Total Knee Arthroplasty

Principles
 Total Knee Arthroplasty

Excellent and durable relief of pain

Improvement in functional status

 Conditions That Lead To TKA

Osteoarthritis
Primary (OA)
Secondary (post-traumatic OA)
Rheumatoid arthritis (RA)
 Non Operative Treatment
Do not alter the underlying disease
May diminish pain and disability
 Non Operative Treatment
Health and behavior modifications
Physical therapy
Weight loss
knee braces
Pharmacotherapy
Acetaminophen, NSAIDs
Glucosamine and/or Chondroitin sulfate

Intra-articular injections
Corticosteroid injections
Hyaluronic acid (viscosupplementation)
 Operative Treatment

One of the key principles:

Correction of deformity in all three planes
(frontal, sagittal and axial)

Patients who need TKA will have deformity in

at least one of these three planes

In the majority of cases, normal knees without

any deformity do not develop arthritis
 Preoperative Planning

A comprehensive medical and drug history is

mandatory to confirm that the patient is an
appropriate candidate for major surgery and
anesthesia
Good-quality radiographs must be obtained
It is critical to evaluate both the ipsilateral hip
and lumbar spine to rule out hip or spine
pathology as a major contributor to knee pain
 Preoperative Radiographs
Standing bilateral AP knee
Extension and Flexion lateral
Merchant view
Standing full-length AP hip to ankle
 Quality Parameters for
Radiographs
Trochanter minor should not be visible
Patella in the center
Joint gap and Tibial spine visible
Fibular head one third covered by the tibia
Tallus centrally at the ankle joint

Well executed long leg standing radiographs

have an accuracy of 1-2
 Quality Parameters for
Radiographs
Using the wrong protocol may lead to
unacceptable results with outliers up to 10
A flexion contracture or recurvatum of more
than 15 might not allow to see the joint gap
Internal malrotation of the leg will cause valgus
and external malrotation will increase varus
deformity
 Operative Treatment

Implant survival is determined by:

Biomechanics
Patient related factors (body weight and life style)
 Operative Treatment

Surgical technique is responsible for:

Correction of deformities
Adapting the soft tissues to the new biomechanical
situation with proper soft tissue balancing

Prosthesis design should allow nearly normal

kinematics and offer a safe and forgiving
biomechanical environment
 Technical Goals of TKA
Restore neutral mechaincal alignment of limb
Restore joint line
Balanced ligaments
Normal Q angle
 Operative Treatment

Two different worlds for deformity

correction and rotational alignment exist
Measured resection technique
Balanced flexion gap technique

Both techniques are completely different

but have stood the test of time
Measured resection technique
Bone cuts are made according to
biomechanics (mechanical axis, AP axis,
transepicondylar, posterior condylar
surfaces) only and biology (soft tissue)
have to be adopted to the new
biomechanical situation after making bone
cuts
 Balanced flexion gap technique
Bone cuts are made according to the existing
biology and only very limited soft tissue
releases are accepted especially in extension

In the axial plane the femoral component is

parallel to the proximal tibia cut and not to the
surgical epicondylar line
It still remains controversial
which technique is superior
for patients outcome
Measured resection technique
Preferred by 80% of surgeons
Bone cuts independent from ligaments
Three different landmarks possible
Minimum 3 degrees ER for all
Soft tissue control after all cuts
 Preoperative planning

Measuring the different angles and comparing

them to the normal range in the different
planes, allows to identify deformities as well as
correct planning of the bone cuts

Without planning, proper bone cuts are difficult

to be performed in all three planes
 Bone Cuts

The five standard bone cuts:

Distal femoral condylar resection
Anterior and posterior condylar resections
Anterior and posterior chamfer resections from the
distal femur
Transverse proximal tibial resection
Retropatellar cut (in patellar resurfacing)
The sixth step of the intercondylar box or box cut is
performed only for posterior stabilized designs.
 Bone Cuts

Bone cuts are made to align the implanted

knee joint perpendicular to the mechanical
axis, thereby distributing weight-bearing
forces evenly between the medial and
lateral compartments

