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Total Knee Arthroplasty,
A Technique Manual
THIRD EDITION
Richard D. Scott, MD
Professor of Orthopaedic Surgery, Emeritus
Harvard Medical School
Boston, Massachusetts
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TOTAL KNEE ARTHROPLASTY, A TECHNIQUE MANUAL, THIRD EDITION ISBN: 978-0-323-71065-7

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Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
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International Standard Book Number: 978-0-323-71065-7
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my inspiration at home: my wife, Mary, and sons, Jordan and Andrew.
To my inspiration at work: my own mentors and the hundreds of residents and fellows who
allowed me to mentor them.
To my colleague and friend, Tom Thornhill, who traveled much of this road with me.
v
Preface
The first edition of Total Knee Arthroplasty was published control, computer guidance, robotic surgery, and personal-
in 2006. It was a summary of four decades of my personal ized components and instruments as they, too, will continue
experience with the evolution of knee arthroplasty designs to evolve.
and surgical techniques. The second edition, published in My goal is to provide a book that is as “timeless” as pos-
2015, added to this body of knowledge. sible. I hope it will be useful to orthopedic residents and
The purpose of this third edition is to distill my experi- joint arthroplasty fellows as they learn basic arthroplasty
ence into total knee arthroplasty principles and techniques techniques, and hope that it will be helpful to any orthope-
that should endure the test of time. I have eliminated chap- dic surgeon in practice who may be seeking guidance when
ters that covered subjects such as repeat operation after total encountering a difficult preoperative case or a complicated
knee arthroplasty because they provided information that intraoperative or postoperative event.
will continue to evolve in the years to come. I have also
eliminated two chapters on the topic of unicompartmental Richard D. Scott, MD
knee arthroplasty and will address this topic in a separate Professor of Orthopedic Surgery, Emeritus, Harvard
book. Medical School,
I have added a discussion of posterior cruciate sacrifice Founding Member and Past President of The Knee Society,
and substitution techniques as well as a discussion of the Founding Member of The Journal of Arthroplasty,
concepts of measured resection and gap balancing. I will Former Chief of Arthroplasty Brigham and Women’s and
not address contemporary issues such as postoperative pain New England Baptist Hospitals, Boston, MA
vii
1
Posterior Cruciate Ligament Retention
Versus Substitution
Historical Perspective arthritis. Because patients with rheumatoid arthritis often

had significant involvement of the upper extremities, the
The controversy over whether to retain or substitute for the potential for enhanced flexion by retention of the PCL
posterior cruciate ligament (PCL) has been ongoing since was very attractive. Unless patients achieved well over 100
the advent of condylar total knee arthroplasty (TKA) in the degrees of knee flexion, they would have difficulty rising
early 1970s, and three schools exist. One preserves the PCL from a chair and negotiating stairs and would depend on
and uses a tibial insert without much conformity. The sec- their upper extremities for these activities. The cruciate-
ond sacrifices or partially releases the PCL and uses an insert preserving technique, therefore, was adopted in Boston to
with increased sagittal conformity (i.e. “ultra-congruent” or better serve the rheumatoid population.2 Nearly all Bos-
“medial pivot”). I like to refer to this technique as “PCL ton orthopedic residents and fellows were trained in this
supplementation.”1 The third school sacrifices the PCL and technique, whereas in New York the practice of sacrific-
substitutes it with an insert that restores its stabilizing func- ing the PCL predominated. This led to a friendly rivalry
tion via a polyethylene post on the tibial insert that articu- between the Boston and New York camps and spawned
lates with a constraint on the intercondylar portion of the many formal and informal debates that have continued
femoral component. for decades. In the United States in the 1980s and 1990s,
Historically, Boston has been considered the school of the ratio of retaining to sacrificing the PCL was 60:40 in
PCL retention, whereas New York has been the school of favor of retention. By 2010, this ratio had slowly reversed
PCL sacrifice and substitution. In 1974, when I was chief and has remained constant at 60:40 in favor of PCL
resident in orthopedic surgery at Massachusetts Gen- sacrifice.
eral Hospital, a surgeon and an engineer from New York
(Drs. Chit Ranawat and Peter Walker) came to Boston to
share their latest designs for condylar knee prostheses. Both Advantages of Posterior Cruciate
were at the Hospital for Special Surgery at that time and Ligament Retention
collaborated with Dr. John Insall on early knee prosthetic
designs. A meeting was held in the Smith-Petersen room There are many potential advantages of preserving the
and notable attendees included Dr. William Jones, Chief PCL. Because stability is imparted by a biologic structure,
of the Knee Service, and Dr. William Harris, Chief of the the prosthesis can be less constrained; therefore less force is
Hip Service. We were shown two options: total condylar imparted on the insert–tray interface and the prosthesis–
prosthesis, which sacrificed the PCL, and the duopatellar cement (or bone) interface.
prosthesis, which preserved it. The total condylar option With PCL retention, it is also possible to preserve the
had a dished tibial sagittal topography; whereas the duo- joint line at a near-normal location. When the PCL is cut,
patellar tibial topography was flat. With the PCL retained the flexion gap increases and requires a thicker polyethyl-
and functioning, this flat tibial topography allowed the ene insert for any given amount of bone resection. This
femur to roll back on the tibia and enhance potential thicker polyethylene in turn requires a greater than ana-
flexion (Fig. 1.1). Users of the total condylar technique tomic distal femoral resection to allow full extension of
were reporting an average flexion of approximately 85 the knee. Thus the joint line is elevated in both flexion and
degrees, and duopatellar users were achieving more than extension by several millimeters with cruciate-sacrificing
100 degrees of flexion. These findings were shared with designs. This means there is a mandatory distortion of the
surgeons at The Robert B. Brigham Hospital, where 85% collateral ligament kinematics. Although it is possible to
of patients undergoing TKA at that time had rheumatoid equalize the 90-degree flexion gap with the full extension
1
2 CHA P T E R 1 Posterior Cruciate Ligament Retention Versus Substitution
I have developed two simple intraoperative tests for

PCL balancing that allow the surgeon to adequately assess
these two possibilities and remedy either problem in both
fixed-bearing and mobile-bearing knees. The procedure for
a fixed-bearing TKA is called the pull-out lift-off (POLO)
test.3 The pull-out test is to assess the knee for flexion lax-
ity. With the trial components in place (the tibial com-
ponent should be placed before the femoral component),
the knee is flexed 90 degrees. The surgeon then tries to
pull out the tibial component from underneath the femur
(Fig. 1.4). This test must be performed with an insert that
has a curved sagittal topography. The one I prefer has a
posterior lip that is approximately 2.5 mm higher than the
• Fig. 1.1
Diagram showing how a posterior cruciate ligament–retain- midpoint of the articulation. In essence, the pull-out test
ing round-on-flat articulation allows rollback and enhances potential is done to determine whether at least 2.5 mm of laxity or
flexion. distraction is present in the flexion gap; I prefer the flexion
gap to be on the tighter side. A corollary of the pull-out
gap, midflexion laxity is bound to occur to some extent test is the push-in test. In this case, the surgeon pushes
when the joint line is elevated. There are some designs of the trial tibial component into place underneath the pre-
cruciate-sacrificing knees whose femoral components pro- viously inserted femoral component. If this is possible in
vide increased thickness of the posterior condyle relative a cruciate-retaining knee, my opinion is that the knee is
to the posterior condylar bone resection. These, in theory, too loose in flexion, unless the surgeon is using a totally
should lead to less distortion of the joint line. flat posterior sagittal topography. If the knee fails the pull-
Finally, cruciate-retaining knees allow for preservation of out test, thicker inserts are tried until pull-out is no lon-
intercondylar bone stock for future revision, if it becomes ger possible. I should also note that I use the pull-out test
necessary. when using a PCL-sacrificing prosthesis to ensure that that
flexion gap is adequately tight and not totally relying on
constrained tibial topography.
Candidates for Posterior Cruciate Once the knee has proved to be not too loose, I ensure
Ligament Retention it is not too tight by performing a tight PCL with the lift-
off test. With the same trial components in place, the knee
In my experience, the position that knees with severe defor- is flexed between 80 and 100 degrees. If the PCL is too
mity require PCL sacrifice and substitution is a miscon- tight, then it will pull the femur posteriorly on the tibia in
ception. I think that at least 98% of primary knees can be which the posterior condyles impinge on the posterior lip
treated with PCL retention. In fact, in my last several years of the tibial insert, pushing it down in back with lift-off in
of clinical practice, I replaced over 1000 consecutive pri- front (Fig. 1.5). A tight PCL usually can be visualized as the
mary knees without ever requiring PCL substitution (Fig. source of the rollback, posterior impingement, and lift-off
1.2A–B) because the PCL does not have to be “normal” to (Fig. 1.6). The tightest fibers are usually the more anterior
be retained. In knees with severe varus deformity, the PCL and lateral fibers. My preference is to release the PCL under
often is encased by intercondylar osteophytes, which must direct visualization with the trial components in place (Fig.
be débrided to define the ligament origin (see Fig. 1.2C– 1.7). The release can be gradual and sequential until lift-
D). When medial structures are subsequently released (see off disappears. Some surgeons prefer to perform the release
Chapter 3) to balance lax lateral structures, the PCL is from the tibial attachment. This technique can be effective
usually too tight relative to these structures and must be but does not allow a selective release with the trial compo-
released to some extent to balance the knee. nents in place.
In severe valgus deformity, it is not only possible to It is important to remember that lift-off can be caused
preserve the PCL, but it may be preferred because of the by at least two factors other than a tight PCL. If the lift-
medial stabilizing force of the PCL (see Chapter 4). Again, off test is performed with the patella everted and the knee
similar to severe varus deformity, the PCL often has to be has a tight quadriceps mechanism (e.g., a preoperatively
released after the tight lateral side is released to balance the stiff knee), then the everted quadriceps will artificially draw
lax medial side (Fig. 1.3). the tibia forward and into external rotation. In such cases,
lift-off should be tested with the patella returned to the
Balancing the Posterior Cruciate Ligament trochlear groove. If lift-off no longer takes place, then PCL
release is not necessary. The second cause of lift-off, other
Another misconception is that balancing the PCL is a dif- than a tight PCL, is failure to clear the posterior femur of
ficult and complicated maneuver. Balancing the PCL essen- uncapped bone or retained osteophytes (Fig. 1.8). Impinge-
tially means leaving the knee with a PCL that is neither too ment of the posterior lip of the tibial component on this
loose nor too tight. bone will cause lift-off.
CHAPTER 1 Posterior Cruciate Ligament Retention Versus Substitution 3
A B
C D
• Fig. 1.2
(A–B) Correction of severe varus deformity without posterior cruciate ligament (PCL) substitution.
(C–D) PCL is intact beneath intercondylar osteophytes but is not normal.
Two other intraoperative signs of a tight PCL are the to the front of the tray. An overly tight PCL is the most
“pop-off” and patellar tilt signs. A relatively loose femoral likely cause of “spinout” in a rotating platform knee, mak-
trial will pop off the prepared femoral bone when the knee ing proper PCL balance critical.
is passively flexed beyond 90 degrees if the PCL is too tight.
A securely fixed femoral component, however, will roll back
and away from the patella in flexion beyond 90 degrees, giv- Disadvantages of Posterior Cruciate
ing the illusion of patellar tilt. Ligament Retention
I have also described a simple test called “the slide back
test” to assess the need for PCL release in a mobile-bearing Advocates of PCL sacrifice (with or without substitution)
rotating platform knee.3 In this test, the trial tibial insert is correctly point out some potential disadvantages of PCL
placed on top of the real polished tibial tray without using retention. The possibility exists for late AP instability if
the trial post that constrains it on the tray. With a femoral the PCL stretches over time. I have rarely seen this in my
component in place (trial or real), the knee is flexed 80 to own practice and think it is the result of a combination of
100 degrees and the anteroposterior (AP) positioning of the a flexion gap left too loose initially and a tibial topography
insert relative to the front of the tray is noted. If the PCL that is flat in the sagittal plane. In addition, if the sur-
is too loose, then the insert slides forward of the tray. If the geon inadvertently applies an upslope to the tibial resec-
PCL is too tight, then the insert slides backward. In a bal- tion, then posterior subluxation of the tibia on the femur
anced PCL, the insert’s front edge is 1 to 3 mm posterior is more likely.
A B
C
• Fig. 1.3 Posterior cruciate ligament (PCL) retention in severe valgus deformity requiring a partial femoral
release. (A) Preoperative. (B) Postoperative. (C) Partial PCL release.
A B
• Fig. 1.4 Pull-out test (knee flexed 90 degrees). (A) Negative test. (B) Positive test.
• Fig. 1.6 Tight posterior cruciate ligament causing anterior tray lift-off.
• Fig. 1.7 Lift-off resolves after femoral release of the posterior cruciate
ligament.
B
• Fig. 1.5Lift-off test (knee flexed 80 to 100 degrees). The test is posi-
tive with both the (A) patella everted or (B) returned to the trochlear
groove.
A second historical criticism of PCL retention was the • Fig. 1.8 Posterior impingement also can cause lift-off.
apparent need for more frequent lateral release for patel-
lar tracking. I think this was true for early PCL experi- between cruciate-preserving and cruciate-substituting
ences when proper attention was not given to appropriate techniques.
femoral and tibial component rotational alignment. A third historical criticism is a higher incidence of late
With improvements in surgical technique and prosthetic top-side polyethylene wear. Again, this was true in earlier
designs that promote better patellar tracking, I think the experiences for several reasons. The earliest PCL retention
difference has been resolved in the lateral release rate designs had high contact stresses from a round-on-flat
• Fig. 1.9 Point contact can lead to high stresses on the polyethylene.
articulation (Fig. 1.9). Stresses are related to the confor-

