Knee Osteoarthritis

Authors: Evan Watts, Mark Karadsheh

Topic updated on 02/29/16 10:53pm

Introduction
Definition
o degenerative disease of synovial joints that causes progressive
loss of articular cartilage
Epidemiology
o incidence
hip OA (symptomatic)
88 per 100,000 per year
knee OA (symptomatic)
240 per 100,000 per year
Risk factors
o modifiable
articular trauma
occupation, repetitive knee bending
muscle weakness
large body mass
metabolic syndrome
central (abdominal) obesity, dyslipidemia (high
triglycerides and low-density lipoproteins), high
blood pressure, and elevated fasting glucose
levels.
o non-modifiable

 gender
females >males
increased age
genetics
race
African American males are the least likely to
receive total joint replacement when compared to
whites and Hispanics
Pathophysiology
o pathoanatomy
articular cartilage
increased water content
alterations in proteoglycans
eventual decrease in amount of
proteoglycans
collagen abnormalities
organization and orientation are lost
binding of proteoglycans to hyaluronic acid
synovium and capsule
early phase of OA
mild inflammatory changes in synovium
middle phase of OA
moderate inflammatory changes of synovium

 synovium becomes hypervascular

late phases of OA
synovium becomes increasingly thick and
vascular
bone
subchondral bone attempts to remodel
forming lytic lesion with sclerotic edges
(different than bone cysts in RA)
bone cysts form in late stages
Cell biology
o proteolytic enzymes
matrix metalloproteases (MMPs)
responsible for cartilage matrix digestion
examples
stromelysin
plasmin
aggrecanase-1 (ADAMTS-4)
tissue inhibitors of MMPS (TIMPs)
control MMP activity preventing excessive
degradation
imbalance between MMPs and TIMPs has been
demonstrated in OA tissues
inflammatory cytokines
secreted by synoviocytes and increase MMP

synthesis
examples
IL-1
IL-6
TNF-alpha
Genetics
o inheritance
non-mendilian
o genes potentially linked to OA
vitamin D receptor
estrogen receptor 1
inflammatory cytokines
IL-1
leads to catabolic effect
IL-4
matrilin-3
BMP-2, BMP-5
Presentation
History
o identify age, functional activity, pattern of arthritic involvement,
overall health and duration of symptoms
Symptoms

o function-limiting knee pain

effect on walking distances
o pain at night or rest
o activity induced swelling
o knee stiffness
o mechanical
instability, locking, catching sensation
Physical exam
o inspection
body habitus
gait
often an increased adductor moment to the limb
during gait
limb alignment
effusion
skin (e.g. scars)
o range of motion
lack of full extension (>5 degrees flexion contracture)
lack of full flexion (flexion <110 degrees)
o ligament integrity
Imaging
Radiographs

o recommended views
weight-bearing views of affected joint
o optional views
knee
sunrise view
PA view in 30 degrees of flexion
o findings
pattern of arthritic involvement
medial and/or lateral tibiofemoral, and/or
patellofemoral
characteristics
joint space narrowing
osteophytes
eburnation of bone
subchondral sclerosis
subchondral cysts
Studies

Histology
o loss of superficial chondrocytes
o replication and breakdown of the tidemark
o fissuring
o cartilage destruction with eburnation of subchondral bone

Treatment

Nonoperative
o non-steroidal anti-inflammatory drugs
indications
first line treatment for all patients with symptomatic
arthritis
technique
Non-steroidal anti-inflammatory drugs (first choice)
selection should be based on physician
preference, patient acceptability and cost
duration of treatment based on effectiveness,
side-effects and past medical history
outcomes
AAOS guidelines: strong evidence for
o rehabilitation, education and wellness activity
indications
first line treatment for all patients with symptomatic
arthritis
technique
self-management and education programs
combination of supervised exercises and home program
have shown the best results
these benefits lost after 6 months if exercises are
stopped
outcomes
AAOS guidelines strong evidence for

o weight loss programs

indications
patients with symptomatic arthritis and BMI > 25
technique
diet and low-impact aerobic exercise
outcomes
AAOS guidelines: moderate evidence for
o controversial treatments
acupuncture
AAOS guidelines: strong evidence against
viscoelastic joint injections
AAOS guidelines: strong evidence against
glucosamine and chondroitin
AAOS guidelines: strong evidence against
needle lavage
AAOS guidelines: moderate evidence againnst
lateral wedge insoles
AAOS guidelines: moderate evidence against

Operative
o high-tibial osteotomy
indications
younger patients with medial unicompartmental OA

 technique
valgus producing proximal tibial oseotomy
outcomes
AAOS guidelines: limited evidence for
o unicompartmental arthroplasty (knee)
indications
isolated unicompartmental disease
outcomes
TKA have lower revision rates than UKA in the setting
of unicompartmental OA
o total knee arthroplasty
indications
symptomatic knee osteoarthritis
failed non-operative treatments
techniques
cruciate retaining vs. crucitate sacrificing implants show
no difference in outcomes
patellar resurfacing
no difference in pain or function with or without
patella resurfacing
lower reoperation rates with resurfacing
drains are not recommended

TKA Prosthesis Design

Author: Mark Karadsheh

Topic updated on 02/03/16 9:21pm

Introduction

Designs include
o unconstrained
posterior-cruciate retaining (CR)
posterior-cruciate substituting (PS)
o constrained
nonhinged
hinged
o fixed versus mobile bearing

History

19th century
o interposition of soft tissues for reconstruction of articular surfaces
1950s
o Walldius designs first hinged knee replacement
1958
o MacIntosh and McKeever introduce acrylic tibial plateau prosthesis
to correct deformity

 1960s
o Gunston introduces first cemented surface arthroplasty of knee
joint
1970
o Guepar develops a new hinged prosthesis based on design by
Walldius that increases motion and decreases bone loss
~1973
o "total condylar prosthesis" is introduced which is first to resurface all
three compartments (PCL sacrificing)
Concepts in Prosthetic Design

Femoral rollback
o definition

the posterior translation the femur with progressive flexion

o importance

improves quadriceps function and range of knee flexion by preventing

posterior impingement during deep flexion

o biomechanics

rollback in the native knee is controlled by the ACL and PCL

o design implications

both PCL retaining and PCL substituting designs allow for femoral
rollback

PCL retaining

native PCL promotes posterior displacement of femoral

condyles similar to a native knee

PCL substituting

tibial post contacts the femoral cam causing posterior

displacement of the femur

Constraint
o definition

the ability of a prosthesis to provide varus-valgus and flexionextension stability in the face of ligamentous laxity or bone loss

o importance

in the setting of ligamentous laxity or severe bone loss, standard

cruciate-retaining or posterior-stabilized implants may not provide
stability

o design implications

in order of least constrained to most constrained

cruciate-retaining

posterior-stabilized (cruciate-substituting)

varus-valgus constrained (non-hinged)

rotating-hinge

Modularity
o definition

the ability to augment a standard prosthesis to balance soft tissues

and/or restore bone loss

o options include

metal tibial baseplate with modular polyethylene insert

more expensive than all-polyethylene tibial component

has an equivalent rate of aseptic loosening compared with allpolyethylene tibia component

metal augmentation for bone loss

modular femoral and tibial stems

o advantages

ability to customize implant intraoperatively

o disadvantages

increased rates of osteolysis in modular components

backside polyethylene wear

micromotion between tibial baseplate and undersurface of

polyethylene insert that occurs during loading

Cruciate-Retaining (CR) Design

Design

o minimally constrained prosthesis that depends on an intact PCL to provide

stability in flexion

Indications
o arthritis with minimal bone loss, minimal soft tissue laxity, and an intact PCL
o varus deformity < 10 degrees
o valgus deformity < 15 degrees

Radiographs
o radiographs won't show box in the central portion of the femoral component
as PS knees have (see PS knee radiographs)

Advantages
o avoids tibial post-cam impingement/dislocation that may occur in PS knees
o more closely resembles normal knee kinematics (controversial)
o less distal femur needs to be cut than in a PS knee
o improved proprioception with preservation of native PCL

Disadvantages
o tight PCL may cause accelerated polyethylene wear
o loose or ruptured PCL may lead to flexion instability and subluxation

Posterior Stabilized (PS) Design

Design
o slightly more constrained prosthesis that requires sacrifice of PCL
o femoral component contains a cam that engages the tibial polyethylene post
during flexion
o polyethylene inserts are more congruent, or deeply "dished"

Indications
o previous patellectomy

reduces risk of potential anteroposterior instability in setting of a weak

extensor mechanism

o inflammatory arthritis

inflammatory arthritis may lead to late PCL rupture

o deficient or absent PCL

Radiographs
o lateral radiograph will show the outline of the cam, or box, in the femoral
component

Advantages
o easier to balance a knee with absent PCL
o arguably more range of motion
o easier surgical exposure

Disadvantages
o cam jump

mechanism

with loose flexion gap, or in hyperextension, the cam can rotate

over the post and dislocate

treatment

initial

closed reduction by performing an anterior drawer

maneuver

final

revision to address loose flexion gap

o tibial post polyethylene wear

o patellar "clunk" syndrome

mechanism

scar tissue gets caught in box as knee moves into extension

treatment

arthroscopic versus open resection of scar tissue

o additional bone is cut from distal femur to balance extension gap

Constrained Nonhinged Design

Design

o constrained prosthesis without axle connecting tibial and femoral components

(nonhinged)
o large tibial post and deep femoral box provide

varus/valgus stability

rotational stability

Indications
o LCL attenuation or deficiency
o MCL attenuation or deficiency

o flexion gap laxity

o moderate bone loss in the setting of neuropathic arthropathy

Radiographs
o

Advantages
o prosthesis allows stability in the face of soft tissue (ligamentous) or bony
deficiency

Disadvantages
o more femoral bone resection

necessary to accommodate large box

o aseptic loosening

as a result of increased constraint

Constrained Hinged Design

Design
o most constrained prosthesis with linked femoral and tibial components

(hinged)
o tibial bearing rotates around a yoke on the tibial platform (rotating hinge)

decreases overall level of constraint

Indications
o global ligamentous deficiency
o hyperextension instability

seen in polio or tumor resections

o resection for tumor

o massive bone loss in the setting of a neuropathic joint

Radiographs
o

Advantages
o prosthesis allows stability in the face of soft tissue (ligamentous) or bony
deficiency

Disadvantages
o aseptic loosening

as a result of increased constraint

large amount of bone resection required

Mobile Bearing Design

Design
o minimally constrained prosthesis where the polyethylene can rotate on the
tibial baseplate
o PCL is removed at time of surgery

Indications

o young, active patients (relative indication)

Advantages
o theoretically reduces polyethylene wear

increased contact area reduces pressures placed on polyethylene

(pressure=force/area)

Disadvantages
o bearing spin-out

mechanism

occurs as a result of a loose flexion gap

tibia rotates behind femur

treatment

initial

closed reduction

final

revision to address loose flexion gap

TKA Approaches
Author: Mark Karadsheh
Topic updated on 02/11/15 10:51pm
Introduction

Surgical approach may be dictated by

o surgeon preference
o prior incisions
o degree of deformity
o patella baja
o patient obesity

Incision planning
o if multiple incision, choose more lateral

blood supply comes from medial side

o generally safe to cross previous transverse incisions at right angles

o ensure adequate skin bridge

exact length of skin bridge needed is controversial

Approaches
o "simple" primary knee arthroplasty approaches

medial parapatellar

midvastus

subvastus

minimally invasive

o "complex" primary or revision total knee arthroplasty

medial parapatellar

quadriceps snip

V-Y turndown

tibial tubercle osteotomy

Standard Medial Parapatellar Approach

Overview
o most commonly completed through a straight midline incision

Advantages
o familiar for most orthopaedic surgeons
o excellent exposure even in challenging cases

Disadvantages
o possible failure of medial capsular repair
o development of lateral patellar subluxation
o access to lateral retinaculum less direct
o may jeopardize patellar circulation if lateral release is performed

Lateral Parapatellar Approach

Overview
o useful for addressing lateral contractures but difficult eversion of
patella makes exposure challenging

Advantages

o useful for a fixed valgus deformity

o preserves blood supply to patella
o prevents lateral patellar subluxation
o allows direct access to lateral side in a valgus knee

Disadvantages
o technically demanding

medial eversion of patella is more difficult

o may require tibial tubercle osteotomy

Midvastus

Overview
o similar approach to medial parapatellar that spares VMO insertion
and may lead to quicker recovery

Advantages
o vastus medialis insertion on quad tendon is not disrupted
o potentially allows accelerated rehab due to avoiding disruption of

extensor mechanism
o patellar tracking may be improved compared to medial parapatellar

approach

Disadvantages
o less extensile
o exposure difficult in obese patients
o exposure difficult with flexion contractures

Relative contraindications
o ROM <80 degrees

o obese patient
o hypertrophic arthritis
o previous HTO
Subvastus Approach

Overview
o muscle belly of vastus medialis is lifted off intermuscular septum

Advantages
o patellar vascularity preserved
o extensor mechanism remains intact
o minimal need for lateral retinacular release

Disadvantages
o least extensile
o potential for denervation of VMO

Relative contraindications
o revision TKA
o large quadriceps
o previous HTO
o obese patient
o previous parapatellar arthrotomy

Minimally Invasive Surgical Approach

Overview
o often need special instruments for exposure and implant insertion

o technically demanding

Outcomes
o short term data suggests more rapid recovery
o long term data needed to compare outcomes to traditional exposures

Indications to convert to a standard parapatellar approach

o patellar tendon starts to peel off the tibial tubercle
o incision is too small for proper jig placement

Extensile Exposures

Quadriceps snip
o technique

snip made at apex of quadriceps tendon obliquely across tendon at a

45-degree angle into vastus lateralis

o advantages

no change in post-operative protocol

minimal, if any, long-term consequences

o disadvantages

not as extensile as a turndown or tibial tubercle osteotomy

V-Y turndown
o technique

straight medial parapatellar arthrotomy with diverging incision down

the vastus lateralis tendon towards lateral retinaculum

o advantages

allows excellent exposure

allows lengthening of quadriceps tendon

preserves patellar tendon and tibial tubercle

o disadvantages

extensor lag

may affect quadriceps strength

knee needs to be immobilized post-operatively

Tibial tubercle osteotomy

o technique

6-10 cm bone fragment cut from medial to lateral

fixed with screws or wires

o advantages

excellent exposure

avoids extensor lag seen with V-Y turndown

avoids quadriceps weakness

o disadvantages

some surgeons immobilize or limit weight-bearing post-operatively

tibial tubercle avulsion fracture

non-union

wound healing problems

Bilateral Total Knee Arthroplasty

Definitions
o simultaneous

two surgeons performing the bilateral TKA at the same time

o sequential

one surgeon performing one TKA and then the contralateral TKA under one
anesthetic

o staged

one surgeon performing each TKA under a separate anesthetic

timing ranges from 3 days to one year in between each side

Other

Antibiotic loaded bone cement

o routine use in all TKA increases the risk of aseptic loosening
o reduces deep infection in revision TKA
o indications for use in primary TKA are controversial

tKA Axial Alignment

Author: Derek Moore
Topic updated on 07/10/15 6:24pm

Introduction


Important consideration
o pre-op planning
o component insertion
o ligament balancing
o prosthetic design selection
Normal anatomy
o distal femur in 5-7 degrees of valgus
o proximal tibia is 2-3 degrees of varus
Technical goals
o restore mechanical alignment (mechanical alignment of 0)
o restore joint line ( allows proper function of preserved

ligaments. e.g., pcl)

o balanced ligaments (correct flexion and extension gaps)
o maintain normal Q angle (ensures proper patellar femoral
tacking)
Mechanical axis of Limb
o axis from center of femoral head to center of ankle
Preoperative Evaluation

Radiographs
o standing AP and lateral of knee
to evaluate for
joint space narrowing
collateral ligament insufficiency (look for lateral
gapping)
subluxation of femur on tibia
bone defects
o standing full-length radiographs (AP and Lateral)
are indicated to determine an accurate valgus cut angle when
the patient has
femoral or tibial deformity
very tall or short stature
o extension and flexion laterals
o sunrise view
Femoral Alignment
Anatomic axis femur (AAF)

o a line that bisects the medullary canal of the femur

o determines entry point of femoral medullary guide rod
o intramedullary femoral guide goes down anatomic axis of the
femur
Mechanical axis femur
o defined by line connecting center of femoral head to point
where anatomic axis meets intercondylar notch
o obtaining a neutral mechanical axis allows even load sharing
between the medial and lateral condyles of a knee prosthesis
Valgus cut angle (~5-7 from AAF )
o difference between AAF and MAF
o perpendicular to mechanical axis
o jig measures 6 degrees from femoral guide (anatomic axis)
o will vary if people are very tall (VCA < 5) or very short (VCA >
7)
o can measure on a standing full length AP x-ray
Tibial alignment
Anatomic axis of tibia (AAT)
o a line that bisects medullary canal
o tibia medullary guide (internal or external) runs parallel to it
o determines entry point for tibial medullary guide rod
Mechanical axis of tibia
o line from center of proximal tibia to center of ankle

o proximal tibia is cut perpendicular to mechanical axis of tibia

o usually mechanical axis and anatomic axis of tibia are
coincident and therefore you can usually can cut the proximal
tibia perpendicular to anatomic axis (an axis determined by
an intramedullary jig)
o if there is a tibia deformity and the mechanical and anatomic
axis are not the same, then the proximal tibia must be cut
perpendicular to the mechanical axis (therefore
an extramedullary tibial guide must be used)
Patellofemoral Alignment
Q angle
o Abnormal patellar tracking, although not the most serious, is
the most common complication of TKA.
o The most important variable in proper patellar tracking is
preservation of a normal Q angle (11 +/- 7)
the Q angle is defined as angle between axis of extensor
mechanism (ASIS to center of patella) and axis of
patellar tendon(center of patella to tibial tuberosity)
o Any increase in the Q angle will lead to increased lateral
subluxation forces on the patella relative to the trochlear
groove, which can lead to pain and mechanical symptoms,
accelerated wear, and even dislocation.
It is critical to avoid techniques that lead to an increased
Q angle. Common errors include:
internal rotation of the femoral prosthesis
medialization of the femoral component
internal rotation of the tibial prosthesis
placing the patellar prosthesis lateral on the patella

o Q angle management in TKA

Joint Line Preservation

Goal is to restore the joint line by inserting a prosthesis that is the
same thickness as the bone and cartilage that was removed
o this preserves appropriate ligament tension
o if there are bone defects they must be addressed so the joint
line is not jeopardized
o elevating the joint line (> 8mm leads to motion problems) and
can lead to
mid-flexion instability
patellofemoral tracking problems
an "equivalent" to patella baja
never elevate joint line in a valgus knee until after
balancing to obtain full extension
o lowering joint line can lead to
lack of full extension
flexion instability

TKA Coronal Plane Balancing

Author: Chad Krueger
Topic updated on 03/26/16 12:28pm

Introduction
Definition
o both medial and lateral ligaments may be stretched or
contracted with time

 it is essential to balance these ligament in both the

coronal and sagital plane to obtain an optimum outcome
Pathophysiology
o concave side
tight ligaments that need release
o convex side
stretched ligaments that need tightening
o must test balancing in both flexion and extension
Varus Deformity
Anatomy
o lateral side stretched (convex), medial side tight (concave)

Goal is to create symmetrical bone cuts, and then release the tight
medial ligaments and tighten the lax lateral ligaments to balance
flexion and extension gaps

Medial releases (usually osteophytes and deep MCL is adequate)

o In order
1) osteophytes, meniscus and its capsular attachments
2) deep MCL and capsule (usually osteophytes and deep
MCL is sufficient release)
3) posteromedial corner
semimembranosus and capsule
4) superficial MCL
can find as it blends into pes anserine complex
cannot completely release or will have valgus

instability (requires constrained prosthesis).

Therefore perform subperiosteal elevation only
differential release: performed with two
components of superficial MCL
posterior oblique portion is tight in extension
(release if tight in extension)
anterior portion is tight in flexion (release if
tight in flexion)
5) PCL
release is rarely indicated

Lateral tightening
o use a prosthesis that is sized to "fill up" the gap and make the
stretched lateral ligaments taut

Valgus Deformity (medial is convex side of deformity)

Anatomy
o lateral side tight (concave), medial side stretched (convex)
Goal is is to create symmetrical bone cuts, and then to release the
tight lateral ligaments and tighten the lax medial ligaments to balance
flexion and extension gaps
Lateral release in order
o 1) osteophytes
o 2) lateral capsule
o 3) iliotibial band if tight in extension (release if tight in
extension)
with Z-plasty or release off Gerdy's tubercle
o 4) popliteus if tight in flexion (release if tight in flexion)

 release the anterior part of its insertion

for severe deformities release both the iliotibial band and
the popliteus
o 5) LCL
some authors prefer to release this structure first if tight
in both flexion and extension
other authors prefer to release the LCL last
if released, consider using a constrained
prosthesis
o differential release: performed by differentially release the IT
band and popliteus
Medial tightening
o fill up medial side until medial ligament complex is taut
Flexion / Contracture Deformity
Anatomy
o concave side is posterior- needs to be released
Posterior release order
o 1) osteophytes
o 2) posterior capsule
o 3) gastronemius muscles (medial and lateral)
1. All releases are performed with knee at 90 degrees of flexion
o allows the popliteal artery to fall posteriorly to decrease risk of
injury
o You do not want to address a contracture by removing more
tibia

o will change the joint line and lead to patella alta

Complications

Peroneal nerve palsy

o correction of valgus and flexion contracture deformity has highest
risk of peroneal nerve palsy
o if patient presents with a peroneal palsy in recovery room then

then take of dressing and flex the knee

watch for three months to see if function returns

if function does not return, consider nerve conduction studies

or operative exploration to access for damage

TKA Sagittal Plane Balancing

Author: Derek Moore
Topic updated on 05/14/16 3:01pm

Introduction

Goal is to obtain a gap that is equal in flexion and extension. This will
ensure that the tibial insert is stable throughout the arc of motion.
o balancing is complex due to two radii of curvatures
(patellofemoral articulation and tibiofemoral articulation)
o often requires soft tissue release and bony resection to obtain
balance

 General Rules
o adjust femur if asymmetric
distal femur cut affects extension gap
posterior femur cut affects flexion gap
o adjust tibia if problem is symmetric (same in both flexion and
extension)
tibia cut affects both flexion and extension gap
o remember increasing/decreasing the size of the femoral
component only changes the AP diameter and does not affect
the height of the prosthesis.
Evaluation & Treatment

The following chart shows different conditions found with the trials in place and the
treatment strategy for each condition.
Tight in Flexion
(can not fully flex)
Tight in Extension,
Tight in Flexion

Tight in
Extension
(can not fully
extend)

Balanced in
Flexion

Tight in Extension,
Balanced in Flexion
Problem:
Problem:
Did not cut enough
Did not cut enough distal femur or did not
tibia
release enough
Solution:
posterior capsule
Cut more proximal
Solution:
tibia
1) Release posterior
capsule
2) Cut more distal
femur

Balanced in
Balanced
in Extension, Tight in
Flexion
Extension
Problem:
Did not cut enough

Loose in Flexion
(large drawer test)
Tight in Extension,
Loose in Flexion
Problem:
Distal femur too long.
Solution:
1) Resect more distal
femur or use thinner
distal femoral
augmentation wedge
(revision scenario)
2) Upsize femoral
component

Balanced in
Balanced in Extension,
extension, Balanced
Loose in Flexion
in Flexion (Perfect)

Problem:

posterior femur, PCL

scarred and too tight.
Solution:
1) Decrease size of
femoral component
2) Recess & release
PCL
3) Resect posterior
slope in tibia
4) Resect more
posterior femoral
condyle
5) Release posterior
capsule

Cut too much posterior

femur.
Solution:
1) Increase size of
femoral component
(AP only)
2) Posteriorize femoral
component (augment
posterior femur).

Loose in Extension,
Tight in Flexion

Loose in Extension,
Loose in Extension,
Balanced in Flexion
Loose in Flexion
Problem:
Problem:
Loose in
Solution:
Cut too much distal Cut too much tibia.
Extension 1) Downsize femur
femur.
Solution:
(recurvatum) and use thicker tibial
Solution:
1) Use thicker tibia PE
insert until balanced.
1) Augment distal
2) Use thicker tibial
femur
metal insert

TKA in Patella Baja (Infera)

Author: Tracy Jones
Topic updated on 07/11/15 10:07pm

Introduction
Patella baja is characterized by lowering of the patella relative to its
normal position
o may be congenital or acquired (this topic)
Pathophysiology of acquired patella baja
o common causes include
proximal tibial osteotomy
patella baja is the most common complication seen

following proximal tibial opening-wedge osteotomy

may be caused by shortening of the patellar
tendon during tibial osteotomy or from scarring of
the patellar tendon post-operatively
tibial tubercle slide or transfer
trauma to the proximal tibia
technical error during primary total knee replacement
Associated conditions
o

total knee arthroplasty

patella infera is an important consideration when
performing total knee arthroplasty
improper technique may cause patella baja
special techniques must be utilized when
performing TKA in patients with patella baja from
congenital or acquired (tibial osteotomy, prior TKA)
causes

Presentation
Symptoms
o anterior impingement knee pain
o knee stiffness
Physical exam
o mechanical block to full flexion

Imaging

limited flexion due to patellar impingement on the tibia in

extremes of flexion

Radiographs
o recommended views

AP and lateral views of the knee

lateral view of the knee in 30 degrees of flexion

used to measure Insall-Salvati ratio

measures ratio patellar tendon length to patellar bone

length

normal Insall-Salvati is 1:1 between length of

the patellar tendon length to patellar bone length

o findings

lateral view in extension

distal positioning of the patella in relation to the trochlear

groove

Insall-Salvati ratio of < 0.8 is consistent with patella baja

Treatment

Nonoperative
o activity modifications, physical therapy

indications

mild symptoms in younger patients

Operative
o total knee replacement

indications

severe impingement in older patients with osteoarthritis

Techniques

Total knee arthroplasty in patient with patella baja

o methods to address patella infera during TKA

place patellar component superiorly
indications
mild patella baja
technique
use a smaller patellar dome placed on superior
aspect of patella
trim inferior bone to decrease flexion
impingement

lower joint line

indications
moderate patella baja
technique
add distal femoral augmentation
cut more proximal tibia to lower joint line (lower
tibial cut)
avoid bone cuts that raise the joint line
raising the joint line will effectively
increase the patella baja deformity
may require revision knee system

transfer tibial tubercle to cephalad position

indications
moderate patella baja

 technique
technique is difficult due to complexity of a tibial
transfer in proximity to a cemented tibial
component
outcomes
unpredictable bone healing leads to variable, and
often poor, outcomes
patients may be left with extensor lag
patellectomy
indications
severe patella baja
techniques
alters the tension in the anterior knee mechanism
therefore must use a cruciate substituting
system

TKA Rehabilitation
Author: Mark Karadsheh
Topic updated on 10/11/14 11:57am
Introduction

Rehabilitation requires coordinated effort from

o orthopaedic surgeon
o physical therapist
o occupational therapist

o case manager
o nursing staff
o patient and patient's family
Care can be broken down into different phases including
o inpatient acute care (hospital)
o inpatient extended care (rehab/SNF)
o outpatient home care
Inpatient Acute Care (Hospital)
Pain management
o preoperative
NSAIDS and opioids given immediately before procedure
reduce postoperative pain
o intraoperative
regional anesthesia (spinal and/or epidural)
preferred over general anesthesia
peripheral nerve blocks
useful adjuvant to decrease postoperative pain
periarticular multimodal drug injection
decrease postoperative pain with minimal risks
o postoperative
multimodal oral drug therapy
gold standard

 Range of motion
o requirements
swing phase of gait
65 degrees of flexion
activities of daily living
90 degrees of flexion
rise from a chair
105 degrees of flexion
o continuous passive motion (CPM) machine
may improve early knee flexion
has not been shown to have a long-term benefit
Discharge home criteria
o medically stable
o 80-90 degrees AROM knee flexion
o ambulate 75-100 feet
o ascend or descend stairs
Inpatient Extended Care (Rehab)

Earlier discharge to rehab from hospital associated with improved outcomes

Discharge criteria to home similar to those in hospital

Outpatient Care

Physical therapy
o 2-3x per week for at least 2 weeks

o focused on closed-chain concentric exercises

o gradually advance from crutches to cane to unassisted

Return to activities
o low-impact closed chain exercises preferred

eliptical

biking

golf

handicap will show rise after TKA (stays same with THA)

o impact activities may decrease longevity of implant

running is discouraged

Driving recommendations
o 4 weeks after a right total knee
o less than 4 weeks after a left total knee

