PREPRINT
jkl keys enabled
2173 views

Total Knee Arthroplasty

Thomas S. Thornhill, MD, David J. Lee, MD
Brigham and Women's Hospital

Transcriptions

INTRODUCTION

I think it's very important in doing a total knee to - the preoperative planning - not only before in the decision-making, but just at around the beginning of the operation. And the two things that I like to do: one is to look at the x-rays and sorta get a sense of what we're doing, and then before we start, we’ll get a feel of the knee to sort of see what the soft tissues are like.

I like to take a 3-foot film - particularly of the femur. And then I draw the line from the center of the femoral head to the center of the trochlea, and then a perpendicular to that line will give us what is necessary to have a mechanical neutral femur. Then I draw a line from the center of the tibia to the center of the talus, and a perpendicular to that line will give you the sense of how much tibia resection you’re gonna do in the medial and lateral side. It doesn't really tell you the amount; it just tells you the proportion, so when I make my comparisons with my instruments on, I see if they are in accord with this.

The other important thing to remember here is you don't want to be in the center of the intermalleolar distance; you want to be in the center of the talus. So therefore, you're going to have to be about 5 to 6 mm medial to the intermalleolar distance to account for that. 3 mm is because of the fact that the center of the talus is about 3 mm medial, and then the proximal medial tibia is another 3 mm. And that will keep you from consistently putting the tibial component in - into varus.

So if you then blow this up, you're gonna see, in this case, we're going to be taking roughly the same amount of bone - if not a little bit more on the medial side than on the - than on the lateral side. And here you'll see we’ll be taking roughly the same cuz she has a - quite a - a - a perpendicular tibia as opposed to many people who have tibia vara. So again, it's not the amount of bone you take but the relative proportion. And one thing that this nice 66-year-old lady has is much of her disease is in the patellofemoral joint. So that while her AP joint doesn't look bad and she has some changes laterally, I think we'll see that she will have changes in all 3 compartments in the knee, and our plan is to do a tricompartmental procedure.

So the patient's name we've - we've talked about. Medical record number is here. We are doing a left total knee replacement. It is marked as such. She's in the supine position. We have our implants available, I see. Fluids for irrigation. Has antibiotic prophylaxis been given? Okay. DVT prophylaxis provided? Yes. This should take us a little bit longer because we are recording it but not too much. No abnormal steps. It will be routine. Anesthesia concerns? All the blades and wires? Nursing concerns? Okay and we have the imaging we've already gone over.

CHAPTER 1

Okay so now one of the important things we talked about is - is that not only the X-ray we’ve gone over but also to get a feel of the knee. In other words, is it a varus knee? Is it a valgus knee? Is it a tight knee? Is it a loose knee? Does it have a flexion contracture? Does it hyperextend? And this lady, who 66 years of age, who has mainly patellofemoral disease, if you look, has some laxity. It’s - and it's in both directions. She if anything's slightly hyperextends. She certainly doesn't have a flexion contracture. So we don't want to over resect her distal femur, and since she is slightly loose and symmetrical, we don't really want to do too much release on either side.

Now I don't use a tourniquet through much of the procedure, but what we will do is use it just for the exposure until we get the knee flexed. So we will put the tourniquet up to 250 millimeters of mercury in a moment. Tourniquet up please.

CHAPTER 2

Table up a little bit please. Incision. Gelpis please. I make a midline incision but little bit to the medial side. Adsons please. Knife. Army-Navy. Now I don't do much of a lateral release here because I don't - I don't have to go there. I just want to be able to see on the medial side of the patella. I'll start out with a small incision, but I have no concerns about increasing the incision. I don't want the ends of the wound to be in a - I want it to look like a V and not a U. Buzz please. Now I like to see - I like to see the vastus medialis obliquus because it allows me - and you can begin to see it right there.

So I enter the knee. I've done subvastus approaches. I've done vastus medialis approaches. I have done the median parapatellar. I do the median parapatellar in virtually every case. It's important not to - not to come way over in the tendon but just be at the edge of the vastus medialis and the tendon. Leave yourself a little cuff and go into the medial side of the knee. I split the fat pad. I like to preserve some of the fat pad. Now I'm gonna just do a small medial release cuz this is not a big varus knee. I just want to be able to get over the side. And since we know she's relatively loose, I don't need to do that much.