mity of the articulation and specifically to the difference
• Fig. 1.10Late posterior wear can result from excessive rollback with
between the radius of curvature of the articulating sur- a tight posterior cruciate ligament.
faces. The amount of stress increases with an increased
difference; for example, less stress occurs with a round-
on-round articulation such as hip arthroplasty and a flat- I reverted back to less rotationally conforming inserts to
on-flat articulation such as the undersurface of a rotating minimize stresses that can be transferred by a conforming
platform. A round-on-flat articulation, however, has a top side to the insert–tray interface, promoting back-side
larger difference between the radii of curvature and there- motion and back-side wear.5
fore higher stresses. Early designs of cruciate-retaining
knees were mostly round-on-flat articulation; therefore the
higher stresses led to a higher incidence of wear in con- Indications for Posterior Stabilized
trast to cruciate-sacrificing designs with curved-on-curved Primary Total Knee Arthroscopy
articulations. This was also compounded by the fact that
these early inserts were sterilized by gamma radiation in Since I “grew up” learning how to save and eventually bal-
air, leading to oxidation and weakening of the polyethyl- ance the PCL, it was unusual for me to perform a primary
ene’s physical properties. Our retrievals of PCL-retaining PCL-substituting TKA. I acknowledge, of course, that this
knees that failed because of wear showed a common wear procedure has definite advantages for selected patients; those
pattern. Most of these knees functioned well for a vari- patients made up 1% to 2% of my practice. I practiced in
able number of years with excellent range of motion, but a teaching environment, and I thought that if I could teach
eventually the knees showed late posterior wear as a result residents and fellows to save and balance the PCL in almost
of excessive rollback of the femur on the tibia combined all cases, they would understand ligament balance better
with the high stresses of a round-on-flat articulation (Fig. and perform a better PCL-substituting knee if they eventu-
1.10). In our early experience with PCL retention, sur- ally chose that technique.
geons allowed the knee to adjust to the cruciate. If the The advantages of PCL substitution include that it is
cruciate was left too tight, then the femur would have easier to expose the tibia and that it is more forgiving when
excessive rollback and possible late posterior wear.4 If the balancing deformity. The knee is also more forgiving of
cruciate was left too loose, then the tibia could undergo slight flexion laxity. It is also easier to correct and stabilize
subluxation posteriorly and the wear pattern would move a knee with a severe flexion contracture (see Chapter 7).
forward. This occurred in combination with the round- Modern designs of cruciate substitution provided con-
on-flat articulation. This experience led to the evolution trolled rollback for better potential range of motion, espe-
of PCL-preserving designs with curved tibial topography cially in preoperatively ankylosed knees (see Chapter 6).
in the sagittal plane. With these designs, the knee would Finally, the partial rotational constraint between the post
no longer adjust to the cruciate, but the cruciate would and the femoral housing allows the surgeon more con-
have to be adjusted to each individual knee. This need to trol in determining the Q-angle of the knee to facilitate
balance the PCL is what led me to develop the POLO test. patellar tracking in cases of patellar instability. This rota-
In the early 1990s, my experience progressed to virtually tional constraint, however, comes with the disadvantage
100% use of curved inserts throughout this decade, with of imparting rotational forces through the polyethylene
PCL release from the femur as needed. More recently, with to the insert–tray interface in modular tibial components
improvement in the wear characteristics of polyethylene, (Fig. 1.11).
• Fig. 1.11 Tibiofemoral malalignment causes torsional stresses on the

stabilizing post.
I propose that ideal candidates for PCL substitution are

the ankylosed knee, the knee with a severe flexion contrac- A
ture, the knee with chronic patellar dislocation, and the
postpatellectomy knee. Although the patellectomized knee
possibly can be treated with PCL retention, it is vulnerable
to late instability because of a deficient quadriceps mecha-
nism, and an imbalanced, lax PCL is more likely to stretch,
allowing instability to progress. Because PCL substitution
is more forgiving, it should be used for borderline cases.
Whether the PCL is retained or substituted in the patient
undergoing patellectomy, I think it is important to “tube”
the quadriceps mechanism if it is thin and requires rein-
forcement (see Chapter 5).
Finally, most total knee revision arthroplasties are
probably best handled with cruciate-substituting tech-
niques. On the femoral side, this permits the use of
modular stems for enhanced fixation, which are often
combined with modular augments for the femoral con-
dyles (Fig. 1.12).
Disadvantages of Posterior Cruciate

