A Basic Initial Evaluation and Management 1 Obtain focused history and performs focused exam Identify medical issues that may impact surgical care Knee specific exam should include assessment of soft tissues, range of motion, laxity, and distal neurovascular exam 2 Interprets basic imaging studies (radiographs) Understands Radiographic views of the arthritic knee weight-bearing AP sunrise view Identifies normal anatomic landmarks of the kneee Identifies pathologic findings of the arthritic knee 3 Prescribes and manages nonoperative treatment NSAIDs Physical therapy Assistive devices Injections 4 Makes informed decision to proceed with operative treatment Documents failure of non-operative management Describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation Postop: 2-3 week postoperative visit wound check remove sutures/staples check radiographs continue physical therapy diagnose and management of early complications<br /> Postop: 3 month postoperative visit <br> check radiographs diagnosis and management of early/late complications<br> Postop: 1 year postoperative visit check radiographs diagnosis and management of late complications B Advanced Initial Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies Advanced radiographic views, MRI, CT, nuclear medicine imaging, etc. 2 Appropriately recommends surgical intervention 3 Modifies and adjusts post-operative treatment plan as needed C Preoperative History and Physical Exam 1 Obtains history and performs physical exam Identify medical issues that may impact surgical care Knee specific exam should include assessment of soft tissues, range of motion, laxity, and distal neurovascular exam 2 Order basic imaging studies Multiplanar radiographs of the knee, preferably weight bearing 3-foot standing films for leg alignment (optional) 3 Perform operative consent Describe complications of surgery infections thromboembolic events peri-prosthetic fracture neurovascular compromise malalignment patellar maltracking
E Preoperative Plan 1 1 Radiographic templating Upload AP knee film with radiographic marker into templating software system Identify the radiographic view, side to be templated, and calibrate the image Determine the AP resection lines for the femur and tibia relative to the anatomic axes the proximal tibial resection is perpendicular to the anatomic axis the distal femoral resection is in 5 degrees of valgus relative to the anatomic axis Measure the distance between the IM cutting guide and the lateral femoral condyle Upload the lateral knee film and calibrate the image Measure the depth of the anterior femoral cut relative to the tip of the anterolateral flange of the distal femur Evaluate for posterior femoral osteophytes Measure the amount of posterior tibial slope 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 P 1 Surgical instrumentation Confirm that all necessary surgical instrumentation is on the back table and sterile 2 Room setup and patient positioning An OR table with removable leg extensions is used The patient is placed in the supine position Secure both arms to well-padded arm boards placed at 90 degrees of abduction A thigh tourniquet is placed as proximal as possible on the operative leg A foot holder plate is placed such that the knee bends to 90 degrees The ipsilateral leg extension is removed The nonoperative leg is padded and secured to the bed with tape An ipsilateral hip bump is placed so that the patella points straight toward the ceiling Secure the patient's torso with a seatbelt attached to the bed A mayo stand is brought in from the head of the bed on the nonoperative side Pearls The removable leg extension facilitates surgeon access to the front of the knee 3 Surgical preparation and draping Cover the mayo stand and each arm with two quarter sheets Isolate the operative extremity with an adhesive impervious drape placed just distal to the tourniquet A stockinette is used to grab the foot from the circulator An adhesive drape with tails is placed over the impervious drape distally The foot is placed into a foot holder and secured with a wrap An adhesive bar drape functions as the upper drape for anesthesia A blue towel with suction, bovie, pulsed lavage, and clamps is opened and secured to the Mayo stand, which is now covered by the upper drape An adhesive drape is used to cover all exposed skin on the operative limb The leg is elevated and the tourniquet is inflated G Medial Parapatellar Approach to the Knee 1 P 1 Identify anatomy and planned incision Mark the medial aspect of the tibial tubercle Mark the medial, lateral, proximal, and distal patellar borders Draw a midline longitudinal incision from 2.5 cm above the patella, through the middle of the patella, and to the medial border of the tibial tubercle 2 Incision and superficial dissection Create the planned skin incision with the knee flexed this can be performed in extension as well Use bovie electrocautery to perform subcutaneous dissection to the level of the extensor mechanism Develop medial and lateral full-thickness flaps expose the "lateral soft spot" expose the medial patellar border and VMO fibers Pearls Assistant retraction facilitates medial and lateral flap development H Arthrotomy and Deep Exposure 1 P 1 Identify anatomic landmarks for medial parapatellar arthrotomy Identify the medial quadriceps tendon, VMO muscle fibers, medial patella, and medial tibial tubercle Mark the planned arthrotomy with bovie electrocautery Pearls Place finger at the lateral soft spot and palpate the medial patella and