PREOPERATIVE DIAGNOSES:
1. Left knee arthritis.
2. Obesity.
POSTOPERATIVE DIAGNOSES:
1. Left knee arthritis.
2. Obesity.
OPERATION PERFORMED: Left total knee arthroplasty.
SURGEON: John Doe, MD
ANESTHESIA: Spinal and femoral.
COMPLICATIONS: None apparent.
COMPONENTS PLACED: Zimmer size G LPS-Flex gender specific femoral component, 35 mm patella (NexGen), a NexGen size 5 stemmed tibial component with taper plug and a 10 mm articular surface (LPS-Flex), and Palacos antibiotic-impregnated cement.
BRIEF DESCRIPTION OF PROCEDURE: After the establishment of spinal anesthetic, IV antibiotics were given, and the left lower extremity was prepped and draped in the normal sterile fashion. After standard prepping and draping, Ioban drapes were placed. Gloves were changed. The leg was wrapped with an Esmarch and tourniquet was insufflated.
Anterior approach to the knee was performed followed by medial parapatellar arthrotomy. The ACL, PCL, and medial and lateral menisci were excised. Intramedullary reference was used for a 5 degree valgus cut on the distal femur. An additional 2 mm was resected given the patient’s preoperative flexion contracture. Following this, femoral rotation was selected based off the epicondylar axis and Whiteside’s line and pinned in this rotation for a size G, which had good coverage without significant notch formation.
Standard cuts were performed. A 7 degree posterior slope cut was performed on the tibia using extramedullary reference. Osteochondral fragment was removed. A few millimeters were resected off the low side. The flexion-extension balancing was excellent at 0 and 90 and therefore the box cut was performed to the femur given equal flexion and extension gaps. Free-floating trial with full extension to 145 degree of knee flexion and good native patellofemoral tracking.
Therefore, the tibia was drilled in line with this rotation, which did coincide with the medial third of the tibial tubercle. A size 5 had good coverage without significant overhang. After this was drilled and punched, osteophyte was removed from posterior midline and the posterior away from the midline, followed by recessing the patella approximately 9 mm for a size 35 mm patella. Care was taken to prevent over-resection.
After this was placed in a superior medial location with good coverage, free-floating trial had excellent patellofemoral tracking with excellent varus-valgus stability throughout 0 to 140 degree range of motion. Therefore, all trials were removed. Gloves were changed. The tibial, femoral and patellar components were cemented after irrigation and drying. They were cemented in a clean dry bed. The real liner was locked in locking mechanism. The knee was brought into extension while the cement cured.
Once the cement cured, the patellar clamp was removed followed by irrigation, followed by placement of medicine circumferentially throughout the retinaculum to decrease postoperative pain and swelling and possibly decrease risk of infection, followed by placement of fibrin sealant, followed by closure of arthrotomy in flexion with Quill. A watertight closure was noted and tested in flexion with no gap formation.
Then, 2-0 Vicryl was used for deep dermis layer closure followed by staples on the skin. A bulky dressing was applied and a knee immobilizer. A femoral nerve block was given by Anesthesia. No apparent complications.
Knee Arthroplasty Sample #2
PREOPERATIVE DIAGNOSIS: Left knee osteoarthritis.
POSTOPERATIVE DIAGNOSIS: Left knee osteoarthritis.
OPERATION: Left total knee arthroplasty.
SURGEON: John Doe, MD
COMPLICATIONS: None.
COMPONENTS: Zimmer Legacy size E femur, size 5 tibia, 12 mm poly, and 32 mm patella.
INDICATIONS: This is a (XX)-year-old female with a long history of osteoarthritis of the left knee who has failed conservative management and desires elective operative treatment. She understood the risks of surgery including infection, bleeding, neurovascular trauma, malpositioning or loosening of components, deep venous thrombosis, pulmonary embolus, and death and agrees to the procedure after medical clearance.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room suite and placed in supine position. Spinal anesthesia was administered. The patient’s left leg was prepped and draped in usual sterile fashion. Preoperative antibiotics were given. Martin bandage was used to exsanguinate the leg, and the tourniquet was inflated to 300 mmHg.
A longitudinal midline incision was made and taken down through soft tissues achieving hemostasis with electrocautery. A median parapatellar approach to the knee was performed. The proximal tibia was exposed medially and laterally. The patella was everted and flexed to 90 degrees. Then, the anterior cruciate ligament and the anterior portion of the menisci were removed. The femoral canal was opened and then the femur was sized and then cut in 3 degrees of external rotation and 6 degrees of valgus.
Following this, the size E cutting block was used, and posterior, anterior, and chamfer cuts were made. The posterior portion of the menisci and the posterior cruciate ligament were then resected, and tibial tray used followed by the intramedullary alignment guide. Tibia was resected 10 mm below the lateral joint line. Flexion and extension spaces were balanced and measured to be equal. Soft tissues were balanced medially and laterally. Posterior osteophytes were excised.
Following this, attention was directed back to the femur. Box cut made. Then, trial component was placed and noted to fit well. The proximal tibia was measured and then drilled and punched. Trial component placed and noted to fit well. The knee was put through a range of motion. There was noted to be lateral patellar tracking, and lateral release was performed.
Following this, the undersurface of the patella was resected, measured, and drilled. Trial component was placed and noted to track well. Trial components were removed. Pulse lavage irrigation was used after drying the bony surfaces. Then, the following components were impacted into place: Zimmer Legacy size E femur, size 5 tibia, 12 mm poly, and 32 mm patella. Excess cement was removed and cement allowed to harden. The knee was put through range of motion and noted to have excellent range of motion with full extension and good patellar tracking. The real poly was placed. The knee was irrigated.
Fascia was closed with #1 Vicryl over a deep drain, and subcutaneous tissue closed with 2-0 Vicryl. The skin was closed with staples. Sterile dressing was applied. Sponge, needle, and instrument counts were correct. Estimated blood loss was less than 25 cc. The patient tolerated the procedure well and was sent to the recovery room in stable condition.
