Total knee replacement Genesis 2 (PS) with bi-convex patella (Smith and Nephew)

The Rosenburg Radiograph is a PA flexion film at 45 degrees and this particularly stresses the lateral Tibio-femoral joint. Whilst the wear pattern in this patient is predominantly anteromedial , there is also reduction between the femur and tibia on the lateral side.

The lateral radiograph with a weight bearing patient shows the full thickness joint space loss with contact between the femur and tibia – above the annotation marked 1.
I also routinely arrange a preoperative weight -bearing long leg radiograph. This allows for measurement of the angle between the anatomical axis of the femur and the centre of the hip. This can then be used to set the planned distal femoral valgus cut relative to the intra-medullary canal during the TKR.

I do not routinely arrange an MRI, but in this case I was considering a medial unicondylar knee – the MRI shows bone marrow oedema in the medial tibial plateau and full thickness joint space loss medially…..

The MRI however revealed significant patellofemoral wear particularly on the lateral facet of the patella, which to me is a contra-indication to medial Uni.

The operative table should be placed with the head of the patient on the outline of the laminar flow. This ensures sufficient space within the laminar flow for all the operative sets.
The set-up position is identical to any total knee replacement with a side support and foot roll. Patient warming may be achieved by warmed under blanket or hot air surrounding blanket, however caution must be observed during application of a forced air warming device to ensure that there is no leak of air over the operative site. Instead the leak of hot air should be from the head end and outside of the laminar flow zone.
My personal preference is for a foot pump on the contralateral leg, a pre-wash with chlorhexidine and then 2% alcoholic preparation of chlorhexidine to include the whole lower limb and then draping with U-drape then an exclusion limb drape.

Once the knee is prepared in flexion the leg is extended and the foot prepared before application of a sterile glove.

The rest of the leg is then prepared with Chlorhexidine 2% in alcohol.
Here I am using ChloraPrep which is proprietary brand – I find this an easy application method.

Draping with U-drape then an exclusion limb drape.

The exclusion limb drape has been applied.
Free draping of the limb to allow flexion and extension with a resting position of approximately 90°

The leg is wrapped in a sterile Ioban and the foot roll is set with a knee flexion of approximately 90°.

Local Infiltration Anaesthesia using a long needle; a grey (16G) venflon needle with both screw cap and adaptor removed makes a good, cheap and long needle for this purpose.
REMEMBER TO ASPIRATE AND TELL THE ANAESTHETIST BEFORE INFILTRATING.
I use a cocktail (known locally as ‘Murray Mix’) of 150ml of 0.1% Marcaine with 0.6mg Adrenaline, 30mg Ketorolac and 10mg Morphine. The maximum dose of Marcaine used is based on the patients body weight.
The Ketorolac and Morphine are placed in one of the three 50ml syringes.
Syringe 1. Skin – infiltrated at the start of the procedure.
Syringe 2. Periosteal and capsule – instilled after preparation
Syringe 3 (Morphine and Ketorolac) – instilled deep into the posterior capsule – it is vital to aspirate and I suggest moving the needle 4 times to guard against intravascular infiltration.
I use the first 50ml syringe at this point in the operation – the start – for pain reduction on incision and for bleeding reduction as I do not use a tourniquet.

A longitudinal and slightly oblique skin incision, proximal medial to distal lateral, is centred on the medial side of the patella.

