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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
PGO PROF DEIARY KADER
• 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
?
PGO PROF DEIARY KADER
Postgraduate Orthopaedics
PGO PROF DEIARY KADER
45 Y Male
Bricklayer
PGO PROF DEIARY KADER
58 Y old Female
office worker
PGO PROF DEIARY KADER
Osteotomy
vs
Unicompartmental replacement?
PGO PROF DEIARY KADER
Age
Sex
Activity level
Ligament stability
Deformity
PGO PROF DEIARY KADER
Evidence based
None-operative
Treatment for OA?
PGO PROF 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
PRP????
Stem Cells???
Unloader
brace
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Right knee
after HTO
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
34 yo
PGO PROF DEIARY KADER
Proximal Tibia (HTO)
or
Distal Femur Osteotomy
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Principles
osteotomy planning
PGO PROF DEIARY KADER
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)
PGO PROF DEIARY KADER
Mechanical Axis of the Lower Limb
Mechanical axis of the lower
limb 1. 3°varus
4-8 mm medial
PGO PROF DEIARY KADER
Mechanical Axis deviation MAD
PGO PROF DEIARY KADER
33%
20
5%
PGO PROF DEIARY KADER
Fujisawa point
PGO PROF DEIARY KADER
Fujisawa point
Overcorrection of 3º–5º above the 6º–7º normal valgus angle
62.5% across tibial plateau from medial side
PGO PROF DEIARY KADER
Double Varus
1- Varus alignment
Progressive medial joint narrowing
2- Lateral opening
LCL laxity
>5 mm laxity ( stress radiograph)
Varus thrust
PGO PROF DEIARY KADER
Triple Varus
Varus alignment
Posterolateral corner laxity
Increased Ext-Rotation
Hyperextension
Lateral opening
Varus	
recurvatum
deformity
PGO PROF DEIARY KADER
Compensating for Abnormal
AP Laxity
ACL Rupture PCL Rupture
Usually by CWHTO Usually by OWHTO
ACL
DEC
CLOSE
PCL
INC
OPEN
PGO PROF DEIARY KADER
N ACL # PCL #
Ant
Post
F
F F F
F
T
T
T
T
T
Usually by CWHTO
PROF KADER PGO
PGO PROF DEIARY KADER
In PCL rupture Increasing
the slope will allow the femur to slide back
PGO PROF DEIARY KADER
Who is the IDEAL candidate
for HTO?
PGO PROF 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
PGO PROF DEIARY KADER
The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
PGO PROF DEIARY KADER
Which Osteotomy
Open or Closed?
PGO PROF DEIARY KADER
Lateral closed-wedge high tibial osteotomies have
been the treatment of choice since 1965
(Coventry, 1965).
PGO PROF 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
PGO PROF 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
PGO PROF DEIARY KADER
Open W HTO
PGO PROF 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?
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
O W HTO
PGO PROF 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
PGO PROF DEIARY KADER
Distal Femur Osteotomy for Valgus
Malalignment
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Knee Arthroplasty
30 minutes
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Aseptic complications after TKR
Wound healing
Extensor Mechanism complications
Stiffness
Periprosthetic fractures
Loosening
Neurologic injuries
Vascular injuries
PGO PROF DEIARY KADER
What are the
Biomechanical aims of
TKR?
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Joint Orientation in TKR
Anatomic
F=+9
T=-3
Classic
TKR
AT EASE STANDING POSITION
PGO PROF DEIARY KADER
Which knee replacement and why?
ODEP is the Orthopaedic Data Evaluation Panel
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Constraint ladder in implant
design
PGO PROF DEIARY KADER
PGO PROF 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).
