Total knee replacement J. Emmer, Z. Rozkydal, L. Nachtnebl, T. Tomáš Knee has a complicated structure Articulating bones: Femur, tibia and patela rozkydal_koleno_back rozkydal_koleno_front rozkydal_koleno_iso Stability of the knee Koleno medial Medial side Stability of the knee KOleno lateral Lateral side Stability of the knee Cruciate ligaments Koleno ACL Koleno PCL Stability of the knee Menisci Koleno menisky Stability of the knee KOleno zepředu Muscles Movements in the knee joint Level Movement Sagital flexion/extension rolling glinding Transversal ext./ internal rotation Frontal adduction /abduction Koleno průřez Indications for TKA Painful condition + uncuccesful conservative treatment No other proceduces for mantaining of good function are available Severe dyscomfort FOTO 22 M- artróza kolena Indications Osteoarthrosis - primary - secondary - Aseptic necrosis of femoral condyle Revmatoid arthritis Psoriatic arthropaty Tumors Haemofilic arthropaty TKR cotraindications •Poor general condition, poor physical status (ASA IV) •Persistent infection •Severe comorbidity with poor prognosis •Poor vascular status of extremity •Neurogenic arthorpaty •Extreme obesity •Strong malcompliance • • • • TKA •Cemented • • •Hybrid • • •Uncemented • TKA rev Kopečná 3 TKR fixation options •Cemented –Most frequent –Good results –Usus of departement/clinic –Price – – • • TKR fixation options •Hybrid •Tibia cementless (most cases) •Better life expectancy • • TKR fixation options •Cementless –Good results –Young patients –Bone cement alergy –Price? • • Material Materials •Tibial component + articulation plateau - requirements –Biocompatibility –Wear resistance!! –Modulus of elasticity similar as bone –Osteointegration (cementless implants) –Antialergic implants (if metal allergy presented) –Future? Biofilm resistance – • • Materials •Tibial component –Metalback – titanium alloys –PE plateau •UHMWPE - Ultra high molecular weight polyethylen ) – golden standard, good elasticity modulus x wear resistence ratio • – • • Materials •Cementless implants requirements – bone adjacent surface –Biocompatibility –Osteoinductive material –Rapid bone ingrowth and reliable incorporation –Trabecular titan –Trabecular tantal – – • • TKA •Unicompartmental • • •Bicompartmental • • •Tricompartmental N Nik_0023 M TKA •Unicondylar •Condylar • - PCL retaining • - PCL sucrifising • •Condylar with stem • • •Hinge • •For tumors fronková8 M+ SVL koleno TKA rev Zárychta 5 UKR – Unicompartmental knee replacement •Medial (very most cases), lateral (rare) •Indications: –Medial OA –Intact all ligaments (ACL included) –Varus/valgus up to 10°; reponible –Extension deficit up to 5°, flexion over 120° –Asymtomatic FP compartment •Benefits: –Bigger ROM –Proprioception –Natural kinematics –TKR conversion possible • – • • • Nečasová 2 Unicondylar replacement TKU TKR – condylar replacement •Very most implantations •All poly/ metal backed tibial c. •ACL resection •Intact functional PCL, LCM, LCL • – • • • Condylar – PCL retaining AP 5 TKA – all poly type AP 11 All Poly 2 All Poly 1 Janda perop Condylar TKA – PCL sacrifising TKR Stems, augments, posterior stabilized (PS) •Poor bone quality •Bridging of bone defects •Posttraumatic OA •Revisions •PS if PCL deficient/missing •Intact functional LCM, LCL! • • – • • • fronková5 fronková8 Condylar TKA with stems Tu - TKR •Resection Tu/meta around knee joint • Onkological radicality first!! •Custom - made implants •Inferior outcome (compare TKR) •Higer complication ratio • • – • • • Sukop 11 TUP Sukop 11 TKA for tumors TUP syrový 5 TUP Syrový 3 TKA for tumors TKR – patelar replacement •Second stage surgery – if FP copmartment symtomatic after TKR (philosophy?) •If rotation of femoral component correct, no need in very most cases •If femoral component malposition – patellar maltracking • – • • • M+ patela u Sigmy M- PE patela Replacement of the patella M- fem M- fem patel náhrada Femoropatelar replacement M- fem patel náhrada Resection of the patella Preoperative examination •ASA •Infection focus exclusion (neg ESR, CRP), • stomatological examination •Attention: –Warfarin –NSAID –PAD –Vascular status – • • – • • • M- osa DK 2 M-osa DK Mechanical alignment Anatomical alignment M- dlouhý rtg formát M- zátěž X ray in standing position Operation technique •Standardized •Medial parapatellar approach x mid x subvastus •Partial Hoffa fat pad resection •Patella – eversion, denervation + cheilectomy x parc. resection x patellar replacement implantation •Distal femoral cut •Proximal tibial cut •Soft tissue balancing!! • • – • – • • • Operation technique •Flexion x extension gap •Femoral component rotation •Femoral resection •Probe component (soft tissue balance test) •Tibial preparation (correct rotation!) •Pulsed lavage •Original components + bony cement •Reliable suture! • • – • – • • • Operation technique • Tibia first • X •Femur first • X •Extension gap technique • • – • – • • • Related image M- osy tibie M- roviny resekce Resection levels S S- resekce tibie S-fem cílení S- resekce femoru 1 S- pulzní laváž S S