The skin is raised medially to expose the vastus medialis muscle. Laterally the skin should be raised to expose the patella. It is imperative to maintain full thickness skin flaps to avoid problems with superficial necrosis.I prefer a subvastus medial approach, but I would advise surgeons to use their standard set-up and approach for TKR. I have described the medial subvastus approach I use in detail elsewhere on OrthOracle and those unfamiliar should read this in detail at:
Total knee replacement: Vanguard XP cruciate retaining (Zimmer-Biomet)
Haemostasis is maintained. There are two very reproducible vessels which require electrocautery during the medial sub-vastus approach; The first of these is in the centre of the vastus medialis seen here held by the forceps and the second is adjacent to the MPFL

The medial subvastus approach is initiated by finding the sub-muscular pocket beneath the Vastus Medialis.The sub-muscular pocket is developed by blunt the section with the operator’s finger

The capsulotomy is made in an L-shaped manner, the distal half of the capsulotomy being identical to a medial parapatellar approach. Proximally the fascia just distal to the Vastus Medialis (VM) should be incised and the MPFL divided close to its origin.Once this is released the VM will mobilise allowing for subluxation of the patella laterally.

The patella is subluxed laterally, everted and osteophytes removed.Attention is then turned to the patella.
In this slide the patella is exposed a Hohman’s retractor lifting the vastus medialis away proximally and lifting the patella up vertically into the wound.
In bicruciate retaining knees I find that preparing the patella first and then subluxing the flat cut surface of the patella into the lateral gutter creates some space and makes this operation easier, but in standard TKR I just remove osteophytes at this stage.

There is significant patellofemoral wear as the MRI demonstrated.
The peri-patella osteophytes are then removed. I use a combination of saw and bone rongeurs/nibblers depending on the size of the osteophytes.

Notice the predominantly medial degenerative change in the tibiofemoral joint – as the MRI suggested.
The ACL (1) is divided – it is advisable to take the ACL off from the tibia to reduce risk of iatrogenic injury to the PCL ( for PCL – retaining surgeons) and also the posterior neuromuscular structures.
I routinely release the PCL as well ( as I use posterior-stabilised implants), but it is advisable to remove this structure from the medial wall of the femur – again to minimise the chance of vascular injury posteriorly.

The knee is now fully exposed by the use of:
Excising the fat pad
Circumscribing the anterolateral tibia as I am doing in this image allows for easy removal of the cut tibial plateau later on in the procedure. Simply use a knife or electro-cautery (surgeon’s preference – personally I prefer the knife) to remove soft tissue from around the proximal 10mm of the anterolateral tibia. Caution with the Patella Tendon insertion, but this is much more distal.
Flexion – I find that deep flexion really allows the tibia to be delivered into the wound
Blunt Hohman’s behind the proximal tibia – in the femoral notch
Sharp Hohman’s medially and laterally

The femoral canal is opened up by the intramedullary drill from the Genesis II set.The femoral opening drill opening is approximately at the top of the femoral notch (1), but the exact position depends on the femoral alignment.
Remember that the entry point is in line with the anatomical axis of the femur and should be marked on your Radiographs using a digital angle measurement system or preoperative templating platform BEFORE you start the case.
When starting the drill hole it is sensible to aim perpendicular to the bone surface and then drop into the line of the intra-medullary canal, which has been clearly identified preoperatively on the Radiographs.

The femoral intramedullary rod with the femoral distal cutting block, is then inserted into the femoral canal opening.

A close-up view of the Genesis distal femoral cutting block (1) over the intramedullary guide rod (2). The distal femoral cutting guide has the 5 degree valgus bushing (3) inserted.
There are 5,6 or 7 degree bushings which should be chosen relative to the patient’s femoral axis relative to the weight bearing axis..
In this case a 5 degree angle has been chosen by measuring the long leg radiographs.

The distal femoral cutting block is pinned in place – there are two parallel pins placed in one of the 3 pairs of holes on the cutting block, allowing for further bone resection later.
To secure the block there is an oblique pin hole at the medial and lateral margin of the cutting jig
The intramedullary rod can then be removed.

The femoral jig is then removed to leave the distal femoral cutting block on the anterior surface.

The distal femoral cut is performed carefully with saw. Notice the protection for the collateral ligaments with Hohman retractors.
There needs to be resection from both condyles to allow bony support for the eventual implant on both the medial and lateral condyles.

