Surgical Technique for TKR


 - Main Menu:
    - PreOp Planning
 
    - radiographs and templating

- Surgical Exposure:
    - Patient Positioning, Preping, Draping 
    - Anterior Longitudinal Midline Approach 
    - Deep Articular Exposure 
    - Patellar Eversion:


- Patella:
    -
patellar resurfacing
           - prior to patellar resurfacing, determine the propensity for the native patella to subluxate;
           - if subluxation is present (tibial component is properly rotated), then patellar component should be medialized as much as possible; 
           - if patellar subluxation is present after patellar resurfacing, then perform a lateral retinacular release
           - patellar resurfacing can be performed early in the exposure in order to thin patella and facilitate eversion;
    - non resurfaced patella considerations:
    - patella baja (avoidance);
           - Patella baja and total knee arthroplasty (TKA): etiology, diagnosis, and management
           - Patellar impingement against the tibial component after total knee arthroplasty



- Femoral Preparation:
    - IM Alignment Rod 
    - Distal Femoral Resection: (avoid elevation of joint line
    - Distal Femoral Sizing Guide: (rotational alignment)
          - apply tibial extramedullary cutting guide to help align the femoral sizing
                     guide (should be a rectangle);



    - Anterior, Posterior, & Chamfer Cuts:
    - Box Cut: (for posterior stabilized prosthesis);

           

          - references:
                - Cutting errors in preparation of femoral components in total knee arthroplasty.
                - Improved tibial cutting accuracy in knee arthroplasty.
                - Excursion of oscillating saw blades in total knee arthroplasty.


- Proximal Tibial Resection:
          - preparation and exposure for the proximal tibial cut 
          - extramedullary guides 
          - rotation of tibial component 
          - posterior slope of the tibial component:
          - depth of tibial cut   (note joint line position)
          - resect remnant menisci:
                 - it is important to sharply remove the remaining menisci, but beaware of the potential for vascular injury;
                 - popliteal artery lies behind the posterior horn of the lateral mensicus, and will be partially protected by the popliteus mucle;
                 - the popliteal vein lies directly posterior;
                 - menisci are removed by pulling them into the joint and transecting them w/ knife directed parallel to posterior tibial surface;

                                


- Trial Components:
    - Remove Posterior Osteophytes 
    - Sizing and Seating of the Tibial Tray 
          - rotation of tibial component 
          - bone grafts in TKR 
          - tibial stem
    - test ROM, knee stability, and patellar tracking;
    - it is wise to test patellar tracking before the patella is resurfaced;
          - if subluxation is present, then the patella can be medialized;
          - if subluxation is not present, then the patella can be placed in a central (or a slightly medialized) position;
                  - it is certainly possible to over-medialize the patellar component, which may cause the button to ride medially out of the notch;

- Tibial Stem Preparation:
    - tibial trial plate is used as a jig to prepare seating holes for the pegs or stemm on the undersurface of the actual tibial component;
    - be sure that rotation of tibial component is optimal;
    - some jigs used to create canal for the tibial stem, will slightly wobble, meaning that the stem could inadvertently placed in varus;
            - this is avoided by aiming the broaching devices towards the talus;

             


 - Cement Mixing: 
     - prior to cement mixing, be sure that:
            - all of the components are on the table and have been placed in their respective inserters; 
            - ref: Femoral Bone Plug in Total Knee Replacement
     - pulsatile lavage
            - that the transected bony surfaces have been irrigated w/ pulsatile lavage;
                   - this will remove the fatty contents of the medullary canal, and will help to prevent fat embolization; 
            - references:
                   - Pulsed lavage yields greater fixation strength in total knee arthroplasty
                   - Patellar component stability improves with pulsatile lavage in total knee arthroplasty.

- Component Insertion  / Poly Insertion / Final Soft Tissue Release

- Wound Closure  
       - rush medical center betadine protocol:
       - vancomycin powder, 1 gm, applied into knee cavity
       - local anesthesia:
               - Intraoperative Adductor Canal Block for Augmentation of Periarticular Injection in Total Knee Arthroplasty: A Cadaveric Study
               - Efficacy of Intra-articular Local Anesthetics in Total Knee Arthroplasty
               - local anesthetic administration: standford VA protocol:
               - local Analgesia Infiltration Techniques – Hip and Knee Arthroplasty
      
- post operative dressing:
       - reduction in bleeding:
              
- Postoperative Care:

    - prevention of deep venous thrombosis
    - evaluation of vascular injuries
    - femoral nerve block 
    - physical therapy following TKR
           - ref: Impact of Psychological Distress on Pain and Function Following Knee Arthroplasty
    - management of wound complications, hematoma, necrosis, and infection
    - medical complications:
           - management of postoperative fever: 
                  - references: 
                         - The Role of Blood Cultures in the Acute Evaluation of Postoperative Fever in Arthroplasty Patients
                         - Urinary-Bladder Management After Total Joint-Replacement Surgery
                         - Pyrexia following total knee replacement.  
                         - Febrile response after knee and hip arthroplasty
                         - Fever: Fact and fiction.
                         - Evaluation of Postoperative Fever and Leukocytosis in Patients After Total Hip and Knee Arthroplasty
                         - Don't Do Unnecessary Work-ups for Elevated WBC After Lower-Extremity Joint Arthroplasty 
           - ileus:
                  - ref: Postoperative Ileus After Total Joint Arthroplasty
           - adrenal failure/hemorrhage
                  - ref: Unilateral Adrenal Hemorrhage After Total Knee Arthroplasty



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 5, 2016 9:21 am