The Open Orthopaedics Journal


ISSN: 1874-3250 ― Volume 11, 2017
RESEARCH ARTICLE

Total Knee Arthroplasty In Patients With Parkinson's Disease- A Critical Analysis of Available Evidence



Munis Ashraf1, *, Sruthi Priyavadhana2, Senthil Nathan Sambandam1, Varatharaj Mounasamy3, Om Prakash Sharma4
1 Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Arts College Road, Coimbatore 641018, Tamil Nadu, India
2 Medical student Saveetha medical college Chennai, Tamil Nadu, India
3 VCU Medical Center Ambulatory Care Center, 417 North 11th Street, Richmond, Virginia, USA
4 Orthopedic surgeon Essentia Health St.Mary’s Detroit Lakes Clinic, Minnesota, USA

Abstract

Background:

In this era of modern medicine, there is an increase in life expectancy and thereby an ageing population. Among this group one of the most common neurological disorder is Parkinson disease and one of the most common operation done in elderly population is a total joint arthroplasty. But total joint arthroplasty in Parkinson disease is a relatively uncommon entity. There is sparse literature available with regards to total knee arthroplasty (TKA) in Parkinson disease. This review focusses on the necessity, complications and previous experiences on TKA in PD based on the literature available.

Method:

The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to total knee replacement in patients with Parkinson’s disease. The following keywords were used; Total knee arthroplasty, Parkinson’s disease, Hoehn and Yahr, Flexion Contracture.

Results:

The review indicates that the functional outcome is comparable to that of controls in immediate post-operative phase, one year and three-year phase, but the long term functional outcome seems to deteriorate significantly.

Conclusion:

Total knee arthroplasty can serve as an effective tool in alleviating pain in short term as well as long term periods, whereas the functional outcome seems to deteriorate post operatively on a long-term basis. Nevertheless, TKA in PD is a challenging situation, thereby necessitating a holistic approach with the efforts from various specialists needed at each stage to ensure a successful operation.

Keywords: Total knee arthroplasty, Parkinson’s Disease, Hoehn yahr, Flexion contracture, Physical therapy, Columbia classification.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
First Page: 1087
Last Page: 1093
Publisher Id: TOORTHJ-11-1087
DOI: 10.2174/1874325001711011087

Article History:

Received Date: 20/04/2017
Revision Received Date: 16/06/2017
Acceptance Date: 18/07/2017
Electronic publication date: 30/09/2017
Collection year: 2017`

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© 2017 Ashraf et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Orthopaedics, K.G Hospital and Post Graduate Medical Institute, Coimbatore, India; Tel: +914222212121; E-mail: munis6@gmail.com




1. INTRODUCTION

Parkinson’s disease (PD) is a neurodegenerative disorder affecting approximately 4 million people worldwide. The disease is due to the decrease in the dopaminergic activity in the nigro striatal pathway leading to a dysfunction of the basal ganglia and is characterised by motor disturbances and cognitive impairments [1Lees AJ, Hardy J, Revesz T. Parkinson’s disease. Lancet 2009; 373(9680): 2055-66.
[http://dx.doi.org/10.1016/S0140-6736(09)60492-X] [PMID: 19524782]
]. The mean age of onset is 55 years [2Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. 1967. Neurology 1998; 50(2): 318-16.
[http://dx.doi.org/10.1212/WNL.50.2.318] [PMID: 9484345]
]. With the improvement in life expectancy, the prevalence of Parkinson’s disease is projected to be on the rise and thereby a significant increase in number of total knee arthroplasty (TKA) to be performed in PD. Therefore, it is of paramount importance for the orthopaedic surgeon to have clarity and knowledge in the approach of TKA in PD amidst varying results as recorded in available literature till date. This review tries to delineate the common problems encountered, factors influencing the outcome and considerations for TKA in PD based on the available literature.

2. FACTORS AFFECTING THE OUTCOME FOR TOTAL KNEE ARTHROPLASTY IN PARKINSON’S DISEASE

2.1. General Considerations

2.1.1. Age:

A review of epidemiology in knee arthroplasty highlights that there has been a fivefold increase in the rates of primary TKA since 1980, primarily due to an ageing population [3Singh JA. Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J 2011; 5: 80-5.
[http://dx.doi.org/10.2174/1874325001105010080] [PMID: 21584277]
]. The mean age at the time of presentation varies from 70-73 years in the available literature [4Oni OO, Mackenney RP. Total knee replacement in patients with Parkinson’s disease. J Bone Joint Surg Br 1985; 67(3): 424-5.
[PMID: 3997953]
-7Tinning CG, Cochrane LA, Singer BR. Primary total knee arthroplasty in patients with Parkinson’s disease: analysis of outcomes. Acta Orthop Belg 2013; 79(3): 301-6.
[PMID: 23926733]
]. Higher age group is associated with increased mortality and ironically a decrease in revision rates [8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
].

