A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam check range of motion check neurovascular status concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Interprets basic imaging studies AP lateral tunnel view 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures/staples check radiograph continue physical therapy diagnose and management of early complications<br /> postop: ~ 3 month postoperative visit check radiograph diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI, CT , nuclear medicine imaging and advanced radiographs views 2 Appropriately recomends surgical intervention 3 Modifies and adjusts post-operative treatment plan as needed C Preoperative H & P 1 Obtains history and performs basic physical exam check ROM of the knee check neurovascular status identify medical co-morbidities that might impact surgical treatment 2 Screen medical studies to identify and contraindications for surgery labs ESR and CRP bone scan 3 Order basic imaging studies triplanar radiographs of the knee 4 Perform operative consent describe complications of surgery including infections dislocations thromboembolic dz peri-prosthetic fracture neurovascular compromise malalignment patellar maltracking
E Preoperative Plan 1 Radiographic templating template implant sizes 2 Execute surgical walkthrough describe steps of the procedure to the attending prior to the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation knowledge of the particular implant system and instruments 2 Room setup and equipment required operative table leg holder (optional) 3 Patient positioning supine position use a bump under the operative hip to minimize hip external rotation. <br> A foot holder is used to hold the knee at 90 degrees or more of flexion for parts of the case.<br /> A tourniquet is placed, but must be proximal to allow adequate room for prepping and draping. G Superficial Dissection 1 Identify previous incision and anatomy identify tibial tubercle, patella, and patellar ligament. extend the midline incision more proximal to allow adequate access 2 Expose the extensor mechanism expose the entire extensor mechanism (quad tendon, patella, and patellar ligament.) 3 Create Skin Flaps elevate skin flaps just deep the the fascia the perforating arteries which supply the skin run just superficial to the deep fascia H Arthrotomy and Deep Exposure 1 Identify medial aspect of patellar tendon and quadriceps tendon identify the medial aspect of the patellar ligament, medial aspect of the patella and the quad tendon lateral to the vastus medialis oblique (VMO). 2 Perform an extended arthrotomy start from the proximal aspect in a longitudinal manner curving medially around the patella, leave 3-5 mm of soft tissue on the patella complete the arthrotomy by a straight distal cut along the medial border of the patellar ligament.<br> extended exposure is needed to visualize the medial and lateral femoral gutters avoid any disruption of the tendon insertion on the tibial tubercle the main danger of the approach is avulsion of the patellar ligament. <br> 3 Clear the medial and lateral femoral gutters clear and excise any excessive synovium that is overlying the distal femur in the suprapatellar pouch remove any fibrotic fat pad that is present 4 Perform quadriceps snip incise the quadriceps tendon incise in a lateral oblique fashion from distal to proximal at a 45 degree angle split the vastus lateralis muscle fibers this will increase lateral patellar subluxation,knee flexion and exposure of the lateral compartment of the knee quadriceps snip should exit the quadriceps tendon distal to the musculotendinous junction of the rectus femoris 5 Flex knee, and evert patella flex the knee to at least 90 degrees and evert the patella 6 Place retractors A lateral retractor is then placed under the lateral meniscus near the mid-coronal plane a medial retractor retracts the medial sleeve posterior retractor (PCL or Homan style) is placed in front to the PCL to push the tibia anteriorly I Component Removal 1 Remove polyethylene place an osteotome at the interface of the polyethylene and the tray use the osteotome to lever the tray out if a pin is present posteriorly, use a saw to divide the post to expose the metal pin remove the pin with a rongeur 2 Remove tibial component identify the prosthesis cement interface or the prosthesis bone interface disrupt the interface use a thin saw blade to disrupt the interface externally rotate the tibia to expose the posterior aspect of the tibias component create a clear path for component removal the posterolateral aspect of the tibial component must clear the posterolateral femoral condyle hyperflexion is needed to achieve this disimpact the tray with a punch if does not separate easily then stack osteotomes avoid levering the bone to prevent bone loss remove any remaining cement with rongeurs if needed 3 Remove femoral component identify the prosthesis cement interface or the prosthesis bone interface disrupt the interface use a thin saw blade to disrupt the interface use osteotomes to deepen disruption of the interface disrupt the interface from medial and lateral sides don`t try to traverse the entire interface from one side disrupt the posterior condylar interface with a curved or angled osteotoe remove the implant by hand or with a punch after it has been dislodged remove any remaining cement with rongeurs if needed 4 Remove patellar component identify the prosthesis cement interface or the prosthesis bone interface disrupt the interface use a thin saw blade to disrupt the interface burr out the pegs J Create Tibial Platform 1 Size the tibial component maximize coverage of the upper end of the tibia 2 Place the tibial component place the component in slight external rotation align the center of the component with the junction of the medial and middle third of the tibial tubercle K Femoral Trial and Augments 1 Trial the femoral component with long stem this determines the varus aligment place a posterolateral augment this is to ensure the appropriate external rotation of the revision component L Trialing of Implants 1 Trial the knee with varying thickness of polyethylene 2 Balance extension gap balance extension gap in extension. 3 Balance flexion gap 4 Check varus valgus balance. perform soft issue release perform appropriate releases (medial, lateral, AP ) 5 Confirm implant size and have team prepare cement. 6 Place the cement pulse lavage bone to prepare for cementing. <br> place cement on tibia and femur. 7 Place final implants place tibial, femoral, and patellar components and trial poly liner 8 Confirm final flexion, extension, varus, valgus stability treat any intraoperative complications N Wound Closure 1 Irrigate and obtain hemostasis 2 Place drain (optional) 3 Repair the quadriceps tendon repair the tendon in a side to side fashion 4 Closure joint capsule with running suture the joint capsule is closed with interrupted or running suture closing the capsule at the proximal and distal patellar poles works well to line up the remaining capsular closure. 5 Perform superficial closure use interrupted 3-0 vicryl for subcutaneous tissue run subcutaneous monocryl sutures to approximate the skin edges to lessen tension on the skin closure. apply staples reinforces closure for early rehabilitation 6 Dressing is applied add xeroform over staples apply soft dressing
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics prescribe DVT Prophylaxis appropriately orders and interprets basic imaging studies obtain radiographs of the knee in postop inpatient pt initiate physical therapy POD 1 weight bear as tolerated immediate range of motion exercises to knee 2 Appropriate medical management and medical consultation 3 Discharges patient appropriately prescribe outpatient physical therapy pain meds DVT prophylaxis schedule follow-up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans treats infections dislocations neurovascular compromise