PREOPERATIVE DIAGNOSIS: Right knee degenerative joint disease.
POSTOPERATIVE DIAGNOSIS: Right knee degenerative joint disease.
OPERATION: Right total knee arthroplasty.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General LMA.
ESTIMATED BLOOD LOSS: 100 mL.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating room table. A tourniquet was placed. After undergoing placement of a Foley and general anesthesia with placement of LMA, the patient’s right lower extremity was prepped and draped in standard fashion. The leg was exsanguinated and the tourniquet was inflated to 275 mmHg.
The initial incision was made over the anterior aspect of the knee. Dissection was carried sharply down to the extensor mechanism, where a second knife was used to create a medial arthrotomy. The patella was everted and the knee flexed up. Attention was turned to the distal femur after clearing up soft tissues and exposing the proximal medial part of the tibia. The distal femur was cut at 5 degrees of valgus based on preoperative long leg templating.
Attention was then turned to the proximal tibia and that was then cut at 90 degrees to the mechanical axis of the tibia. The patient did have a bow noted preoperatively. Using a 10 mm rotating platform spacer block, the lateral side was little more loose than the medial side, and a limited medial release was then performed to obtain equal balance both medially and laterally in extension.
Attention was then turned to the flexion gap after sizing the tibia and femur at size 3. Using a laminar spreader and a size 3 Ranawat block, the appropriate femoral rotation was dialed in to achieve equal balance medially and laterally in 90 degrees of flexion. Using the Ranawat block, anterior and posterior cuts were performed, followed by notch cuts and chamfer cuts. Trials were then inserted with a size 3 femur, a size 3 tibia, and a 10 mm spacer.
The patient had excellent balance throughout range of motion and flexed to approximately 145 degrees in the operating room with this construct. All of the trials were then removed and the patella was then prepared for a 38 mm oval dome 3 peg patella. The proximal tibia was then prepared for final implantation, and all bony surfaces were then thoroughly irrigated and dried. Two bags of DePuy #3 cement were mixed on the back table. Proximal tibial exposure was accomplished, and when the cement had reached an appropriate viscosity, the tibia was cemented into place with attention to removing any excess cement that had extruded from outside the implant.
Next, the femur was impacted into place using 10 mm trial insert. The knee was then placed in extension and any excess cement was removed around the implants. The patella was then cemented into place. The undersurface of the quadriceps tendon was then debrided of any excess tissue. The patient did have an excess amount of tissue underneath the quadriceps tendon due to some prior scarring from previous surgeries. Once the cement dried, the knee was flexed up and any excess hard cement was removed using an osteotome and the wound was then thoroughly irrigated.
The patient had excellent balance medially and laterally with this construct. The trial insert was removed and the final 10 mm size 3 posterior cruciate substituting insert was then implanted. The knee reduced. The tourniquet deflated at 70 minutes. The knee was then flexed up and lateral release was not required today. The wound was then irrigated again.
The arthrotomy was closed using 0 Vicryl, subcutaneous tissues using 2-0 Vicryl, and skin using staples. The patient was then dressed with Xeroform, 4 x 4s, ABDs, Webril, a cooling pad, Ace wrap, and then a knee immobilizer. The patient was transferred to the PACU in stable condition.