Now we’ll take our Gelpis out and see if we can flex the knee. And as I flex the knee, we're gonna watch the medial side. Table down please. Z. So now if you just take a look, you can see here that there is eburnated bone in the - in - on the patella. Neither facet. Mainly in the lateral facet, corresponding to her X-rays. Her trochlea is essentially bare. I hope you can see the difference. Her medial side is worse than her X-ray looks, but we knew because of the osteophyte. Her lateral side is not great. I don't know if you can see, but there's some grade three changes here. And so she's currently got bicompartmental disease and changes in the third compartment, so in my hands, she gets a tricompartmental replacement.

So I’m gonna take out a portion of the medial meniscus. Half inch curved osteotome please. And just to free the posterior blank ligament, I just come around inside the superficial collateral ligament. And what this will allow us to do - mallet please - is just get in, and you can see, you can now externally rotate the tibia a bit if you're having trouble. Z please. Then I'm going to do in the lateral side of the knee - and if you take this Z retractor and put it in, it will often times just fall right into the popliteal fossa. Knife and pickups please.

Now we got to watch out. Don't pull too hard to here. So now I'm going to go into the popliteal fossa, and I'm going to take out part of the lateral meniscus. Now I’m also gonna take out a portion of the fat pad here, and what I do is I start down here and slowly go through the fat pad until I see the infrapatellar tendon, right here. Then if you go inside that, you can cut directly to bone and then come up and take out part of the lateral meniscus.

Could you let the tourniquet down now please? If we could keep her systolic pressure as long as we are perfusing her. Half inch straight osteotome. Now I remove the osteophytes, and I remove them for three reasons. Number one: as you come across, these osteophytes project distally, and so it can make you under resect your medial side. So I will just go ahead and take part of these out. It also gives you a little bit of a media release, and the third thing: it helps you size - size the femur. I'm gonna do a notchplasty at the same time. And we may get a little bit more bleeding, but I think the benefit - as long as we can keep her systolic pressure at a reasonable control, we will have the benefit of not having the ischemic time. And then I will generally put the thing back up.

Schnidt please. Grab the Bovie Steve. We’ll take the anterior cruciate ligament out. There are some bicruciate - okay, Kocher please and a knife. Plunger. Now I'd like to see - I - I’m a PCL sparing primary surgeon in most cases though I will do cruciate substituting knees as well. Most of my revisions are all cruciate substituting knees. Can I have a small sponge and a Kelly? Schnidt. And what you can see here then is the posterior cruciate is right here, and you - and you can also see - I'm not sure you can see with the picture you have, but this - this actually doesn't insert as you know on the - on the top of the tibia; it inserts back of the tibia. And I think that's an important - an important point to understand here.

CHAPTER 3

So now we are ready. For years I was a - let me have a Bent Hohmann. For years I did the tibia first. I now do the femur first. I don't think it matters. I think the other important thing in this video is to understand that the principles are the same, but there's a lot of different ways of getting there. So what you're seeing here is the way we drape, the way we think about it, the way we make our cuts, but there's lots of ways you can do it. I'm showing you a cruciate retaining knee. Cruciate substituting knees - the results are - they’re - they're really pretty indistinguishable. I have reasons for doing the cruciate retaining knee, but - but it's - I think it's important to understand they’re different operations.

So we're gonna be showing you the cruciate retaining knee. Now what - the first thing that I will do will be I like to determine the trans-trochlear line. Here is the top of the intercondylar notch, and here is the top of the trochlea. The fact is that that is the trans-trochlear line. In my opinion - but looking at the posterior condyles, the epicondyles, the lateral epicondyles is a single point. The medial epicondyle is a sulcus b - between a - a - the two bumps - so the surgical epicondyle - and therefore, I will draw the trans-trochlear condyle. I may be in your way for just a second, but in my opinion, it is in this particular case almost exactly where this is. It frequently is a couple degrees externally rotated to that.

And then what I will do is I enter. You don't want to enter in the middle. If you enter in the middle, you're going to get more valgus because the exit from the intermedullary shaft is anterior and medial, and it is just above the femoral origin of the posterior cruciate ligament as you see. So now, I - I - I will make my entrance at the intramedullary shaft, and this has a - a wider at the end so that now I will have a hole that is large enough that I will not have to have the introitus here influence the position that I'm going to go in.

