CONSIDERATIONS IN TKA<br />JAVIER MATA<br />
HISTORY OF TKA<br />Total knee arthroplasty is one of the most important advances in orthopaedics during the last 30 years...
ANATOMY AND SOFT TISSUES<br />A thorough knowledge of the knee anatomy, bones,mechanical, anatomical axis,ligaments and so...
     THE PEFECT KNEE IS BALANCED<br />
The vertical axis.<br />The mechanical axis.<br />The anatomical axis<br />
WHICH KNEE SHOULD WE USE ? ? <br />
TODAY,THINGS ARE CHANGING<br />
WHAT ABOUT CLINICAL RESULTS? 	WHAT DOES THE CURRENT KNEE MARKET HAVE ?<br />
ARE WE GOING FOR A  C.R.  OR P.S. TOTAL KNEE?<br />Retaining the posterior cruciate ligament is more natural, but in pract...
WHAT TYPE OF INCISION?<br />Medial approach(varus or valgus knees)<br />Lateral approach(lateral knees)<br />Subvastus app...
MEDIAL APPROACH<br />Varus Deformities.<br />We start with a straight line incision if possible.<br />Medial parapatellar....
MEDIAL APPROACH<br />Valgus Deformaties.<br />Straight line skin incision.<br />Medial parapatellar.<br />Anterior deep M....
L<br />A<br />T<br />E<br />R<br />A<br />L<br />M<br />E<br />D<br />I<br />A<br />L<br />
LATERAL APPROACH<br />Valgus Deformities (Keblish)<br />Straight line skin incision.<br />Lateral parapatellar.<br />Later...
Popliteus & lateral collateral ligament<br />
SUBVASTUS APPROACH<br />Varus knees.<br />Straight line skin incision.<br />Medial parapatellar( not going into the quads)...
MID VASTUS APPRAOCH<br />Varus knees( Engh)<br />Same as subvastus but here we go slightly into the vastus medialis.<br />
L<br />A<br />T<br />E<br />R<br />A<br />L<br />M<br />E<br />D<br />I<br />A<br />L<br />
TIBIAL TUBERCLE OSTEOTOMY<br />Straight line skin incision.<br />Medial parapatellar.<br />Tibial tubercle osteotomy of ab...
RECTUS SNIP OR VASTUS TURNDOWN<br />Straight line skin incision.<br />Medial parapatellar.<br />Transverse cut into the qu...
Good Preoperative Planning is essential<br />
GOOD KNEE EXPOSURE<br />It is very important to achieve  good knee exposure. This will facilitate the whole procedure.<br ...
Remove all osteophytes<br />
ESTABLISH  YOUR REFERENCES<br />What is the valgus angle going to be?<br />Mark and draw the epicondylar axis line for cor...
Epicondylar axis line and Whitsides’ line<br />
Restore the Joint Line<br />
Where is the “Joint Line” ?<br />About 16 to 18mm from the fibula head.<br />46mm off the medial distal femur at the adduc...
ANTERIOR REFERENCING<br />Most of the knee instrumentations use anterior referencing of the femoral component.<br />Here w...
POSTERIOR REFERENCING<br />We respect the posterior femoral condyles, thus re-establish the joint line in flexion.<br />Th...
PERFORM ACCURATE BONE CUTS<br />The key to success is the sawblade.<br />Go for the femur or the tibia. It’s surgeons pref...
Be in the right place when drilling into the femur or tibia!!<br />Look at your X rays to establish your entry points into...
TIBIAL PREPARATION<br />You can prepare your tibial cut extramedullary or intramedullary.<br />Be sure to check this cut b...
Use  extramedullary  tibial  instrumentation  here!<br />
When using a posterior slope, you must watch out!!!<br />Internal rotation will result in a valgus cut of the tibia.<br />...
Extramedullary tibial resection guide over the top<br />
Intramedullary resection guide<br />
When working intramedullary, check extramedullary<br />
In varus knees, you will cut off more laterally than medially.<br />In valgus cases, you will cut about the same amounts m...
Reference landmarks<br />The posterior cortical axis is 10° internally rotated.<br />The inermalleolar axis is 15° externa...
INSTRUMENTATION<br />Use the instrumentation correctly but don’t depend fully on it.<br />Be like Einstein,use your brains...
Not correct<br />This is the correct way<br />
CHECK YOUR FLEXION AND EXTENSION GAPS:THEY MUST BE EXACT  !!!!<br />
Flexion and extension spacers<br />
PATELLA TRACKING<br />Patella tracking is extremely important in TKA.The following points are important to achieve good pa...
PATELLA PREPARATION<br />Surgeons have different approaches to implant a patella component.<br />Some do it free hand.<br ...
Check the natural, eroded patella size<br />
Resurfacing the patella<br />
Inlay patella technique<br />
‘  Cut ‘  the cement away<br />
TRIAL REDUCTION<br />It is imperative to achieve full extension and good flexion with the trial components in place during...
Be sure to achieve good flexion and extension<br />
CEMENTING<br />Take good and meticulous care in cementing the components in place.<br />Do not pressurize in full extensio...
METICULOUS IRRIGATION IS ESSENTIAL!!!!<br />
GO FOR A CLEAN AND DRY BONE SITUATION<br />
PRESSURIZE THE CEMENT INTO THE BONE<br />
GRACIAS<br />
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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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Considerations In Knee Artroplasty

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