Ligament Substitution
Several possible disadvantages can be enumerated for the B
PCL substitution technique. As mentioned previously,
because of the higher constraint in the articulation, greater • Fig. 1.12 Many revisions require posterior cruciate ligament substitu-
tion to restore stability. (A) Prerevision. (B) Postrevision.
stress is imparted through the polyethylene to the modular
insert–tray or bone–cement interface. In theory, these forces
would lead to increased motion between the insert and tray the patella on the quadriceps tendon. This scar can become
and increase back-side wear.5 These same forces could also entrapped in the intercondylar housing of the stabilized
increase the potential for loosening of the prosthesis at the femoral component in flexion, causing internal derange-
fixation interface. ment as the knee is extended. When these symptoms are
A second problem that is unique to PCL-substituting disabling, arthroscopic débridement of the scar tissue is
designs is the patellar clunk syndrome. This occurs when necessary. This complication is minimized by removing all
a buildup of scar tissue occurs above the superior pole of synovial tissue from the quadriceps tendon just above the
superior pole of the patella at the time of the original arthro- tibial component must be avoided. For example, 3 degrees
plasty (Fig. 1.13). It is also minimized by using a femoral of femoral component flexion combined with 7 degrees
component with a smoothed and lowered transition from of posterior tibial slope might allow post impingement
the trochlea into the intercondylar notch. to occur with little or no anatomic hyperextension of the
A third disadvantage of PCL substitution is the removal knee.
of intercondylar bone stock for the housing of the femoral Finally, the tibial post of stabilized designs is vulnerable
component. The amount of bone removed varies across to wear from rotational malalignment between the femur
designs. More conservative prostheses save bone but and the tibia that either is created by the surgeon at the
have less constraint and therefore a higher potential for time of arthroplasty or occurs dynamically because of the
dislocation. patient’s gait or flexion pattern. Many surgeons arbitrarily
Another design-related disadvantage is the potential align the rotation of the tibial component relative to a
inability of the posterior stabilized system to accommodate landmark on the tibial tubercle. The junction between the
hyperextension of the knee without anterior impingement medial and middle thirds of the tubercle is often chosen.
of the post on the housing (Fig. 1.14). Some early designs Although this may be appropriate for most knees, others
provided for no hyperextension, although most now allow may require an alignment that is significantly internal or
for approximately 10 to 12 degrees of hyperextension. external to this landmark. Intuitively, the tibial alignment
Even with these more forgiving designs, the combination that is neutral with the femur will depend on the femoral
of femoral component flexion with posterior slope of the rotational alignment chosen by the surgeon for that specific
knee. The alignment is also influenced by the dynamics of
the surrounding ligaments. I have the strong opinion that
the rotational alignment of the tibia should be determined
by extending the knee with the trial components in place
and rotating the tibial component into a neutral position
beneath the established femoral component6 (see Chapter 2).
Rotating-platform mobile-bearing knees have the advan-
tage of accommodating to malrotation created either by the
surgeon or dynamically by the patient during functional
activities.
Both PCL-retaining and PCL-substituting techniques
have been available for over 4 decades. Each technique has
yielded excellent 10- to 15-year results. Both techniques
have advantages and disadvantages. Most prosthetic systems
provide for either alternative, and surgeons can make their
• Fig. 1.13 Retained synovium on the quadriceps tendon can be the choice on what is comfortable for them based on their train-
nidus for the clunk syndrome. ing and experience.
A B
• Fig. 1.14 Wear can occur from impingement in rotation or hyperextension. (A) Wear from rotational
impingement. (B) Wear from impingement in extension.
References 4. Swany MR, Scott RD. Posterior polyethylene wear in PCL retain-
ing total knee arthroplasty. J Arthroplasty. 1993;8:439–446.
1. Scott RD, Thornhill TS. Posterior cruciate supplementing total 5. Schwarzkopf R, Scott RD, Carlson EM, Currier JH. Does in-
knee replacement using conforming inserts and cruciate recession. creased topside conformity in modular TKA lead to increased
Clin Orthop. 1994;309:146–149. backside wear? Clin Orthop Relat Res. 2015;473(1):220–225.
2. Scott RD, Volatile TB. Twelve years’ experience with poste- 6. Scott RD. Femoral and tibial component rotation in total
rior cruciate-retaining total knee arthroplasty. Clin Orthop. knee arthroplasty: methods and consequences. Bone Joint J.
1986;205:100–107. 2013;95B:140–143.
3. Scott RD, Chmell MJ. Balancing the posterior cruciate ligament
during cruciate-retaining fixed and mobile-bearing total knee ar-
throplasty: description of the pullout, lift off and slide back tests.
J Arthroplasty. 2008;23:605–608.
2
Primary Total Knee Arthroplasty
Surgical Technique
RICHARD D. SCOTT
I
have tried to make the surgical technique of primary flexion after satisfactory exposure has been achieved. The
total knee arthroplasty (TKA) as generic as possible. level for this support therefore is independent of the preop-
Obviously, TKA systems will vary in terms of instru- erative range of motion but reflects the flexion that will be
mentation and nuances of surgical technique. Some dif- achieved once the quadriceps mechanism is everted and the
ferences will also exist between posterior cruciate ligament knee is mobilized.
(PCL) retention, sacrifice, and substitution. Some surgeons
will prefer femur first preparation and others will prefer Sterile Preparation of the Leg
tibia first preparation. Some prefer the “measured resection”
technique, whereas others rely on the “tap balancing” tech- Any shaving of hair around the area of the planned incision
nique. I actually think that a technique of measured resec- is done just before sterile preparation of the leg. I draw the
tion combined with gap balancing is most appropriate and knee incision with an indelible marking pen before the skin
this will be included in the discussion. preparation. Any prior incisions are outlined and incorpo-
rated, if appropriate. The incision is drawn with the knee
Positioning of the Patient flexed 90 degrees to account for the fact that the skin is
translated laterally about 1 cm from extension to flexion
TKA is always performed with the patient in the supine because the tibia internally rotates.2 If the patient desires to
position. The operating table is usually level. The rare kneel after surgery and the incision is drawn in extension,
exception occurs when TKA is performed below a fused or he or she will most likely kneel on the incision atop the
ankylosed hip.1 In this case, the table is in the level position tibial tubercle, possibly causing discomfort. I include the
for the exposure and closure. During the arthroplasty, the foot in the preparation and then hold the foot with a sterile
patient is placed in Trendelenburg position and the foot of towel as the remainder of the leg is prepped. An impervious
the table is dropped; the uninvolved leg is supported on a stockinette is then rolled from the foot to the level of the
separate stool or table. thigh tourniquet. An extremity sheet completes the draping.
I usually expose the knee in flexion, especially in obese The stockinette is incised vertically to expose the drawn skin
patients or if a tourniquet is not used. An exception might incision and the operating surgeon’s initials to positively
be the knee with a prior incision, especially a curvilinear identify the patient and complete the mandated time out.
one, in which skin flaps need to be elevated. I close the knee Finally, a betadine-impregnated plastic drape is used to seal
in extension except for placement of the most proximal the surgical site.
sutures in the quadriceps mechanism, which is facilitated by
a flexed knee and a proximal self-retaining retractor. The Tourniquet
Placement of the Footrest With two exceptions, I apply a tourniquet for all TKAs, but
I use it only for the initial exposure (less than 5 minutes)
I prefer a commercially available cylindrical footrest that and for cementing of the components (approximately 15
supports the knee in flexion during the arthroplasty. If this minutes). One exception is in the morbidly obese patient,
is not available, a satisfactory substitute is a towel or blanket especially one with a short thigh, in which a tourniquet is
rolled into a cylinder and taped into position. The optimal often ineffective and compromises the proximal extent of
level for placement of this support is at the fattest part of the the surgical field. For these patients I will still have a sterile
patient’s calf (Fig. 2.1). This supports the knee in maximal tourniquet available.
11
12 CHA P T E R 2 Primary Total Knee Arthroplasty Surgical Technique
• Fig. 2.1Transverse bar is placed at the bulkiest part of the calf to sup-
port the knee in flexion during the procedure.
The second exception is a patient with known peripheral

