Primary Knee Arthroplasty

MODERATOR :- DR Ponnanna KM
Presentor:- Dr Gavikrishna k
 INTRODUCTION

• Knee joint is a complex type of Modified Hinge joint

• Composed of 2 distinct articulations located within a single joint

capsule –
1. Tibiofemoral Joint
2. Patellofemoral joint
 TIBIOFEMORAL ALIGNMENT

• ANATOMICAL AXIS - The relationship

of long axis of femur to the long axis of
tibia

• Forms an angle of 180 - 185 degree at

medial side of knee

• Creating a slight Physiological Valgus

at the knee
• MECHANICAL AXIS - Line drawn
between the center of the
Femoral head to the center of
the Talar head

• Typically should project through

the center of the knee –
“Neutral” Mechanical axis
MECHANICAL VARUS OR VALGUS
ALGINMENT
 WEIGHT BEARING FORCES

• In Bilateral stance, the weight bearing stresses on the knee joint are
equally distributed between Medial and Lateral Compartment

• However, once the unilateral stance is adopted the line of force shifts
medially to the knee joint center.

• This medial shift increases the Compressive stresses medially and

Tensile stresses laterally
 MENISCI
• The relative Tibio-Femoral incongruence is improved by addition of
medial and lateral menisci

• Fibrocartilaginous discs which are semicircular in shape

• Medial meniscus is C shaped whereas Lateral meniscus forms Four-

Fifth of a circle. Therefore, covering about 4/5TH of the articular
surface
 FUNCTION OF MENISCI

• 1. Distribute stress across the

knee during weight bearing
2. Increase the contact area and
reduces the stress at the knee
joint
3. Provide shock absorption and
Facilitate joint gliding
4. Serve as secondary joint
stabilizers
 TIBIOFEMORAL JOINT KINEMATICS

• The primary angular motion of Tibiofemoral Joint is Flexion and

Extension although Internal and External rotation and Valgus/Varus
motions occur to a smaller extent

• Each of these motions occur about changing but a well defined axis
 FLEXION-EXTENSION

• If the large convex femoral condyles

were permitted to roll posteriorly on
the flat tibial plateau the femur would
run out of tibia.

• This will cause femoral rolling of the

tibia and would limit flexion
MEDIAL-LATERAL ROTATION
 MEDIAL-LATERAL ROTATION
• The maximum range of axial rotation is available at 90 degree of knee flexion

• The magnitude of axial rotation diminishes as knee approaches both full

extension and full flexion

• At 90 degree, the axial rotation available is appx. 35 degree with range of lateral
rotation being 0-20 degree and medial rotation being 0-15 degree
 LOCKING OR SCREW-HOME MECHANISM
OF KNEE
• There is an obligatory lateral rotation of tibia that accompanies the final stage of
knee extension that is not voluntary or produced by muscular forces

During the last 30 degree of knee extension, the shorter lateral tibial
plateau/femoral condyle pair completes its rolling-gliding motion before the longer
medial articular surfaces do
|
As extension continues, the longer medial condyle continues to roll and glide
anteriorly after the lateral side of plateau is halted
|
 LOCKING OR SCREW-HOME MECHANISM
OF KNEE
This continued anterior motion of the medial tibia condyle results in lateral rotation
of tibia on femur, with motion most evident in the final 5 degree of extension
|
The tibial tubercles are now lodged in the intercondylar notch, the menisci are
tightly imposed between tibia and femoral condyles and the ligaments are taut
bringing the knee into its closed pack or taut position
|
To initiate knee flexion from full extension, the knee must first be unlocked; i.e.
laterally rotated tibia must first medially rotate concomitantly as the flexion is
initiated
 PATELLOFEMORAL STABILITY
• Patellofemoral stability is maintained
by a combination of the articular
surface geometry and soft-tissue
restraints.

• The Q angle is the angle between the

extended anatomic axis of the femur
and the line between the center of
the patella and the tibial tubercle.
• Males : 8-10
• Females : 15+/- 5
 PATELLOFEMORAL STABILITY

• The quadriceps acts primarily in line with the anatomic axis of the
femur, with the exception of the vastus medialis obliquus, which acts
to medialize the patella in terminal extension.

