no obvious benefit in postoperative TKA alignment. should always be ruled out prior to any revision, considered the most common reason for revision TKA overall based on national database epidemiology studies, when categorized further, infection is the most common cause of early (<2 years from primary) failure, aseptic loosening is the second most common reason for revision TKA overall based on national database epidemiology studies, when categorized further, aseptic loosening is the most common cause of late (>2 years from primary) failure, tibial loosening more common than femoral, femoral loosening more difficult to detect due to obscured view of posterior femoral condyles where lesions typically occur, MCL/LCL incompetence can to lead to laxity, femoral component placed in excessive extension, need for revision due to combination of excessive comminution/bone loss with loose component, fibrotic scar tissue that 'clunks' as the knee moves from flexion into extension and patella jumps the femoral notch, arthroscopic treatment to remove fibrotic tissue, original etiology and indications for TKA, preoperative range of motion, ambulatory status, history of infection, thrombophlebitis, recent falls, type of implant, review of prior records and imaging, persistent since index procedure or new onset pain (may indicate potential acute vs. chronic infection), pain with weight bearing indicates likely mechanical etiology, environment of instability (i.e. 2023 Lineage Medical, Inc. All rights reserved. 10/18/2019. 0 % 0 % Flashcards. 0 % 0 % 4. . 2023 Lineage Medical, Inc. All rights reserved, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, Question SessionTKA Prosthesis Design & Lumbar Disc Herniation, interposition of soft tissues for reconstruction of articular surfaces, Walldius designs first hinged knee replacement, MacIntosh and McKeever introduce acrylic tibial plateau prosthesis to correct deformity, Gunston introduces first cemented surface arthroplasty of knee joint, Guepar develops a new hinged prosthesis based on design by Walldius that increases motion and decreases bone loss, "total condylar prosthesis" is introduced which is first to resurface all three compartments (PCL sacrificing), the posterior translation the femur with progressive flexion, improves quadriceps function and range of knee flexion by preventing posterior impingement during deep flexion, rollback in the native knee is controlled by the, both PCL retaining and PCL substituting designs allow for femoral rollback, native PCL promotes posterior displacement of femoral condyles similar to a native knee, exhibits paradoxical anterior translation in the first 40 degrees of flexion, tibial post contacts the femoral cam causing posterior displacement of the femur, the ability of a prosthesis to provide varus-valgus and flexion-extension stability in the face of, in the setting of ligamentous laxity or severe bone loss, standard cruciate-retaining or posterior-stabilized implants may not provide stability, in order of least constrained to most constrained, posterior-stabilized (cruciate-substituting), metal tibial baseplate with modular polyethylene insert, more expensive than all-polyethylene tibial component, has an equivalent rate of aseptic loosening compared with all-polyethylene tibia component, ability to customize implant intraoperatively, micromotion between tibial baseplate and undersurface of polyethylene insert that occurs during loading, high viscosity cement has longer working time, trabecular surface allows for long term biologic fixation, arthritis with minimal bone loss, minimal soft tissue laxity, and an intact PCL, won't show box in the central portion of the femoral component, avoids tibial post-cam impingement/dislocation, more closely resembles normal knee kinematics (controversial), less distal femur needs to be cut than in a PS knee, newer poly-options can allow for PCL substitution via anterior-stabilized or ultra-congruent shapes in cases of PCL insufficiency without loss of functional results, slightly more constrained prosthesis that requires, resection of PCL increases the flexion gap in relationship to extension gap so posterior must be matched to avoid flexion-extension mismatch, femoral component contains a cam that engages the tibial polyethylene post during flexion, polyethylene inserts are more congruent, or deeply "dished", reduces risk of potential anteroposterior instability in setting of a weak extensor mechanism, outline of the cam, or box, in the femoral component, with loose flexion gap, or in hyperextension, the cam can rotate over the post and dislocate, closed reduction by performing an anterior drawer maneuver, scar tissue gets caught in box as knee moves into extension, arthroscopic versus open resection of scar tissue, additional bone is cut from distal femur to balance extension gap, without axle connecting tibial and femoral components, large tibial post and deep femoral box provide, prosthesis allows stability in the face of soft tissue (ligamentous) or bony deficiency, tibial bearing rotates around a yoke on the tibial platform (rotating hinge), massive bone loss in the setting of a neuropathic joint, minimally constrained prosthesis where the, polyethylene can rotate on the tibial baseplate, young, active patients (relative indication), increased contact area reduces pressures placed on polyethylene (pressure=force/area), occurs as a result of a loose flexion gap. medializing the patellar component is one strategy to decrease the Q angle. Primary or secondary medial knee arthrosis is the most common indication, Isolated lateral compartment osteoarthritis is much less common, Angular deformity in the knee leads to abnormal distribution of weight bearing stresses, accelerate wear in medial or lateral compartments, HTO is commonly combined with cartilage restoration procedures, can be assessed by drawing Orthobullets Team Recon - TKA Sagittal Plane Balancing; Listen Now 31:26 min. 2023 Lineage Medical, Inc. All rights reserved, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, distal femur is ~9 degrees of valgus (anatomic axis compared to joint line), 5-7 deg valgus of femur refers to difference of anatomic axis to mechanical axis, proximal tibia is 2-3 degrees of varus (anatomic axis to joint line), axis from center of femoral head to center of ankle, lateral gapping in varus & medial gapping in valgus deformities, are indicated to determine an accurate valgus cut angle when the patient has, a line that bisects the medullary canal of the femur, determines entry point of femoral medullary guide rod, intramedullary femoral guide goes down anatomic axis of the femur, defined by line connecting center of femoral head to point where anatomic axis meets intercondylar notch, obtaining a neutral mechanical axis allows even load sharing between the medial and lateral condyles of a knee prosthesis, jig measures 6 degrees from femoral guide (anatomic axis), will vary if people are very tall (VCA < 5) or very short (VCA > 7), can measure on a standing full length AP x-ray, tibia medullary guide (internal or external) runs parallel to it, determines entry point for tibial medullary guide rod, proximal tibia is cut perpendicular to mechanical axis of tibia, usually mechanical axis and anatomic axis of tibia are coincident and therefore you can usually can cut the proximal tibia perpendicular to anatomic axis (an axis determined by an, if there is a tibia deformity and the mechanical and anatomic axis are not the same, then the proximal tibia must be cut perpendicular to the mechanical axis (therefore an, Abnormal patellar tracking, although not the most serious, is the most common complication, The most important variable in proper patellar tracking is preservation of a normal Q angle (11 +/- 7), the Q angle is defined as angle between axis of. no obvious benefit in outcomes or patient satisfaction. results in uncoverage of lateral facet. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. the epicondylar axis is parallel to the cut tibial surface, a posterior femoral cut parallel to the epicondylar axis will create the appropriate rectangular flexion gap, defined as a line running across the tips of the two posterior condyles, this line is in ~ 3 degrees of internal rotation from the transepicondylar axis, the femoral prosthesis should be externally rotated 3 degrees from this axis to produce a rectangular flexion gap, if the lateral femoral condyle is hypoplastic, use of the posterior condylar axis may lead to internal rotation of the femoral component. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. This will increase the Q angle to the tibial tubercle, Medialization of the Femoral Prosthesis will Increase Q angle, a medialized femoral prosthesis will bring the trochlear groove to a more medial position, and thus bring the patella medial with it, thus increasing the Q angle, therefore, you want the femoral component to be slighly lateral if anything. Cards. two general designs in total knee prosthesis include. 2023 Lineage Medical, Inc. All rights reserved, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, if multiple incision, choose more lateral, generally safe to cross previous transverse incisions at right angles, exact length of skin bridge needed is controversial, "simple" primary knee arthroplasty approaches, "complex" primary or revision total knee arthroplasty, most commonly completed through a straight midline incision, excellent exposure even in challenging cases, possible failure of medial capsular repair, development of lateral patellar subluxation, access to lateral retinaculum less direct, may jeopardize patellar circulation if lateral release is performed, useful for addressing lateral contractures but difficult eversion of patella makes exposure challenging, allows direct access to lateral side in a valgus knee, medial eversion of patella is more difficult, similar approach to medial parapatellar that spares VMO insertion and may lead to quicker recovery, vastus medialis insertion on quad tendon is not disrupted, potentially allows accelerated rehab due to avoiding disruption of extensor mechanism, patellar tracking may be improved compared to medial parapatellar approach, exposure difficult with flexion contractures, muscle belly of vastus medialis is lifted off intermuscular septum, minimal need for lateral retinacular release, often need special instruments for exposure and implant insertion, data shows no clinically significant improvement in patient reported outcomes, gait patterns or quadriceps strength, quadriceps-sparing