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1. Orthopedic surgery department, Soroka KNEE TKA APPROACHES and AXIAL ALIGNMENT

2. ALIGNMENT Pre-op PLANNING Goals you want to achieve are restore mechanical axis, joint line, correct flexion and extension gaps, maintain normal Q angle. Radiographs - standing AP and LATERAL of knee (joint narrowing and collateral ligament insufficiency, bone defects) extension and flexion laterals sunrise view Intro and Preoperative Evaluation

3. ALIGNMENT Femoral - anatomic axis and mechanical axis obtaining neutral mechanical axis allows even load sharing between the medial and lateral condyles of a knee prosthesis Valgus cut angle (approx 5-7 degree) is the difference between AAF and MAF. very tall will have lower than 5 and very short will have more than 7 radiograph of choice is standing full length AP x-ray Femoral, Tibial and Patellofemoral

4. Tibial - Anatomic axis and mechanical axis usually MA and AA of tibia are overlap if overlap then cut perpendicular to AA if not overlap due to deformity for example, so must be cut perpendicular to the MA ALIGNMENT Femoral, Tibial and Patellofemoral

5. Patellafemoral - Q angle, most common complication of TKA is abnormal patellar tracking. normal Q angle (11+/- 7 degree) increase in Q angle will lead to pain and mechanical symptoms accelerated wear dislocation critical to avoid techniques that can lead to an increase in Q angle internal rotation of femoral or tibial prosthesis medialization of the femoral component ALIGNMENT Femoral, Tibial and Patellofemoral

6. Goal is to restore the joint line by inserting a prosthesis that is the same thickness as the bone and cartilage that was removed. keeps the appropriate ligament tension elevate the joint line can lead to - mid flexion instability and patellofemoral tracking problems lowering joint line can lead to - lack of full extension and flexion instability Joint Line Preservation ALIGNMENT

7. APPROACHES The surgical approach is gonna be dictated by several factors among them can be found: surgeon preferences, prior incisions, degree of deformity, patient obesity. when you come to plan the incision site think about: 1. multiple incisions? go lateral due to blood supply coming from the medial side 2. previous transverse incisions? cut at right angle, generally safe Approaches “Simple “- Medial Parapatellar, Midvastus, Subvastus, Minimally Invasive and Lateral Parapatellar “Complex” or for revision TKA - Medial Parapatellar, Quardriceps snip, V-Y turndown and Tibial Tubercle Osteotomy Intro

8. The patient is placed supine on the operating table. After suitable skin preparation, drapes are applied in order to leave the leg free. A pneumatic tourniquet is applied as high as possible as to minimize compression of the thigh muscles, which would otherwise restrict knee mobility. A special table support or another option is to add a roll support on an ordinary table administration of a short-acting, non-depolarizing muscle relaxant that should provide sufficient muscle paralysis before and during the surgery (minimum duration is 30-40 min) as soon as the patient is prepped, the landmarks for the surgical incision will be determined with the knee in extension. Patient Preparation APPROACHES

9. Use a standard anterior midline incision (5 cm proximal to apex of patella the the tibial tubercle) Dissect subcutaneous tissues and enter the capsule through a medial parapatellar approach, approx 1 cm form the medial border of the patella. incise the quadriceps longitudinally to allow a better patella eversion and sufficient knee flexion. evert patella laterally with the knee maintained in extension keep the patella everted laterally, flex the knee to expose the knee joint Do the magic Medial Parapatellar APPROACHES

10. APPROACHES Medial Parapatellar

11. Midline incision Dissection of subcutaneous tissue but avoid to cut via the fascia covering the vastus medialis obliquus muscle identify the inferior border of VMO and cut its overlying fascia medial to the patellar border using surgeons finger or a retractor to pull the inferior border of the muscle VMO superiorly, separating it from the underlying synovial knee joint lining. cut below the VMO till reaching the medial border of the patella turning 90 degree, parallel to the medial patella border and to the patella tendon. evert patella knee is flexed and extended in various degrees to allow a better visualization depending on the stage of the surgery. Subvastus APPROACHES

12. midline skin incision parallel to the medial border of the patella and extended proximally and distally incise the superficial fascia covering the quadriceps to decrease the extensor mechanism’s tension and permit mobilization of the quads - will help to move the quads laterally so it will be easier to see the knee joint. cut the muscle fibers of VMO, running oblique 4-6 cm proximally and lateral down to the medial border of the patella incision ends in the tibial tuberosity. patella exerted knee joint exposed. Midvastus APPROACHES

13. Useful for addressing lateral contractures but it is difficult to evert the patella, making the exposure challenging. + is useful for a fixed valgus deformity, keeps the blood supply to the patella - is technically demanding due to medial eversion of patella is more difficult and may require tibial tubercle osteotomy Lateral Parapatellar APPROACHES

14. Need of special instruments for exposure and implant insertion technically demaning! no data to support the clinical advantages, if they are at all convert to the standard approach is patellar tendon starts to peel off the tibial tubercle incision is too small for the proper jig placement Minimally Invasive APPROACHES

15. Quadriceps snip - snip is made at the apex of the Quads tendon obliquely across tendon at a 45 degree angle into the Vastus Laterlais + is minimal long term consequences - is not as extensile as a turndown or tibial tubercle osteotomy V-Y turndown straight medial parapatellar arthrotomy with diverging incision down the VL tendon towards lateral retinaculum. + are excellent exposure, lengthening of the Quads tendon, preserves patellar tendon and tibial tubercle - are extensor lag, may affect the Quads strength and the knee needs to be immobilized after surgery. TTO 6-10 cm bone fragment cut from medial to lateral fixed with screws or wires + are excellent exposure, avoid extensor lag, avoids Quads weakness - are limited weight bearing post op, avulsion fracture, non union, wound healing problems Extensile Exposures APPROACHES

16. Q בת 67 לאחר קרע ברצועה צולבת קדמית במהלך משחק כדורסל כאשר הייתה בת 35. היא שמה לב לזה שהרגל שלה מתחילה לפתח דיפורמציה וארועים של חולשה פתאומית (episodes of giving way) ועכשיו גם כאב שמונע ממנה להמשיך בפעילויות יומיומיות. טיפול שמרני לא עזר ולא הקל עליה. איזה טיפול מתאים לה כרגע? 1 1. אסטאוטומית פתיחת יתד גבוהה של השוקה 2. אוסטאוטומית סגירת יתד מקורבת של השוקה 3.ניתוח מפרק בין-פוזיציוני מדיאלי 4. ניתוח מפרק ברך חד-קומפרטי מדיאלי 5. החלפת מפרק ברך מלאה

17. Q בזמן ניתוח של החלפת ברך בגישה מינימלית לא פולשנית (minimal invasive) יחד עם גישה של לחוס על השריר הארבע ראשי של הירך, החשיפה לא מספיקה ודי מוגבלת ויוצרת בעיות עם היישור הג׳יג (jig alignment), מה הדרך הבאה הכי טובה? 2 1. להחליף לגישה של סאב-וסטוס 2. אוסטאוטומי של הטוברקל של הטיביה 3. להחליף לגישה של 2 חתכים 4. להחליף לגישה סטנדרטית של פארא-פאטלאר 5. שחרור גיד על מנת להגדיל חשיפה