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Frank R. Ebert, MD Union Memorial Hospital Baltimore, Maryland TOTAL KNEE ARTHROPLASTY.

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Presentation on theme: "Frank R. Ebert, MD Union Memorial Hospital Baltimore, Maryland TOTAL KNEE ARTHROPLASTY."— Presentation transcript:

1 Frank R. Ebert, MD Union Memorial Hospital Baltimore, Maryland TOTAL KNEE ARTHROPLASTY

2 Total Knee Arthroplasty Goal Restore mechanical alignment Restore mechanical alignment Restore joint line Restore joint line

3 Normal Knee Anatomy l Position in single leg stance l Mechanical axis valgus 3º l Femoral shaft axis valgus 6º l Proximal tibia varus 3º

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5 Total Knee Arthroplasty Radiographic Evaluation Standing full length – AP Standing full length – AP Standing AP Standing AP Extension/Flexion laterals Extension/Flexion laterals Tunnel view Tunnel view Sunrise view Sunrise view

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7 Total Knee Arthroplasty Radiographic Evaluation Weight Bearing X-rays Extent of joint space narrowing Extent of joint space narrowing Ligament stretch out Ligament stretch out Subluxation of femus on tibia Subluxation of femus on tibia

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9 Total Knee Arthroplasty Radiographic Analysis Anatomic Axis – Femur Line that bisects the medullary canal of the femur Line that bisects the medullary canal of the femur Determines the entry point of the femoral medullary guide rod Determines the entry point of the femoral medullary guide rod

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11 Total Knee Arthroplasty Radiographic Analysis Mechanical Axis – Femur (MAF) A line from center of femoral head to center of distal femur A line from center of femoral head to center of distal femur

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13 Total Knee Arthroplasty Radiographic Analysis Anatomic Axis Tibia (AAT) A line that bisects the medullary canal of the tibia A line that bisects the medullary canal of the tibia Determines the entry point of the guide rod Determines the entry point of the guide rod

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15 Total Knee Arthroplasty Radiographic Evaluation Mechanical Axis – Tibia (MAT) Line from center of proximal tibia to center of ankle Line from center of proximal tibia to center of ankle Proximal tibia is cut perpendicular to (MAT) Proximal tibia is cut perpendicular to (MAT)

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17 Issues with Surgical Techniques Traditional Joint Line Orientation l Tibial cut perpendicular to the MAT l Femoral shaft at a valgus angle 5º to 8º valgus based off the ong standing x-ray

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19 Surgical Technique l Incision straight longitudinal incision l Tissue handling key l Avoid flaps l Preserve soft tissue flap about the patella

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21 Surgical Technique Remember 7cm Rule between incisions

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23 Issues with Surgical Techniques l Exposure options Subvastus / midvastusSubvastus / midvastus u Routine knee replacements z Quicker rehab Medial parapatellar / midlineMedial parapatellar / midline u Difficult total knee obese patients u Revisions

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26 MIS vs MINI TKA Capsulotomy only? Mid vastus? Sub vastus? MIS

27 MIS vs MINI TKA Mid vastus? Sub vastus? Quad sparing? MIS

28 Area of Variation Type I-High Insertion Type II-Pole Insertion Type III-Low Insertion Anatomic Variations of VMO Insertion

29 Type I- High VMO Insertion Retinacula r Incision Area of extended retinaculu m Muscle Insertion

30 Type II-Pole Insertion Capsular or Retinacul ar Incision Muscle Insertion

31 Type III-Low VMO Insertion Area of Extended VM Muscle Insertion

32 Issues with Surgical Techniques l Alignment Extramedullary vs IntramedullaryExtramedullary vs Intramedullary Accuracy vs increased PE risk Accuracy vs increased PE risk Femur – Intramedullary Femur – Intramedullary z Overdrill opening and insert slowly IM guide z Overdrill opening and insert slowly IM guide z Caution with bilateral Total Knee Arthroplasty Tibia – Extramedullary Tibia – Extramedullary

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34 Issues with Surgical Techniques l Femoral Rotation LandmarksLandmarks Posterior femoral condyles Epicondyles 5º external rotation to the posterior condyles

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38 Issues with Surgical Techniques l Femur Measured resections: equal bone distally and posteriorlyMeasured resections: equal bone distally and posteriorly Tensioning devices & ligament releasesTensioning devices & ligament releases Do not alter bone resection for ligament tightnessDo not alter bone resection for ligament tightness

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40 Issues with Surgical Techniques Tibial Component Rotation Transmalleolar axisTransmalleolar axis Posterior tibial plateauPosterior tibial plateau Tibial tubercle lies lateralTibial tubercle lies lateral

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44 Malalignment Tibial Component Internally Rotated Tubercle Too Lateral Tubercle Too Lateral