approach may lead to high rates of component malposition, Indications to convert to a standard parapatellar approach, patellar tendon starts to peel off the tibial tubercle, incision is too small for proper jig placement, snip made at apex of quadriceps tendon obliquely across tendon at a 45-degree angle into vastus lateralis, not as extensile as a turndown or tibial tubercle osteotomy, straight medial parapatellar arthrotomy with diverging incision down the vastus lateralis tendon towards lateral retinaculum, preserves patellar tendon and tibial tubercle, knee needs to be immobilized post-operatively, 6-10 cm bone fragment cut from medial to lateral, avoids extensor lag seen with V-Y turndown, some surgeons immobilize or limit weight-bearing post-operatively, two surgeons performing the bilateral TKA at the same time, one surgeon performing one TKA and then the contralateral TKA under one anesthetic, done surgeon performing each TKA under a separate anesthetic, timing ranges from 3 days to one year in between each side, indications for use in primary TKA are controversial, in vitro studies have shown a theoretical risk of decreased cement strength with adding antibiotics (dilution), however, there are no current studies that have shown ALBC to increase the rate of aseptic loosening, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Preoperative Planning in Primary Total Knee Arthroplasty 222 Journal of the American Academy of Orthopaedic Surgeons. TKA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior TKA. TKA Axial Alignment TKA Coronal Plane Balancing TKA Sagittal Plane Balancing . indications. Orthopedic Sports Medicine Surgeon at The Orthopedic Institute of New. N/A. Summary. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 124 Video/Pods 21 Techniques 3 4.4 ( 107 ) 37 Expert Comments Topic Podcast Images introduction Designs include unconstrained posterior-cruciate retaining (CR) posterior-cruciate substituting (PS) constrained nonhinged hinged fixed versus mobile bearing History 19th century interposition of soft tissues for reconstruction of articular surfaces Contraindications include inflammatory arthritis, flexion contracture > 15 degrees, bicompartmental osteoarthritis, and ligamentous instability. TKA Axial Alignment TKA Coronal Plane Balancing . TECHNIQUE STEPS. If a patient benefits from the brace, they are likely to benefit from surgery. 604 plays. and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. Team Orthobullets (AF) Recon - TKA Templating; Listen Now 23:14 min. diabetic woman undergoing total knee arthroplasty. draw a line of the hip-to-ankle view that shows the overall mechanical axis. The Orthobullets Podcast In this episode, we review the high-yield topic of TKA Patellofemoral Alignment from the Recon section. . straight line from, center of femoral head to the center of the 1055 plays . Are you sure you want to trigger topic in your Anconeus AI algorithm? Stephen Incavo MD. Rotation measurements performed on radiographs are limited and less reliable compared to 2D computed tomography (CT). Posterolateral corner (PLC) injuries are traumatic knee injuries that are associated with lateral knee instability and usually present with a concomitant cruciate ligament injury (PCL > ACL). TKA Sagittal Plane Balancing } Douglas Dennis MD Experts 149 Bullets 71 Questions 20 Cases 2 Evidence 31 Video/Pods 3 Techniques 3 Introduction Goal is to obtain a gap that is equal in flexion and extension. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. Most surgeons agree that the ar-thritic knee with valgus deformitypresents a unique set of problemsthat must be addressed at the time of total knee arthroplasty (TKA).Correction of the deformity andrestoration of anatomic alignmentshould be achieved to maximize thelongevity of the replaced compo-nents. Team Orthobullets 4 Recon - Knee Osteoarthritis; Listen Now 10:56 min. Total knee arthroplasty (TKA) is an effective method for the treatment of severe osteoarthritis of the knee [].One of the foundations of a successful TKA is the restoration of neutral knee alignment [].Mechanical alignment (MA) in TKA aims to position both femoral and tibial components perpendicular to the mechanical axis of each bone. Are you sure you want to trigger topic in your Anconeus AI algorithm? 120 plays. Rotation measurements performed on radiographs are limited and less reliable compared to 2D computed tomography (CT). Derek T. Bernstein MD. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Abnormal Q angle an increase in the Q angle will lead to an increased lateral subluxation forces on the patella relative to the trochlear groove TKA - Parapatellar Approach. } Consider removing to lessen risk of lateral facet syndrome. Our aim was to review the different coronal alignment paradigms of TKA and summarize the historical and contemporary outcomes of different alignment techniques.Methods: A systematic review was performed in March 2017 via PubMed using the search terms: coronal alignment, kinematic alignment, and total knee replacement using Boolean "and" in-betwe. 4. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. 