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PCL retaining or
substituting and
why
PGO PROF DEIARY KADER
PS or CR
PGO PROF DEIARY KADER
PCL retaining (CR)
PGO PROF 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
PGO PROF 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)
PGO PROF 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
PGO PROF 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
PGO PROF DEIARY KADER
PCL substitution/sacrificing
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
PGO PROF 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
PGO PROF DEIARY KADER
GII PS + Pat
PGO PROF 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
PGO PROF 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
PGO PROF DEIARY KADER
Coronal plane
sequential ligament
release in TKR
PGO PROF 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
PGO PROF DEIARY KADER
H	Schroeder-Boersch
Medial Ligament Restraint
Range of Ligament restraint medial knee
PGO PROF DEIARY KADER
Pie-Crusting Technique
Extension
Osteophytes excision
Deep MCL to posteromedial corner
Flexion
PGO PROF DEIARY KADER
Ligament restraint Lateral knee
H	Schroeder-Boersch
PGO PROF DEIARY KADER
PCL 0º-120º more in flexion
It is “a central stabiliser”
15mm
PCL insertion
15mm
PGO PROF DEIARY KADER
LCL 0º-120º & Popliteus 30º-120º
PGO PROF DEIARY KADER
Valgus Knee
Posterior capsule
LCL release
Flexion and extension tightness
PGO PROF DEIARY KADER
Tight in Flexion
Tight in Extension
Valgus Knee
PGO PROF DEIARY KADER
Medial release for varus knee
Osteophytes excision
Deep MCL to posteromedial corner
Semimembranosus aponeurosis
Superficial MCL
PCL
Pes anserinus insertion
PGO PROF DEIARY KADER
What are the problems
associated with valgus
knees
PGO PROF 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°.
PGO PROF 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
PGO PROF DEIARY KADER
Easy way to
remember
Gap balancing
PGO PROF 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
PGO PROF DEIARY KADER
Balancing Flexion and Extension Gaps
PGO PROF DEIARY KADER
What are the technical
difficulties in converting
Uni to TKR?
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
50% of Uni knees had a significant bone defect
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Technical Considerations in TKR
How would you determine the rotation
of the femoral component?
PGO PROF DEIARY KADER
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
PGO PROF 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
PGO PROF DEIARY KADER
Surgical
Anatomic
PGO PROF DEIARY KADER
1-The epicondylar axis
Problems
Difficult to identify
Misuse of the surgical epicondylar axis rather
than the Anatomic one
PGO PROF 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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
4- The Anterior Femoral Cortical Line
Dr Mervyn Cross
PGO PROF 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
PGO PROF DEIARY KADER
What if the Femoral
component internally rotated?
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
The role of Computer Navigation
& Robotics in TKR
PGO PROF DEIARY KADER
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).
PGO PROF DEIARY KADER
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)
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Robotic Knee Replacement
PGO PROF DEIARY KADER
What is “Robotic” Navigation?
Robotic Surgery- NAVIO- Smith+Nephew
PGO PROF DEIARY KADER
What is the NAVIO?
Infrared Camera
and Reflective Arrays
Handheld
Robotic Tool
Surgeon Controlled
Interface
Portable Cart
Burr Motor
Monitor
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
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.
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
113
Would you resurface
the Patella during TKR?
PGO PROF DEIARY KADER
GII PS + Pat
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
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.
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Titanium or Cobalt Chrome
for Tibial component?
PGO PROF DEIARY KADER
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)
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Painful TKR
65 minutes
PGO PROF DEIARY KADER
Management
History &
Examination
PGO PROF DEIARY KADER
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)
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Indications for Revision TKA
• Aseptic loosening (30-40%)
• Infection (22%)
• Pain (10%)
• Mal-alignment 7-10%
PGO PROF DEIARY KADER
Polyethylen Wear
What are the factors that determine poly
wear??
PGO PROF DEIARY KADER
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)
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Bone defects
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Metaphyseal Sleeves & Cones
PGO PROF DEIARY KADER
Trabecular Metal Cones
PGO PROF DEIARY KADER
Either Sleeves or CCK
PGO PROF DEIARY KADER
Poly difference in
TKR and THR
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
chemical reaction or
radiation energy.