border of the patellar tendon to define arthrotomy 2 Perform medial parapatellar arthrotomy Perform medial parapatellar arthrotomy with a scalpel along the planned incision to aid in subsequent closure, 5 mm of quadriceps tendon is left attached to the VMO likewise, a 5 mm cuff of retinaculum is left attached to the medial border of the patella care must be taken distally not to incise the patellar tendon or its distal insertion 3 Perform superficial MCL partial release Using a scalpel, release the anterior horn of the medial meniscus and partially release the superficial MCL fibers directly off of the proximal tibia ensure dissection directly off of bone Pearls The extent of release depends on the severity of deformity Varus = greater release Valgus = less release 4 Expose and prepare the joint space Extend the knee to release fat pad from proximal tibia Flex the knee and place medial and lateral homans Resect the patellar fat pad Release the ACL, PCL, and lateral anterior meniscal horn Pearls Homan placement should be under the menisci and directly adjacent to the proximal tibia This improves soft tissue retraction and joint exposure I Create the Extension Gap 1 P P 1 Identify proper femoral rotation Place the knee in 90 degrees of flexion Introduce distal femoral intramedullary canal reamer anteromedial corner of intercondylar notch Set femoral rotation with intramedullary rotation guide and mark this with bovie electrocautery Pearls When setting femoral rotation, the primary landmark is perpendicular to the mechanical axis of the tibia Secondary checks include Whiteside's line and the transepicondylar axis The goal is to perform femoral cuts parallel to the eventual cut surface of the tibia in order to achieve balanced gaps 2 Place intramedullary guide and perform anterior femoral rotational cut Insert the intramedullary alignment guide and orient according to the previously marked rotation The anterior cutting guide is placed and secured to the IM guide this should be oriented perpendicular to the mechanical axis of the tibia An oscillating saw is used to make the anterior femoral cut the "grand piano" sign confirms adequate resection Pearls A stylus is placed at the anterolateral femoral cortex to determine the amount of anterior resection Pitfalls Take care to avoid femoral notching, especially laterally 3 Perform distal femoral cut Remove the anterior cutting guide and place the distal femoral cutting guide Secure the distal femoral cutting guide with pins and remove the intramedullary alignment guide Retract the medial and lateral skin flaps with homans to obtain adequate distal femoral exposure An oscillating saw is used to perform the distal femoral cut Pearls The desired amount of distal femoral valgus is based off the IM alignment guide As a general guideline after the distal femoral cut, the cancellous bone of the condyles should approach one another If the cancellous bone meets across the middle, the femoral cut may be excessive 4 Expose the tibia and perform tibial resection Maximally flex the knee and place medial and lateral retractors to maximally expose the joint space A PCL retractor is placed along the posterior tibia and levered to sublux the tibia anteriorly The tibial cutting guide is positioned with an extramedullary alignment rod the alignment rod is oriented from the tibial tubercle to the center of the ankle The depth of resection is set using a stylus and the appropriate tibial slope is set an angel wing stylus can be used to assess the planned resection The alignment rod is removed and an oscillating saw is used to perform the tibial resection A broad, straight osteotome is used to elevate the resected tibia A spiked clamp is applied to allow for manipulation and the resected tibia is stripped from any remaining soft tissue attachments Pearls The PCL retractor is critical to sublux the tibia, maximizing exposure Occasionally, particularly tight knees cannot be subluxed and must be carefully cut in situ Pitfalls Avoid cutting the collateral ligaments, the popliteus tendon, and the neurovascular structures of the posterior knee 5 Evaluate the extension gap Place the extension gap block on the proximal tibia and bring the knee into exension Assess leg alignment, extension gap symmetry, and stability J Create the Flexion Gap 1 P 1 Place the appropriately sized femoral 4-in-1 cutting guide in proper rotation Flex the knee to 90 degrees and insert the flexion gap block Mark the planned posterior femoral condylar resection from the guide Place the appropriate-sized 4-in-1 cutting guide on the distal femur and mark the planned posterior resection Pearls Femoral component sizing is determined by the 4-in-1 cutting guide whose posterior cut matches that of the flexion gap block 2 Perform posterior femoral, anterior femoral, and chamfer cuts Secure the 4-in-1 cutting guide with two threaded pins Use an oscillating saw to perform all femoral cuts, taking care to avoid notching Remove all guides and use an osteotome and rongeur to remove bone from each cut Pearls The second anterior femoral cut allows for fine-tuning of femoral component rotation based upon balanced flexion gap 3 Resect the menisci and remove posterior osteophytes Place femoral intramedullary retractor and open the flexion space Resect the lateral meniscus Resect the medial meniscus Remove posterior femoral osteophytes with a curved osteotome and mallet a curved curette and rongeur can be used to retrieve the osteophytes and any posterior loose bodies Local anesthetic cocktail