Attention is then turned to the tibia and the posterolateral corner is circumscribed to allow easy removal after cutting. In addition this coagulates any bleeding vessels (branches of the lateral geniculate artery) to reduce bleeding.

Tibial preparation. This is started with the extramedullary jig placementAs the jig has a posterior slope, it is important to position this rotationally at the start.
The rotational position of the jig is determined using a number of reference points. The tibial tuberosity is usually quoted as the most important marker for rotation and whilst it is useful I would stress the importance of the tibial intercondylar eminence and the tibial anterior crest as reference points.
I like to align the jig with the tibial spines so that the anterior extramedullary jig that I am holding lies parallel to the tibial crest.
The tibial jig has two different height pins to allow an initial fixation by a gentle tap with the mallet, then fine tuning of rotation or slope before hitting home as in the next slide.

The tibial extra-medullary jig has been impacted down onto the tibia.
Notice that the gold lever (1) on the anterior most margin of the jig is ‘open’ pointing anteriorly.

The 9mm stylus (there is only a 9mm stylus in our set, but there are other options so check this) is inserted and is resting on the lateral plateau which is well preserved.
The jig and cutting block are now locked by rotating the gold levers (1) through 90 degrees so that they point medio-laterally rather than anteriorly in the last slide.

The tibial jig is pinned in place with two anterior pins.

Once the extra medullary jig is removed the tibial cutting block is pushed posteriorly such that the block touches the anterior tibia. This reduces error of cutting.

The quick release handle (1) has been inserted into the cutting block and two drop rods have been inserted anteriorly to check alignment.
By having two rods in the jig, the accuracy is increased by forcing the operator to line up with both rods reduces parallax error.

A third pin is inserted to fully lock the jig in position – remember the first two parallel pins allow the jig to be removed and lowered should further resection be required -i.e if the surgeon has ‘undercut’ with the first resection.

The proximal tibial cut is performed through the positioned tibial jig.Please remember that as the surgeon, you are holding a saw, cutting through a bone which is immediately anterior to the Popliteal artery and Tibial Nerve!
The techniques I use to minimise the risk of iatrogenic damage here include:
No tourniquet – in major revision cases where there is considerable bone loss, it is possible to see the pulsation from the Popliteal Artery.
Hyperflexion of the knee with the femur subluxed posterior to the tibia, delivering the tibia out of the wound. Remember this is for bi-cruciate resection TKA’s.
Posterior tibial protection. I prefer a blunt Hohman retractor (1)
I always use two hands on the saw – one hand holds the handle and the opposite hand (2) sits in front of the saw as a guard to prevent a sudden ‘jump’ forward of the saw.
Some surgeons prefer to complete the cut with osteotomes.

The tibial jig has been removed and the saw replaced through the cut slot to complete the tibial cut. Again, this can be done with osteotomes.
Notice careful protection with Hohmans:
Sharp Hohman’s laterally protecting the patella tendon
Blunt Hohman posteriorly protecting the Neurovascular structures
Sharp Hohman medially protecting the MCL

A Kocher clamp has been applied on the medial side of the cut plateau and the resected tibia is then externally rotated. There is usually some residual PCL attachment centrally and laterally there is often capsular attachment which needs releasing from the resected plateau by sharp dissection under direct view.
By externally rotating with the Kocher, the tibial plateau resection rotates away from eh tibia to reveal the remaining soft-tissue attachment requiring release.
Please be careful with your dissection posteriorly – a good tip is to stick to the bone of the resected tibial plateau.

The resection specimen of the tibia showing medial wear as full thickness, but a small degree of fibrillation laterally (1)

Extension space checking – using the black spacer block.The black ‘spacer block’ is inserted using the minimum gap balancing space of 9mm.
Remember to check that you are using the rectangular side of the spacer block as one side is asymmetric to check the flexion space.

The drop rods are linked, by screwing them together, to make a long extra-medullary rod which is inserted in the black spacer block.

