasi jangka panjang adalah Vitamin K antagonis oral  dalam kelas coumarin, seperti warfarin.

VII.5 Review tentang Dabigatran Etexilate®

VII.5.1 Latar belakang

Lebih dari lima decade, vitamin K antagonis warfarin sudah menjadi standart koagulan oral jangka panjang yang dipakai secara klinis. Meskipun efektif, obat ini masih banyak kekurangan.Beberapa dari faktor yang mempengaruhi keefektifan warfarin dalam thromboprophylaxis meliputi perbedaan genetic saat metabolism, asupan vitamin K, konsumsi alcohol, dan meminum obat bersama-sama dengan obat. Dosis sehari-hari warfarin dapat bervariasi secara luas, dari kurang dari 1 sampai lebih dari 20 mg/hari, berdasarkan pemeliharaan pasien dalam batas target International Normalized Ratio (INR). Dengan demikian pengawasan ketat dan perbaikan dosis sangat dibutuhkan.Warfarin juga merupakan reaksi onset yang lambat.Ketika antikoagulasi cepat dibutuhkan, pasien mendapat terapi antrithrombin parenteral bersamaan dengan heparin.Panjang waktu paruh dari warfarin, yang dikombinasi dengan waktu paruh dari vitamin K berdasarkan faktor pembekuan, juga berkontribusi pada onset reaksi yang lambat.Obat antikoagulan alternative juga dibutuhkan diberikan secara oral.

Obat antikoagulan oral baru Pradaxa® memberikan harapan. Penelitian menunjukkan bahwa obat ini mempunyai onset dan offset reaksi yang cepat dan menunjukkan antikoagulan yang dapat diprediksi, mengurangi kebutuhan untuk memonitor koagulasi. Obat ini tidak menunjukkan adanya interaksi dengan makanan dan potensial untuk berinteraksi dengan obat lain juga dipertimbangkan rendah.

Setelah persetujuan dari EMEA pertemuan ilmuwan (CHMP), dabigatran etexilate diluncurkan dengan nama dagang Pradaxa® di negara-negara Europe pada tahun 2008, dan sekarang dipasarkan di di seluruh negara anggota Europe. Obat ini diindikasikan untuk mencegah terajdinya venous thromboembolism pada pasien yang telah menjalani operasi THR/TKR. Obat ini juga dipasarkan di Kanada dengan nama dagang Pradax®.

VII.5.2 Mekanisme aksi

Interaksi antara beberapa faktor pro- dan antikoagulan mempertahankan keseimbangan antara hemostasis dan thrombosis yang normal.Ketika terdapat luka pada dinding dari pembuluh darah, faktor jaringan dan unsur pokok subendothelial lainnya dikeluarkan.Faktor jaringan berinteraksi dengan faktor VII aktif untuk membentuk thrombin.Thrombin merubah fibrinogen ke fibrin dan merupakan pemeran utama dalam formasi thrombus.

Thrombin juga mengaktifkan faktor XI, faktor V dan faktor VIII.Hal ini mengakselerasi produksi molekul thrombin tambahan.Sebagai tambahan, thrombin mempercepat aktivasi platelet.Bekuan darah berikatan dengan thrombin lalu mengaktifkan kaskade koagulasi.Dengan demikian thrombin memegang peranan penting pada tiga fase dari inisiasi kaskade koagulasi, perkembangan dan pembentukan bekuan darah. Oleh karena itu thrombin adalah target tepat untuk menginhibisi terbentuknya kaskade bekuan darah. Sebagian besar antikoagulan natural seperti anti-thrombin dan sistem protein C berperan melawan produksi maupun aksi dari thrombin.

Dabigatran etexilate merupakan inovatif kelas terbaru dari antikoagulan, yang mengarah sebagai direct thrombin inhibitors (DTIs), dimana mengikat secara langsung dan reversible pada thrombin dan menghambat proses pembekuan. Dabigatran etexilate secara spesifik dan selektif menghambat ikatan fibrin amupun thrombin bebas dengan mengikat sisi aktif dan mencegah konversi dari fibrinogen ke fibrin.Dengan demikian menghambat perkembangan dari thrombus.

Molekul thrombin mempunyai tiga sisi dimana inhibitor thrombin dapat bekerja: exosite 1, exocsite 2, dan site A aktif. Exosite 1 adalah tempat melekatnya fibrin, sedangkan exosite 2 adalah tempat heparin melekat.Heparin secara tidak langsung menghambat thrombin dengan mengkatalisasi fungsi dari anti-thrombin.Heparin menginduksi perubahan konformasi antithrombin, dimana kemudian secara permanen mengikat sisi aktif dari thrombin dan menghambatnya.

Seperti direct thrombin inhibitor (DTI), dabigatran adalah bentuk anti-thrombin tidak terikat dan secara langsung mengikat dengan sisi aktif dari molekul thrombin dengan interaksi hidrofobik. Ketika DTI bivalent dapat berikatan dengan exosite 1 dan sisi aktif, DTI univalent, seperti dabigatran, mengikat hanya sisi yang aktif. Secara langsung memblok thrombin, dabigatran memblok konversidari fibrinogen ke fibrin, aktivasi platelet, dan regulasi dari faktor V,VIII dan IX.