Polymer chains
PGO PROF DEIARY KADER
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)
PGO PROF 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
PGO PROF DEIARY KADER
PERI-PROSTHETIC JOINT
INFECTION (PJI)
TKR
PGO PROF DEIARY KADER
J Am Acad Orthop Surg 2010;18: 760-770
PGO PROF DEIARY KADER
PGO PROF 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
PGO PROF DEIARY KADER
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
PGO PROF DEIARY KADER
Infection
Revision for
Infection (22%)
PGO PROF DEIARY KADER
Commonly used CCK in UK
PFC Sigma
TC3 (DePuy)
Triathlon TS
(Stryker)
Legion
Smith &
Nephew
Vanguard SSK
(Biomet)
NexGen
(Zimmer)
PGO PROF DEIARY KADER
Mal-Alignment
Places mechanical and shear stresses on the
bearing surfaces
bone/prosthesis interfaces
ALSO
•Changes the forces going through the soft-tissue envelope
PGO PROF DEIARY KADER
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).
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Patella
POSTGRAD	ORTH	Deiary	Kader
PGO PROF DEIARY KADER
PGO PROF 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
POSTGRAD	ORTH	Deiary	Kader
PGO PROF 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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Principles of PFJR
PGO PROF 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
PGO PROF DEIARY KADER
PFJ OA
Non-operative treatment
Anti-inflammatory medications
Activity modification
Quadriceps strengthening
Bracing,
Steroid injections
Viscosupplement
PGO PROF DEIARY KADER
PFJ OA
PFJ replacement or TKR?
PGO PROF DEIARY KADER
PFJ OA
PFJ replacement or TKR?
1. Age
2. Other compartments
3. Implant failure rate
PGO PROF 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
PGO PROF 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
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
Peri- prosthatic fracture
after TKR approach and
management
PGO PROF DEIARY KADER
88 Y lady from a nursing home had knee revision 8 years ago
PGO PROF DEIARY KADER
75 Y lady lives alone. knee revision 5 years ago was doing well
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
POSTGRAD	ORTH	Deiary	Kader
PGO PROF DEIARY KADER
Distal Femur Replacement
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER
PGO PROF DEIARY KADER

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KNEE RECON KADER 2022.pdf

  • 1. 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
  • 2. PGO PROF DEIARY KADER • 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 ?
  • 3. PGO PROF DEIARY KADER Postgraduate Orthopaedics
  • 4. PGO PROF DEIARY KADER 45 Y Male Bricklayer
  • 5. PGO PROF DEIARY KADER 58 Y old Female office worker
  • 6. PGO PROF DEIARY KADER Osteotomy vs Unicompartmental replacement?
  • 7. PGO PROF DEIARY KADER Age Sex Activity level Ligament stability Deformity
  • 8. PGO PROF DEIARY KADER Evidence based None-operative Treatment for OA?
  • 9. PGO PROF 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 PRP???? Stem Cells??? Unloader brace
  • 10. PGO PROF DEIARY KADER 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
  • 12. PGO PROF DEIARY KADER Right knee after HTO
  • 14. PGO PROF DEIARY KADER 34 yo
  • 15. PGO PROF DEIARY KADER Proximal Tibia (HTO) or Distal Femur Osteotomy
  • 18. PGO PROF DEIARY KADER Principles osteotomy planning
  • 19. PGO PROF DEIARY KADER 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)
  • 20. PGO PROF DEIARY KADER Mechanical Axis of the Lower Limb Mechanical axis of the lower limb 1. 3°varus 4-8 mm medial
  • 21. PGO PROF DEIARY KADER Mechanical Axis deviation MAD
  • 22. PGO PROF DEIARY KADER 33% 20 5%
  • 23. PGO PROF DEIARY KADER Fujisawa point
  • 24. PGO PROF DEIARY KADER Fujisawa point Overcorrection of 3º–5º above the 6º–7º normal valgus angle 62.5% across tibial plateau from medial side
  • 25. PGO PROF DEIARY KADER Double Varus 1- Varus alignment Progressive medial joint narrowing 2- Lateral opening LCL laxity >5 mm laxity ( stress radiograph) Varus thrust
  • 26. PGO PROF DEIARY KADER Triple Varus Varus alignment Posterolateral corner laxity Increased Ext-Rotation Hyperextension Lateral opening Varus recurvatum deformity
  • 27. PGO PROF DEIARY KADER Compensating for Abnormal AP Laxity ACL Rupture PCL Rupture Usually by CWHTO Usually by OWHTO ACL DEC CLOSE PCL INC OPEN
  • 28. PGO PROF DEIARY KADER N ACL # PCL # Ant Post F F F F F T T T T T Usually by CWHTO PROF KADER PGO
  • 29. PGO PROF DEIARY KADER In PCL rupture Increasing the slope will allow the femur to slide back
  • 30. PGO PROF DEIARY KADER Who is the IDEAL candidate for HTO?