Attention is then turned back to the tibia briefly and an assessment of tibial size made, by using the Genesis tibial trial trays.
I use the anteromedial corner (pointed out by forceps), anterior tibial crest (for rotation) and the posterolateral corner as the key reference points for sizing.
It is important to know an approximate tibial size before the final femoral size is chosen, because of the possible matches which are allowed between femoral and tibial sizes when using a posterior stabilised Genesis II.
In summary for each combination tibial polyethelene liner (size 3-4, size 5-6, Size 7-8) the femur may be one size larger or smaller.
For Example a size 3 or 4 tibia can match to a 2,3,4 or 5 femur.

Femoral sizing can then take place using the posterior referenced block – there is only one femoral measuring block.
I like to pay attention to the rotational alignment as well at this point; by referencing to the trans-epicondylar axis (TEA) as well as the ‘feet’ on the posterior referencing block errors of rotation (usually internal) and sizing can be avoided.
The TEA is between the epicondyles – palpate the sulcus of the medial epicondyle and the ridge of the lateral epicondyle.
For example if there is an obvious difference between the posterior referenced block position and the TEA, then the block should be aligned to the TEA, leaving the posterolateral ‘foot’ off the posterolateral condyle to correct the over-internal rotation. This will usually increase the size of the component.
With the stylus on the anterior cortex, this block measures size 3 as pointed out by my forceps.

Once the surgeon is happy with the mediolateral coverage and the rotation of the femoral jig, the two central pins are hit home with a mallet. The block is then removed and replaced with the femoral cutting Jig which fits into the two central holes that have just been fashioned.

Completion of the femoral chamfer cuts once the flexion space is checked.The femoral cutting Jig is located on the cut surface of the distal femur.

The femoral jig is then hit home using the tibial impactor to prevent metal debris occurring.

Before the femoral cutting block is pinned it is important to check both the flexion space and the anterior cut to prevent anterior notching.
In this slide I have placed the angel wing through the posterior cutting slot, to ensure there is at least a sliver of bone resection thus ensuring good bone support for the implant.
Similarly it is important not to resect too much posterior condyle. This assessment comes with experience, but the trick in the next slide will help….

I then place the black spacer block onto the angel wing positioned in the posterior cutting slot and bring the tibia to 90° of flexion. This estimates the flexion space relative to the spacer block from the cutting slot of the femoral jig.
The spacer block represents the minimum 9mm polyethylene thickness (plus implants)
The black spacer block should fit the space between the posterior cut femur and the proximal tibia (1). However it is sensible to measure and check BEFORE cutting the posterior femur and hence this step, referencing off the femoral cutting guide BEOFRE the femoral cut is made.
In summary this prevents over excision posteriorly and therefore flexion instability.

The angel wing is placed in the anterior cut slot to ensure there will be no notching anteriorly.
Notching is a common term in knee replacement surgery to describe an anterior femoral cut which breaches the anterior femoral cortical line – a line down the anterior femoral cortex.
Notching is caused:
Over-extension of the femoral jig
Over-resection of the anterior femur by undersizing of the femoral component
Over-resection of the anterior femur by malposition of an appropriate sized femoral jig, but placed TOO posterior.
Over resection of the anterior femur medial OR laterally due to femoral malrotation

The femoral cutting block is pinned with two oblique pins – medial and lateral – there are two pin holes on each side which allows for minor corrections and then re-fixation in the second hole after small movements. Otherwise the pin would find the same track and the block would return to the original position.

The femoral chamfer cuts are made starting posteriorly, with careful protection of the collateral ligaments
The saw is held with two hands and directed antero-posteriorly in line with the block, avoiding angling media-latearlly as this is more likely to damage the collateral structures and cause more metal debris.

The anterior femoral chamfer cut should be made last to prevent de-stabilisation of the femoral block on the distal femur – the anterior chamfer is the largest bone resection.

