correcting varus deformity of the knee in total knee replacement
TRANSCRIPT
Dr Vaibhav BagariaConsultant Joint Replacement & Sports Surgeon
Sir HN Reliance Foundation HospitalMumbai, India
THE VARUS KNEE
Welcome you all!
Simplifying Complexities
Varus KneeUnderstanding Anatomy
Classification
Soft Tissue Management
Bone Management
Tips Tricks and Traps
Medial Structures
MCL Attachments
Defining Varus
Maquet Line
Load Bearing Axis, Passes from centre of
Femoral head to Centre of Talus
Classification
Intraarticular
Metaphyseal
PAGODA deformity
Extra articular
Algorithmic approach
Think in terms of anatomy & Classify
Decide in terms of Soft tissue & Bone deformity
Execute with tips tricks and traps of special techniques.
Basic TenetsPreoperative Plan
Assess & Classify
Medial Release
Osteophyetctomy
Metaphysical Bumpectomy
Quadrant of deformity & Bone Loss management
Avoid Over release
Medial releases
A sequential release is performed until the medial structures reach a length equalizing that of the lateral structures.
Create a Medial Sleeve - medial parapatellar approach is preferred.
Creating Medial SleeveThe periosteal elevator is passed deep to the superficial MCL
Elevation should start 3 – 4 cm from the medial tibial plateau where the tibial metaphysis merges with the diaphysis
Bent Homan is inserted to create the sleeve
Creating Medial Sleeve
Order of Medial ReleaseDeep MCL
Posterior capsule
Superficial MCL
Posterior oblique ligament
Semimembranosous tendon
Pes tendon
Popliteus tendon
Medial Release
Semi Membranous release
Posterior Oblique Lig
Osteophyte removal
Remove all osteophytes from Femur & Tibia as they can tent the medial soft tissue sleeve & shorten the MCL
Osteophyte RemovalRemember to check the Posterior femoral condyle and Posteromedial tibia -> as they tighten extension gap.
Cruciate's
For severe deformities- it may be better to use PS type Knees
PCL may prevent complete correction
Non functioning PCL with CR knees —> loss of roll back functioning —> anterior opening and loosening
PCL
Posterior Release15mm or ¾ “ osteotome is used to release the posterior capsule and remove the osteophytes.
By doing this maneuver not only the flexion deformity is corrected, it also releases the medial head of gastrocnemius improving the varus deformity medially
Check the Gaps
Shift & ResectIn case of severe deformities where the gap is still not balanced, it may be a good idea to undersize and laterlize the tibia and remove the medial sclerotic bone.
After the cuts, an undersized trial tibial implant is placed & medial boundaries of the implant are marked with methylene blue. Excess bone removed with saw or an osteotome
Shift And Resect
Shift & Resect
Shift & Resect
Pie Crusting
lengthen soft tissue under tension
use 16 G needle
Remember AF PE ( Atrial Fib - Pulmonary Embolism) Mnemonic
Responsible Structures
Dealing - Residual laxityLateral laxity post balancing can be an issue
IT band is dynamic stabiliser
Medial release can be increased and thicker poly can be used
LCL advancement is an alternative
Take HomeAssess & Plan
Create Medial Sleeve
Do complete osteophtectomy & lumpectomy
Sequential Release
Shift & Resect
Pie Crust