Now I'm going to make a knee generally 5, 6, or 7 degrees of femoral valgus. In a valgus knee it is - should never be put in more than 5 degrees. You can put it in 4 degrees occasionally. I usually use 5 degrees for a valgus knee and 5, 6, or 7. Females rarely get 7. And what I do is I put it - I put it in, and then I look and see so that I can make sure I'm taking the relative proportion of medial and lateral bone that my preoperative X-rays told me. Now that we made our hole and we know it's large enough so it won't influence us into more valgus, we will take this, and I will generally put it in 5, 6, or 7 degrees of - of valgus, according to what my X-rays tell me. Pin. I just put a little pin in here to hold this. Let's switch, Steve.

So what this does is - and you can't see this, but now I'm looking down and seeing where these two platforms touch. So in this particular case - tap that in just a little bit. In this particular case, I'm touching medially, but I am off laterally. And I'm off about 3 mm. I don't want to be that far, so what I'm going to do is I'm going to put this to 6. I wouldn't put her at 7. Okay, now put this back in. Okay. Now let me have the scimitar. And in a varus knee I like to just touch the intercondylar area so that I complete the bridge, and I'll show you that in a minute. In a valgus knee, you never want to complete the bridge. Since this patient is actually slightly hyper-extended or fully extended, I'm not going to take more bone off, and this is just about right for her. So let's go ahead and drill this. Table down all the way please. Kocher.

So I'll make my distal femoral cut. You can see this is translocated a bit. It's just the way it was in. We can - it's not - not a problem. We just need to make sure we get over here. I think it's important to cut this at full power and go slowly in this cut. So you can - you can see that we're going down a little bit on the medial side, a little bit on the lateral side, and then we'll stop, coming all the way back up before we do it. And then we'll go down the middle. And then once we do that, now we’ll go back and finish our condyle on either side, but notice that every time we move over, we go all the way back up so we're not on an inclined plane. And you can also see, we want to get out onto the lateral side of this condyle.

So now, let me just show you one trick. If you have a little cartilage here - and we don't have much - and this was a very - I think this was a very nice cut that was made. So we're just gonna try this again, but remember - we haven't quite connected this bridge, but she’s slightly hyperextends so that's - we're in pretty good shape. Just see - just give it one more pass and see if it does anything. I don't think it will. Good. Pin puller. Knife and pickups.

Okay, now we're going to size our femur, and in order to do that, I want to take out just a little pledget - Army-Navy - of this synovium here cuz there's a little sulcus right at the - right at the top of the trochlea, and that's where you want to size it. If you size it up on the lateral femoral condyle, I think what you're going to do is oversize the femur frequently. So now this particular instrument - and there are different instruments for different systems - this instrument now will allow me to size my femoral component. I go right onto there. This is a size 4. And - and now we want to get our rotation, and if you look here, we're - we're with the left knee so right now this is on 5. This is on - on - on 5, which means - of my rotation - internal and external rotation. And what I want to do is to make this bar parallel to my trans trochlear line, and that's ideal for me right there. And so now I'm going to go ahead and pin this. And this is a - this is a size 4 cutting block. It has little slots here, which now can allow me to get the right area by just doing that. Threaded headed. Army-Navy. Saw please. Take me up here.

So now we make our anterior cut then our posterior cut. Z please. Anterior chamfer. And we’ll save this anterior chamfer bone. Take the pins out. And you can see we have a little bit of bleeding here, but - but the fact is I think the benefit of - of not having the leg ischemia is probably better. Saw. Osteotome please. Okay, now we're going to go ahead and - and make our tibial cut, and the importance of cutting the femur here is it makes it - it makes it easier to see the tibia. Pickle fork please. Bent Hohmann. Knife and pickups. Kocher.

Now here's one thing that I - I - you see, we didn't make a big incision, but I - knife please - I think it's really important to see the anterolateral aspect of the tibia. So I want to just see that. Now I'm going to make my - my cut, and what I want to do is I want to start with this instrument. And then I want to - as I said earlier, I want to be medial. So we have a left knee, so I'm going to go medial two of these blocks. So that will now get me into the center of the talus. So now I put this on the tibia. And then the cutting block I use is this one, which I like, and it has these wings, which allows me to get right into the - right - right into the - or on the infrapatellar tendon. Now do you have a stylus? And I take the stylus, and I put it in. I'm not going to cut this through the slot, so I want to sort of see where this thing sits. And then the posterior slope - I just want to reproduce her slope, which is usually about 5 to 7 degrees. Large blade upside down. In this particular cut, I put the blade upside down. And I think the reason is it keeps it at the level, and I think it makes the cut easier to make. So I'm protecting the collateral ligament here. Kocher please. Just come right around there. Knife please. Pin puller. Knife and pickups please. 15.

