DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: End-stage arthritis, right knee, with valgus flexion contracture.
POSTOPERATIVE DIAGNOSIS: End-stage arthritis, right knee, with valgus flexion contracture.
OPERATION PERFORMED: Right total knee arthroplasty.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General, spinal, right femoral nerve block.
TOURNIQUET TIME: 40 minutes.
ESTIMATED BLOOD LOSS: 200 mL.
DRAINS: None.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with end-stage arthritis of her right knee. She has a 10-degree valgus deformity and 20-degree flexion contracture. The patient has failed conservative treatment and is now undergoing right total knee arthroplasty.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine fashion on the operating table for right total knee arthroplasty, and general anesthesia was induced. Foley catheter was placed. She was turned on her side and spinal anesthetic was administered. She was rolled back supine. A tourniquet was placed about the right upper thigh, and the right leg was prepped and draped in sterile fashion. Ioban sheeting was used, and gloves were changed.
We wrapped the leg with an Esmarch, flexed the knee, and inflated the tourniquet. We made an anterior longitudinal incision followed by a median parapatellar arthrotomy and synovectomy. We elevated the deep fibers of the MCL very conservatively off the upper medial tibia with a key elevator and a Bovie. We excised a portion of the fat pad and carefully everted the patella and flexed the knee. We excised the ACL and the anterior meniscal remnants.
We then used the IM guide with a short blade due to the fact that the patient had a previous total hip, set at 6 degrees of valgus, in line with the transepicondylar axis of the femur. We pinned the distal femoral cutting block in place and made our cuts with the oscillating saw.
We then incised the femur to a size E, pinned this cutting block in place, and made our cuts with the oscillating saw. We trimmed any osteophytes. We subluxed the tibial floor with a blunt Hohmann retractor and made an attempt to preserve the PCL. We placed the lateral Bodnar retractor.
Then, we used the IM guide on the tibia to pin our tibial cutting block in place in the appropriate rotation. We made a cut with the oscillating saw and then placed a lamina spreader in the knee, balanced the flexion and extension gaps and removed any posterior osteophytes and meniscal remnants.
The knee was tight on the posterior lateral corner in flexion, so we released the popliteus from its origin and then elected to go with a posterior stabilized knee since this knee was acting even more valgus than it appeared. We excised the PCL and then we drilled and punched our keel hole after sizing the proximal tibia to size 3.
We placed our tibial component, placed our femoral box cutting guide, and made a box cut with the reciprocating saw. We then assembled the knee with size 3 tibial component, size E, gender specific LPS-Flex femoral component. We were slightly too tight in both flexion and extension, and therefore, we removed our components.
We made a second cut at the tibia, an additional 2 mm, and this balanced very nicely, once our components were replaced. The knee had full extension, excellent alignment and tracking with flexion 0 to 130 degrees.
We then everted the patella, held it with towel clips, resected the articular surface with the oscillating saw and then used the 29 mm template to drill our three peg holes. With the patellar trial in place, it tracked nicely throughout the range of motion. We then removed all of our trial components. We plugged the medullary canals of the femur and tibia with bone plugs and did a pulsatile lavage and dried the bony surfaces.
We mixed up two batches of Simplex cement and sequentially cemented on a size 3 tibial component and size E gender specific LPS-Flex femoral component. We scraped away the excess cement and reduced the knee with a 10 mm trial insert. We cemented on a 29 mm resurfacing patellar component, held this with a clamp and scraped away excess cement.
Once the cement had hardened, we let down the tourniquet at 40 minutes. We cauterized any bleeders. The lateral geniculum was bleeding, and we exposed this very carefully and cauterized it. Once hemostasis was secured, we then went through the knee and meticulously removed any retained cement. We then snapped in a 10 mm trial insert, put the knee through full range of motion, and we were very pleased with this.
As our final step, we placed our retractors and snapped in the size 3, 10 mm posterior stabilized tibial permanent insert, checked it for security, and then ranged the knee several more times.
We irrigated once more. We infiltrated the muscle and fascia with 25 mL of bupivacaine to a dull morphine combination. We then closed the fascia with interrupted figure-of-eight #1 Ethibond sutures.
We closed the subcutaneous tissue with inverted 2-0 Vicryl and the skin with staples. We infiltrated the wound itself with 0.25% Marcaine and applied a sterile dressing followed by a well-padded Jones dressing. The anesthesiologist then placed a right femoral nerve block catheter and then we transferred the patient to the recovery room in satisfactory condition. Sponge and needle counts were verified correct x2.
