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Considerations In Knee Artroplasty
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Considerations In Knee Artroplasty

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  • Dear Dr Javier Mata,I really liked your ppt presentation: Considerations in TKA, until I noticed that half of the slides are a copy of one of my own presentations. Most of the clinical pictures are taken in my operating room. My scrub nurse and my assistant are on the slides ! The only thing I miss is a reference to me as the real author of most of this slide presentation. I really do not appreciate this. Dr Hendrik P Delport, orthopaedic surgeon, Belgium www.ortho-expert.be
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  • 1. CONSIDERATIONS IN TKA
    JAVIER MATA
  • 2. HISTORY OF TKA
    Total knee arthroplasty is one of the most important advances in orthopaedics during the last 30 years.
    Patients with severe arthritis have reduced pain, correction of deformity and improved function as well as life quality after TKA implantation.
    Today, increasing interest is showed in the mobile bearing type of knees. Long term results will have to prove that they are better!
    Several surgical points need to be considered !!!
  • 3.
  • 4. ANATOMY AND SOFT TISSUES
    A thorough knowledge of the knee anatomy, bones,mechanical, anatomical axis,ligaments and soft tissues must clearly be understood ( John Insall ).
    Total knee arthroplasty is the correct alignment of the components and soft tissue balancing. The last is the formula 1 “Fine Tuning”.
  • 5. THE PEFECT KNEE IS BALANCED
  • 6. The vertical axis.
    The mechanical axis.
    The anatomical axis
  • 7. WHICH KNEE SHOULD WE USE ? ?
  • 8. TODAY,THINGS ARE CHANGING
  • 9. WHAT ABOUT CLINICAL RESULTS? WHAT DOES THE CURRENT KNEE MARKET HAVE ?
  • 10.
  • 11.
  • 12. ARE WE GOING FOR A C.R. OR P.S. TOTAL KNEE?
    Retaining the posterior cruciate ligament is more natural, but in practice more difficult to achieve good tension.Or it is too tight or too loose. Rarely the correct tension( Stiehl)
    Implanting a PS knee gives the surgeon reproducible mechanical rollback.It is an easier operation!
    The available literature suggests that PS TKA is superior in results than CR TKA.
  • 13. WHAT TYPE OF INCISION?
    Medial approach(varus or valgus knees)
    Lateral approach(lateral knees)
    Subvastus approach(varus knees)
    Midvastus approach(varus knees)
    Tibial tubercle osteotomy(L. Whitside)
    Rectus snip(vastus turndown)
  • 14. MEDIAL APPROACH
    Varus Deformities.
    We start with a straight line incision if possible.
    Medial parapatellar.
    About 1 cm medial to the tibial tubercle.
    Deep M.C.L.
    Superficial M.C.L.
    Semimembranosus.
    Subluxation of the tibia(rotation).
    patello-femoral ligament.
  • 15. MEDIAL APPROACH
    Valgus Deformaties.
    Straight line skin incision.
    Medial parapatellar.
    Anterior deep M.C.L.
    Illiotibial band.
    Straight anterior subluxation.
    Lateral capsular ligament.
    Arcurate ligament.
    Popliteus&L.C.L.
  • 16. L
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  • 17. LATERAL APPROACH
    Valgus Deformities (Keblish)
    Straight line skin incision.
    Lateral parapatellar.
    Lateral capsular ligament.
    Partial tubercle release.
  • 18. Popliteus & lateral collateral ligament
  • 19. SUBVASTUS APPROACH
    Varus knees.
    Straight line skin incision.
    Medial parapatellar( not going into the quads).
    Elevate proximally.
    Avoid saphenous nerve.
    Sometimes difficult patella exposure with obese patients
  • 20.
  • 21.
  • 22.
  • 23.
  • 24.
  • 25. MID VASTUS APPRAOCH
    Varus knees( Engh)
    Same as subvastus but here we go slightly into the vastus medialis.
  • 26. L
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  • 27. TIBIAL TUBERCLE OSTEOTOMY
    Straight line skin incision.
    Medial parapatellar.
    Tibial tubercle osteotomy of about 10cm.
    Leave soft tissues intact laterally.
    Fixation with wires,screws,staples etc..
  • 28. RECTUS SNIP OR VASTUS TURNDOWN
    Straight line skin incision.
    Medial parapatellar.
    Transverse cut into the quads.
    Medial closure.
    No lateral release.
  • 29. Good Preoperative Planning is essential
  • 30. GOOD KNEE EXPOSURE
    It is very important to achieve good knee exposure. This will facilitate the whole procedure.
    First thing to do, is to take all protruding osteophytes away. This from the femur and the tibia.
    If partial ligament release is necessary, do it. Disadhere the ligaments.
    So, restore the anatomy.
