UR GERY
`
`OFTHEK
`
`SECOND EDITION
`
`JOHN N. INSALL, M.D.
`Direclor, lnsall Scott
`lnslitutc for
`lklh Israel i'vkdical Center-North Di
`
`RUSSELL WINDSOR, M.D.
`
`W. NORMAN SCOTT, M.D.
`
`MICHAEL A. KELLY, M.D.
`
`and
`Beth Israel Medical Centerb·~North Division,
`New 'York,
`York
`
`PAOLO AGLIETTI, M.D.
`Clinical Professor of
`Cl
`of
`
`l ..•
`
`-i-
`
`Smith & Nephew Ex. 1037
`IPR Petition - USP 9,295,482
`
`

`
`of
`
`Second Edilion Churchill Liviug~lone Inc l'J<.JJ
`First Edition Churchill
`Im'. 191!~
`
`Cf!'
`
`ii
`
`-ii-
`
`

`
`26
`
`Surgical Techniques and
`Instrumentation in Total
`Knee Arthroplasty
`John
`
`Insall
`
`NOR.i\ilAL
`REI
`A A'H)f\'IY AND
`ATIC
`AIJGNMl£NT
`
`it is estimated that
`is not
`the knee
`of these forces are carried
`hct>vecn 60 and 7 5
`of the knee.
`the
`As the transverse axis of the knee
`with the axis of the tibial
`to 10
`
`the
`
`mcnts. the
`tract - which a re
`force. 31
`
`OHJECl'IVES OF PROSl'llETIC
`REPl,ACEMENT
`
`-739-
`
`

`
`the Knee I
`
`n
`
`' ' I
`'
`' I
`' ' I
`
`more varus than
`knc\'
`There
`
`and
`
`Tile mechanical axis
`about
`medial femoral
`
`a fom-
`
`-740-
`
`

`
`(Jmptcr
`
`and lnstrumclllation in Total Knee
`
`Practical an<l economic considernlions dictate that in(cid:173)
`to seven sizes.
`bdicve !hat restoration of normal
`or
`often achil~vctL Docs this
`anatomy is
`matlcr'l On pn.·sem evidence
`models
`mismatched
`
`reduce wear. A I
`q uircnwnts needed
`between the componcms
`considered ncccs-
`strcsscs and
`
`of !he
`meniscal-
`
`Tl IEORJES OF SURGICAL
`TECH NJ QUE
`
`-741-
`
`

`
`742 / Surgery of the Knee / Chapter 26
`
`Fig. 26-5. The extension gap must
`exactly equal the flexion gap.
`
`
`
`Fig. 26—6. The flexion gap is created first removing bone
`from the tibial plateaus and posterior femoral condyles.
`
`“Gap” Technique
`
`The gap techniqtie'“*‘9’“ is used in conjunction with
`cruciate-substituting prostheses and some cruciate»
`retaining devices (often accompanied by posterior eru-
`ciate release from the posterior tibia). Ligament releases
`(see below) are performed to correct fixed deformity,
`bringing the limb into approximate alignment before the
`bone cuts are made (Fig. 2695).
`
`The Flexion Gap
`
`To create a flexion gap, an osteotomy of the proximal
`tibia is performed about 5 mm below the most normal
`area ofthe articular surface and directed at right angles to
`the long axis of the tibial shaft in both anteroposterior
`and mediolateral planes (Figs. 26-6 and 26-7). The
`anteroposterior diameter of the femur is measured from
`the anterior cortical surface, and the appropriate femoral
`template is selected: When the measurement falls be
`tween template sizes the smaller is generally preferred.
`The posterior femoral condyles are resected.
`
`-742-
`
`-742-
`
`

`
`
`
`Chapter 26 / Surgical Techniques and Instrumentation in Total Knee Arthroplasty / 743
`
`Fig. 26-7. The correct cut on the
`tibia ignores defects and removes 5 to
`7 mm from the normal side out at
`right angles to the long axis in the cor-
`onal plane (A), and sloped posteriorly
`up to 5 degrees in the sagittal plane
`
`(3).
`
`ROTATIONAL ALIGNMENT or THE FEMUR
`
`Th
`otat'o al ali nment of the femoral tem late is
`decidzdrby tll1€l:3OI'1ditgiOn ofthe medial soft tissuespwhen
`'
`
`done a rectangular flexion gap is created by the ligament
`release itself, and the femoral template can be positioned
`.
`.
`.
`anatomically wnh regard to. the dlstai femoral anatomy‘
`The landmarks for rotational position on the femur
`as
`
`compensate for the normal medial inclination of the
`tibial plateau and flexion laxity of the lateral ligamen-
`tous structures (Fig. 26-8). Only by this external rotation
`can a rectangular “llexion gap” be produced (Figs. 26-9
`and 26» 1 0). However, when a medial soft—tissue release is
`
`l. Posterior femoral condyles
`2. Trochlear surface
`3. Lateral ridge on the distal femoral metaphysis
`4. Medial and lateral epicondyles
`
`
`
`normal medial slope of the tibial
`plateau;
`relaxed lateral ligament
`
`prosthesis in place, greater laxity
`of lateral ligament in flexlon
`
`SOLUTION
`
`Fig. 26-8.
`
`lmitating the normal anatomy results in lateral laxity in flexion.
`
`-743-
`
`-743-
`
`