4. overall knee alignment, the surgeon should look for the presence of thrust and/or hyperextension during walking, which indicates ligamen-tous laxity. The best method of total knee arthroplasty (TKA) alignment remains controversial 1. Instead, both the distal femur and the tibia are cut to be . . Are you sure you want to trigger topic in your Anconeus AI algorithm? A 55-year-old male undergoes a revision total knee arthroplasty of an implant that is only 3 years old. another alternative is use of an oval shaped patella with the apex medialized. medial compartment concavity allows lateral compartment to translate between flexion and extension, equivalent outcomes and survivorship in short and mid-term studies, femoral and tibial cutting block instrumentation based on imaging specific to patient's anatomy, less instrumentation to process peri-operatively, no obvious benefit in postoperative TKA alignment, no obvious benefit in outcomes or patient satisfaction, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. 0. A medial unloader brace can be used for therapeutic and diagnostic purposes. Follow Orthobullets on Social Media: 0. 2023 Lineage Medical, Inc. All rights reserved, 1) Decrease femoral component size which required an increase in resection of the posterior femoral condyle Recess vs. release of PCL Release posterior capsule Decrease femoral component size which required an increase in resection of the posterior femoral condyle, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, balancing is complex due to two radii of curvatures (patellofemoral articulation and tibiofemoral articulation), often requires soft tissue release and bony resection to obtain balance, adjust tibia if problem is symmetric (same in both flexion and extension), tibia cut affects both flexion and extension gap, increasing/decreasing the size of the femoral component only changes the AP diameter, Resect more distal femur or use thinner distal femoral augmentation wedge (revision scenario), 1) Decrease femoral component size which required an increase in resection of the posterior femoral condyle, 4) Recut proximal tibia with increased slope, Balanced in extension, Balanced in Flexion (Perfect). Step 2. estimate magnitude of coronal deformity. 3.7 (3) EXPERT COMMENTS (9 . the most important variable in proper patellar tracking is preservation of a normal Q angle. 22. Orthobullets Team TKA Polyethylene Wear & Manufacturing Experts. maintain the joint line perpendicular to mechanical axis of the leg, can be done for varus knee with medial compartment degeneration (more common), best results achieved by overcorrection of the anatomical axis to 8-10 degrees of valgus, narrow lateral compartment cartilage space with stress radiographs, Used less commonly than distal femoral osteotomy, produces obliquity of the tibiofemoral joint line, can be done for valgus knee with lateral compartment degeneration, <12 degrees or else the joint line will become oblique, distal femoral osteotomy better if lateral femoral condyle hypoplasia present, adjunct to soft tissue reconstructive surgeries (ACL/PCL/MACI) when there is coronal malalignment, wedge of bone removed with tibia via an anterolateral approach, more inherent stability allows for faster rehab and weight bearing, transverse bone cut made in proximal tibia, and wedged open on medial side, avoids peroneal nerve in anterior compartment, the center of the dome is located at the center of rotation of angulation (CORA), corrects limb alignment with the least translation of bone ends, refers to a shortened patellar tendon which decreases the distance of the patellar tendon from the inferior joint line, raising tibiofemoral joint line in opening wedge osteotomies, retropatellar scarring and tendon contracture, can cause bony impingement of patella on tibia, more common in lateral opening wedge osteotomy and lateral closing wedge osteotomy, minimal risk in medial opening wedge osteotomy, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Progression to the next phase is based on Clinical Criteria and/or Time Frames as PMID: 27655141 DOI: 10.1007/s00167-016-4325-5 Abstract Purpose: One of the most important factors leading to revision of total knee arthroplasties (TKA) is malrotation of femoral and/or tibial component. Many authors advocate the traditional neutral mechanical alignment concepts (components perpendicular to. . Internal Rotation of Femoral Prosthesis will Increase Q angle, by internally rotating the femoral prosthesis, you are effectively bringing the groove and the patella medially. ownsize femur anduse thicker tibial insert until balanced. 2023 Lineage Medical, Inc. All rights reserved, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, ReconTKA Coronal Plane Balancing (ft. Dr. Doug Dennis), both medial and lateral ligaments may be stretched or contracted with time, it is essential to balance these ligament in both the coronal and sagital plane to obtain an optimum outcome, must test balancing in both flexion and extension, principle of placing implants in more varus or valgus based on patient anatomy, constitutionally varus = varus tibial implant, constitutionally valgus = valgus tibial implant, outcomes are roughly equivalent with neutrally aligned knees, medial side is tight (concave), lateral side stretched (convex), balance flexion and extension gaps by adjustment of polyethylene bearing thicknesss, Deep MCL Release To Mid-Coronal Plane Of Tibia, Release