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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

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48 Surgical Techniques Varus Knee 1.Pes anserinus 2.Joint Capsule 3.Deep Tibial Collateral 4.Semimembranosus 5.Posterior Medial Capsule

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52 Varus Knee

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56 Surgical Techniques Valgus Knee 1.Iliotibial Band 2.Popliteus Tendon 3.Posterior Lateral Capsule 4.Lateral Head of Gastroc 5.Biceps Femoris

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60 Surgical Techniques Valgus Knee Peroneal nerve palsy – valgus / flexion deformityPeroneal nerve palsy – valgus / flexion deformity TreatmentTreatment u Release dressings or flex the knee

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62 Surgical Techniques: Flexion Contracture 1.Posterior capsule 1.Posterior capsule 2.Gastroc origins 2.Gastroc origins 3.Posterior cruciate 3.Posterior cruciate 4.Distal femur 4.Distal femur

63 Fixed Flexion Deformity in TKA Complex Combinations: musculotendinous contracturemusculotendinous contracture ligamentous contracture ligamentous contracture capsular contracture capsular contracture osteophytes of posterior condyle osteophytes of posterior condyle

64 Fixed Flexion Deformity in TKA Biomechanics increased quadriceps force for knee stabilization during weight bearingincreased quadriceps force for knee stabilization during weight bearing increased forces transmitted to the patellofemoral joint increased forces transmitted to the patellofemoral joint

65 Fixed Flexion Deformity in TKA Biomechanics increased forces are placed on posterior tibial plateauincreased forces are placed on posterior tibial plateau femoral condyles sink into the tibial plateau femoral condyles sink into the tibial plateau contact between intercondylar notch and tibial eminence form a boney block contact between intercondylar notch and tibial eminence form a boney block

66 Fixed Flexion Deformity in TKA Associated deformity varus deformity40% - > 5º range 5 to 30º varus varus deformity40% - > 5º range 5 to 30º varus valgus deformity30% - > 5º range 5 to 22º valgus valgus deformity30% - > 5º range 5 to 22º valgus Firestone et al COOR 92

67 Fixed Flexion Deformity in TKA Incidence of Problem – Review of 700 TKA & Revision TKAs 60% before primary TKA 60% before primary TKA 21% before revision TKA 21% before revision TKA Tew & Forster JBJS (B) 87

68 Fixed Flexion Deformity in TKA Soft tissue release Varies with angular deformity Varies with angular deformity Firestone et al COOR 92

69 Fixed Flexion Deformity in TKA Surgical Treatment l Soft tissue release l Additional bone resection l Combination

70 Fixed Flexion Deformity in TKA Postoperative Correction the more severe the deformity must consider the pros and cons of additional bone resection and/or soft tissue release 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 Deformity in TKA Additional bone resection – pros joint line is positioned slightly more proximal joint line is positioned slightly more proximal functionally lengthens the collaterals and posterior capsule forward extension functionally lengthens the collaterals and posterior capsule forward extension doesnt compromise flexion stability doesnt compromise flexion stability Firestone et al COOR 92

72 Fixed Flexion Deformity in TKA Additional bone resection cons (excessive) Collateral ligament laxity Collateral ligament laxity Quadriceps redundancy Quadriceps redundancy Hyperextension Hyperextension Bone quality can be compromised Bone quality can be compromised McPherson et al 94

73 Additional Femoral Resection

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75 Fixed Flexion Deformity in TKA Surgical Treatment for Deformity < 10º FFC l Soft tissue release – only necessary posterior capsule posterior capsule possibly PCL possibly PCL posterior osteophytes posterior osteophytes

76 Fixed Flexion Deformity in TKA Surgical Treatment for Deformity 10-20º FFC consider distal femoral resection 3 to 5 mm consider distal femoral resection 3 to 5 mm Posterior capsule Posterior capsule PCL resection posterior osteophytes PCL resection posterior osteophytes Firestone et al COOR 92

77 Fixed Flexion Deformity in TKA Surgical Treatment for Deformity 20-30º FFC distal femoral resection 3 to 5 mm distal femoral resection 3 to 5 mm posterior capsule posterior capsule PCL resection posterior osteophytes PCL resection posterior osteophytes Firestone et al COOR 92

78 Fixed Flexion Deformity in TKA Surgical Treatment for Deformity > 30º FFC consider pre-op casting consider pre-op casting distal femoral resection 5 mm distal femoral resection 5 mm proximal tibial resection proximal tibial resection PCL resection PCL resection posterior osteophytes posterior osteophytes Firestone et al COOR 92 et al J of Arthro 99

79 Fixed Flexion Deformity in TKA l Peroneal Nerve Palsy l Vascular Insufficiency l Anterior Pressure Ulcers l Manipulation

