frank r. ebert, md union memorial hospital baltimore, maryland

Frank R. Ebert, MDFrank R. Ebert, MDUnion Memorial HospitalUnion Memorial Hospital

Baltimore, MarylandBaltimore, Maryland

TOTAL KNEE TOTAL KNEE

ARTHROPLASTYARTHROPLASTY

Total Knee ArthroplastyTotal Knee Arthroplasty

GoalGoal—Restore mechanical Restore mechanical

alignmentalignment—Restore joint lineRestore joint line

Normal Knee AnatomyNormal Knee Anatomy

Position in single leg stancePosition in single leg stance Mechanical axis valgus 3ºMechanical axis valgus 3º Femoral shaft axis valgus 6ºFemoral shaft axis valgus 6º Proximal tibia varus 3ºProximal tibia varus 3º

Radiographic EvaluationRadiographic Evaluation—Standing full length – APStanding full length – AP—Standing APStanding AP—Extension/Flexion lateralsExtension/Flexion laterals—Tunnel viewTunnel view—Sunrise viewSunrise view

Radiographic EvaluationRadiographic Evaluation

Weight Bearing X-raysWeight Bearing X-rays—Extent of joint space Extent of joint space

narrowingnarrowing—Ligament stretch outLigament stretch out—Subluxation of femus on tibiaSubluxation of femus on tibia

Radiographic AnalysisRadiographic AnalysisAnatomic Axis – FemurAnatomic Axis – Femur

—Line that bisects the Line that bisects the medullary canal of the femurmedullary canal of the femur

—Determines the entry point of Determines the entry point of the femoral medullary guide the femoral medullary guide rodrod

Radiographic AnalysisRadiographic Analysis

Mechanical Axis – Femur (MAF)Mechanical Axis – Femur (MAF)—A line from center of femoral A line from center of femoral

head to center of distal femurhead to center of distal femur

Radiographic AnalysisRadiographic Analysis

Anatomic Axis Tibia (AAT)Anatomic Axis Tibia (AAT)—A line that bisects the A line that bisects the

medullary canal of the tibiamedullary canal of the tibia—Determines the entry point of Determines the entry point of

the guide rodthe guide rod

Radiographic EvaluationRadiographic Evaluation

Mechanical Axis – Tibia (MAT)Mechanical Axis – Tibia (MAT)—Line from center of proximal Line from center of proximal

tibia to center of ankletibia to center of ankle—Proximal tibia is cut Proximal tibia is cut

perpendicular to (MAT)perpendicular to (MAT)

Issues with Surgical Issues with Surgical TechniquesTechniques

Traditional Joint Line OrientationTraditional Joint Line Orientation Tibial cut perpendicular to the Tibial cut perpendicular to the

MATMAT Femoral shaft at a valgus angle Femoral shaft at a valgus angle

5º to 8º valgus based off the ong 5º to 8º valgus based off the ong standing x-raystanding x-ray

Surgical TechniqueSurgical Technique

Incision — straight longitudinal incisionIncision — straight longitudinal incisionTissue handling keyTissue handling keyAvoid flapsAvoid flapsPreserve soft tissue flap about the Preserve soft tissue flap about the patellapatella

Surgical TechniqueSurgical Technique

Remember 7cm Remember 7cm Rule between Rule between incisionsincisions

Issues with Surgical Issues with Surgical TechniquesTechniques Exposure optionsExposure options

—— Subvastus / midvastusSubvastus / midvastus Routine knee replacementsRoutine knee replacements

Quicker rehabQuicker rehab—— Medial parapatellar / midlineMedial parapatellar / midline

Difficult total knee — obese Difficult total knee — obese patientspatients

RevisionsRevisions

MIS vs MINI TKAMIS vs MINI TKA

Capsulotomy Capsulotomy only?only?

Mid vastus?Mid vastus?

Sub vastus?Sub vastus?

MIS vs MINI TKAMIS vs MINI TKA

Mid vastus?Mid vastus?

