Steven B. Haas MD Chief, the Knee Service John N. Insall Chair, - - PowerPoint PPT Presentation

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Feb 16, 2023 101 likes •337 views

Steven B. Haas MD Chief, the Knee Service John N. Insall Chair, Knee Surgery Hospital for Special Surgery Professor Weill Cornell Medical College Disclosure Smith & Nephew Orthopaedics Designer (Royalty income), Consultant and

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Steven B. Haas MD Chief, the Knee Service John N. Insall Chair, Knee Surgery Hospital for Special Surgery Professor Weill Cornell Medical College

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Disclosure

– Smith & Nephew Orthopaedics

Designer (Royalty income), Consultant and Research

Support on Knee Products for

– OpLogix Technology

Ownership

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Incision

Fragile Skin
Extend Incision as

Needed!

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Several Approach to TKR

Midvastus Medial Parapatellar

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Balancing The Varus Knee

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Soft Tissue Balancing in the Varus Knee Principles

Goal

– Rectangular flexion & extension gaps – Symmetric medial & lateral soft tissue tension

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Balancing The Varus Knee

Items for consideration:

– Fixed versus flexible – Tightness:

Flexion
Extension or both !

– Osteophytes – Bone Loss – Subluxation and or effect upon rotation – Flexion Contracture

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Preoperative planning

Distal femur
Medial Bone Loss
Causes additional distal resection
Tibia
Often Minimal or no medial resection
Estimate resection thickness
Measure intraop
Plan releases

Mechanical Alignment

90° 90°

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

EXPOSURE-VARUS KNEE Dissection around medial tibia - Subperiosteal Release Deep MCL

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Osteophytes removal

Tibia - Externaly rotate to get posteriorly

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Postero-medial corner Osteophytes removal

Reduces tension on posterior capsule and posterior oblique fibers of deep medial collateral ligament which are two of the main medial joint stabilizers at 0° to 20° of flexion

Whiteside J. Arthroplasty 2003

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Medial femoral condyle

Osteophytes removal

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Soft tissue balancing

Spacer block in flexion Spacer block in extension

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Postero-medial corner

Release Semimembranosis

Reduces tension on posterior capsule and posterior oblique fibers of deep medial collateral ligament which are two of the main medial joint stabilizers at 0° to 20° of flexion

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Remove medial edge of tibia Elevate MCL distally

Medial Reduction Osteotomy Severe Varus Knee

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Shift-and-resect technique Medial Reduction Osteotomy

Uncovered area is resected vertically Tension on superficial MCL is reduced, bone gaps

pen a few mm

medially

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Severe Deformities

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Subperiosteal release MCL

Severe Varus Knee

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Alternative MCL release: needle puncturing

Progressive stretching of MCL (step by step) Both in extension and flexion (?)

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

MCL release: needle puncturing MCL release

in extension in flexion

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Summary

TKA is a “soft tissue” operation

– Every knee has its own identity

Classic Method of bone resection

– Re-establish mechanical axis – Appropriate soft tissue releases – Balance the flexion and extension gaps

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT