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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_17_библиотеки_им_акад_М_И_Перельмана
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N. R. Patel et al.
. Fig. 15.2 a, b Draping. a Standard draping of the left extremity utilizing a thigh-high tourniquet and b an Alvarado boot. (Printed with
permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
15.4.2 Tibial Preparation
With the use of the extramedullary tibial guide, the
varus/valgus is set at neutral alignment and the slope is
built-in at 7° when the guide is parallel to the tibial crest.
> However, the tibial slope should match the patient’s
native slope. Since lateral compartment disease has a
greater effect on femoral condyle than a tibial plateau, the tibial resection is minimal.
The extramedullary guide is typically set to resect
around 1–2mm below the tibial defect. The guide should
be xed to the tibia with one pin to prevent any risk of
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. Fig. 15.3 Laterally based incision is made from 1cm proximal to
the superior pole of the patella to the proximal, lateral border of the
tibial tubercle. (Printed with permission of Joint Implant Surgeons,
Inc., New Albany, Ohio)
fracture (. Fig. 15.6a). The amount of tibia resected
varies for each patient but, once removed, the extension
gap should have enough space to accommodate the tibial template and a 3mm feeler gauge. If this is not the
case, more bone should be excised.
The rst tibial bone cut is the vertical tibial cut. It is
The intercondylar notch osteophytes, lateral tibial
osteophytes, and the visible portion of the lateral meniscus are removed to allow for adequate exposure
(. Fig.15.5). However, the lateral femoral osteophytes
should be retained, as they help guide the positioning of
completed with a stiff and narrow reciprocating saw
blade. Care must be taken to saw in the exion axis and
parallel to the plate as lifting the hand may violate the
posterior cortex and increase the risk of fracture. This
cut sets the rotation of the tibial component.
the femoral component during femoral preparation.
Next, the anterior tibia is exposed from the tibial tubercle to the rim of the plateau and Gerdy’s tubercle. Once
proper exposure is achieved, a Hohmann retractor is
> It should be in line with the medial border of the lat-
eral femoral condyle and internally rotated 10–15°
from the mid-sagittal plane of the tibia.
placed on the medial epicondyle to evaluate the patellofemoral and medial compartments for degeneration.
Prior to tibial preparation, isolated lateral disease and
an intact anterior cruciate ligament should be conrmed
to achieve reproducible results.
This amount of internal rotation will place the patellar
tendon in the path of the reciprocating saw blade. There-
fore, the tendon should be carefully retracted when mak-
ing the vertical tibial cut (. Fig.15.6b).
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. Fig. 15.4 a Arthrotomy. Lateral arthrotomy is performed from
proximal to distal, staying lateral to the patellar tendon. b Infrapatellar fat pad preserved to augment thin lateral retinacular tissue to
. Fig. 15.5 a, b Exposure. The intercondylar notch osteophytes, lateral tibial osteophytes, and the visible portion of the lateral meniscus
are removed to allow for adequate exposure. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
facilitate water-tight closure. (Printed with permission of Joint
Implant Surgeons, Inc., New Albany, Ohio)
abc
. Fig. 15.6 a–c Tibial preparation. a The extramedullary tibial
guide is xed to the tibia with a single pin. b The patellar tendon is
retracted medially and a vertical tibial resection is made with a stiff,
narrow reciprocating saw blade. c With the patellar tendon retracted
medially, and the iliotibial (IT) band and lateral collateral ligament
(LCL) protected laterally, the horizontal tibial cut is made using
12-mm-wide oscillating saw blade. (Printed with permission of Joint
Implant Surgeons, Inc., New Albany, Ohio)
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N. R. Patel et al.
. Fig. 15.7 a The resected tibia is released from soft tissue attachments and then excised. b The resected tibia is measured against a contra-
lateral trial to determine appropriate sizing. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
> This is a critical step, as the adequate amount of the
tibial component‘s internal rotation not only ensures
the femoral component articulate with the tibial polyethylene evenly throughout the screw-home mechanism but it also enlarges the implant surface area and
helps to prevent subsidence.
A common mistake is to externally rotate the tibial component. Furthermore, the reciprocating saw should be
handled along the exion axis of the tibia because excessively lifting the hand will lead to violation of the posterior cortex and increased risk of fracture.
With the patellar tendon retracted medially, and the
iliotibial (IT) band and lateral collateral ligament (LCL)
15
protected laterally, the horizontal tibial cut is made
using a 12-mm-wide oscillating saw blade (. Fig.15.6c).