  • 31. PGO PROF 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
  • 32. PGO PROF DEIARY KADER The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
  • 33. PGO PROF DEIARY KADER Which Osteotomy Open or Closed?
  • 34. PGO PROF DEIARY KADER Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965 (Coventry, 1965).
  • 35. PGO PROF 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
  • 36. PGO PROF 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
  • 37. PGO PROF DEIARY KADER Open W HTO
  • 38. PGO PROF 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?
  • 39. PGO PROF DEIARY KADER 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
  • 40. PGO PROF DEIARY KADER O W HTO
  • 41. PGO PROF 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
  • 42. PGO PROF DEIARY KADER Distal Femur Osteotomy for Valgus Malalignment
  • 43. PGO PROF DEIARY KADER 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
  • 44. PGO PROF DEIARY KADER Knee Arthroplasty 30 minutes
  • 45. PGO PROF DEIARY KADER 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
  • 46. PGO PROF DEIARY KADER Aseptic complications after TKR Wound healing Extensor Mechanism complications Stiffness Periprosthetic fractures Loosening Neurologic injuries Vascular injuries
  • 47. PGO PROF DEIARY KADER What are the Biomechanical aims of TKR?
  • 48. PGO PROF DEIARY KADER 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
  • 50. PGO PROF DEIARY KADER Joint Orientation in TKR Anatomic F=+9 T=-3 Classic TKR AT EASE STANDING POSITION
  • 51. PGO PROF DEIARY KADER Which knee replacement and why? ODEP is the Orthopaedic Data Evaluation Panel
  • 53. PGO PROF DEIARY KADER Constraint ladder in implant design
  • 55. PGO PROF 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).
  • 57. PGO PROF DEIARY KADER PCL retaining or substituting and why
  • 58. PGO PROF DEIARY KADER PS or CR
  • 59. PGO PROF DEIARY KADER PCL retaining (CR)
  • 60. PGO PROF 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
  • 61. PGO PROF 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)
  • 62. PGO PROF 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
  • 63. PGO PROF 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
  • 64. PGO PROF DEIARY KADER PCL substitution/sacrificing 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
  • 65. PGO PROF 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
  • 66. PGO PROF DEIARY KADER GII PS + Pat
  • 67. PGO PROF 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
  • 68. PGO PROF 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
  • 69. PGO PROF DEIARY KADER Coronal plane sequential ligament release in TKR
  • 70. PGO PROF 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
  • 71. PGO PROF DEIARY KADER H Schroeder-Boersch Medial Ligament Restraint Range of Ligament restraint medial knee
  • 72. PGO PROF DEIARY KADER Pie-Crusting Technique Extension Osteophytes excision Deep MCL to posteromedial corner Flexion
  • 73. PGO PROF DEIARY KADER Ligament restraint Lateral knee H Schroeder-Boersch
  • 74. PGO PROF DEIARY KADER PCL 0º-120º more in flexion It is “a central stabiliser” 15mm PCL insertion 15mm
  • 75. PGO PROF DEIARY KADER LCL 0º-120º & Popliteus 30º-120º
  • 76. PGO PROF DEIARY KADER Valgus Knee Posterior capsule LCL release Flexion and extension tightness
  • 77. PGO PROF DEIARY KADER Tight in Flexion Tight in Extension Valgus Knee
  • 78. PGO PROF DEIARY KADER Medial release for varus knee Osteophytes excision Deep MCL to posteromedial corner Semimembranosus aponeurosis Superficial MCL PCL Pes anserinus insertion
  • 79. PGO PROF DEIARY KADER What are the problems associated with valgus knees
  • 80. PGO PROF 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°.
