Downloaded 13 times
More Related Content
Combo_3.ppt
- 1. Frank R. Ebert,MD Union Memorial Hospital Baltimore, Maryland TOTAL KNEE ARTHROPLASTY
- 2. Total Knee Arthroplasty Goal —Restoremechanical alignment —Restore joint line
- 3. Normal Knee Anatomy Position in single leg stance Mechanical axis valgus 3º Femoral shaft axis valgus 6º Proximal tibia varus 3º
- 5. Total Knee Arthroplasty RadiographicEvaluation —Standing full length – AP —Standing AP —Extension/Flexion laterals —Tunnel view —Sunrise view
- 7. Total Knee Arthroplasty RadiographicEvaluation Weight Bearing X-rays —Extent of joint space narrowing —Ligament stretch out —Subluxation of femus on tibia
- 9. Total Knee Arthroplasty RadiographicAnalysis Anatomic Axis – Femur —Line that bisects the medullary canal of the femur —Determines the entry point of the femoral medullary guide rod
- 11. Total Knee Arthroplasty RadiographicAnalysis Mechanical Axis – Femur (MAF) —A line from center of femoral head to center of distal femur
- 13. Total Knee Arthroplasty RadiographicAnalysis Anatomic Axis Tibia (AAT) —A line that bisects the medullary canal of the tibia —Determines the entry point of the guide rod
- 15. Total Knee Arthroplasty RadiographicEvaluation Mechanical Axis – Tibia (MAT) —Line from center of proximal tibia to center of ankle —Proximal tibia is cut perpendicular to (MAT)
- 17. Issues with Surgical Techniques TraditionalJoint Line Orientation Tibial cut perpendicular to the MAT Femoral shaft at a valgus angle 5º to 8º valgus based off the ong standing x-ray
- 19. Surgical Technique Incision —straight longitudinal incision Tissue handling key Avoid flaps Preserve soft tissue flap about the patella
- 21. Surgical Technique Remember 7cm Rulebetween incisions
- 23. Issues with Surgical Techniques Exposure options — Subvastus / midvastus u Routine knee replacements z Quicker rehab — Medial parapatellar / midline u Difficult total knee — obese patients u Revisions
- 26. MIS vs MINITKA Capsulotomy only? Mid vastus? Sub vastus? MIS
- 27. MIS vs MINITKA Mid vastus? Sub vastus? Quad MIS
- 28. Area of Variation Type I-High Insertion TypeII-Pole Insertion Type III-Low Insertion Anatomic Variations of VMO Insertion
- 29. Type I- HighVMO Insertion Retinacula r Incision Area of extended retinaculu m Muscle Insertion
- 30.
- 31. Type III-Low VMO Insertion Areaof Extended VM Muscle Insertion
- 32. Issues with Surgical Techniques Alignment — Extramedullary vs Intramedullary u Accuracy vs increased PE risk u Femur – Intramedullary z Overdrill opening and insert slowly IM guide z Caution with bilateral Total Knee Arthroplasty u Tibia – Extramedullary
- 34. Issues with Surgical Techniques Femoral Rotation — Landmarks Posterior femoral condyles Epicondyles 5º external rotation to the posterior condyles
- 38. Issues with Surgical Techniques Femur — Measured resections: equal bone distally and posteriorly — Tensioning devices & ligament releases — Do not alter bone resection for ligament tightness
- 40. Issues with Surgical Techniques TibialComponent Rotation — Transmalleolar axis — Posterior tibial plateau — Tibial tubercle — lies lateral
- 44.
- 46. Management of Deformity 1.Release the tight side of the deformity 2. Tighten the loose side 3. Accept some residual soft tissue imbalance 4. Combination
- 48. Surgical Techniques Varus Knee 1.Pes anserinus 2. Joint Capsule 3. Deep Tibial Collateral 4. Semimembranosus 5. Posterior Medial Capsule
- 52.
- 53.
- 54.
- 55.
