DESCRIPTION OF OPERATION: After suitable general anesthesia, the patient’s right lower extremity, with a tourniquet cuff in place, was prepped and draped in the usual sterile fashion. The outline of the skin incision was marked out. This was centered over the patella and extended distally, longitudinally, to the tibial tuberosity. Proximally, it followed the previous skin scar in the suprapatellar area which was in a slightly oblique fashion towards the lateral side. Next, the tourniquet cuff was elevated to 300 mmHg after exsanguination of the extremity with the help of the Esmarch bandage. A skin incision was made and then deepened. The blood vessels were cauterized as the dissection proceeded. On the anterior aspect of the patella, the patellar retinaculum was noted to be markedly scarred extending proximally from its previous injury. A medial flap was dissected and then the knee joint was entered by standard medial parapatellar incision. A fair amount of clear straw-colored synovial fluid was removed. The incision extended distally along the medial side of the patellar ligament to the level of the tibial tuberosity and, proximally, it was carried into the tendon of the quadriceps for short distance. After suitable dissection, the patella was everted and the knee joint was then opened by flexing the knee. There was noted to be marked osteoarthrosis involving all the knee joints. There were prominent osteophytes around the margins of the patella as well as the femoral and the tibial condyles. The articular cartilage of the joint including the patella, femoral, and tibial condyle was noted to be absent down to subcondylar bone in the majority surface of the joint. The menisci were noted to be very degenerative and absent in places. The anterior cruciate ligament was also noted to be very degenerative. First, the osteophytes on the margin were trimmed, some osteophytes in the intercondylar notch were also removed as well as the anterior cruciate ligament. Then, a drill hole was made in the center of the distal femoral condyle just anterior to the intercondylar notch. The femoral canal was opened and then the T-handle was passed to further open it proximally. Next, the distal femoral cutting jig was placed in position and aligned properly and then fixed. The distal femoral cut was then made and checked for smoothness, then the jig too was placed in position and sizing was done, and it was seen that it would require a large prosthesis. Following this, after making the drill hole for the peg hole for the prosthesis, the second sizing block was placed in position, and using the instrumentation, it was confirmed that a large prosthesis was the most adequate size as an extra large prosthesis would cause notching of the distal femur. Next, the 4-in-1 cutting block was placed in position, and after protecting the posterior tissues, the anterior-posterior femoral cuts and the anterior-posterior chamfer cuts were made and checked for smoothness. After these cuts were made, there were noted to be multiple loose bodies posterior to the femoral condyles, which were removed. There were also osteophytic ridges posteriorly, which were removed with the curved osteotomes. Next, the large size femoral prosthesis was taken and placed over the prepared distal end of the femur and packed in position and found to be an excellent fit. Following this, peg holes for the prosthesis were made. At this point, the remnants of the meniscal cartilage were removed as well as further osteophytes. Then, preparation of the proximal tibia was done. The tibial cutting jig was taken, assembled and then placed in satisfactory alignment, and after double checking its alignment, the proximal tibial cut was made after protecting posterior tibial tissues. Care was taken not to cut the posterior cruciate ligament. Next, the cut surface was checked for smoothness and further small loose and semi-attached osteophytic bodies were removed from behind the tibia. Next, sizing of the proximal tibia was done and it was seen that an L2 tibial trial base plate afforded the best coverage. This was then fixed in position after double checking its alignment. At this point, the femoral trial prosthesis was again placed back in position and then first an 11 mm tibial trial insert was placed in position and the knee reduced by extending it. However, it was seen that it was slightly loose in extension; therefore, this was removed and the 13 mm tibial trial insert was placed with the base plate and the knee joint reduced, and it was seen that it could be extended to 0 degree and flexed fully with the prosthesis remaining stable. There was no laxity of the collateral ligament. At this point, it was decided that these were the proper size components. Next, preparation of the patella was done. The synovium around the margin was incised for a short distance and then the thickness of the patella was measured with a caliper and then the patellar cutting jig was placed in position and set to remove about 10 mm of the joint surface. Following the cutting process, it was seen that there was still about 1 mm thickness remaining from the previous measurements, so this was removed by free hand sawing. Next, the peg holes for the patellar prosthesis was made in the proper alignment and sizing, and it was seen that the medium size patella afforded the best coverage. At this point, since most of the bony cuts were made, the trial prosthesis was removed, and before the tibial base plate was removed, the cruciform cut was made. Next, the tourniquet cuff was released and the knee joint was irrigated. The bleeding points were then controlled with electrocautery, and after hemostasis had been obtained and the limb had been perfused for about 12 minutes or so, the tourniquet cuff was again elevated to 300 mmHg after exsanguination of the extremity with the help of Esmarch bandage. The knee joint was then again opened up, and then using the SysTec lavage, the prepared bony ends were thoroughly cleaned out and dried. Next, implantation of the prosthesis was done in the following sequence. First, the methyl methacrylate cement was mixed and while in the low viscosity stage was applied over the prepared surface of the tibia and some was also applied over the tibial base plate, which was then taken and in the correct alignment and orientation introduced down the cruciform cut and impacted in position. Excess cement from the margin was quickly removed. Following this, the 13 mm tibial insert was placed over the base plate and locked in position. The femoral trial prosthesis was placed over the femur and the knee joint was then reduced and held in the reduced position till the cement had cured. Following this, the knee joint was then again opened and checked for any loose pieces of cement, none were found. Next, another batch of methyl methacrylate cement was mixed and then applied over the prepared distal femur and hand packed in the peg holes. Some cement was also applied over the posterior skids of the femoral prosthesis, which was then taken and aligned in the peg holes and impacted in position. Excess cement around the margin was removed. The knee joint was then reduced by extending the knee and held in that position. Some cement was also placed over the patellar surface and the patellar prosthesis, which was then taken and placed in the position and held in place with a patellar clamp. Excess cement around the margin was removed. After the cement had cured, the patellar clamp was removed. The knee joint was opened up and checked for any loose fragments of cement. Next, patellar tracking and range of motion was done and was found to be satisfactory. The knee joint could be extended to 0 degree and flexed to 120 degrees and the patella was noted to be tracking well. At this point, the knee joint was again thoroughly irrigated. Hemovac was placed in the lateral parapatellar gutter area and brought out through a separate stab incision situated proximally. Next, the synovium capsule retinacular layer was closed with a single layer using interrupted sutures of #1 Vicryl. The incision in the quadriceps, proximally, and the retinacular layer, distally, was also closed with interrupted sutures using #1 Vicryl. The subcutaneous tissue was closed with interrupted sutures using a combination of #0 and #2-0 Vicryl and finally the skin with staples. Xeroform and a bulky knee dressing were applied. The tourniquet cuff was released with good flow to the lower extremity. The patient was then awakened and transferred to the recovery room in a stable condition. The first tourniquet time was 80 minutes, second tourniquet time was 81 minutes. Needle and sponge counts were correct at the end of the procedure.
