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Revision Knee Replacement in Stiff Knee Post Spacer by Dr Anoop Jhurani
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Revision Knee Replacement in Stiff Knee Post Spacer by Dr Anoop Jhurani
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T00H10M50S
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https://cadmoreoriginalmedia.blob.core.windows.net/0cbb3e48-b9b0-488a-a92c-2ee567b6914c/Revision knee replacement in stiff knee post spacer by Dr An.mp4?sv=2019-02-02&sr=c&sig=ZBk1tPH%2Bxaqfuie%2F%2BAl5TDuavj7DGc4Ws4lthFcIYgk%3D&st=2024-11-23T09%3A58%3A00Z&se=2024-11-23T12%3A03%3A00Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. Periprosthetic joint infection can have disastrous consequences. So this patient, a young patient who had history of a lateral condyle fracture and was plated, first developed end stage arthritis for which total knee replacement was done elsewhere. Now we know that post traumatic situations have higher incidence of periprosthetic joint infection.
ANOOP JHURANI: And unfortunately, it got infected and the surgeon there explanted the joint and then put a spacer, but the infection was still resistant and then the patient was referred to us for definitive treatment. When we received the patient, the patient had a draining sinus and was very painful. His CRP ESR were highly elevated. So we use the White site technique of an intra articular Hickman catheter.
ANOOP JHURANI: We extensively debrided the joint, put antibiotic beads into the canal, and put a Hickman catheter, as you can see on the X-ray for intra articular antibiotics. He grew MRSA and we gave him appropriate antibiotics for six weeks intra articular monitoring his creatinine, body monitoring his other vitals and ensured that the patient had full chances of getting infection free.
ANOOP JHURANI: Now, after about 8 or nine months, his CRP ESR is near normal and is decreasing. And we still waited for another three months till his CRP ESR came back to normal. He was clinically OK, but by the time he had lost quite a bit of range of motion because he sustained another fall and his range of motion, as you can see, is barely 0 to 30 degrees
ANOOP JHURANI: so it's a stiff knee. Whenever we are dealing with a stiff knee, we got to plan our exposure very carefully, very meticulously and this case, we have planned rectus snip pre operatively. Now, if the tightness is in FRA patella accompanied by patella varhar, then a tibial tubercle osteotomy is the most appropriate way to expose a stiff knee. But in this case, the tightness was supra patella. So we did a rectus snip,
ANOOP JHURANI: as you can see, that rectus snip is at the highest edge of the quadriceps tendon. Where there is the vastus lateralis muscular origin so that's where the rectus snip is, and then we release the lateral gutter carefully, the medial gutter, clear the gutters, and then gradually flex the knee. So the first thing is the rectus snip then is a lateral release to facilitate the range of motion of the knee.
ANOOP JHURANI: So now you can see the knees bending up to 40, 45 degrees, still very tight because the spacer is broken. You can see that there is broken spacer and we'll remove it piecemeal. So that's the broken spacer coming out piecemeal and then we'll further flex the knee to take out the tibial part of the spacer. But the important thing is to do the rectus slip
ANOOP JHURANI: if the range of motion is less than 45 degrees to plan a rectus snip or a tibial tubercle osteotomy, especially if there is patella varhar, then tibial tubercle osteotomy is the best way to expose the joint. But in this case, the rectus snip worked pretty well, and gradually by clearing the gutters, you facilitate further range of motion of the knee. So here you can see that we have taken out the tibial spacer, also the femoral spacer, and now the knee is flexing up to 110 degrees because we need that amount of range of motion to complete the reconstructive operation
ANOOP JHURANI: there is a revision. Now we are clearing the posterior capsule to facilitate further range of motion and continuous debridement goes on and wash goes on. And once we debride thoroughly, we wash thoroughly, now we can see and analyze and assess both the extension and flexion gaps. So you can see that the flexion gap is bigger, usually in these situations the flexion gap is bigger, especially medially opening up.
ANOOP JHURANI: So you can see that the flexion gap is bigger than the extension gap so we need to posterior rise the femur and upsides of the femur. The first thing is to take the tibial cut, make the tibial platform nicely, do an intramedullary rod after we cleared all the cement. It's very important to clear all the cement so that the rod goes in the right direction, and is not misguided by any remnant cement.