- 56. Surgical Techniques Valgus Knee 1.Iliotibial Band 2. Popliteus Tendon 3. Posterior Lateral Capsule 4. Lateral Head of Gastroc 5. Biceps Femoris
- 60. Surgical Techniques Valgus Knee —Peroneal nerve palsy – valgus / flexion deformity — Treatment u Release dressings or flex the knee
- 62. Surgical Techniques: Flexion Contracture 1.Posterior capsule 2. Gastroc origins 3. Posterior cruciate 4. Distal femur
- 63. Fixed Flexion Deformityin TKA Complex Combinations: — musculotendinous contracture — ligamentous contracture — capsular contracture — osteophytes of posterior condyle
- 64. Fixed Flexion Deformityin TKA Biomechanics — increased quadriceps force for knee stabilization during weight bearing — increased forces transmitted to the patellofemoral joint
- 65. Fixed Flexion Deformityin TKA Biomechanics — increased forces are placed on posterior tibial plateau — femoral condyles sink into the tibial plateau — contact between intercondylar notch and tibial eminence form a boney block
- 66. Fixed Flexion Deformityin TKA Associated deformity — varus deformity 40% - > 5º range 5 to 30º varus — valgus deformity 30% - > 5º range 5 to 22º valgus Firestone et al COOR ‘92
- 67. Fixed Flexion Deformityin TKA Incidence of Problem – Review of 700 TKA & Revision TKA’s — 60% before primary TKA — 21% before revision TKA Tew & Forster JBJS (B) 87
- 68. Fixed Flexion Deformityin TKA Soft tissue release — Varies with angular deformity Firestone et al COOR ‘92
- 69. Fixed Flexion Deformityin TKA Surgical Treatment Soft tissue release Additional bone resection Combination
- 70. Fixed Flexion Deformityin TKA Postoperative Correction — the more severe the deformity must consider the pros and cons of additional bone resection and/or soft tissue release Volz COOR ‘89
- 71. Fixed Flexion Deformityin TKA Additional bone resection – pros — joint line is positioned slightly more proximal — functionally lengthens the collaterals and posterior capsule forward extension — doesn’t compromise flexion stability Firestone et al COOR ‘92
- 72. Fixed Flexion Deformityin TKA Additional bone resection — cons (excessive) • Collateral ligament laxity • Quadriceps redundancy • Hyperextension • Bone quality can be compromised McPherson et al ‘94
- 73.
- 75. Fixed Flexion Deformityin TKA Surgical Treatment for Deformity < 10º FFC Soft tissue release – only necessary — posterior capsule — possibly PCL — posterior osteophytes
- 76. Fixed Flexion Deformityin TKA Surgical Treatment for Deformity 10-20º FFC — consider distal femoral resection 3 to 5 mm — Posterior capsule — PCL resection posterior osteophytes Firestone et al COOR ‘92
- 77. Fixed Flexion Deformityin TKA Surgical Treatment for Deformity 20-30º FFC — distal femoral resection 3 to 5 mm — posterior capsule — PCL resection posterior osteophytes Firestone et al COOR ‘92
- 78. Fixed Flexion Deformityin TKA Surgical Treatment for Deformity > 30º FFC — consider pre-op casting ≠ — distal femoral resection 5 mm — proximal tibial resection — PCL resection — posterior osteophytes Firestone et al COOR ‘92 et al J of Arthro ‘99
- 79. Fixed Flexion Deformityin TKA Peroneal Nerve Palsy Vascular Insufficiency Anterior Pressure Ulcers Manipulation
- 83. Fixed Flexion Deformityin TKA No formula is exact for treatment of the problem Consider a balance between soft tissue release vs bone resection
- 84. Issues with Surgical Techniques StiffKnee Remove osteophytes Insall Turn Down Osteotomize the tibial tubercle Rectus snip
- 89. Issues with Surgical Techniques StiffKnee u Epicondylar osteotomy for large flexion / contracture u Lateral release to evert the patella
- 93. Issues with Surgical Techniques Patellar resurfacing — Recommended for all RA patients — Without resurfacing 4% to 6% incidence of anterior knee pain — With resurfacing increased incidence of fracture