Unicompartmental Knee Replacement

Author: Daniel Hatch
Topic updated on 03/12/16 8:19pm

Introduction

Surgical option for knee arthritis when only one compartment

of the knee is involved

Epidemiology
o 5% of surgeries where knee arthroplasty is indicated are
unicompartmental knee replacements
o location

 medial compartment is most common

Types of implants
o fixed-bearing
historical standard of care
o mobile-bearing
pros
weightbearing through the meniscus increases
conformity and contact without increasing
constraint
decrease in wear pattern
excellent survivorship out to the second decade
cons
technically demanding
bearings can dislocate
Advantages
o compared to TKA
faster rehabilitation and quicker recovery
less blood loss
less morbidity
less expensive
preservation of normal kinematics
theory is that retaining ACL, PCL and other
compartments leads to more normal knee
kinematics

 smaller incision
less post-operative pain leading to shorter hospital
stays
o compared to osteotomy
faster rehabilitation and quicker recovery
improved cosmesis
higher initial success rate
fewer short-term complications
lasts longer
easier to convert to a TKA
Indications

Indications
o controversial and vary widely
o as an alternative to total knee arthroplasty or osteotomy for unicompartmental
disease
o classicaly reserved for older (>60), lower-demand, and thin (<82 kg) patients

6% of patient's meet the above criteria with no contraindications

o new effort to expand indications to include younger patients and patients with
more moderate arthrosis

Contraindications
o inflammatory arthritis
o ACL deficiency

absolute contraindication for mobile-bearing UKA and lateral

UKA

controversial for medial fixed-bearing

o fixed varus deformity > 10 degrees

o fixed valgus deformity >5 degrees
o restricted motion

arc of motion < 90

flexion contracture of > 5-10

o previous meniscectomy in other compartment

o tricompartmental arthritis (diffuse or global pain)
o younger high activity patients and heavy laborers
o overweight patients (> 82 kg)
o grade IV patellofemoral chondrosis (anterior knee pain)
Technique

Procedural tips
o avoid overcorrections

undercorrect the mechanical axis by 2-3 degrees

overcorrection places excess load on unresurfaced compartment

o remove osteophytes (peripheral and notch)

o resect minimal bone
o avoid extensive releases
o avoid edge loading
o prevent tibial spine impingement with proper mediolateral placement
o avoid making a varus tibial cut which increases the chance for loosening
o use caution when placing the proximal tibial guide pins to avoid stress

fractures
o correct varus deformity to 1-5 degrees of valgus
Complications

Stress fractures
o always involve tibia
o associated with high activity and patient weight
o clinically there will be a pain free interval followed by spontaneous pain with
activity
o blood commonly found on joint aspiration

Tibial component collapse

o poor mechanical properties of bone

Outcomes

Fixed-bearing
o 1st decade results

10-year survivorship from studies done in 1980s and 1990s ranges

from 87.4% to 96%

the standard faliure rate in the first decade is 1%

o 2nd decade results

rapid decline in survivorship ranging from 79% to 90%

Mobile-bearing
o excellent clinical results with 15-year survivorship reported at 93%

Long-term results
o lateral compartment arthroplasties have equivalent results to medial
o revision rates are worse than total knee revision rates

o causes of late failure

other compartment degeneration (idiopathic, over-correction, more

common with mobile-bearing)

component failure (overload due to under-correction)

component loosening (common in fixed-bearing)

patella impingement on femoral component (patella pain)

polyethylene wear

Knee Arthrodesis
Author: Ben Taylor
Topic updated on 05/25/14 7:34pm

Introduction

Indications

o painful ankylosis after infection or trauma

o neuropathic arthropathy
o tumor resection
o salvage for failed TKA (most common)
o loss of extensor mechanism
Contraindications
o absolute
active infection
o relative
bilateral knee arthrodesis

 contralateral leg amputation

significant bone loss
ipsilateral hip or ankle DJD
Optimal Position
o 5-8 valgus
o 0-10 of external rotation (match other leg)
o 0-15 of flexion
o some limb shortening advantageous for patient self-care
Surgical Technique

Intramedullary rod fixation

o technique
can be one long antegrade device or a two part device
connected at the knee
patella can be left alone or incorporated into arthrodesis
External fixation
o technique
must allow compression of arthrodesis site
done with unilateral external fixation, Ilizarov, or Taylor
Spatial Frame
Plate fixation

o technique

 can be done alone in combination with intramedullary nailing

Complications

Nonunion
Infection
Low back pain
Ipsilateral hip degenerative changes
Contralateral knee degenerative changes
Fracture
o supracondylar femur or proximal tibial metaphysis fractures
these occur from increased stress in these regions after
arthrodesis