The pins and then the distal femoral cutting block are removed with slap hammer

The tibial rotation is fixed, but do not complete the preparation of the tibia yet.Attention is turned back to the tibia and the trial size 2 in this case is then pinned in situ using the headed pins once the surgeon has aligned the rotation relative to the tibial crest and tubercle

An extra medullary drop rod is seen through the quick release handle and the second headed locking pin is inserted into the tibial jig

The femoral component is then inserted onto the cut distal femur – notice the close fit of the metal femoral trial relative to the distal femoral chamfer cuts

Osteophyte or overhanging femur can then be removed with an osteotome with caution for the collateral ligaments

The femoral trial implant is then pinned anteriorly

The central femoral milling guide is then inserted…

…and the corresponding reamer for the removal of the femoral box is then used moving the milling guide anteriorly and posteriorly

The Genesis posteriorly stabilised box chisel (1) is then inserted to ensure there is no debris in the centre of the femur

There is often soft tissue remnant of the PCL which requires removal at this stage – I prefer to do this with electrocautery to minimise any bleeding
Again – any dissection posteriorly should be taken with care as previously mentioned the popliteal artery and tibial nerve are relatively close!

The femoral central post box (1) is then inserted into the femoral trial from the last slide, the anterior pin removed and a trial bearing inserted – in this case a 9 mm PS

The trials are inserted and a range of movement and balance assessment performed.The yellow 9 mm PS insert (1) is visible with the knee in near full extension. However there should be no block to full extension at all at this stage……
Therefore more resection is required. However it is important to remove the osteophytes and any residual tibia outside the trial tibia posteriorly as this is likely to correct the fixed flexion problem.

To improve the range of movement and allow the knee to go into full extension, further excision of posteromedial tibia is performed with an osteotome.
This case was a varus OA pattern and so the predominant osteophytes are medially – Posteromedially – hence the clinical picture of Varus with fixed flexion.

The 9 mm PS insert is then replaced and the knee now moves into full extension.
In this photograph full extension is achieved compared to the ‘near full extension’ two slides previously.
If the knee fails to fully extend, then insufficient extension gap exists.
If the flexion gap is good then further distal femur should be taken – although this is impossible in this case as we achieved full extension with the Black Spacer Block earlier
If both flexion and extension are tight, then further proximal tibial resection should be performed.

The knee is cycled through into flexion – maximal flexion being approximately 130° – and assessments of varo-valgus stability throughout the range of motion should be made.
There are classic sequences to release the varus knee medially to achieve balance. This is a complete topic in itself and further reference should be sought.
However, if the surgeon sticks to the bone excision release described two slides previously this will suffice for the vast majority of knees.

Patella preparation using the Bi-Convex inset single peg Genesis buttonThe Genesis Biconvex Inset jig. This is the smallest (size 23mm) ‘tower’ which is attached to the jig (1). Were the patella larger then a larger tower could be added by releasing the gold button on the clamp and exchanging 1 for a larger jig (26, 29 mm etc).

The patella clamp is applied to achieve good coverage – mediolaterally and super-inferiorly.

The patella is measured in both width and thickness. I try to reconstruct as close as possible to the natural ratio observed in the native knee as published by Sullivan et al and described as BIPWiT (Bristol Index of Patella Width to Thickness. (Knee. 2014 Dec;21(6):1058-62)
Here the width is measured with the Genesis calliper.

Here the thickness is measured with the Genesis calliper.

The patella is milled to leave sufficient bone such that in addition to the patella implant the thickness will be in the native ratio of 1.8 as in the above reference.

The patella 23mm trial biconvex button is inserted down the tower with forceps.

The patella & bone construct thickness is re-measured after cutting.

The Biconvex 23mm Genesis button is exposed after removal of the tower patella jig, but notice the surrounding ridges which must be removed.

…the ridges around the patella button are removed with saw / nibbler depending on the size.

