\\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TOTAL KNEE REPLACEMENT MUDR. JAN EMMER, I. ORTOPEDICKÁ KLINIKA FNUSA V BRNĚ \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Hinge synovial type joint(femur, tibie, patella) •Ligaments, static stabilizers: •MQF tendon, ligamentum patellae •Retinacula patellae •Lig. Collateralis tibiale et fibulare •Lig. Popliteum obliquum, lig. Popliteum arcuatum •Ligamena cruciata genus (anterieor et posterior) •Meniscus medialis et lateralis •Joint capsule • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Muscles- extenzors •MQF (n. femoralis) • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Muscles – flexors •M. biceps femoris (+ aditional hip extension; n. ischiadicus) •M. semitendinosus (+ aditional hip extension and adduction , I.R. knee joint; n ischadicus) •M. semimembranosus (+ aditional hip extension and adduction , I.R. knee joint; n ischadicus) •M. sartorius (+E.R. hip joint, aditional hip flexion; n. femoralis) •M. gracilis (+Hip addkuction, aditional hip flexion; n. obturatorius) •M. triceps surae (aditional knee flexion, postural muscle; n. tibialis) •M. popliteus (aditional knee flexion, tendon intraarticlulary!) • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png KNEE JOINT KINEMATICS • •S 0-0-140 (hyperextension fyziol. up to 10 st, passively bigger flection) •Motion: •1: Initial rotation („unlocking knee joint“) internal tibial rotation , initial 5° st felxion •2: Rolling motion (meniscofemoral joint) •3: Rollback (terminal flexion, femur on tibia moves dorzaly) •4: Terminal tibial external rotation \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR INDICATIONS •Painfull knee condition •Poor effect of conservative therapy •No salvage surgeries indicated •Life comfort deteriorated • • FOTO 22 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR INDICATIONS •OA primary •OA secundary •Psoriatic arthropathy •Aseptic femoral condyle necrosis (m. Ahlback) •Hemophilic arthropathy •Rheumatoid arthropathy •Tumors •Traumas • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR FIXATION OPTIONS •Cemented •Most frequent •Good results •Usus of departement/clinic •Price • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR FIXATION OPTIONS •Hybrid •Tibia cementless (most cases) •Better life expectancy • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR FIXATION OPTIONS •Cementless •Good results •Young patients •Bone cement alergy •Price? • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png KNEE REPLACEMENT RANGE •Unicompartmental •Bicompartmental •Tricompartmental • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR IMPLANT TYPES (STABILITY) •CR (cruciate retaining – PCL retaining) •UC (ultra congruent) – „deeper“ tibial plateau – higer stability •PS (posterieor stabilized – insuficient/missing PCL ) Component design takes over function of PCL •CCK (condylar constrained knee replacement) – if correct soft tissue ballancing impossible (varus over 15°, LCL lesion) •Hinged (Always if LCM insuficient!) Fully constrained design. Revisions, tumors, extreme pimary valgozity • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Femoral component - requirements •Biocompatibility •Wear resistance •Mechanical strenght •Osteointegration (cementless implants) •Antialergic implants (if metal allergy presented) •Future? Biofilm resistance • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Tibial component •Metalback – titanium alloys •PE plateau •UHMWPE - Ultra high molecular weight polyethylen ) – golden standard, good elasticity modulus x wear resistence ratio •HXLCPE- Highly cross-linked polyethylene – poor results so far (too rigid?) • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Cementless implants requirements – bone adjacent surface •Biocompatibility •Osteoinductive material •Rapid bone ingrowth and reliable incorporation • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Cementless implants requirements – bone adjacent surface •Trabecular titan •Trabecular tantal • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png DESIGN OF COMPONENTS •Aim – as much natural kinematics as possible •Medial pivot •Multi radius femoral komponent – higer flexion of TKR • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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: •Biger ROM •Proprioception •Natural kinematics •TKR conversion possible • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TKR – CONDYLAR REPLACEMENT •Very most implantations •All poly/ metal backed tibial c. •ACL resection •Intact functional PCL, LCM, LCL • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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! • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TU - TKR •Resection Tu/meta around knee joint including joint ends •Onkological radicality first!! •Custom - made implants •Inferior outcome (compare TKR) •Higer complication ratio • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PREOPERATIVE EXAMINATION •ASA •Infection focus exclusion (neg FW, CRP), stomatological examination incl. OPG •CAVE! •Warfarin •NOAK •NSAID •PAD •Vascular status • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PREOPERATIVE PLANNING •Long film X ray •Mechanical x anatomical axis •Ideal 6° valgus • • • • • • • M-osa DK M- osa DK 2 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png BASIC IMPLANTATION PHILOSOPHY •MA (mechanical alignement) •Respect mechanical axis •Does not respect individual status •Resection to gain 6°valgosity •Goal – physiological mechanical axis • • • • • • • M-osa DK \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png BASIC IMPLANTATION PHILOSOPHY •Kinematic alignment •Does not respect physiological mechanical axis •Respect individual knee situation •Goal – gain axis used to be before severe OA developed •„resurfacing“ • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png BASIC IMPLANTATION PHILOSOPHY •Planning • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png BASIC IMPLANTATION PHILOSOPHY • • • • • • • • • • Mechanical alingnment Kinematic alignment • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png OPERATION TECHNIC •Standardized •Medial parapatellar approach x mid x subvastus •Parc. Hoff fat pad resection •Patella – Eversion, denervation + cheilectomy x parc. resection x patellar replacement implantation •Distal femoral cut •Proximal tibial cut •Soft tissue balancing!! • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png OPERATION TECHNIC •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! • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png OPERATION TECHNIC • Tibia first • X •Femur first • X •Extension gap technique • • • • • • • • Related image \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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) • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPUTER NAVIGATION •Reference points mapping • • • • • •3D virtual model • • • • • • • • IMGP2621 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPUTER NAVIGATION •Proximal tibial cut planning • • • • • •Distal femoral cut planning • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC JOINT INFECTION (PJI) PREVENTION •Preop. Examination! •ATB perioperatively – Cefazolin i.v. 1 dose before + 3 doses post op. •Drainage EX in 24h •If urinary catheter present - ATB •Strict régime at op. theater •Wound care till healing •Lege artis diagnostic and therapy protocol of eventual PJI • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png POST OP. MANAGEMENT •ICU (post op ward) one day if no complication •Hospitalization at orotpedic ward for 5 days •Verticalization first post op. day •Complex rehabilitation protocol, rehabitalitation nurse obligatory •6. day – tranfer to rehabilitation ward •Spa – in CZ coverd by public health insurance in 3 post op. months •DVT prevention – standard 10 days (LMWH), if risk factor presented, 6 weeks (NOAK) •Trends: Shoretening inpation period (risc of nosocomial infection, economic aspects) • Fast track physiotherapy • Outpatient surgery? • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FOLLOW UP •Standardized •First check up by ortopedical surgeon in 6 weeks (X ray included) •Second in 3 months, then 6 month •Further each 2 years (X ray included) if no problem present •EDUCATION, EDUCATION, EDUCATION! •Activity, limitation and régime with TKR •PJI prevention •Urgent check – up if suspected PJI • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •Peri and early pos op. morbidity and mortality •Nervous and vascular injury •Blood loss •Perioperative fracture (femoral condyle) •Pulmonary embolism •IM •General decompensation •Development of delirium • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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) • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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. \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC INFECTION (PJI) TKA rev Chylíková 10 TKA rev Chylíková 11 Chronic PJI X ray \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC INFECTION (PJI) ATB spacer Rigid (stiff) Articulation TKA rev Chylíková 4 TKA rev Chylíková 3 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC INFECTION (PJI) •Revision, new TKR implantation • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTEHTIC INFECTION (PJI) •Relapse of infection – ultimum refugium •Fusion •Amputation (rarely) • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FRACTURE •Relatively frequent complication •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) • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FEMORAL FRACTURE; CLASSIFCATION • •Su •Lewis and Roarbeck • • •Neer, Tomáš, DiGioia and Rubash, Chen… \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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) • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC TIBIAL FRACTURE; CLASSIFICATION •Mayo, Felix • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC TIBIAL FRACTURE; THERAPY •conservative – no/minimal displacement + implant retention; poor general condition •ORIF (unstable fracture, stable implant) •Replantation of tib. component + stem (unstable tib. component) • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png •Thank you for yor attention