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 must test balancing in both flexion and extension Kinematic alignment 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 Varus Deformity Anatomy medial side is tight (concave), lateral side stretched (convex) Goals create precise bone cuts release the tight medial ligaments tighten the lax lateral ligaments balance flexion and extension gaps by adjustment of polyethylene bearing thicknesss Steps of medial release Step 1 Deep MCL Release To Mid-Coronal Plane Of Tibia Step 2 Medial Osteophyte Removal Step 3 Release Posteromedial Corner (Posterior Oblique Ligament) Step 4 Medial Tibial Reduction Ostectomy Step 5: Consider PCL Release/Substitution If Imbalance Persists At This Point (If Substitution Not Initially Chosen) Step 6 Release Semimembranosis (Especially If There Is An Associated Flexion Contracture) Step 7 Pie Crust Superficial MCL (Favor Use Of 18 Gauge Needle) Step 8 Complete Superficial MCL Release / Pes Anserinus Rarely Required Even In Severe Cases 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) Lateral tightening 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) Anatomy lateral side is tight (concave), medial side stretched (convex) Goals create precise bone cuts release the tight lateral ligaments tighten the lax medial ligaments balance flexion and extension gaps by adjustment of polyethylene bearing thicknesss Lateral release in order Step 1 osteophytes Step 2 posterolateral capsule Step 3 iliotibial band if tight in extension with pie crust or release off Gerdy's tubercle Step 4 popliteus if tight in flexion (release if tight in flexion) release the anterior part of its insertion for severe deformities release both the iliotibial band and the popliteus Step 5 LCL 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 Medial tightening 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 Flexion / Contracture Deformity Anatomy concave side is posterior- needs to be released Posterior release order 1) posterior femoral & posterior tibial osteophytes 2) posterior capsule 3) additional resection of distal femur 4) gastronemius muscles (medial and lateral) 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 Complications Peroneal nerve palsy correction of valgus and flexion contracture deformity has highest risk of peroneal nerve palsy if patient presents with a peroneal palsy in recovery room then then take off dressing and flex the knee 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Parapatellar Approach Derek T. Bernstein Stephen Incavo Recon - High Tibial Osteotomy Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek T. Bernstein Stephen Incavo Recon - TKA Axial Alignment Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall William Gallivan Recon - TKA Axial Alignment
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.58) A 66-year-old patient is planning to undergo a right total knee arthroplasty. Figure A demonstrates the preoperative radiograph. Placing the components in a kinematic alignment (compared to neutral mechanical alignment) would result in which of the following? QID: 212954 FIGURES: A Type & Select Correct Answer 1 Increased aseptic loosening 17% (499/2917) 2 Varus tibial cuts and valgus femoral cuts 66% (1924/2917) 3 Lower rates of patient satisfaction 6% (163/2917) 4 Decreased ROM 1% (32/2917) 5 Increased reoperation rate 10% (280/2917) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16HK.20) A 75-year-old female presents with chronic severe and progressively worsening right knee pain. Her symptoms have been present for nearly a decade, and she has failed an appropriate course of conservative management but remains persistently symptomatic. Radiographs are shown in Figures A through C. The patient finally elects to have surgery and receives a posterior-stabilized (PS) total knee arthroplasty (TKA). The surgeon prefers an intramedullary femoral guide, posterior referencing, and an intra-medullary tibial guide. The surgeon should pay special attention to which of the following due to the nature of the deformity and preferred surgical technique? QID: 211328 FIGURES: A B C Type & Select Correct Answer 1 Angulation of the femoral component 12% (233/1868) 2 Exposure of the patella and posterolateral corner 4% (67/1868) 3 Flexion of the femoral component 3% (64/1868) 4 Rotation of the femoral component 72% (1352/1868) 5 Rotation of the tibial component 7% (139/1868) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.210) Performing an isolated release of the popliteus tendon during a total knee arthroplasty is most appropriate in which of the following scenarios? QID: 3303 Type & Select Correct Answer 1 Valgus deformity that is tight in extension 25% (1108/4377) 2 Varus deformity that is tight in extension 4% (192/4377) 3 Valgus deformity that is tight in flexion 60% (2629/4377) 4 Valgus deformity that is tight in both flexion and extension 7% (300/4377) 5 Varus deformity that is tight in flexion 3% (127/4377) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ05.117) A 65-year-old woman with painful knee arthritis and the deformity seen in Figure A, is scheduled to undergo a total knee arthroplasty. All the following are risk factors for a post-operative peroneal palsy EXCEPT: QID: 1003 FIGURES: A Type & Select Correct Answer 1 Pre-operative flexion contracture >10 degrees 1% (57/3930) 2 History of lumbar laminectomy 33% (1284/3930) 3 Female gender 37% (1435/3930) 4 Valgus deformity of >12 degrees 2% (91/3930) 5 Epidural anesthesia 27% (1044/3930) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (9) Podcasts (2) Login to View Community Videos Login to View Community Videos Total Knee Arthroplasty. A Distal Femoral Preparation. (A Touch Surgery Video - Apps TM) Kemal Gokkus Recon - TKA Coronal Plane Balancing 12/23/2022 98 views 4.5 (2) Login to View Community Videos Login to View Community Videos Surgical Techniques and Instrumentation in Total Knee Arthroplasty. Kemal Gokkus Recon - TKA Coronal Plane Balancing 8/6/2022 182 views 5.0 (1) 2021 California Orthopaedic Association Annual Meeting TKA: Tips & Tricks - Erik Hansen, MD Recon - TKA Coronal Plane Balancing A 6/25/2021 1289 views 4.7 (3) Recon⎜TKA Coronal Plane Balancing (ft. Dr. Doug Dennis) Team Orthobullets 4 Recon - TKA Coronal Plane Balancing Listen Now 23:55 min 10/18/2019 152 plays 5.0 (1) Recon⎪TKA Coronal Plane Balancing Orthobullets Team Recon - TKA Coronal Plane Balancing Listen Now 22:8 min 6/4/2020 745 plays 5.0 (1) See More See Less
2018 HSS Holiday Knee & Hip Course 52M Severe Knee Pain s/p Osteotomies (C101129) Steven B. Haas Recon - TKA Coronal Plane Balancing E 11/15/2018 99 1 0 2018 HSS Holiday Knee & Hip Course 62F with Progressive Bilateral Knee Pain (C101128) Steven B. Haas Recon - TKA Coronal Plane Balancing E 11/15/2018 116 10 2 Left knee osteoarthritis - valgus deformity of the ipsilateral tibia. (C2066) Ilias Alexandros Kosmidis Recon - TKA Coronal Plane Balancing E 11/18/2014 322 1 12 See More See Less