KNEE RECON KADER 2022.pdf

PGO PROF DEIARY KADER
Research/Education War Trauma
Elective
Postgraduate Orthopaedics
KNEE
RECON/TKR,HTO,UNI,REVISION
Professor Deiary F Kader
Knee Surgeon
Deputy Medical Director (SW London Elective Orthopaedic Centre)
President of BOSTAA ( British Sports Surgeons)
Chairman of NGMV charity
War Trauma Reconstruction Surgeon ICRC/Swisscross
CHARITY
Life Academy

• Evidence based non operative treatment of OA —Post operative Mx of TKR
• Why TKR have different implant materials in the femur and tibia
• Which knee prosthesis and why?
• Flexion extension gab balance
• When to operate on PFJ pain if at all
• Principles of PFJR?
• Catastrophic wear- in TKR how to prevent?
• The role of computer navigation/ Robotics in TKR
• Coronal plane sequential ligament release in TKR
• Uni knees indications. Osteotomy cut off age.
• Do you resurface the patella?
• How does changing slop in osteotomy affect load transmission?
• Which HTO-- open or close
• PCL retaining or substituting and why
• What are the technical difficulties in converting Uni to TKR?
• Periprosthetic fracture after TKR approach and management
• Poly difference in TKR and THR
Questions from the Attendee
?

Postgraduate Orthopaedics

45 Y Male
Bricklayer

58 Y old Female
office worker

Osteotomy
vs
Unicompartmental replacement?

Age
Sex
Activity level
Ligament stability
Deformity

Evidence based
None-operative
Treatment for OA?

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
PRP????
Stem Cells???
Unloader
brace

Indications for 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

Right knee
after HTO

Proximal Tibia (HTO)
or
Distal Femur Osteotomy

Principles
osteotomy planning

Alignment refers to the
collinearity of the hip, knee, and
ankle.
Joint Orientation
refers to the position of each
articular surface relative to the
axes of the individual limb
segments (tibia/ femur)

Mechanical Axis of the Lower Limb
Mechanical axis of the lower
limb 1. 3°varus
4-8 mm medial

Mechanical Axis deviation MAD

33%
20
5%

Fujisawa point

Fujisawa point
Overcorrection of 3º–5º above the 6º–7º normal valgus angle
62.5% across tibial plateau from medial side

Double Varus
1- Varus alignment
Progressive medial joint narrowing
2- Lateral opening
LCL laxity
>5 mm laxity ( stress radiograph)
Varus thrust

Triple Varus
Varus alignment
Posterolateral corner laxity
Increased Ext-Rotation
Hyperextension
Lateral opening
Varus
recurvatum
deformity

Compensating for Abnormal
AP Laxity
ACL Rupture PCL Rupture
Usually by CWHTO Usually by OWHTO
ACL
DEC
CLOSE
PCL
INC
OPEN

N ACL # PCL #
Ant
Post
F
F F F
F
T
T
T
T
T
Usually by CWHTO
PROF KADER PGO

In PCL rupture Increasing
the slope will allow the femur to slide back

Who is the IDEAL candidate
for HTO?

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

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Which Osteotomy
Open or Closed?

Lateral closed-wedge high tibial osteotomies have
been the treatment of choice since 1965
(Coventry, 1965).

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

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

Open W HTO

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?

Open wedge HTO
Disadvantages
Requires a bone graft (substitute, autograft, Allo)
Increased incidence of non or delayed union
Large correction may affect leg lengthening
Loss of fixation and recurrence of varus deformity
Worsens patella Baja

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

Distal Femur Osteotomy for Valgus
Malalignment

Coventry report
Outcome
5-year survival of 88%
10-year survival of 66%
However the 5-year survival was reduced to
38% if under-corrected or overweight

Knee Arthroplasty
30 minutes

Consenting/complications
Consent this patient for TKR
✦ 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

Aseptic complications after TKR
Wound healing
Extensor Mechanism complications
Stiffness
Periprosthetic fractures
Loosening
Neurologic injuries
Vascular injuries

What are the
Biomechanical aims of
TKR?

