DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right knee osteoarthritis.
POSTOPERATIVE DIAGNOSIS: Right knee osteoarthritis.
OPERATION PERFORMED: Right total knee arthroplasty.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMEN: Bone from femur, tibia, and patella on the right.
ESTIMATED BLOOD LOSS: 250 mL.
COMPLICATIONS: None.
TOURNIQUET TIME: 58 minutes.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female with right knee pain due to arthritis. The patient’s discomfort became worse and worse. She had valgus alignment with degeneration of the patellofemoral joint as well as the lateral compartment. She has failed conservative management, including exercises, therapy, as well as injections, which initially gave her relief. She is now indicated for operative intervention. The risks and benefits were discussed with the patient prior to the procedure and consent was obtained prior to the surgery.
DESCRIPTION OF OPERATION: The patient was brought to the operating suite and placed in the appropriate position. One gram of Ancef and 80 mg of gentamicin were administered intravenously after the administration of anesthesia, which was general in this case. The patient was placed in the supine position, and a Foley catheter was inserted. Anesthesia was unable to get spinal anesthesia and thereby converted to general anesthesia. The nonoperative extremity was padded. A proximal thigh tourniquet was placed, and the lower extremity was prepped and draped in the normal sterile fashion. The right lower extremity was elevated, exsanguinated, flexed, and the tourniquet was elevated to 300 mmHg.
The knee was approached through a standard medial parapatellar approach. The knee was extended, patella was everted, and the knee was flexed again. Anterior horns of both menisci were excised. A very conservative medial release was performed to the posteromedial corners due to her valgus alignment. Osteophytes were removed from the femoral condyle and then the intercondylar notch using a rongeur. The patient had significant degeneration of the trochlea as well as the lateral compartment with bone-on-bone articulation. The femoral drill was placed 1 mm above the central roof of the intercondylar notch and aligned with the femoral shaft. The 5/16 inch drill was used to open the femoral canal. The drill was toggled upon exit to allow for venting. The canal was suctioned. Intramedullary rod was placed and removed.
The distal femoral cutting guide was placed with the screws down to account for the lowest cartilage. The guide was rotationally drilled and pinned with both screws resting on the femoral condyle. The jig was removed, and the distal femur was cut with a new saw blade for saw capture. All saw cuts were cooled with irrigation. The patient did have a flexion contracture preoperatively. Therefore, 2 additional mm were cut off the distal femur. The distal femur sizing guide was centered and the distal femur cut adjusted for external rotation and pinned into place. The femoral lug holes were not drilled at this time since the femur was sized to be approximately a little bit over 2. In order to avoid any notching, the 2 mm cheater block was then placed, shifting the cutting block 2 mm anteriorly. The lug holes were then drilled. The size 2 AP cutting block was then placed, and the anterior condyles were cut without notching. The posterior condyles were cut while protecting the collateral ligament. A size 2 chamfer guide was placed, and the anterior and posterior chamfers were cut. The trochlear notch cut was made, a 1/2 inch blade. A bone plug was placed in the canal opening.
Attention was now directed towards the tibia. The ACL was removed with a rongeur. Posterior tibial retractor was gently placed over the posterior horn of the lateral meniscus to sublux the tibia forward. The remaining menisci were excised. The lateral inferior geniculate artery was seen and cauterized. The PCL was sacrificed. The proximal tibial cutting guide was placed and set for rotation, slope and depth of resection. The cutting block was pinned into place. The alignment rod was placed and found to fold towards the center of the ankle. The proximal tibia was then cut while protecting the collateral ligament. The medial side measured approximately 10 mm and the lateral side 9 mm due to bone loss from the arthritis. The tibia was checked for flatness and the proximal tibial pins were pulled. The tibia was sized to allow for the most coverage without overhang. A size 1 proximal tibial drill guide was then pinned into place after adjusting for coverage and rotation. The tibia was broached. The reamer and broach for the cobalt chrome tibial base plate was used in preparation for implantation of a cobalt chrome stem component.
All instruments were removed. Posterior osteophytes were present and removed with 3/4 inch curved osteotome and curettes. Trials were placed. A 9 mm flat tibial insert was inserted. The knee sprung to full extension, and it was stable to varus/valgus stress in both flexion and extension. All trials were removed. Attention was then directed towards the patella. The patella was everted with the aid of a towel clip. The patella was peripherally denervated using electrocautery. Patellar thickness was measured using calipers and was approximately 21 mm. The center of the sagittal ridge was identified and drilled. The osteochondral junction was identified and the cutting guide was placed. The depth of the resection was measured and the patella was cut. The patellar thickness was measured again. The patella was sized and centered in the previously drilled hole. It was then reamed deep enough to reproduce the original thickness of 1 mm or less. Once the component was placed, the drill guide was placed and the appropriate holes were drilled. Cement was now mixed. All cut cancellous surfaces were copiously irrigated and dried.
The base of the preassembled proximal tibia and polyethylene was coated with cement. The proximal tibia was exposed. The tibia was impacted into place. Excess cement was removed after being heated with warm saline. Distal femur was exposed. The component was precoated with cement. Lugs and lug holes were lined up with the femoral component, which was impacted into place. Excess cement was removed after being heated with warm saline. Patellar thickness was then cemented into place, compressed, and excess cement was removed. Lateral facet was trimmed. Final patellar thickness was approximally 20 cm. Tourniquet was deflated at 58 minutes. The knee was copiously irrigated with pulsatile irrigation fluid and hemostasis was achieved. The knee was closed in flexion over a medium suction drain. The arthrotomy was closed using #1 Ethibond and #2 Vicryl, 2-0 Vicryl used for the subcutaneous tissue, and staples for the skin.
Sterile dressings were applied. A bulky compressive dressing was applied over a cooling pad. The patient tolerated the procedure well and was taken to the recovery room in stable condition. Sponge and instrument counts were correct at the end of the case.