Again, the minimum amount of tibia resected should
accommodate the tibial template and a 3 mm feeler
gauge in the extension gap. Next, an osteotome is used
. Fig. 15.8 The keel-prep tibial trial is placed on the lateral tibia to
assess implant rotation and size. (Printed with permission of Joint
Implant Surgeons, Inc., New Albany, Ohio)
to lever the resected tibia, which is then secured with a
straight Kocher forceps. The soft tissue attachments are
then excised, thereby removing the resected tibia
Fig. 15.7). The resected tibia is matched up against
(.
the contralateral tibial baseplate trials to evaluate for
appropriate sizing. Once an appropriate size is determined, the keel-prep tibial trial is placed on the lateral
tibia to assess implant rotation and size (. Fig.15.8).
notch with the knee at 45° of exion (.
IM rod is inserted and directed toward the anterior infe-
rior iliac spine (AIIS). The knee is exed to 90° and the
femoral drill guide is positioned against the distal femur
with the foot in contact with the posterior femoral con-
dyle. The IM link guide now connects the IM rod and
the femoral drill guide (.
Fig.15.10). This will ex the
femoral component 5°. After coupling the IM rod with
Fig.15.9). The
the femoral drill guide, the drill guide is positioned in
15.4.3 Femoral Preparation
the middle of the femoral condyle. This ultimately sets
the position of the femoral component.
Femoral preparation begins with the introduction of the
intramedullary (IM) guide into the femoral canal. An
entrance drill hole is introduced in the distal femur 1cm
anterior to the anterolateral corner of the intercondylar
> Just like medial UKA, the femoral guide has a ten-
dency to migrate medially and care must be taken to
center the guide on the lateral femoral condyle.
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. Fig. 15.9 Femoral preparation. With the knee in 45° exion, the
entrance hole is made 1cm anterior to the anterolateral corner of the
intercondylar notch and the rod is directed toward anterior inferior
iliac spine (AIIS). (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
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The screw-home mechanism of the knee describes the
relative external rotation of the tibia with respect to the
femur during extension.
> A femoral component placed too medial in exion
may seem appropriately positioned; however, with
knee extension, the femoral component impinges
against the tibial spine eminence or edge loads the
tibial polyethylene.
This is a critical step as placing the drill guide in the
middle of the lateral condyle or even slightly lateral will
lead to a decrease in impingement.
After the drill guide is placed in the appropriate position, a 4mm drill in passed through the upper drill slot,
and a 6mm drill is passed through the lower drill slot.
The femoral drill guide and the linking guide are
removed (. Fig.15.11). The femoral saw block is now
placed into the drill holes; the IT band and LCL are protected with a laterally placed retractor. The posterior
15
abc
. Fig. 15.10 a Intramedullary (IM) rod placement. b The knee is
exed to 90° and the femoral drill guide is positioned against the
distal femur with the foot in contact with the posterior femoral con-
dyle. c The IM link guide connects the IM rod and the femoral drill
guide. (Printed with permission of Joint Implant Surgeons, Inc.,
New Albany, Ohio)
. Fig. 15.11 a With the drill guide in appropriate position, a 4mm drill is passed through the upper hole and b a 6mm drill is passed
through the lower hole. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
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N. R. Patel et al.
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. Fig. 15.12 The femoral saw block is now placed into the drill
holes, the iliotibial band, and lateral collateral ligament are protected, and the posterior femoral resection is made using a broad
sagittal saw. (Printed with permission of Joint Implant Surgeons,
Inc., New Albany, Ohio)
femoral resection is made using a broad, thin sagittal
saw (. Fig.15.12). During this step, slightly exing the
saw will lead to a cut that is planar with the cutting
guide. Following the posterior femoral resection, the
saw block is removed along with the bony fragment. The
lateral meniscus and soft tissue can now be appropriately removed.
Next, the distal femur is prepared by milling the lateral condyle into a round, spherical shape in order to
accept the femoral trial. This is accomplished by inserting the 0 spigot into the 6 mm (lower) drill hole and
milling over it. Generally, the 0 spigot will not remove
any distal femoral bone secondary to distal femoral
hypoplasia. Once the mill stops advancing, the 0 spigot
is removed. The residual protruding corners of bone are
removed with an osteotome, which is directed tangentially to the milled surface (. Fig.15.13).
15.4.4 Balancing theFlexion
andExtensionGaps
. Fig. 15.13 The distal femur is initially milled with a 0 spigot.
(Printed with permission of Joint Implant Surgeons, Inc., New
Albany, Ohio)
. Fig. 15.14 The femoral trial and the tibial template are placed to
evaluate the exion and extension gap. (Printed with permission of
Joint Implant Surgeons, Inc., New Albany, Ohio)
femur osteophytes are moved, the trials are placed, and
the extension and exion gaps are re-evaluated
Fig.15.15). It is critical not to mallet in the spigots as
(.
the sizing is based on the depth created by the 6mm drill.
The femoral trial and the tibial template are placed
to evaluate the exion and extension gap. The exion
gap is measured at 95° of exion with a feeler gauge
(. Fig. 15.14). The extension gap is measured in full
extension with a feeler gauge that is at least 2mm smaller
than what was measured for the exion gap.
