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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating

  • template implant size


Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical Instrumentation

  • endoprosthetic system of the distal femur


Room setup and Equipment

  • Standard radiolucent OR table
  • fluoroscopy (optional)


Patient Positioning

  • supine position with bump underneath the hip

Extensile Longitudinal Medial Approach


Mark the incision

  • make a longitudinal incision proximally along the sartious border and follow it distally towards the medial aspect of the tibial tubercle
  • Any previous biopsy tract should be kept in line with the incision and should be ellipsed


Identify the saphenous nerve

  • identify and protect the saphenous nerve


Create interval

  • open the interval between the sartorius and vastus medialis
  • expose the superficial femoral artery and vein along the saphenous nerve

Tumor Margins and Neurovascular Mobilization


Mobilize structures

  • dissect the vessels and the saphenous nerve from proximal to distal
  • reflect the structures posterior and medial with the sartorious


Tie off vessels

  • tie off all geniculate vessels with 2-0 or 3-0 silk ties as they course from the vessels towards the distal femur and tumor
  • be careful to not tie off the medial or lateral sural vessels that are found posteriorly and are the main blood supply to the respective gastrocnemius muscles
  • these vessels will be the base of the gastroc flap if needed
  • be careful at the canal of Hunter because these vessels are just deep to the adductor tendon


Dissect out the popliteal vessels

  • distal to the canal of Hunter, dissect the popliteal vessels and reflect posterior and medial
  • visualize the short head of the biceps proximal to distal joining the long head laterally


Identify and protect the sciatic nerve


Expose the tumor

  • reflect the quadriceps laterally off the femur by separating the junction between the adductors and the vastus medialis proximal and medial to the tumor


Ligate the appropriate vessels

  • ligate the terminal profunda artery and vein just deep the medial intermuscular septum


Dissect out neurovascular structures

  • dissect the superficial femoral vessels, saphenous nerve and popliteal vessels from the tumor throughout its length to below the joint line


Incise the medial gastrocneumius

  • be sure not to ligate the medial sural vessels


Expose the distal aspect of the tumor

  • with the femoral vessels dissected and reflected, reflect a portion of or entire quadriceps along with the patella and patellar tendon over the tumor
  • this leaves the vastus intermedialis as an oncologic margin


Open the joint capsule

  • cut the ACL, PCL, popliteus tendon and the collateral ligaments
  • cut the posterior capsule while the popliteal vessels are kept in direct view or under your finger to prevent injury


Reflect the quadriceps over the tumor

  • leave a cuff of muscle on top of the tumor as the tumor margin


Make cortical marks

  • before dislocating the knee, place marks proximally on the femur and tibia
  • mark the distance between the points
  • this distance should be the same after the prosthesis is implanted
  • the anterior cortex is marked on the proximal femur to help with rotary alignment during the femoral stem insertion
  • the linea aspera is also used to approximate rotary position


Dislocate the knee

  • cut the short head of the biceps and the rest of the posterior capsule

Femoral Resection


Cut the femur

  • cut the femur with a saw at the predetermined level
  • remove one centimeter more than the assembled length of the femur


Identify pathology

  • send a sample of proximal marrow to pathology for fresh frozen analysis and tumor margin


Prepare the femur

  • ream the femur to accept the largest stem possible
  • chamfer the cut end
  • clean the cut end with an irrigating brush

Tibia Cuts


Prepare the tibia

  • remove 7 mm of proximal tibia
  • osteotomize the tibia with an oscillating saw with a slightly posterior slope

Confirm Length, Rotation, And Trial Components


Place trial components

  • remove half of the undersurface of the patellar fat pad
  • remove and prepare the undersurface of the patella with a burr to receive the patellar component
  • resurfacing the patella is optional as some surgeons opt not to resurface for pediatric patients


Perform trial reduction

  • measure to make sure that the post-construction distance is the same as the pre-resection difference
  • passively range the knee to assess for rotation, length, and patellar traction
  • check the tension of the neurovascular structures

Final Implant Placement and Hinge Assembly


Cement in the appropriate order

  • cement the tibia component and the patella first


Insert the femoral component

  • insert the femoral component slowly


Confirm measurements

  • make a final measurement with the components in place

Wound Closure


Perform deep closure

  • close the joint capsular tissue to the remaining capsule around the proximal tibia
  • use 0-Vicryl for deep closure
  • suture the sartorius to the vastus medialis over a 10 mm flat drain with an 0-Vicryl suture


Perform superficial closure

  • place a 10 mm flat drain
  • use 2-0 vicryl for subcutaneous closure
  • use 3-0 monocryl or staples for skin


Place dressings

Postoperative Patient Care
Private Note

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