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POSTGRAD ORTH Deiary Kader
SPORTS INJURIES/ KNEE
FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader
Knee Surgeon
SW London Elective Orthopaedic Centre
Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University
ICRC Specialist Surgeon (Geneva)
KNEE Recon
POSTGRAD ORTH Deiary Kader
PLAN
1. Osteotomy around the knee
2. Uni compartmental Knee
3. TKR
4. PFJ OA
5. Revision TKR
POSTGRAD ORTH Deiary Kader
Candidate’s questions ?
• Which TKR and why? How to choose knee prosthesis?
• principles of PFJR?
• principles of osteotomy angel measurements
• KM survival of TKR • Biomechanics of TKR
• Principles of knee bracing and callipers and condition which they work best
• Easy way to remember how to answer flexion extension gab balance
• When to operate for PFJ if at all
• TKR in Jehovah's witness
• Catastrophic wear in TKR
• Evidence based non operative treatment of OA —Post operative Mx of TKR
• The role of computer navigation in TKR
• Coronal plane sequential ligament release in TKR
• Osteotomy cut off age. Uni knees indications
• Do you resurface the patella?
• How does changing slop in osteotomy affect load transmission?
• Which osteotomy open or close
• PCL retaining or substituting and why
• Why TKR have different implant materials in the femur and tibia
• Prevention of catastrophic wear mean
• What are the technical difficulties in converting Uni to TKR?
• Periprosthatic fracture after TKR approach and management
• Poly difference in TKR and THR • The role of lateral facetectomy in patella arthritis
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
45 Y
Male
Bricklayer
POSTGRAD ORTH Deiary Kader
Evidence based
None-operative
Treatment for OA?
POSTGRAD ORTH Deiary Kader
OA Nonoperative treatment
Evidence
Weight loss
Exercise
Patient education
Analgesia, (NSAIDs)
Bracing
Intra-articular (IA) injections. Cochrane reviews
Steroids (better than placebo but not longer than 4wks)
HA more prolonged effect than steroids
POSTGRAD ORTH Deiary Kader
Proximal Tibia (HTO)
or
Distal Femur Osteotomy
POSTGRAD ORTH Deiary Kader
Osteotomy plan
Angle measurements
Principles
Planning osteotomy
POSTGRAD ORTH Deiary Kader
Overcorrection of 3º–5º above the 6º–7º normal valgus angle
62.5% across tibial plateau from medial side
POSTGRAD ORTH Deiary Kader
Mechanical Axis of the Lower Limb
Mechanical axis of
the lower limb
4-8mm medial
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Mechanical Axis deviation MAD
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POSTGRAD ORTH Deiary Kader
33%
20
5%
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POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
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Double Varus
1- Varus alignment
Progressive medial joint narrowing
2- Lateral opening
LCL laxity
>5 mm laxity ( stress radiograph)
Varus thrust
POSTGRAD ORTH Deiary Kader
Triple Varus
Varus alignment
Posterolateral corner laxity
Increased Ext-Rotation
Hyperextension
Lateral opening
Varus recurvatum
deformity
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Osteotomy for arthritis of the knee
Aims of valgus osteotomy
Unload the medial compartment
Unloading any ligament reconstruction
in patients with a varus thrust
To change the tibial slope in order to
reduce translational forces and
improve AP instability
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Compensating for
Abnormal AP Laxity
ACL Rupture PCL Rupture
Usually by CWHTO Usually by OWHTO
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Who is the IDEAL candidate
for HTO?
POSTGRAD ORTH Deiary Kader
Proximal or High Tibial Osteotomy (HTO)

The IDEAL candidate for HTO
Age <65 years
Isolated medial OA/Intact Ligaments
Non-Smoker
BMI<30
Almost Full ROM >120°
Less than 5° FFD knee
Patients should be
Able to use crutches
Have no major varicose veins
No peripheral vascular disease
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Osteotomy
vs
Unicompartmental replacement?
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45 Y Male Bricklayer
Vs
58 Y old Female manager
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Age
Sex
Activity level
ligament stability
Deformity
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Which Osteotomy
Open or Closed?
POSTGRAD ORTH Deiary Kader
Lateral closed-wedge high tibial osteotomies
have been the treatment of choice since 1965

(Coventry, 1965).
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Fibular osteotomy, Separating tibiofibular joint
Contracture of the patellar tendon, patellar baja
leg shortening
Nerve injuries
Varus laxity (loose LCL)
TKR is harder
High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and
Early Motion. Long-Term Follow-up*
ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A.
HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ
Bone Joint Surg Am, 2000 Jan
Closed wedge HTO 

Disadvantages
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POSTGRAD ORTH Deiary Kader
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OPEN Wedge HTO 1987
The open-wedge high tibial osteotomy gained
recognition after the encouraging reports of
(Hernigou et al., 1987).
Wedges of bone that were obtained from the iliac
crest were inserted into the defect
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Open W HTO
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Open Wedge HTO 

Advantages

Easier to adjust correction angle
Preserves bone stock (subsequent TKR easier)
Makes MCL tightening easier
Allows LCL or posterolateral -Reconstruction
No risk to peroneal nerve
Less dissection?
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POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Open wedge HTO 

Disadvantages
Requires a bone graft (substitute, autograft, Allo)
Increased incidence of non-union and delayed un
Large correction may affect leg lengthening
Loss of fixation and recurrence of varus deformity
Worsens patella Baja
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O W HTO
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RCT 92 pts and 6 years FU
OW-HTO vs CW-HTO
More Complications in open WHTO & more conversion to TKR in closed WHTO
SEPT 2014
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Distal Femur Osteotomy for Valgus
Malalignment
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POSTGRAD ORTH Deiary Kader
Coventry report

Outcome
5-year survival of 87%
10-year survival of 66%
However the 5-year survival was reduced
to 38% if under-corrected or overweight
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POSTGRAD ORTH Deiary Kader
What are the
Biomechanical aims of
TKR?
POSTGRAD ORTH Deiary Kader
The Primary Aim of TKR
Restoring neutral mechanical axis of 0 (+/- 3º)
Balancing the flexion/extension gap (ER of FC)
Joint line perpendicular to the Mech axis
Preserving the joint line height
Balancing Ligaments ( 2-3 mm play)
Restoring normal joint alignment and Q angle
POSTGRAD ORTH Deiary Kader
Which knee
replacement and why?
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Constraint ladder in
implant design
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Constraint ladder in implant design
PCL-retaining (cruciate-retaining, or CR)
Rotating platform
PCL-substituting or posterior-stabilised
Unlinked constrained condylar CCK/ VVC
Linked, constrained condylar implant
(rotating-hinge knee, RHK).
POSTGRAD ORTH Deiary Kader