2.1.2. Gender:

The utilisation rates of arthroplasty seems to be equal in males and females. In PD post TKA, males are seen to have an increase in mortality whereas females are associated with an increase duration of hospital stay [8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
].

2.1.3. Clinical features:

Selection of patients with a preoperative flexion contracture, dementia and medical co morbidities like cardiovascular disease are associated with increased mortality and decreased functional outcome post TKA [8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
].

2.1.4. Stage of Parkinson’s disease:

A pre-operative staging of disease is essential to determine to what extent the PD symptoms can worsen postoperatively in a given time. A scoring system would help in delineating patients who can be candidates for TKA. PD patients with impaired righting reflexes and physical instability are a contraindication for TKA. Patients with a Modified Hoehn and Yahr stage of disease less than 3 can be operated upon after taking into account the associated comorbidities. Modified Hoehn and Yahr staging (Table 1), Columbia classification (Table 1a) were used in the studies [5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
, 6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
, 9Shah SN, Hornyak J, Urquhart AG. Flexion contracture after total knee arthroplasty in a patient with Parkinson’s disease: successful treatment with botulinum toxin type A. J Arthroplasty 2005; 20(8): 1078-80.
[http://dx.doi.org/10.1016/j.arth.2004.11.008] [PMID: 16376267]
, 10Fast A, Mendelsohn E, Sosner J. Total knee arthroplasty in Parkinson’s disease. Arch Phys Med Rehabil 1994; 75(11): 1269-70.
[http://dx.doi.org/10.1016/0003-9993(94)90018-3] [PMID: 7979942]
].

Table 1
Staging of parkinsons disease.


Table 1a
Staging of parkinsons disease.


2.1.5. Bone Mineral Density:

Patients with PD have a positive correlation with reduced bone density and are prone to vitamin D deficiency. The bradykinesia and rigidity results in the lack of spontaneous activity and muscle disuse. This in turn predisposes for an increased osteoclast mediated calcium resorption. The reduced bone mass can lead to an increased risk of peri prosthetic fracture in patients with PD. Treatment with bisphosphonates and teriparatide has been tried, however there are no consensus in this regard. However, it is imperative that bone density is assessed in patients with PD and treated appropriately pre-operatively [11Kao CH, Chen CC, Wang SJ, Chia LG, Yeh SH. Bone mineral density in patients with Parkinson’s disease measured by dual photon absorptiometry. Nucl Med Commun 1994; 15(3): 173-7.
[http://dx.doi.org/10.1097/00006231-199403000-00010] [PMID: 8190408]
].

The authors feel that the indication for TKA in PD is almost similar to that of TKA in general population, mostly due to the degenerative osteoarthritis. In addition, x ray studies have shown that the medial compartment is more commonly affected than the lateral compartment [6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
].

2.2. Intra Operative Considerations

2.2.1. Anaesthesia:

From the available studies the use of general anaesthesia is to be avoided as the chances of post-operative confusion and psychological co morbidities is higher. More specifically, the use of levodopa and bromocriptine is known to cause orthostatic hypotension and therefore it is suggested that these medications are administered at low doses. Propofol is widely used for induction in general anaesthesia for neurodegenerative conditions but it is associated with spontaneous involuntary movements in patients with Parkinson’s. There occurs an increased sensitivity of the myocardium to the catecholamines when halothane is used in patients receiving levodopa. Due to the risk of exacerbation of extra pyramidal symptoms, anti-emetics like phenothiazine and metoclopramide are best avoided. Factoring in on these inherent complications of general anaesthesia in patients with PD, the use of regional anaesthesia spinal, epidural / combined has been suggested to be a safer option [11Kao CH, Chen CC, Wang SJ, Chia LG, Yeh SH. Bone mineral density in patients with Parkinson’s disease measured by dual photon absorptiometry. Nucl Med Commun 1994; 15(3): 173-7.
[http://dx.doi.org/10.1097/00006231-199403000-00010] [PMID: 8190408]
].

