DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Failed right knee unicompartmental arthroplasty.
2. Failed plate fixation hardware with seven broken screws, right upper medial tibia.
POSTOPERATIVE DIAGNOSES:
1. Failed right knee unicompartmental arthroplasty.
2. Failed plate fixation hardware with seven broken screws, right upper medial tibia.
OPERATION PERFORMED: Revision right total knee arthroplasty, all components, with removal of seven broken screws and plate.
SURGEON: John Doe, MD
ANESTHESIA: General spinal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 300 mL.
DRAINS: None.
TOURNIQUET TIME: 118 minutes.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female three years post right knee unicompartmental arthroplasty. Postoperatively, after that procedure, she sustained an upper medial tibial plateau fracture, which was treated with an ORIF with a medial buttress plate and seven screws. This went on to fail. The knee developed a severe varus deformity and all of the screws broke.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine fashion on the operating table and then rolled on her side. Spinal anesthetic was administered. She was rolled back supine. General anesthesia was administered, and the Foley catheter was placed. A tourniquet was placed about the right upper thigh, and the right leg was prepped and draped in sterile fashion. Ioban sheet was used. Gloves were changed.
We wrapped the leg with an Esmarch, flexed the knee, and inflated the tourniquet. We elliptically excised the patient’s previous 12 cm anterior longitudinal incision and extended it 10 cm distally and 10 cm proximally. We then made a medium parapatellar arthrotomy, and there was evidence of metallosis within the joint as expected from the failed hardware.
We performed a complete synovectomy and recreated the medial and lateral gutters as well as the suprapatellar pouch. We elevated the deep fibers of the MCL off the upper medial tibia extensively in order to facilitate removal of the buttress plate and the broken screw heads x7.
We then removed the failed tibial medial unicompartmental arthroplasty component and then set about exposing the tibia after we carefully everted the patella and flexed the knee. We excised the ACL, the PCL, and anterior meniscal remnants. We then subluxed the tibia forward and then set about removing the seven broken screws from the upper tibia utilizing a combination of the Midas Rex R-10 bur and the broken screw extractor set.
Once we had accomplished this, we measured the medial tibial defect to be 10 mm, and we cut it again with the oscillating saw to a level cut perpendicular to the AP long axis of the tibia. We then cut the lateral half of the tibia with the oscillating saw, using extramedullary alignment and then thoroughly pulsatile lavaged and irrigated the tissue. Medial tibial defect had two holes, which were made round so as to not create a stress riser on the medial tibial metaphyses 5 cm down from the medial joint line.
We carefully opened up the tibial canal, and then, using 9 and 9.5 and finally a 10.0 reamer reamed down to a 150 mm depth. We then used the tibial alignment guide to drill our proximal hole in the appropriate rotation and then used the Midas R-10 to make our thin cuts.
We then assembled a size 3 tibial component with a 10 mm medial hemiblock build up and a 10 x 100 stem for a total length of 145 mm. We set this in place and then retouched our cuts so that it would have optimal bone contact, and we were very satisfied with this position.
Prior to this, we removed the medial femoral component with combination of the saw and osteotomes preserving as much medial femoral condyle as possible. We took the PCL in order to effectively balance the knee and then we used our intramedullary cutting guide on the femur to make our distal femoral cut at 6 degrees valgus, orientation along with the transepicondylar axis of the femur, using this as a referencing point since the medial femoral condyle had been previously operated.
We then incised the femur to a size D, pinned this cutting block in place and made our cuts with the oscillating saw and trimmed any osteophytes. We used the femoral box cutting guide to make our femoral box cut, but we did not have to stem the femur since there were no significant bony defects.
We then assembled the knee with a size D LPS-Flex femoral component and 10 mm posterior stabilizer to ensure the skin has full extension and flexion to 105 degrees with excellent balance, alignment, and tracking.
We everted the patella, held it with towel clips, resected the articular surface with the oscillating saw and then drilled the three peg holes to the 29 mm trial. The trial tracked nicely throughout the range of motion.
We then removed all of our trial components, thoroughly pulsatile lavaged and irrigated and dried the bony surfaces. We then mixed up one batch of Simplex cement with 1.2 gram of tobramycin powder and cemented on a size 3 tibial component with a 10 x 100 stem and a 10 mm medial hemiblock into position and scraped away excess cement and held this until the cement dried.
We then mixed up a separate batch of Simplex cement, again with 1.2 gram of tobramycin powder and cemented on D LPS-Flex femoral component, scraped away excess cement and then cemented on a 29 mm resurfacing patellar component, held this with the clamp, reducing the knee with a 10 mm trial insert and scraped away excess cement from the patella. Once the cement hardened, we let down the tourniquet at 118 minutes. We cauterized any bleeders. No unusual bleeding was encountered.
We then meticulously went through the knee and removed any retained cement. We then placed a trial insert once again and arranged the knee, and we were very pleased with this result. We then snapped in the permanent 10 mm size 3 posterior stabilized tibial insert, checked it for security and reduced the knee, put the knee through full range of motion.
We irrigated once more and then closed using #1 figure-of-eight Vicryl sutures for the fascia, inverted 2-0 Vicryl for the subcutaneous tissue, and staples for the skin. We infiltrated the wound with 0.25% Marcaine and applied a sterile dry dressing followed by well-padded Jones dressing. The anesthesiologist then placed the right femoral nerve block, and we transported the patient to recovery in satisfactory condition. Sponge and needle counts were correct x2.