Posteromedial Corner (Posterior Oblique Ligament), Consider PCL Release/Substitution If Imbalance Persists At This Point, Release Semimembranosis (Especially If There Is An Associated Flexion Contracture), Pie Crust Superficial MCL (Favor Use Of 18 Gauge Needle), Complete Superficial MCL Release / Pes Anserinus, Destabilizes Medial Flexion Gap / Consider A Constrained Prosthesis, Differential release: performed with two components of superficial MCL, posterior oblique portion is tight in extension (release if tight in extension), anterior portion is tight in flexion (release if tight in flexion), use a prosthesis that is sized to "fill up" the gap and make the stretched lateral ligaments taut, if a polyethylene bearing thickness of >15mm is required to gain appropriate lateral ligamentous tension, consider use of a constrained prosthesis to avoid excessive joint line elevation, Valgus Deformity(lateral side is concave/tight), lateral side is tight (concave), medial side stretched (convex), with pie crust or release off Gerdy's tubercle, release the anterior part of its insertion, for severe deformities release both the iliotibial band and the popliteus, some authors prefer to release this structure first if tight in both flexion and extension, other authors prefer to release the LCL last, if LCL & Popliteus require release, flexion gap stability is lost so consider constrained prosthesis, differential release: performed by differentially release the IT band and popliteus, fill up medial side until medial ligament complex is taut, In severe cases, if a polyethylene bearing thickness >15mm is required to obtain appropriate medial tension, consider a constained prosthesis to avoid excessive joint line elevation, Avoid internal rotation of the femoral component, internal rotation is common due to hypoplasia of the lateral femoral condyle, internal rotation of the femoral component may lead to patellofemoral maltracking and a coronally asymmetric flexion gap, if posterior referencing is used, verify femoral component rotation against the epicondylar and anteroposterior axes, concave side is posterior- needs to be released, 1) posterior femoral & posterior tibial osteophytes, All releases are performed with knee at 90 degrees of flexion, allows the popliteal artery to fall posteriorly to decrease risk of injury, You do not want to address a contracture by removing more tibia, will change the joint line and lead to patella alta, if patient presents with a peroneal palsy in recovery room then, watch for three months to see if function returns, if function does not return, consider nerve conduction studies or operative exploration to access for damage, Coronal plane deformities >20 degrees cannot be corrected by intra-articular bone cuts and soft-tissue balancing alone and require an extra-articular osteotomy, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Mechanical Alignment. TKA Patellar Prosthesis Loosening is a complication following TKA that is more common with metal-backed patellar components. This will ensure that the tibial insert is stable throughout the arc of motion. TKA Approaches } Mark Karadsheh MD Experts 41 Bullets 128 Cards 3 Questions 7 Cases 2 Evidence 24 Video/Pods 49 Techniques 3 3.6 ( 62 ) 14 Images Introduction Surgical approach may be dictated by surgeon preference prior incisions degree of deformity patella baja patient obesity Incision planning if multiple incision, choose more lateral
, sharply dissect enough of the medial capsular sleeve off of the tibia to provide exposure of the joint, the amount of dissection is variable, depending on the particular knee, but a good rule of thumb is to dissect the tibia posteriorly to the mid-coronal plane
, dissection may need to be carried even more posteriorly to provide exposure, medial tibial osteophytes are often present, and removal of them will provide more release of the medial collateral ligament/capsular sleeve, medial laxity may already be present, so a conservative medial dissection is advisable to start, flex the knee to at least 90 degrees and evert the patella, the anterior horn of the lateral meniscus, (the medial meniscus is usually dissected with the medial capsular flap), a lateral retractor is then placed under the lateral meniscus near the mid-coronal plane, a medial retractor retracts the medial sleeve, posterior retractor (PCL or Hohmann style) is placed in front to the PCL to push the tibia anteriorly, identify correct femoral rotation judged by 3 landmarks, a line perpendicular to the long axis of the tibia, this is perhaps where surgeons have the greatest disagreement - the measured resection technique usually references from the epicondylar axis or the intercondylar sulcus while the gap balancing technique uses the axis perpendicular to the tibia when the knee is distracted at 90 degrees of flexion, the femoral rotation axis can be performed before or after the distal femoral cut is made, the entry point is in the midline just anterior to the intercondylar notch, use a starter reamer for identification of the femoral canal for placement of the distal femoral cutting jig, suction the canal to remove the marrow contents, place and secure the distal femoral cutting jig, place the appropriately sized cut block in the selected rotation and size (careful not to internally rotate the jig), utilize a jig anchored on the posterior condyles, resects an amount of bone equal to the implant thickness, this is done after the tibia is cut with the joint tensed at 90 degrees of flexion, the posterior bone cut is selected to produce the desired flexion gap (femur and tibia)
