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Prof. Romain Seil, MD, PhD
Centre Hospitalier
de Luxembourg Orthopaedic
Surgery
Sports Medicine
Research Laboratory
Centre de Recherche
Public – Santé,
Luxembourg
5th course of advanced surgery of the knee
Val d’Isère, 02-2014
Gap balancing in TKA: dealing with
the sagittal plane (recurvatum, flexion
contracture, patellar height)
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Recurvatum
• < 1% of TKA patients
• Associated to other deformities:
genu valgum, capsular, ligamentous laxity &
neurological diseases
• Specific attention to neurol. disorders:
Fixed plantar flexion, limb muscle function From: Erceg M, Rakic M, Acta Clin Croat 2012
Neurological disorders must be ruled out
(recurrence of recurvatum)
Meding JB, Clin Orthop Relat Res 2003
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Recurvatum
Distribution (n=57)
Meding JB, Clin Orthop Relat Res 2001
0
10
20
30
40
50
60
5° 10° 15° 20°
%
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Recurvatum
Hyperextension
collapse
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Recurvatum
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Recurvatum
Severe stretching of
posterior capsule & PCL Bony collapse distal femur
& proximal tibia
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Recurvatum
Proximalisation of patella
& shortening of extensor
mechanism
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Recurvatum
1. Minimum resection of distal femur
2. Underresection proximal tibia
(debatable)
3. Choose small femoral component
4. Choose right level of constraint
5. Avoid slight residual
recurvatum intraoperatively
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Planning extension gap
? ?
Recurvatum
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Planning extension gap
17.5 - 64.5
mm
• Up to 15 mm femoral distal augment
• 8.5 mm femoral condyle
• Up to 31 mm PE insert
• Up to 10 mm tibial augment
Recurvatum
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28
mm
20mm
ME
JL
Planning extension gap: epicondylar referencing
Recurvatum
Medial epicondylar line serves as reference (ME at 28 + 3,5 mm from joint line)
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Use previous
or contralateral x-rays
If tight flexion gap:
Use smaller femoral component
rather than reconsidering
increasing tibial resection
Planning flexion gap
Recurvatum
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Which level of constraint ?
Lombardi AV, JBJS-A, 2007
Continuum of constraint
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Lombardi AV, JBJS-A, 2007
Levels of ligamentous incompetency
Level of
constraint
Type of
prosthesis
PCL Collaterals Quad
0 PCL
retaining
+ + +
1 Post.
Stabilized
- + +
2 Constrained
condylar
- +/- +
3 Rotating
hinge
- - +
4 Rigid hinge - - -
Recurvatum
knee
Which level of constraint ?
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♀, 63 years
Rheumatoid arthritis
Major frontal & sagittal instability,
30° recurvatum
Level of
constraint
Type of
prosthesis
0 PCL
retaining
1 Post.
Stabilized
2 Constrained
condylar
3 Rotating
hinge
4 Rigid hinge
Which level of constraint ?
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Recurvatum
1. Minimum resection
of distal femur &
proximal tibia
2. Restoring extension
gap
2. Choose adequate
level of constraint
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Recurvatum
Level of
constraint
Type of
prosthesis
0 PCL
retaining
1 Post.
Stabilized
2 Constrained
condylar
3 Rotating
hinge
4 Rigid hinge
♂, 61 years
140 kg
Moderate recurvatum
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Recurvatum
Level of
constraint
Type of
prosthesis
0 PCL
retaining
1 Post.
Stabilized
2 Constrained
condylar
3 Rotating
hinge
4 Rigid hinge
♀, 59 years
Congenital abnormality,
Mild recurvatum
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Flexion contracture
• Osteoarthritis
• Inflammatory arthritis
• Hemophilia
• Neuromuscular disorders
• More frequent than recurvatum
• Either isolated or in association
with varus/valgus knee
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Flexion contracture
Mild
< 10°
Moderate
10°-30°
Severe
> 30°
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Flexion contracture
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Flexion contracture
Shortening of
posterior capsule &
soft-tissues
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Flexion contracture
Increase of
patellofemoral
forces
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Flexion contracture
Posterior
femoral osteophytes
Anterior tibial
& intercondylar
osteophytes
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Surgical goals:
1. Realign limb
2. Bone resection
3. Restore soft tissue balance
4. Replace PCL (depending on degree of ©)
Flexion contracture
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Flexion contracture
Adequate bone resection & removal of posterior
condylar osteophytes
+/- subperiosteal elevating of posterior capsule
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Flexion contracture
Proper ligament balancing
Here: Stryker Ligament Balancer
Planning extension gap
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Flexion contracture
Additional distal femur resection
(systematic in moderate flexion contractures: +2mm)
Planning extension gap
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Flexion contracture
From: Scuderi G and Kochhar T,
J Arthroplasty 2007
Incisions of posterior capsule
• In extension
• Laminar spreader
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Which level of constraint ?
Conservation of PCL ?
Level of
constraint
Type of
prosthesis
0 PCL
retaining
1 Post.
Stabilized
2 Constrained
condylar
3 Rotating
hinge
4 Rigid hinge
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Which level of constraint ?
Conservation of PCL ?
Level of
constraint
Type of
prosthesis
0 PCL
retaining
1 Post.
Stabilized
2 Constrained
condylar
3 Rotating
hinge
4 Rigid hinge
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Anterior
femoral
undersizing
Quadriceps
insufficiency +
anterior knee pain
♂ 73 years
Patellofemoral
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Lack of flexion
♂ 73 years
Patellofemoral
overstuffing
Patellofemoral
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Patella baja
Patellar resurfacing:
• Not systematically (in my hands)
• As proximal as possible with smaller
patellar button
• Remove inferior portion of patella without
compromising stability of patellar tendon
From: Hocking & MacDonald. Managing Patella Problems in Primary TKA.
In: Lotke PA, Lonner JH. Master Techniques in Orthopaedic Surgery.
Knee Arthroplasty.
Wolters Kluwer/Health 2009
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ATT proximalization
1. Identify physiologic patellar height by
lateral radiograph at 90° of knee
flexion on contralateral knee
2. Fluoroscopic intraoperative control
3. ATT osteotomy (fragment > 5 cm)
4. Create step-off at superior pole
5. Use compression screws (posterior
cortex)
Laurin CA, JBJS-B, 1977
Labelle-Laurin method
Patella baja
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16th ESSKA Congress
May 14-17, 2014
AMSTERDAM / THE NETHERLANDS
CONGRESS PRESIDENT
C. Niek van Dijk
ESSKA PRESIDENT
João Espregueira-Mendes
SCIENTIFIC CHAIRMEN
Stefano Zaffagnini
Roland Becker
Gino Kerkhoffs
ORGANISER
www.esska-congress.org