We’ve now cut our tibia and now we have a - we want to clean up a little bit of the rest of the meniscus on the medial side and on the lateral side. Okay, could I have a lamina spreader? And at this point now, I can look in the back of the knee, and I think it's important for you to see this part. Let me have a 15 blade. And could you grab the suction? Okay, now this is really the reason that I save the posterior cruciate ligament in most knees. The fact is that I have a lamina spreader in here. If you look - and I hope you can see - if we - if we - if we zoom in - here's the posterior cruciate ligament. I can feel it. And if you think about the medial - the - the flexion space, the medial side of the flexion space is made up of the broad medial collateral ligament that goes from femur to tibia. And on the lateral side, it's the short round fibular collateral ligament that actually goes not to the tibia but to the fibula. And then it's also the popliteus, which is a dynamic structure. So normally, the lateral side of the knee is more loose in flexion to allow for rollback. Since rollback really occurs laterally and not medially, the fact is - is the posterior cruciate ligament is the lateral ligament of the medial side of the knee. It's sort of balances the difference between the tighter, stronger medial side and the loser lateral side. Suction please. Just to clear this out a little bit.

And so if I my take lamina spreader and I put it in the medial side of the knee - David, why don't you do that? Release it down, but don't it that out. Now watch as - as David opens this up. Watch what happens to the lateral side of the knee. The lateral side of the knee sort of self-aligns. Now, since the lateral side is looser, if I put this in, I can make it I can make it bigger. It - it's looser, but it's the posterior cruciate ligament that balances that difference. Okay now what we want to do - if we want to get better flexion, what we have to be careful is that we don't have posterior osteophytes. And you can use the femoral component to do that, or you can use an instrument called - we call it a "PORT" for posterior osteophyte resection tool. And it's size specific, and this goes in. Drill - drill pins. And this allows us to do two things. In this particular system it requires a very small sulcus cut in order to facilitate the patellofemoral groove. And so you can make this - many people do it free hand, but I just do it like that. Pop that one up.

And that's done. Now let me have a - a bone hook and then the osteotome. And this is a - this is a little chisel that is - has the same curvature as the posterior part of the component, and since this is not fixed - suction please - I can now place this in. And I can get this in all three areas just behind the component, and particularly in a PCL sparing knee, you want to make sure you don't have any central osteophyte back there cuz that could impinge. Now let me have a - let's take this off. Then I'll take the lamina spreader again. Pituitary please. And you can see that's a little osteophyte that was on the - in the mesial part of the medial femoral condyle, and that could impinge. There isn't one really there. So we're pretty good now.

Now I'm gonna do something that I think has been very important. And many people are doing this, and these are using pericapsular injections. It’s a - this particular cocktail is a combination of ropivacaine rather than Marcaine because it's - it's less cardiotoxic. It's got clonidine. It's got epinephrine. It's got ketorolac. It doesn't have steroids and doesn't have morphine. And it's - it’s q.s. to 100 mL, so we put that in each knee. So it's dose specific, and - I find - and what - but it's really important where you put it. On the lateral side, I put 10 - 10 CC's sort of on the mesial part of the lateral femoral of - of the posterior lateral structure. If you put too much out on this side, you may find the peroneal nerve goes to sleep for a while. Then on the medial side, I put 20. One sort of in the same place and another a little bit more - rake please.

And then these are perhaps the most two - the two most important. One is over here. David you do that so I'm not in the way. And we're going in, and we're raising the periosteum. I hope you can see this. In my experience this substantially helps with the bleeding, and it helps with - and it helps with post-operative pain. We've also been using tranexamic acid, and we're using the Mayo Clinic protocol, which is a gram at surgery and a gram just as we close. So here you see, on the lateral side, we’ll try to raise this wheel. And you may be able to see the periosteum coming up here.