vascular disease and absent pulses confirmed by Doppler
examination. These patients will always have a consultation
with a vascular surgeon preoperatively for clearance and
advice. Even if the patient has undergone successful bypass
surgery, I still do not use a tourniquet.
For routine use, tourniquet pressure is 250 mm Hg.
Occasionally, pressure as high as 325 mm Hg is necessary
to avoid a venous tourniquet effect. I elevate the limb for
30 seconds before inflation of the tourniquet. I prefer not • Fig. 2.2 Incision is vertical, 13 to 15 cm in length, one-third above
to exsanguinate the limb with an elastic bandage (Esmarch and two-thirds below the patella, centered above on the femoral shaft,
over the medial third of the patella, and ending just medial to the tibial
bandage) so that some blood remains in the superficial
tubercle.
veins; this makes the veins easier to identify.
The first dose of prophylactic antibiotics is given at least
10 minutes before tourniquet inflation (see Chapter 12). doing, however, I had several names I could give them!
That ended the discussion.
The Incision Skin incisions must be modified in the presence of prior
incisions about the knee (see Chapter 13). I prefer to avoid
The incision and initial exposure will be made with the knee elevating large skin flaps and creating dead space. The sub-
in flexion, which minimizes bleeding and allows the vessels cutaneous dissection heads directly toward the landmarks
to be coagulated as they are encountered. for a medial parapatellar arthrotomy. Elevation of skin over
As mentioned previously, the incision is also drawn the dorsal surface of the patella is the only amount sufficient
with the knee flexed before the surgical preparation. A to safely apply a holding clamp for cementing the patellar
standard incision is straight, vertical, and approximately component. I always sewed in moist wound towels to pro-
15 cm long. The incision is centered proximally over the tect the subcutaneous tissues from desiccating (see Chapter
shaft of the femur. In its midportion, the incision is over 12 and Fig. 12.1).
the midthird of the patella and distally ends just medial
to the tibial tubercle (Fig. 2.2). There is a trend toward Medial Parapatellar Arthrotomy
making shorter incisions, and this can be done by lessen-
ing the proximal half of the skin incision. If the initial I prefer a medial parapatellar arthrotomy for all primary
exposure and closure are done with the knee in flexion, knees. During my career, I have had experience with three
the proximal quadriceps can be accessed through a shorter alternative approaches to the knee: subvastus, midvastus,
skin incision. I am not in favor of “minimally invasive” and lateral parapatellar. I certainly do not object to their use
incisions if they compromise exposure or require excessive in selected patients. Each, however, has potential disadvan-
pulling or stretching that could injure the soft tissues and tages. For example, the subvastus and midvastus approaches
make them more vulnerable to infection. When patients can be difficult in short, obese, and muscular individuals.
questioned me about using a minimally invasive tech- If a medial advancement is necessary at the time of closure,
nique, I told them that I would make the shortest inci- it may be difficult to achieve with these approaches. The
sion possible that allowed me to repair the knee properly. I lateral approach for valgus knees may prevent the surgeon
told them that I refused to compromise their result by not from safely everting the patella medially. It also may be dif-
being able to see what I was doing. If they wanted their ficult to seal the arthrotomy from the subcutaneous space
knee done by someone who could not see what they were just beneath the skin incision with this approach.
CHAPTER 2 Primary Total Knee Arthroplasty Surgical Technique 13
• Fig. 2.4 Patellofemoral ligament is identified and cut.
No. 10 blade is slid upside down into the bursa and tan-
gential to the anterolateral tibial cortex. The scalpel is then
passed coronally in this plane, severing the coronary liga-
ment and anterior horn of the lateral meniscus. In almost
every case, the patella is then easily and safely everted. If
eversion is difficult, I do not hesitate to perform a proxi-
• Fig. 2.3 Medial and lateral borders of the arthrotomy are marked at mal release, as discussed in Chapter 6. In morbidly obese
the level of the superior pole of the patella to facilitate an anatomic patients or ankylosed knees, the clamp used to cement the
closure. patellar component can be used to grip the patella securely
and facilitate eversion.3
The medial parapatellar approach can be used in virtually
every case regardless of the preoperative deformity and range Completing the Exposure
of motion. The three essential landmarks are the proximal
medial border of the quadriceps tendon, a point halfway Before preparation of the bones is initiated, certain mea-
between the medialis insertion and the superior medial pole sures are taken to maximize exposure and mobilize the knee.
of the patella, and the medial border of the tubercle. First, the patellofemoral ligament is released (Fig. 2.4).
With this approach 2 or 3 mm of the medial border of This is accomplished by putting a Z-retractor into the lateral
the quadriceps tendon is preserved proximally. At the supe- compartment to tension this ligament. A curved hemostat
rior pole of the patella, a soft tissue cuff is preserved to facili- is passed beneath its leading anterior edge, and a cutting
tate closure. At the tibial tubercle, a medial soft tissue cuff cautery severs its fibers. This further mobilizes the patella
is carefully preserved for closure to the medial border of the and improves the exposure to the lateral compartment. Care
patellar tendon. I mark the medial and lateral edges of the must be taken to avoid inadvertently injuring the quadri-
arthrotomy at the level of the superior pole of the patella to ceps tendon or placing the clamp so deeply it involves the
facilitate an anatomic closure at the end of the procedure popliteus tendon or lateral collateral ligament.
(Fig. 2.3). Next, the Z-retractor is placed medially, and the anterior
At the joint line, the arthrotomy severs the anterior horn of the medial meniscus is excised. This gains access
horn of the medial meniscus. This facilitates eversion of to the plane between the deep medial collateral ligament
the medial capsular tissue with the remaining meniscus (MCL) and the superior border of the medial tibial plateau.
attached for safe dissection of a subperiosteal anteromedial A curved, 1-cm osteotome is inserted into this plane and
flap. Careful preservation of this flap permits a secure distal tapped posteriorly until it dissects its way into the semi-
closure at the end of the procedure and allows for the pos- membranous bursa (Fig. 2.5). The anterior cruciate liga-
sibility of a side-to-side repair to the patellar tendon should ment, if intact, is completely sacrificed. The tibia can then
the tendon’s insertion be compromised (see Chapter 13). be delivered in front of the femur by hyperflexing the knee,
I have seen many surgeons use electrocautery for this and pulling the tibia forward, and externally rotating it.
other parts of the dissection. With a few exceptions, I prefer Before removing the lateral meniscus, a scalpel is used to
sharp dissection with a scalpel rather than create dead tissue create a 1- to 2-cm slit just peripheral to the lateral menis-
as a nidus for infection with the cautery. cus at the junction between its anterior and middle thirds.
The initial lateral dissection involves defining the infrapa- Through this slit a bent Hohmann retractor is placed, which
tellar bursa to the level of the patellar tendon insertion. A will be used throughout the operation for lateral exposure.
• Fig. 2.5
Curved, 1-cm osteotome dissects a plane between the deep
medial collateral ligament and proximal tibia. • Fig. 2.7 Lateral inferior genicular artery and vein (arrow) are located
and coagulated during excision of the lateral meniscus.
• Fig. 2.6 Tibia is delivered in front of the femur, and a bent Hohmann
retractor is placed just outside the lateral meniscus.
The lateral compartment is now well exposed (Fig. 2.6).

The entire lateral meniscus is removed with sharp dissec-
tion; I find it is easiest to start at the posterior horn and • Fig. 2.8 Intercondylar osteophytes are removed to define the poste-
then return to the anterior horn and midsubstance until the rior cruciate ligament.
resection is complete. The lateral inferior genicular artery
will be encountered just peripheral to the meniscus during and the alignment angles are independent of each other if
this dissection. The open lumen of both artery and vein are the surgeon’s goal is to perform measured resections based on
usually easily visualized in the posterior lateral corner of the thickness of components and maintenance of the joint line.
knee and are coagulated to minimize postoperative bleeding The only bone cuts that are dependent on one another are
(Fig. 2.7). Finally, the fat pad is dissected off the anterior those that determine the rotational alignment of the femoral
proximal portion of the lateral tibial plateau to allow even- component. Surgeons performing tibia-first procedures create
tual placement of the tibial cutting jig. A small amount of flexion gap symmetry by using a tensor apparatus or spacer
the fat pad can be removed, if necessary, for better exposure. blocks. Surgeons using femur-first procedures can establish
flexion gap symmetry by relating the femoral component
Preparation of the Femur rotation to an external tibial alignment device.
To prepare the femur, it is important to first define the
Either the femur or the tibia can be prepared first for TKA. I anatomy of the intercondylar notch and expose and define
prefer preparing the femur first in primary surgeries in which the PCL origin. Intercondylar osteophytes are removed with
the PCL is retained because after femoral resection has been a ⅜-inch osteotome and dissected free of the PCL (Fig. 2.8).
completed, the tibial exposure is facilitated. In revision sur- The medullary canal of the femur is entered approximately 1
gery, however, I always prepare the tibia first. In a primary cm above the origin of the PCL and a few millimeters medial
procedure, the amount of femoral and tibial bone resection to the true center of the intercondylar notch (Fig. 2.9). One
• Fig. 2.9 Entry point into the femoral canal is defined.
• Fig. 2.11
Introducing an undersized rod (circle) will show the surgeon
how to reorient the larger rod for easier passage.
valgus bushing. The actual angle of the distal femoral resec-

tion becomes 9 degrees or 10 degrees of valgus.
Once the entry point is chosen, I prefer to use a small
gouge to initiate the hole and allow the drill to subsequently
enter into the chosen spot precisely. The drill hole should
be larger than the diameter of the intramedullary alignment
rod. I use a ⅜-inch drill and a ¼-inch-diameter alignment
rod. Some surgeons aspirate the fatty marrow from the distal
femur and irrigate the canal. I have not found this to be nec-
essary as long as the intramedullary alignment rod is smaller
than the entry hole, fluted, and introduced slowly and gen-
tly. If difficulty is encountered introducing the rod, then the
entry hole should be enlarged. On rare occasions when the
rod fails to pass easily, I have found it helpful to first intro-
duce an undersized rod to define the orientation of the canal.
This method may reveal that the entry hole must be enlarged
into one of four quadrants to allow easy passage (Fig. 2.11).
• Fig. 2.10 It is helpful to locate this entry point on the preoperative
radiograph.
Distal Femoral Resection
way to define this area is to draw the Whiteside line down The decision then must be made about the amount of distal
the deepest part of the trochlear sulcus and mark the entry resection and the desired valgus angle. I think many tech-
point 1 cm above the top of the intercondylar notch and 1 nique brochures are misleading concerning the amount of
mm or 2 mm medial to the Whiteside line. The preoperative distal resection appropriate when the PCL is retained. The
anteroposterior (AP) radiograph of the femur will also help brochures often recommend removing an amount of bone
locate the entry point for the intramedullary alignment rod. that is equivalent to the thickness of the metallic distal femoral
This can be done by passing a line down the center of the condyle of the prosthesis. They should clarify that the amount
shaft of the femur and seeing where it exits in the intercon- of resection also should include the thickness of cartilage that
dylar notch (Fig. 2.10). As noted, this entry point is usually was once present. Otherwise, the distal femoral resection will
several millimeters medial to the true center. If the canal were be approximately 2 mm more than a true “anatomic” amount.
to be entered in the true center of the notch, the valgus angle This would slightly elevate the joint line and possibly set up a
chosen would be effectively increased by several degrees. I knee that is looser in extension than in flexion.
think this is the most common reason surgeons inadvertently In a PCL-preserving technique, the goal should be to
place the femoral component in too much valgus. They enter restore the femoral joint line as precisely as possible and
the canal in the true center of the notch and use a 7-degree avoid a knee that is tighter in flexion than in extension.
• Fig. 2.12 Angle of the resection is 90 degrees to a line from the center • Fig. 2.13 Difference between the lines representing the mechanical
of the hip to the center of the knee. and anatomic axis is usually 5 to 7 degrees.
Erring toward underresecting the distal femoral condyle

will achieve this goal. If, after initial preparation of both the
femur and tibia, the knee still is tighter in extension than in
flexion, the distal femur can be revisited for another 2 mm
of resection. This is quick and simple to accomplish. Exces-
sive distal femoral resection is better tolerated in a PCL-
substituting technique. Removing the PCL enlarges the
flexion gap and allows the thicker polyethylene required to
stabilize the knee in flexion also to be tolerated in extension.
In the presence of a preoperative flexion contracture, more
than an anatomic amount of the distal condyle is usually
resected to aid in correction of the contracture (see Chapter 7).
To summarize the amount of distal femoral resection in a
patient without a flexion contracture, I would recommend
7 mm of bone resection for a 9-mm-thick femoral compo-
nent in the PCL-preserving technique. In a PCL-sacrificing
technique, I would recommend 9 mm of bone resection for
a 9-mm-thick femoral component.
The Valgus Angle

