Instability in TKR
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Transcript of Instability in TKR
INSTABILITY IN TKR..!!
DR RISHI RAM POUDEL
DR RISHIRAJ
PROF R.MALHOTRA
Total Knee Arthoplasty..!!!
Aims:
• Restoration of mechanical axis
• Restoration of joint line
• Balance soft tissues
• Equalize flexion & extension gaps
• Restore patellofemoralalignment & mechanics
Basic principles..!!
• Tibiofemoral alignment should be restored to 6±2º of anatomic valgus
Coronal plane: femur in 5-10 degrees of valgus
tibia resected at 90±2º in relation to
tibial shaft axis
Sagittal plane: femoral component in 0-10º of flexion
tibial component neutral or 5º posterior slope
Rectangular & equal flexion & extension gaps
Bone cuts in TKA..!!!
• Resection of proximal tibia influences both FLEXION & EXTENSION gaps
• Resection of distal femur selectively influences the EXTENSION gap
• Resection of posterior femur selectively influences the FLEXION gap
• Resection of anterior femur influences both FLEXION gap & PATELLOFEMORAL JOINT
Bone cuts in TKA..!!! Distal femoral cut
Intramedullary jig in desired valgus angle
Femoral cutting guide Distal femoral cut
Bone cuts in TKA..!!Proximal tibial bone cut
Extramedulaary cutting guide Resected tibial bone
Bone cuts in TKA..!!
Femoral sizing:
Antero-posterior femoral cuts
Posterior referencing Anterior referencing
If sizing falls into “between “ sizes:Smaller size recommended in anterior referencing to avoid over-stuffiing of flexion gapLarger size recommended in posterior referencing to avoid anterior notching of femur
Bone cuts in TKA..!!Rotation of femoral component
Antero-posterior femoral cuts
Epicondylar axis is 3º externally rotated to Posterior condylar axis
Whiteside’s line perpendicular to Epicondylar axis
In valgus knees posterior condylar axis distorted by dysplastic lateral femoral condyle
Relation between epicondylar axis & whiteside’s line remains constant
Bone cuts in TKA..!!Antero-posterior femoral cuts
Transepicondylar axis: key reference for rotation of femoral component
Bone cuts in TKA..!!
Antero-posterior femoral cuts
Trans-epicondylar axis Femoral sizing jig
Bone cuts in TKA..!!Antero-posterior femoral cuts
Headless pins in 3º external rotation Angels wing to estimate level of cut
Why usual 3 º external rotation??
Because tibial resections are performed perpendicular to long axis—not the normal 3º medial inclination of the medial plateau—externally rotated femoral component is necessary to ensure balanced flexion-extension gaps
Internal rotation of femoral component has higher rates of patellar mal-tracking & subluxation
Bone cuts in TKA..!!Antero-posterior femoral cuts
Anterior femoral cut Posterior condylar cuts
Rectangular flexion & extension gaps..!!
Flexion & extension gaps…!!
Flexion gap & extension gaps should be rectangular & equal
Balancing the gaps..!!
Preoperative Planning to prevent instability in Total Knee Arthoplasty :OCNA volume 32.number 4.October 2001
BALANCING THE GAPS..!!
BALANCING THE GAPS..!!
JOINT LINE LEVEL..!!!
Normal joint line Lowered joint line Elevated joint line
Correct joint line level should be maintained to ensure good patellar tracking & collateral ligament symmetry
JOINT LINE LEVEL..!!
Properly placed joint-line should be:
10 mm from lower pole of patella
approximately 30 mm distal to medial femoral epicondyle
25 mm distal to lateral epicondyle
10-15 mm proximal to fibular head
TKR Failure..!!
1.Aseptic loosening
2.Instability3.Structural failure of implant
4.Sepsis
5.Extensor mechanism rupture
6.Stiffness
7.Peri-prosthetic fracture
8.Undiagnosed Pain
Little attention directed towards instability despite it being a cause of failure and reason for revision in 10-22 percent cases
Leading causes for failure: INFECTION (38%) & INSTABILITY (27%)
Malalignment & Instability are major causes of early failue ,therefore ligamentous balancing & appropiate alignment are paramountin performing the surgery..!!
Instability after TKA…!!
Tibio-femoral instability
Instability in extension Instability in flexion
Symmetric AssymetricMid-flexion Antero-posterior
Patellar instability
Approach to "instability”..!!
“Patient’s report of instability is not a diagnosis..!!”
