Download the Take Home Message Book in PDF format

More documents

Recommendations

Info

GAP BALANCING TECHNIQUE AND STABILITY ASSESSMENT José Romero Endoclinic Zurich, Zurich, Switzerland Symmetrically balanced collateral soft tissues in extension and in flexion 1, 2 and alignment of the tibial and femoral components perpendicular to the mechanical axis in the coronal plane 3 are identical goals for both methods, the “femur first technique” and the “tibia first technique”. The major difference between the two methods is on how rotation of the femoral component is determined to achieve these goals. The “femur first technique” addresses the femur before the tibial plateau is resected. Rotation of the femoral component is referenced on bony landmarks, and there are three methods accepted. The first method is historically known as the measured resection technique because it removes a determined amount of bone of the posterior condyles with a routine 3° external rotation. The second method resects the posterior condyles perpendicular to the trochlear groove (Whiteside line), and the third methods resects the posterior condyles parallel to the transepicondylar axis. The remaining ligamentous imbalance in flexion is corrected by selective soft tissue releases. However, such releases in flexion affect the balance in extension to a unknown extend 5,6 . It may therefore be difficult in some cases to achieve symmetric balance in flexion and extension if the releases are performed at the end after having performed all bony cuts. The first step of the “tibia first technique” is the resection of the tibial plateau perpendicular to the tibial long shaft axis, the second step is the distraction of the flexion gap and the third step is the resection of the posterior condyles parallel to the tibial resection plane according to the ligamentous tension in flexion. Then the extension gap is addressed: The distal femur is resected perpendicular to the line connecting the center of the distal femur and the center of the femoral head. If the extension gap is released at the end to correct for remaining ligamentous balance imbalance it may affect the balance of the flexion gap. A combination of both methods may overcome the problem of such unequal effects of ligamentous releases for the flexion and extension gap. The first step of this method, called the balanced flexion gap technique, resects the proximal tibia and the distal femur perpendicular to the tibial and femoral mechanical axis. Then the extension gap is analysed using a distractor. If a ligamentous imbalance of the extension gap exists it is released until a rectangular extension gap is achieved under distraction. The flexion gap is then also set under distraction and the posterior condyles are resected parallel to the tibial resection plane. The extension gap stays rectangular since the resection of the posterior condyles which determines rotational alignment of the femoral component has only an impact on the flexion gap selectively without changing the balance in extension 6 . It has been shown that an asymmetric flexion gap is associated with a clinically inferior outcome and that it is correlated to femoral component rotation 7. The balanced flexion gap technique is a useful method particularly for a fixed varus or valgus deformation that determines the rotation of the femoral component individually each patient. However, until know, no comparative studies exist to prove which method provides superior patient satisfaction and longevity of the implant. References 1. Freeman MAR: Anonymous Arthritis of the knee: Clinical features and surgical management. Springer-Verlag, New York, 1980. 2. Insall JN: Choices and compromises in total knee arthroplasty. Clin Orthop 226:43, 1988. 3. Insall JN: Surgical techniques and instrumentation in total knee arthroplasty. In Insall JN, Windsor RE, Kelly MA, Scott WN, Aglietti P (eds): Surgery of the knee. Churchill Livingstone, New York, Edinburgh, London, Madrid, Melbourne, Tokyo, 1993, pp. 739. 4. Krackow AK, Mihalko WM: The effect of medial release on flexion and extension gaps in cadaveric knees. Am J Knee Surg 12:222–228, 1999. 5. Krackow AK, Mihalko WM: Flexion-extension joint gap changes after lateral structure release for valgus deformity correction in total knee arthroplasty. J Arthroplasty 14:994–1004, 1999. 6. Romero J, Duronio JF, Sohrabi A, et al: Varus and valgus flexion laxity of total knee alignment methods in loaded cadaveric Knees. Clin Orthop 394:243, 2002. 7. Romero J., Stähelin T., Binkert C., Pfirrmann C.W., Hodler J., Kessler O.: The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty 22(2):235-40, Feb 2007. 50
MEASURED RESECTIONS WITH PSI IN A FIXED VALGUS DEFORMITY Emmanuel Thienpont Saint Luc University Hospital, Brussels, Belgium Introduction Valgus knees are less frequent then varus knees and therefore we as surgeons are less experienced. The valgus knee is not just an inversed varus knee. We should distinguish in between the iatrogenic valgus knee, which exists after complete lateral meniscectomy, after overcorrected high tibial osteotomy and after trauma. This talk will cover the intrinsic valgus knee, which is a question of dysplasia. We shall cover how Patient Specific Instruments (PSI) can help us obtain reproducible results. Key points Place for the far medial subvastus approach in valgus knee The problem of valgus knees is dysplasia - Of the MCL - Of the posterolateral condyle - Of the trochlea - Of the patella with extreme bone loss sometimes - Of the posterior capsule with hyperextension and medial laxity Release of the soft tissues (fixed valgus knee) Contracture of the ITB in extension Why PSI in valgus knees - Preoperative mechanical axis analysis - Idea about the levels of resections and need for CCK implants - Idea about the sizes - Helps determine the epicondylar axis since PCA and AP-axis are not reliable because of dysplasia - Helps correct HKA to 180° despite intrinsic valgus of femoral/tibial bones Pitfalls - Check the Ir planning - Often ML size is narrow compared to AP size in valgus knees - Default planning of 10 mm resection of lateral side is NOT allowed of course - Beware of the hyperextension in valgus and often need of less proximal femoral resection Conclusions PSI can have a place to improve accuracy in the valgus knee, if the planning is checked by an experienced surgeon that understands the secrets of valgus knees. Especially on the femoral side PSI guides can have some added value. PSI is not a substitute for good surgical technique and soft tissue balancing in these often complicated knees 51
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 32 and 33: BONE CUTS +ROTATIONAL POSITION Norb
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 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
show all

Download the Take Home Message Book in PDF format

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?