A Practical Operative Guide for Total Knee & Hip Replacement Ajit Kumar Mehta
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1A Practical Operative Guide for Total Knee and Hip Replacement2
3A Practical Operative Guide for Total Knee and Hip Replacement
Second Edition
Ajit Kumar Mehta MBBS D Ortho MS (Ortho) Senior Consultant Orthopedic Surgeon Orthopedic and Joint Replacement Center Jagjivan Ram Hospital Mumbai, Maharashtra, India
4
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A Practical Operative Guide for Total Knee and Hip Replacement
First Edition : 2008
Second Edition : 2015
9789351524823
Printed at
5Dedicated to
My parents and My teachers6
7Preface to the Second Edition
Total knee and hip replacement surgeries are special operations which require highest order of aseptic precaution, surgical skill and good team with almost fixed preoperative, peroperative and postoperative techniques and protocols with some modifications according to the individual case. We are strictly following the protocols and steps which are mentioned here. The first edition of this book (2008) had been written after gaining the experience in more than 800 cases of total knee and hip replacement surgeries with successful outcome. The second edition of this book (2015) has been revised after gaining experience in more than 3,000 total knee and hip replacement surgeries and vast experience with management of various complications.
Extension of chapters like total knee replacement (TKR) by navigation system, important points and total hip replacement (THR) in difficult situations, bone cement, ultrasonic system for cemented and uncemented revision surgeries, complications and revision THR, physiotherapy in TKR and THR has been made. In revision THR, we have used uncemented modular revision stem with distal fixation (solution revision stem or REEF) in addition to cemented C-stem and uncemented Summit stem. To make these special surgeries easier, diagrammatic and some more original photographs have been included. Outline of TKR by navigation system has been mentioned. Basic principles and technique remain the same as conventional technique, only the assessment of tibial and femoral resections is made by morphing the hip center, femoral mechanical axis, whiteside line, tibial mechanical axis, various femoral and tibial landmarks and surfaces. Ligament balancing and patellar tracking are being seen on computer. TKR with navigation system is more useful in patients with arthritis of the knee and extra-articular femoral and/or tibial deformity, retained hardware or intramedullary implants.
Various techniques of postoperative analgesia like patient-controlled analgesia (PCA) have been added in addition to epidural analgesia.
In place of unicondylar knee replacement for medial compartment osteoarthritis, we are performing high tibial osteotomy (HTO) by hemicallotasis (HCO) using dynamic axial fixator (DAF) with the principle of neohistogenesis and gradual correction of varus deformity. The chapter of high tibial osteotomy by hemicallotasis has been separated from second edition of this book and published as a separate book titled Step by Step High Tibial Osteotomy by Hemicallotasis—parts of dynamic axial fixator, technique of fixator application and audiovisual presentation for education to medial compartment osteoarthritis patients for easy and better understanding of the steps.
Postoperative pain management has been described after TKR and THR. Management of complications like supracondylar fracture femur and infection following TKR have been included. Technique of revision TKR and THR has been mentioned. Whenever planned for arthrodesis of the knee following infected TKR, the technique has been described with limb reconstruction system (LRS).
A patient's guide to arthritis and joint replacement and ultrasonic cement removal system for revision joint replacement surgeries have been added.
Technically well-performed joint replacement surgeries and postoperative good physiotherapy give excellent results. Long-term success of joint replacement depends on restoration of the normal alignment of the lower limb, thereby, bringing the transverse axis of the knee parallel to the ground in anatomic two-legged stance and restoring normal weight distribution across the joint.
Ajit Kumar Mehta8
9Preface to the First Edition
Severe arthritis of the knee and hip is a painful disabling condition which cripples millions of people around the world and make them dependent on others even for activities of daily living. Due to increase in the life-expectancy, there is increase in the disease of advancing age like painful and disabling arthritis of knee and hip joints which require total knee and hip replacement (TKR and THR). A successful total knee and hip replacement not only provides relief from pain and disability but also makes a person fit to perform most of normal activities with some modification in life style. Total knee and hip replacements are extremely reliable and universally-accepted procedures that improve the quality of life significantly.
