Frank R. Ebert, MD Union Memorial Hospital Baltimore, Maryland
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Transcript of Frank R. Ebert, MD Union Memorial Hospital Baltimore, Maryland
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Frank R. Ebert, MDFrank R. Ebert, MDUnion Memorial HospitalUnion Memorial Hospital
Baltimore, MarylandBaltimore, Maryland
TOTAL KNEE TOTAL KNEE
ARTHROPLASTYARTHROPLASTY
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Total Knee ArthroplastyTotal Knee Arthroplasty
GoalGoal—Restore mechanical Restore mechanical
alignmentalignment—Restore joint lineRestore joint line
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Normal Knee AnatomyNormal Knee Anatomy
Position in single leg stancePosition in single leg stance Mechanical axis valgus 3ºMechanical axis valgus 3º Femoral shaft axis valgus 6ºFemoral shaft axis valgus 6º Proximal tibia varus 3ºProximal tibia varus 3º
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic EvaluationRadiographic Evaluation—Standing full length – APStanding full length – AP—Standing APStanding AP—Extension/Flexion lateralsExtension/Flexion laterals—Tunnel viewTunnel view—Sunrise viewSunrise view
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic EvaluationRadiographic Evaluation
Weight Bearing X-raysWeight Bearing X-rays—Extent of joint space Extent of joint space
narrowingnarrowing—Ligament stretch outLigament stretch out—Subluxation of femus on tibiaSubluxation of femus on tibia
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic AnalysisRadiographic AnalysisAnatomic Axis – FemurAnatomic Axis – Femur
—Line that bisects the Line that bisects the medullary canal of the femurmedullary canal of the femur
—Determines the entry point of Determines the entry point of the femoral medullary guide the femoral medullary guide rodrod
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic AnalysisRadiographic Analysis
Mechanical Axis – Femur (MAF)Mechanical Axis – Femur (MAF)—A line from center of femoral A line from center of femoral
head to center of distal femurhead to center of distal femur
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic AnalysisRadiographic Analysis
Anatomic Axis Tibia (AAT)Anatomic Axis Tibia (AAT)—A line that bisects the A line that bisects the
medullary canal of the tibiamedullary canal of the tibia—Determines the entry point of Determines the entry point of
the guide rodthe guide rod
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Total Knee ArthroplastyTotal Knee Arthroplasty
Radiographic EvaluationRadiographic Evaluation
Mechanical Axis – Tibia (MAT)Mechanical Axis – Tibia (MAT)—Line from center of proximal Line from center of proximal
tibia to center of ankletibia to center of ankle—Proximal tibia is cut Proximal tibia is cut
perpendicular to (MAT)perpendicular to (MAT)
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Issues with Surgical Issues with Surgical TechniquesTechniques
Traditional Joint Line OrientationTraditional Joint Line Orientation Tibial cut perpendicular to the Tibial cut perpendicular to the
MATMAT Femoral shaft at a valgus angle Femoral shaft at a valgus angle
5º to 8º valgus based off the ong 5º to 8º valgus based off the ong standing x-raystanding x-ray
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Surgical TechniqueSurgical Technique
Incision — straight longitudinal incisionIncision — straight longitudinal incisionTissue handling keyTissue handling keyAvoid flapsAvoid flapsPreserve soft tissue flap about the Preserve soft tissue flap about the patellapatella
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Surgical TechniqueSurgical Technique
Remember 7cm Remember 7cm Rule between Rule between incisionsincisions
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Issues with Surgical Issues with Surgical TechniquesTechniques Exposure optionsExposure options
—— Subvastus / midvastusSubvastus / midvastus Routine knee replacementsRoutine knee replacements
Quicker rehabQuicker rehab—— Medial parapatellar / midlineMedial parapatellar / midline
Difficult total knee — obese Difficult total knee — obese patientspatients
RevisionsRevisions
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MIS vs MINI TKAMIS vs MINI TKA
Capsulotomy Capsulotomy only?only?
Mid vastus?Mid vastus?
Sub vastus?Sub vastus?
MIS
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MIS vs MINI TKAMIS vs MINI TKA
Mid vastus?Mid vastus?
Sub vastus?Sub vastus?