Range of motion is checked again with particular emphasis on patella tracking.
If the patella is jumping, then careful assessment of bony prominence around the button should be assessed.
If the patella is tracking on the lateral side of the femur then it is important to check that the button has been milled perpendicular to the medio-lateral plane of the patella. Similarly patella tracking problems may be due to the rotation of the femoral, tibial or both components.

The tibial rotation is now fully defined and the keel is prepared.Now that I am happy with patella tracking the tibial component rotation is confirmed by drilling and impacting the keel. Remember that the tibial trial tray was already pinned in position with headed pins – please check these are secure before drilling.

The tibial keel is impacted.

The headed pins are removed from the tibial jig by slap hammer

The femoral trial is removed by slap hammer

Local Infiltration Anaesthesia using a long needle; a grey (16G) venflon needle with both screw cap and adaptor removed makes a good, cheap and long needle for this purpose.
REMEMBER TO ASPIRATE AND TELL THE ANAESTHETIST BEFORE INFILTRATING.
We use a cocktail (known locally as ‘Murray Mix’) of 150ml of 0.1% Marcain with 0.6mg Adrenaline, 30mg Ketorolac and 10mg Morphine.
The Ketorolac and Morphine are placed in one of the three 50ml syringes.
Syringe 1. Skin – infiltrated at the start of the procedure.
Syringe 2. Periosteal and capsule – instilled after preparation
Syringe 3 (Morphine and Ketorolac) – instilled deep into the posterior capsule – it is vital to aspirate and I suggest moving the needle 4 times to guard against intravascular infiltration.
I use the first 50ml syringe at this point in the operation – the start – for pain reduction on incision and for bleeding reduction as I do not use a tourniquet.

Bone surface preparation for cemented implants.The bones are prepared in the standard manner for cementation using pulsed lavage with 0.05% Chlorehexidine, followed by packing with dry gauze.

The femoral intramedullary canal is plugged with autograft bone from the femoral offcuts – usually the anterior chamfer divided in half is excellent for this and I find that the tibial keel impactor with its concave inferior surface is excellent for controlling the impaction into the femoral canal.

The bone surfaces need to be free of blood and bone and exposed sufficiently to allow optimal insertion of the prosthesis.
Note that the femoral cut surface is protected with a swab for tibial implantation.

The implants are double checked and opened. Here we have a Genesis II Posterior Stabilised Size 3 right femur, size 2 right tibia and a 23mm Bi-Convex Patella.
Clean gloves for scrub nurse, surgeon and assistant.

The components are opened, without touching the ‘under-surface’ which is to receive the cement. Blood and fat reduce the effectiveness of the cement grouting onto the implant.
The femoral implant is attached to the posterior stabilised femoral introducer, by hooking the ‘notch-holder’ (1) into the femoral box of the implant, the trigger (out of view) is the squeezed and the hook (2) located over the inter-condylar bar at the base of the box.
Finally the nut (3) is tightened to secure the box holder in position to allow introduction of the implant onto the cut, prepared bone surfaces.

The cement gun nozzle is cut obliquely to provide an ergonomic and wider surface area for injection into the prepared bone surfaces.

Cementation – both of the implant and bone surfaces.I use Palacos Regular Viscosity Cement with Gentacmin (Heraeus). I like to gun this into the tibial cut surfaces and place onto the tibial undersurface of the component.

The tibial component undersurface is coated with cement (5-10mm) and then kept in its packaging box whilst the tibia is cemented.

The tibial cut surface is injected with cement from the gun – including the stem. I try and apply approximately 2-3mm over the bone surfaces.

Implantation of the definitive implants starting with the tibia.The tibial component is the first to be gently inserted, carefully locating the stem and fins to ensure correct orientation to the planned position of the trial implant earlier.

The tibial component is gently hit home with the tibial impactor after cementation.

Excess cement is removed in a standard manner with a MacDonald.

