Review Article
Preoperative Planning in Primary
Michael Tanzer, MD, FRCSC
Asim M. Makhdom, MD, MSc
From the Division of Orthopaedic
Surgery, McGill University, Montreal,
Quebec, Canada (Dr. Tanzer and
Dr. Makhdom), and the Department of
Orthopaedic Surgery, King Abdulaziz
University, Jeddah, Saudi Arabia,
(Dr. Makhdom).
Dr. Tanzer or an immediate family
member serves as a paid consultant
to Pipeline Biotechnology and
Zimmer; has received research or
institutional support from Johnson &
Johnson and Zimmer; has received
nonincome support (such as
equipment or services), commercially
derived honoraria, or other non
research-related funding (such as
paid travel) from Zimmer; and serves
as a board member, owner, officer, or
committee member of The Hip
Society. Neither Dr. Makhdom nor any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2016;24:
220-230
http://dx.doi.org/10.5435/
JAAOS-D-14-00332
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
220
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Knee Arthroplasty
Abstract
Preoperative planning is of paramount importance in primary total
knee arthroplasty. A thorough preoperative analysis helps the
surgeon envision the operation, anticipate any potential issues,
and minimize the risk of premature implant failure. Obtaining a
thorough history is critical for appropriate patient selection. The
physical examination should evaluate the integrity of the soft tissues,
the neurovascular status, range of motion, limb deformity, and the
status of the collateral ligaments to help determine the soft-tissue
balancing and constraint strategy required. Standard radiographs,
with a known magnification, should be obtained for preoperative total
knee arthroplasty templating. Routine standing AP, lateral, and
skyline radiographs of the knee can help the surgeon plan the bone
cuts and tibial slope as well as the implant size and position at the time
of surgery. In certain circumstances, such as severe coronal
deformities, bone deficiencies, and/or extra-articular deformities,
additional measures are frequently necessary to successfully
reconstruct the knee. Constrained implants, metal augments, and
bone graft must be part of the surgeons armamentarium.
P rimary total knee arthroplasty
(TKA) is an increasingly common
procedure; the number of procedures
of subsequent TKA failure and
improve the surgical outcome.4 In
addition, preoperative planning
performed in the last two decades has helps the surgeon to visualize the
increased 162%.1 It is projected that procedure and thereby appropri-
the number of revisions in the United ately counsel patients about poten-
tial surgical complications. Careful
States will increase by 600%
between 2005 and 2030.2 Although planning allows the surgeon to
excellent functional outcomes and communicate with the surgical team
long-term survival rates have been preoperatively to ensure the avail-
ability of the required instrumen-
reported, infection, instability, wear,
osteolysis, mechanical loosening, tation and implants.
and periprosthetic fracture are
common causes of revision TKA.3 History and Physical
Many of these failure modes are Examination
related directly to the surgical tech-
nique and, therefore, are under the Obtaining a thorough history is cru-
control of the surgeon. cial for patient selection and for
Thorough preoperative planning the evaluation of potential post-
is critical in optimizing implant operative complications. Factors that
position and soft-tissue balancing, should be considered include the
which will minimize the probability preoperative diagnosis, patient age
Journal of the American Academy of Orthopaedic Surgeons