Quad Quad sparing?sparing?
MIS
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Area of Variation
Type I-High Insertion
Type II-Pole Insertion
Type III-Low Insertion
Anatomic Variations of VMO Anatomic Variations of VMO InsertionInsertion
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Type I- High VMO Type I- High VMO InsertionInsertion
Retinacular Incision
Area of extended retinaculumMuscle
Insertion
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Type II-Pole Type II-Pole InsertionInsertion
Capsular or Retinacular Incision
Muscle Insertion
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Type III-Low VMO Type III-Low VMO InsertionInsertion
Area of Extended VMMuscle
Insertion
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Issues with Surgical Issues with Surgical TechniquesTechniques
AlignmentAlignment— Extramedullary vs IntramedullaryExtramedullary vs Intramedullary
Accuracy vs increased PE riskAccuracy vs increased PE riskFemur – IntramedullaryFemur – Intramedullary Overdrill opening and Overdrill opening and
insert insert slowly IM guideslowly IM guide Caution with bilateral Total Caution with bilateral Total
Knee ArthroplastyKnee ArthroplastyTibia – ExtramedullaryTibia – Extramedullary
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Issues with Surgical Issues with Surgical TechniquesTechniques
Femoral RotationFemoral Rotation— LandmarksLandmarks
Posterior femoral condylesPosterior femoral condyles
Epicondyles 5º external Epicondyles 5º external rotation to the posterior rotation to the posterior condylescondyles
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Issues with Surgical Issues with Surgical TechniquesTechniques
FemurFemur
— Measured resections: equal Measured resections: equal bone distally and posteriorlybone distally and posteriorly
— Tensioning devices & Tensioning devices & ligament releasesligament releases
— Do not alter bone resection Do not alter bone resection for ligament tightnessfor ligament tightness
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Issues with Surgical Issues with Surgical TechniquesTechniques
Tibial Component RotationTibial Component Rotation
— Transmalleolar axisTransmalleolar axis
— Posterior tibial plateauPosterior tibial plateau
— Tibial tubercle — lies lateralTibial tubercle — lies lateral
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MalalignmentMalalignment
Tibial ComponentTibial Component
Internally RotatedInternally Rotated
Tubercle Too LateralTubercle Too Lateral
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Management of DeformityManagement of Deformity
1.1. Release the tight side of the Release the tight side of the deformitydeformity
2.2. Tighten the loose sideTighten the loose side
3.3. Accept some residual soft tissue Accept some residual soft tissue imbalanceimbalance
4.4. CombinationCombination
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Surgical TechniquesSurgical Techniques
Varus KneeVarus Knee
1.1. Pes anserinusPes anserinus
2.2. Joint CapsuleJoint Capsule
3.3. Deep Tibial CollateralDeep Tibial Collateral
4.4. SemimembranosusSemimembranosus
5.5. Posterior Medial CapsulePosterior Medial Capsule
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Varus KneeVarus Knee
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Varus KneeVarus Knee
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Varus KneeVarus Knee
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Varus KneeVarus Knee
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Surgical TechniquesSurgical Techniques
Valgus KneeValgus Knee
1.1. Iliotibial BandIliotibial Band
2.2. Popliteus TendonPopliteus Tendon
3.3. Posterior Lateral CapsulePosterior Lateral Capsule
4.4. Lateral Head of GastrocLateral Head of Gastroc
5.5. Biceps FemorisBiceps Femoris
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Surgical TechniquesSurgical Techniques
Valgus KneeValgus Knee
— Peroneal nerve palsy – valgus / Peroneal nerve palsy – valgus / flexion deformityflexion deformity
— TreatmentTreatment Release dressings or flex the Release dressings or flex the
kneeknee
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Surgical Techniques:Surgical Techniques:
Flexion ContractureFlexion Contracture
1.1. Posterior capsulePosterior capsule
2.2. Gastroc originsGastroc origins
3.3. Posterior cruciatePosterior cruciate
4.4. Distal femurDistal femur
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Complex Combinations:Complex Combinations:
—— musculotendinous contracturemusculotendinous contracture