  • 31. Remove all osteophytes
  • 32. ESTABLISH YOUR REFERENCES
    What is the valgus angle going to be?
    Mark and draw the epicondylar axis line for correct femoral exorotation. Check with the Whitsides line.
    Restore the joint line.Use available anatomical reference landmarks.
  • 33. Epicondylar axis line and Whitsides’ line
  • 34. Restore the Joint Line
  • 35. Where is the “Joint Line” ?
    About 16 to 18mm from the fibula head.
    46mm off the medial distal femur at the adductor tubercle ( A. Hofmann )
    About 27mm distal off the medial femoral epicondyle.
    Look for the old meniscal scar in the joint capsule= joint line
  • 36. ANTERIOR REFERENCING
    Most of the knee instrumentations use anterior referencing of the femoral component.
    Here we respect the anterior part of the femur.
    If , between 2 sizes, we can downsize.
    The counterpart is that we cut more posterior femoral condyle off. This elevates the joint line in flexion.
  • 37. POSTERIOR REFERENCING
    We respect the posterior femoral condyles, thus re-establish the joint line in flexion.
    The counterpart is that we cannot downsize, if between sizes. Otherwise we will notch the anterior femoral cortex.
    There are instruments that compromise, like the Fudge A/P sizer.
  • 38.
  • 39. PERFORM ACCURATE BONE CUTS
    The key to success is the sawblade.
    Go for the femur or the tibia. It’s surgeons preference.
    Restore the mechanical axis, joint line and do a good soft tissue balance.
    Achieve in flexion and extension exact rectangles.
  • 40. Be in the right place when drilling into the femur or tibia!!
    Look at your X rays to establish your entry points into the bone.
  • 41. TIBIAL PREPARATION
    You can prepare your tibial cut extramedullary or intramedullary.
    Be sure to check this cut because it is one of the most important cuts in TKA.
    A tibial cut should be perpendicular to it’s mechanical axis.
    A neutral cut is the best. Slight valgus cut is tolerated
    A VARUS CUT IS BAD
  • 42. Use extramedullary tibial instrumentation here!
  • 43. When using a posterior slope, you must watch out!!!
    Internal rotation will result in a valgus cut of the tibia.
    External rotation will result in a varus cut of the tibia
    Be sure to be in exact A/P when using a tibial resection guide.
  • 44. Extramedullary tibial resection guide over the top
  • 45. Intramedullary resection guide
  • 46. When working intramedullary, check extramedullary
  • 47. In varus knees, you will cut off more laterally than medially.
    In valgus cases, you will cut about the same amounts medially and laterally.
  • 48. Reference landmarks
    The posterior cortical axis is 10° internally rotated.
    The inermalleolar axis is 15° externally rotated.
    The tibial crest is neutral.
    The tuberosity is just lateral
  • 49. INSTRUMENTATION
    Use the instrumentation correctly but don’t depend fully on it.
    Be like Einstein,use your brains and common sense.
    Establish correct flexion and extension gaps.How? Use spacer blocks or tensioners to achieve this.
  • 50. Not correct
    This is the correct way
  • 51. CHECK YOUR FLEXION AND EXTENSION GAPS:THEY MUST BE EXACT !!!!
  • 52. Flexion and extension spacers
  • 53.
  • 54. PATELLA TRACKING
    Patella tracking is extremely important in TKA.The following points are important to achieve good patella tracking.
    Surgical approach,correct femoral size,lateralisation,correct exorotation of the femoral component,slight exorotation and lateralisation of the tibial component,medialisation of the patella component.( AAOS comments )
  • 55. PATELLA PREPARATION
    Surgeons have different approaches to implant a patella component.
    Some do it free hand.
    Others resurface or inlay the patella button.
    Some don’t and leave the natural patella in situ.
    Most do a “Denervation” around the natural patella.
  • 56. Check the natural, eroded patella size
  • 57. Resurfacing the patella
  • 58. Inlay patella technique
  • 59.
  • 60. ‘  Cut ‘  the cement away
  • 61. TRIAL REDUCTION
    It is imperative to achieve full extension and good flexion with the trial components in place during the operation.
    Try the Bob Booths full extension test.
    Try the gravity test for evaluation of the flexion.
    Try the P.O.L.O. test.
    If using a PS knee, try and luxate the femur from the tibia(hop over test).
  • 62. Be sure to achieve good flexion and extension
  • 63. CEMENTING
    Take good and meticulous care in cementing the components in place.
    Do not pressurize in full extension otherwise you will end up with an anterior tibial slope of your tibial component.Hold the leg at about 30 degrees of flexion.
  • 64. METICULOUS IRRIGATION IS ESSENTIAL!!!!
  • 65. GO FOR A CLEAN AND DRY BONE SITUATION
  • 66. PRESSURIZE THE CEMENT INTO THE BONE
  • 67. GRACIAS