• Limbs with larger Q angles have a greater tendency for lateral patellar
subluxation.
 INCREASED Q ANGLE

• Genu valgum
• Increased femoral anteversion.
• External tibial torsion.
• Laterally positioned tibial tuberosity.
• Tight lateral retinaculum
Classification implants

• Designs include
• 1.unconstrained
• posterior-cruciate retaining (CR)
• posterior-Stabilising (PS)
• 2. constrained
• nonhinged
• hinged
• 3. fixed versus mobile bearing
 Hinged Knee implants
• 1. Two polyethylene and cobalt chrome bearings allow flexion-
extension and axial rotation.
• The rotating hinge type of implant offers constraint in the sagittal
and coronal planes while allowing free rotation in the transverse
plane
• 2 revision TKR, severe ligamentous insufficiency, severe flexion and
extension gap mismatch, recurvatum deformity, neuromuscular disease
Role of PCL in TKA
PCL retaiining PCL substituting

Roll forward positioning of Roll back of femur is

medial femoral condyle on achieved by tibial post and
polythene insert with flexion femoral cam mechanism

Low failure rate compared Higher failure rate by

PS implant wear and tear by
loosening

Symmetric gait Slightly asymmetrical gait

Joint line to be maintained Joint line can be slightly

at same level to balance elevated to matin flexionand
flexion and extension gaps extension gaps

Not seen Patellar clunk syndrome is

seen
Indication and contraindication
• TOTAL KNEE ARTHROPLASTY
• The primary indication for TKA is to relieve pain caused by severe
arthritis after trying conservative methods

• Younger patient
• OA or from o systemic arthritis with multiple joint involvement or
osteonecrosis with subchondral collapse of a femoral condyle.
Severe pain from chondrocalcinosis and pseudogout

• Deformity:- with arthritis flexibility contractor more than 20 Degree

• Contra indication are ;-
• 1. Recent or current septic arthritis
• 2. Remote source of infection , extensor mechanism discontinuity
• 3. Recurvatum deformity secondary to neuromuscular disease
• 4. Relative :- who can't withstand analgesia , immunodeficiency,
Atherosclerotic changes of operative leg , skin infection , psoriasis
recurrent UTI, BMI>40, neuropathic arthropathy,
Indication and consideration for simultaneous
TKA
• 1simultaneous bilateral procedures can reduce hospital
• charges by 58% compared with staged procedures because of
• overall decreases in operative time and total length of hospital stay.
•
• 2. greater degree of postoperative thrombocytopenia the second day
after surgery
• and more frequent deep vein thrombosis (DVT) and pulmonary
embolism (PE)
• Pre operative workup:-

• 1. A medical history
• 2. Thorough physical examination
• 3.Laboratory workup
• 4. Pre anaesthetic workup

• Radiologically:-
• 1. Anteroposterior X ray
• 2.. Lateral X ray
• 3. Bilateral lower linmb svannogram
• Anaesthetic options;-

• 1.general versus epidural anesthesia , DVT is more associated with GA

• 2. benefits : of epidural anesthesia include vasodilation of the lower

extremity, resulting in increased blood flow, hemodilution, and
decreased blood viscosity.

• 3.A fibrinolytic effect also has been postulated for epidural anesthesia
Pain management
• 1.cox 2 inhibitor
• 2. Use of one nonnarcotic oral preoperative medication with either a
femoral nerve block or intraarticular injection can give excellent pain
relief.
• 3.postoperative pain control after primary TKA using 20 mL of
liposomal bupivacaine with 20 mL of 0.5% plain bupivacaine and 80
mL of normal saline in a targeted infiltration technique With
dexamethasone and ketolrolac
• 4.Cryoneurolysis of the anterior femoral cutaneous and infrapatellar
branch of the saphenous nerve before TKA surgery
BLOOD PRESERVATION MANAGEMENT
IN PARTIAL AND TOTAL KNEE
ARTHROPLASTY
• For intravenous tranexemic acid inj administration, the dose should
be 10 to 15 mg/kg or 1 g, with consideration of a preoperative dose
given 20 minutes before tourniquet inflation and a repeat dose given
about 15 minutes before tourniquet deflation.
• For topically administered dosing, 1.5 to 3 g diluted in 100 mL normal
saline should be placed in the wound and intracapsular space for 5
minutes before tourniquet deflation.
Pre operative radiological evalution
TEMPLATING TKA
• Approaches –
• “Simple” primary knee arthroplasty approaches –
• Medial Parapatellar
• Lateral Parapatellar
• Midvastus
• Subvastus
• Minimally Invasive
Medial parapatellar approach
• Most commonly done through straight midline incision
• Advantages –
• Most familiar approach
• Excellent exposure
• Disadvantages –
• Possible failure of medial capsular repair
• Development of lateral patellar subluxation
• May jeopardize patellar circulation if lateral release is
• perforned
Medial capsule and deep portion of medial Lateral patellofemoral plicae are cut to allow
collateral ligament are elevated subperiosteally mobilization of extensor mechanism
Lateral parapatellar approach
• Useful for lateral contractures
• Advantages –
• Useful for fixed valgus deformity
• Preserves blood supply to patella
• Prevents lateral patellar subluxation
• Allows direct access to lateral side in valgus knee
• Disadvantages –
• Medial eversion of patella difficult (Exposure is
challenging)
Subvastus approach

• Muscle belly of vastus medialis is lifted off intermuscular septum

• Advantages –
• Patellar Vascularity preserved
• Extensor mechanism remains intact
• Minimal need for retinacular release
• Disadvantages –
• Least extensile
• Relative C/I-
• Revision TKA
• Large Quadriceps
• Previous HTO
• Obese patient
Subvastus approach involves lifting entire extensor mechanism off
medial intermuscular septum and subluxing it laterally for exposure.
C, Tine retractor placed overtop of femur and secured on lateral
surface places vastus medialis under tension while muscle
attachment to intermuscular septum is sharply detached with
scissors. D, Complete release ofquadriceps to medial intermuscular
septum. Exposure obtained after full eversion of patella
 Midvastus approach

• Similar to medial parapatellar approach that spares VMO insertion

• Advantages –
• Vastus medialis insertion on quadriceps tendon is not disrupted
• Accelerated rehab
• Patellar tracking improved
• Disadvantages –
• Less extensile
• Potential for partial VMO denervation
• Exposure difficult with flexion contractures
• Relative C/I -
• ROM <80 degrees
• Obesity, Hypertrophic arthritis
• Previous HTO
Midvastus approach shown as green dashed line with right knee in 90 degrees
flexion.
Alignements in TKA
• Anatomical alignment
• Mechanical alignment – measured resection,gap balancing
• kinematic alignement
Anatomical alignment
Femoral cut 8 to 9 degree valgus
Tibial cut 2 to 3 degree varus
Mechanical alignment

1.Insall – femoral and tibial cut perpendicular to the mechanical axis

2. Insall – 1 the knee joint aligned through the anatomical alignment may be loaded more
medially with a meadial tibial plateau fixation failure

3. Cuts perpendicular to mechanical axis

A, measured resection – bony landmarks ( preserve joint line)

B, gap balancing – ligament tension
C, combined / modern
Distal femoral cuts
• Entry : starting point for femoral IM rod insertion is made 8-10mm
anterior to origin of PCL, and slightly medial to the mid portion of
intercondylar notch
• The correct thickness of distal femoral cut just skims the roof of
intercondylar notch
Intramedullary guide
• Aim is DFC to be perpendicular to mechanical axis
• Varus knee : 5 to 7 degree valgus cut
• Valgus knee: 0 to 3 degree valgus cut
• Distal femoral cuts correlates with thicknessof
metallic femoral component provides-
- varus/valgus alignment
- Flexion/ extension
- Proximal/distal position
Distal femoral cuts in frontal and saggital
view
Severe FFD
• In general , for each 10,degree of flexion contracture additional 2 mm
resection
Femur sizing
• Posterior referencing
• Anterior referencing
Placing of the 4 in 1 cutting block
aim is that prosthesis must be in externalrotation
• Transepicondylar axis: lateral to medial epicondyle , apex of the medial
prominence – anatomical TEA, medial sulcus – surgical TEA

• Posterior condylar axis : in 3 to 5 degree of IR/ valgus

• Anteroposterior axis ( Whistesides line):