— — ligamentous contractureligamentous contracture
— — capsular contracturecapsular contracture
— — osteophytes of posterior condyleosteophytes of posterior condyle
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
BiomechanicsBiomechanics
—— increased quadriceps force for increased quadriceps force for knee stabilization during weight knee stabilization during weight bearingbearing
— — increased forces transmitted to the increased forces transmitted to the patellofemoral jointpatellofemoral joint
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
BiomechanicsBiomechanics
—— increased forces are placed on increased forces are placed on posterior tibial plateauposterior tibial plateau
— — femoral condyles sink into the femoral condyles sink into the tibial plateautibial plateau
— — contact between intercondylar contact between intercondylar notch and tibial eminence form a notch and tibial eminence form a boney blockboney block
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Associated deformityAssociated deformity
— — varus deformityvarus deformity 40% - > 5º range40% - > 5º range 5 to 30º varus5 to 30º varus
— — valgus deformityvalgus deformity 30% - > 5º range30% - > 5º range5 to 22º valgus5 to 22º valgus
Firestone et alFirestone et alCOOR ‘92COOR ‘92
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Incidence of Problem – Review of Incidence of Problem – Review of 700 TKA & Revision TKA’s700 TKA & Revision TKA’s
— — 60% before primary TKA60% before primary TKA
— — 21% before revision TKA21% before revision TKA
Tew Tew && Forster ForsterJBJSJBJS (B) 87 (B) 87
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Soft tissue releaseSoft tissue release
— — Varies with angular deformityVaries with angular deformity
Firestone et alFirestone et alCOOR ‘92COOR ‘92
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Surgical TreatmentSurgical Treatment Soft tissue releaseSoft tissue release Additional bone resectionAdditional bone resection CombinationCombination
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Postoperative CorrectionPostoperative Correction
— — the more severe the deformity must the more severe the deformity must consider the pros and cons of consider the pros and cons of additional bone resection and/or soft additional bone resection and/or soft tissue releasetissue release
Volz COOR ‘89Volz COOR ‘89
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Additional bone resection – prosAdditional bone resection – pros
— — joint line is positioned slightly more joint line is positioned slightly more proximalproximal
— — functionally lengthens the collaterals functionally lengthens the collaterals and posterior capsule forward and posterior capsule forward extensionextension
— — doesn’t compromise flexion stabilitydoesn’t compromise flexion stability
Firestone et alFirestone et alCOOR ‘92COOR ‘92
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Additional bone resection — cons Additional bone resection — cons (excessive)(excessive)
• Collateral ligament laxityCollateral ligament laxity
• Quadriceps redundancyQuadriceps redundancy
• HyperextensionHyperextension
• Bone quality can be compromisedBone quality can be compromisedMcPherson et al ‘94McPherson et al ‘94
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Additional Femoral Additional Femoral
ResectionResection
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Fixed Flexion Deformity in Fixed Flexion Deformity in TKATKA
Surgical Treatment for Deformity < 10º FFCSurgical Treatment for Deformity < 10º FFC Soft tissue release – only necessarySoft tissue release – only necessary
— — posterior capsuleposterior capsule
— — possibly PCLpossibly PCL
— — posterior osteophytesposterior osteophytes
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Surgical Treatment for Deformity Surgical Treatment for Deformity 10-20º FFC10-20º FFC
— — consider distal femoral resection consider distal femoral resection 3 to 5 mm3 to 5 mm
— — Posterior capsulePosterior capsule
— — PCL resection posterior PCL resection posterior osteophytesosteophytes
Firestone et al COOR ‘92Firestone et al COOR ‘92
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Fixed Flexion Deformity in Fixed Flexion Deformity in TKATKA
Surgical Treatment for Deformity 20-30º FFCSurgical Treatment for Deformity 20-30º FFC
— — distal femoral resection 3 to 5 mmdistal femoral resection 3 to 5 mm
— — posterior capsuleposterior capsule
— — PCL resectionPCL resection posterior osteophytesposterior osteophytes