Dalam perbedaan yang lain, DTI dapat bereaksi pada keduanya (larutan) sama baiknya ikatan fibrin thrombin, ketika heparin complex antithrombin tidak dapat berinteraksi dengan ikatan fibrin thrombin, seperti dalam bekuan darah. Reaksi dari dabigatran adalah reversible.Dabigatran etexilate memisahkan dari thrombin, meninggalkan sebagian kecil, secara enzimatik mengaktifkan thrombin untuk hemostasis normal.

BAB VIII

KESIMPULAN

Sendi lutut merupakan persendian yang paling besar pada tubuh manusia. Sendi ini terletak  pada  kaki  yaitu  antara  tungkai atas dan tungkai bawah. Pada dasarnya sendi lutut ini terdiri dari dua articulatio condylaris diantara condylus femoris medialis dan lateralis dan condylus tibiae yang terkait dan sebuah sendi pelana , diantara patella dan fascies patellaris femoris. Gerakan yang dapat dilakukan oleh sendi lutut yaitu gerakan fleksi , ekstensi dan sedikit rotatio.

Fungsi dari sendi lutut ini adalah untuk mengatur pergerakan dari kaki, dan untuk menggerakkan kaki ini diperlukan koordinasi berikut ini :

  • Otot- otot yang membantu menggerakkan sendi.
  • Capsul sendi yang berfungsi untuk melindungi bagian tulang yang bersendi supaya jangan lepas bila bergerak.
  • Adanya permukaan tulang yang dengan bentuk tertentu yang mengatur luasnya gerakan.
  • Adanya cairan dalam rongga sendi yang berfungsi untuk mengurangi gesekan antara tulang – tulang rawan pada permukaan sendi.
  • Ligamentum - ligamentum yang ada di sekitar sendi lutut yang merupakan penghubung kedua buah tulang yang bersendi sehingga tulang menjadi kuat untuk melakukan gerakan-gerakan tubuh.

Total knee arthrosplasty modern terdiri dari pengangkatan penyakit permukaan articular dari lutut yang diikuti dengan melapisi kembali dengan komponen metal dan polietilen prostetik.Indikasi utama untuk total knee arthroplasty adalah untuk mengurangi rasa nyeri yang berhubungan dengan arthritits di lutut pada pasien yang gagal dengan terapi non operatif.

Evaluasi pra operasi yang hati-hati harus dilakukan untuk menentukan diagnosa yang tepat, mengidentifikasi kebutuhan untuk operasi, membantu perencanaan operasi dan mencegah komplikasi pada periode perioperatif.Management postoperatif ini meliputi profilaxis melawan infeksi, vena tromboemboli dan terapi fisik yang paling cocok agar mendapatkan pergerakan lutut yang paling baik dan rehabilitasi yang aman yang dapat dipraktekkan.

MIS Quad-Sparing TKA meredakan sakit lutut dan memungkinkan beberapa pasien untuk pulih dan kembali pada pekerjaan dan kegiatan sehari-hari lebih cepat daripada mereka melakukan operasi knee replacement tradisional.Ketika cartilago pada satu bagian lutut mengalami kerusakan, ahli bedah mungkin dapat mengganti hanya bagian yang rusak dari sendi tersebut.Prosedur ini disebut partial atau unicompartmental atau unicondylar knee replacement.

Dipercaya bahwa operasi besar pada ortopedi, merusak bone marrow, impaksi oleh semen tulang, statis selama prosedur operasi, pencetus kuat dari terbentuknya thrombin secara local dan sistemik dan aktivitas yang menyebabkan terjadinya formasi thrombus pada bagian yang dioperasi atau bagian lain yang resisten (locus minoris resistentia).Obat antikoagulan oral baru Pradaxa® memberikan harapan. Penelitian menunjukkan bahwa obat ini mempunyai onset dan offset reaksi yang cepat dan menunjukkan antikoagulan yang dapat diprediksi, mengurangi kebutuhan untuk memonitor koagulasi.Obat ini diindikasikan untuk mencegah terajdinya venous thromboembolism pada pasien yang telah menjalani operasi THR/TKR.

 

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  35. Turpie, Alexander G.G. 2008. “ Deep Venous Thrombosis”. The Merk Manuals Online Medical Library
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  38. Dahl, Ola E. 2009. “Biography of Dabigraphy Etexilate for Primary Prevention and Treatment of Venous Thromboembolism”. London. nowPharma Ltd
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  40. Schulman, Sam. 2009. “Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism”. The New England Journal of Medicine 361;24 December 2009.
  41. Danielsson, A, Raub, E, Lindahl, U, Bjork, I. Role of ternary complexes, in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin or factor Xa. J Biol Chem 1986; 261:15467.
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  44. Olson, ST, Bjork, I, Sheffer, R, et al. Role of the antithrombin-binding pentasaccharide in heparin acceleration of antithrombin-proteinase reactions. Resolution of the antithrombin conformational change contribution to heparin rate enhancement. J Biol Chem 1992; 267:12528.
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