A 71-year-old Former Marathon Runner with 15 Degree Valgus: A - PowerPoint PPT Presentation

A 71-year-old Former Marathon Runner with 15 Degree Valgus: A Winning Checklist William A. Jiranek MD, FACS Professor and Vice Chair Duke University Orthopaedic Summit 2017 Las Vegas, Nev. Dec. 6-9, 2017 Adult Reconstruction

Disclosure • Personal • Institution – Royalties – Research • Depuy and clinical – Consultant support: • Depuy • Depuy – BOD and • Stryker Committee • AAHK S, Hip Society

Game Plan Preop – What do I assess? • Preop – Clinical Issues Patellar tracking Prior incisions Lumbar Spine issues – Shared Decision Making Risk of peroneal palsy (.7-4%) Risk of patella maltrack Musculoskeletal Key Chap 14

Game plan Preop - What’s the coronal femoral < ?

Game Plan - Preop • Consider position of patella – Is there already subluxation? – If markedly subluxed consider a lateral arthrotomy – Often the patella is markedly thinned on the lateral facet

Game Plan - Intraop • Approach – Chance of devascularizing patella is significant if extensive lat release !

Get tibial resection right • Reference thickness of cut off good (medial) side • Protect but do not release MCL, be careful with saw on medial side

How do you get the femur right?

Game Plan - Intraop • Make sure your femoral • Tendency in measure component is adequately resection is to internally rotate externally rotated – account the jig (and component) due for posterolateral wear to the posterolateral wear of the femur

How do I get the gaps right? • Balancer • Lamina spreaders • Poor man’s balancer

How do I get tibial rotation right?

Trial Reduction

What releases do you perform? • John Insall approach: • Most released – Release what is tight – Lateral retinaculum – IT band (off Gerdy’s) – LCL (off femoral side, or by pie crust)

How do I get the lateral release right?

Close in flexion • Leave the knee in flexion overnight • Don’t wrap the Ace too tight • Always assess peroneal nerve

Conclusion • Respect old lateral incisions • Preserve patellar vascularity • Careful femoral rotation – keep flexion gap equal – External rotation helps patella tracking • Make proper bony cuts and delay releases till trial reduction • Resurface patella if there is maltracking, and lateral release

Moving forward. Climbing higher. Moving forward. Climbing higher.

Moving forward. Climbing higher.