PCL retaining or
substituting and
why
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PS or CR
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POSTGRAD ORTH Deiary Kader
PCL retaining (CR)
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
PCL retaining (CR)
Provides least constraint
Less forces at the interface
Preserves proprioceptive fibres (intact PCL)
Greater stability during stair climbing
(quadriceps strength)
Less risk of condylar fracture
POSTGRAD ORTH Deiary Kader
PCL retaining (CR) 2
Fewer patella complications
Preserve bone stock on the femoral side
Better kinematics
Avoids the tibial post–cam impingement
Ease of management of supracondylar
fracture (plate/nail)
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PCL retaining (CR)
Disadvantages
Less conforming surfaces to allow roll-back
Slide/shear stress causes poly delamination
Technically difficult to balance
Late PCL dysfunction
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POSTGRAD ORTH Deiary Kader
GII PS + Pat
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POSTGRAD ORTH Deiary Kader
Indications for PCL Sacrificing Implants
Previous patellectomy
Rheumatoid arthritis
Stiff knee in post-traumatic arthritis
Previous high tibial osteotomy (HTO)
Large deformity, over-released PCL
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POSTGRAD ORTH Deiary Kader
PCL substitution/sacrificing
Advantages
PCL histologically and kinematically abnormal
The cam-post mechanism improves AP stability
Provides a degree of VVC
Conforming surfaces allowing roll-back
No component slide
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PCL substitution/sacrificing
Advantages
Higher degree of flexion
Less joint line sensitive (Restored within 8-9mm, Figgie)
Congruent joint surfaces reduces wear
Facilitates deformity correction
Superior and more reproducible kinematics
Technically easier than CR
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POSTGRAD ORTH Deiary Kader
PCL substitution/sacrificing
Disadvantages
High stresses at fixation interface
Femoral bone loss/fracture
Tibial peg increases wear
Post dislocation
3X greater joint line alteration than CR
Patella clunk/ crunch syndrome
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POSTGRAD ORTH Deiary Kader
Summary
Both CR & PS knees work very well
Long term outcome comparable
One design wont fit all
PS knees outcome is more predictable
We should be able to do both when it is
indicated
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader




Coronal plane
sequential ligament
release in TKR
POSTGRAD ORTH Deiary Kader
Knee Ligaments
Lateral Complex
ITB
LCL
Popliteus
Biceps Femoris
Central Complex
ACL
PCL
Med Menx
Lat Menx
Medial Complex
MCL
POL
Capsule
Semi-Memb
Pes anserinus
POSTGRAD ORTH Deiary Kader
H Schroeder-Boersch
Medial Ligament Restraint

Range of Ligament restraint medial knee

POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Ligament restraint Lateral knee
H Schroeder-Boersch
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PCL 0º-120º more in flexion
It is “a central stabiliser”
15mm
PCL insertion
15mm
POSTGRAD ORTH Deiary Kader
LCL 0º-120º & Popliteus 30º-120º
POSTGRAD ORTH Deiary Kader
Medial release for varus knee
Osteophytes excision
Deep MCL to posteromedial corner
Semimembranosus aponeurosis
Superficial MCL
PCL
Pes anserinus insertion
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Pie-Crusting Technique
Extension
Osteophytes excision
Deep MCL to posteromedial corner
Flexion
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POSTGRAD ORTH Deiary Kader
What are the problems
associated with valgus
knees
POSTGRAD ORTH Deiary Kader
Valgus knee
Multiple problems associated with valgus knees
Soft-tissue abnormality
Bony deficiencies — acquired or pre-existing
Patella subluxation
Lateral capsule and ligament contracture
PCL dysfunctional in severe valgus
Distal femoral rotational deformity with externally
rotated epicondylar axis up to 10°.
POSTGRAD ORTH Deiary Kader
Soft-tissue release in valgus knees
Osteophyte excision
Lateral patellofemoral ligament (LPFL) release
Release posterolateral capsule off the tibia
Sacrifice PCL in moderate-severe valgus.
Flexion and extension tightness
Release (or pie-crust) lateral collateral ligament (LCL) from
the femur.
Flexion tightness
Release Popliteus
Extension tightness
Release (or pie-crust) the iliotibial band at Gerdy’s tubercle
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Valgus Knee
Posterior capsuleLCL release
Flexion and extension tightness
POSTGRAD ORTH Deiary Kader
Tight in FlexionTight in Extension
Lateral collateral release for valgus knee
POSTGRAD ORTH Deiary Kader
Easy way to
remember
Gap balancing 



POSTGRAD ORTH Deiary Kader
Flexion & Extension gaps
Tibial Cut Flexion and extension gaps
Distal femur Extension Gap
Posterior osteophytes Extension Gap
Posterior condyles Flexion Gap
Tibial slope Flexion Gap
Implant size Flexion Gap
PCL Excision Flexion Gap
Asymmetric Extension Gap soft tissue or tibia
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Balancing Flexion and Extension Gaps
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What are the technical
difficulties in converting
Uni to TKR?
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
50% of Uni knees had a significant bone defect
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Post op Mx of TKR



POSTGRAD ORTH Deiary Kader
Pain Control
1) Patient education

2) Preemptive analgesics

3) Epidural analgesia

4) Peripheral nerve block: Add/femoral nerve block

5) Periarticular injection

6) Patient-controlled analgesia (PCA)?

7) Oral analgesics

POSTGRAD ORTH Deiary Kader
Consenting/complications
✦ Infection
✦ DVT
✦ Pulmonary embolism
✦ CVA or MI
✦ Skin numbness
✦ Implant longevity
✦ Fracture
✦ Neurovascular injury
✦ Delayed wound
healing
✦ Extensor mechanism
injury
✦ Death
✦ Rehab-Golden 2
weeks
✦ Smoking
✦ Pain postop
✦ Skin problems
✦ Remote infection
✦ Nickel allergy
✦ Blood transfusion
Consent this patient for TKR
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POSTGRAD ORTH Deiary Kader
Aseptic complications after TKR
Wound healing
Extensor Mechanism complications
Stiffness
Periprosthetic fractures
Loosening
Neurologic injuries
Vascular injuries
Thromboembolic disease
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Poly difference in
TKR and THR
POSTGRAD ORTH Deiary Kader
Processing methods for
XLPE acetabular liner
and tibial insert for
total hip and knee
arthroplasty
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
KNEE
TKR is less constrained
less conformed
high contact stresss
Sheering force
subjected to fatigue wear (delamination)
POSTGRAD ORTH Deiary Kader
Highly Cross Linked Polyethylene
(XLPE)
Cross-linking Dramatically reduces
volumetric wear BUT
1. Reduces toughness
2. Decrease the ultimate tensile strength
3. Decrease resistance to fatigue crack
propagation
POSTGRAD ORTH Deiary Kader
Technical Considerations in TKR
How would you determine the
rotation of the femoral component?
Femoral Component
What is the optimal external rotation ?
Suggesting that 2–5° of external rotation is the optimal position
referenced off the posterior condylar axis
Kim et al. (2014)
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Rotational alignment of the femoral component 