Total knee and hip replacement surgeries are special operations which require highest order of aseptic precaution, surgical skill and good team with almost fixed preoperative, peroperative and postoperative techniques and protocols with some modifications according to the individual case. We are strictly following the protocols and steps which are mentioned here. This book has been written after gaining the experience in more than 800 cases of total knee and hip replacement surgeries with successful outcome. It is very important to select the patients, educate them about the surgery, physiotherapy and postoperative protocols. Before doing the surgery plan properly, if required template, assess the difficult situations like FFD more than 30°, stiff knee (flexion <30°), large medial or lateral defects (i.e. severe varus or valgus deformity), post-HTO. Keep in mind the important points, sequential soft tissue release, cementing technique and avoid silly mistake in TKR. In cases of THR, look for acetabular dysplasia, posterior osteophytes, protrucio acetabuli, coxa magna, fractured acetabular floor, bony ankylosis of hip, adductor tightness, poor bone stock and plan properly before surgery. We have used the cruciate-substituting fixed-bearing PFC sigma knee implants and rotating platform high flexed (RPF) design for TKR. C-stem for cemented THR and Summit-tapered hip system for uncemented THR have been used. Whatever the implants used the basic principle remains the same. In this book the important points have been explained and demonstrated by the original photographs which will be helpful for the beginners. As these surgeries require highest order of aseptic precaution, so I have mentioned about the operation theater setup specification. It is advisable to have an adequate exposure of these surgeries before starting independently because there is no scope for even a small error which may jeopardize the activities of daily living (ADL) of the patients and early implant failure resulting into revision surgeries which are more difficult and less survival of the joint. Patients are coming for better quality of life so they cannot accept any error or complication. It is also important to note that till joint is not operated the joint remains the patient's joint but once operated it becomes the surgeon's joint and hence the operating surgeon has to look after the joint whatever the problem arises.
Postoperative pain management has been described after TKR and THR. Management of complications like periprosthetic fracture and infection following TKR have been included. Technique of revision TKR has been mentioned. Whenever planned for arthrodesis of the knee following infected TKR, the technique has been described with limb reconstruction system (LRS). Patient's guide to arthritis and joint replacement has been added.
We have used high tibial osteotomy by hemicallotasis using dynamic axial fixator for medial compartment osteoarthritis of knee with the principle of neohistogenesis and gradual correction of varus deformity in place of unicondylar knee replacement surgery with excellent result. The selection criteria and technique of HTO using dynamic axial fixator has been described for desired outcome.
Ajit Kumar Mehta10
11Acknowledgments
First of all I thank Prof Sudhir Kumar, New Delhi under the guidance of whom I really learnt the discipline of orthopedics during the tenure of my senior residency at BP Koirala Institute of Health Sciences, Dharan, Nepal. I take this opportunity to thank Dr SS Vengsarkar, Honorary Consultant and Dr JP Jain, Ex-HOD who have continuously guided while performing total joint replacement surgeries. I gladly acknowledge my debt to Dr Mangal Parihar who took the trouble of reading over sections of the manuscript and offering helpful comments. I sincerely thank him for his timely valuable suggestions. My special thanks to Dr VK Ramteke, Ex-Director General of Indian Railway Health Services, Ministry of Railways, Delhi, India, who has taken keen interest in developing this center during his tenure as Chief Medical Director and under guidance of whom, the best possible treatment is being provided to the patients.
My special thanks to my younger brother Mr Binay Mehta, Director, Dedicated Academy, who has encouraged and inspired me to write this book for the benefits of the beginner orthopaedic surgeons in total joint replacement surgeries. I am thankful to my wife Mrs Kiran Mehta who has taken care and my son Aman Raj who has spared time for me whenever I remained busy.
I am also very much thankful to anesthesiologists, especially Dr Reena Parampil, Dr Atul Sharma, Dr Dinesh Sahu, Dr Chandrakant Patel, Dr Ashish Korgaonker and Dr Anand Nirgude for writing the postoperative pain management in patients of TKR and THR.
My sincere thank to Dr Ashok Kumar Malviya and Dr Vipin Maheshwari from Ratlam, Madhya Pradesh, India for valuable comments and suggestions. My special and extended thanks to Dr Vipin Maheshwari for contribution of tibial flare index and thorough reading over manuscripts and grammatical corrections.
I am also thankful to physiotherapist Mrs Mrinalini S Bapat for valuable contribution of chapter on physiotherapy in TKR and THR and pre- and postoperative care of the patients.
I am very much thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, and their Mumbai Branch Manager, Mr CS Gawde and Senior Sales Executive, Mr YT Bist (Mumbai Branch), who approached me for publishing the second edition of this book and their subsequent cooperation.