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83 Fixed Flexion Deformity in TKA l No formula is exact for treatment of the problem l Consider a balance between soft tissue release vs bone resection

84 Issues with Surgical Techniques Stiff Knee l Remove osteophytes l Insall Turn Down l Osteotomize the tibial tubercle l Rectus snip

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89 Issues with Surgical Techniques Stiff Knee u Epicondylar osteotomy for large flexion / contracture u Lateral release to evert the patella

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93 Issues with Surgical Techniques l Patellar resurfacing Recommended for all RA patientsRecommended for all RA patients Without resurfacing 4% to 6% incidence of anterior knee painWithout resurfacing 4% to 6% incidence of anterior knee pain With resurfacing increased incidence of fractureWith resurfacing increased incidence of fracture

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95 Issues with Surgical Techniques l Patellar resurfacing Thickness shouldnt exceed 25 mmThickness shouldnt exceed 25 mm For every 1 mm thicker reduces flexion by 3ºFor every 1 mm thicker reduces flexion by 3º

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99 Issues with Surgical Techniques Patellar Baja Proximal tibial osteotomy Proximal tibial osteotomy Tibial tubercle shift Tibial tubercle shift Prior fracture Prior fracture

100 Issues with Surgical Techniques Patellar Baja Dont raise joint line Dont raise joint line Consider lowering joint line Consider lowering joint line Distal femoral alignment Distal femoral alignment Trim anterior tibial poly to avoid impingement of patella Trim anterior tibial poly to avoid impingement of patella

101 Issues with Surgical Techniques Patellar Clunk Syndrome Seen at 35º-40º knee flexion Seen at 35º-40º knee flexion Treatment is arthroscopic or open resectionTreatment is arthroscopic or open resection

102 Issues with Surgical Techniques Sagittal Plane Balancing SituationProblem Solution Cut Tight Symmetrical –cut more in extension gapproximal tibia Cut Tight in flexion Cut Tight Asymmetrical –Release PCL; in extension gapPosterior capsule Cut Loose Consider PCL in flexionsubstituting prosthesis –Resection distal femur AVOID recurvatum –Resection distal femur AVOID recurvatum

103 Issues with Surgical Techniques Sagittal Plane Balancing SituationProblem 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 gapaugmentation Cut Loose– Adjust to larger in flexion femoral component

104 Complications in Total Knee Arthroplasty Periprosthetic Fractures Periprosthetic Fractures Infected Total Knee Arthroplasty Infected Total Knee Arthroplasty

105 Supracondylar Fractures of the Femur After Total Knee Arthroplasty

106 Supracondylar Fractures After TKR lNotching of the femoral cortex lOsteoporosis lProlonged steroid use lPreexisting neurologic disorders

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108 Supracondylar Fractures After TKR OSTEOPOROSIS Bogoch, et al, CORR 1986

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110 Supracondylar Fractures After TKR lMajor trauma is not required to produce fractures in many TKA patients lAlignment not correlated with fracture lWeight not a significant factor

111 Fractures After TKA Neer Classification 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 Type 1 – Nondisplaced

113 Supracondylar Fractures After TKR Type 1 fractures 83% success rate Chen, et al, 1994

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115 Supracondylar Fractures After TKR Type 2 fractures 69% success rate Chen, et al, 1994

116 Supracondylar Fractures After TKR lCasting lTraction followed by rest Non Operative Method

117 Supracondylar Fractures After TKR Type 2 fractures 67% success rate Chen, et al, 1994

118 Supracondylar Fractures After TKR lPlates / Screw fixation lIntramedullary rods lRush pins lExternal fixation lPrimary arthrodesis lRevision arthroplasty Operative Method

119 Supracondylar Fractures After TKR lPatients ability to tolerate traction lAbility of bone to hold screws lAbility of the surgeon Type 2 Considerations

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122 Intercondylar Distances of Commonly Used Femoral Prostheses Biomet, (Warsaw, IN)AGC18 Universal18 DePuy, (Warsaw, IN)AMK20 Dow Corning Wright, (Arlington, TN) Whitesides modular20 Howmedica, (Rutherford, NJ) PCA18.5 Intermedics, (Austin, TX) Natural14 Johnson and Johnson, (New Brunswick, NJ) Press-fit condylar20 Insall-Burstein*15 (posterior stabilized) Kirschner, (Timonium, MD) Performance14 Zimmer, (Warsaw, IN)Insall-Burstein I*16 Insall-Burstein II15 (posterior stabilized* or constrained condylar) Miller-Galante I Small / small + 11 Regular / regular Large / large + 15 Large Miller-Galante II13 ManufacturerModel Intercondylar Distance (Smallest Size) (mm)

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124 Supracondylar Fractures After TKR No one form of treatment gives uniformly good results