Sub vastus?Sub vastus?

Quad Quad sparing?sparing?

Area of Variation

Type I-High Insertion

Type II-Pole Insertion

Type III-Low Insertion

Anatomic Variations of VMO Anatomic Variations of VMO InsertionInsertion

Type I- High VMO Type I- High VMO InsertionInsertion

Retinacular Incision

Area of extended retinaculumMuscle

Insertion

Type II-Pole Type II-Pole InsertionInsertion

Capsular or Retinacular Incision

Muscle Insertion

Type III-Low VMO Type III-Low VMO InsertionInsertion

Area of Extended VMMuscle

Insertion

AlignmentAlignment— Extramedullary vs IntramedullaryExtramedullary vs Intramedullary

Accuracy vs increased PE riskAccuracy vs increased PE riskFemur – IntramedullaryFemur – Intramedullary Overdrill opening and Overdrill opening and

insert insert slowly IM guideslowly IM guide Caution with bilateral Total Caution with bilateral Total

Knee ArthroplastyKnee ArthroplastyTibia – ExtramedullaryTibia – Extramedullary

Femoral RotationFemoral Rotation— LandmarksLandmarks

Posterior femoral condylesPosterior femoral condyles

Epicondyles 5º external Epicondyles 5º external rotation to the posterior rotation to the posterior condylescondyles

FemurFemur

— Measured resections: equal Measured resections: equal bone distally and posteriorlybone distally and posteriorly

— Tensioning devices & Tensioning devices & ligament releasesligament releases

— Do not alter bone resection Do not alter bone resection for ligament tightnessfor ligament tightness

Tibial Component RotationTibial Component Rotation

— Transmalleolar axisTransmalleolar axis

— Posterior tibial plateauPosterior tibial plateau

— Tibial tubercle — lies lateralTibial tubercle — lies lateral

MalalignmentMalalignment

Tibial ComponentTibial Component

Internally RotatedInternally Rotated

Tubercle Too LateralTubercle Too Lateral

Management of DeformityManagement of Deformity

1.1. Release the tight side of the Release the tight side of the deformitydeformity

2.2. Tighten the loose sideTighten the loose side

3.3. Accept some residual soft tissue Accept some residual soft tissue imbalanceimbalance

4.4. CombinationCombination

Surgical TechniquesSurgical Techniques

Varus KneeVarus Knee

1.1. Pes anserinusPes anserinus

2.2. Joint CapsuleJoint Capsule

3.3. Deep Tibial CollateralDeep Tibial Collateral

4.4. SemimembranosusSemimembranosus

5.5. Posterior Medial CapsulePosterior Medial Capsule

Varus KneeVarus Knee

Valgus KneeValgus Knee

1.1. Iliotibial BandIliotibial Band

2.2. Popliteus TendonPopliteus Tendon

3.3. Posterior Lateral CapsulePosterior Lateral Capsule

4.4. Lateral Head of GastrocLateral Head of Gastroc

5.5. Biceps FemorisBiceps Femoris

Valgus KneeValgus Knee

— Peroneal nerve palsy – valgus / Peroneal nerve palsy – valgus / flexion deformityflexion deformity

— TreatmentTreatment Release dressings or flex the Release dressings or flex the

kneeknee

Surgical Techniques:Surgical Techniques:

Flexion ContractureFlexion Contracture

1.1. Posterior capsulePosterior capsule

2.2. Gastroc originsGastroc origins

3.3. Posterior cruciatePosterior cruciate

4.4. Distal femurDistal femur

Fixed Flexion Deformity in TKAFixed Flexion Deformity in TKA

Complex Combinations:Complex Combinations:

—— musculotendinous contracturemusculotendinous contracture

— — ligamentous contractureligamentous contracture

— — capsular contracturecapsular contracture

— — osteophytes of posterior condyleosteophytes of posterior condyle

BiomechanicsBiomechanics

—— increased quadriceps force for increased quadriceps force for knee stabilization during weight knee stabilization during weight bearingbearing

— — increased forces transmitted to the increased forces transmitted to the patellofemoral jointpatellofemoral joint

BiomechanicsBiomechanics

—— increased forces are placed on increased forces are placed on posterior tibial plateauposterior tibial plateau

— — femoral condyles sink into the femoral condyles sink into the tibial plateautibial plateau

— — contact between intercondylar contact between intercondylar notch and tibial eminence form a notch and tibial eminence form a boney blockboney block

Associated deformityAssociated deformity

— — varus deformityvarus deformity 40% - > 5º range40% - > 5º range 5 to 30º varus5 to 30º varus

— — valgus deformityvalgus deformity 30% - > 5º range30% - > 5º range5 to 22º valgus5 to 22º valgus

Firestone et alFirestone et alCOOR ‘92COOR ‘92

Incidence of Problem – Review of Incidence of Problem – Review of 700 TKA & Revision TKA’s700 TKA & Revision TKA’s

— — 60% before primary TKA60% before primary TKA

— — 21% before revision TKA21% before revision TKA

Tew Tew && Forster ForsterJBJSJBJS (B) 87 (B) 87

Soft tissue releaseSoft tissue release

— — Varies with angular deformityVaries with angular deformity

Surgical TreatmentSurgical Treatment Soft tissue releaseSoft tissue release Additional bone resectionAdditional bone resection CombinationCombination

Postoperative CorrectionPostoperative Correction

— — the more severe the deformity must the more severe the deformity must consider the pros and cons of consider the pros and cons of additional bone resection and/or soft additional bone resection and/or soft tissue releasetissue release

Volz COOR ‘89Volz COOR ‘89

Additional bone resection – prosAdditional bone resection – pros

— — joint line is positioned slightly more joint line is positioned slightly more proximalproximal

— — functionally lengthens the collaterals functionally lengthens the collaterals and posterior capsule forward and posterior capsule forward extensionextension

— — doesn’t compromise flexion stabilitydoesn’t compromise flexion stability

Additional bone resection — cons Additional bone resection — cons (excessive)(excessive)

• Collateral ligament laxityCollateral ligament laxity

• Quadriceps redundancyQuadriceps redundancy

• HyperextensionHyperextension

• Bone quality can be compromisedBone quality can be compromisedMcPherson et al ‘94McPherson et al ‘94

Additional Femoral Additional Femoral

ResectionResection

Fixed Flexion Deformity in Fixed Flexion Deformity in TKATKA

Surgical Treatment for Deformity < 10º FFCSurgical Treatment for Deformity < 10º FFC Soft tissue release – only necessarySoft tissue release – only necessary

— — posterior capsuleposterior capsule

— — possibly PCLpossibly PCL

— — posterior osteophytesposterior osteophytes

Surgical Treatment for Deformity Surgical Treatment for Deformity 10-20º FFC10-20º FFC

— — consider distal femoral resection consider distal femoral resection 3 to 5 mm3 to 5 mm

— — Posterior capsulePosterior capsule

— — PCL resection posterior PCL resection posterior osteophytesosteophytes

Firestone et al COOR ‘92Firestone et al COOR ‘92

Fixed Flexion Deformity in Fixed Flexion Deformity in TKATKA

Surgical Treatment for Deformity 20-30º FFCSurgical Treatment for Deformity 20-30º FFC

— — distal femoral resection 3 to 5 mmdistal femoral resection 3 to 5 mm

— — posterior capsuleposterior capsule

— — PCL resectionPCL resection posterior osteophytesposterior osteophytes

Firestone et al COOR ‘92Firestone et al COOR ‘92

Surgical Treatment for Deformity > 30º Surgical Treatment for Deformity > 30º FFCFFC

— — consider pre-op casting ≠consider pre-op casting ≠

— — distal femoral resection 5 mmdistal femoral resection 5 mm

— — proximal tibial resectionproximal tibial resection

— — PCL resectionPCL resection

— — posterior osteophytesposterior osteophytesFirestone et al COOR ‘92Firestone et al COOR ‘92

et al et al J of ArthroJ of Arthro ‘99 ‘99

Peroneal Nerve PalsyPeroneal Nerve Palsy

Vascular InsufficiencyVascular Insufficiency

Anterior Pressure UlcersAnterior Pressure Ulcers

Manipulation Manipulation

No formula is exact for No formula is exact for treatment of the problemtreatment of the problem

Consider a balance between Consider a balance between soft tissue release vs bone soft tissue release vs bone resectionresection

Stiff KneeStiff Knee Remove osteophytesRemove osteophytes Insall Turn DownInsall Turn Down Osteotomize the tibial tubercleOsteotomize the tibial tubercle Rectus snipRectus snip

Stiff KneeStiff Knee

Epicondylar osteotomy for large Epicondylar osteotomy for large flexion / contractureflexion / contracture

Lateral release to evert the Lateral release to evert the patellapatella

Patellar resurfacingPatellar resurfacing

— Recommended for all RA Recommended for all RA patientspatients

— Without resurfacing 4% to 6% Without resurfacing 4% to 6% incidence of anterior knee painincidence of anterior knee pain

— With resurfacing increased With resurfacing increased incidence of fractureincidence of fracture

Patellar resurfacingPatellar resurfacing— Thickness shouldn’t exceed 25 Thickness shouldn’t exceed 25

mmmm— For every 1 mm thicker reduces For every 1 mm thicker reduces

flexion by 3ºflexion by 3º

Issues with Surgical TechniquesIssues with Surgical Techniques

Patellar BajaPatellar Baja

• Proximal tibial osteotomyProximal tibial osteotomy

• Tibial tubercle shiftTibial tubercle shift

• Prior fracturePrior fracture

Patellar BajaPatellar Baja

• Don’t raise joint lineDon’t raise joint line

• Consider lowering joint lineConsider lowering joint line

— — Distal femoral alignmentDistal femoral alignment

• Trim anterior tibial poly to avoid Trim anterior tibial poly to avoid impingement of patellaimpingement of patella

Patellar Clunk SyndromePatellar Clunk Syndrome

— — Seen at 35º-40º knee flexionSeen at 35º-40º knee flexion

—— Treatment is arthroscopic or Treatment is arthroscopic or open resectionopen resection

Issues with Surgical TechniquesIssues with Surgical Techniques Sagittal Plane BalancingSagittal Plane Balancing

SituationSituation Problem Problem SolutionSolution

Cut Tight Cut Tight Symmetrical Symmetrical –– cut morecut morein extension in extension gap gap proximal tibiaproximal tibiaCut Tight in flexionCut Tight in flexion

Cut Tight Cut Tight Asymmetrical Asymmetrical –– Release PCL;Release PCL;in extensionin extension gap gap Posterior capsule Posterior capsule Cut Loose Cut Loose Consider PCL Consider PCL in flexionin flexion substituting prosthesissubstituting prosthesis

–– Resection distal femurResection distal femur AVOID recurvatumAVOID recurvatum

Issues with Surgical TechniquesIssues with Surgical Techniques Sagittal Plane BalancingSagittal Plane Balancing

SituationSituation Problem Problem SolutionSolution

Cut Good Cut Good Asymmetrical Asymmetrical –– Resection additional Resection additional in extension in extension gap gap tibia tibia

Cut Tight in flexionCut Tight in flexion –– May need to release May need to release PCLPCL

–– Ensure posterior Ensure posterior slope of tibiaslope of tibia

Cut Good Cut Good Asymmetrical Asymmetrical –– Need femoral Need femoral in extensionin extension gap gap augmentation augmentation

Cut LooseCut Loose – – Adjust to larger Adjust to larger in flexion in flexion femoral componentfemoral component

Complications in Total Complications in Total Knee ArthroplastyKnee Arthroplasty

Periprosthetic FracturesPeriprosthetic FracturesInfected Total Knee Infected Total Knee

ArthroplastyArthroplasty

SupracondylarSupracondylarFractures of the Fractures of the

FemurFemur

After Total Knee After Total Knee ArthroplastyArthroplasty

Supracondylar Fractures Supracondylar Fractures After TKRAfter TKR

l Notching of the femoral cortexNotching of the femoral cortex

l OsteoporosisOsteoporosis

l Prolonged steroid useProlonged steroid use

l Preexisting neurologic Preexisting neurologic disorders disorders

OSTEOPOROSISOSTEOPOROSIS

Bogoch, et al, CORR 1986Bogoch, et al, CORR 1986

l Major trauma is not required to Major trauma is not required to produce fractures in many TKA produce fractures in many TKA patientspatients

l Alignment not correlated with Alignment not correlated with fracturefracture

l Weight not a significant factor Weight not a significant factor

Fractures After TKAFractures After TKA

Neer Classification of Supracondylar Neer Classification of Supracondylar FracturesFracturesl Type IType I - - Minimal displacementMinimal displacementl Type IIA Type IIA -- Medial displacement of Medial displacement of

condylescondylesl Type IIB Type IIB -- Lateral displacement Lateral displacement

of condylesof condylesl Type III Type III -- Supracondylar and shaft Supracondylar and shaft

fracturesfractures

TREATMENTTREATMENT

Type 1 – NondisplacedType 1 – Nondisplaced

Type 1 fractures 83% Type 1 fractures 83% success ratesuccess rate

Chen, et al, 1994Chen, et al, 1994

Type 2 fractures Type 2 fractures 69% success rate69% success rate

l CastingCasting

l Traction followed by rest Traction followed by rest

Non Operative MethodNon Operative Method

Type 2 fractures Type 2 fractures 67% success rate67% success rate

l Plates / Screw fixationPlates / Screw fixationl Intramedullary rodsIntramedullary rodsl Rush pinsRush pinsl External fixationExternal fixationl Primary arthrodesisPrimary arthrodesisl Revision arthroplastyRevision arthroplasty

Operative MethodOperative Method

l Patients’ ability to tolerate tractionPatients’ ability to tolerate traction

l Ability of bone to hold screwsAbility of bone to hold screwsl Ability of the surgeonAbility of the surgeon

Type 2Type 2ConsiderationsConsiderations

Intercondylar Distances of Commonly Used Femoral ProsthesesIntercondylar Distances of Commonly Used Femoral Prostheses

Biomet,Biomet, (Warsaw, IN)(Warsaw, IN) AGCAGC 1818 UniversalUniversal 1818

DePuy,DePuy, (Warsaw, IN)(Warsaw, IN) AMKAMK 2020

Dow Corning Wright, Dow Corning Wright, (Arlington, TN)(Arlington, TN) Whitesides modularWhitesides modular 2020Howmedica, Howmedica, (Rutherford, NJ)(Rutherford, NJ) PCAPCA 18.518.5Intermedics, Intermedics, (Austin, TX)(Austin, TX) NaturalNatural 1414Johnson and Johnson, Johnson and Johnson, (New Brunswick, NJ)(New Brunswick, NJ) Press-fit condylarPress-fit condylar 2020

Insall-Burstein*Insall-Burstein* 1515 (posterior stabilized)(posterior stabilized)

Kirschner, Kirschner, (Timonium, MD)(Timonium, MD) PerformancePerformance 1414Zimmer, Zimmer, (Warsaw, IN)(Warsaw, IN) Insall-Burstein I*Insall-Burstein I* 1616

Insall-Burstein IIInsall-Burstein II 1515 (posterior stabilized* or(posterior stabilized* or constrained condylar†)constrained condylar†) Miller-Galante IMiller-Galante I Small / small + ‡Small / small + ‡ 1111 Regular / regular + Regular / regular + 12.512.5 Large / large + Large / large + 1515 Large + + Large + + 1818 Miller-Galante IIMiller-Galante II 1313

ManufacturerManufacturer ModelModelIntercondylar DistanceIntercondylar Distance(Smallest Size) ((Smallest Size) (mmmm))

No one form of treatment No one form of treatment gives uniformly good gives uniformly good

resultsresults

Infection in Total Knee Infection in Total Knee ArthroplastyArthroplasty

Complications in ArthroplastyComplications in Arthroplasty

Infection – Risk FactorsInfection – Risk Factors

l Skin ulcerations / necrosisSkin ulcerations / necrosis

l Rheumatoid ArthritisRheumatoid Arthritis

l Previous hip/knee operationPrevious hip/knee operation

l Recurrent UTIRecurrent UTI

l Oral corticosteroidsOral corticosteroids

Infection – Risk FactorsInfection – Risk Factors

l Chronic renal insufficiencyChronic renal insufficiency

l Diabetes Diabetes

l Neoplasm requiring chemoNeoplasm requiring chemo

l Tooth extractionTooth extraction

Infection – Clinical CourseInfection – Clinical Course

l Pain #1Pain #1

l SwellingSwelling

l FeverFever

l Wound breakdown drainageWound breakdown drainage

Windsor et alWindsor et alJBJSJBJS; 1990; 1990

Early < 3 monthsEarly < 3 months

Lab ValueLab Value

Mayo Series Mayo Series Mean 7,500Mean 7,500

l Differential Differential 67 PMN’s67 PMN’s

l Sed rateSed rate 71 mm/hr71 mm/hr

l ArthrocentesisArthrocentesis

Infections About TKRInfections About TKR

Late > 3 monthsLate > 3 months

Symptoms: 52 patientsSymptoms: 52 patients

PainPain 96%96% swellingswelling 77%77% DebrideDebride 27%27% Active drainageActive drainage 27%27% Sed rate 63 mm/hrSed rate 63 mm/hr WBC - 8300WBC - 8300

Windsor et alWindsor et alJBJSJBJS; 1990; 1990

Infection – Surgical TechniquesInfection – Surgical Techniques

l Avoid skin bridgesAvoid skin bridges

l Avoid creation of skin flapsAvoid creation of skin flaps

l HemostasisHemostasis

l Prolonged operating timeProlonged operating time

Infection – Work-UpInfection – Work-Up

l Wound HistoryWound History

l Physical ExamPhysical Exam

l Serial RadiographsSerial Radiographs

l Lab/sed rate/CRPLab/sed rate/CRP

l Bone scan / Indium scanBone scan / Indium scan

InfectionInfection

ArthrocentesisArthrocentesisl Cell countCell countl Diff > 25,000 pmnDiff > 25,000 pmnl Protein Protein – – highhighl Glucose Glucose – – low low

InfectionInfection

l Host ResponseHost Response

GlycocalyxGlycocalyx

GristinaGristinaJBJS;JBJS; 1983 1983

Micro OrganismsMicro Organisms

Organisms Isolated from 71 Patients Organisms Isolated from 71 Patients With Infected Knee ReplacementWith Infected Knee Replacement

StaphylococcusStaphylococcus 6464

S. aureusS. aureus, penicillin sensitive , penicillin sensitive 1414 S. aureusS. aureus, penicillin resistant, penicillin resistant 2828 S. epidermisS. epidermis 2222

Gram negativeGram negative 1212 PseudomonasPseudomonas 77 Escherichia coliEscherichia coli 55

AnærobicAnærobic 66

OtherOther 1717

OrganismOrganism PercentPercent

Treatment OptionsTreatment Options

l Antibiotic suppressionAntibiotic suppression

l Aggressive wound debridementAggressive wound debridement

Treatment OptionsTreatment Optionsl Antibiotic suppressionAntibiotic suppression

Indicated in med compromisedIndicated in med compromised

Organism - gram+ strep staphepiOrganism - gram+ strep staphepi

Treatment OptionsTreatment Options

l Resection arthroplastyResection arthroplasty

l 2 Stage re-implant2 Stage re-implant

l ArthrodesisArthrodesisl AmputationAmputation

Treatment OptionsTreatment Optionsl Debridement with antibiotic Debridement with antibiotic

suppression therapysuppression therapy

Strep/staphepi -- bestStrep/staphepi -- bestAvoid repeated attemptsAvoid repeated attemptsFrozen tissue sectionFrozen tissue sectionSuction drainsSuction drains

Two-Stage ReimplantationTwo-Stage Reimplantation

l Most successful treatmentMost successful treatment

l Procedure of choiceProcedure of choice

Two-Stage Reimplantation ProcedureTwo-Stage Reimplantation Procedure

l Remove components, cement, Remove components, cement, II&&DD

l Fabricate and place spacerFabricate and place spacer

l 6 weeks of antibiotics6 weeks of antibiotics

l ReimplantationReimplantation

Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II

l create antibiotic spacer create antibiotic spacer impregnated with antibioticsimpregnated with antibiotics

l wound closurewound closure

Two-Stage Reimplantation Two-Stage Reimplantation

l Spacer Antibiotic RegimenSpacer Antibiotic Regimen

Tobramycin Tobramycin 2.4 gm/3.6 gm per2.4 gm/3.6 gm per 40 gms of PMMA40 gms of PMMA

VancomycinVancomycin > gm to 1 gm per> gm to 1 gm per gms of PMMAgms of PMMA

Intra-operative Frozen SectionIntra-operative Frozen Section

l < 5 PMN’s per HPF< 5 PMN’s per HPF – – no no infectioninfection

l > 10 PMN’s per HPF> 10 PMN’s per HPF –– infectioninfection

Mirra; Mirra; JBJSJBJS

Results — Gm positiveResults — Gm positive

Windsor et alWindsor et al 92 % 92 % JBJSJBJS 1990 1990

Insall et alInsall et al 97%97% JBJSJBJS 1983 1983

Resection ArthroplastyResection Arthroplasty

l Removal all componentsRemoval all components

l Remove all cementRemove all cement

l Effective in medically Effective in medically compromised patientcompromised patient

Arthrodesis IndicationsArthrodesis Indicationsl Extensor mechanism disruptionExtensor mechanism disruptionl Resistant bacteriaResistant bacterial Inadequate bonestockInadequate bonestockl Inadequate soft tissuesInadequate soft tissuesl Young patientYoung patient

AdvantagesAdvantages

Definitive treatmentDefinitive treatment

Little chance of recurrenceLittle chance of recurrence

ArthrodesisArthrodesis

DisadvantagesDisadvantages

Difficulty with transfers / small Difficulty with transfers / small spacesspaces

Increase energy requirementsIncrease energy requirements

ArthrodesisArthrodesis

AlgorithmAlgorithm

TKATKAClinical SepsisClinical Sepsis

(GRAM + (GRAM + Organism) Organism)

< 3 wks< 3 wks > 3 wks> 3 wks

DebridementDebridementAntibiotics (6 wks)Antibiotics (6 wks)

2-Stage2-StageReplantReplant

AlgorithmAlgorithm

DebridementDebridementAntibioticsAntibiotics

SuccessSuccess

2-stage2-stage ReplantReplant ArthrodesisArthrodesis

No No SuccessSuccess

2-stage Replant2-stage Replant

SuccessSuccessNo No

SuccessSuccess

ResectionResectionArthroplastyArthroplasty

Thank YouThank You

frank r. ebert, md union memorial hospital baltimore, maryland

femoral shaft axis valgus

center of proximal tibia

low insertiontype

high insertiontype

pole insertiontype

sub vastus

ankleproximal tibia

center of femoral head

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