The Primary Aim of TKR
Restoring neutral mechanical axis of 0 (+/- 3º)
Balancing the flexion/extension gap (ER of FC)
Preserving the joint line height
Balancing Ligaments ( 2-3 mm play)
Restoring normal joint alignment and Q angle
➢Joint line perpendicular to the Mech axis

Joint Orientation in TKR
Anatomic
F=+9
T=-3
Classic
TKR
AT EASE STANDING POSITION

Which knee replacement and why?
ODEP is the Orthopaedic Data Evaluation Panel

Constraint ladder in implant
design

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).

PCL retaining or
substituting and
why

PS or CR

PCL retaining (CR)

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

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)

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

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

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

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

GII PS + Pat

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

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

Coronal plane
sequential ligament
release in TKR

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

H Schroeder-Boersch
Medial Ligament Restraint
Range of Ligament restraint medial knee

Pie-Crusting Technique
Extension
Osteophytes excision
Deep MCL to posteromedial corner
Flexion

Ligament restraint Lateral knee
H Schroeder-Boersch

PCL 0º-120º more in flexion
It is “a central stabiliser”
15mm
PCL insertion
15mm

LCL 0º-120º & Popliteus 30º-120º

Valgus Knee
Posterior capsule
LCL release
Flexion and extension tightness

Tight in Flexion
Tight in Extension
Valgus Knee

Medial release for varus knee
Osteophytes excision
Deep MCL to posteromedial corner
Semimembranosus aponeurosis
Superficial MCL
PCL
Pes anserinus insertion

What are the problems
associated with valgus
knees

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°.

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

Easy way to
remember
Gap balancing

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

Balancing Flexion and Extension Gaps

What are the technical
difficulties in converting
Uni to TKR?

50% of Uni knees had a significant bone defect

Post op Mx of TKR
Pre-operative patient education reduces length of stay after knee joint arthroplasty.
Jones S, Alnaib M, Kokkinakis M, Wilkinson M, St Clair Gibson A, Kader D.
Ann R Coll Surg Engl. 2011 Jan;93(1):71-5.
PMID: 21418755 [PubMed - indexed for MEDLINE] Free PMC Article

Pain Control
1) Patient education
2) Preemptive analgesics
3) Epidural analgesia
4) Peripheral nerve block: Add canal /femoral nerve block
5) Periarticular injection
6) Patient-controlled analgesia (PCA)?
7) Oral analgesics

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)
LATERAL

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

Surgical
Anatomic

1-The epicondylar axis
Problems
Difficult to identify
Misuse of the surgical epicondylar axis rather
than the Anatomic one

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

3-Anteroposterior (AP) axis
The line deepest part of the trochlear to the Centre of the
intercondylar notch posteriorly
Difficult to Identify
In trochlear dysplasia or destructive arthritis or deformity
Whiteside’s line

4- The Anterior Femoral Cortical Line
Dr Mervyn Cross

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 Femoral
component internally rotated?

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

The role of Computer Navigation
& Robotics in TKR

The Knee is a Modified Hinge Joint
Six degrees of freedom
Varus/valgus
Flexion/extension
Internal/external rotation
Medial/lateral translation
Proximal/distal placement
Anterior/posterior translation).

Accuracy in component placement
For Each of these DOF there are 3 outcomes.
In the coronal plane for each component:-
valgus, varus, and neutral alignments.
6x3=18
for the 3 components Femur, tibia, patella there is
18x18x18 =5832 possible different
combinations
Excluding variations in the degree of abnormality (for
example, 2°,4°,or 6°of varus deformity)

Navigated Knee Replacement
Computer assisted knee surgery
Computer Assisted Orthopaedic Surgery
CAOS
Coronal malalignment of more than 3°
has been shown to cause premature implant
failure
Significant errors in mechanical axis of > 3°
occur in at least 10% of TKAs, including those
performed by experienced surgeons

Robotic Knee Replacement

What is “Robotic” Navigation?
Robotic Surgery- NAVIO- Smith+Nephew

What is the NAVIO?
Infrared Camera
and Reflective Arrays
Handheld
Robotic Tool
Surgeon Controlled
Interface
Portable Cart
Burr Motor
Monitor

The NAVIO Basics
Exposure Control - Continually adjusts
exposure of the bur beyond a static guard
to modulate cutting.
Speed Control - Continually varies speed
of a fully exposed bur to modulate cutting
(static guard is removed).
q Robotic Driver
q Tracker Array
q Calibration
q Burr Selection Size
q Burr Selection Mode
HANDPIECE

Challenges with adopting navigation
➢The tools -expensive and cumbersome
➢They frequently introduce extra surgical steps
➢Increased operative time (25%)
➢The alignment goals often sought by navigation
programs have been called into question.
➢There is virtually no evidence that the use of CAOS
techniques leads to improved clinical outcomes.