• Fig. 2.14For most varus knees, a neutral mechanical axis at the joint
The valgus angle chosen for the distal resection depends on line touches bone medially and intact cartilage laterally.
preoperative templating and certain clinical factors. The
goal in the majority of knee arthroplasties is to restore the Another advantage of this preoperative templating is to
mechanical axis to neutral. This is most efficiently achieved show the relative amounts of resection of the medial and
by creating a neutral mechanical axis at the distal femur and lateral distal femoral condyles. Unless there is some sort of
a neutral mechanical axis at the proximal tibia. To deter- osteotomy, fracture, or dysplastic deformity, the amount of
mine this angle, a long AP radiograph from the hip to the resection usually is slightly more medial than lateral. The
knee is taken in neutral rotation. A line is drawn from the line formed at the joint for a neutral mechanical axis will
center of the hip to the center of the knee. A perpendicular often be at the level of eburnated bone medially and intact
line is then made at the knee to this line (Fig. 2.12). Finally, cartilage laterally, or roughly 2 mm away from the actual
the angle formed by this line and a line of the center of the bone of the distal lateral condyle (Fig. 2.14). This infor-
shaft of the femur can be measured. Usually the angle is mation is useful when the distal cutting guide is applied
between 5 and 7 degrees (Fig. 2.13). and confirms what is shown on the preoperative templated
A B
• Fig. 2.15 (A) “Precut” of the trochlea is made parallel to the trans-sulcus line. (B) The anterior femoral
cortex is better defined.
radiograph. In severe valgus knees (see Chapter 4), this dis- the trochlea. The anterior femoral cortex can sometimes be
crepancy can be quite considerable (see Fig. 4.8). difficult to define. To facilitate this, I now make a prelimi-
A few exceptions exist to attempting to accurately nary conservative trochlear resection perpendicular to the
restore a neutral femoral mechanical axis. The excep- Whiteside line (Fig. 2.15).
tions all involve leaving the knee in slight (1 degree or If the sizing measurement shows a dimension at a half
2 degrees) mechanical varus alignment because it would size or larger, then I use the larger size. An exception to this
decrease stress on the MCL. The most common situation rule would be a patient with poor preoperative flexion in
involves correction of a severe valgus deformity with an which an attempt is made to make the prosthetic trochlea as
attenuated MCL. By overcorrecting the alignment into a flush with the anterior cortex as possible to increase quad-
degree or two of mechanical varus, stress is taken off the riceps excursion. Another exception would be the patient
medial side of the knee. Similarly, if inadvertent injury to (usually female) whose mediolateral dimension is propor-
the MCL occurs, some residual varus mechanical align- tionally smaller than the AP dimension. Using the larger
ment will protect any surgical repair of the ligament (see size would cause too much mediolateral overhang; thus the
Chapter 13). smaller size is chosen (see Chapter 13).
Residual varus mechanical alignment used to be dis- For half sizes and smaller, I choose the smaller size. The
couraged in the routine primary knee, but it is preferred two options that allow downsizing without notching the
for cosmetic purposes over residual mechanical valgus anterior cortex are to make the distal femoral resection in
alignment in the obese patient with excessive medial soft a few degrees of flexion or to size the femur from anterior
tissues. Clinically, these patients appear to be in much downward. See Chapter 13 for discussion of the techniques
more anatomic valgus than that represented by their radio- and consequences of using these two methods. Many of
graphic alignment. If a neutral mechanical axis is chosen the newer prosthetic systems offer a large inventory of AP
for these patients, they should be forewarned of the appar- and mediolateral dimensions that allow more precise sizing
ent valgus appearance of the limb. In addition, it is also but at the cost of a very large, cumbersome inventory. In
easier to achieve symmetric extension balancing if the Chapter 13, I will show a simple efficient way to double the
surgeon accepts slight mechanical varus. I cut most varus size of your inventory.
knees in no more than 5 degrees of valgus to facilitate liga-
ment balance (see Chapter 3). Determining the Rotational Alignment of
the Femoral Component
Sizing the Femur
After the femoral component has been sized, its proper rota-
I prefer to size the femur from posterior upward. This is tional alignment must be determined. At least four methods
the most reliable method to restore the joint line in flexion, are popularly used to determine femoral component rota-
balance the PCL, and minimize the chance for midflexion tion4: perpendicular to the Whiteside line (the trans-sulcus
laxity. In this procedure two skids slide under the posterior axis) (Fig. 2.16), the transepicondylar axis (Fig. 2.17), 3
condyles, and a moveable stylus measures the AP dimension degrees of external rotation off the posterior condyles (Fig.
of the femur based on the anterior cortex just superior to 2.18), and rotational alignment that yields flexion gap
• Fig. 2.16 Whiteside line is perpendicular to a line down the deepest

part of the trochlear groove.
• Fig. 2.17 Transepicondylar axis is usually parallel to the Whiteside

line.
B
• Fig. 2.19 (A) Rectangular flexion gap can be established by tensing
the medial and lateral tissues and relating the femoral rotation to the
external tibial alignment jig. (B) Pinholes should be parallel to the align-
ment jig.
symmetry (Fig. 2.19A–B). During surgery, I assess all four

methods, but my primary consideration is flexion gap sym-
metry.5 (This is where the techniques of measured resection
and gap balancing merge to allow the creation of the most
appropriately aligned and balanced knee.)
Most sizing guides will provide for the placement of pin-
holes for the subsequent cutting guides that can automatically
build in 3 degrees or 5 degrees of external rotation (see Fig.
• Fig. 2.18Most total knee systems provide a way to build in 3 degrees
of external femoral rotation off the posterior condylar axis. In this sys- 2.18). I start with 3 degrees to set my preliminary rotation
tem, the upper hole is pinned medially and the lower hole is pinned and then add more external rotation as needed to achieve a
laterally. balanced rectangular flexion gap; this part of the technique is
as 7 degrees may be required to restore a rectangular gap. Sur-

geons who use spacer blocks to check balancing of the full
extension and 90-degree flexion spaces will sometimes use a
spacer block placed on the initially resected tibia to tense the
knee in flexion and guide them toward the appropriate femo-
ral rotation.
In rare cases, the knee may require no external rota-
tion off the posterior femoral condyles or actually require
intentional internal rotation. One instance occurs in a knee
with laxity of the anterior aspect of the MCL. In these
cases, internally rotating the femoral component will close
down the medial flexion gap and restore medial stability in
A flexion. The second instance can occur when converting a
patient with a proximal tibial osteotomy that has healed in
excessive valgus with a valgus tibial joint line. In such a case,
when the knee is flexed 90 degrees, the femoral condyles sit
in marked external rotation on the valgus tibial joint line
(see Chapter 8, Fig. 8.9). In these cases, if any method other
than gap balancing is used to determine femoral component
rotation, more flexion gap asymmetry will be created and an
extensive lateral collateral release will be required to balance
the flexion gap. Most surgeons are concerned that purpose-
ful femoral component internal rotation will compromise
patellar tracking. Note, however, that mathematical calcula-
tion of the actual effect of rotation on the displacement of
the trochlear groove shows that for every 4 degrees of femoral
B component rotation, the groove is displaced approximately
• Fig. 2.20 (A) In this valgus knee, more external rotation of the pinholes 2 mm.5 This relatively small amount can be compensated
is necessary for flexion gap symmetry. (B) To increase the external rota- for by undersizing the patellar component by one size and
tion, the lateral pinhole is lowered with a navicular gouge. shifting it medially, beveling the uncapped patellar bone to
prevent impingement.
known as gap balancing. In varus knees, the extension gap is Some publications in the literature suggested that femoral
balanced first by the appropriate medial release. In most val- or tibial component malrotation can cause pain or stiffness
gus knees that can be balanced without lateral collateral liga- and subsequent failure of the arthroplasty. This conclusion
ment release (see Chapter 4), prior extension balancing is not could also be the consequence of a malrotated femoral com-
required. After extension balancing in the varus deformity, ponent occurring in the hands of an inexperienced surgeon
the knee is placed in 90 degrees of flexion and some form who has also made a constellation of other errors in prepara-
of tensiometer is applied to the medial and lateral compart- tion of the arthroplasty.
ments. The femoral component is then rotated into flexion
gap symmetry. Laminar spreaders can be used for this pur-
pose (Fig. 2.20). A laminar spreader will open up the medial Placement of the Anteroposterior
gap a finite amount, regardless of the tension applied, unless Cutting Jig
the anterior aspect of this ligament is abnormal or injured.
Remember, however, that that lateral compartment is more Most AP cutting jigs have spikes that will fit into the holes
pliable in flexion than the medial compartment. For this rea- created through the initial sizing guide. The guide is seated
son, it is probably helpful to use a calibrated spreader on the flush with the distal condylar resections. The proper con-
lateral side even though the exact amount of tension to apply tact of the jig with the bone should be assessed by viewing
has not been established. I have used 20 pounds of tension it directly from the side. Some jigs provide ancillary pins
for more than a decade with good results. When using this (smooth or threaded) that will further secure the cutting jig
method, well over 90% of knees end up in 5 degrees of exter- on the end of the distal femur.
nal rotation relative to the posterior femoral condylar line.
Two exceptions to this exist: one occurs in the severe valgus
Completing the Femoral Cuts
knee with a hypoplastic posterior lateral femoral condyle in Trochlear Resection
which 7 degrees or 8 degrees may be indicated (see Fig. 2.20), The anterior or trochlear cut is made first (Fig. 2.21). The
and the second is seen in the severe varus knee in which the main concern with this cut is to be certain to avoid notch-
medial posterior femoral condyle is hyperplastic, and as much ing the anterior cortex. The amount of resection for each
• Fig. 2.22 Lateral radiograph of a femur with a “hypoplastic” trochlea.
it appears that the planned trochlear resection would notch

the anterior cortex, then the femur should be recut in a few
degrees of flexion (see Chapter 13), or the pinholes for the
cutting jig should be displaced the appropriate distance
anteriorly by means of the navicular gouge technique.
Posterior Condylar Resection

