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

13. 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?

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

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

Knee recon 2018 deiary kader post grad

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