Causes of buckling & giving away:
1. Pain
2. Fixed flexion contracture
3. Quadriceps weakness
4. Patellar dislocation
Kelly G. Vince ,Ayesha Abdeen ,Tanzo sugimori:The unstable total knee arthoplasty causes and cures: The journal of Arthoplasty vol.21 No.4 suppl.1 2006
Approach..!!
Presentation:
Gross instability: FRANK DISLOCATION
Subtle mechanical instability:
1. Vague complaints of anterior knee pain
2. Recurrent effusions
3. Soft tissue tenderness to palpation
4. Difficulty starting ambulation after being seated
Approach…!!
History:
1. Original diagnosis precipitating knee replacement
2. Pre-operative deformity or contracture
3. Type of prosthesis
4. Specifics of operative procedure
5. Post-operative rehabilitation program
6. Any trauma to knee after surgery
Approach..!!
Physical examination:
1. Generalised ligamentous laxity
2. Gait (varus or valgus thrust)
3. Anteroposterior & varus-valgus stability in extension,30 degrees of flexion & 90 degree of flexion
4 .Patellar tracking & intregity of extensor mechanism
Radiographs…!!
1. AP,Lateral & Sky-line views
2. Scannogram B/L Lower Limbs
3. NCCT knee
Extension Instability..!!
Symmetric
• Uncommon
• Components don’t fill space.
Asymmetric
• Common
• One side is not balanced correctly.
Extension instability..!!
Potential instability corrected by using thicker tibial insert
symmetric
Sebastein Paratte ,Mark W Pagnano:Instability After Total Knee ArthoplastyJBJS vol 90 A.No 1.January 2008
Extension instability..!!symmetric
Using thicker tibial insert will elevate the joint line with tight flexion space,midflexion instability and patella baja
Solution:distal femoral augments
Undercorrection of fixed angular deformity ,out of fear of creating instability in opposite direction…!!
Extension instability..!!assymetric
Inadequate release
Medial release for varus knees..!!
Medial release for varus knee..!
Periosteal stripping of medial structures while maintaining continuous soft tissue sleeve
Needle puncturing is new,effective,and safe technique for correction of MCL tightness in varus knees
Lateral release for valgus knees..!!
“Inside-out” technique..
Sequence:
1.Removal of lateral osteophytes
2.Placement of lamina spreader to assist gap tightness
3.PCL release completely from femur
4.Postero-lateral capsule release intra-articularly with electrocautery
5.ITB lengthening with “pie-crust” technique
6.Popliteus release if still tight laterally The depth of surgical blade kept at <5mm
to avoid peroneal nerve injury..!!
Lateral release..is it over-released??
With trial prosthesis in place ,limb in ‘figure-4’ position..!!
“If dislocation: thicker or more constrained tibial insert to be used”
Iatrogenic collateral injury..!!
During proximal tibial resection & vigorous varus-valgus stability testing..!
1.Surgical re-approximation of ligament with use of krackow-pattern sutures.
2.Augmentation with hamstring tendon
3. Constrained condylar implant to add stability..!
MCL Augmentation with hamstring tendon..!!
The hamstring tendon can be run through a drill hole to the femur & tied over a button
Use of increased constraint contributes to favorable outcome
Treatment without increased constraint were associated with residual instability requiring revision
FLEXION INSTABILITY..!!PS KNEES
DSF or” jump distance”:distance needed for cam to ride over the post before dislocating.
FLEXION INSTABILITY..!!PS KNEES
Most common activity leading dislocation is marked knee flexion plus a varusstress(putting ankle of operated limb on contralateral knee)
FLEXION INSTABILITY..!!• Loose flexion gap
associated with LCL laxity
At risk: who had correction of large valgus deformity & regained knee flexion with aggressive rehabilitation
1st dislocation:closedreduction ,trial of bracing & avoiding activity leading to dislocation
Recurrent dislocation:
1.Thicker insert(if room in extension space)
2. Constrained condylar implant
The new construct to be checked in fig-4 position.
PS KNEES
• Sense of instability without giving away
• Difficulty ascending & descending stairs
• Recurrent knee effusions
• Peri-retinaculartenderness
• Excessive anterior translation
8 out of 10 patients of symptomatic flexion instability treated with revision arthoplasty.
1.Obtaining balanced flexion-extension gaps
2.Careful attention in filling flexion space with larger femoral component & posterior femoral augments
FLEXION INSTABILITYwithout dislocation:
PS KNEES
FLEXION INSTABILITY..!!