The posterior condylar cuts are completed next. The MCL
is in jeopardy during the medial posterior condylar resec-
tion (see Chapter 13). It is important to have a well-placed
medial retractor to protect the ligament from the medial
B excursion of the saw blade (see Fig. 13.5). If a wide saw
blade is initially used, then the cuts are best completed with
• Fig. 2.21 (A) Trochlear resection through the anteroposterior cutting
jig. (B) Posterior condylar resection. a narrower saw blade or an osteotome.
Chamfer Cuts
individual case can be gauged by reviewing the preoperative The chamfer cuts are completed next. Most systems provide
lateral radiograph. Occasionally, the trochlea is hypertro- an AP cutting guide with slots for the chamfer cuts (Fig.
phic with a large amount of osteophyte formation, creating 2.23A). Despite this, I like to revisit the chamfer cuts with a
the illusion that the trochlea resection will be excessive. At separate chamfer guide if I am planning cementless femoral
the opposite end of the spectrum is the hypoplastic trochlea fixation. I do this because sometimes the AP cutting block
seen in patients with patella alta and patellofemoral dys- is not fully or symmetrically seated or may lift off slightly
plasia (Fig. 2.22). If there is a concern that the trochlear from the end of the femur. Redoing the chamfer cuts with
resection might be excessive, the precut of the trochlea will the isolated block ensures that they are accurate for press fit
help determine this (see Fig. 2.15). This cut will expose the application (see Fig. 2.23B).
proximal junction between the trochlea and the anterior
cortex of the femur and allow a more accurate assessment to Final Preparation of the Femur
be made concerning the potential for notching the anterior Final preparation of the femur is accomplished after tibial
cortex. I would recommend against the practice of many preparation when posterior exposure is greater. Then the
surgeons who remove the fat overlying the anterior cortex trial femoral component is applied for the first time. I use a
and incise the periosteum. I think this action predisposes femoral inserter that holds the component rigidly so I can
the knee to form heterotopic bone in this area, which could apply an extension force as the trial is seated (Fig. 2.24).
limit postoperative quadriceps excursion (see Chapter 6). If Femoral components tend to go into flexion when they are
• Fig. 2.25 Femoral component is positioned flush with the lateral

cortex.
first applied. There are two reasons for this: a trochlear cut
that diverges slightly more than dictated by the anterior cut-
ting guide, and underresection of a posterior condyle, which
is almost always on the medial side. The hard medial bone
deflects the saw blade into a diverging pathway.
Both situations can be assessed and remedied by reap-
plying the AP cutting guide when the chamfer cuts have
been completed. Slight divergence of the saw blade that is
not apparent with the chamfer cuts intact becomes obvious
when they are missing.
Once the trial femoral component is seated, it must be
properly positioned in the mediolateral dimension. Medial
or lateral overhang of the prosthesis must be avoided; it is
B
most commonly seen in the female patient (see Chapter
•Fig. 2.23 (A) Making the chamfer cut through a slotted guide. (B) 13). The optimal mediolateral position for the component
Confirming the accuracy of the chamfer cut with an open guide. is flush with the lateral distal femoral cortex at the level of
the trochlea and distal condyle (Fig. 2.25). The ability to
achieve this position varies with the prosthetic design. Only
asymmetric femoral components can optimally cap the cut
trochlear surface of the femur. Symmetric components that
come flush with the medial cortex at the level of the troch-
lea cannot possibly fully cap the cut surface of the trochlea.
Intuitively, this will compromise patellar tracking in the first
30 degrees of flexion.
After the femoral component has been moved laterally
to be flush with the lateral cortex, any remaining peripheral
osteophytes are removed. It is most important to achieve
this at the level of the origin of the popliteus tendon to
prevent popliteus impingement syndrome6 (Fig. 2.26; see
Chapter 13). Any overhanging medial osteophytes are also
removed flush with the femoral component.
Finally, it is important to remove posterior condylar
osteophytes and any uncapped posterior condylar bone.
This is best achieved with the trial femoral component in
• Fig. 2.24Applying the trial femoral component for the first time while place and the tibial resection completed. While an assistant
applying an extension force. elevates the femur using a bone hook in the intercondylar
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64. Full mighty seemed Atli | as o’er them he

stood,
The wise one he blamed, | and his words
reproached her:
“It is morning, Guthrun; | now thy dear ones dost
miss,
But the blame is part thine | that thus it has
chanced.”
[523]
Guthrun spake:
65. “Thou art joyous, Atli, | for of evil thou tellest,

But sorrow is thine | if thou mightest all see;
Thy heritage heavy | here can I tell thee,
Sorrow never thou losest | unless I shall die.”
Atli spake:
66. “Not free of guilt am I; | a way shall I find

That is better by far,— | oft the fairest we shunned;
—
With slaves I console thee, | with gems fair to see,
And with silver snow-white, | as thyself thou shalt
choose.”
Guthrun spake:
67. “No hope shall this give thee, | thy gifts I shall
take not,
Requital I spurned | when my sorrows were
smaller;
Once grim did I seem, | but now greater my
grimness,
There was nought seemed too hard | while Hogni
was living.
[524]
68. “Our childhood did we have | in a single house,

We played many a game, | in the grove did we
grow;
Then did Grimhild give us | gold and necklaces;
Thou shalt ne’er make amends | for my brother’s
murder,
Nor ever shalt win me | to think it was well.
69. “But the fierceness of men | rules the fate of

women,
The tree-top bows low | if bereft of its leaves,
The tree bends over | if the roots are cleft under it;
Now mayest thou, Atli, | o’er all things here rule.”
70. Full heedless the warrior | was that he trusted

her,
So clear was her guile | if on guard he had been;
But crafty was Guthrun, | with cunning she spake,
Her glance she made pleasant, | with two shields
she played.
[525]
71. The beer then she brought | for her brothers’

death-feast,
And a feast Atli made | for his followers dead;
No more did they speak, | the mead was made
ready,
Soon the men were gathered | with mighty uproar.
72. Thus bitterly planned she, | and Buthli’s race

threatened,
And terrible vengeance | on her husband would
take;
The little ones called she, | on a block she laid
them;
Afraid were the proud ones, | but their tears did not
fall;
To their mother’s arms went they, | and asked what
she would.
Guthrun spake:
73. “Nay, ask me no more! | You both shall I
murder, [526]
For long have I wished | your lives to steal from
you.”
The boys spake:
“Slay thy boys as thou wilt, | for no one may bar it,
Short the angry one’s peace | if all thou shalt do.”
74. Then the grim one slew both | of the brothers

young,
Full hard was her deed | when their heads she
smote off;
Fain was Atli to know | whither now they were
gone,
The boys from their sport, | for nowhere he spied
them.
Guthrun spake:
75. “My fate shall I seek, | all to Atli saying,

The daughter of Grimhild | the deed from thee
hides not;
No joy thou hast, Atli, | if all thou shalt hear,
Great sorrow didst wake | when my brothers thou
slewest.
[527]
76. “I have seldom slept | since the hour they were

slain,
Baleful were my threats, | now I bid thee recall
them;
Thou didst say it was morning,— | too well I
remember,—
Now is evening come, | and this question thou
askest.
77. “Now both of thy sons | thou hast lost . . .

. . . . . . . . | as thou never shouldst do;
The skulls of thy boys | thou as beer-cups didst
have,
And the draught that I made thee | was mixed with
their blood.
78. “I cut out their hearts, | on a spit I cooked

them,
I came to thee with them, | and calf’s flesh I called
them;
Alone didst thou eat them, | nor any didst leave,
[528]
Thou didst greedily bite, | and thy teeth were busy.
79. “Of thy sons now thou knowest; | few suffer

more sorrow;
My guilt have I told, | fame it never shall give me.”
Atli spake:
80. “Grim wast thou, Guthrun, | in so grievous a

deed,
My draught with the blood | of thy boys to mingle;
Thou hast slain thine own kin, | most ill it
beseemed thee,
And little for me | twixt my sorrows thou leavest.”
Guthrun spake:
81. “Still more would I seek | to slay thee thyself,

Enough ill comes seldom | to such as thou art;
Thou didst folly of old, | such that no one shall find
[529]
In the whole world of men | a match for such
madness.
Now this that of late | we learned hast thou added,
Great evil hast grasped, | and thine own death-
feast made.”
Atli spake:
82. “With fire shall they burn thee, | and first shall
they stone thee,
So then hast thou earned | what thou ever hast
sought for.”
Guthrun spake:
“Such woes for thyself | shalt thou say in the

morning,
From a finer death I | to another light fare.”
83. Together they sat | and full grim were their

thoughts,
Unfriendly their words, | and no joy either found;
In Hniflung grew hatred, | great plans did he have,
To Guthrun his anger | against Atli was told.
[530]
84. To her heart came ever | the fate of Hogni,

She told him ’twere well | if he vengeance should
win;
So was Atli slain,— | ’twas not slow to await,—
Hogni’s son slew him, | and Guthrun herself.
85. Then the warrior spake, | as from slumber he

wakened,
Soon he knew for his wounds | would the bandage
do nought:
“Now the truth shalt thou say: | who has slain
Buthli’s son?
Full sore am I smitten, | nor hope can I see.”
Guthrun spake:
86. “Ne’er her deed from thee hides | the daughter

of Grimhild, [531]
I own to the guilt | that is ending thy life,
And the son of Hogni; | ’tis so thy wounds bleed.”
Atli spake:
“To murder hast thou fared, | though foul it must

seem;
Ill thy friend to betray | who trusted thee well.
87. “Not glad went I hence | thy hand to seek,

Guthrun,
In thy widowhood famed, | but haughty men found
thee;
My belief did not lie, | as now we have learned;
I brought thee home hither, | and a host of men
with us.
88. “Most noble was all | when of old we

journeyed,
Great honor did we have | of heroes full worthy;
Of cattle had we plenty, |and greatly we prospered,
Mighty was our wealth, | and many received it.
89. “To the famed one as bride-gift | I gave jewels

fair, [532]
I gave thirty slaves, | and handmaidens seven;
There was honor in such gifts, | yet the silver was
greater.
90. “But all to thee was | as if nought it were worth,