Firestone et al COOR ‘92Firestone et al COOR ‘92
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Surgical Treatment for Deformity > 30º Surgical Treatment for Deformity > 30º FFCFFC
— — consider pre-op casting ≠consider pre-op casting ≠
— — distal femoral resection 5 mmdistal femoral resection 5 mm
— — proximal tibial resectionproximal tibial resection
— — PCL resectionPCL resection
— — posterior osteophytesposterior osteophytesFirestone et al COOR ‘92Firestone et al COOR ‘92
et al et al J of ArthroJ of Arthro ‘99 ‘99
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
Peroneal Nerve PalsyPeroneal Nerve Palsy
Vascular InsufficiencyVascular Insufficiency
Anterior Pressure UlcersAnterior Pressure Ulcers
Manipulation Manipulation
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Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA
No formula is exact for No formula is exact for treatment of the problemtreatment of the problem
Consider a balance between Consider a balance between soft tissue release vs bone soft tissue release vs bone resectionresection
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Issues with Surgical Issues with Surgical TechniquesTechniques
Stiff KneeStiff Knee Remove osteophytesRemove osteophytes Insall Turn DownInsall Turn Down Osteotomize the tibial tubercleOsteotomize the tibial tubercle Rectus snipRectus snip
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Issues with Surgical Issues with Surgical TechniquesTechniques
Stiff KneeStiff Knee
Epicondylar osteotomy for large Epicondylar osteotomy for large flexion / contractureflexion / contracture
Lateral release to evert the Lateral release to evert the patellapatella
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Issues with Surgical Issues with Surgical TechniquesTechniques
Patellar resurfacingPatellar resurfacing
— Recommended for all RA Recommended for all RA patientspatients
— Without resurfacing 4% to 6% Without resurfacing 4% to 6% incidence of anterior knee painincidence of anterior knee pain
— With resurfacing increased With resurfacing increased incidence of fractureincidence of fracture
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Issues with Surgical Issues with Surgical TechniquesTechniques
Patellar resurfacingPatellar resurfacing— Thickness shouldn’t exceed 25 Thickness shouldn’t exceed 25
mmmm— For every 1 mm thicker reduces For every 1 mm thicker reduces
flexion by 3ºflexion by 3º
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Issues with Surgical TechniquesIssues with Surgical Techniques
Patellar BajaPatellar Baja
• Proximal tibial osteotomyProximal tibial osteotomy
• Tibial tubercle shiftTibial tubercle shift
• Prior fracturePrior fracture
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Issues with Surgical TechniquesIssues with Surgical Techniques
Patellar BajaPatellar Baja
• Don’t raise joint lineDon’t raise joint line
• Consider lowering joint lineConsider lowering joint line
— — Distal femoral alignmentDistal femoral alignment
• Trim anterior tibial poly to avoid Trim anterior tibial poly to avoid impingement of patellaimpingement of patella
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Issues with Surgical TechniquesIssues with Surgical Techniques
Patellar Clunk SyndromePatellar Clunk Syndrome
— — Seen at 35º-40º knee flexionSeen at 35º-40º knee flexion
—— Treatment is arthroscopic or Treatment is arthroscopic or open resectionopen resection
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Issues with Surgical TechniquesIssues with Surgical Techniques Sagittal Plane BalancingSagittal Plane Balancing
SituationSituation Problem Problem SolutionSolution
Cut Tight Cut Tight Symmetrical Symmetrical –– cut morecut morein extension in extension gap gap proximal tibiaproximal tibiaCut Tight in flexionCut Tight in flexion
Cut Tight Cut Tight Asymmetrical Asymmetrical –– Release PCL;Release PCL;in extensionin extension gap gap Posterior capsule Posterior capsule Cut Loose Cut Loose Consider PCL Consider PCL in flexionin flexion substituting prosthesissubstituting prosthesis
–– Resection distal femurResection distal femur AVOID recurvatumAVOID recurvatum
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Issues with Surgical TechniquesIssues with Surgical Techniques Sagittal Plane BalancingSagittal Plane Balancing
SituationSituation Problem Problem SolutionSolution
Cut Good Cut Good Asymmetrical Asymmetrical –– Resection additional Resection additional in extension in extension gap gap tibia tibia