ANOOP JHURANI: So once the cement is clear, you just take one or two millimeters off especially on the lateral side so that the cut becomes absolutely neutral. You can see the cut. The cut is nice, perpendicular to the mechanical axis and varus valgus and then you use the offsetting of this tibular system to your advantage because the rod will dictate the tibial component position.
ANOOP JHURANI: So you ensure that your tibial component is well sitting, so this is a 360 degree offset stem, so you can rotate it in any position. So the best is to laturalise the tibial trim by medialising the offset. So the offset and that component moves in opposite direction. So in this case, the, the offset is medialised to lateralize the tibial trace. So that's the offset perforation first and then the stem preparation.
ANOOP JHURANI: The key principle is that the offset needs to be utilized, the stem position needs to be utilized to our advantage for the tibial and the femoral components. Then the distal femur cut, the distal femur cut is again minimal, a millimeter or two, not more than that. Since this case, the extension space was a little tighter than the flexion space. We took one, one and a half millimeter of femur to make it at six degree valgus perpendicular to the mechanical axis.
ANOOP JHURANI: And that's important, so that your component sits on flat board. In case your extension space is loose, then you can use distal augments. But in this case, the distal augments may not be required because the flexion space is looser. Again, we are using off setting of the femoral stem. You can see it can be rotated 360 degrees. So the important thing is to inferiorise so that your flexion gap becomes snug, so inferiorise so that you're flush with the anterior cortex,
ANOOP JHURANI: The saw blade is on the anterior cortex and you can lateralize and posterior rise the femur component so that your flex in space is sunk snug, your anterior offset is minimal, and that facilitates the patellar range of motion, the patellar tracking and the range of motion. So this is an important concept is to posterior rise the femur component so that your patella and the anterior compartment is not overstuck and your patellar tracking is good.
ANOOP JHURANI: Then the chamfer cuts, again it doesn't cut much, but you need to move the saw so that a millimeter or two, whatever bone is there, it comes in your way, gets sawed off. Then the preparation for the offset is stem and finally, the preparation for the box. So this is a size 6 of the femur and size 6 on the tibia as well. So this is a male patient, big sizes and then we clear the patella of any soft tissues ideal to resurface the patella
ANOOP JHURANI: but in this case, the one side was truly hibernated and the thickness wasn't great. So we decided to let it remain and resurfaced. But ideally speaking, patella should be resurfaced in every revision case. But you need to assess the bone quality because the patient was immobile. The bone quality of the patella becomes really poor, osteoporotic and eroded on one side.
ANOOP JHURANI: So then we make drill holes on the sclerotic bone surface. So no tibial stem or any augment was needed on the femur side in this case. So the important thing is, again, to reemphasize the principle of offsetting that is you offset the component as per the tibial stem and the femur stem. So you can see that the tibial stem is medialised to offset the tibial component laterally. And on the femur,
ANOOP JHURANI: the, the offset is posterior so that the component moves posterior. So the stem moves anterior, the component moves posterior. So that's the important concept to understand. Then the final cementation, it's important to cement it well and do hybrid cementing, so the cement is still the offset. There's a broad part which goes into the sclerotic bone and the stem is well fixed.
ANOOP JHURANI: It's 16 on the femur side, 15 on the tibial side. So it's a very snug cortical purchase of the stem. You got to get very good cortical bite on both the stems so that there is good physeal fixation. The metaphyseal fixation comes by cementing of the offset and the diaphyseal fixation comes by cementing of the component. So that's the final implant you can see, and it needed a big lateral release to facilitate patella tracking.
ANOOP JHURANI: So the important points here were exposure by rectus snip, gradual flexion of the knee by clearance of gutters. Then using the offset, you can see that the offset has been used to posteriorize the femur and lateralize the tibial component. Solid diaphyseal purchase, cementing up to the metaphyses and very good alignment, and good range of motion of the knee up to 90 degrees.
ANOOP JHURANI: The patient is counseled that because of chronic stiff knee he may not get more than 100 degrees and so but we get full extension, we get good patellar tracking by doing a patellar release, a lateral release and get overall alignment and range of motion. So friends, that those were the important principles of doing a posterior spacer revision TK in a stiff knee, because posterior spacer post multiple surgeries, the knee becomes very stiff.