After initial gap measurement with feeler gauges, the
distal femur is sequentially milled in millimeter increments until the gaps are balanced in exion and extension. With each size increase in the spigot, an additional
1mm of distal femur is removed, thereby increasing the
extension gap by 1mm. After each milling, the distal
> Balancing the gaps in the lateral compartment differs
from a medial UKA or TKA.In the lateral compartment of a normal knee, the exion gap is loose compared with the extension gap.
This normal disparity should be recreated without overcorrection.
> The authors’ preference is to balance 2–3mm lax at
90° of exion and “tight” or 0mm at full extension.
This will allow for the tibiofemoral screw-home
mechanism and translation.
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c
. Fig. 15.15 a–d Balancing gaps. a After each milling, b the distal femur osteophytes are moved, c the trials are placed, and d the extension
and exion gaps are re-evaluated. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
Once the gaps are adequately balanced, the trials are
d
> Care is taken not to drill deep holes into the tibia.
removed and a tibial template is placed on the tibia. The
tibial keel slot is prepared with a keel cut saw
(. Fig. 15.16). The template is forced medially against
the vertical border and held in place with a tibial template
nail. The keel cut saw is introduced in the template slot
and advanced anterior to posterior. Once the saw cut is
complete, the groove is excavated with a cemented tibial
groove cutter to allow for proper cementation of the keel.
The nal trial is subsequently performed with a trial
bearing (.
Fig.15.17).
The authors’ preference is the use of high-viscosity bone
cement with Biomet Bone Cement (Zimmer- Biomet,
Warsaw, IN). The cement is prepared in a standard fashion with 1g of vancomycin and subsequently placed on
the implants. The cement is placed on the undersurface
of both the tibial and femoral implants (.
During the tibial preparation, a thin layer of cement
is placed into the prepared tibial bone with a curved
osteotome to ensure pressurization and limit posterior
extrusion of the cement (. Fig.15.20). The tibial component with a small amount of cement is inserted rst
and malleted from posterior to anterior direction. This
15.4.5 Cementation andComponent
Fixation
will limit the amount of cement that is extruded into the
posterior capsule (. Fig. 15.21a). Next, a 90-degree
Woodson curette is utilized to remove extruded cement
The trials are removed and the bony surfaces are prepared with pulsatile lavage to provide a dry and clean
surface for cement interdigitation. Drill holes are placed
circumferentially around the femur and tibia utilizing a
short segment drill (. Fig.15.18).
from the posterior to anterior direction (. Fig.15.21b).
The leg is subsequently extended to tighten the posterior
capsule and compress the remaining posterior cement
onto the implant. The Woodson elevator is utilized
again to remove any remaining cement.
Fig.15.19).
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N. R. Patel et al.
. Fig. 15.16 a Once the gaps are adequately balanced, the trials are removed and a tibial template is placed on the tibia. b The tibial keel
slot is prepared with a keel cut saw. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
. Fig. 15.17 The nal trial
is subsequently performed
with a trial bearing. (Printed
with permission of Joint
Implant Surgeons, Inc., New
Albany, Ohio)
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. Fig. 15.18 Cementation and component xation. Drill holes are placed circumferentially around the femur (a) and tibia (b) utilizing a
short segment drill. (Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
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. Fig. 15.19 Cementation and component xation. The cement is placed on the undersurface of both the femoral (a) and tibial (b) implants
(Printed with permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
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. Fig. 15.20 a, b Tibial cementation preparation. A thin layer of
cement is placed into the prepared tibial bone with a curved osteotome to ensure pressurization and limit posterior extrusion of the
. Fig. 15.21 Tibial cement xation. a With a small amount of
cement,the tibial component is inserted rst and malleted from posterior to anterior direction. b A 90-degree Woodson curette is uti-
cement. (Printed with permission of Joint Implant Surgeons, Inc.,
New Albany, Ohio)
lized to remove extruded cement from posterior to anterior direction.
(Printed with permission of Joint Implant Surgeons, Inc., New
Albany, Ohio)
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N. R. Patel et al.
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. Fig. 15.22 a A suction tip is placed on the prior 4mm drill hole
to induce negative pressure within the bone and nger pressurized
into distal femur. b, c The femoral component loaded with cement is
impacted into the bone with an impactor. d Both components are
compressed at 45° of knee exion with a 2 mm feeler gauge and
extruded cement is removed from both components. (Printed with
permission of Joint Implant Surgeons, Inc., New Albany, Ohio)
Once the tibial component is set, attention is now
placed on the femoral component. A suction tip is placed
on the prior 4mm drill hole to induce negative pressure
within the bone. An adequate amount of cement is nger
pressurized into the prepared distal femur (. Fig.15.22a).
