- PreOp Planning:
-
radiographs and templating:
- Surgical Exposure:
-
Patient Positioning, Preping, Draping:
-
Anterior Longitudinal Midline Approach:
-
Medial and Lateral Capsular Exposure:
-
Patellar Eversion: patellar resurfacing: patellar resurfacing can be performed early in the exposure inorder to thin patella and facilitate eversion;
- Articular Exposure:
- evert the patella and flex the knee;
- use scissors to transect the patello-femoral ligament off the femur;
- synovectomy: is performed at this point (if appropriate):
- incise the tibial insertion of the ACL which allows the tibial to be subluxated forward to allow complete visualization of the plateau surfaces;
- rongeur is used to remove osteophytes in medial & lateral aspects of femoral condyles as well and intercondylar space;
- remove any osteophytes from intercondylar notch of femur, particularly if prosthesis is designed to retain PCL;
- trim any remaining osteophytes from the articular margin of tibia and patella;
- references:
-
Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis.
- 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 the patellar component should be medialized as much as possible (to minimize subluxation);
- if patellar subluxation is present after patellar resurfacing, then perform a
lateral retinacular release;
- Femoral Preparation:
-
IM Alignment Rod:
-
Distal Femoral Resection: (avoid
elevation of joint line):
-
Distal Femoral Sizing Guide:
- note that in some cases, the posterior fins of the distal femoral sizing guide will not sit down flush on the posterior femoral condyles,
and in this case, it is wise to procede on with the
proximal tibial cut;
-
Anterior, Posterior, & Chamfer Cuts:
-
Box Cut: (for
posterior stabilized prosthesis);
- 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/ the knife blade 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:
- at this point, the 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;
- note: many of the jigs used to create the 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;
- 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;
- Component Insertion: 
- Wound Closure and Complications:
-
0-PDS-plus Running Verticle Matress Suture
- this suture technique takes care of the subcutaneous and skin layers;
- it allows for a rapid closure, with optimally everted skin edges, free of asymmetric wound tension
- patients can be allowed to max out on the CPM without concerns of skin necrosis or breakdown;
-
off the shelf closed suction wound dressings;
- a cheap alternative to the wound vac concept involves use of gauze, fenestrated drain, and tegaderm;
- gauze is applied over the wound, followed by application of fenetrated drain, followed by more gauze;
- tegaderm is applied, airtight, and the tubing is applied to wall suction at about 175-200 mm Hg;
-
advantages: the gauze contracts down (paradoxically like a pressure dressing), and the skin edges are pressed together (because of the dressing
contraction), so that the dressing often remains free of blood and often does not have to be changed during the post op period;
- Post Operative Dressing:
- Postoperative Care:
- femoral nerve block:
- physical therapy following TKR:
- Impact of Psychological Distress on Pain and Function Following Knee Arthroplasty
- osteoporosis:
- The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After TKR.
- Effect of Oral Alendronate on Net Bone Ingrowth Into Canine Cementless Total Hips.
- prevention of infection:
- 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.
- Early Return to Surgery for Evacuation of a Postoperative Hematoma After Primary Total Knee Arthroplasty
- Fever: Fact and fiction.
- prevention of deep venous thrombosis:
- ileus:
- Postoperative Ileus After Total Joint Arthroplasty
- vascular ischemia:
- Embolization of traumatic pseudoaneurysms after total knee arthroplasty.
- Arterial and ischemic aspects of total knee arthroplasty.
- Acute arterial occlusion after total knee arthroplasty.
- Vascular Injuries After Total Joint Arthroplasty
- Acute Arterial Thrombosis After Bilateral Total Knee Arthroplasty
- Popliteal Pseudoaneurysm After Total Knee Arthroplasty Secondary to Intraoperative Arterial Injury With a Surgical Pin: Review of the Literature
- Endovascular Management of Pseudoaneurysms Following Lower Limb Orthopedic Surgery
- Acute arterial complications associated with total hip and knee arthroplasty
- Johnson and Johnson:
