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Total knee arthroplasty in patients with ipsilateral fused hip: a technical note.

Goodman SB, Huddleston JI, Hur D, Song SJ - Clin Orthop Surg (2014)

Bottom Line: The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky.The final outcome provided satisfactory results at a minimum of 2 years postoperatively.TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA.

ABSTRACT
We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient's medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

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The position of the table during the tibial and femoral bone resection. (A) A tibial resection can be performed accurately using an extramedullary guide system in the Trendelenburg position even though the patients' knees were stiff preoperatively. (B) Gentle flexion of the knee can be performed after the tibial resection, and the femoral intramedullary guide system could be placed safely.
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Figure 1: The position of the table during the tibial and femoral bone resection. (A) A tibial resection can be performed accurately using an extramedullary guide system in the Trendelenburg position even though the patients' knees were stiff preoperatively. (B) Gentle flexion of the knee can be performed after the tibial resection, and the femoral intramedullary guide system could be placed safely.

Mentions: For the surgical procedure, the patient was placed supine on the operating table and the knee was placed at the level of the break in the table. Throughout the procedure, the table was elevated and lowered episodically, and the foot of the table was flexed and flattened as needed, keeping the area sterile, using multiple sheets at the distal end when the table was lowered or flexed. After inflation of the tourniquet, a midline skin incision was made with a medial parapatellar capsular approach. The patella was everted 90° and a resection of 8-mm thickness was made initially. To facilitate exposure, the table was placed in the Trendelenburg position. Both of the patients' knees were very stiff preoperatively, making initial femoral guide placement difficult. After excising the menisci and cruciate ligaments, a tibial resection was first made using an extramedullary guide system to make gentle flexion of the knee possible for distal femoral resection (Fig. 1A). We resected 10 mm of bone from the less worn plateau to achieve a tibial cut surface that was perpendicular to the shaft of the tibia in the coronal plane. The posterior tibial slope was set to 7° in the sagittal plane, as recommended by the manufacturer (NexGen, Zimmer, Warsaw, IN, USA). The end of table was flexed more, and the knee was gently flexed. A femoral intramedullary guide rod was placed, and an anterior provisional resection was made using the reference to the transepicondylar axis (Fig. 1B). Subsequently, the distal femoral resection was made at 5° of valgus, per the preoperative templating, considering the angle between the anatomical and mechanical axes of the femur. The size for the femoral component was selected, and the final anterior and posterior femoral cuts were then made. The flexion and extension gaps and limb alignment were evaluated using a spacer block and proximal and distal alignment rods. Osteophytes were excised and contracted soft tissues were released to balance the knee. Finally, tibial, femoral, and patellar preparation were performed and trial components placed. Patellofemoral tracking was checked with the "no thumbs" technique. All components were cemented onto cleaned, dried surfaces. The postoperative rehabilitation protocol was similar to our primary cases.


Total knee arthroplasty in patients with ipsilateral fused hip: a technical note.

Goodman SB, Huddleston JI, Hur D, Song SJ - Clin Orthop Surg (2014)

The position of the table during the tibial and femoral bone resection. (A) A tibial resection can be performed accurately using an extramedullary guide system in the Trendelenburg position even though the patients' knees were stiff preoperatively. (B) Gentle flexion of the knee can be performed after the tibial resection, and the femoral intramedullary guide system could be placed safely.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4233229&req=5

Figure 1: The position of the table during the tibial and femoral bone resection. (A) A tibial resection can be performed accurately using an extramedullary guide system in the Trendelenburg position even though the patients' knees were stiff preoperatively. (B) Gentle flexion of the knee can be performed after the tibial resection, and the femoral intramedullary guide system could be placed safely.
Mentions: For the surgical procedure, the patient was placed supine on the operating table and the knee was placed at the level of the break in the table. Throughout the procedure, the table was elevated and lowered episodically, and the foot of the table was flexed and flattened as needed, keeping the area sterile, using multiple sheets at the distal end when the table was lowered or flexed. After inflation of the tourniquet, a midline skin incision was made with a medial parapatellar capsular approach. The patella was everted 90° and a resection of 8-mm thickness was made initially. To facilitate exposure, the table was placed in the Trendelenburg position. Both of the patients' knees were very stiff preoperatively, making initial femoral guide placement difficult. After excising the menisci and cruciate ligaments, a tibial resection was first made using an extramedullary guide system to make gentle flexion of the knee possible for distal femoral resection (Fig. 1A). We resected 10 mm of bone from the less worn plateau to achieve a tibial cut surface that was perpendicular to the shaft of the tibia in the coronal plane. The posterior tibial slope was set to 7° in the sagittal plane, as recommended by the manufacturer (NexGen, Zimmer, Warsaw, IN, USA). The end of table was flexed more, and the knee was gently flexed. A femoral intramedullary guide rod was placed, and an anterior provisional resection was made using the reference to the transepicondylar axis (Fig. 1B). Subsequently, the distal femoral resection was made at 5° of valgus, per the preoperative templating, considering the angle between the anatomical and mechanical axes of the femur. The size for the femoral component was selected, and the final anterior and posterior femoral cuts were then made. The flexion and extension gaps and limb alignment were evaluated using a spacer block and proximal and distal alignment rods. Osteophytes were excised and contracted soft tissues were released to balance the knee. Finally, tibial, femoral, and patellar preparation were performed and trial components placed. Patellofemoral tracking was checked with the "no thumbs" technique. All components were cemented onto cleaned, dried surfaces. The postoperative rehabilitation protocol was similar to our primary cases.

Bottom Line: The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky.The final outcome provided satisfactory results at a minimum of 2 years postoperatively.TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA.

ABSTRACT
We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient's medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

Show MeSH
Related in: MedlinePlus