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BONE CUTS +ROTATIONAL POSITION Norberto Confalonieri, Alfonso Manzotti 1st Orthop Dept CTO Hospital, Milan, Italy Key Points 1. There are a total of 7 bone cuts in a typical total knee replacement (TKR): • Tibia (or femur first) • distal femur • anterior femur • posterior femur • anterior chamfer, • posterior chamfer, • and patella. Each of these cuts has its own special science, and each cut can affect the other cuts and potentially the outcome of the TKR. Aims of bone cuts • correct mechanical axis • restoration joint line • equalizing flexion and extension gaps • balancing soft tissues • correct patella-femoral kinematics Techniques 2. Measured Resection (femur fist): Basis: • anatomical reconstruction of the femur • remove amount of bone as component thickness • rotation based on anatomical landmarks Advantages Maintaining joint line Minimize mid-flexion instability May be easier to be performed Disadvantages Unpredictable femoral rotation Asymmetric flexion gap Predispose to lateral laxity and condylar lift-off Gap balancing technique (tibia first) Basis: • Ligament balanced femoral resection • Flexion/extension gap determining distal femoral resection • Flexion gap determine femoral component rotation (irrespective of bone landmarks!!!) • Parallelism to the epycondilar axis is not the objective (+6°) Advantages Create equal and symmetric flexion/extension gaps with equal symmetric collateral ligaments tensions Enhances patellar tracking Disadvantages More difficult joint line restoration Depends on accurate tibial cut to create rectangle in flexion and appropriately roatae the femoral component More difficult to be performed without any CAS tools Aims of rotational positionnement: • Avoid patellar maltracking (abnormal Q angle) • To achieve a symmetric flexion-extension gap • To achieve a more “normal” kinematics • To minimize instability/wear/pain 32
Techniques Femoral Rotation • Transepincondylar Axis • Posterior Condylar Line • Balanced Flexion Gap • Whiteside Line • Functional Flexion axes Tibial Rotation • “Rom technique” • Posterior Lateral corner Lockeh Technique (“PLCL”) • Anterior tibial tuberosity (1cm medially) • Posterior tibial margin • PCL insertion • Projected tranepycondylar axis • Center of 2 tibial plateaus • Akagi line • Anterior tibial plateau marging (“curve to curve”) Ancillary Tools: • Conventional intra/extramedullary guide • Patient Specific Instrumentation (PSI) • Computer assisted technique CAS (offers to the surgeon the numbers and a real feed back in O.R., without losing his control!) • Robot (maybe in future) Pearls The BONE CUTS CORRECT ARTHRITIS DEFORMITY and the THICKNESS of PROSTHESIS BALANCES THE KNEE. Minimal bone cut rule: prosthesis thickness (mm) minus arthritis deformity (degrees) = mm of bone to remove Navigation offers the numbers to be considered during all the phases of your procedure to assess alignment, gaps balancing and rotational aspects Take home message • Correct the arthritis deformity by bone cuts • Remove the minimal bone stock • Restore the joint line • Balance the ligament with the same joint spaces and the prosthesis thickness • Do not accept passively any dogma in rotation (do not rotate the femur, check the piano sign...) • CAS tools (navigation, psi, robot, ecc.) are not a different technique but an ancillary tool for better information about your personal procedure 33
Page 1 and 2: The Osteoarthritic Knee Best Curren
Page 3 and 4: Patellofemoral + medial OA in a 60
Page 5 and 6: SESSION 8 INFECTION Chairmen: S. Ho
Page 7 and 8: LOAD ABSORPTION - A SOLUTION TO DEL
Page 9 and 10: THE ROLE OF HIGH TIBIAL OSTEOTOMY P
Page 11 and 12: PATIENTS EXPECTATIONS AND OUTCOME A
Page 13 and 14: CASE 1 OSTEOARTHRITIS GRAD II MEDIA
Page 15 and 16: CASE 1 GRADE II OA NEUTRAL ALIGNMEN
Page 17 and 18: CASE 2 GRADE II MEDIAL OA IN ACTIVE
Page 19: CASE 3 OSTEOARTHRITIS GRAD III MEDI
Page 22 and 23: CASE 3 GRADE III MEDIAL OA IN ACTIV
Page 24 and 25: CASE 4 GRADE III LATERAL OA IN ACTI
Page 26 and 27: CASE 5 PATELLOFEMORAL + MEDIAL OSTE
Page 28 and 29: CASE 5 PATELLOFEMORAL + MEDIAL OA I
Page 30 and 31: PLANNING + APPROACH Roland Becker D
Page 34 and 35: SOFT TISSUE BALANCING + PATELLAR TR
Page 36 and 37: BLOOD MANAGEMENT + PAIN CONTROL & R
Page 38 and 39: WHO WILL PAY THE COSTS OF NEW TECHN
Page 40 and 41: HOW TO IMPROVE PATELLO-FEMORAL TRAC
Page 42 and 43: placement (in flexion and posterior
Page 44 and 45: PLANNING WITH CONVENTIONAL X-RAY OR
Page 46 and 47: MULTIMODAL APPROACHES FOR A SHORTER
Page 48 and 49: STAYING OUT OF TROUBLE AT PRIMARY T
Page 50 and 51: GAP BALANCING TECHNIQUE AND STABILI
Page 52 and 53: “ADAPTED” MEASURED RESECTION TE
Page 54 and 55: PATELLAR RESURFACING TECHNICAL TIPS
Page 56 and 57: TKA IN POST-TRAUMATIC OSTEOARTHRITI
Page 58 and 59: TKA IN THE STIFF KNEE Michel Bonnin
Page 60 and 61: HOW DO I MANAGE SEVERELY DEFORMED K
Page 62 and 63: which will create easier extension
Page 64 and 65: PLANNING AND CORRECTION OF EXTRA-AR
Page 66 and 67: Fig. 2. Case number 10, a 74-year-o
Page 68 and 69: INFECTION DIAGNOSIS - A EUROPEAN PE
Page 70 and 71: MANAGEMENT EARLY WOUND HEALING COMP
Page 72 and 73: DEBRIDEMENT AND POLYETHYLENE LINER
Page 74 and 75: 4. Barrack RL, Engh G, Rorabeck C,
Page 76 and 77: FAILURE ANALYSIS AND PATIENT SELECT
Page 78 and 79: APPROACH / IMPLANT REMOVAL + 3 STEP
Page 80 and 81: References 1. Meneghini RM, Lewalle
Page 82 and 83:
LEVEL OF CONSTRAINT + EXTENSOR MECH
Page 84 and 85:
WHICH IS THE BEST STEM EXTENSION FO
Page 86 and 87:
WHICH IS THE BEST STEM EXTENSION FO
Page 88 and 89:
FILLING THE DEFECT. METAPHYSEAL SOL
Page 90 and 91:
THE BEST SPACER FOR THE INFECTED TK
Page 92 and 93:
EXPOSURE FOR REVISION TKA: HOW DO Y
Page 94 and 95:
USE OF HINGES IN REVISION TOTAL KNE
Page 96 and 97:
References 1. Lachiewicz PF. Tantal
Page 98 and 99:
DIAPHYSEAL PREPARATION AND FIXATION
Page 100 and 101:
HOW TO TREAT A DAMAGED PATELLA DURI
Page 102 and 103:
REVISION TKA WITH ASSOCIATED EXTRA-
Page 104:
CASE - BILATERAL INFECTED TKA: EVAL
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