Cut Tight in flexionCut Tight in flexion –– May need to release May need to release PCLPCL
–– Ensure posterior Ensure posterior slope of tibiaslope of tibia
Cut Good Cut Good Asymmetrical Asymmetrical –– Need femoral Need femoral in extensionin extension gap gap augmentation augmentation
Cut LooseCut Loose – – Adjust to larger Adjust to larger in flexion in flexion femoral componentfemoral component
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Complications in Total Complications in Total Knee ArthroplastyKnee Arthroplasty
Periprosthetic FracturesPeriprosthetic FracturesInfected Total Knee Infected Total Knee
ArthroplastyArthroplasty
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SupracondylarSupracondylarFractures of the Fractures of the
FemurFemur
After Total Knee After Total Knee ArthroplastyArthroplasty
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
l Notching of the femoral cortexNotching of the femoral cortex
l OsteoporosisOsteoporosis
l Prolonged steroid useProlonged steroid use
l Preexisting neurologic Preexisting neurologic disorders disorders
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
OSTEOPOROSISOSTEOPOROSIS
Bogoch, et al, CORR 1986Bogoch, et al, CORR 1986
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
l Major trauma is not required to Major trauma is not required to produce fractures in many TKA produce fractures in many TKA patientspatients
l Alignment not correlated with Alignment not correlated with fracturefracture
l Weight not a significant factor Weight not a significant factor
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Fractures After TKAFractures After TKA
Neer Classification of Supracondylar Neer Classification of Supracondylar FracturesFracturesl Type IType I - - Minimal displacementMinimal displacementl Type IIA Type IIA -- Medial displacement of Medial displacement of
condylescondylesl Type IIB Type IIB -- Lateral displacement Lateral displacement
of condylesof condylesl Type III Type III -- Supracondylar and shaft Supracondylar and shaft
fracturesfractures
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
TREATMENTTREATMENT
Type 1 – NondisplacedType 1 – Nondisplaced
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
Type 1 fractures 83% Type 1 fractures 83% success ratesuccess rate
Chen, et al, 1994Chen, et al, 1994
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
Type 2 fractures Type 2 fractures 69% success rate69% success rate
Chen, et al, 1994Chen, et al, 1994
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
l CastingCasting
l Traction followed by rest Traction followed by rest
Non Operative MethodNon Operative Method
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
Type 2 fractures Type 2 fractures 67% success rate67% success rate
Chen, et al, 1994Chen, et al, 1994
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
l Plates / Screw fixationPlates / Screw fixationl Intramedullary rodsIntramedullary rodsl Rush pinsRush pinsl External fixationExternal fixationl Primary arthrodesisPrimary arthrodesisl Revision arthroplastyRevision arthroplasty
Operative MethodOperative Method
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
l Patients’ ability to tolerate tractionPatients’ ability to tolerate traction
l Ability of bone to hold screwsAbility of bone to hold screwsl Ability of the surgeonAbility of the surgeon
Type 2Type 2ConsiderationsConsiderations
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Intercondylar Distances of Commonly Used Femoral ProsthesesIntercondylar Distances of Commonly Used Femoral Prostheses
Biomet,Biomet, (Warsaw, IN)(Warsaw, IN) AGCAGC 1818 UniversalUniversal 1818
DePuy,DePuy, (Warsaw, IN)(Warsaw, IN) AMKAMK 2020
Dow Corning Wright, Dow Corning Wright, (Arlington, TN)(Arlington, TN) Whitesides modularWhitesides modular 2020Howmedica, Howmedica, (Rutherford, NJ)(Rutherford, NJ) PCAPCA 18.518.5Intermedics, Intermedics, (Austin, TX)(Austin, TX) NaturalNatural 1414Johnson and Johnson, Johnson and Johnson, (New Brunswick, NJ)(New Brunswick, NJ) Press-fit condylarPress-fit condylar 2020
Insall-Burstein*Insall-Burstein* 1515 (posterior stabilized)(posterior stabilized)
Kirschner, Kirschner, (Timonium, MD)(Timonium, MD) PerformancePerformance 1414Zimmer, Zimmer, (Warsaw, IN)(Warsaw, IN) Insall-Burstein I*Insall-Burstein I* 1616