S S S- in situ implantát S- sutura Principles • •Correct tension of soft tissues • •Correct alignment 5 -7° valgus • •Correct joint level Osa DK 3 Osa DK 9 Osa DK 10 Flection gap Extension gap External rotation of tibial component Implantation •Flection and extension gap Femoral component •On anterior cortex • •Paraler with transepicondylar line • •External rotation 3° • • Osa DK 8 All Poly 1 M- centrace pately 3 M- centrace pately 2 Patellar tracking Correct Incorrect Implantation • balancing of soft tissue Computer navigation •Optional, some hospital /countries obligatory •Mapping reference points and kinematics into SW •Special instrumentary •Surgeon is guided •Necesserry if intramedular instrumentary • impossible (trauma) • • – • – • • • CI navigation • Computer navigation • • •Proximal tibial cut planning • • • • • •Distal femoral cut planning • • – • – • • • Pointer •Centre of the hip •Centre of the ankle •Centre of the knee IMGP2621 Multiple points • Tibial resection Resection of the femur • Balancing of soft tissues IMGP2624 Alignment of the knee Physiotherapy 1.Isometric exercise, breathing, vessel gymnastic 2.Removal of drainage, start flexion and extension active 3.Walking on crutches, leg- touch down 4.Active flexion and extension of the knee passive splints- continous passive movements 5.Self independence on walking 6.Stairs 7.-8 day- discharge to physiotherapy unit 10 days - 2 weeks in physiotherapy unit Then exercise at home or ambulation units Full weigth bearing after 3 months Up to 3 months- spa resort admission for 4 weeks In special centres- fast track physiotherapy The goal- to get active flexion and extension 0-90 up to 15 days Complications - local •Perioperative: nerve lesions, vessel lesions, • bleeding • Postoperative: hematoma,wound problem, early • infection • •Late: PE wear, osteolysis, aseptic loosening • instability, limited joint movement • patellar pain • periprosthetic fracture, dislocation • infection • Complications – –Pulmonary embolism –Myocardila infarction –General decompensation –Development of delirium • • Aseptic loosening •Most frequent TKR revision reason •Macrophage-induced inflammatory response resulting in bone loss and implant loosening •PE particle inducted granuloma • • • fronková7 Fronková 2 TKA rev Vahala 3 TKA rev Seltner 3 Aseptic loosening - therapy •Revision, replantation –Revision implant, stems, augmens. Cement with ATB –Double ATB combination – higer infection risk • • • TKA rev Vahala 3 TKA rev Vahala 4 TKA rev Vahala 6 TKA rev Vahala 5 Revision TKA mixa2 RTKA RS1 RTKA femur1 RTKA tibie 2 M., 1927., primary TKR in 1997 Large defect of bone in the tibia TKA rev Seltner 9 TKA rev Seltner 8 Revision TKR ,PFC Σ Modular Knee System Bone cement in the tibia RTKA komponenty Sigma 2004 TKA rev Seltner 7 TKA rev Seltner 6 M., 1927., revision TKR ,PFC Σ Modular Knee System Bone cement in tibia, cortical contact of the stems RTKA seltner 2 RTKA seltner 1 2006 Aseptic loosening - prevention •Modern quality PE (minimal wear rate) •Correct surgery technique - ballancig •Reasonable régime after TKR •Follow up, early revision indication. • • • TKA rev Seltner 3 Complications •Periprosthetic infeciton (PJI) – 1-2% primo, 5-10% revision –Early – up to 2 weeks after surgery –Late hematogenic – –Diagnostic •General symptomas of infection •Local condition •Artrocentesis + aspiration - cultivation + PCR •Fistula with purulent secretion •Radiolucent periprosthehic lines around implant on X ray (chronic PJI) • • Periprosthetic infection (PJI) •Therapy –Up to 2 weeks from manifestation - DIAR (debridement, ATB, implant retention) –Uprard of 2 weeks – revision, debridement, replantation •One stage – dubious outcome •Two stage – cemented ATB spacer, after healing ínfection revision and new implant possible •ATB supression of chronic infection optional (old patients with no perspective to surgery) – •ATB therapy –Cultivation(punciton + aspiration, perioperativly samples, sonication of implant) –ATB i.v. 2 weeks minimum –6 weeks p.o. Periprosthetic infection (PJI) ATB spacer Rigid (stiff) Articulation TKA rev Chylíková 4 TKA rev Chylíková 3 Periprosthetic infection (PJI) •Revision, new TKR implantation • Periprostethic infection (PJI) •Recerurrence of infection – ultimum refugium –Fusion –Amputation (rarely) • Prevention of infection Preop. examination Asepsis in operating theatre Perioperative antibiotics Correct technique Cement with antibiotics N7 Periprosthetic fracture •Dist. femur x prox tibia x patella •Older patients, worse general condition •Osteoporosis, poor implant retention •High mortality and morbidity rate •High compliction rate •Demanding surgeries • experienced surgeon) • • • Periprosthetic femoral fracture; therapy •conservative – no/minimal displacement + implant retention; poor general condition •IM stem (implant retention + fr. above fem. component) •OS (LCP, condylar plate –implant rtention + fr. In the level of fem. component) •Femoral component replantation + stem (loosening of fem. component) • • • • Thank You for Your attention