2.2.2. Implants:

Implant selection is of great importance as it can decide the functional outcome of TKA in PD. The most important consideration while selecting the implant is the role of extensor mechanism of PD patients. The extensor mechanism is prone to disruption due to rigid hamstrings or severe flexion contracture and this can lead to implant dislocation. Condylar constrained, hinged knee device or cruciate retaining device is used to overcome this [6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
, 12Burton DA, Nicholson G, Hall GM. Anaesthesia in elderly patients with neurodegenerative disorders: special considerations. Drugs Aging 2004; 21(4): 229-42.
[http://dx.doi.org/10.2165/00002512-200421040-00002] [PMID: 15012169]
]. No single design of TKA is suitable for every patient, the design should be chosen with the conditions of the patient and the comfort of the operating surgeon in mind.

2.2.3. Unilateral versus Bilateral:

The scope of a bilateral TKA in PD is less. Duffy and Trousdale have found that a bilateral TKA is associated with a poor knee society functional score (KSFS) at 3 years and further decline in KSFS score at end of five years. With unilateral TKA there is an improvement in KSFS score after three years but a decline in KSFS score is noted at the end of five years [6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
].

2.2.4. Blood loss:

Till date there is no evidence in literature stating the blood loss and its role in TKA for PD patients.

2.3. Post-Operative Considerations

2.3.1. Pain management:

Unlike pain management of TKA in general population, the use of opioids is avoided in PD. The reason for avoidance of opioids is its ability to significantly depress the CNS in an already co-existing cognitive dysfunction. Patients with neurogenerative diseases are likely to be on monoamine oxidase inhibitors (MAOI) and the use of opioids in conjunction with the MAOI’s can lead to the development of serotonin syndrome. Hence, the opioids are contraindicated [11Kao CH, Chen CC, Wang SJ, Chia LG, Yeh SH. Bone mineral density in patients with Parkinson’s disease measured by dual photon absorptiometry. Nucl Med Commun 1994; 15(3): 173-7.
[http://dx.doi.org/10.1097/00006231-199403000-00010] [PMID: 8190408]
] and the anti-inflammatory medications are used for pain management post operatively in patients with normal renal functions [13O’Hara DA, Fanciullo G, Hubbard L, et al. Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain. Pharmacotherapy 1997; 17(5): 891-9.
[PMID: 9324179]
].

2.3.2. Infections:

The occurrence of superficial skin infection as well as deep infection are noted in studies [6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
, 8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
]. This points to a strict vigil that needs to be maintained during wound checks and sufficient antibiotic prophylaxis to be administered.

2.3.3. Physical therapy:

The initial studies on TKA in PD have proven that a delay in initiation in physical therapy results in flexion contracture, quadriceps rupture and a poor functional outcome. There should be a gradual increase in initiation of physical therapy as conventional post-operative TKA physical therapy protocols can result in disruption of extensor mechanism (14,15).

2.3.4. Musculoskeletal issues:

As noted in many of the earlier studies, the occurrence of flexion contracture, extensor mechanism disruption due to a rigid hamstring are a few musculoskeletal complications which can occur post operatively [4Oni OO, Mackenney RP. Total knee replacement in patients with Parkinson’s disease. J Bone Joint Surg Br 1985; 67(3): 424-5.
[PMID: 3997953]
, 5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
, 9Shah SN, Hornyak J, Urquhart AG. Flexion contracture after total knee arthroplasty in a patient with Parkinson’s disease: successful treatment with botulinum toxin type A. J Arthroplasty 2005; 20(8): 1078-80.
[http://dx.doi.org/10.1016/j.arth.2004.11.008] [PMID: 16376267]
]. Proper rehabilitation methods are needed to be in place to check these complications [15Gobbi LT, Oliveira-Ferreira MD, Caetano MJ, et al. Exercise programs improve mobility and balance in people with Parkinson’s disease. Parkinsonism Relat Disord 2009; 15(Suppl. 3): S49-52.
[http://dx.doi.org/10.1016/S1353-8020(09)70780-1] [PMID: 20083007]
].

2.3.5. Worsening of Parkinson’s Disease:

Most of the studies indicate an increase in severity of the disease post operatively on a long-term basis [7Tinning CG, Cochrane LA, Singer BR. Primary total knee arthroplasty in patients with Parkinson’s disease: analysis of outcomes. Acta Orthop Belg 2013; 79(3): 301-6.
[PMID: 23926733]
, 8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
]. This change can be detected by worsening cognition, impaired righting reflexes or an increase in muscle imbalance [16Price CC, Levy SA, Tanner J, et al. Orthopedic Surgery and Post-Operative Cognitive Decline in Idiopathic Parkinson’s Disease: Considerations from a Pilot Study. J Parkinsons Dis 2015; 5(4): 893-905.
[http://dx.doi.org/10.3233/JPD-150632] [PMID: 26683785]
].