- 95. Issues with Surgical Techniques Patellar resurfacing — Thickness shouldn’t exceed 25 mm — For every 1 mm thicker reduces flexion by 3º
- 99. Issues with SurgicalTechniques Patellar Baja • Proximal tibial osteotomy • Tibial tubercle shift • Prior fracture
- 100. Issues with SurgicalTechniques Patellar Baja • Don’t raise joint line • Consider lowering joint line — Distal femoral alignment • Trim anterior tibial poly to avoid impingement of patella
- 101. Issues with SurgicalTechniques Patellar Clunk Syndrome — Seen at 35º-40º knee flexion — Treatment is arthroscopic or open resection
- 102. Issues with SurgicalTechniques Sagittal Plane Balancing Situation Problem Solution Cut Tight Symmetrical – cut more in extension gap proximal tibia Cut Tight in flexion Cut Tight Asymmetrical – Release PCL; in extension gap Posterior capsule Cut Loose Consider PCL in flexion substituting prosthesis – Resection distal femur AVOID recurvatum
- 103. Issues with SurgicalTechniques Sagittal Plane Balancing Situation Problem Solution Cut Good Asymmetrical – Resection additional in extension gap tibia Cut Tight in flexion – May need to release PCL – Ensure posterior slope of tibia Cut Good Asymmetrical – Need femoral in extension gap augmentation Cut Loose – Adjust to larger in flexion femoral component
- 104. Complications in Total KneeArthroplasty Periprosthetic Fractures Infected Total Knee Arthroplasty
- 105. Supracondylar Fractures of the Femur AfterTotal Knee Arthroplasty
- 106. Supracondylar Fractures After TKR lNotching of the femoral cortex l Osteoporosis l Prolonged steroid use l Preexisting neurologic disorders
- 108. Supracondylar Fractures After TKR OSTEOPOROSIS Bogoch,et al, CORR 1986
- 110. Supracondylar Fractures After TKR lMajor trauma is not required to produce fractures in many TKA patients l Alignment not correlated with fracture l Weight not a significant
- 111. Fractures After TKA NeerClassification of Supracondylar Fractures l Type I - Minimal displacement l Type IIA - Medial displacement of condyles l Type IIB - Lateral displacement of condyles l Type III - Supracondylar and shaft fractures
- 112. Supracondylar Fractures After TKR TREATMENT Type1 – Nondisplaced
- 113. Supracondylar Fractures After TKR Type1 fractures 83% success rate Chen, et al, 1994
- 115. Supracondylar Fractures After TKR Type2 fractures 69% success rate Chen, et al, 1994
- 116. Supracondylar Fractures After TKR lCasting l Traction followed by rest Non Operative Method
- 117. Supracondylar Fractures After TKR Type2 fractures 67% success rate Chen, et al, 1994
- 118. Supracondylar Fractures After TKR lPlates / Screw fixation l Intramedullary rods l Rush pins l External fixation l Primary arthrodesis l Revision arthroplasty Operative Method
- 119. Supracondylar Fractures After TKR lPatients’ ability to tolerate traction l Ability of bone to hold screws l Ability of the surgeon Type 2 Considerations
- 122. Intercondylar Distances ofCommonly Used Femoral Prostheses Biomet, (Warsaw, IN) AGC 18 Universal 18 DePuy, (Warsaw, IN) AMK 20 Dow Corning Wright, (Arlington, TN) Whitesides modular 20 Howmedica, (Rutherford, NJ) PCA 18.5 Intermedics, (Austin, TX) Natural 14 Johnson and Johnson, (New Brunswick, NJ) Press-fit condylar 20 Insall-Burstein* 15 (posterior stabilized) Kirschner, (Timonium, MD) Performance 14 Zimmer, (Warsaw, IN) Insall-Burstein I* 16 Insall-Burstein II 15 (posterior stabilized* or constrained condylar†) Miller-Galante I Small / small + ‡ 11 Regular / regular + 12.5 Large / large + 15 Large + + 18 Miller-Galante II 13 Manufacturer Model Intercondylar Distance (Smallest Size) (mm)
- 124. Supracondylar Fractures After TKR Noone form of treatment gives uniformly good results
- 125. Infection in TotalKnee Arthroplasty
