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procedure
By Stepes
1. Background
Total Knee Arthroplasty(from now on referred to as TKA) is a surgery which
replaces the weight-bearing(tibiofemural) surfaces of the knee with metal and
polyethylene prosthetics to relieve knee pain. It has been practiced in different forms
for around 50 years with varying degrees of success. Since then the techniques as well
as the implants have improved significantly giving very good results and satisfied
patients.
It is usually performed to alleviate pain and unstable and deformed knees.
This usually results from osteoarthritis(Fig.1) which is observed in around 66% of
people over 65 years but from which only around 50% show symptoms and have to
get operated. The operation is also performed in other cases such as bone dysplasias
and reymatoid arthritis.
Patients who choose undergo surgery have preoperatively strong aches, which
often keep them awake at night and disturb most of their daily activities. For the
doctor to agree to perform the surgery he has first to rule out any other possible
diseases and exhaust all other traditional therapies which could help like anti-
inflammatory medications, braces, analgesics or for obese patients which often suffer from knee
problems weight loss. Often doctors prescribe rehabilitation with a physiotherapists as this might help
strengthening the knee and provides a wider range of motion and flexion.
The reason for this is both the high cost of the operation(in the US around $40.000) and the
great amount of postoperative pain caused by the surgery. Another reason is that the
mean lifetime of such prostheses is around 10-15 years after which sometimes the bone
reacts to some elements of the cement used and can cause serious problems. Also the
polyethylene used in the prostheses has to be replaced after some time due to
deterioration.
Before the operation the patient is given antibiotics and is then anesthetized and taken to the
operation room. His leg is again cleaned with a betadine solution to decrease chances of infection. It is
of extreme importance to keep the knee from getting infected and for this reason the rest of the body is
sealed off with lots of sterile drapes only exposing the part of the knee that has to be opened. For the
same reason the whole surgical team has to wear protective clothing and gloves too and all the
equipment has to be sterilized. Computers and other machines have to be sealed with plastics too.
When all the bones have been cut according to the computed plan, more holes are drilled into
them and then the trial prosthetic components are added for testing. The surgeon checks if the
prosthesis are matching with the navigation computer model and then tests the knee movement. He
tests the range of motion, the flexion and the gaps between the components that need to be even. The
computer navigation already takes all that into account when making the plan so that no gaps occur that
could produce premature friction of the components and difficulties in motion.
If the results are satisfactory, the trial components are removed, a polymethyl methacrylate
cement is applied which will hold the final components in place and the final components are put into
position. The team stretches the patients leg out so that it applies pressure to the components and then
they have to wait 10-15 minutes for the cement to harden. Then the range of motion and angles of the
leg are checked again and if all is correct the marker arrays are removed from the bones, the patella put
back in position, the deep tissue and fat is sutured and then the skin too. Then the tourniquet is deflated
for accurate hemostasis and removed. The pulse on the foot is checked and the operation is finished
with success.
Start of OP
Patient
Preperartion. Apply Tourniquet Open knee,
Antibiotics, and sterile drapes cauterize veins
Anesthesia
Digital
adapted
Register knee bone model
position and
surface on
computer
Jig
orientation
proposal
Apply the three
cutting jigs.
Check ligament
tension on model
Drill holes and
apply trial
components Check component
positioning on
model
Check component
Apply cement and positioning on
add final model
components
Test alignment
and range of
motion
End of OP
References:
[1] http://de.wikipedia.org/wiki/Arthrose
[2] Simon H Palmer, et al. “Total Knee Arthroplasty”
http://emedicine.medscape.com/article/1250275-overview
[3] Edheads + COSI Virtual Knee Surgery,
http://www.edheads.org/activities/knee/
[4] H. Bäthis, et al. “Alignment in total knee arthroplasty”
http://www.jbjs.org.uk/cgi/reprint/86-B/5/682.pdf
[5]Tim Alexander Walde ,et al. “Process Optimization in Navigated Total Knee Arthroplasty”
http://www.orthosupersite.com/view.aspx?rid=4074
[6] “Computer Assisted Total Knee Replacement” 2 part video by http://www.orangeorthopaedics.com
http://www.youtube.com/watch?v=yBdCiwcGiPA
http://www.youtube.com/watch?v=YfvUATneyXs
[7] “Computer Assisted Navigation for Orthopedic Procedures of the Pelvis and Appendicular
Skeleton”
http://blue.regence.com/trgmedpol/surgery/sur136.html
[8] OrthoPilot® Navigation System
http://www.orthopilot.de/cps/rde/xchg/ae-orthopilot-de/hs.xsl/7245.html
[9] “Computer-assisted TKA: Greater Precision, Doubtful Clinical Efficacy: Opposes”
http://www.orthosupersite.com/view.aspx?rid=42846
[10] DICOM Supplement 131
[11] DICOM Supplement 134