Next, the femoral component loaded with cement is
impacted into the bone with an impactor (. Fig.15.22b,
c). At this point, the extruded cement is removed from
the margins with the Woodson curette. Both components
are compressed at 45° of knee exion with a 2mm feeler
gauge; and, any extruded cement is subsequently removed
from both components (. Fig. 15.22d). The wound is
irrigated with warm saline and prepared for closure.
15.4.6 Closure
The capsular tissue is approximated with 2
Quill™PDO(RX-2066Q, Angiotech Pharmaceuticals,
Vancouver, BC, Canada) (. Fig.15.23), subcutaneous-
. Fig. 15.23 The arthrotomy and capsular tissue are closed with 2
Quill™ PDO. (Printed with permission of Joint Implant Surgeons,
Inc., New Albany, Ohio)
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tissue with 0 Quill™Monoderm™ (YA-1029Q,
Angiotech Pharmaceuticals, Vancouver, BC, Canada),
and the skin is closed with 2–0 Quill™Monoderm™(YA2024Q, Angiotech Pharmaceuticals, Vancouver, BC,
Canada), and Dermabond® Skin Adhesive (DNX12,
Ethicon Inc., Somerville, NJ).
15.5 Discussion ofCurrent Literature
In the past, various surgical techniques and devices have
been utilized in the treatment of lateral compartment
arthritis with varying degrees of survivorship (. Table15.1).
> In recent years, multiple studies have demonstrated a sig-
nicant increase in survivorship as devices and
techniques continue to improve (.
Tabl e15.1).
surgical
In one of the largest series, Berend etal. reported 99%
survivorship in 100 lateral UKA presented with 3-year
follow-up (Berend et al. 2012). Smith et al. reported
95.5% survivorship for 101 lateral UKA at 5 years
(Smith etal. 2014). Berend etal. reported similar survivorship on a non-modular, xed-bearing, metal- backed
tibial component utilizing a lateral parapatellar
approach at a 2.3-year follow-up (Berend et al. 2015).
Recently, Greco etal. reported on similar survivorship
and clinical outcomes utilizing a lateral-specic xedbearing implant at 2.7 years follow-up (Greco et al.
2019).
Van der List et al. performed the largest systemic
review with 96 eligible studies and reported the survivorship in medial and lateral UKA.With regard to lateral
UKA survivorship, 15 cohort studies and a single registry’s data were analyzed. This study reported 93.2% survivorship at 5years, 91.4% survivorship at 10years, and
89.4% survivorship at 15years (van der List etal. 2015).
Although isolated lateral compartment osteoar-
thritis exhibits decrease incidence relative to medial
compartment osteoarthritis, it still presents with relative frequency and is amenable to appropriate treatment. With proper patient diagnosis and surgical
technique, multiple studies have demonstrated excellent survivorship.
. Table 15.1 Published results of lateral unicompartmental knee arthroplasty
Authors Year #
Scott and
Santore (1981)
Mallory and
Danyi (1983)
Marmor (
Kozinn etal.
(
1989)
Magnussen and
Bartlett (
Christensen
1991)
(
Rougraff etal.
(1991)
Scott etal.
1991)
(
Capra Jr. and
Fehring (1992)
Heck etal.
1993)
(
1984) 1984 14 Marmor (Smith & Nephew), cemented, all-poly
1990)
1981 12 Brigham I & II (DePuy); cemented, all-poly
1983 4 Polycentric 17% (Stryker); Marmor 83% (Smith
1989 11 Brigham Mod (DePuy), cemented, metal-
1990 9 PCA (Stryker), cementless, metal-backed (2–3.3) 100% at 2years (0)
1991 54 St. Georg Sled (Link), cemented, all-poly tibia 3.9 (1–9) 98.4% at 3.9years (na)
1991 14 Compartmental I & II (Zimmer), cemented,
1991 12 Brigham I & II (Stryker); cemented, all-poly
1992 4 Marmor (Richards) 11.1 (8–14) 100% at 11.1years (0)
1993 39 Marmor (Smith & Nephew); compartmental I
Knees
8 Compartmental II (Zimmer) 6.3 (4–11) 100% at 6.3years (0)
Type of implant (manufacturer) Follow-up
tibia
& Nephew); both cemented, all-poly tibia
tibia
backed
all-poly
tibia
& II (Zimmer)
Survivorship (# Revisions)
(years)
3.5 (2–6) 83.3% at 3.5years (2)
5.6 (5.1–8.1) 50% survival at 5.6years
(2)
7.4 (2.5–9.83) 85.7% at 7.4years (2)
5.5 (4.5–6) 100% at 5.5years (0)
6.5 (0.7–13.5) 92.9% at 6.5years (1)
(8–12) 83.3% at 9years (2)
6 (maximum
14.8)
97.4% at 6years (1)
(continued)
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