While the land lay before thee | that Buthli had left
me;
Thou in secret didst work | so the treasure I won
not;
My mother full oft | to sit weeping didst make,
No wedded joy found I | in fullness of heart.”
Guthrun spake:
91. “Thou liest now, Atli, | though little I heed it; [533]
If I seldom was kindly, | full cruel wast thou;
Ye brothers fought young, | quarrels brought you
to battle,
And half went to hell | of the sons of thy house,
And all was destroyed | that should e’er have done
good.
92. “My two brothers and I | were bold in our

thoughts,
From the land we went forth, | with Sigurth we
fared;
Full swiftly we sailed, | each one steering his ship,
So our fate sought we e’er | till we came to the
East.
93. “First the king did we slay, | and the land we

seized, [534]
The princes did us service, | for such was their
fear;
From the forest we called | them we fain would
have guiltless,
And rich made we many | who of all were bereft.
94. “Slain was the Hun-king, | soon happiness

vanished,
In her grief the widow | so young sat weeping;
Yet worse seemed the sorrow | to seek Atli’s
house,
A hero was my husband, | and hard was his loss.
95. “From the Thing thou camst never, | for thus

have we heard,
Having won in thy quarrels, | or warriors smitten;
Full yielding thou wast, | never firm was thy will,
In silence didst suffer, | . . . . . . . .”
Atli spake:
96. “Thou liest now, Guthrun, | but little of good [535]

Will it bring to either, | for all have we lost;
But, Guthrun, yet once | be thou kindly of will,
For the honor of both, | when forth I am borne.”
Guthrun spake:
97. “A ship will I buy, | and a bright-hued coffin,

I will wax well the shroud | to wind round thy body,
For all will I care | as if dear were we ever.”
98. Then did Atli die, | and his heirs’ grief doubled;
The high-born one did | as to him she had
promised;
Then sought Guthrun the wise | to go to her death,
But for days did she wait, | and ’twas long ere she
died.
99. Full happy shall he be | who such offspring

has,
Or children so gallant, | as Gjuki begot;
Forever shall live, | and in lands far and wide,
Their valor heroic | wherever men hear it.
[499]
[Contents]
NOTES
[500]
1. Men: Atli and his advisers, with whom he planned the death of the
sons of Gjuki, Gunnar and Hogni. The poet’s reference to the story
as well known explains the abruptness of his introduction, without
the mention of Atli’s name, and his reference to Guthrun in stanza 3
simply as “the woman” (“husfreyja,” goddess of the house).
2. Princes: Atli, Gunnar, and Hogni. Bulwark: Atli’s slaying [501]of his
wife’s brothers, who were ready to support and defend him in his
greatness, was the cause of his own death.
3. The woman: Guthrun, concerning whose marriage to Atli cf.

Guthrunarkvitha II. The sea: a late and essentially Greenland
variation of the geography of the Atli story. Even the Atlakvitha,
perhaps half a century earlier, separates Atli’s land from that of the
Gjukungs only by a forest.
4. Runes: on the two versions of Guthrun’s warning, and also on the

name of the messenger (here Vingi), cf. Drap Niflunga and note.
Limafjord: probably the Limfjord of northern Jutland, an important
point in the wars of the eleventh century. The name was derived
from “Eylimafjǫrþ,” i.e., Eylimi’s fjord. The poet may really have
thought that the kingdom of the Burgundians was in Jutland, or he
may simply have taken a well-known name for the sake of vividness.
[502]
5. Some editors assume a gap after this stanza.
6. Some editions place this stanza between stanzas 7 and 8.

Kostbera (“The Giver of Food”) and Glaumvor (“The Merry”):
presumably creations of the poet. Both: Atli’s two emissaries, Vingi
and the one here unnamed (Knefröth?).
7. It is altogether probable that a stanza has been lost between

stanzas 6 and 7, in which Gunnar is first invited, and replies
doubtfully. Made promise: many editions emend the text to read
“promised the journey.” The text of line 4 is obscure; the manuscript
reads “nitti” (“refused”), which many editors have changed to “hlitti,”
which means exactly the opposite.
8. No gap is indicated in the manuscript; Bugge adds (line [503]3):

“Then the warriors rose, | and to slumber made ready.” The
manuscript indicates line 4 as beginning a new stanza, and some
editions make a separate stanza out of lines 1–2. Others suggest the
loss of a line after line 4.
9. The manuscript does not indicate line 1 as the beginning of a

stanza; cf. note on stanza 8.
10. Some editions combine this stanza with lines 1–2 of stanza 11.
The manuscript indicates no gap. Grundtvig adds (line 2): “But sleep
to the woman | so wise came little.”
11. Some editions make a separate stanza out of lines 1–2, or

combine them with stanza 10, and combine lines 3–4 with stanza
[504]12 (either lines 1–4 or 1–2). The manuscript marks line 3 as
beginning a new stanza.
12. Line 5 may be spurious, or else all that is left of a lost stanza.
The manuscript marks it as the beginning of a new stanza, which, as
the text stands, is clearly impossible.
13. The manuscript, followed by some editions, has “Hogni spake” in

the middle of line 1. Ill: the manuscript and many editions have “this.”
The king: Atli.
14. The manuscript does not indicate the speakers in this dialogue
between Kostbera and Hogni (stanzas 14–19). Two lines may
possibly have been lost after line 2, filling out stanza 14 and
[505]making stanza 15 (then consisting of lines 3–4 of stanza 14 and
lines 1–2 of stanza 15) the account of Kostbera’s first dream. The
manuscript marks line 3 as beginning a new stanza. In any case, the
lost lines cannot materially have altered the meaning.
15. Saw I: the manuscript here, as also in stanzas 16, 18, 21, 22,
and 24, has “methought,” which involves a metrical error. Some
editors regard lines 3–4 as the remains of a four-line stanza.
Regarding Kostbera’s warning dreams, and Hogni’s matter-of-fact
interpretations of them, cf. Guthrunarkvitha II, 39–44.
16. The meaning of the first half of line 3 in the original is obscure.
[506]
17. Two lines may have been lost after line 2, but the Volsungasaga
paraphrase gives no clue. Ice-bear: polar bears, common in
Greenland, are very rarely found in Iceland, and never in Norway, a
fact which substantiates the manuscript’s reference to Greenland as
the home of the poem.
18. The manuscript indicates no gap, but most editors assume the
loss of a line after line 1 or 2; Grundtvig adds, after line 1: “Black
were his feathers, | with blood was he covered.” Atli’s spirit: the
poet’s folk-lore seems here a bit weak. Presumably he means such a
female following-spirit (“fylgja”) as appears in Helgakvitha
Hjorvarthssonar, prose following stanza 34 (cf. note thereon), but the
word he uses, “hamr” (masculine) means “skin,” “shape.” He may,
however, imply that Atli had assumed the shape of an eagle for this
occasion.
19. The manuscript indicates line 4 as beginning a new stanza. [507]
20. The manuscript indicates no gap, but none of the many

attempted emendations have made sense out of the words as they
stand. The proper location for the missing words is sheer guesswork.
Two roads: probably the meaning is that their way (i.e., their
success) would be doubtful.
21. The manuscript does not indicate the speakers in this dialogue
(stanzas 21–26). No gap is indicated after line 2. Most editors
assume the loss of two lines or of a full stanza after [508]stanza 21
giving Gunnar’s interpretation of Glaumvor’s dream, but the
Volsungasaga gives no clue, as it does not mention this first dream
at all. Grundtvig suggests as Gunnar’s answer: “Banners are
gleaming, | since of gallows didst dream, / And wealth it must
mean | that thou serpents didst watch.” Gods’ doom: an odd, and
apparently mistaken, use of the phrase “ragna rök” (cf. Voluspo,
introductory note).
23. Perhaps two lines have been lost after line 2. Possibly the
concluding phrase of line 2 should be “bloody spears,” as in the
Volsungasaga paraphrase.
24. Again Gunnar’s interpretation is missing, and most editors either

assume a gap or construct two Malahattr lines out of the
Volsungasaga prose paraphrase, which runs: “The grain shall
[509]flow, since thou hast dreamed of rivers, and when we go to the
fields, often the chaff rises above our feet.”
25. The meaning of line 4 is uncertain, but apparently it refers to the

guardian spirits or lesser Norns (cf. Fafnismol, 12–13 and notes).
26. Possibly a line has been lost from this stanza.
27. Five: Gunnar, Hogni, and the three mentioned in stanza 28.
28. Perhaps a line has been lost before line 1; Grundtvig supplies:
“Gunnar and Hogni, | the heirs twain of Gjuki.” Snævar (the
manuscript here has “Snevar”), Solar and Orkning [510]appear only in
this poem and in the prose narratives based on it. Lines 2–3 may
have been expanded out of one line, or possibly line 3 is spurious.
The manuscript indicates line 4 as beginning a new stanza, and
many editions make a separate stanza out of lines 4–5, many of
them assuming the loss of two lines. Shield-tree: warrior (Orkning),
here identified as Kostbera’s brother. Fair-decked ones: women, i.e.,
Glaumvor and Kostbera. Fjord: perhaps specifically the Limafjord
mentioned in stanza 4.
30. The manuscript indicates no gap. Grundtvig inserts (line 2): “The
evil was clear | when his words he uttered.”
31. Bera: Kostbera; the first element in compound feminine

[511]proper names was not infrequently omitted; cf. Hild for Brynhild
(Helreith Brynhildar, 6). The manuscript indicates no gap; Grundtvig
inserts (line 2): “And clear was her cry | to her kinsmen dear.”
32. Hogni’s method of cheering his wife and sister-in-law is

somewhat unusual, for the meaning of lines 3–4 is that good wishes
and blessings are of little use in warding off danger.
33. Perhaps two lines have been lost after line 2; Grundtvig supplies:
“Then weeping did Glaumvor | go to her rest-bed, / And sadly did
Bera | her spinning wheel seek.”
34. Keel, etc.: in the Nibelungenlied, and presumably in the older