  • 81. PGO PROF 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
  • 82. PGO PROF DEIARY KADER Easy way to remember Gap balancing
  • 83. PGO PROF 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
  • 84. PGO PROF DEIARY KADER Balancing Flexion and Extension Gaps
  • 85. PGO PROF DEIARY KADER What are the technical difficulties in converting Uni to TKR?
  • 87. PGO PROF DEIARY KADER 50% of Uni knees had a significant bone defect
  • 88. PGO PROF DEIARY KADER 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
  • 89. PGO PROF DEIARY KADER 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
  • 90. PGO PROF DEIARY KADER Technical Considerations in TKR How would you determine the rotation of the femoral component?
  • 91. PGO PROF DEIARY KADER 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
  • 92. PGO PROF 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
  • 93. PGO PROF DEIARY KADER Surgical Anatomic
  • 94. PGO PROF DEIARY KADER 1-The epicondylar axis Problems Difficult to identify Misuse of the surgical epicondylar axis rather than the Anatomic one
  • 95. PGO PROF 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
  • 96. PGO PROF DEIARY KADER 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
  • 97. PGO PROF DEIARY KADER 4- The Anterior Femoral Cortical Line Dr Mervyn Cross
  • 98. PGO PROF 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
  • 99. PGO PROF DEIARY KADER What if the Femoral component internally rotated?
  • 100. PGO PROF DEIARY KADER 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
  • 101. PGO PROF DEIARY KADER The role of Computer Navigation & Robotics in TKR
  • 102. PGO PROF DEIARY KADER 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).
  • 103. PGO PROF DEIARY KADER 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)
  • 104. PGO PROF DEIARY KADER 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
  • 105. PGO PROF DEIARY KADER
  • 106. PGO PROF DEIARY KADER Robotic Knee Replacement
  • 107. PGO PROF DEIARY KADER What is “Robotic” Navigation? Robotic Surgery- NAVIO- Smith+Nephew
  • 108. PGO PROF DEIARY KADER What is the NAVIO? Infrared Camera and Reflective Arrays Handheld Robotic Tool Surgeon Controlled Interface Portable Cart Burr Motor Monitor
  • 109. PGO PROF DEIARY KADER
  • 110. PGO PROF DEIARY KADER 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
  • 111. PGO PROF DEIARY KADER 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.
  • 112. PGO PROF DEIARY KADER 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. PGO PROF DEIARY KADER 113 Would you resurface the Patella during TKR?
  • 114. PGO PROF DEIARY KADER GII PS + Pat
  • 115. PGO PROF DEIARY KADER
  • 116. PGO PROF DEIARY KADER 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.
  • 117. PGO PROF DEIARY KADER 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
  • 118. PGO PROF DEIARY KADER Titanium or Cobalt Chrome for Tibial component?
  • 119. PGO PROF DEIARY KADER 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)
  • 120. PGO PROF DEIARY KADER 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
  • 121. PGO PROF DEIARY KADER 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
  • 122. PGO PROF DEIARY KADER Painful TKR 65 minutes
  • 123. PGO PROF DEIARY KADER Management History & Examination
  • 124. PGO PROF DEIARY KADER 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)
  • 125. PGO PROF DEIARY KADER 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
  • 126. PGO PROF DEIARY KADER Indications for Revision TKA • Aseptic loosening (30-40%) • Infection (22%) • Pain (10%) • Mal-alignment 7-10%
  • 127. PGO PROF DEIARY KADER Polyethylen Wear What are the factors that determine poly wear??