Anatomical landmarks for reference:
Epicondylar axis
Posterior condylar axis
Anteroposterior axis ( Whiteside’s line)
The ant cortex of the femur
POSTGRAD ORTH Deiary Kader
Surgical
Anatomic POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
1-The epicondylar axis
Problems
Difficult to identify, peaks are often obscured
by the everted patella Overlying collateral
ligaments and adipose tissue.
Misuse of the surgical epicondylar axis rather
than the Anatomic one
POSTGRAD ORTH Deiary Kader
2-The posterior condylar axis
Problems
Inaccurate in severe arthritis
Anatomy of the femur varies
Gender variation
Valgus knee hypoplastic LFC
Varus knee MFC larger
POSTGRAD ORTH Deiary Kader
3-Anteroposterior (AP) axis
The line deepest part of the trochlear to the Centre of the
intercondylar notch posteriorly
Difficult to Identification
In trochlear dysplasia or destructive arthritis
knees with significant varus or valgus deformity
Whiteside’s line
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4- The Anterior Femoral Cortical Line
Dr Mervyn Cross
POSTGRAD ORTH Deiary Kader
Tibial Tray Rotation
Medial border of the tib tub
Medial 1/3 of the tibial
tubercle
Middle of the tibial tubercle
Patellar tendon
PCL attachment
Transverse axis of the tibia
Posterior condylar line
(tibia)
Mid-sulcus of the tibial spine
Malleolar axis
The second metatarsal
Reference from the femur
What if the FC internally rotated
•Asymmetric flexion gap
•Shift into valgus alignment with flexion
•Increase in Q angle
•Patella mal-tracking/Instability
•Severe patellar wear if resurfaced
•Asymmetric tibial component load
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POSTGRAD ORTH Deiary Kader


The role of computer navigation
in TKR


POSTGRAD ORTH Deiary Kader
prospectively compared the results of 520 patients with
osteoarthritis who underwent computer-navigated total knee
arthroplasty for one knee and conventional total knee arthroplasty
for the other.
Results demonstrated no difference in
clinical function or alignment and
survivorship of the components
RCT	520	pts	Navigated	vs	Conventional
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Titanium or Cobalt Chrome
for Tibial component?




POSTGRAD ORTH Deiary Kader
Cobalt Chrome Property Titanium
Yes Fatigue resistance Better
No Stress Shielding Much Better
220 GPa Elastic modulus 110 GPa
Excellent Bearing surface Never unless treated
Resistant Wear Poor characteristics
less Scratch sensitive Scratch sensitive
Poly (osteolysis) Debris Metallic debris
(toxic)
POSTGRAD ORTH Deiary Kader
Materials in TKR
Material Elastic Modulus
Stiffness
316L Stainless Steel 230 GPa
Cobalt-Chrome alloy 220 Giga Pascal
Ti6Al4V 110 GPa
Cortical Bone 21 GPa
Trabecular Bone 15 GPa
PMMA Cement 4 GPa
POSTGRAD ORTH Deiary Kader
Ti or CoCr for tibia
Titanium oxide and Titanium alloys have great corrosion
resistance, inert biomaterial, fast bone bonding and reduce
stress shielding
Titanium alloy knees generated significantly more metallic debris
more toxic to the surrounding tissue
CoCr knees more polyethylene debris and more likely to release
inflammatory cytokines causing osteolysis
POSTGRAD ORTH Deiary Kader
Principles of PFJR



POSTGRAD ORTH Deiary Kader
PFJ OA
kneeling, squatting, climbing stairs, and
getting up from a low chair.
More subtle than knee OA
Swelling para-patella
Crepitus anterior knee
POSTGRAD ORTH Deiary Kader
PFJ OA
Non-operative treatment
Anti-inflammatory medications
Activity modification
Quadriceps strengthening
Bracing,
Steroid injections
Viscosupplement
POSTGRAD ORTH Deiary Kader
PFJ OA
PFJ replacement or TKR?
POSTGRAD ORTH Deiary Kader
PFJ OA
PFJ replacement or TKR?
1. Age
2. Other compartments
3. Implant failure rate
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PFJR
Revision rate 9% in 5 years
revision rate is 19% in 10 years
why?
Failure to regard as a Soft tissue procedure
Maltracking
Catching
Subluxations
Implant design
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Priciples
Understanding the pathology and Dx
Is there instability?
Meticulous surgical technique
Soft tissue balance/lateral release
External rotation of the trochlea
Avoid over/understuffing the patella
Implant design use on-lay not inlay
AVON Stryker
FPV Vialli Wright medical
Journey by S&N
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Would you resurface
the Patella during TKR?



POSTGRAD ORTH Deiary Kader
Patella
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Patella resurfacing debate
For
Reduces anterior knee pain
Improves strength in flexion stair descent
Less likely to revise the knee for AKP
Secondary resurfacing results are inferior
Better results in RA
POSTGRAD ORTH Deiary Kader
Patella resurfacing debate
Against
No difference in outcome
Increase wear particles
Early technical complications
Long-term patellar fracture
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Patellofemoral maltracking
DO NOT
Overstuff the patella.
Oversize the femoral component
Internally rotate of the tibial component
(increases the Q angle)
Avoid an excessive valgus angle
Avoid raising the joint line
Avoid inferior placement of the patella component
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Indications for
selective patella replacement: 

Advanced osteoarthritic patella
Rheumatoid arthritis
Preoperative patellofemoral pain
Obese patients
Overweight females
Chondrocalcinosis
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Prospective, randomised, double-blinded study of 350 TKR
with selective patellar resurfacing
Follow-up of 7.8 years demonstrated that satisfaction was
higher in patients with a resurfaced patella.
Followed for at least 10 years, no significant difference was
found. No difference was found in KSS scores,
survivorship and no complications of resurfacing were
identified.
The vast majority of patients with remaining
patellar articular cartilage
do very well with TKA regardless of patellar resurfacing.
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Patella resurfacing in TKR 

(Randomised trial)
Barrack et al Sept 2001 JBJSA
118 TKR F/U >five years
No difference in outcome
Ant knee pain relate to
Component design
Surgical technique
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Patella resurfacing in TKR 

(Randomised trial)
Wood et al Feb 2002 JBJSA
220 TKR mean F/U 48 months
Superior results in term of
Stair descent
Ant knee pain 16 % compared to 31%
10 % had revision in the resurfacing gp
POSTGRAD ORTH Deiary Kader
14 Causes for Patellar problems
7 in the Femur: IR, ER, medial, Valgus, Ant,
Post, oversized
4 in the Tibia: IR, Medial, Valgus, Ant
3 in the Patella: under-resection, Over-
resection, lateral
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader




Peri-prosthatic fracture
after TKR approach and
management
POSTGRAD ORTH Deiary Kader
88 Y lady from a nursing home had knee revision 8 years ago
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POSTGRAD ORTH Deiary Kader
75 Y lady lives alone. knee revision 5 years ago was doing well
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Distal Femur Replacement
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
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Mal-Alignment
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Common causes of
Painful knee arthroplasty
• Infection
• Aseptic loosening
• Instability
• Stiffness
• Malrotation
• Malalignment
• Patellar pain
• Patellar dislocation
• Extensor mechanism Inj
• Incompetent MCL
• Periprosthetic fracture
• Implant breakage
• CRPS
• Hip or spine pathology
• Unexplained pain (1/300)
POSTGRAD ORTH Deiary Kader
Indications for Revision TKA
• Aseptic loosening (30-40%)
• Infection (22%)
• Pain (10%)
• Mal-alignment 7-10%
POSTGRAD ORTH Deiary Kader
The primary goal of revision TKR
To restore knee alignment and stability
through a full range of movement
Re-establish the native joint line
Well-fixed implants
Appropriate soft tissue balancing ensures
stability
Avoids intra-operative extensor mechanism
complications
POSTGRAD ORTH Deiary Kader
Management
History &
Examination
POSTGRAD ORTH Deiary Kader
Investigations
Plain weight-bearing X-ray
Bloods (including WCC, ESR and CRP – IL-6 (expensive)
in specialist units
Knee aspiration
Fluoroscopic alignment check
CT scan to check rotation and long leg films to assess the
overall alignment
Bone scan (not helpful until a year after the index
procedure), white cell-labelled bone scan
SPECT-CT has also been a novel imaging option to detect
loosening / infection and highlight areas of maximal
activity.
The Synovasure™ Alpha Defensin Test
POSTGRAD ORTH Deiary Kader
AAOS Clinical guideline for Dx infection 2010
The working group strongly recommended:
Testing ESR and CRP
Joint aspiration
The use of intraoperative frozen sections
Obtaining multiple intraoperative cultures ( at least 3 but no
more than 6 using different instrument for each sample and
from different areas)
• Against initiating antibiotic treatment until after cultures
• Against the use of intraoperative Gram stain
Nuclear imaging was weakly recommended as an option
POSTGRAD ORTH Deiary Kader
What is the Definition of
Peri-prosthetic joint Infection?
What is the AAOS Clinical guideline for Dx
infection 2010
POSTGRAD ORTH Deiary Kader
What is the Definition of
Peri-prosthetic joint Infection
International Consensus Meeting in 2013 as:
Musculoskeletal Infection Society
A sinus tract communicating with the joint
OR
2 positive cultures with identical organisms
OR
3-4 of the following minor criteria:
Elevated CRP and ESR
Single positive culture
Elevated synovial fluid WCC —1,100 to 4,000 cells/µL
Elevated synovial fluid PMN 64%-69%
Presence of purulence in the affected joint
Isolation of a microorganism in one culture of tissue or fluid
Greater than 5 neutrophils per high-power field in five high-power fields
observed from histology at 400 times magnification
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Infection
Revision for
Infection (22%)
POSTGRAD ORTH Deiary Kader
Commonly used CCK in UK
PFC Sigma
TC3 (DePuy)
Triathlon TS
(Stryker)
Legion
Smith &
Nephew
Vanguard SSK
(Biomet)
NexGen
(Zimmer)
POSTGRAD ORTH Deiary Kader
CCK progression to Hinged knee
One should be aware of
inter species
compatibility
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Bone defects
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Metaphyseal Sleeves & Cones
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Trabecular Metal Cones
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TKR in Jehovah's witness
POSTGRAD ORTH Deiary Kader
JEHOVAH’S WITNESSES
RCS Professional and Clinical Standards November 2016
Pre-admission patient optimisation
• Essential blood samples, FBC, U&Es, LFTs, Clotting screen and fibrinogen, B12 and folate and iron
studies
• General health optimisation
• Erythropoietin Hb <13g/dL M and Hb ≤ 12g/dL
• Erythropoietin ineffective in patients with iron, B12 or folate deficiency
Intraoperative considerations – blood conservation strategies
• Consider minimal invasive
• Hypotensive anaesthesia and even controled hypothermia
• Cell Salvage
• Coagulation stimulants such as Tranexamic acid and factors (VIIa, VIII, IX) and desmopressin
• Haemostatic aids: diathermy and radiofrequency ablation
• Regional anaesthesia with the consultant anaesthetist
Postoperative considerations
• Monitor and minimise blood loss postoperatively
• Monitor and avoid sepsis
• Consider postoperative EPO and/or Iron/B12 replacements
• Where appropriate and acceptable to the patient, use blood salvage from drains (cell saver)
POSTGRAD ORTH Deiary Kader
Knee Arthrodesis

Indications
• Failed TKR
• Uncontrollable sepsis/ Resistant organisms
• Neuropathic joint
• Disruption of extensor mechanism
• Poor soft-tissue envelope
• Systemically immunocompromised
• Post-traumatic OA (heavy manual labourer)?
POSTGRAD ORTH Deiary Kader
Contraindications
• Bilateral knee disease
• Ipsilateral ankle or hip disease
• Ipsilateral hip arthrodesis
• Severe segmental bone loss
• Contralateral limb amputation.
POSTGRAD ORTH Deiary Kader
Optimal position for knee fusion

• 7°–10° of external rotation
• Slight valgus
• 10°–20° of flexion
• The above may be easier to achieve with
external fixator rather than IM nail.
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Techniques
Intramedullary arthrodesis
External fixation
Plate fixation
POSTGRAD ORTH Deiary Kader
Complications
Non-union
Malunion
Delayed union
Recurrent infection
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Thank You

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Knee recon 2018 deiary kader post grad