- 126. Complications in Arthroplasty Infection– Risk Factors l Skin ulcerations / necrosis l Rheumatoid Arthritis l Previous hip/knee operation l Recurrent UTI l Oral corticosteroids
- 127. Complications in Arthroplasty Infection– Risk Factors l Chronic renal insufficiency l Diabetes l Neoplasm requiring chemo l Tooth extraction
- 128. Complications in Arthroplasty Infection– Clinical Course l Pain #1 l Swelling l Fever l Wound breakdown drainage Windsor et al JBJS; 1990
- 129. Early < 3months Lab Value Mayo Series Mean 7,500 l Differential 67 PMN’s l Sed rate 71 mm/hr l Arthrocentesis Infections About TKR
- 130. Late > 3months Symptoms: 52 patients Pain 96% swelling 77% Debride 27% Active drainage 27% Sed rate 63 mm/hr WBC - 8300 Windsor et al JBJS; 1990 Infections About TKR
- 131. Complications in Arthroplasty Infection– Surgical Techniques l Avoid skin bridges l Avoid creation of skin flaps l Hemostasis l Prolonged operating time
- 133. Complications in Arthroplasty Infection– Work-Up l Wound History l Physical Exam l Serial Radiographs l Lab/sed rate/CRP l Bone scan / Indium scan
- 135. Complications in Arthroplasty Infection Arthrocentesis lCell count l Diff > 25,000 pmn l Protein – high l Glucose – low
- 136. Complications in Arthroplasty Infection lHost Response Glycocalyx Gristina JBJS; 1983
- 138.
- 139. Organisms Isolated from71 Patients With Infected Knee Replacement Staphylococcus 64 S. aureus, penicillin sensitive 14 S. aureus, penicillin resistant 28 S. epidermis 22 Gram negative 12 Pseudomonas 7 Escherichia coli 5 Anærobic 6 Other 17 Organism Percent
- 140. Complications in Arthroplasty TreatmentOptions l Antibiotic suppression l Aggressive wound debridement
- 141. Complications in Arthroplasty TreatmentOptions l Antibiotic suppression Indicated in med compromised Organism - gram+ strep staphepi
- 142. Complications in Arthroplasty TreatmentOptions l Resection arthroplasty l 2 Stage re-implant l Arthrodesis l Amputation
- 143. Complications in Arthroplasty TreatmentOptions l Debridement with antibiotic suppression therapy Strep/staphepi -- best Avoid repeated attempts Frozen tissue section Suction drains
- 144. Complications in Arthroplasty Two-StageReimplantation l Most successful treatment l Procedure of choice
- 145. Complications in Arthroplasty Two-StageReimplantation Procedure l Remove components, cement, I&D l Fabricate and place spacer l 6 weeks of antibiotics l Reimplantation
- 146. Complications in Arthroplasty Two-StageReimplantation Stage I l create antibiotic spacer impregnated with antibiotics l wound closure
- 148. Complications in Arthroplasty Two-StageReimplantation l Spacer Antibiotic Regimen Tobramycin 2.4 gm/3.6 gm per 40 gms of PMMA Vancomycin > gm to 1 gm per gms of PMMA
- 149. Complications in Arthroplasty Intra-operativeFrozen Section l < 5 PMN’s per HPF – no infection l > 10 PMN’s per HPF– infection Mirra; JBJS
- 150. Complications in Arthroplasty Results— Gm positive Windsor et al 92 % JBJS 1990 Insall et al 97% JBJS 1983
- 151. Complications in Arthroplasty ResectionArthroplasty l Removal all components l Remove all cement l Effective in medically compromised patient
- 152. Complications in Arthroplasty ArthrodesisIndications l Extensor mechanism disruption l Resistant bacteria l Inadequate bonestock l Inadequate soft tissues l Young patient
- 153. Advantages Definitive treatment Little chance of recurrence Arthrodesis
- 154. Disadvantages Difficulty withtransfers / small spaces Increase energy requirements Arthrodesis
- 155. Algorithm TKA Clinical Sepsis (GRAM + Organism) < 3wks > 3 wks Debridement Antibiotics (6 wks) 2-Stage Replant Infections About TKR
- 156. Algorithm Debridement Antibiotics Success 2-stage Replant Arthrodesis InfectionsAbout TKR No Success 2-stage Replant Success No Success Resection Arthroplasty
- 157.