Alright. Now, in this particular system, if we've used a 4 femur, we need to use a 4 tibia insert, but the actual platform of the tibia can be whatever fits best cuz this is a central locking mechanism. And I think it's important to - to - to - to template this from the lateral femoral condyle. You can look. There’s space in the medial side, but it's the lateral side cuz you don't want overhang. So a 4 is the ideal size here. We will trim a bit of this bone off. Let me have a rongeur please. So I'm going to use a 4 - 6. So my - my tibial insert requires two numbers. So it will be 4 to correspond to the femur and 6 mm thick, which is gonna - and I have these in pretty much millimeter increments. K - come out. Femur please. Just in my hand. Compactor.

Okay, so now we'll check our - we'll check our extension and see how we're doing an extension in this case. She doesn't hyperextend. Now I would anticipate I use a little thicker component in this patient because she really was somewhat loose.

So - but before I can check my flexion space, I need to prepare my patella, so we'll do that now. I'm going to get my rotation of my tibia. I want to get as much externally rotated as I can without overhanging anteromedially, and I - I want to make sure that I still have intercondylar congruity here. Okay, table way up please. Knife and pickups. So this is done in three segments. The first thing I'm gonna do is clean some of the soft tissue. I take a little bit of the fat pad out - table up please - until I can see the nose of the patella. Then I want to see the chondro-osseous junction. That's fine thank you. And then up here, I want to remove this little pledget of synovium. John Insall said that this may have been the derivation of the patellar clunk syndrome, and as you know, that's more in the cruciate substituting knee because of the box - but you can see it in a cruciate retaining knee - but it allows me to get my measurements.

So I'm going to measure the thickness here. So the thickness here - this is a relatively thin patella. So it's about 20 to 21 millimeters, and what I want to do - pickups please - I want to cut. I want to be into the nose of the patella. I want to be in the chondro-osseous junction here and here and the tendon superiorly. There's an instrument that I found helpful. Do you have the adapter for it? So this will give me about 9.5 mm, but I don't want to take that because of my relatively thin patella. So I put that a little adapter on it, which gets me down to 7.5. So now I go over here and grab onto the - onto the lateral side. I bring this down, and I don't really have to bring it all the way down because I'm dealing with a thinner patella. So now if I hold this up, we can cut through these slots. I'd sorta come over to the side so they can see. Caliper. And we'll have a 38. So we'll measure the thickness again. And we are down to about 13, so that's just about what we had. And then I use a - go above me, Steve, if you would - drill. Drill those three. Table all the way down please.

CHAPTER 4

Okay so now I think we're maybe just a little bit loose in ex - in extension. I'm probably going to go up to a 7 in a moment, which is about what I expected to be using. And now as I flex here - now we're going to put the tourniquet back up in a moment. We've had - our systolic pressure is now down, but I think we're going to want to put that up for cementing.

Now, it looks to me - and with this system I've been able to do very few posterior cruciate recessions, but the important thing when you check this is to look and see what the - what the rollback is. You want it to be in the center of the medial condyle and roll back a little bit on the lateral side, and you want to be able to have a situation where you can palpate the cruciate. I think that the posterior cruciate in this case is going to be ideal, but when we go to a 7, it may be a little tight - but we'll see. So as we flex up here and we look, feel the cruciate, feel - the cruciate feels - it's a little bit pliable. You can see it's under some tension, and it's pretty uniform. So I think that's gonna be fine, but we're gonna go up to a 7 and see - but let's put the tourniquet up. Just a little bit. Flex up a little bit. Good. Mallet. Impactor.

Now feel the posterior cruciate. As we've gone up 1 millimeter, the posterior cruciate has tightened. Okay. So I think what we're gonna see now is the posterior cruciate is a little tight, and we're going to just adjust it. There are three ways of adjusting. If the whole cruciate is tight, I take it off the tibia because it has a very broad decussation of fibers. If it's just the anterolateral fibers, I will take them off the femur. If the thing is just a little bit tight, what I will do will be to take it off with a pin. I'll just sort of make multiple puncture wounds like you might do it in an achilles tendon. So if we come into extension here, we still come to the full extension, and our tension is - is, I think, ideal. You really - you want to be able to open about a millimeter on the medial side. The lateral side will open a couple millimeters cuz it's looser.