Challenges
Capital Cost
Training (Surgeon and Theatre Staff)
Additional Trauma due to Pin Insertion
Lengthens Operation Duration
Does Not Account for soft tissue
Surgeon / Assistant Positioning
Limited Implant Compatibility
Benefits
Accuracy in Operative Planning
Planning Multiple Scenario
Enhanced Cut Precision
Bone Conservation / Consistency
Real-time Assessment of Balance
Medico-legal Record-keeping
Robotics Pros and Cones

113
Would you resurface
the Patella during TKR?

Decision
making process
Knee specific Patient Reported Outcome
Measures (PROMs) naturally assume priority
essential to consider other factors such as
1) Re-operation rate,
2) Patient quality of life and inconvenience
3) Cost-effectiveness, Implant cost and time
4) The burden of secondary patella resurfacing
5) Influence of implant design,
6) Surgical risks, Surgeons’ learning curve
7) The fate of the remaining patella articular
cartilage when not resurfaced.

Factors to Consider
PPR
Resurfacing
PPNR
Non-
resurface NOTE
Knee specific (PROMs) comparable
Re-operation rate 0.8-2.3% 3%-6.5%
All cause revision 6.3%-10.6% 8.2%-14.7%
Re-operation rate for anterior knee
pain 1% 4.6%
Absolute risk reduction after
Resurfacing 4%-4.6%
Patient quality of life
QALY gain
0.64 comparable
Patient inconvenience (Admission for
SPR) 28-29 months
Cost-effectiveness, Intra-operative
time
£104 cheaper
3 minutes
more±
Outcome of secondary patella
resurfacing (SPR)
44-50%
benefit
COMPLICATIONS ARE HISTORIC
PFC Sigma PS knee revision rate 2.6% 10y 4.37% 10y
Attune PS 2.93% 3.85%
4.47% 10y-
•Equivocal clinical outcomes
•Lower re-operation rates
•Economic viability
•Low risk of complications

Titanium or Cobalt Chrome
for Tibial component?

Cobalt Chrome Property Titanium
less Fatigue resistance Better
yes Stress Shielding less/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)

Materials in TKR
Material Elastic Modulus
Stiffness
Stainless Steel
230 GPa
Cobalt-Chrome alloy 220 Giga Pascal
Ti6Al4V
110 GPa
Cortical Bone
20 GPa
Trabecular Bone 1.0 GPa
PMMA Cement
4 GPa

Ti or CoCr for tibia
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

Painful TKR
65 minutes

Management
History &
Examination

Common causes of
Painful knee arthroplasty
Aseptic loosening
Infection
Instability
Stiffness
Malrotation
Malalignment
Patellar pain
Patellar dislocation
Extensor mechanism Prob
Incompetent MCL
Periprosthetic fracture
Implant breakage
CRPS
Soft tissue (Neuroma, Menx)
Hip or spine pathology
Unexplained pain (1/300)

Investigations
Plain weight-bearing X-ray
Bloods (including WCC, ESR and CRP – 16S Ribosomal)
Knee aspiration
Fluoroscopic alignment check
CT scan to check rotation
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 an option to detect loosening / infection and
highlight areas of maximal activity.
The Synovasure™ Alpha Defensin Test

Indications for Revision TKA
• Aseptic loosening (30-40%)
• Infection (22%)
• Pain (10%)
• Mal-alignment 7-10%

Polyethylen Wear
What are the factors that determine poly
wear??