German tradition, Hagene breaks his oar steering the Burgundians
across the Danube (stanza 1564), and, after all have landed,
splinters the boat (stanza 1581) in order that there may be no
retreating. The poet here seems to have confused the story,
[512]connecting the breaking of the ship’s keel with the violence of
the rowing, but echoing the older legend in the last line, wherein the
ship is allowed to drift away after the travellers have landed. Oar-
loops: the thongs by which the oars in a Norse boat were made fast
to the thole-pins, the combination taking the place of the modern
oarlock.
35. The manuscript indicates line 4 as beginning a new stanza, and

many editions combine it with stanza 36, some of them assuming the
loss of a line from stanza 35. In the Volsungasaga paraphrase the
second half of line 4 is made a part of Vingi’s speech: “Better had ye
left this undone.”
36. Cf. note on preceding stanza; the manuscript does not indicate
line 1 as beginning a stanza. Line 3 may be spurious.
37. In the Volsungasaga paraphrase the second half of line 1 and the
first half of line 2 are included in Hogni’s speech. [513]
38. Possibly two lines have been lost after line 2.
39. It is probable that a considerable passage has been lost between

stanzas 39 and 40, for the Volsungasaga paraphrase includes a
dialogue at this point. The manuscript indicates no gap, and most
editions combine stanzas 39 and 40 as a single stanza. The prose
passage, indicating the substance of what, if anything, is lost, runs
as follows: “ ‘Be welcome among us, and give me that store of gold
which is ours by right, the gold that Sigurth had, and that now
belongs to Guthrun.’ Gunnar said: ‘Never shalt thou get that gold,
and men of might shalt thou find here, ere we give up our lives, if it is
battle thou dost offer us; in truth it seems that thou hast prepared this
feast in kingly fashion, [514]and with little grudging toward eagle and
wolf.’ ” The demand for the treasure likewise appears in the
Nibelungenlied.
40. These two lines, which most editions combine with stanza 39,
may be the first or last two of a four-line stanza. The Volsungasaga
gives Atli’s speech very much as it appears here.
41. The manuscript does not indicate the speaker; Grundtvig adds
as a first line: “Then Hogni laughed loud | where the slain Vingi
lay.” Many editors assume the loss of a line somewhere in the
stanza. Unarmed: Hogni does not see Atli’s armed followers, who
are on the other side of the courtyard (stanza 39). One: Vingi.
42. Most editors assume the loss of one line, after either line 1 or line
3.
43. The manuscript reading of lines 1–2, involving a metrical error, is:
“In the house came the word | of the warring without, / Loud in
front of the hall | they heard a thrall shouting.” Some editors
assume a gap of two lines after line [515]2, the missing passage
giving the words of the thrall. The manuscript marks line 3 as the
beginning of a stanza, and many editions make a separate stanza of
lines 3–5, some of them assuming the loss of a line after line 3. With
the stanza as here given, line 5 may well be spurious.
44. Niflungs: regarding the application of this term to the

Burgundians cf. Atlakvitha, 11, and Brot, 17, and notes. The
manuscript here spells the name with an initial N, as elsewhere, but
in stanza 83 the son of Hogni appears with the name “Hniflung.” In
consequence, some editors change the form in this stanza to
“Hniflungs,” while others omit the initial H in both cases. I have
followed the manuscript, though admittedly its spelling is illogical.
[516]
46. The warlike deeds of Guthrun represent an odd transformation of

the German tradition. Kriemhild, although she did no actual fighting
in the Nibelungenlied, was famed from early times for her cruelty and
fierceness of heart, and this seems to have inspired the poet of the
Atlamol to make his Guthrun into a warrior outdoing Brynhild herself.
Kriemhild’s ferocity, of course, was directed against Gunther and
especially Hagene, for whose slaying she rather than Etzel was
responsible; here, on the other hand, Guthrun’s is devoted to the
defense of her brothers.
47. Line 3 is very likely an interpolation. The manuscript marks line 4

as the beginning of a new stanza, and some editions make a
separate stanza of lines 4–5. Atli’s brother: doubtless a reminiscence
of the early tradition represented in the Nibelungenlied by the slaying
of Etzel’s brother, Blœdelin (the historical Bleda), by Dancwart. [517]
48. Line 3 may well be spurious, for it implies that Gunnar and Hogni
were killed in battle, whereas they were taken prisoners. Some
editors, in an effort to smooth out the inconsistency, change
“themselves” in this line to “sound.” Line 5 has also been questioned
as possibly interpolated. Niflungs: on the spelling of this name in the
manuscript and the various editions cf. note on stanza 44.
49. Line 2 is probably an interpolation, and the original apparently

lacks a word. There is some obscurity as to the exact meaning of
lines 4–5. The two sons of Bera: Snævar and Solar; her brother is
Orkning; cf. stanza 28.
50. The warrior: Atli. Thirty: perhaps an echo of the “thirty warriors”
of Thjothrek (cf. Guthrunarkvitha III, 5). Subtracting the eighteen
killed by Snævar, Solar and Orkning (stanza 49), and Vingi, killed by
the whole company (stanza [518]38), we have eleven left, as Atli
says, but this does not allow much for the exploits of Gunnar and
Hogni, who, by this reckoning, seem to have killed nobody. The
explanation probably is that lines 4–5 of stanza 49 are in bad shape.
51. Five brothers: the Volsungasaga speaks of four (not five) sons of
Buthli, but names only Atli. Regarding the death of the first two
brothers cf. stanza 91 and note. The manuscript marks line 3 as
beginning a stanza, and many editions combine lines 3–4 with
stanza 52. Some insert lines 2–3 of stanza 52 ahead of lines 3–4 of
stanza 51.
52. Possibly a line has been lost from this stanza. The manuscript
marks line 3 as beginning a new stanza, which is impossible unless
something has been lost. Gold: the meaning of this half line is
somewhat doubtful, but apparently Atli refers to Sigurth’s treasure,
which should have been his as Brynhild’s brother. Sister: Brynhild;
regarding Guthrun’s indirect responsibility for Brynhild’s death cf.
Gripisspo, 45 and note. [519]
53. The manuscript does not name the speaker. The Volsungasaga
gives the speech, in somewhat altered form, to Hogni: “Why
speakest thou so? Thou wast the first to break peace; thou didst take
my kinswoman and starved her in a prison, and murdered her and
took her wealth; that was not kinglike; and laughable does it seem to
me that thou talkest of thy sorrow, and good shall I find it that all
goes ill with thee.” This presumably represents the correct form of
the stanza, for nowhere else is it intimated that Atli killed Guthrun’s
mother, Grimhild, nor is the niece elsewhere mentioned. Some
editions make a separate stanza of lines 4–5, Grundtvig adding a
line after line 3 and two more after line 5. Other editors are doubtful
about the authenticity of either line 3 or line 5.
54. The manuscript does not indicate the speaker. [520]
56. The text of the first half of line 3 is somewhat uncertain, but the
general meaning of it is clear enough.
57. Beiti: not elsewhere mentioned. The Atlakvitha version of this

episode (stanzas 23–25) does not mention Beiti, and in the
Volsungasaga the advice to cut out Hjalli’s heart instead of Hogni’s is
given by an unnamed “counsellor of Atli.” In the Atlakvitha Hjalli is
actually killed; the Volsungasaga combines the two versions by
having Hjalli first let off at Hogni’s intercession and then seized a
second time and killed, thus introducing the Atlakvitha episode of the
quaking heart (stanza 24). The text of the first half of line 3 is
obscure, and there are many and widely varying suggestions as to
the word here rendered “sluggard.”
58. Some editions mark line 5 as probably interpolated. [521]
59. Cook: the original word is doubtful. The Volsungasaga does not
paraphrase lines 3–5; the passage may be a later addition, and line
5 is almost certainly so.
61. It is probable that a stanza describing the casting of Gunnar into

the serpents’ den has been lost after this stanza. Sons of day: the

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Last digit is the print number: 9 8 7 6 5 4 3 2 1

Historical Perspective arthritis. Because patients with rheumatoid arthritis often

I have developed two simple intraoperative tests for

articulation (Fig. 1.9). Stresses are related to the confor-

• Fig. 1.11 Tibiofemoral malalignment causes torsional stresses on the

I propose that ideal candidates for PCL substitution are

Disadvantages of Posterior Cruciate

The second exception is a patient with known peripheral

• Fig. 2.4 Patellofemoral ligament is identified and cut.

The lateral compartment is now well exposed (Fig. 2.6).

• Fig. 2.9 Entry point into the femoral canal is defined.

valgus bushing. The actual angle of the distal femoral resec-

Erring toward underresecting the distal femoral condyle

The Valgus Angle

• Fig. 2.16 Whiteside line is perpendicular to a line down the deepest

• Fig. 2.17 Transepicondylar axis is usually parallel to the Whiteside

symmetry (Fig. 2.19A–B). During surgery, I assess all four

as 7 degrees may be required to restore a rectangular gap. Sur-

• Fig. 2.22 Lateral radiograph of a femur with a “hypoplastic” trochlea.

it appears that the planned trochlear resection would notch

Posterior Condylar Resection

• Fig. 2.25 Femoral component is positioned flush with the lateral

64. Full mighty seemed Atli | as o’er them he

65. “Thou art joyous, Atli, | for of evil thou tellest,

66. “Not free of guilt am I; | a way shall I find

68. “Our childhood did we have | in a single house,

69. “But the fierceness of men | rules the fate of

70. Full heedless the warrior | was that he trusted

71. The beer then she brought | for her brothers’

72. Thus bitterly planned she, | and Buthli’s race

The boys spake:

74. Then the grim one slew both | of the brothers

75. “My fate shall I seek, | all to Atli saying,

76. “I have seldom slept | since the hour they were

77. “Now both of thy sons | thou hast lost . . .

78. “I cut out their hearts, | on a spit I cooked

79. “Of thy sons now thou knowest; | few suffer

80. “Grim wast thou, Guthrun, | in so grievous a

81. “Still more would I seek | to slay thee thyself,

“Such woes for thyself | shalt thou say in the

83. Together they sat | and full grim were their

84. To her heart came ever | the fate of Hogni,

85. Then the warrior spake, | as from slumber he

TOTAL KNEE ARTHROPLASTY, A TECHNIQUE MANUAL, THIRD EDITION ISBN: 978-0-323-71065-7