, The potential complications during bone cuts are cutting the MCL or, rarely, the popliteal artery, important in patients with a pre-operative flexion contracture, especially over 10 degrees, maximally flex the knee and expose the proximal tibia, place the cutting jig in the desired varus/valgus alignment and posterior slope, saw cut is made and the resected bone is removed, remove any remaining meniscus and posterior osteophytes
, the trial tibial base plate is sized and placed in the proper rotational position (medial 1/3 of patellar ligament), place the trial implants and test the joint for stability and balance in both flexion and extension, Knee should be able to fully extend (no flexion contraction), Components should not extrude in full flexion ("lift off sign" indicating too tight), perform soft tissue releases as needed to address any discrepancies, goal is reproduce the original patellar thickness (remnant cut patella + patellar component), expose the articular surface of the patella, remove marginal osteophytes, and cut the patella at the appropriate height, check patellar tracking within trochlea without manually guiding patella ("no-hands" technique), pulse lavage bone to prepare for cementing and dry as best as possible
, place tibial, femoral, and patellar components and trial poly liner, the joint capsule is closed with interrupted or running suture, closing the capsule at the proximal and distal patellar poles works well to line up the remaining capsular closure, subcutaneous tissue and skin closure per surgeon preference (generally vicryl suture for subcutaneous closure and staples or monocryl suture for skin closure), appropriately orders and interprets basic imaging studies, initiate physical therapy as soon as possible, immediate range of motion exercises to knee, outpatient physical therapy/rehabilitation. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. In a revision total knee arthroplasty, or in cases where there is more connective tissue involvement, Phase I and II should be progressed with more caution to ensure adequate healing. 1; Previous . 0. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. 0 % 0 % Evidence. Private Note. neutral mechanical axis should bisect the center of knee. start from the proximal aspect in a longitudinal manner curving medially around the patella, leave 3-5 mm of soft tissue on the patella to assist with arthrotomy closure later in the case, complete the arthrotomy by a straight distal cut along the medial border of the patellar ligament
, avoid any disruption of the tendon insertion on the tibial tubercle, the main danger of the approach is avulsion of the patellar ligament. Review Topic. 5.0 (1) ReconTKA Coronal Plane Balancing . One of the most important factors leading to revision of total knee arthroplasties (TKA) is malrotation of femoral and/or tibial component. At full extension, 30 degrees of flexion, and 90 degrees of flexion, the knee is found to be tight laterally . 0 % Topic. This will ensure that the tibial insert is stable throughout the arc of motion. 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, standard short-leg cast applied with mild equinus, windowed over posterior heel to allow for frequent skin checks, requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture, weekly cast changes are necessary due to high incidence of skin complications, high incidence of vascular insufficiency and diabetes in this population, ideal for poor soft tissue coverage or patients with peripheral vascular disease, Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place, additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments, calcaneal transfixin pin can be used to distract fracture, percutaneus tamps and elevators can be used to raise the articular surface, pins are cut flush with the skin and removed 8-10 weeks post-op, can be combined with distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, fracture opened and medial wall reduced going medial to lateral, reduction confirmed indirectly via fluoroscopy, tuberosity reduction is done under direct visualization, manual traction, Schanz pins, and minidistractors, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, minimally invasive incision that minimizes soft tissue dissesction, reduces wound complications associated with extensile lateral incision, allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial, provides distraction and aids with reduction, fibrous debris and fat removed from sinus tarsi, small elevator or lamina spreader placed under posterior facet fragment to aid in reduction, K-wires inserted for provisional fixation aimed towards the sustentaculum, two screw are placed lateral-to-medial to engage sustentaculum and support facet, one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op, manipulate the heel to increase the calcaneal varus deformity, manipulate the heel to correct the varus deformity with a valgus reduction, stabilize the reduction with percutaneous K-wires or open fixation as described above, arthroscopic-assisted reduction and internal fixation, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, loose bodies and cartilage fragments are removed with a shaver, Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, fracture fragment is mobilized and debrided, plantar flexion of foot aids with reduction, presence of gastrocnemius tightness may preclude reduction, Strayer procedure may be performed to aid in reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Orthobullets Team . Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 0. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. total knee arthroplasty. . Any increase in the Q angle will lead to increased lateral subluxation forces on the patella relative to the trochlear groove, which can lead to pain and mechanical symptoms, accelerated wear, and even dislocation. Nowadays, 2D-CT and 3D-CT can be distinguished in measuring rotation of the TKA components. Introduction Abnormal patellar tracking is the most common complication of TKA. stairs, level ground, rising from chair), gait (stiff legged gait, inability to fully extend during stance phase), skin changes, presence of effusion, warmth (infection vs. complex regional pain syndrome (CRPS)), Serial AP and lateral radiographs to provide timeline of TKA, Weight bearing radiographs can provide evaluation of any asymmetric wear, Standing leg length views to assess overall alignment, Femoral version study can aide in assessing component rotation when also compared to the femoral neck, Can also aide in assessing severity and location of bony defects, Can be positive for up to 2 years after primary TKA, can indicate loosening, infection, or stress fracture, Knee aspiration to rule out infection via cell count and culture, Unconstrained Posterior Cruciate Retaining, always have a PCL substituting implant available as it is difficult to evaluate the integrity of the PCL prior to surgery, Unconstrained Posterior Cruciate Substituting, large central post substitutes for MCL/LCL function, MCL attenuation or deficiency (controversial because load may lead to breaking of central post), Constrained Hinged with rotating platform, tibial component is allowed to do internal/external rotation within a yoke, reduces rotational forces that would otherwise be on prosthesis-bone interface, MCL attenuation or deficiency (deficiency of MCL is controversial because load may lead to breaking of central post), flexion gap laxity with component mismatch, resection of the knee for tumor or infection, relatively indicated for charcot arthropathy, extraction of components with minimal bone loss and destruction, when compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach shows no difference in outcomes, tibial side first by establishing tibial joint line, tibial joint line should be 1.5 to 2 cm above head of fibula (use xray of contralateral knee to determine exact distance), after tibia joint line established proceed with femoral side to match the tibia, keep patellar thickness >12mm to avoid fracture, Anderson Orthopaedic Research Institute (AORI) Classification, Minor bone defects with intact metaphyseal bone that do not compromise stability, Metaphyseal bone damage that involves 1 femoral condyle or tibial plateau, Metaphyseal bone damage that involves both femoral condyles or tibial plateaus, Massive bone loss comprising a large portion of condyle/plateau, and can involve the collateral ligaments/patellar tendon, Bulk allografts, custom implants, megaprosthesis, porous tantalum, metaphyseal sleeves, rotating hinge, Metaphyseal bone in TKR is often severely deficient due to, classification systems not used as commonly as revision THA, long stems to promote load sharing to the femoral and tibial diaphysis, usually done with a long intramedullary stem, can use in scenarios of excessive femoral bow, increases complexity of any future revision, cement is adequate for small defects, structurally better than allograft, efficient, simple, can be used as cutting guides, variety of shapes/sizes with custom shaping/contouring is possible, trials/specific instrumentation available, compatible with several different implant companies, satsifactory survivorship in mid-to-long term, long-term failure due to graft resorption, pain scores less favorable than primary TKR, activity related pain can be expected for 6 months, peroneal nerve subject to injury with correction of valgus and flexion deformity, upwards of 4-7%, double the risk of primary TKA, prior scars should be incorporated into skin incision whenever possible, bloody supply to anterior knee is medially based, so lateral skin edge is more hypoxic, extensor mechanism allograft using achilles tendon bone block, residual lag due to attenuation is common, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. At the time of . High Tibial Osteotomy (HTO) is a surgical procedure that is performed to correct angular deformities of the knee to prevent development or progression of unicompartmental osteoarthritis. Primary Chapala St. Santa Barbara, California 93101, US Get directions Employees at Orthobullets Ashley J. Bassett, M.D. Step 3. determine the femoral resection angle. For decades, astable knee with a neutrally aligned lower limbhas beenone ofthe primary goals