2.3.6. Thromboprophylaxis:

Vince et al [5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
] had reported incidence of DVT and pulmonary embolism, hence the initiation of mechanical thromboprophylaxis with incentive spirometry, chest physiotherapy, pneumatic compression devices is essential. However, it is to be noted that there are no studies specifically indicating the rates of thromboembolic episodes in patients with PD. The authors suggest that for patients with PD, DVT prophylaxis measures should be practiced just as in TKA in general population.

3. THE FUNCTIONAL OUTCOME OF TKA IN PD

The functional outcome was quantified in three studies. Among the three studies, the study conducted in Dundee, UK was the sole exclusive outcome analysis study [7Tinning CG, Cochrane LA, Singer BR. Primary total knee arthroplasty in patients with Parkinson’s disease: analysis of outcomes. Acta Orthop Belg 2013; 79(3): 301-6.
[PMID: 23926733]
]. This study had used the knee society score and knee society function score. The other two studies used the knee society score [5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
, 6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
] (Table 2).

Table 2
Review of literature.


These reports indicate that the functional outcome is comparable to that of controls in immediate post-operative phase, one year and three-year phase, but the long term functional outcome seems to deteriorate significantly. The deterioration in functional outcome can be attributed to the progression of the Parkinson’s disease and not the operation per se.

4. COMPLICATIONS RELATED TO TKA IN PD

Some of the complications post TKA in PD based on available literature is discussed below and given in Table 3.

Table 3
Complications.


4.1. Flexion Contracture

The most highlighted complication in literatures is of the development of a flexion contracture in post TKA patients. This can be viewed in two aspects; first one being a delayed initiation of physical therapy and second aspect being development of flexion contracture in PD patients who had pre-operative muscle imbalance and ataxia [4Oni OO, Mackenney RP. Total knee replacement in patients with Parkinson’s disease. J Bone Joint Surg Br 1985; 67(3): 424-5.
[PMID: 3997953]
, 5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
]. Flexion contracture post operatively was observed only in three studies (Oni and Mackenney in 1985, Insall et al 1989 and Shah et al 2004). In all these three studies initiation of physical therapy was delayed by atleast a week post operatively; whereas in other studies there was prompt early mobilisation which resulted in no flexion contracture post operatively, thereby highlighting the need for early mobilisation postoperatively. A study by Shah et al [9Shah SN, Hornyak J, Urquhart AG. Flexion contracture after total knee arthroplasty in a patient with Parkinson’s disease: successful treatment with botulinum toxin type A. J Arthroplasty 2005; 20(8): 1078-80.
[http://dx.doi.org/10.1016/j.arth.2004.11.008] [PMID: 16376267]
] in 2004 demonstrated the potential role of injecting Botulinum toxin type A into the muscle to relieve flexion contracture. Presence of flexion contracture postoperatively can significantly affect the functional capacity and range of movements in patients sometimes necessitating revision in such patients [4Oni OO, Mackenney RP. Total knee replacement in patients with Parkinson’s disease. J Bone Joint Surg Br 1985; 67(3): 424-5.
[PMID: 3997953]
, 5Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
].

5. INFECTIONS

Superficial necrosis and wound infection was seen in five patients in the study conducted by G.P.Duffy and Robert Trousdale [6Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
] that led to a delay in the outcome process. The infection rates in PD post TKA is comparable with that of the controls as stated in the nationwide registry of Finland study [8Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
].

CONCLUSION

Total knee Arthroplasty is not an absolute contraindication but can be a relative indication in patients with Parkinson’s disease where conservative line of management has failed. Preoperative assessment, collaborated efforts of specialists from various disciplines, appropriate surgical prosthesis design, early physiotherapy aids to prevent postoperative complications and a reduced hospital stay. TKA can serve as an effective tool in alleviating pain in short term as well as long term, whereas the use of TKA for the functional outcome rather seems to decrease post operatively on a long-term basis. Further studies focussing on functional outcome in post TKA PD patients with parameters like progression of disease, severity of disease and associated medical comorbidities should be compared and studied with matched controls over a long term for better understanding of tolerance of TKA in PD. TKA in PD is a challenging situation, thereby necessitating a holistic approach with the efforts from various specialists needed at each stage to ensure a successful operation.

