I have just signed a contract with an international publisher to produce a multimedia book on “Master Techniques of Knee Arthroplasty”. Unlike conventional books, this would be a visual approach, high on descriptive video content.
Presented below is the first video in this series, a cruciate retaining cemented knee replacement.
FACT FILE
72 year old female, with polyarticular Rheumatoid Arthritis, with damaged and deformed knees, primarily medial compartment. The patient is the mother of a surgeon, who was allowed to be present in the theatre during surgery.
Left knee was more damaged, and presented with 28 degrees varus deformity, 12 degrees fixed flexion deformity, and a movement up to 90 degrees. She used a stick and her walking distance was about a hundred yards.
I used a cruciate retaining cemented prosthesis, and the complete steps are below.
MY TECHNIQUE AND PROCEDURES ARE AT A SLIGHT VARIANCE FROM THAT DESCRIBED BY OTEHR AUTHORS, AND HERE ARE THE ESSENTIAL POINTS.
1, I rarely use a tourniquet, and never use them in rheumatoid arthritis. In my view, a tourniquet is more for the surgeon’s convenience than patients benefit.
2, My knees are usually performed under a spinal anaesthesia, using an extremely thin needle, to allow early mobilisation, and in some cases discharge the patient the same day.
3, As a tourniquet is not used, it is essential to do a meticulous haemostasis, to ensure a blood less field.
4, We must correct all deformities including the ffd, and bring the knee to 5 degrees valgus, even before we do the very first bone cut.
5, The distal femoral cut should be at six degrees valgus, and proximal tibial cut at three to four degrees posterior slope.
6, The flexion, extension and mid flexion gaps should be equal, and the coronal and sagittal soft tissue tensions should be identical in all these situations.
7, The patella should track evenly and knee bend to maximum, with the trial components.
8, The bone removed from the knee should match the thickness of the prosthesis implanted, to allow the joint line to be exactly at the same level.
9, As a drain is not used, it is essential to perform a meticulous haemostasis before closure.
10, Closure should be layer by layer, using continuous sutures, and leave no dead spaces.
11, A magic cocktail containing .5% buprivocaine, 1.5 grams Cefuroxime, 80 mg Depomederol, 5 mg Morphine, diluted with 30 ml of saline, is injected layer by layer starting from posterior capsule and periosteum, going right up to the subcutaneous tissue and skin, provides sustained pain relief post operatively.
12, I do not use staples, preferring continuous sutures with nylon which are far easier to remove.
13, As no drains are used, meticulous haemostasis, layer by layer perfect closure, decent padding and a compression bandage, are essential.
14, The operating time was 45 minutes, and the detailed hd video is posted
below.
It was as much fun performing the surgery, as it was to edit the video, give it a voice over, add transitions, and post it here.