PREOPERATIVE DIAGNOSIS: Painful right total knee replacement.
POSTOPERATIVE DIAGNOSIS: Painful right total knee replacement.
OPERATION PERFORMED: (1) Revision right total knee patellar component. (2) Polyethylene exchange, right total knee. (3) Open arthrolysis, right knee.
ANESTHESIA GIVEN: Epidural.
INDICATIONS FOR PROCEDURE: See the History and Physical report.
DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room. He was placed supine on the operating room table. After a suitable anesthetic had been obtained by an epidural anesthesia, the right lower extremity was prepped and draped in the usual sterile fashion. The right lower extremity was then exsanguinated with the use of an Esmarch bandage and the tourniquet was inflated to 350 mmHg.
The operation commenced with a midline right knee incision that incorporated his previous right total knee replacement incision. This incision was deepened through skin and subcutaneous tissues and the extensor mechanism was exposed. A standard medial parapatellar incision was then made and a laterally-based quadriceps snip was performed to allow for safer mobility of the patella. Subperiosteal dissection was performed along the medial tibial plateau and remaining osteophytes were removed. The patellar tendon was seen to be fibrotic and thickened and the undersurface of the patellar tendon was debrided. With the patella everted, rongeurs and Bovie electrocautery were used to expose the patellar component. The polyethylene was removed, leaving the undersurface metal backing. This was seen to be extremely well affixed and it was felt that to downsize the patella to eliminate patellar overstuffing, that the patella would need to be revised. Flexible and rigid, straight and curved, osteotomes were utilized to separate the metal backing from the underlying bone. This resulted in a significant amount of fragmentation of the periphery of the patella.
The patellar component was ultimately removed, and again, was seen to be well affixed, including bone ingrowth on the three fixation pegs. Attention was now turned towards the tibial side. The tibial bone interface was exposed medially and laterally and there was seen to be no gross motion of the patella. This was performed after removing the rotating patellar platform. The osteotomes were used along the anterior edge and cephalad directed burs with mallet in several different positions were attempted, again without any evidence of tibial side loosening. At this point, it was felt that with the expected bone ingrowth along the tibial stem, that to remove the tibial component would create a significant undue stress on normal bone, and it was felt that the majority of the patient's complaints could be addressed by addressing patellar overstuffing and arthrofibrosis. Arthrolysis was completed in both medial and lateral gutters in the suprapatellar pouch region and in the parapatellar region.
A standard plus/large size 10-mm thick rotating platform trial was then implanted and the knee was taken through a range of motion. There was seen to be approximately 5-10 degrees of recurvatum and flexion easily to 120 degrees. There was good medial, lateral, and AP stability noted. It was felt that this would be the appropriate polyethylene sized insert to implant. The implant was removed and the knee was then copiously irrigated with pulsatile lavage containing antibiotic solution. Deep cultures were obtained for aerobic and anaerobic cultures. A DePuy LCS standard plus/large sized deep dish rotating platform insert was then placed. The knee was then brought back into extension and once again, range of motion and stability were checked.
Attention was now turned towards the patellar side. Using a three-peg polyethylene guide, three drill holes were made in the base of the patella and an LCS three-peg polyethylene patellar insert of standard plus size was cemented into position. Excessive cement was retrieved and loose bone from the patella as well as bone removed from the prominent tibial tubercle ossicle (history of Osgood-Schlatter disease), was morcellized and placed around the periphery of the polyethylene insert. These morcellized bone segments were then gently secured with 2-0 Vicryl by closure of soft tissues around the implant. Patellar tracking was checked and was felt to be excellent and preparations were made for closure.
Consta Vac drains were brought out superiorly and the medial parapatellar incision and lateral leg of the quadriceps snip were repaired with interrupted #2 Ethibond and interrupted 0-Ethibond suture. Once again, the wound was irrigated. The subcutaneous tissue was closed with 2-0 Vicryl. The skin was closed with staples. A light compressive dressing was applied followed by Ace bandage wrap. The tourniquet was deflated. A right lower extremity knee immobilizer was placed. The patient was recovered from the anesthetic and returned to the recovery room in stable condition. There were no complications.
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