  • 1. POSTGRAD ORTH Deiary Kader SPORTS INJURIES/ KNEE FRCS(Tr&Orth) Revision Course Professor Deiary F Kader Knee Surgeon SW London Elective Orthopaedic Centre Epsom & St Helier University Hospitals Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva) KNEE Recon
  • 2. POSTGRAD ORTH Deiary Kader PLAN 1. Osteotomy around the knee 2. Uni compartmental Knee 3. TKR 4. PFJ OA 5. Revision TKR
  • 3. POSTGRAD ORTH Deiary Kader Candidate’s questions ? • Which TKR and why? How to choose knee prosthesis? • principles of PFJR? • principles of osteotomy angel measurements • KM survival of TKR • Biomechanics of TKR • Principles of knee bracing and callipers and condition which they work best • Easy way to remember how to answer flexion extension gab balance • When to operate for PFJ if at all • TKR in Jehovah's witness • Catastrophic wear in TKR • Evidence based non operative treatment of OA —Post operative Mx of TKR • The role of computer navigation in TKR • Coronal plane sequential ligament release in TKR • Osteotomy cut off age. Uni knees indications • Do you resurface the patella? • How does changing slop in osteotomy affect load transmission? • Which osteotomy open or close • PCL retaining or substituting and why • Why TKR have different implant materials in the femur and tibia • Prevention of catastrophic wear mean • What are the technical difficulties in converting Uni to TKR? • Periprosthatic fracture after TKR approach and management • Poly difference in TKR and THR • The role of lateral facetectomy in patella arthritis POSTGRAD ORTH Deiary Kader
  • 4. POSTGRAD ORTH Deiary Kader 45 Y Male Bricklayer
  • 5. POSTGRAD ORTH Deiary Kader Evidence based None-operative Treatment for OA?
  • 6. POSTGRAD ORTH Deiary Kader OA Nonoperative treatment Evidence Weight loss Exercise Patient education Analgesia, (NSAIDs) Bracing Intra-articular (IA) injections. Cochrane reviews Steroids (better than placebo but not longer than 4wks) HA more prolonged effect than steroids
  • 7. POSTGRAD ORTH Deiary Kader Proximal Tibia (HTO) or Distal Femur Osteotomy
  • 8. POSTGRAD ORTH Deiary Kader Osteotomy plan Angle measurements Principles Planning osteotomy
  • 9. POSTGRAD ORTH Deiary Kader Overcorrection of 3º–5º above the 6º–7º normal valgus angle 62.5% across tibial plateau from medial side
  • 10. POSTGRAD ORTH Deiary Kader Mechanical Axis of the Lower Limb Mechanical axis of the lower limb 4-8mm medial
  • 11. POSTGRAD ORTH Deiary Kader Mechanical Axis deviation MAD POSTGRAD ORTH Deiary Kader
  • 12. POSTGRAD ORTH Deiary Kader 33% 20 5% POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 14. POSTGRAD ORTH Deiary Kader Double Varus 1- Varus alignment Progressive medial joint narrowing 2- Lateral opening LCL laxity >5 mm laxity ( stress radiograph) Varus thrust
  • 15. POSTGRAD ORTH Deiary Kader Triple Varus Varus alignment Posterolateral corner laxity Increased Ext-Rotation Hyperextension Lateral opening Varus recurvatum deformity POSTGRAD ORTH Deiary Kader
  • 16. POSTGRAD ORTH Deiary Kader Osteotomy for arthritis of the knee Aims of valgus osteotomy Unload the medial compartment Unloading any ligament reconstruction in patients with a varus thrust To change the tibial slope in order to reduce translational forces and improve AP instability
  • 18. POSTGRAD ORTH Deiary Kader Compensating for Abnormal AP Laxity ACL Rupture PCL Rupture Usually by CWHTO Usually by OWHTO POSTGRAD ORTH Deiary Kader
  • 19. POSTGRAD ORTH Deiary Kader Who is the IDEAL candidate for HTO?
  • 20. POSTGRAD ORTH Deiary Kader Proximal or High Tibial Osteotomy (HTO)
 The IDEAL candidate for HTO Age <65 years Isolated medial OA/Intact Ligaments Non-Smoker BMI<30 Almost Full ROM >120° Less than 5° FFD knee Patients should be Able to use crutches Have no major varicose veins No peripheral vascular disease POSTGRAD ORTH Deiary Kader
  • 21. POSTGRAD ORTH Deiary Kader The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine POSTGRAD ORTH Deiary Kader
  • 22. POSTGRAD ORTH Deiary Kader Osteotomy vs Unicompartmental replacement?
  • 23. POSTGRAD ORTH Deiary Kader 45 Y Male Bricklayer Vs 58 Y old Female manager
  • 24. POSTGRAD ORTH Deiary Kader Age Sex Activity level ligament stability Deformity
  • 25. POSTGRAD ORTH Deiary Kader Which Osteotomy Open or Closed?
  • 26. POSTGRAD ORTH Deiary Kader Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965
 (Coventry, 1965). POSTGRAD ORTH Deiary Kader
  • 27. POSTGRAD ORTH Deiary Kader Fibular osteotomy, Separating tibiofibular joint Contracture of the patellar tendon, patellar baja leg shortening Nerve injuries Varus laxity (loose LCL) TKR is harder High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up* ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ Bone Joint Surg Am, 2000 Jan Closed wedge HTO 
 Disadvantages POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 28. POSTGRAD ORTH Deiary Kader OPEN Wedge HTO 1987 The open-wedge high tibial osteotomy gained recognition after the encouraging reports of (Hernigou et al., 1987). Wedges of bone that were obtained from the iliac crest were inserted into the defect POSTGRAD ORTH Deiary Kader
  • 29. POSTGRAD ORTH Deiary Kader Open W HTO POSTGRAD ORTH Deiary Kader
  • 30. POSTGRAD ORTH Deiary Kader Open Wedge HTO 
 Advantages
 Easier to adjust correction angle Preserves bone stock (subsequent TKR easier) Makes MCL tightening easier Allows LCL or posterolateral -Reconstruction No risk to peroneal nerve Less dissection?
  • 31. POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 32. POSTGRAD ORTH Deiary Kader Open wedge HTO 
 Disadvantages Requires a bone graft (substitute, autograft, Allo) Increased incidence of non-union and delayed un Large correction may affect leg lengthening Loss of fixation and recurrence of varus deformity Worsens patella Baja POSTGRAD ORTH Deiary Kader
  • 33. POSTGRAD ORTH Deiary Kader O W HTO POSTGRAD ORTH Deiary Kader
  • 34. POSTGRAD ORTH Deiary Kader RCT 92 pts and 6 years FU OW-HTO vs CW-HTO More Complications in open WHTO & more conversion to TKR in closed WHTO SEPT 2014
  • 35. POSTGRAD ORTH Deiary Kader Distal Femur Osteotomy for Valgus Malalignment POSTGRAD ORTH Deiary Kader
  • 36. POSTGRAD ORTH Deiary Kader Coventry report
 Outcome 5-year survival of 87% 10-year survival of 66% However the 5-year survival was reduced to 38% if under-corrected or overweight POSTGRAD ORTH Deiary Kader
  • 37. POSTGRAD ORTH Deiary Kader What are the Biomechanical aims of TKR?
  • 38. POSTGRAD ORTH Deiary Kader The Primary Aim of TKR Restoring neutral mechanical axis of 0 (+/- 3º) Balancing the flexion/extension gap (ER of FC) Joint line perpendicular to the Mech axis Preserving the joint line height Balancing Ligaments ( 2-3 mm play) Restoring normal joint alignment and Q angle
  • 39. POSTGRAD ORTH Deiary Kader Which knee replacement and why?
  • 41. POSTGRAD ORTH Deiary Kader Constraint ladder in implant design
  • 42. POSTGRAD ORTH Deiary Kader Constraint ladder in implant design PCL-retaining (cruciate-retaining, or CR) Rotating platform PCL-substituting or posterior-stabilised Unlinked constrained condylar CCK/ VVC Linked, constrained condylar implant (rotating-hinge knee, RHK).
  • 43. POSTGRAD ORTH Deiary Kader 
 