LIST OF ABBREVIATIONS

PD  = Parkinsons disease
TKA  = Total knee arthroplasty
DVT  = Deep Vein Thrombosis
KSFS  = Knee society functional score
MAOI  = Mono amine oxidase inhibitors

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals/Humans were used for studies that are base of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Decleared none.

REFERENCES

[1] Lees AJ, Hardy J, Revesz T. Parkinson’s disease. Lancet 2009; 373(9680): 2055-66.
[http://dx.doi.org/10.1016/S0140-6736(09)60492-X] [PMID: 19524782]
[2] Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. 1967. Neurology 1998; 50(2): 318-16.
[http://dx.doi.org/10.1212/WNL.50.2.318] [PMID: 9484345]
[3] Singh JA. Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J 2011; 5: 80-5.
[http://dx.doi.org/10.2174/1874325001105010080] [PMID: 21584277]
[4] Oni OO, Mackenney RP. Total knee replacement in patients with Parkinson’s disease. J Bone Joint Surg Br 1985; 67(3): 424-5.
[PMID: 3997953]
[5] Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br 1989; 71(1): 51-4.
[PMID: 2915005]
[6] Duffy GP, Trousdale RT. Total knee arthroplasty in patients with parkinson’s disease. J Arthroplasty 1996; 11(8): 899-904.
[http://dx.doi.org/10.1016/S0883-5403(96)80130-6] [PMID: 8986567]
[7] Tinning CG, Cochrane LA, Singer BR. Primary total knee arthroplasty in patients with Parkinson’s disease: analysis of outcomes. Acta Orthop Belg 2013; 79(3): 301-6.
[PMID: 23926733]
[8] Jämsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MU. Surgical outcomes of primary hip and knee replacements in patients with Parkinson’s disease: a nationwide registry-based case-controlled study. Bone Joint J 2014; 96-B(4): 486-91.
[http://dx.doi.org/10.1302/0301-620X.96B4.33422] [PMID: 24692615]
[9] Shah SN, Hornyak J, Urquhart AG. Flexion contracture after total knee arthroplasty in a patient with Parkinson’s disease: successful treatment with botulinum toxin type A. J Arthroplasty 2005; 20(8): 1078-80.
[http://dx.doi.org/10.1016/j.arth.2004.11.008] [PMID: 16376267]
[10] Fast A, Mendelsohn E, Sosner J. Total knee arthroplasty in Parkinson’s disease. Arch Phys Med Rehabil 1994; 75(11): 1269-70.
[http://dx.doi.org/10.1016/0003-9993(94)90018-3] [PMID: 7979942]
[11] Kao CH, Chen CC, Wang SJ, Chia LG, Yeh SH. Bone mineral density in patients with Parkinson’s disease measured by dual photon absorptiometry. Nucl Med Commun 1994; 15(3): 173-7.
[http://dx.doi.org/10.1097/00006231-199403000-00010] [PMID: 8190408]
[12] Burton DA, Nicholson G, Hall GM. Anaesthesia in elderly patients with neurodegenerative disorders: special considerations. Drugs Aging 2004; 21(4): 229-42.
[http://dx.doi.org/10.2165/00002512-200421040-00002] [PMID: 15012169]
[13] O’Hara DA, Fanciullo G, Hubbard L, et al. Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain. Pharmacotherapy 1997; 17(5): 891-9.
[PMID: 9324179]
[14] Macaulay W, Geller JA, Brown AR, Cote LJ, Kiernan HA. Total knee arthroplasty and Parkinson disease: enhancing outcomes and avoiding complications. J Am Acad Orthop Surg 2010; 18(11): 687-94.
[http://dx.doi.org/10.5435/00124635-201011000-00006] [PMID: 21041803]
[15] Gobbi LT, Oliveira-Ferreira MD, Caetano MJ, et al. Exercise programs improve mobility and balance in people with Parkinson’s disease. Parkinsonism Relat Disord 2009; 15(Suppl. 3): S49-52.
[http://dx.doi.org/10.1016/S1353-8020(09)70780-1] [PMID: 20083007]
[16] Price CC, Levy SA, Tanner J, et al. Orthopedic Surgery and Post-Operative Cognitive Decline in Idiopathic Parkinson’s Disease: Considerations from a Pilot Study. J Parkinsons Dis 2015; 5(4): 893-905.
[http://dx.doi.org/10.3233/JPD-150632] [PMID: 26683785]
[17] Erceg M, Maricević A. Recurrent posterior dislocation following primary posterior-stabilized total knee arthroplasty. Croat Med J 2000; 41(2): 207-9.
[PMID: 10853054]

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Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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