10/31/18. How Do I Get Out of this Jam? David Halsey, MD. Intra-operative problem solving. Femoral side
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1 How Do I Get Out of this Jam? David Halsey, MD Intra-operative problem solving My systematic approach to patellar tracking problems during a primary total knee arthroplasty: Pre-op plan Femur alignment Tibia alignment Patella alignment Soft tissue balancing... last Goals: Rotation alignment in flexion. Optimize trochlear position Assess: relationship to transepicondylar axis/whitesides AP line Corrective action: recut femur in proper rotation with 4-in-1 block 1
2 Goal: Coronal alignment in extension creating proper mechanical avoid valgus > 7 degrees Assess: review pre-op plan and check surgical result by confirming restoration of mechanical axis Corrective action: Recut distal femur as needed Goal: Coronal position - Optimize patellar tracking Assess: femoral component position on distal femur Corrective action: lateralize femur as needed without lateral overhang Goal: Recreate PF joint composite thickness to avoid overstuffing Assess: Anterior femoral resection thickness with caliper and compare to femoral component anterior flange thickness Correction: Recut anterior femur to ensure flush cut on anterior femur vs. subtle cortical blend 2
3 Goals: Tibial tray rotation that provides best tibial coverage and aligns PFJ forces. Avoid tibial internal tray internal rotation Assess: Inspect tibial tray position and confirm centered on junction middle and medial third of TT (in most cases). Ensure no posterolateral conflict forcing tibial component internal rotational Corrective action: Correct any malrotation identified Tibial side Tibial side Goal: Coronal position, optimize trochlear position & avoid medial overhang Assess: Medial-lateral tibial tray position Corrective action: Lateralize tibial tray while maintaining rotational alignment Tibial side Goal: Alignment with femur component Assess: Compare to femoral AP axis femoral or femoral component marking in flexion and extension Corrective action: Translate tibial tray to align with femur while maintaining proper rotational alignment with tibial tuberosity 3
4 Goal: Patellar bone cut parallel to anterior patella surface Assess: Inspect/palpate patella resection alignment with anterior patella Haptic assessment Corrective action: Recut as needed while considering remaining patellar bone stock Goal: Measured resection equal to patellar component thickness to avoid PFJ overstuffing; residual patellar bone thickness > 12mm Assess: Measure patellar resection thickness with caliper Corrective action: If too little bone resected, consider additional resection to match component thickness if patellar bone stock allows Goal: Restore patella dome position to native median ridge or slightly more Assess: Patellar trial surface position on patella (proximal/distal & medial/lateral) Corrective action: Medialize patella to optimize patellar tracking 4
5 Goal: Avoid uncovered lateral bone that could tent lateral soft tissues or impinge on the lateral trochlear ridge Assess: Residual lateral uncovered patella Corrective action: Perform partial lateral patelloplasty Goal: Appropriate rotational alignment if using asymmetric patella Assess: Confirm that axis of component is properly aligned with trochlear groove Corrective action: Reposition to asymmetric patella properly Goal: No lateral soft tissue crepitance or impingement Assess: inspect/palpate lateral gutter for synovial thickening/scar Corrective action: debride residual lateral gutter pathologic synovium/scar 5
6 Goal: Balanced PFJ soft tissues throughout full range of motion Soft tissues Assess: Inspect/palpate for tight lateral retinaculum No thumbs test Towel clip test Vertical patella test Corrective action: Stepwise lateral release protecting superolateral geniculate artery Towel Clip Test 6
7 Lateral release Soft tissues Goal: No lateral soft tissue crepitance or impingement Assess: Inspect/palpate lateral gutter for synovial thickening/scar Corrective action: Debride residual lateral gutter pathologic synovium/scar 1. Preop planning Take home 5 2. Femoral alignment 3 D 3. Tibial alignment 3 D 4. Patellar alignment 2 D 5. Soft tissue tension 7
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