Polyethylen Wear
• Patient factors: age, size and activity level
• Surgical factors: alignment, rotation, cementing, balancing
• Implant factors:
• Poly thickness
• Material, property and polymerization
• Manufacturing method: compression moulding preferred to machined
component
• Sterilization method: avoiding gamma radiation in air
• Cross-linking: moderately/highly cross-linked polyethylene – may
offer improved resistance in the knee.
• Packing vacuum pack is still in date (free radicals)

Causes of catastrophic wear
PE thickness <8mm
articular surface design- flat tibial PE
Kinematics Varus alignment & dyskinetic sliding
PE sterilization O2 rich environment leads to
subsurface delamination
pitting
fatigue cracking
PE machining use direct-compression molding of PE

Bone defects

Planning
parameters to be considered
➢ Anatomic variation
➢ Implant fixation
➢ Extensor mechanism integrity
➢ Patellar
➢ Joint line height
➢ Tibial or femoral bowing
➢ Narrow intramedullary canal
➢ Ipsilateral hip prosthesis

The success of revision depends
✓ Identifying the cause of failure
✓ Thorough preoperative planning
✓ Precise surgical technique
✓ Reconstruction of the leg axis
Good component design and availability of
diverse implant options

Revision Knee
Technical Problems
➢ Under sizing Implant
➢ Bone defects
➢ Flexion & Extension Gap Mismatch
➢ Sold Stems causing pain
➢ Stems impacting/causing stress riser on cortex
➢ Stem position not compatible with Component position
➢ Inadequate Component stability on the Epiphysis
➢ Metal sensitivity

Metaphyseal Sleeves & Cones

Trabecular Metal Cones

Either Sleeves or CCK

Poly difference in
TKR and THR

Processing methods for XLPE
acetabular liner and tibial insert
for total hip and knee
arthroplasty
HXLPE weakens the
mechanical properties,
including strength and
fatigue resistance and
reduced fracture
toughness
But reduces volumetric wear

chemical reaction or
radiation energy.
Polymer chains

KNEE
TKR is less constrained
less conformed
high contact stress
High compressive stresses 3x higher
High Sheering force 2X higher
Subjected to fatigue wear (delamination)

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

PERI-PROSTHETIC JOINT
INFECTION (PJI)
TKR

J Am Acad Orthop Surg 2010;18: 760-770

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

What is the Definition of
Peri-prosthetic joint Infection
International Consensus Meeting in 2018 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 > 1mg/dl, D-dimer >860 ng/ml and ESR > 30mm/h
Elevated synovial fluid WCC —> 3000 cells/µL
– Alpha-defesin >1 signal to cutoff ration (human neutrophil peptide)
– Leukocyte Esterase ++ (an enzyme produced by leukocytes)
Serum interleukin-6

Infection
Revision for
Infection (22%)

Commonly used CCK in UK
PFC Sigma
TC3 (DePuy)
Triathlon TS
(Stryker)
Legion
Smith &
Nephew
Vanguard SSK
(Biomet)
NexGen
(Zimmer)

Mal-Alignment
Places mechanical and shear stresses on the
bearing surfaces
bone/prosthesis interfaces
ALSO
•Changes the forces going through the soft-tissue envelope

Implant malalignment has been reported to be
• Most influential factors in determining the long-term outcomes
• The primary reason for revision in 7-10 % of TKAs (Schroer et al. 2013)
• Linked to decreased implant survival (Ritter et al. 2011)
• Inferior patient-reported outcomes (Choong et al. 2009, Longstaff et al. 2009).

Patella

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

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

Principles of PFJR

PFJ OA
kneeling, squatting, climbing stairs, and
getting up from a low chair.
More subtle than knee OA
Swelling para-patella
Crepitus anterior knee

PFJ OA
Non-operative treatment
Anti-inflammatory medications
Activity modification
Quadriceps strengthening
Bracing,
Steroid injections
Viscosupplement

PFJ OA
PFJ replacement or TKR?

PFJ OA
PFJ replacement or TKR?
1. Age
2. Other compartments
3. Implant failure rate

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

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

Peri- prosthatic fracture
after TKR approach and
management

88 Y lady from a nursing home had knee revision 8 years ago

75 Y lady lives alone. knee revision 5 years ago was doing well

Distal Femur Replacement

KNEE RECON KADER 2022.pdf

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