`
`744
`
`the Knee I
`
`arc used
`the 11exion gap
`conslanl, but there
`lhc anterior fcrnoral cortex, or of
`of the bone (
`
`a
`
`when i deem this ncces-
`, and I am
`make small
`cuts
`from the distal femur m extension. Ho'>vever the virtue
`of a constant llexion gap cannot
`when the
`cruciate
`The size
`the gap bet'vveen the
`l!,'1m1rnl
`and the cut surface
`thl'. upper tibia
`\
`ll~nser (
`spacer (
`of this space
`to the
`tibial anti
`thickness
`the thickness of tibial
`lizc the knee in llexion.
`
`26-9.
`
`ln the osteoarthritic
`
`can be in-definett
`
`The \at-
`present, even in revision
`is
`but is the hardest to
`Femoral rota-
`difficult to instrument nr<''l'l<;f•hr
`
`REFERENCE POINT: THE ANTERIOR CORTEX
`PosTERIOR FEMORAL Cmmvu~s?
`
`Given that there will seldom be an exact match be-
`t\veen the
`of the femoral componem
`
`is made In
`that are re(cid:173)
`sornewhat variable.
`
`-744-
`
`

`
`and lnstrumentation in Total Knee
`
`745
`
`A
`
`Internal
`rotation
`
`!he
`that th~: medial
`A fourth ref~
`on the
`mtational
`For
`or the
`the lateral fcmo~
`result in internal rota~
`
`B
`
`from the
`
`-745-
`
`

`
`instrument
`of the k.mur.
`
`The flexion gap
`lows
`26-1
`
`maybe
`
`as fol-
`
`The
`
`I. Cut the tibia at the
`Obtain
`balance.
`Measure the femur from the
`the femoral size
`
`4.
`
`leveL
`
`The
`method.
`
`achieved
`
`the
`
`5.
`
`6.
`
`A
`
`9-11 mm
`
`often made on the distal femur
`femoral
`The
`
`-746-
`
`

`
`and Instrumentation in Total Knee
`
`747
`
`26-15. The flexion and
`it must be
`than the flexion
`the spacer system.
`
`smaller
`\Vhen !he extension gap
`a
`are
`the rest~ction of exlrn distal fomoral bone. The arnount m~edcd is
`spacers are available when the llexion gap
`thinnest
`
`-747-
`
`

`
`A
`
`B
`
`the
`
`the medial anti lateral thumbscrews,
`the mechanical
`
`IO create an
`gap of the correct di mcnsions.
`
`-748-
`
`

`
`and Instrumentation in Total Knee
`
`I 749
`
`Eroded
`
`md
`
`-749-
`
`

`
`26
`
`osteotomizcd inde(cid:173)
`co1rre!mcmdmg to the
`The
`<t::.:>c~:~1,;u ;vilh a spacer,
`is reeut when necessary match the
`and the distal
`flexion gap. The amount of additional resection is de(cid:173)
`cided
`a series
`thinner spacers (and when
`necessarv the so-called minus
`fn
`26-
`way.the amount of additional resection can he cal(cid:173)
`culated, from the
`between the flexion spacer
`and the thinner spacer that is used to
`the pre(cid:173)
`if an 8-mm spacer
`formed
`gap. (
`spacer is needed to
`and a minus
`stabilize the bone in
`the additional resection
`will he
`
`Linc
`
`stabilizer of Ilic knee
`
`that the
`to cancel-
`
`4.
`
`is osteotomizcd
`
`the strongest avail-
`
`For the PCL to fulfill
`
`anatomic
`
`areas
`
`I. The
`able
`
`3.
`
`l. The
`
`and
`contractures.
`2. The method ensures
`
`In
`the PCL meet
`fow systems
`and some em the
`all
`the
`
`-750-
`
`

`
`and lnstrumenlat.ion in Total Knee
`
`better "fod" and
`
`-751-
`
`

`
`Wolli's law.
`
`"There
`
`roll-back of the !cm ur
`
`-752-
`
`

`
`While some surgeons
`
`753
`
`The
`
`is a very im-
`Tht' anterior cruciate
`and its
`funetional element in the normal
`but an abnormal
`
`PCL.
`PCL
`
`-753-
`
`

`
`mended unless both arc present. In many arthritic
`the ACL is
`and most
`removal of the AC[ ..
`
`Philoso1>hy on
`Influence of
`Technique and Instrumentation
`
`releases arc
`after the upper
`made or
`has been osteotornized. In co111.rnsl,
`and femur
`
`PREOPERA'rI
`
`Pl
`
`NI
`
`,Joint
`
`and
`
`-754-
`
`

`
`Chapter
`
`and Instrumentation in Total Knee
`
`A
`
`B
`
`Exposure
`
`-755-
`
`

`
`756
`
`the Knee I
`
`insertion until the
`latcrnl
`closure the lateral
`can
`amount
`
`The Rectus "Snip"
`
`-756-
`
`

`
`in Total Knee
`
`the vast us lateralis and are ""''"'"'""''"'
`is from the fi hers of the vast us
`
`Osteotomy
`
`Vv'h
`
`a
`must he detached
`of this size may be
`or screws at the conclusion of the
`small
`in
`hone
`substance for successful
`have used this
`
`course. tfowever.
`a 23 percent
`rate
`These authors also cm-
`
`ment.
`
`error
`
`-757-
`
`

`
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`-766-
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`Chapter
`
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`
`-774-
`
`

`
`Chapter 26 /
`
`and Instrumentation in Total Knee
`
`A
`
`B
`
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`osteoarthritis and seldom
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`
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`-776-
`
`-776-
`
`

`
`and Instrumentation in
`
`brace does not
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`
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`and
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`
`A
`
`-777-
`
`

`
`l. Correct and balance to
`then brace the knee for
`This
`
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`
`-778-
`
`

`
`v
`
`A
`
`and Instrumentation in Total Knee
`
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`
`to the bone cuts or
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`
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`-779-
`
`

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`and lns1rnmcntation in Total Knee
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