Insall-Burstein IIInsall-Burstein II 1515 (posterior stabilized* or(posterior stabilized* or constrained condylar†)constrained condylar†) Miller-Galante IMiller-Galante I Small / small + ‡Small / small + ‡ 1111 Regular / regular + Regular / regular + 12.512.5 Large / large + Large / large + 1515 Large + + Large + + 1818 Miller-Galante IIMiller-Galante II 1313
ManufacturerManufacturer ModelModelIntercondylar DistanceIntercondylar Distance(Smallest Size) ((Smallest Size) (mmmm))
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Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR
No one form of treatment No one form of treatment gives uniformly good gives uniformly good
resultsresults
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Infection in Total Knee Infection in Total Knee ArthroplastyArthroplasty
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Complications in ArthroplastyComplications in Arthroplasty
Infection – Risk FactorsInfection – Risk Factors
l Skin ulcerations / necrosisSkin ulcerations / necrosis
l Rheumatoid ArthritisRheumatoid Arthritis
l Previous hip/knee operationPrevious hip/knee operation
l Recurrent UTIRecurrent UTI
l Oral corticosteroidsOral corticosteroids
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Complications in ArthroplastyComplications in Arthroplasty
Infection – Risk FactorsInfection – Risk Factors
l Chronic renal insufficiencyChronic renal insufficiency
l Diabetes Diabetes
l Neoplasm requiring chemoNeoplasm requiring chemo
l Tooth extractionTooth extraction
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Complications in ArthroplastyComplications in Arthroplasty
Infection – Clinical CourseInfection – Clinical Course
l Pain #1Pain #1
l SwellingSwelling
l FeverFever
l Wound breakdown drainageWound breakdown drainage
Windsor et alWindsor et alJBJSJBJS; 1990; 1990
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Early < 3 monthsEarly < 3 months
Lab ValueLab Value
Mayo Series Mayo Series Mean 7,500Mean 7,500
l Differential Differential 67 PMN’s67 PMN’s
l Sed rateSed rate 71 mm/hr71 mm/hr
l ArthrocentesisArthrocentesis
Infections About TKRInfections About TKR
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Late > 3 monthsLate > 3 months
Symptoms: 52 patientsSymptoms: 52 patients
PainPain 96%96% swellingswelling 77%77% DebrideDebride 27%27% Active drainageActive drainage 27%27% Sed rate 63 mm/hrSed rate 63 mm/hr WBC - 8300WBC - 8300
Windsor et alWindsor et alJBJSJBJS; 1990; 1990
Infections About TKRInfections About TKR
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Complications in ArthroplastyComplications in Arthroplasty
Infection – Surgical TechniquesInfection – Surgical Techniques
l Avoid skin bridgesAvoid skin bridges
l Avoid creation of skin flapsAvoid creation of skin flaps
l HemostasisHemostasis
l Prolonged operating timeProlonged operating time
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Complications in ArthroplastyComplications in Arthroplasty
Infection – Work-UpInfection – Work-Up
l Wound HistoryWound History
l Physical ExamPhysical Exam
l Serial RadiographsSerial Radiographs
l Lab/sed rate/CRPLab/sed rate/CRP
l Bone scan / Indium scanBone scan / Indium scan
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Complications in ArthroplastyComplications in Arthroplasty
InfectionInfection
ArthrocentesisArthrocentesisl Cell countCell countl Diff > 25,000 pmnDiff > 25,000 pmnl Protein Protein – – highhighl Glucose Glucose – – low low
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Complications in ArthroplastyComplications in Arthroplasty
InfectionInfection
l Host ResponseHost Response
GlycocalyxGlycocalyx
GristinaGristinaJBJS;JBJS; 1983 1983
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Micro OrganismsMicro Organisms
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Organisms Isolated from 71 Patients Organisms Isolated from 71 Patients With Infected Knee ReplacementWith Infected Knee Replacement
StaphylococcusStaphylococcus 6464
S. aureusS. aureus, penicillin sensitive , penicillin sensitive 1414 S. aureusS. aureus, penicillin resistant, penicillin resistant 2828 S. epidermisS. epidermis 2222
Gram negativeGram negative 1212 PseudomonasPseudomonas 77 Escherichia coliEscherichia coli 55
AnærobicAnærobic 66
OtherOther 1717
OrganismOrganism PercentPercent
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Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Options
l Antibiotic suppressionAntibiotic suppression
l Aggressive wound debridementAggressive wound debridement
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Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Optionsl Antibiotic suppressionAntibiotic suppression