-line connecting the lowest point of patellar groove and top of
intercondylar notch
- Femoral component rotation is oriented perpendicular to it
Confirmation of external rotaion
grand piano sign
4 in 1 block
• Anterior and posterior femur cuts – determine rotation , femoral
component position
• Anterior and posterior chamfer cuts – for accommodation of
prostheis
Box cutting
Ranawat monouvre

- Subperiosteal elevation of deep MCL

- Hyperflexion of knee
- External rotaion of leg
- Delivering tibia forward
Proximal tibial cut
• Tibial cut must be must be made perpendicular
to the mechanical axisof tibia
• Methods : intramedullary / extramedullary
alignment guide
• Extramedullary :
landmarks :
proximally: anterior to origin of PCL, medial 1/3rd
of tibial tuberosity
Distal: centre of ankle , 2nd MT, EHL
Frontal and saggital view
Posteror tibial slope
• Range : b/w 0 to 7 degree
• Indian population: 11.54 degree +/-4.5 exceptions : ,alunited IA
fracture, HTO
Tibial preparation and sizing
- Anteromedial border if not involved disease process
- Alignment
- Akagi line
 COMPLICATIONS
THROMBOEMBOLISM

1. Factors that have been correlated with an increased risk

of DVT include age older than 40 years, estrogen use, stroke,
nephrotic syndrome, cancer, prolonged immobility, previous
thromboembolism, congestive heart failure, indwelling
femoral vein catheter, inflammatory bowel disease, obesity,
varicose veins, smoking, hypertension, diabetes mellitus, and
myocardial infarction.
Prophylaxis: enoxheparin 30 mcg s/c twice daily for 10 days Or
RRB 10 mg OD for 10 days

2. Venography is the classic radiographic method of detection of

DVT and is still considered the gold standard
3. Venography carries the risk of anaphylactic reaction to the contrast
media and a small risk of inducing DVT. Duplex ultrasound has been
reported as an alternative method of diagnosis of DVT after total joint
arthroplasty
4. Many methods of DVT prophylaxis are available, including mechanical
devices such as compression stockings or foot pumps and
pharmaceutical agents such as low-dose warfarin, low-molecular-weight
heparin (LMWH), factor Xa inhibitor,and low- and high-dose aspirin
infection
1. The use of filtered vertical laminar flow operating rooms,
body exhaust suits, and prophylactic antibiotics has greatly
reduced postoperative infection rates in total joint arthroplasty.

2. the most common organisms causing postoperative

infection are Staphylococcus aureus, Staphylococcus
epidermidis, and Streptococcus species, the usual choice of
prophylactic antibiotic is a first-generation cephalosporin,
• Radio graphic changes of infection : bone resorption at bone cement
interface, cyst formation, occasional periosteal new bone formation ,
Several points have been recommended that could lead to
higher success rates for debridement:
1. Infectious disease consultation and antibiotic monitoring
2. Diagnosis and treatment of hematogenous sources of
infection
3. Newer antibiotics
4. Six-week duration of postoperative intravenous
antibiotics
5. Repeat cultures within 2 weeks of the initial debridement
and repeat debridement if these cultures were positive
6. Polyethylene exchange at the time of debridement;
exchange of gown, gloves, and instruments; and redraping
at the time of wound closure
Resection arthroplasty consists of removal of the infected
prosthesis and cement and debridement of the synovium
Antibiotic-impregnated polymethyl methacrylate
spacers are useful to maintain joint space and ligamentous
relationships, as well as motion of knee, during interval between
debridement and reimplantation.

Antibiotic-impregnated PMMA spacers

the effectiveness of antibiotic-containing
cement spacers have included mixing 3.6 g of tobramycin
with 3 g of vancomycin per pack of Palacos cement (Zimmer,
Warsaw, IN) to improve elution rates

Knee arthrodesis with intramedullary nail fixation

after failed total knee arthroplasty
Patellofemoral complication
• Patellofemoral complications include patellofemoral
instability,patellar fracture, patellar component failure,
patellarcomponent loosening, patellar clunk syndrome, and
extensormechanism rupture
• Nagarathnamma
• 54 years female
• RH01001352

• Diagnosis: b/l oa knee right > left

• Plan: right TKR, left UKR
• Faizuddin khan
• 60 years male
• RH00977210
• Diagnosis: b/l oa knee

• Staged b/l tkr