 PCL retaining or substituting and why
  • 44. POSTGRAD ORTH Deiary Kader PS or CR POSTGRAD ORTH Deiary Kader
  • 45. POSTGRAD ORTH Deiary Kader PCL retaining (CR) POSTGRAD ORTH Deiary Kader
  • 46. POSTGRAD ORTH Deiary Kader PCL retaining (CR) Provides least constraint Less forces at the interface Preserves proprioceptive fibres (intact PCL) Greater stability during stair climbing (quadriceps strength) Less risk of condylar fracture
  • 47. POSTGRAD ORTH Deiary Kader PCL retaining (CR) 2 Fewer patella complications Preserve bone stock on the femoral side Better kinematics Avoids the tibial post–cam impingement Ease of management of supracondylar fracture (plate/nail)
  • 48. POSTGRAD ORTH Deiary Kader PCL retaining (CR) Disadvantages Less conforming surfaces to allow roll-back Slide/shear stress causes poly delamination Technically difficult to balance Late PCL dysfunction POSTGRAD ORTH Deiary Kader
  • 49. POSTGRAD ORTH Deiary Kader GII PS + Pat POSTGRAD ORTH Deiary Kader
  • 50. POSTGRAD ORTH Deiary Kader Indications for PCL Sacrificing Implants Previous patellectomy Rheumatoid arthritis Stiff knee in post-traumatic arthritis Previous high tibial osteotomy (HTO) Large deformity, over-released PCL POSTGRAD ORTH Deiary Kader
  • 51. POSTGRAD ORTH Deiary Kader PCL substitution/sacrificing Advantages PCL histologically and kinematically abnormal The cam-post mechanism improves AP stability Provides a degree of VVC Conforming surfaces allowing roll-back No component slide
  • 52. POSTGRAD ORTH Deiary Kader PCL substitution/sacrificing Advantages Higher degree of flexion Less joint line sensitive (Restored within 8-9mm, Figgie) Congruent joint surfaces reduces wear Facilitates deformity correction Superior and more reproducible kinematics Technically easier than CR POSTGRAD ORTH Deiary Kader
  • 53. POSTGRAD ORTH Deiary Kader PCL substitution/sacrificing Disadvantages High stresses at fixation interface Femoral bone loss/fracture Tibial peg increases wear Post dislocation 3X greater joint line alteration than CR Patella clunk/ crunch syndrome POSTGRAD ORTH Deiary Kader
  • 54. POSTGRAD ORTH Deiary Kader Summary Both CR & PS knees work very well Long term outcome comparable One design wont fit all PS knees outcome is more predictable We should be able to do both when it is indicated POSTGRAD ORTH Deiary Kader
  • 55. POSTGRAD ORTH Deiary Kader 
 
 Coronal plane sequential ligament release in TKR
  • 56. POSTGRAD ORTH Deiary Kader Knee Ligaments Lateral Complex ITB LCL Popliteus Biceps Femoris Central Complex ACL PCL Med Menx Lat Menx Medial Complex MCL POL Capsule Semi-Memb Pes anserinus
  • 57. POSTGRAD ORTH Deiary Kader H Schroeder-Boersch Medial Ligament Restraint
 Range of Ligament restraint medial knee
 POSTGRAD ORTH Deiary Kader
  • 58. POSTGRAD ORTH Deiary Kader Ligament restraint Lateral knee H Schroeder-Boersch
  • 59. POSTGRAD ORTH Deiary Kader PCL 0º-120º more in flexion It is “a central stabiliser” 15mm PCL insertion 15mm
  • 60. POSTGRAD ORTH Deiary Kader LCL 0º-120º & Popliteus 30º-120º
  • 61. POSTGRAD ORTH Deiary Kader Medial release for varus knee Osteophytes excision Deep MCL to posteromedial corner Semimembranosus aponeurosis Superficial MCL PCL Pes anserinus insertion
  • 62. POSTGRAD ORTH Deiary Kader Pie-Crusting Technique Extension Osteophytes excision Deep MCL to posteromedial corner Flexion POSTGRAD ORTH Deiary Kader
  • 63. POSTGRAD ORTH Deiary Kader What are the problems associated with valgus knees
  • 64. POSTGRAD ORTH Deiary Kader Valgus knee Multiple problems associated with valgus knees Soft-tissue abnormality Bony deficiencies — acquired or pre-existing Patella subluxation Lateral capsule and ligament contracture PCL dysfunctional in severe valgus Distal femoral rotational deformity with externally rotated epicondylar axis up to 10°.
  • 65. POSTGRAD ORTH Deiary Kader Soft-tissue release in valgus knees Osteophyte excision Lateral patellofemoral ligament (LPFL) release Release posterolateral capsule off the tibia Sacrifice PCL in moderate-severe valgus. Flexion and extension tightness Release (or pie-crust) lateral collateral ligament (LCL) from the femur. Flexion tightness Release Popliteus Extension tightness Release (or pie-crust) the iliotibial band at Gerdy’s tubercle POSTGRAD ORTH Deiary Kader
  • 66. POSTGRAD ORTH Deiary Kader Valgus Knee Posterior capsuleLCL release Flexion and extension tightness
  • 67. POSTGRAD ORTH Deiary Kader Tight in FlexionTight in Extension Lateral collateral release for valgus knee
  • 68. POSTGRAD ORTH Deiary Kader Easy way to remember Gap balancing 
 

  • 69. POSTGRAD ORTH Deiary Kader Flexion & Extension gaps Tibial Cut Flexion and extension gaps Distal femur Extension Gap Posterior osteophytes Extension Gap Posterior condyles Flexion Gap Tibial slope Flexion Gap Implant size Flexion Gap PCL Excision Flexion Gap Asymmetric Extension Gap soft tissue or tibia
  • 70. POSTGRAD ORTH Deiary Kader Balancing Flexion and Extension Gaps
  • 71. POSTGRAD ORTH Deiary Kader 
 
 What are the technical difficulties in converting Uni to TKR?
  • 72. POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 73. POSTGRAD ORTH Deiary Kader 50% of Uni knees had a significant bone defect
  • 74. POSTGRAD ORTH Deiary Kader Post op Mx of TKR
 

  • 75. POSTGRAD ORTH Deiary Kader Pain Control 1) Patient education
 2) Preemptive analgesics
 3) Epidural analgesia
 4) Peripheral nerve block: Add/femoral nerve block
 5) Periarticular injection
 6) Patient-controlled analgesia (PCA)?
 7) Oral analgesics

  • 76. POSTGRAD ORTH Deiary Kader Consenting/complications ✦ Infection ✦ DVT ✦ Pulmonary embolism ✦ CVA or MI ✦ Skin numbness ✦ Implant longevity ✦ Fracture ✦ Neurovascular injury ✦ Delayed wound healing ✦ Extensor mechanism injury ✦ Death ✦ Rehab-Golden 2 weeks ✦ Smoking ✦ Pain postop ✦ Skin problems ✦ Remote infection ✦ Nickel allergy ✦ Blood transfusion Consent this patient for TKR POSTGRAD ORTH Deiary Kader
  • 77. POSTGRAD ORTH Deiary Kader Aseptic complications after TKR Wound healing Extensor Mechanism complications Stiffness Periprosthetic fractures Loosening Neurologic injuries Vascular injuries Thromboembolic disease
  • 78. POSTGRAD ORTH Deiary Kader 
 
