Updated: 10/4/2016

Revision TKA

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Cases
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Techniques
3

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtain focused history and performs focused exam

  • check range of motion
  • check neurovascular status
  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Interprets basic imaging studies

  • AP
  • lateral
  • tunnel view

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures/staples
  • check radiograph
  • continue physical therapy
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • check radiograph
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI, CT , nuclear medicine imaging and advanced radiographs views

2

Appropriately recomends surgical intervention

3

Modifies and adjusts post-operative treatment plan as needed

C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check ROM of the knee
  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment

2

Screen medical studies to identify and contraindications for surgery

  • labs
  • ESR and CRP
  • bone scan

3

Order basic imaging studies

  • triplanar radiographs of the knee

4

Perform operative consent

  • describe complications of surgery including
  • infections
  • dislocations
  • thromboembolic dz
  • peri-prosthetic fracture
  • neurovascular compromise
  • malalignment
  • patellar maltracking

Operative Techniques

E

Preoperative Plan

1

Radiographic templating

  • template implant sizes

2

Execute surgical walkthrough

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

Room Preparation

1

Surgical instrumentation

  • knowledge of the particular implant system and instruments

2

Room setup and equipment

  • required operative table
  • leg holder (optional)

3

Patient positioning

  • supine position
  • use a bump under the operative hip to minimize hip external rotation.
  • A foot holder is used to hold the knee at 90 degrees or more of flexion for parts of the case.
  • A tourniquet is placed, but must be proximal to allow adequate room for prepping and draping.
G

Superficial Dissection

1

Identify previous incision and anatomy

  • identify tibial tubercle, patella, and patellar ligament.
  • extend the midline incision more proximal to allow adequate access

2

Expose the extensor mechanism

  • expose the entire extensor mechanism (quad tendon, patella, and patellar ligament.)

3

Create Skin Flaps

  • elevate skin flaps just deep the the fascia
  • the perforating arteries which supply the skin run just superficial to the deep fascia
H

Arthrotomy and Deep Exposure

1

Identify medial aspect of patellar tendon and quadriceps tendon

  • identify the medial aspect of the patellar ligament, medial aspect of the patella and the quad tendon lateral to the vastus medialis oblique (VMO).

2

Perform an extended arthrotomy

  • start from the proximal aspect in a longitudinal manner curving medially around the patella,
  • leave 3-5 mm of soft tissue on the patella
  • complete the arthrotomy by a straight distal cut along the medial border of the patellar ligament.
  • extended exposure is needed to visualize the medial and lateral femoral gutters
  • avoid any disruption of the tendon insertion on the tibial tubercle
  • the main danger of the approach is avulsion of the patellar ligament.

3

Clear the medial and lateral femoral gutters

  • clear and excise any excessive synovium that is overlying the distal femur in the suprapatellar pouch
  • remove any fibrotic fat pad that is present

4

Perform quadriceps snip

  • incise the quadriceps tendon
  • incise in a lateral oblique fashion from distal to proximal at a 45 degree angle
  • split the vastus lateralis muscle fibers
  • this will increase lateral patellar subluxation,knee flexion and exposure of the lateral compartment of the knee
  • quadriceps snip should exit the quadriceps tendon distal to the musculotendinous junction of the rectus femoris

5

Flex knee, and evert patella

  • flex the knee to at least 90 degrees and evert the patella

6

Place retractors

  • 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 Homan style) is placed in front to the PCL to push the tibia anteriorly
I

Component Removal

1

Remove polyethylene

  • place an osteotome at the interface of the polyethylene and the tray
  • use the osteotome to lever the tray out
  • if a pin is present posteriorly, use a saw to divide the post to expose the metal pin
  • remove the pin with a rongeur

2

Remove tibial component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • externally rotate the tibia to expose the posterior aspect of the tibias component
  • create a clear path for component removal
  • the posterolateral aspect of the tibial component must clear the posterolateral femoral condyle
  • hyperflexion is needed to achieve this
  • disimpact the tray with a punch
  • if does not separate easily then stack osteotomes
  • avoid levering the bone to prevent bone loss
  • remove any remaining cement with rongeurs if needed

3

Remove femoral component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • use osteotomes to deepen disruption of the interface
  • disrupt the interface from medial and lateral sides
  • don`t try to traverse the entire interface from one side
  • disrupt the posterior condylar interface with a curved or angled osteotoe
  • remove the implant by hand or with a punch after it has been dislodged
  • remove any remaining cement with rongeurs if needed

4

Remove patellar component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • burr out the pegs
J

Create Tibial Platform

1

Size the tibial component

  • maximize coverage of the upper end of the tibia

2

Place the tibial component

  • place the component in slight external rotation
  • align the center of the component with the junction of the medial and middle third of the tibial tubercle
K

Femoral Trial and Augments

1

Trial the femoral component with long stem

  • this determines the varus aligment
  • place a posterolateral augment
  • this is to ensure the appropriate external rotation of the revision component
L

Trialing of Implants

1

Trial the knee with varying thickness of polyethylene

2

Balance extension gap

  • balance extension gap in extension.

3

Balance flexion gap

4

Check varus valgus balance.

  • perform soft issue release
  • perform appropriate releases (medial, lateral, AP )

5

Confirm implant size and have team prepare cement.

6

Place the cement

  • pulse lavage bone to prepare for cementing.
  • place cement on tibia and femur.

7

Place final implants

  • place tibial, femoral, and patellar components and trial poly liner

8

Confirm final flexion, extension, varus, valgus stability

  • treat any intraoperative complications
N

Wound Closure

1

Irrigate and obtain hemostasis

2

Place drain (optional)

3

Repair the quadriceps tendon

  • repair the tendon in a side to side fashion

4

Closure joint capsule with running suture

  • 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.

5

Perform superficial closure

  • use interrupted 3-0 vicryl for subcutaneous tissue
  • run subcutaneous monocryl sutures
  • to approximate the skin edges to lessen tension on the skin closure.
  • apply staples
  • reinforces closure for early rehabilitation

6

Dressing is applied

  • add xeroform over staples
  • apply soft dressing

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT Prophylaxis
  • appropriately orders and interprets basic imaging studies
  • obtain radiographs of the knee in postop
  • inpatient pt
  • initiate physical therapy POD 1
  • weight bear as tolerated
  • immediate range of motion exercises to knee

2

Appropriate medical management and medical consultation

3

Discharges patient appropriately

  • prescribe outpatient physical therapy
  • pain meds
  • DVT prophylaxis
  • schedule follow-up appointment in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

  • treats
  • infections
  • dislocations
  • neurovascular compromise
 

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