Indicated in med compromisedIndicated in med compromised
Organism - gram+ strep staphepiOrganism - gram+ strep staphepi
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Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Options
l Resection arthroplastyResection arthroplasty
l 2 Stage re-implant2 Stage re-implant
l ArthrodesisArthrodesisl AmputationAmputation
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Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Optionsl Debridement with antibiotic Debridement with antibiotic
suppression therapysuppression therapy
Strep/staphepi -- bestStrep/staphepi -- bestAvoid repeated attemptsAvoid repeated attemptsFrozen tissue sectionFrozen tissue sectionSuction drainsSuction drains
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Complications in ArthroplastyComplications in Arthroplasty
Two-Stage ReimplantationTwo-Stage Reimplantation
l Most successful treatmentMost successful treatment
l Procedure of choiceProcedure of choice
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Complications in ArthroplastyComplications in Arthroplasty
Two-Stage Reimplantation ProcedureTwo-Stage Reimplantation Procedure
l Remove components, cement, Remove components, cement, II&&DD
l Fabricate and place spacerFabricate and place spacer
l 6 weeks of antibiotics6 weeks of antibiotics
l ReimplantationReimplantation
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Complications in ArthroplastyComplications in Arthroplasty
Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II
l create antibiotic spacer create antibiotic spacer impregnated with antibioticsimpregnated with antibiotics
l wound closurewound closure
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Complications in ArthroplastyComplications in Arthroplasty
Two-Stage Reimplantation Two-Stage Reimplantation
l Spacer Antibiotic RegimenSpacer Antibiotic Regimen
Tobramycin Tobramycin 2.4 gm/3.6 gm per2.4 gm/3.6 gm per 40 gms of PMMA40 gms of PMMA
VancomycinVancomycin > gm to 1 gm per> gm to 1 gm per gms of PMMAgms of PMMA
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Complications in ArthroplastyComplications in Arthroplasty
Intra-operative Frozen SectionIntra-operative Frozen Section
l < 5 PMN’s per HPF< 5 PMN’s per HPF – – no no infectioninfection
l > 10 PMN’s per HPF> 10 PMN’s per HPF –– infectioninfection
Mirra; Mirra; JBJSJBJS
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Complications in ArthroplastyComplications in Arthroplasty
Results — Gm positiveResults — Gm positive
Windsor et alWindsor et al 92 % 92 % JBJSJBJS 1990 1990
Insall et alInsall et al 97%97% JBJSJBJS 1983 1983
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Complications in ArthroplastyComplications in Arthroplasty
Resection ArthroplastyResection Arthroplasty
l Removal all componentsRemoval all components
l Remove all cementRemove all cement
l Effective in medically Effective in medically compromised patientcompromised patient
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Complications in ArthroplastyComplications in Arthroplasty
Arthrodesis IndicationsArthrodesis Indicationsl Extensor mechanism disruptionExtensor mechanism disruptionl Resistant bacteriaResistant bacterial Inadequate bonestockInadequate bonestockl Inadequate soft tissuesInadequate soft tissuesl Young patientYoung patient
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AdvantagesAdvantages
Definitive treatmentDefinitive treatment
Little chance of recurrenceLittle chance of recurrence
ArthrodesisArthrodesis
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DisadvantagesDisadvantages
Difficulty with transfers / small Difficulty with transfers / small spacesspaces
Increase energy requirementsIncrease energy requirements
ArthrodesisArthrodesis
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AlgorithmAlgorithm
TKATKAClinical SepsisClinical Sepsis
(GRAM + (GRAM + Organism) Organism)
< 3 wks< 3 wks > 3 wks> 3 wks
DebridementDebridementAntibiotics (6 wks)Antibiotics (6 wks)
2-Stage2-StageReplantReplant
Infections About TKRInfections About TKR
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AlgorithmAlgorithm
DebridementDebridementAntibioticsAntibiotics
SuccessSuccess
2-stage2-stage ReplantReplant ArthrodesisArthrodesis
Infections About TKRInfections About TKR
No No SuccessSuccess
2-stage Replant2-stage Replant
SuccessSuccessNo No
SuccessSuccess
ResectionResectionArthroplastyArthroplasty
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Thank YouThank You