Greater than 3 degrees of malalignment in

the coronal plane has been associated with
an increased failure rate
 Coronal Plane Ligament
Balancing In TKA
Varus Deformity
Medial compartment release in sequence
Osteophytes
Deep MCL Includes medial knee capsule
Posteromedial corner: Capsule Semimembranosus
Superficial MCL - key structure
Posterior oblique portion tight in extension release
for medial extension tightness
Anterior portion tight in flexion release for medial
 Coronal Plane Ligament
Balancing In TKA
Valgus Deformity
Lateral compartment release in sequence
Osteophytes
Lateral capsule
Iliotibial band - key structure
Release for lateral extension tightness
Popliteus - key structure
Release for lateral flexion tightness
Lateral collateral ligamentlast
 Ligament Balancing In TKA
Flexion Deformity
Posterior knee release in sequence
Osteophytes
Posterior capsule
Gastrocnemius muscle origin
Posterior releases are performed with the knee flexed
(generally at 90 degrees of flexion) Less danger to
popliteal artery
 Sagittal Plane Balancing in
TKA
Balancing the Gaps
Importance:
Full functional knee range
Stability
Pain relief

Unbalanced gaps cause pain from tightness or

pain from instability
 Balancing the Gaps

Flexion gap - controlled by:

Posterior cut of femur
Tibial cut
Posterior cruciate ligament (PCL)

Extension gap - controlled by

Distal cut of femur
Tibial cut
Posterior capsule
 Pearls & Pitfalls

The tibial cutting guide should be aligned with

the tibial crest, and distally, it should fall slightly
medial to the midpoint of the malleoli

If not shifted 35 mm medially from the

intermalleolar axis, varus orientation of the tibial
resection will result
 Pearls & Pitfalls

The tibial cutting guide should be oriented to

produce 37 degrees of posterior slope

If the cutting guide is internally or externally

rotated, the posterior slope will translate into
valgus or varus inclination
 Pearls & Pitfalls

The tibial component should be placed against

the lateral margin of the tibial plateau

A medially located tibial component increases

both the Q-angle (causing patellar maltracking)
and medial overhang
 Pearls & Pitfalls

The starting point for the femoral IM rod

insertion is approximately 1cm anterior to the
PCL insertion

A starting point that is too lateral or too medial

will increase valgus and varus angulation,
respectively
 Pearls & Pitfalls
The femoral component should be sized
appropriately, and the consequences of a
bottom-up or top-down technique should be
realized to help avoid complications
Undersizing introduces the risk of anterior
notching or overresection of the posterior
femoral condyles
Oversizing can cause overstuffing of the flexion
gap or patellofemoral joint, depending on the
position in the sagittal plane.
 Pearls & Pitfalls

Pay close attention to the distal femoral cut in

the sagittal plane to avoid flexion or extension

An extended cut will risk notching, whereas a

flexed cut can risk patellar maltracking and
cam/post impingement in cruciate-substituting
designs
 Pearls & Pitfalls

The distal femoral cut in the coronal plane

should not exceed 7 degrees of valgus

Coronal alignment of the femur in greater than

7 degrees of valgus can increase the Q-angle,
leading to patellar maltracking
 Pearls & Pitfalls

Use a combination of references for assessing

femoral rotation
Using only one reference can result in
malrotation of the femoral component,
particularly in cases of valgus arthritis or femoral
condyle erosion or hypoplasia
 Pearls & Pitfalls

If using the posterior condylar line as a

reference, add an extra degree or two to the
external rotation prior to making cuts in valgus
knees
If not recognized, lateral femoral condylar
hypoplasia in these patients can cause internal
rotation of the femoral component
 Pearls & Pitfalls

Lateralization of the femoral component can

help patellar tracking

Medial overhang of the femoral component can

cause significant tissue irritation and patellar
maltracking by increasing the Q-angle
 Pearls & Pitfalls

The goal of patellar resection is to remove the

same thickness that will be replaced by the
component

Overresection may result in patellar fracture or

osteonecrosis. Decreasing the overall thickness
of the patella can result in extensor mechanism
weakness.
 Pearls & Pitfalls

At least 1214 mm of bone should be left in all

cases

Underresection can result in overstuffing of the

patellofemoral joint, leading to excessive lateral
soft tissue tension, patellar maltracking,
anterior knee pain, and limited flexion
 Pearls & Pitfalls

Medialization and superior positioning of the

patellar component can help tracking

Lateral positioning increases the Q-angle and

causes patellar maltracking
Thank You