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Surgical Technique for TKR

Learn the Rotating Hinge Total Knee Replacement- Nexgen Rotating Hinge (RH) Knee (Zimmer) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of this RH knee for medial collateral ligament deficiency with valgus deformity.

The NexGen RH Knee features a bone conserving modular hinge design that addresses key issues related to many conventional rotating hinge knee designs.  The hinge system utilizes the same stems, cones, patellas, and both Trabecular Metal™ and Precoat augments as the NexGen LCCK Constrained Knee System.  Bone cuts for the RH Knee system are similar to those of the LCCK system.  This feature allows bone conservation as well as easy intra-operative conversions from LCCK.

In many conventional rotating hinge knee designs, the hinge mechanism bears the majority of the compressive load until full extension is achieved. Designs that have the centre of rotation located posteriorly can cause “booking” of the joint, which may result in stress on the cement interfaces or accelerated polyethylene bearing wear in the hinge.

The NexGen RH Knee addresses these concerns as the RH Knee femoral component and articular surfaces are designed to maintain centralized contact throughout ROM (from -3° of hyperextension to 120°) resulting in 95% condylar loading through the tibial condyles.

This is the case of a 91 year old lady who had developed tricompartmental osteoarthritis and medial collateral ligament deficiency leading to valgus deformity. In such case a surgeon may choose to use an implant with less constraint such as a posterior stabilised design, however these can still develop instability and require revision to a hinged knee.

In this technique I will focus on the arthroplasty technique using the Nexgen RH Knee.

The important points to assess preoperatively include attention to instability symptoms in the history and evidence of valgus deformity clinically and radiographically in the coronal plane. Examination often reveals frank medial collateral ligament deficiency and therefore in this situation the surgeon should have a low threshold for proceeding to full constraint with a rotating hinge design.

OrthOracle readers will also find the following techniques of interest:

Revision total Knee Replacement- Legion Rotating Hinge Knee ( Smith and Nephew)

Revision total Knee Replacement: Legion CCK (Smith and Nephew)

Total Knee replacement: Mako Triathlon robotic assisted cruciate retaining TKR (STRYKER)

Total Knee replacement: MAKO robotic triathlon cruciate substituting knee replacement

Total knee replacement Genesis 2 (PS) with bi-convex patella (Smith and Nephew)

Total knee replacement: Vanguard XP cruciate retaining (Zimmer-Biomet)

Total knee replacement-Triathlon (Stryker) posterior stabilised knee.

Total knee replacement (posterior stabilised): Visionaire Genesis II (Smith and Nephew)

Total Knee Replacement: De Puy Attune implant

Total Knee Replacement: Vanguard cruciate retaining knee replacement(Zimmer-Biomet)

Total Knee replacement: Vanguard 360 knee replacement (Zimmer-Biomet)

Read more »

This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

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 - 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