ANOOP JHURANI: So it's important to expose properly, use the principles of clearance of gutters, lateral release and offsetting to reconstruct this kind of knee properly and get right alignment and balance. Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. Periprosthetic joint infection can have disastrous consequences. So this patient, a young patient who had history of a lateral condyle fracture and was plated, first developed end stage arthritis for which total knee replacement was done elsewhere. Now we know that post traumatic situations have higher incidence of periprosthetic joint infection.
ANOOP JHURANI: And unfortunately, it got infected and the surgeon there explanted the joint and then put a spacer, but the infection was still resistant and then the patient was referred to us for definitive treatment. When we received the patient, the patient had a draining sinus and was very painful. His CRP ESR were highly elevated. So we use the White site technique of an intra articular Hickman catheter.
ANOOP JHURANI: We extensively debrided the joint, put antibiotic beads into the canal, and put a Hickman catheter, as you can see on the X-ray for intra articular antibiotics. He grew MRSA and we gave him appropriate antibiotics for six weeks intra articular monitoring his creatinine, body monitoring his other vitals and ensured that the patient had full chances of getting infection free.
ANOOP JHURANI: Now, after about 8 or nine months, his CRP ESR is near normal and is decreasing. And we still waited for another three months till his CRP ESR came back to normal. He was clinically OK, but by the time he had lost quite a bit of range of motion because he sustained another fall and his range of motion, as you can see, is barely 0 to 30 degrees
ANOOP JHURANI: so it's a stiff knee. Whenever we are dealing with a stiff knee, we got to plan our exposure very carefully, very meticulously and this case, we have planned rectus snip pre operatively. Now, if the tightness is in FRA patella accompanied by patella varhar, then a tibial tubercle osteotomy is the most appropriate way to expose a stiff knee. But in this case, the tightness was supra patella. So we did a rectus snip,
ANOOP JHURANI: as you can see, that rectus snip is at the highest edge of the quadriceps tendon. Where there is the vastus lateralis muscular origin so that's where the rectus snip is, and then we release the lateral gutter carefully, the medial gutter, clear the gutters, and then gradually flex the knee. So the first thing is the rectus snip then is a lateral release to facilitate the range of motion of the knee.
ANOOP JHURANI: So now you can see the knees bending up to 40, 45 degrees, still very tight because the spacer is broken. You can see that there is broken spacer and we'll remove it piecemeal. So that's the broken spacer coming out piecemeal and then we'll further flex the knee to take out the tibial part of the spacer. But the important thing is to do the rectus slip
ANOOP JHURANI: if the range of motion is less than 45 degrees to plan a rectus snip or a tibial tubercle osteotomy, especially if there is patella varhar, then tibial tubercle osteotomy is the best way to expose the joint. But in this case, the rectus snip worked pretty well, and gradually by clearing the gutters, you facilitate further range of motion of the knee. So here you can see that we have taken out the tibial spacer, also the femoral spacer, and now the knee is flexing up to 110 degrees because we need that amount of range of motion to complete the reconstructive operation
ANOOP JHURANI: there is a revision. Now we are clearing the posterior capsule to facilitate further range of motion and continuous debridement goes on and wash goes on. And once we debride thoroughly, we wash thoroughly, now we can see and analyze and assess both the extension and flexion gaps. So you can see that the flexion gap is bigger, usually in these situations the flexion gap is bigger, especially medially opening up.
ANOOP JHURANI: So you can see that the flexion gap is bigger than the extension gap so we need to posterior rise the femur and upsides of the femur. The first thing is to take the tibial cut, make the tibial platform nicely, do an intramedullary rod after we cleared all the cement. It's very important to clear all the cement so that the rod goes in the right direction, and is not misguided by any remnant cement.
ANOOP JHURANI: So once the cement is clear, you just take one or two millimeters off especially on the lateral side so that the cut becomes absolutely neutral. You can see the cut. The cut is nice, perpendicular to the mechanical axis and varus valgus and then you use the offsetting of this tibular system to your advantage because the rod will dictate the tibial component position.
