Total knee replacement Z. Rozkydal, L. Nachtnebl, T. Tomáš, P. Janík 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 th eknee Menisci Koleno menisky Stabilita kolena 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 TKA •Cemented • • •Hybrid • • •Uncemented • TKA rev Kopečná 3 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 Nečasová 2 Unicondylar replacement TKU Condylar – PCL retaining AP 5 AP 3 TKA – all poly type AP 11 All Poly 2 All Poly 1 TKA – all poly type Janda perop Condylar TKA – PCL sacrifising fronková5 fronková8 Condylar TKA with stems Sukop 11 TUP Sukop 11 TKA for tumors TUP syrový 5 TUP Syrový 3 TKA for tumors M+ patela u Sigmy M- PE patela Replacement of the patella Resection of the patella M- fem M- fem patel náhrada Femoropatelar replacement M- fem patel náhrada M+ Sigma modular Standard PE plateau PS variant of the plateau Rotating plateau - standard - PS variant TKA Sigma Johnson + Johnson company M+ patela u Sigmy M+ Sigma modular M+ Sigma modular PS variant – TKA Sigma Fixed plateau TKA Sigma Johnson + Johnson Rotating plateau - standard - PS varianta M+ Sigma modular Search – Evolution Aesculap M- Innex TKA Innex - Zimmer company M- mobilní patela LCS LCS TKA M M- mobilní patela LCS M- osa DK 2 M-osa DK Mechanical alignment Anatomical alignment M- dlouhý rtg formát M- zátěž X ray in standing postion 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 M- centrace pately 3 M- centrace pately 2 Patelar tracking Correct Incorrect Osa DK 9 Osa DK 10 Flection gap Extension gap External rotation of tibial component Femoral component •On anterior cortex • •Paraler with transepicondylar line • •External rotation 3° • • Osa DK 8 All Poly 1 Modern trends PC navigation Miniinvasive surgery Rotating plateau M- mobil plato 1 TKA Search Evolution - rotating plateau Implantation •Flection and extension gap Implantation • balancing of soft tissue PC navigation • CI CI navigation • Pointer •Centre of the hip •Centre of the ankle •Centre of the knee IMGP2621 Multiple points • Tibial resection Balancing of soft tissues IMGP2624 Resection of the femur • Implantation Alignment of the knee 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 • Aseptic loosening • Fronková 1 Janda perop fronková7 Fronková 2 Prevention of aseptic loosening •Correct technique •Quality of PE •Correct alignment •Soft tissue balancing •Pulsatile lavage •Regular follow - up TKA rev Seltner 3 Prevention of the infection Preop. examination Asepsis in operating theatre Perioperative antibiotics Correct technique Cement with antibiotics N7 N9 Klinikum Neustadt TKA rev Chylíková 10 TKA rev Chylíková 11 Septic losening TKA rev Chylíková 4 TKA rev Chylíková 3 Cement spacer TKA rev Chylíková 2 TKA rev Chylíková 1 Revision TKA Revision TKA mixa2 RTKA RS1 Mixa před 1 Mixa před 2 M., 62 y., primary TKR 1995 mixa2 Revision with PFC Σ Modular knee system, 30 (60) mm cemented tibial stem AP 3 Small resection Good metaphyseal bone Navrátilová rtg 2 Navrátilová rtg 1 F., 66 y., 1995 2000, aseptic loosening of UNI TKR Navrátilová rtg 3 Navrátilová rtg 4 Navrátilová perop Metalosis Navrátilová perop Navrátilová perop Contact of metal components Navrátilová perop Destruction of PE insert Navrátilová perop Navrátilová perop Navrátilová perop Synovectomy Good quality of trabecular bone of the tibia Navrátilová rtg 6 Navrátilová rtg 5 Revision surgery, PFC Σ Modular Knee System Short cemented tibial stem Good result TKA rev navrátilová 11 TKA rev navrátilová 10 2000 2006 RTKA lysonková 11 RTKA lysonková 12 No progression of raduiolucency on medial side of the tibia, good result RTKA lysonková 2 RTKA Lysonková 1 2006 Augmentace tibiální Augmentation of tibial bone loss, PFC Σ Modular Knee System Nečasová 6 Nečasová 5 TKA rev Vahala 4 TKA rev Vahala 3 M, 1942, primary TKR 1993 Fracture of the tibial tray, PFC Σ Modular Knee system, 1/2005 Cortical contact of the uncemented stem, TKA rev Vahala 6 TKA rev Vahala 5 2004 2005 TKA rev Vahala 2 TKA rev Vahala 1 M., 1942, PFC Σ Modular Knee system, Cortical contact of the uncemented stem, Less amount of bone cement in metaphyseal region, good result. Rev rev 2006 TKA rev Kohout 10 M, 1933, primary TKR 1996, R.A. Osteolysis on both sides Revision TKR with LCCK, Next Gen , Zimmer, PS type, 1/2005, patela baja, good position of tibial tray on bone, wide stems with cortical contact TKA rev Kohout 4 TKA rev Kohout 3 1/2005 TKA rev Kouhout 2 TKA rev kohout 1 Revision of TKR with LCCK, Next Gen , Zimmer patela baja, good position of tibial tray on bone, Wide stems with cortical contact, good result Novotný rev TKA1 Novotný rev 4/2006 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