 Poly difference in TKR and THR
  • 79. POSTGRAD ORTH Deiary Kader Processing methods for XLPE acetabular liner and tibial insert for total hip and knee arthroplasty POSTGRAD ORTH Deiary Kader
  • 80. POSTGRAD ORTH Deiary Kader KNEE TKR is less constrained less conformed high contact stresss Sheering force subjected to fatigue wear (delamination)
  • 81. POSTGRAD ORTH Deiary Kader Highly Cross Linked Polyethylene (XLPE) Cross-linking Dramatically reduces volumetric wear BUT 1. Reduces toughness 2. Decrease the ultimate tensile strength 3. Decrease resistance to fatigue crack propagation
  • 82. POSTGRAD ORTH Deiary Kader Technical Considerations in TKR How would you determine the rotation of the femoral component?
  • 83. Femoral Component What is the optimal external rotation ? Suggesting that 2–5° of external rotation is the optimal position referenced off the posterior condylar axis Kim et al. (2014) POSTGRAD ORTH Deiary Kader
  • 84. POSTGRAD ORTH Deiary Kader Rotational alignment of the femoral component 
 Anatomical landmarks for reference: Epicondylar axis Posterior condylar axis Anteroposterior axis ( Whiteside’s line) The ant cortex of the femur
  • 85. POSTGRAD ORTH Deiary Kader Surgical Anatomic POSTGRAD ORTH Deiary Kader
  • 86. POSTGRAD ORTH Deiary Kader 1-The epicondylar axis Problems Difficult to identify, peaks are often obscured by the everted patella Overlying collateral ligaments and adipose tissue. Misuse of the surgical epicondylar axis rather than the Anatomic one
  • 87. POSTGRAD ORTH Deiary Kader 2-The posterior condylar axis Problems Inaccurate in severe arthritis Anatomy of the femur varies Gender variation Valgus knee hypoplastic LFC Varus knee MFC larger
  • 88. POSTGRAD ORTH Deiary Kader 3-Anteroposterior (AP) axis The line deepest part of the trochlear to the Centre of the intercondylar notch posteriorly Difficult to Identification In trochlear dysplasia or destructive arthritis knees with significant varus or valgus deformity Whiteside’s line
  • 89. POSTGRAD ORTH Deiary Kader 4- The Anterior Femoral Cortical Line Dr Mervyn Cross
  • 90. POSTGRAD ORTH Deiary Kader Tibial Tray Rotation Medial border of the tib tub Medial 1/3 of the tibial tubercle Middle of the tibial tubercle Patellar tendon PCL attachment Transverse axis of the tibia Posterior condylar line (tibia) Mid-sulcus of the tibial spine Malleolar axis The second metatarsal Reference from the femur
  • 91. What if the FC internally rotated •Asymmetric flexion gap •Shift into valgus alignment with flexion •Increase in Q angle •Patella mal-tracking/Instability •Severe patellar wear if resurfaced •Asymmetric tibial component load POSTGRAD ORTH Deiary Kader
  • 92. POSTGRAD ORTH Deiary Kader 
 The role of computer navigation in TKR 

  • 93. POSTGRAD ORTH Deiary Kader prospectively compared the results of 520 patients with osteoarthritis who underwent computer-navigated total knee arthroplasty for one knee and conventional total knee arthroplasty for the other. Results demonstrated no difference in clinical function or alignment and survivorship of the components RCT 520 pts Navigated vs Conventional
  • 94. POSTGRAD ORTH Deiary Kader Titanium or Cobalt Chrome for Tibial component? 
 

  • 95. POSTGRAD ORTH Deiary Kader Cobalt Chrome Property Titanium Yes Fatigue resistance Better No Stress Shielding Much Better 220 GPa Elastic modulus 110 GPa Excellent Bearing surface Never unless treated Resistant Wear Poor characteristics less Scratch sensitive Scratch sensitive Poly (osteolysis) Debris Metallic debris (toxic)
  • 96. POSTGRAD ORTH Deiary Kader Materials in TKR Material Elastic Modulus Stiffness 316L Stainless Steel 230 GPa Cobalt-Chrome alloy 220 Giga Pascal Ti6Al4V 110 GPa Cortical Bone 21 GPa Trabecular Bone 15 GPa PMMA Cement 4 GPa
  • 97. POSTGRAD ORTH Deiary Kader Ti or CoCr for tibia Titanium oxide and Titanium alloys have great corrosion resistance, inert biomaterial, fast bone bonding and reduce stress shielding Titanium alloy knees generated significantly more metallic debris more toxic to the surrounding tissue CoCr knees more polyethylene debris and more likely to release inflammatory cytokines causing osteolysis
  • 98. POSTGRAD ORTH Deiary Kader Principles of PFJR
 

  • 99. POSTGRAD ORTH Deiary Kader PFJ OA kneeling, squatting, climbing stairs, and getting up from a low chair. More subtle than knee OA Swelling para-patella Crepitus anterior knee
  • 100. POSTGRAD ORTH Deiary Kader PFJ OA Non-operative treatment Anti-inflammatory medications Activity modification Quadriceps strengthening Bracing, Steroid injections Viscosupplement
  • 101. POSTGRAD ORTH Deiary Kader PFJ OA PFJ replacement or TKR?
  • 102. POSTGRAD ORTH Deiary Kader PFJ OA PFJ replacement or TKR? 1. Age 2. Other compartments 3. Implant failure rate
  • 103. POSTGRAD ORTH Deiary Kader PFJR Revision rate 9% in 5 years revision rate is 19% in 10 years why? Failure to regard as a Soft tissue procedure Maltracking Catching Subluxations Implant design
  • 104. POSTGRAD ORTH Deiary Kader Priciples Understanding the pathology and Dx Is there instability? Meticulous surgical technique Soft tissue balance/lateral release External rotation of the trochlea Avoid over/understuffing the patella Implant design use on-lay not inlay AVON Stryker FPV Vialli Wright medical Journey by S&N
  • 106. POSTGRAD ORTH Deiary Kader Would you resurface the Patella during TKR?
 

  • 107. POSTGRAD ORTH Deiary Kader Patella POSTGRAD ORTH Deiary Kader
  • 109. POSTGRAD ORTH Deiary Kader Patella resurfacing debate For Reduces anterior knee pain Improves strength in flexion stair descent Less likely to revise the knee for AKP Secondary resurfacing results are inferior Better results in RA
  • 110. POSTGRAD ORTH Deiary Kader Patella resurfacing debate Against No difference in outcome Increase wear particles Early technical complications Long-term patellar fracture POSTGRAD ORTH Deiary Kader
  • 111. POSTGRAD ORTH Deiary Kader Patellofemoral maltracking DO NOT Overstuff the patella. Oversize the femoral component Internally rotate of the tibial component (increases the Q angle) Avoid an excessive valgus angle Avoid raising the joint line Avoid inferior placement of the patella component POSTGRAD ORTH Deiary Kader
  • 112. POSTGRAD ORTH Deiary Kader Indications for selective patella replacement: 
 Advanced osteoarthritic patella Rheumatoid arthritis Preoperative patellofemoral pain Obese patients Overweight females Chondrocalcinosis POSTGRAD ORTH Deiary Kader
  • 113. POSTGRAD ORTH Deiary Kader Prospective, randomised, double-blinded study of 350 TKR with selective patellar resurfacing Follow-up of 7.8 years demonstrated that satisfaction was higher in patients with a resurfaced patella. Followed for at least 10 years, no significant difference was found. No difference was found in KSS scores, survivorship and no complications of resurfacing were identified. The vast majority of patients with remaining patellar articular cartilage do very well with TKA regardless of patellar resurfacing. POSTGRAD ORTH Deiary Kader
  • 114. POSTGRAD ORTH Deiary Kader Patella resurfacing in TKR 
 (Randomised trial) Barrack et al Sept 2001 JBJSA 118 TKR F/U >five years No difference in outcome Ant knee pain relate to Component design Surgical technique
  • 115. POSTGRAD ORTH Deiary Kader Patella resurfacing in TKR 
 (Randomised trial) Wood et al Feb 2002 JBJSA 220 TKR mean F/U 48 months Superior results in term of Stair descent Ant knee pain 16 % compared to 31% 10 % had revision in the resurfacing gp
  • 116. POSTGRAD ORTH Deiary Kader 14 Causes for Patellar problems 7 in the Femur: IR, ER, medial, Valgus, Ant, Post, oversized 4 in the Tibia: IR, Medial, Valgus, Ant 3 in the Patella: under-resection, Over- resection, lateral POSTGRAD ORTH Deiary Kader
  • 117. POSTGRAD ORTH Deiary Kader 
 