can be injected into the posterior knee, superficial MCL, and distal femoral periosteum Pearls Preserve the LCL and popliteus to avoid lateral laxity, particularly in flexion Preserve the MCL to avoid medial laxity 4 Prepare the tibia Maximally flex the knee Place medial and lateral retractors Place a wide PCL retractor to bring the tibia forward Perforate sclerotic bone at the tibial surface with a smooth pin to improve cement fixation Secure the appropriate-sized tray to the tibia in proper rotation with 2 headed pins Use a rongeur to remove tibial osteophytes The proper intramedullary guide is attached to the tibial tray and an entry reamer is introduced to the appropriate depth A keel punch effectively maintains the rotation for the final implant Pearls Ensure that the selected tibial tray size does not overhang Ensure proper rotation with the center of the tray in line with the tibial tubercle K Trial Components and Confirm Balanced Knee 1 P 1 Place tibial base plate trial The tibial guides are removed and the trial tray is retained The trial polyethylene insert is placed 2 Place femoral trial component The PCL retractor is removed and the tibia is reduced in flexion to access the distal femur The appropriate-sized femoral trial component is placed and seated with a mallet The medial-to-lateral position is assessed and adjusted as necessary 3 Confirm balanced extension gap Ensure proper extension gap balancing - the knee should be able to fully extend (indicating no flexion contracture) without hyperextension (indicating a loose extension gap) 4 Confirm balanced flexion gap The trial components should not extrude in full flexion ("lift off sign" indicates the flexion gap is too tight) 5 Confirm AP stability Perform manual AP stress testing with the knee in 90 degrees of flexion 6 Confirm varus/valgus balance Manually assess the varus and valgus stability in full extension (extension gap balance), 30 degrees of flexion, and 90 degrees of flexion (flexion gap balance) 7 Confirm femoral and tibial implant sizes Once the proper trial component sizes and positions are confirmed, the femoral pegs are drilled from the trial Use the oscillating saw to make the femoral trochlear cut 8 Prepare the patella Extend the knee Evert the patella, assemble appropriately-sized patellar reamer, and set desired resection depth Remove marginal osteophytes with a rongeur Drill lug holes through the appropriate patellar drill guide Pearls The patellar reamer clamp is placed flat against the everted patella to ensure even reaming in all 4 quadrants Position the drill guide preferentially superior and medial on the patella to facilitate proper tracking of the implant L Final Implant Placement 1 1 Remove trial implants and prepare the femur and tibia Flex the knee and place retractors medially and laterally Remove the trial poly with a small osteotome Remove trial femur with slotted backslap Irrigate the femur with pulsed lavage, place dry lap and wide PCL retractor Remove the trial tibial tray and pins with wide osteotome 2 Prepare the tibial surface and cement the final tibial component Irrigate the tibia with pulsed lavage and dry with lap Manually place tibial cement mantle and digitally impact it into the cancellous bone Impact final tibial component and remove excess cement 3 Place the tibial polyethylene insert Dry the tibial tray with a lap sponge Manually insert the desired polyethylene insert and lock into place with inserter and mallet 4 Cement the final femoral component Remove the PCL retractor and reduce the tibia Manually place femoral cement mantle and digitally impact into the cancellous bone Use a freer to identify the femoral peg holes Impact final femoral component and remove excess cement 5 Prepare the patellar surface and cement final patellar component Irrigate the patella with pulsed lavage and dry with lap Place patellar component with cement Place patellar clamp and remove excess cement N Wound Closure 1 1 Irrigate and obtain hemostasis once tourniquet is deflated Irrigate the wound and obtain hemostasis with Bovie electrocautery prior to closure 2 Close joint capsule/arthrotomy Arthrotomy closure is performed with interrupted Vicryl suture and reinforced with running Quill suture Local anesthetic is injected into the joint as well as the subcutaneous tissues 3 Perform superficial closure Subcutaneous closure is performed with simple interrupted Vicryl suture Subcuticular closure is performed with running Monoderm suture 4 Dressing is applied Dermabond is placed along incision Steri-strips are applied A pre-fabricated silver dressing is applied Webril and Ace bandages are applied
O Postoperative Inpatient Management 1 Write comprehensive admission orders Advance diet as tolerated Pain control Wound management Foley out when ambulating Check appropriate labs Antibiotics Prescribe DVT Prophylaxis Appropriately orders and interprets basic imaging studies obtain post-op radiographs of the knee Inpatient physical therapy initiate physical therapy as soon as possible weight bearing as tolerated immediate range of motion exercises to knee 2 Appropriate medical management and medical consultation 3 Discharges patient appropriately Pain meds Wound care Outpatient physical therapy/rehabilitation Generally follow up in 2 weeks R Complex Patient with Complication Evaluation and Management 1 Develops unique, complex post-operative management plans 2 Diagnosis and management of complex complications Infections Thromboembolic events Dislocations Neurovascular compromise