A similar approach is made to cementation on the femur – gunned into the distal femur and applied to the undersurface of the implant – all over.

Implantation of the definitive implants – femur second.The femoral component is inserted and then…

The femoral component is impacted gently.

Excess cement is removed in a standard manner and then the trial liner inserted, and the knee extended.
I try to provide axial loading via my assistant standing at the foot of the bed, the leg resting on the foot roll, but avoiding hyper-extension.

The patella cut surface is then prepared with pulsed lavage using Chlorhexidine 0.05%

The patella is partially everted to approximately 90 degrees.
Here there is still blood seen, so more lavage is required until the bone is clean and white.

The patella is therefore further lavaged, before drying and cementation

The cement gun is removed to expose the mantle – there is a only a single peg on the biconvex inset patella, making this and the next step very easy.

The patella inserted in place by hand, excess cement is removed and the Patella clamp applied.

The patella clamp is applied – there are two sizes – I always apply the larger black clamp (1) to ensure I do not squeeze the button too deep into the socket.
Once the clamp is applied over the button (remember to check that the skin is not trapped on the anterior surface!), the clamp is squeezed and the gold nut tightened (2).
To release simply undo the nut (2)!

All excess is removed and a further chlorhexidine lavage performed.

Once the cement has cured all excess is removed.

A further chlorhexidine lavage is performed prior to definitive tibial meniscus implantation.

A Genesis II size 2, 9mm posterior stabilised bearing is inserted by hand, with care to correctly engage the dovetail rails (1)

The polyethylene liner requires a gentle push in a posterior direction to fully seat it and then the knee is extended, maintaining posteriorly directed pressure whilst it palpably “clicks” into its definitive and stable position.

The knee is extended maintaining pressure on the bearing to prevent any anterior movement of the polyethylene.

As the knee is moved into terminal extension, gentle pressure (on the anterior surface of the polyethylene by the operator’s thumb – 1) in a posterior direction will cause a ‘click’ as the locking mechanism engages.
There is a lever that Smith and Nephew provide to perform this step, but personally I prefer a gentle ‘click home’ by the operator’s thumb as described above

A16G epidural catheter is inserted into the knee for a post-operative continuous local anaesthetic infusion for 36-48hours.
I try and site the tube in line with the incision, but far enough apart so that the dressings of the main wound and the tube do not meet, allowing for removal of the tube without disturbance of the main wound dressing after 36-48hours.
I place the tube in the medial gutter – immediately anterior to the adductor canal, beneath the vastus medialis.

A final deep lavage with Chlorhexidine 0.05%.

Standard closure should be employed in layers – capsule, dermis and subcuticular layers.Capsular closure:
I use a barbed number 1 monofilament absorbable suture, such as Stratafix.
A watertight capsular closure should reduce wound problems.

Deep dermis is closed with interrupted absorbable size ‘0’ to oppose the wound then continuous 2-0 absorbable suture.

Skin: subcuticular absorbable barbed 2-0 monofilament (such as Stratafix) is my personal preference
I start in the middle, work distal and proximal and then …….

….return back towards the middle to create a double layer watertight closure.

Skin glue: application of this with the skin wet makes the glue cure much quicker.

Aquacel hydrocolloid, occlusive, showerproof dressing with a clear/pad occlusive dressing around the Local Anaesthetic (LA) Infiltration tube which connects to the LA suffuser .
Wool and Crepe for 24 hours, which is then reduced and a tubigrip applied
When I perform day-case arthroplasty (not as in this case) I do not use a LA suffuser device. Similarly the post-op staff reduce the bandage later the same day (not disturbing the wound occlusive dressing) and apply tubigrip (as a lightweight compression) before discharge.

Postoperative imaging should be performed with plain AP and lateral radiographs
Well sized components on the AP radiograph. No complications (eg fractures, loose cement)

Well sized components on the lateral radiograph. No complications