 Peri-prosthatic fracture after TKR approach and management
  • 118. POSTGRAD ORTH Deiary Kader 88 Y lady from a nursing home had knee revision 8 years ago POSTGRAD ORTH Deiary Kader
  • 119. POSTGRAD ORTH Deiary Kader 75 Y lady lives alone. knee revision 5 years ago was doing well POSTGRAD ORTH Deiary Kader
  • 122. POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 123. POSTGRAD ORTH Deiary Kader Distal Femur Replacement
  • 130. POSTGRAD ORTH Deiary Kader Mal-Alignment
  • 131. POSTGRAD ORTH Deiary Kader Common causes of Painful knee arthroplasty • Infection • Aseptic loosening • Instability • Stiffness • Malrotation • Malalignment • Patellar pain • Patellar dislocation • Extensor mechanism Inj • Incompetent MCL • Periprosthetic fracture • Implant breakage • CRPS • Hip or spine pathology • Unexplained pain (1/300)
  • 132. POSTGRAD ORTH Deiary Kader Indications for Revision TKA • Aseptic loosening (30-40%) • Infection (22%) • Pain (10%) • Mal-alignment 7-10%
  • 133. POSTGRAD ORTH Deiary Kader The primary goal of revision TKR To restore knee alignment and stability through a full range of movement Re-establish the native joint line Well-fixed implants Appropriate soft tissue balancing ensures stability Avoids intra-operative extensor mechanism complications
  • 134. POSTGRAD ORTH Deiary Kader Management History & Examination
  • 135. POSTGRAD ORTH Deiary Kader Investigations Plain weight-bearing X-ray Bloods (including WCC, ESR and CRP – IL-6 (expensive) in specialist units Knee aspiration Fluoroscopic alignment check CT scan to check rotation and long leg films to assess the overall alignment Bone scan (not helpful until a year after the index procedure), white cell-labelled bone scan SPECT-CT has also been a novel imaging option to detect loosening / infection and highlight areas of maximal activity. The Synovasure™ Alpha Defensin Test
  • 136. POSTGRAD ORTH Deiary Kader AAOS Clinical guideline for Dx infection 2010 The working group strongly recommended: Testing ESR and CRP Joint aspiration The use of intraoperative frozen sections Obtaining multiple intraoperative cultures ( at least 3 but no more than 6 using different instrument for each sample and from different areas) • Against initiating antibiotic treatment until after cultures • Against the use of intraoperative Gram stain Nuclear imaging was weakly recommended as an option
  • 137. POSTGRAD ORTH Deiary Kader What is the Definition of Peri-prosthetic joint Infection? What is the AAOS Clinical guideline for Dx infection 2010
  • 138. POSTGRAD ORTH Deiary Kader What is the Definition of Peri-prosthetic joint Infection International Consensus Meeting in 2013 as: Musculoskeletal Infection Society A sinus tract communicating with the joint OR 2 positive cultures with identical organisms OR 3-4 of the following minor criteria: Elevated CRP and ESR Single positive culture Elevated synovial fluid WCC —1,100 to 4,000 cells/µL Elevated synovial fluid PMN 64%-69% Presence of purulence in the affected joint Isolation of a microorganism in one culture of tissue or fluid Greater than 5 neutrophils per high-power field in five high-power fields observed from histology at 400 times magnification
  • 139. POSTGRAD ORTH Deiary Kader Infection Revision for Infection (22%)
  • 140. POSTGRAD ORTH Deiary Kader Commonly used CCK in UK PFC Sigma TC3 (DePuy) Triathlon TS (Stryker) Legion Smith & Nephew Vanguard SSK (Biomet) NexGen (Zimmer)
  • 141. POSTGRAD ORTH Deiary Kader CCK progression to Hinged knee One should be aware of inter species compatibility
  • 142. POSTGRAD ORTH Deiary Kader Bone defects
  • 143. POSTGRAD ORTH Deiary Kader Metaphyseal Sleeves & Cones POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 144. POSTGRAD ORTH Deiary Kader Trabecular Metal Cones
  • 145. POSTGRAD ORTH Deiary Kader 
 
 TKR in Jehovah's witness
  • 146. POSTGRAD ORTH Deiary Kader JEHOVAH’S WITNESSES RCS Professional and Clinical Standards November 2016 Pre-admission patient optimisation • Essential blood samples, FBC, U&Es, LFTs, Clotting screen and fibrinogen, B12 and folate and iron studies • General health optimisation • Erythropoietin Hb <13g/dL M and Hb ≤ 12g/dL • Erythropoietin ineffective in patients with iron, B12 or folate deficiency Intraoperative considerations – blood conservation strategies • Consider minimal invasive • Hypotensive anaesthesia and even controled hypothermia • Cell Salvage • Coagulation stimulants such as Tranexamic acid and factors (VIIa, VIII, IX) and desmopressin • Haemostatic aids: diathermy and radiofrequency ablation • Regional anaesthesia with the consultant anaesthetist Postoperative considerations • Monitor and minimise blood loss postoperatively • Monitor and avoid sepsis • Consider postoperative EPO and/or Iron/B12 replacements • Where appropriate and acceptable to the patient, use blood salvage from drains (cell saver)
  • 147. POSTGRAD ORTH Deiary Kader Knee Arthrodesis
 Indications • Failed TKR • Uncontrollable sepsis/ Resistant organisms • Neuropathic joint • Disruption of extensor mechanism • Poor soft-tissue envelope • Systemically immunocompromised • Post-traumatic OA (heavy manual labourer)?
  • 148. POSTGRAD ORTH Deiary Kader Contraindications • Bilateral knee disease • Ipsilateral ankle or hip disease • Ipsilateral hip arthrodesis • Severe segmental bone loss • Contralateral limb amputation.
  • 149. POSTGRAD ORTH Deiary Kader Optimal position for knee fusion
 • 7°–10° of external rotation • Slight valgus • 10°–20° of flexion • The above may be easier to achieve with external fixator rather than IM nail. POSTGRAD ORTH Deiary Kader
  • 150. POSTGRAD ORTH Deiary Kader Techniques Intramedullary arthrodesis External fixation Plate fixation
  • 151. POSTGRAD ORTH Deiary Kader Complications Non-union Malunion Delayed union Recurrent infection POSTGRAD ORTH Deiary Kader
  • 152. POSTGRAD ORTH Deiary Kader Thank You