  • 128. PGO PROF DEIARY KADER 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)
  • 129. PGO PROF DEIARY KADER 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
  • 130. PGO PROF DEIARY KADER
  • 131. PGO PROF DEIARY KADER
  • 132. PGO PROF DEIARY KADER
  • 133. PGO PROF DEIARY KADER Bone defects
  • 134. PGO PROF DEIARY KADER 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
  • 135. PGO PROF DEIARY KADER 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
  • 136. PGO PROF DEIARY KADER 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
  • 137. PGO PROF DEIARY KADER
  • 138. PGO PROF DEIARY KADER
  • 139. PGO PROF DEIARY KADER Metaphyseal Sleeves & Cones
  • 140. PGO PROF DEIARY KADER Trabecular Metal Cones
  • 141. PGO PROF DEIARY KADER Either Sleeves or CCK
  • 142. PGO PROF DEIARY KADER Poly difference in TKR and THR
  • 143. PGO PROF DEIARY KADER 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
  • 144. PGO PROF DEIARY KADER chemical reaction or radiation energy. Polymer chains
  • 145. PGO PROF DEIARY KADER 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)
  • 146. PGO PROF 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
  • 147. PGO PROF DEIARY KADER PERI-PROSTHETIC JOINT INFECTION (PJI) TKR
  • 148. PGO PROF DEIARY KADER J Am Acad Orthop Surg 2010;18: 760-770
  • 149. PGO PROF DEIARY KADER
  • 150. PGO PROF 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
  • 151. PGO PROF DEIARY KADER 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
  • 152. PGO PROF DEIARY KADER Infection Revision for Infection (22%)
  • 153. PGO PROF DEIARY KADER Commonly used CCK in UK PFC Sigma TC3 (DePuy) Triathlon TS (Stryker) Legion Smith & Nephew Vanguard SSK (Biomet) NexGen (Zimmer)
  • 154. PGO PROF DEIARY KADER Mal-Alignment Places mechanical and shear stresses on the bearing surfaces bone/prosthesis interfaces ALSO •Changes the forces going through the soft-tissue envelope
  • 155. PGO PROF DEIARY KADER 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).
  • 156. PGO PROF DEIARY KADER
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  • 158. PGO PROF DEIARY KADER
  • 159. PGO PROF DEIARY KADER
  • 160. PGO PROF DEIARY KADER Patella POSTGRAD ORTH Deiary Kader
  • 161. PGO PROF DEIARY KADER
  • 162. PGO PROF 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 POSTGRAD ORTH Deiary Kader
  • 163. PGO PROF 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
  • 164. PGO PROF DEIARY KADER
  • 165. PGO PROF DEIARY KADER Principles of PFJR
  • 166. PGO PROF 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
  • 167. PGO PROF DEIARY KADER PFJ OA Non-operative treatment Anti-inflammatory medications Activity modification Quadriceps strengthening Bracing, Steroid injections Viscosupplement
  • 168. PGO PROF DEIARY KADER PFJ OA PFJ replacement or TKR?
  • 169. PGO PROF DEIARY KADER PFJ OA PFJ replacement or TKR? 1. Age 2. Other compartments 3. Implant failure rate
  • 170. PGO PROF 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
  • 171. PGO PROF 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
  • 172. PGO PROF DEIARY KADER
  • 173. PGO PROF DEIARY KADER Peri- prosthatic fracture after TKR approach and management
  • 174. PGO PROF DEIARY KADER 88 Y lady from a nursing home had knee revision 8 years ago
  • 175. PGO PROF DEIARY KADER 75 Y lady lives alone. knee revision 5 years ago was doing well
  • 176. PGO PROF DEIARY KADER
  • 177. PGO PROF DEIARY KADER
  • 178. PGO PROF DEIARY KADER POSTGRAD ORTH Deiary Kader
  • 179. PGO PROF DEIARY KADER Distal Femur Replacement
  • 180. PGO PROF DEIARY KADER
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  • 182. PGO PROF DEIARY KADER