ANOOP JHURANI: So you ensure that your tibial component is well sitting, so this is a 360 degree offset stem, so you can rotate it in any position. So the best is to laturalise the tibial trim by medialising the offset. So the offset and that component moves in opposite direction. So in this case, the, the offset is medialised to lateralize the tibial trace. So that's the offset perforation first and then the stem preparation.
ANOOP JHURANI: The key principle is that the offset needs to be utilized, the stem position needs to be utilized to our advantage for the tibial and the femoral components. Then the distal femur cut, the distal femur cut is again minimal, a millimeter or two, not more than that. Since this case, the extension space was a little tighter than the flexion space. We took one, one and a half millimeter of femur to make it at six degree valgus perpendicular to the mechanical axis.
ANOOP JHURANI: And that's important, so that your component sits on flat board. In case your extension space is loose, then you can use distal augments. But in this case, the distal augments may not be required because the flexion space is looser. Again, we are using off setting of the femoral stem. You can see it can be rotated 360 degrees. So the important thing is to inferiorise so that your flexion gap becomes snug, so inferiorise so that you're flush with the anterior cortex,
ANOOP JHURANI: The saw blade is on the anterior cortex and you can lateralize and posterior rise the femur component so that your flex in space is sunk snug, your anterior offset is minimal, and that facilitates the patellar range of motion, the patellar tracking and the range of motion. So this is an important concept is to posterior rise the femur component so that your patella and the anterior compartment is not overstuck and your patellar tracking is good.
ANOOP JHURANI: Then the chamfer cuts, again it doesn't cut much, but you need to move the saw so that a millimeter or two, whatever bone is there, it comes in your way, gets sawed off. Then the preparation for the offset is stem and finally, the preparation for the box. So this is a size 6 of the femur and size 6 on the tibia as well. So this is a male patient, big sizes and then we clear the patella of any soft tissues ideal to resurface the patella
ANOOP JHURANI: but in this case, the one side was truly hibernated and the thickness wasn't great. So we decided to let it remain and resurfaced. But ideally speaking, patella should be resurfaced in every revision case. But you need to assess the bone quality because the patient was immobile. The bone quality of the patella becomes really poor, osteoporotic and eroded on one side.
ANOOP JHURANI: So then we make drill holes on the sclerotic bone surface. So no tibial stem or any augment was needed on the femur side in this case. So the important thing is, again, to reemphasize the principle of offsetting that is you offset the component as per the tibial stem and the femur stem. So you can see that the tibial stem is medialised to offset the tibial component laterally. And on the femur,
ANOOP JHURANI: the, the offset is posterior so that the component moves posterior. So the stem moves anterior, the component moves posterior. So that's the important concept to understand. Then the final cementation, it's important to cement it well and do hybrid cementing, so the cement is still the offset. There's a broad part which goes into the sclerotic bone and the stem is well fixed.
ANOOP JHURANI: It's 16 on the femur side, 15 on the tibial side. So it's a very snug cortical purchase of the stem. You got to get very good cortical bite on both the stems so that there is good physeal fixation. The metaphyseal fixation comes by cementing of the offset and the diaphyseal fixation comes by cementing of the component. So that's the final implant you can see, and it needed a big lateral release to facilitate patella tracking.
ANOOP JHURANI: So the important points here were exposure by rectus snip, gradual flexion of the knee by clearance of gutters. Then using the offset, you can see that the offset has been used to posteriorize the femur and lateralize the tibial component. Solid diaphyseal purchase, cementing up to the metaphyses and very good alignment, and good range of motion of the knee up to 90 degrees.
ANOOP JHURANI: The patient is counseled that because of chronic stiff knee he may not get more than 100 degrees and so but we get full extension, we get good patellar tracking by doing a patellar release, a lateral release and get overall alignment and range of motion. So friends, that those were the important principles of doing a posterior spacer revision TK in a stiff knee, because posterior spacer post multiple surgeries, the knee becomes very stiff.
ANOOP JHURANI: So it's important to expose properly, use the principles of clearance of gutters, lateral release and offsetting to reconstruct this kind of knee properly and get right alignment and balance. Thank you very much.
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