Causes:
1.Excess flexion gap:undersized femoral component & excessive tibial slope
2.PCL failure
3.Posteromedial polyethylene wear
Symptoms & signs:
1.Sense of instability without giving away
2.Recurrent knee effusion
3.Posterior sag sign
4.Tenderness over pes-anserinus region & retinaculum
CR KNEES
Treatment
Non-operative :poor results
Operative :conversion to Posterior Stabilized implant design with focus on balancing flexion-extension gaps
FLEXION INSTABILITY..!!CR KNEES
Mid flexion instability..!!!
• Relatively newly described problem
• When large distal femoral cut is made to address pre-op flexion contracture
• In full extension posterior capsule will provide varus-valgus stability. With knee past 30º flexion posterior capsule is no longer taut ,collaterals will be loose due to elevation of joint line & instability results..
Mid-flexion instability..!!
Prevention:
Address pre-op flexion contracture with posterior capsule release & removal of osteophytes while minimizing excess distal femoral resection
Preventing mid-flexion instability…!!
Flexion gap>>extension gap Posterior release
Hyperextension..!!
Hyperextension after TKA is very difficult to correct
Best management is “Prevention”
Recurvatum :
1.Severe valgus deformity with ITB contracture :RA
2.Neuromuscular disease:Polio
3.Collateral instability may lead to recurvatum post-operatively
Hyperextension..!!
Hyper-extension..!!
Krackow & Weiss collateral transfer.
Moving femoral origins of MCL & LCL proximally & posteriorly creates a tightening action during full extension of the knee
“HINGED TKR”
Hyper-extension..!!
Patellar instability..!!Etiology..
• Internal rotation & medialisation of femoral component
• Internal rotation malalignmentof tibial component
• Lateralisation of patellar button & faulty patellar resection
• Overall alignment of >10 degree valgus or femoral component in >7 degree valgus
Leading cause for revision surgery
Surprisingly, often the most neglected part of a TKA surgery!!!
Michael Malo,Kelly G. Vince :The unstable patella after TKA,etiology ,prevention & management:J Am acad Orthop Surg 2003;11:364-371
Patellar instability…!!
Medial parapatellar Subvastus Midvastus
Requirement for lateral retinacular release significantly low in subvastus & midvastus approach
Bindeglass DF ,Cohen JL:patellar tilt & subluxation following subvastus & parapatellar approach in TKAJ Arthosplasty 11:507-511,1996Engh GA ,Parks NL,Ammeen DJ:Influence of surgical approach in lateral retinacular release in TKA ClinOrthop 236:44-51,1988
Patellar instability..!!
IR femoral component: lateral patellar tilt & tendency to track laterally
Patellar instability..!!
Medialisation of femoral component has similar effect to that of internal rotation on lateral patellar tracking
Patellar instability..!!
Internal rotation of tibial component forces tibia into external rotation during flexion increasing the Q angle , leading to lateral patellar tracking &subluxation
Patellar instability..!!
Resection of more bone from medial facet is necessary to obtain symmetric patellar cut parallel to anterior surface
Patellar instability..!!
Overstuffing of patellofemoral joint tightens the lateral retinaculum increasing risk of lateral patellar tracking
Patellar instability..!!
Medialisation of patellar component allows patellar button to be centralisedin the trochlear groove
No thumbs technique..!!
Patella should track in the trochlear groove & medial facet should be in touch with femoral prosthesis throughout the ROM
Patellar instability..!!
• Peri-patellar pain & limited flexion without symptoms of frank instability
• Usually pain has been present since surgery different from pain before surgery
Radiology..!!
Laterally subluxated patella in merchant view
Radiology..!!Femoral component evaluation..!!
Berger et al:Rotational instability & malrotation after TKAOCNA vol 32.No 4.October 2001
Radiology..!!
Relation between tibialcomponent axis & tibialtubercle orientation
(normal:18 degrees)
Berger et al:Rotational instability & malrotation after TKAOCNA vol 32.No 4.October 2001
Berger et al:Rotational instability & malrotation after TKA OCNA vol32.No 4.October 2001
Combined component rotation & patellar complications..!!
Management…!
• Non-surgical measures :unsucessful
(strengthening VMO,Bracing)
In absence of component malposition:Lateral retinacularrelease with or without VMO advancement & medial plication
Osteotomy & medial displacement of tibial tubercle
(feared complications: patellar tendon rupture & non union of osteotomy)
When substantial malposition of components revision of components is the procedure of choice..!!
Principles of revision TKA ..!!
Robert B.Bourne ,H.A rawford:Principles of revision total knee arthoplastyOCNA vol 29.No 2.April 1998
Prevention is better than cure..!!
“Preventing instability during primary surgery saves the revision surgery”..!!
Thank You..!!!!!