OKOJ, Volume 10, No. 6

Principles and Techniques of Total Knee Revision Surgery

Failed total knee arthroplasty presents numerous diagnostic and management challenges for the arthroplasty surgeon. Successful revision arthroplasty requires a thorough patient history, physical examination, and imaging evaluation, with a clear indication for revision identified prior to the procedure. Once a failure mode is identified, preoperative planning is essential to the success of revision arthroplasty. The revision procedure follows a stepwise algorithmic approach based on the preoperative plan, which includes wide surgical exposure for optimal joint visualization. When contemplating options for constraint in revision total knee arthroplasty, a variety of issues must be considered. The surgeon must assess the flexion and extension gaps, position of the joint line, ligament and extensor mechanism integrity, and the degree of bone loss. Expedient and successful removal of implants during revision total knee arthroplasty hinges on optimal exposure of the implants and interfaces. Careful removal of components, limiting of iatrogenic bone loss, and preservation of vital soft tissues are paramount. In addition, the surgeon must be prepared to encounter more severe ligamentous compromise and bone loss than was anticipated preoperatively. Multiple treatment options exist for the management of bone loss and ligamentous compromise, and implants and allograft must be readily available to accommodate these situations, should they arise. Postoperative rehabilitation must be patient-specific and be guided by implant fixation, the need to protect bone graft, and ligament and extensor mechanism integrity.

    • Keywords:
    • total knee revision

    • revision knee arthroplasty

    • knee revision principle

    • Anderson Orthopaedic Research Institute (AORI) bone defect classification

    • knee instability

    • Tinel’s sign

    • patellar clunk

    • cemented total knee arthroplasty

    • uncemented total knee arthroplasty

    • knee exposure

    • bone loss

    • ligamentous compromise

    • extensor mechanism integrity

    • femoral component wear

    • polyethylene exchange

    • metaphyseal sleeve augmentation

    • periprosthetic joint infection

    • Subspecialty:
    • Adult Reconstruction

HOT TOPIC: Update on the Management of Calcaneal Fractures

The calcaneus is the most frequently fractured of the tarsal bones, with approximately 75% of calcaneal fractures being of the intra-articular variety. This update is not intended to be a thorough discussion of calcaneal fracture treatment. Rather, it is intended to supplement and extend our previously published OKO article, "Fractures of the Calcaneus." Herein, we discuss techniques and implants in the surgical treatment of calcaneal fractures that have changed or are emerging since the original publication of this paper.

    • Keywords:
    • calcaneus fracture

    • intra-articular calcaneal fracture

    • joint-depression calcaneal fracture

    • tongue-type calcaneal fracture

    • external fixation

    • open reducation and internal fixation

    • ORIF

    • gastrocnemius recession

    • calcaneal fracture-dislocation

    • Subspecialty:
    • Trauma

Management of Fingertip and Thumb Tip Amputations

Management of a digital tip amputation requires a thorough understanding of fingertip anatomy, vascular anatomy, and the various treatment options available. The goals of treatment include facilitating the fastest reasonable recovery, restoring volar soft-tissue pulp and contour, maintaining digital tip support, achieving a pain-free and sensate tip, and tailoring the type of reconstruction to the patient's occupational and avocational needs. Treatment options include healing by secondary intention, skin grafting, bone shortening and amputation revision, complex flap reconstruction, and replantation. The option selected will depend on the tissues involved, pathologic anatomy of the injury, personal needs of the patient, and vascularity of the fingertip. Complications of treatment include nail deformity, painful unstable scar, digital neuroma, cold intolerance, dysesthesias, hypesthesias, poor aesthetics, stiff digits with flexion contracture, and flap necrosis.

    • Keywords:
    • fingertip amputation

    • thumb amputation

    • digital tip amputation

    • skin graft

    • cross-finger flap

    • reverse cross-finger flap

    • thenar flap

    • homodigital advancement flap

    • transposition flap

    • intrinsic digital flap

    • hand flap

    • flap reconstruction

    • replantation

    • toe-to-hand transfer

    • secondary healing

    • Kutler

    • Atasoy

    • V-Y advancement flap

    • homodigital reverse flow island flap

    • heterodigital flap

    • dorsoradial flap

    • dorsoulnar flap

    • Moberg flap

    • Subspecialty:
    • Hand and Wrist

Management of Ruptures of the Distal Triceps Tendon

Injury to the distal triceps brachii tendon is uncommon and usually the result of a fall onto an outstretched hand. Most reports associate such rupture with the use of anabolic steroids, weight lifting, and laceration. Other local and systemic risk factors for injury to the distal triceps tendon include local injection of steroids, bursitis of the olecranon process, and hyperparathyroidism. Also implicated in injury, particularly in professional athletes, is eccentric loading of a contracting triceps muscle. The initial diagnosis may be difficult to make because a palpable defect in the tendon is not always present. Pain and swelling may further limit the ability to evaluate the strength and range of motion of the affected elbow. Although plain radiographs help to rule out other pathology, MRI confirms the diagnosis and may guide management. Treatment for incomplete tears of the distal triceps tendon, with active extension against resistance, is nonsurgical. Surgical repair is indicated in active individuals with complete or incomplete tears of the tendon and loss of strength. Such repair is reported to provide good to excellent results, and even the surgical repair of chronic tears can yield very good results.

    • Keywords:
    • triceps injury

    • triceps tendon rupture

    • triceps tendon tear

    • distal triceps tendon tear

    • distal triceps tendon avulsion

    • triceps brachii tendon rupture

    • distal triceps repair

    • Subspecialty:
    • Shoulder and Elbow