So now if we go up here, I think we'll see the PCL’s gonna be too tight. So as I flex up here, you're gonna see that - pickups please. You're gonna see that the dwell point on the medial side is not central. It is - it is actually slightly posterior. If we now come out here, we can see we're also posterior here, which is the rollback we want, but if I feel the collateral lig - thePCL, which you can't see, it's actually tight. Now since this is tight all over, all I'm going to do is just resect it a bit off the tibia. It's a very broad decussation of fibers, and that's probably all I need to do. People say it's hard to do. You can't do this with a flat on flat design - but you can certainly do it like this, and I have done nothing more than just bring it off the side.

Now, let's go ahead while we're here and prepare our tibia because we know the rotation. That's the mark I made. Mark. Drill. We just need to make sure this is down so the component doesn't hang up. File please. Okay, let's have the - let’s have the 7, and now we'll just check this. I think we can get some components up. Out you come. Come on out. Everybody out. Flex up just a little bit. Mallet. Patella. Come into extension. I'm gonna feel the PCL. Feel the difference in that? Not tight like it was, but we'll see. So now we're going to come out into extension. It's good. And as I flex now, all we've done was just take a little bit off the top. She’s got a very broad decussation, but now you'll see the dwell point on the medial side of the knee is right in the middle. And if you look in the lateral side, it's rolled back a bit. Going to be hard for you to see, and it's a little bit of a problem because as I take the patella out - and then I can feel the cruciate ligament. So I'm - I'm fine.

And we'll go ahead and get ready. The one thing that I like to do is I like to look at the components. I like to say it out loud what we use, and then we'll go ahead and get ready. So if you want to start preparing that. So I have a 38 mm medialized patella button. I have a size 5 tibia, which is the one we used. And the insert is a 4 by 7 mm, and it's antioxidant. And the - we're using a femoral cruciate retaining size 4 left cemented femur, so you can open all four of those please. Now the bone that we use for the interior chamfer - I - many people will plug this with cement. I like to use the bone. Now I think cementing is one of these sort of under-appreciated factors of knee replacement. I'm using a high viscosity cement. It's just more malleable. I do not routinely use antibiotics except in revision cases or people with increased risk factors like diabetics, renal patients. And this is just a little plug of bone that's going to go in.

Can I just pop this in for a sec? Can I have a file please? Mallet. File. Okay, let's clean this up. Pickle fork. So we're going to put some cement on the bone and pack it in. And then we're just smear a little bit of cement on the surface of the tibia, which will give some contact activation, but it will still have a little bit of monomer in it to sort of improve the bonding between the tibial component and the cement. And we’ll do the same thing on the femur but only once we get the femur ready to do. You'll see Mark will put that on. And then we'll be careful to try to prevent interposed blood between the two so that we will get a good bone cement interdigitation and a good prosthesis cement bonding.

Little trick I learned in Saltsburg when I was operating there - I call it therefore, "The Saltsburg Slap," which is a good way to defat a little bit of the bone. And we’ll do the same thing on the femur. Okay, smear just a little on there for me. So that's just mixed. So then that's plenty. That's good - you got plenty. And since I'm using HV, I can go ahead and put it in straight away. Some people will actually take the sucker and put it on one of these holes just to get a little bit of interdigitation, but I like to generally just... Tibia.

Suction. Get this little juice as it comes. Curettes times two. One to David or to Steve. You get this back in the back. I'll come up here. Curette. And you see I brought the tibia all the way forward. I don't like to do that before I've made my posterior femoral condylar cuts cuz I need to stretch out the structures, but otherwise, I think it's important to do cuz you don't want to get cement trapped back there. You've got the lateral complex and the popliteus, and I want to make sure it's free. Okay, do you have the insert please? Get a little more there. Curette. Teflon mallet. Okay, you'll smear a little on the femur and put some on the back condyles. So we'll bring this forward. So we have some in the back, and we smeared a little on here. It's a little bit later that it was on the other one, but I don't want it to get - to start to harden. Curettes. So now once I get this partially cleared, I'm gonna come into full extension. And since - now curette. Then I'll flex back up just a little bit and get the part in the intercondylar area.

