dulouz
Joined: 04 Feb 2003
Location: Uranus
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 Posted: Tue Jul 05, 2005 9:09 pm Post subject: Operative report for K teacher class |
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I have to have teacher class twice a week and the next class will have this... I think they will squirm from the detail or the sheer boredom.
[quote]
OPERATIVE PROCEDURE: TOTAL KNEE REPLACEMENT (ARTHROPLASTY)
The patient was brought to the operating room and placed on the operating table in the supine position. A sand bag was then positioned for maximal knee flexion of the right knee and then taped in position. The right knee was then elevated, and a pneumatic tourniquet, pretested at 350 mm Hg, was placed around the right upper thigh. The right leg was then prepped and draped free.
The preoperative vancomycin intravenous drip was completed. The leg was then elevated and exsanguinated with the use of an Esmarch bandage, and the tourniquet was then inflated.
A midline incision, beginning 3 cm proximal to the superior pole of the patella as well as inferior to the inferior pole of the patella, was then performed with a #20 scalpel through the skin. Meticulous hemostasis was obtained with electrocautery. Dissection was taken down through the same line to the level of the quadriceps tendon, the patellar periosteum, as well as the patellar tendon.
Undermining of the skin flaps to expose the medial and lateral retinacula was then performed, and a paramedial retinacular incision was then performed with a separate #20 scalpel through the midline of the quadriceps tendon, through the medial border of the patella, and down to the level medial to the patellar tendon. The patella was then everted, and the retropatellar fat pad was then excised.
Proximal medial periosteal elevation of the proximal tibia was then performed, and the patella was then everted and flexed. Angle bone spikes were placed into the medial and lateral gutters of the knee with soft tissue debridement of the cruciate ligament and the meniscal bodies, which were then sharply resected and removed.
A Hohmann retractor was placed posteriorly and centrally and anteriorly displaced the tibia. An external tibial alignment guide was then placed around the leg. The highest point of the medial articular surface was then chosen with a stylus. A 5-degree, posteriorly angled, cutting jig was then fixed to the anterior surface of the proximal tibia with transfixion pins.
After this was performed, the alignment device was removed, and the cutting jig was left in place. The oscillating saw was used to resect 4 mm of proximal bone. After this had been performed, the jig and the pins were removed. The rest of the soft tissue of the proximal tibia and menisci were removed as well.
After further irrigation, attention was then shifted to the femur. A step drill was placed anterior to the insertion of the anterior cruciate ligament, and a 0.25-inch drill hole was then placed up into this area, connecting with the intermedullary canal. An intermedullary alignment guide was then placed at 70 degrees of valgus for the right knee and driven up into place. An appropriate amount of rotation was then determined, and the jig was then pinned in place into the distal femur. After this had been performed, a provisional anterior cutting jig was fixed to this, and an oscillating saw was used to make the provisional anterior cut. The alignment of this cut was noted, and the 70 degrees of valgus was deemed acceptable.
The distal femoral cutting jig was then applied to this intramedullary device and pinned into position. The intramedullary device was then removed. A distal cutting jig was used for an 8-mm cut, and the appropriate amount of medial and lateral condyle was removed.
At this point, sizing of the femoral cuts measured approximately a size-7 femur and a size-7 tibia. The anterior-, posterior-, and chamfer-cut jigs were then fixed to the distal portion of the femur, and the appropriate cuts were made with an oscillating saw. Both 8-mm and 10-mm spacer blocks were placed in both flexion and extension, with adequate ligamentous tensing and full extension with the 8-mm block only. The trial prosthesis was then placed on the femur, and adequate seating with all the cuts had been noted. Attention was then turned to the two distal drill holes. With a 0.25-inch drill bit, drilling was done into the distal medial and lateral portions of the condyle, and a notch-cutting jig was then placed after the trial prosthesis was removed. The notch was then cut, both medially and laterally as well as from anterior to posterior, and removed with an osteotome. The trial prosthesis was then reinserted, and a #7 tibial tray and an 8-mm spacer were then placed on the tibia. A trial reduction was performed. Adequate ligamentous tension and extension were noted.
At this point, the notches on the anterior portion of the tibia were then marked with a Bovie for appropriate rotation, and the trial was removed. The template was then pinned in place in appropriate position, and the press-fit fins were then performed with a cutting jig through the template. After this had been performed up to the appropriate size #7, all cutting components were removed, and a trial with a posterior-stabilizing stem was then placed and found to have adequate fixation.
Attention was then shifted to the patella. Debridement around the patellar surface was performed, and a patellar cutting jig was placed into position. The measurement of the depth of the patella was 24 mm, and the appropriate spacing device was then used. An oscillating saw was used to make the cut. A size #11 was noted to be the appropriate-sized patellar button. It was noted on his natural bone that there was medial shift of the ridge of the patella.
Three drill holes were then placed in the bone. A trial button with a medial shift, size #11, was fixed, and the depth of the total component and remaining bone was 24 mm. Reduction was then performed, and adequate tracking was noted as well. All trial components were removed, and irrigation was performed. Two packages of methyl methacrylate were mixed. The insertion components, a size #7 femur with posterior stabilizing and a size #7 tibial tray with press-fit fins, were chosen. A size #11 patellar button was chosen.
Irrigation with pulse lavage with 3 liters of normal saline with 50,000 units of bacitracin was used, and the joint dried.
The patellar button was inserted first and clamped into position. The femoral component was then cemented into position and impacted. The tibial tray was then cemented into position and impacted with some force. A trial tibial spacer was placed in and the knee brought into extension. Adequate alignment was noted at this point. After further debridement of any loose and/or extruded cement, the knee was irrigated. The final posterior-stabilized tibial spacer was then inserted. The knee was again irrigated.
Closure was then performed over two drains. The retinaculum and quadriceps mechanism were repaired with figure-of-eight sutures of 1-0 Vicryl. The subcutaneous layer was closed meticulously with 2-0 Vicryl, and the skin with stainless steel staples.
The patellar tracking was noted to be even, and there was no subluxation. One drain was noted to be pulled out as the dressing was being applied. This was then clamped and tied shut. A sterile compressive dressing was applied. The tourniquet was deflated at 96 minutes. The knee was then placed in a knee immobilizer.
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