of Total Knee Arthroplasty(TKA) because it was supposedto be important for successful clin-ical outcomes and implant survivorship [1]. Measured resection is one technique commonly used by surgeons during TKA to attain correct alignment and soft tissue tension, and ideally deliver a pain-free knee that allows patients a return to daily activities [11]. Bullets. a deeper congruous joint (deeper cut PE) without rollback. Therefore, the aim offor TKA is not to restore the Corresponding author. Goal is to obtain a gap that is equal in flexion and extension. Treatment depends on severity of symptoms, direction of instability and the type of TKA prosthesis present in the knee. High Tibial Osteotomy (HTO) is a surgical procedure that is performed to correct angular deformities of the knee to prevent development or progression of unicompartmental osteoarthritis. the most important variable in proper patellar tracking is preservation of a normal Q angle. Therefore vary angle of femoral rotation based on variances in femoral anatomy. tibial plate is a solid block of polyethylene as opposed to a metal tray with a poly insert. 2023 Lineage Medical, Inc. All rights reserved, avulsion injury of the bifurcate ligament, in-situ arthrodesis with preserved calcaneal height, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws. Lateralization of the patellar prosthesis will increase the Q angle and increase maltracking, Intraoperative lateral subluxation of the patella, if patella laterally subluxes intraoperatively during trialing, deflate tourniquet and recheck before performing a lateral release, patellofemoral arthritis as the main indication for TKA, excision of marginal osteophytes, reshaping of patella, inferior results with secondary resurfacing, trochlear design important: patellar friendly, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Treatment depends on etiology of failure, prior surgery and patient activity demands. - TKA Axial Alignment Flashcards (1) Cards 1 of 1. of images. - TKA Axial Alignment Cards 1 of 1. measure the tibiofemoral angle. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. It is critical to avoid techniques that lead to an, internal rotation of the femoral prosthesis, internal rotation of the tibial prosthesis, placing the patellar prosthesis lateral on the patella, Goal is to restore the joint line by inserting a prosthesis that is the same thickness as the bone and cartilage that was removed, this preserves appropriate ligament tension, if there are bone defects they must be addressed so the joint line is not jeopardized, never elevate joint line in a valgus knee until after balancing to obtain full extension, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Are you sure you want to trigger topic in your Anconeus AI algorithm? possible pain, mechanical symptoms, accelerated wear, and even dislocation. The following chart shows different conditions found with the trials in place and the treatment strategy for each condition. Introduction Definition both medial and lateral ligaments may be stretched or contracted with time it is essential to balance these ligament in both the coronal and sagital plane to obtain an optimum outcome Pathophysiology concave side tight ligaments that need release convex side stretched ligaments that need tightening 0 % 0. 0. TKA Patellofemoral Alignment TKA in Patella Baja (Prior HTO) TKA Postoperative Care . The goal of TKA alignment is to restore the normal mechanical axis. Treatment depends on severity of symptoms, direction of instability and . Are you sure you want to trigger topic in your Anconeus AI algorithm? 124 plays. Questions. multiplanar radiographs of the knee, preferably weight bearing, 3-foot standing films for leg alignment (optional), describe steps of the procedure to the attending prior to the case, describe potential complications and steps to avoid them, knowledge of the particular implant system and instrumentation
, bump under the operative hip to minimize hip external rotation if needed (goal is to have patella facing straight up), leg holder can be used to hold the knee at 90 degrees or more of flexion during certain parts of the procedure, hip tourniquet should be placed as proximal as possible to allow adequate room for prepping and draping (ideally placed in hip crease), identify tibial tubercle, patella, and patellar ligament, draw a straight midline incision starting several centimeters (generally two finger breadths) proximal to the proximal pole of the patella and continuing just distal to the tibial tubercle, carry the skin incision straight down to the deep fascia which marks the extensor mechanism (quad tendon, patella, and patellar ligament), elevate skin flaps just deep to the fascia, the perforating arteries which supply the skin run just superficial to the deep fascia. 10/18/2019. this may leave a portion of the posteromedial tibia uncovered and some overhang of the prosthesis over the tibia on the posterolateral tibia. Are you sure you want to trigger topic in your Anconeus AI algorithm? Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. identify the medial aspect of the patellar ligament, medial aspect of the patella and the quad tendon lateral to the vastus medialis oblique (VMO).
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