125 Infection in Total Knee Arthroplasty

126 Complications in Arthroplasty Infection – Risk Factors lSkin ulcerations / necrosis lRheumatoid Arthritis lPrevious hip/knee operation lRecurrent UTI lOral corticosteroids

127 Complications in Arthroplasty Infection – Risk Factors lChronic renal insufficiency lDiabetes lNeoplasm requiring chemo lTooth extraction

128 Complications in Arthroplasty Infection – Clinical Course Infection – Clinical Course lPain #1 lSwelling lFever lWound breakdown drainage Windsor et al JBJS; 1990

129 Early < 3 months Lab Value Mayo Series Mean 7,500Mayo Series Mean 7,500 l Differential 67 PMNs l Sed rate71 mm/hr l Arthrocentesis Infections About TKR

130 Late > 3 months Symptoms: 52 patients Pain96% swelling77% Debride27% Active drainage27% Sed rate 63 mm/hr WBC Pain96% swelling77% Debride27% Active drainage27% Sed rate 63 mm/hr WBC Windsor et al JBJS; 1990 Infections About TKR

131 Complications in Arthroplasty Infection – Surgical Techniques lAvoid skin bridges lAvoid creation of skin flaps lHemostasis lProlonged operating time

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133 Complications in Arthroplasty Infection – Work-Up lWound History lPhysical Exam lSerial Radiographs lLab/sed rate/CRP lBone scan / Indium scan

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135 Complications in Arthroplasty InfectionArthrocentesis l Cell count l Diff > 25,000 pmn l Protein – high l Glucose – low

136 Complications in Arthroplasty Infection lHost Response Glycocalyx Glycocalyx Gristina JBJS; 1983

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138 Micro Organisms

139 Organisms Isolated from 71 Patients With Infected Knee Replacement Staphylococcus64 S. aureus, penicillin sensitive 14 S. aureus, penicillin resistant28 S. epidermis22 S. aureus, penicillin sensitive 14 S. aureus, penicillin resistant28 S. epidermis22 Gram negative12 Pseudomonas7 Escherichia coli5 Anærobic6 Other17 OrganismPercent

140 Complications in Arthroplasty Treatment Options lAntibiotic suppression lAggressive wound debridement

141 Complications in Arthroplasty Treatment Options lAntibiotic suppression Indicated in med compromised Organism - gram+ strep staphepi

142 Complications in Arthroplasty Treatment Options lResection arthroplasty l2 Stage re-implant lArthrodesis lAmputation

143 Complications in Arthroplasty Treatment Options lDebridement with antibiotic suppression therapy Strep/staphepi -- best Avoid repeated attempts Frozen tissue section Suction drains

144 Complications in Arthroplasty Two-Stage Reimplantation lMost successful treatment lProcedure of choice

145 Complications in Arthroplasty Two-Stage Reimplantation Procedure l Remove components, cement, I & D l Fabricate and place spacer l 6 weeks of antibiotics l Reimplantation

146 Complications in Arthroplasty Two-Stage Reimplantation Stage I l create antibiotic spacer impregnated with antibiotics l wound closure

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148 Complications in Arthroplasty Two-Stage Reimplantation l Spacer Antibiotic Regimen Tobramycin 2.4 gm/3.6 gm per 40 gms of PMMA Tobramycin 2.4 gm/3.6 gm per 40 gms of PMMA Vancomycin> gm to 1 gm per gms of PMMA Vancomycin> gm to 1 gm per gms of PMMA

149 Complications in Arthroplasty Intra-operative Frozen Section l< 5 PMNs per HPF– no infection l> 10 PMNs per HPF–infection Mirra; JBJS

150 Complications in Arthroplasty Results Gm positive Windsor et al92 % JBJS 1990 Insall et al97%JBJS 1983 Insall et al97%JBJS 1983

151 Complications in Arthroplasty Resection Arthroplasty lRemoval all components lRemove all cement lEffective in medically compromised patient

152 Complications in Arthroplasty Arthrodesis Indications lExtensor mechanism disruption lResistant bacteria lInadequate bonestock lInadequate soft tissues lYoung patient

153 Advantages Definitive treatment Definitive treatment Little chance of recurrence Little chance of recurrence Arthrodesis

154 Disadvantages Difficulty with transfers / small spaces Difficulty with transfers / small spaces Increase energy requirements Increase energy requirements Arthrodesis

155 Algorithm TKA Clinical Sepsis (GRAM + Organism) < 3 wks > 3 wks Debridement Antibiotics (6 wks) 2-Stage Replant Infections About TKR

156 Algorithm Debridement Antibiotics Success 2-stage Replant Arthrodesis Infections About TKR No Success 2-stage Replant 2-stage Replant Success No Success Resection Arthroplasty

157 Thank You


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