Kocher please. Cement. Knife. Patellar clamp please. Curette. Can I have a small saw please? If I have any osteophyte or any little bit of the - of the lateral facet of the patella, I'll just do a little facetectomy here just so it doesn't impinge. I'll just take the rest of this, and I'll put a little in the fat pad - David, can you take a curette and clear that little bit of cement out of the medial - medial femoral side there? Put a little in the fat pad down here. Put a little up here along the incision. Can I have a pituitary again? I found another one of our little loose bodies.

Now at this point, I've got to remember whether I had the knee as a hyper-extender, or as a loose knee, or as a tight knee, or as a flexion contracture. And since this is a loose knee, I'm not gonna put any pressure on it. I'm just gonna let it sit. I wanted to sit not - not - not internally rotated or externally rotated but just sit here. I won't press on it. If I'm having a little trouble getting into extension, I'll be much more aggressive about keeping it in extension - maybe even a little hyperextension. I don't think you can do that in varus and valgus. So at this point in time, we're just gonna wait for it to cure. We won't - we won't mess with it. Then we’ll check our range of motion. Then we'll check to make sure that there's no pieces of bone, or any impingement, or any loose bodies. We'll rinse it out because she did have some loose bodies. And we'll - again, we’ll check an extension, mid-flexion, and flexion.

Since I'm using TXA and since I'm using these pericapsular injections with epinephrine, I really have not been using a drain. Unless it is excessively draining, I almost never in primary knees, and - and I won't even use it in revision knees although I used to always use a drain. When we close, I like to start with the - usually, some 2-0 vicryl, and I'll close the fat pad and any synovium that's there. It gives me a bit of a hemostatic stitch, and it prevents the fat pad from invaginated in. And then I've been closing the capsule in the past few years with - with a barbed number 2 suture that goes - that goes from the middle up and then back down. So it's two layers. It's hemostatic. It's barbed, so it really has a good integrity. And then what I think is very important is I then check and look at the amount of flexion that I have against gravity. Extension easily. Flexion against gravity because that's generally the flexion that I'm going to aim for postoperatively, and we record that. An - and then I will close the subcutaneous tissues with generally 2- and/or 3-0 vicryl if I - if I need, and I close the skin with Monocryl and Dermabond unless the patient has a lot of adipose tissue, in which case I will close it with skin staples because I'm a bit concerned about managing the wound. That's a little bit easier to manage the wound.

Post-operatively, she will go to recovery room. Since I've been using the pericapsular injections, I've had much better control of pain, and I think if you block that pain in the first 24 hours, then you're far better off getting the patient going. Most of our patients go home at day two, and we want them to obtain their motion. They get two sore - two courses of physical therapy a day, and then they go home and generally have in home therapy for a while and then outpatient therapy.

So we're just waiting for the cement to cure. Tourniquet down please. So we look at our extension. She's fully extended. She isn't hyperextending. In fact, she was hyper-extended a few degrees pre - preoperatively, and she isn't at all now. She's stable. If I feel the medial collateral ligament - just feel the collateral ligament. You can feel that's what I like. That to me is ideal tension. You can just barely indent it. Now we'll check our flexion, and you see, we're in the dwell point in the middle here. Pituitary. So I want to make sure that I can pass through here - that I can go on either side of the cruciate ligament.

Okay, so we're just about to close. Can we have a 2-0 - 2-0 vicryl? Okay, so if we look at our range of motion here, we're in extension as we flex up. Now we’ve checked it on either side. You can't see it from the side, but our patella - the other thing about the patella - pickups please - is that the patella stays in the grove without us holding it over, and if you look here, it is coming in contact with the medial femoral condyle. And that I think is very important. That's good. Thank you. Thanks Mark. Nice job.

CHAPTER 5

So after we get the capsule closed, now we will - we will flex up against gravity, and she has about 120 degrees of flexion. So that's about what she's going to obtain, and if you go - she will go into - she'll easily go into extension. She may get a little bit more because she was a relatively loose knee, but… And so our anesthetic in this particular case was a general anesthetic. I frequently use a regional anesthetic, but this was patient choice - and she didn't have any contraindications.

I don't use femoral nerve blocks anymore because I find that, postoperatively, it tends to have some weakness and may delay therapy, and with the pericapsular injections, I get the analgesia for the first 24 hours. So I'm pretty much regional anesthesia or general when preferred as long as the patient's not - not a contraindication and then capsular injections because that gives me my pain control. But no femoral blocks anymore. Alright, thank you.