and sex, characteristics of the knee
pain, level of activity, functional
limitations, involvement of other
joints, mechanical symptoms, and
previous treatment. The presence of
comorbid conditions, smoking sta-
tus, alcohol consumption, medica-
tions, and mental status should be
assessed carefully to further guide
preoperative evaluation and medical
optimization. Active infection must
be treated and resolved before sur-
gery to prevent a postoperative
infection. An assessment of the
patients overall venous thrombo-
embolism risk, including any history
of previous deep vein thrombosis or
pulmonary embolism, is recom-
mended to optimize perioperative
management. Evaluation of the
patients social history can guide
postoperative rehabilitation and
discharge planning.
Dementia, diabetes mellitus, a body
mass index .40, and renal and
cerebrovascular diseases have been
shown to be independent predictors
for in-hospital mortality and post-
operative complications after pri-
mary TKA. Therefore, the benefits of
TKA should be weighed against such
risks.5 Patients with neuromuscular
conditions, such as Parkinson dis-
ease, are at high risk of instability
following TKA and may benefit from
specific implant options (eg, varus
valgus-constrained TKA, hinged
knee components).6
The patients gait should be as-
sessed. In addition to observing the
overall knee alignment, the surgeon
should look for the presence of
thrust and/or hyperextension during
walking, which indicates ligamen-
tous laxity. This indication may
prompt the surgeon to consider a
constrained knee design. An intoeing
or out-toeing gait may indicate pre-
existing rotational deformities.
Hindfoot inspection also should be
part of the examination because
hindfoot valgus is not uncommon,
and it tends to shift the mechanical
April 2016, Vol 24, No 4
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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc
axis of the lower extremity after
TKA.7
The presence of surgical scars
should be noted during the skin
examination because it can inform
the decision of whether to use a
standard midline surgical incision.
When multiple previous incisions
are encountered, it has traditionally
been recommended that the most
lateral incision be used and that at
least 5 or 6 cm of skin bridging be
provided between incisions to avoid
postoperative skin complications.8
The presence of local signs of skin
infection or adherence to the
underlying bone also should be
noted. Such findings necessitate
further investigation and treatment
before surgery.
Examination of preoperative knee
range of motion (ROM) is essential.
Although postoperative stiffness is
multifactorial, preoperative ROM
remains the most important predictor
of postoperative motion.9 Identifica-
tion of preoperative knee flexion
contractures can help the surgeon
plan an intraoperative strategy for
correction.
Preoperative assessment of the col-
lateral and cruciate ligaments is
required to guide the strategy for soft-
tissue balancing and the selection of
the implant. The integrity of the col-
lateral ligaments is essential when
performing TKA with an uncon-
strained or semiconstrained implant.
Any fixed coronal deformity found
on physical examination should be
noted to allow for planning of intra-
operative correction.
A thorough neurovascular exami-
nation also should be performed. The
surgeon should note any signs of poor
circulation, such as skin discoloration,
atrophic nails, absent hair, or asym-
metric or absent distal pulses. If any
suspicion of peripheral arterial insuf-
ficiency is present, the ankle-brachial
index should be determined. If the
ankle-brachial index is ,0.9, a pre-
operative vascular surgery consulta-
tion is warranted.10 Because patients
with preexisting peripheral vascular
disease are at high risk of arterial
injuries and compromised blood flow
during TKA, the surgeon should
consider not using a tourniquet dur-
ing the procedure or inflating it just at
the time of cementing.10
Finally, assessment of the ipsilateral
hip and ankle joint and the contralat-
eral limb should be performed to
evaluate the involvement of these
joints and the effects they may have on
the patients postoperative mobility
and rehabilitation. Ipsilateral hip
arthritis can present as isolated knee
pain and must be ruled out. Patients
with a fixed flexion deformity on the
contralateral knee may benefit from a
shoe lift postoperatively. In cases of
severe bilateral deformities, bilateral
one-stage or two-stage TKAs should
be planned.
Imaging and Laboratory
Testing
Plain Radiography
Standard radiographic evaluation for
patients undergoing primary TKA
includes a weight-bearing AP view of
the knee, a lateral view of the knee,
and a patellofemoral joint view, such
as a skyline view. Although a full-
length hip-to-ankle AP weight-
bearing view is not performed
routinely at some institutions, many
authors feel that this view is useful for
preoperative planning, especially in
complex cases.11,12 The AP weight-
bearing hip-to-ankle radiograph
allows the surgeon to rule out extra-
articular deformities, estimate the
amount of coronal laxity, and plan
the bone resection and the position
of the femoral and tibial components
with respect to the mechanical axis.
Radiographic Technique
The full-length hip-to-ankle AP
weight-bearing view typically is
taken with both knees in maximum
221
Preoperative Planning in Primary Total Knee Arthroplasty

Figure 1 diagnosis and ensure appropriate

patient positioning to avoid inaccu-
rate planning. The first step in
radiographic templating is to draw a
line on the full-length hip-to-ankle
view that shows the overall mechan-
ical alignment of the lower extremity
(Figure 1, A). Varus or valgus mal-
alignment and any extra-articular
deformities should be noted. The ti-
biofemoral angle then is drawn to
estimate the magnitude of a coronal
deformity (Figure 1, B). Some
authors use the hip-knee-ankle angle
instead of the tibiofemoral angle to
estimate the degree of the coronal
deformity (Figure 1, C).
When an intramedullary distal
femoral cutting jig is required, the
femoral resection angle, which is the
A through C, Full-length hip-to-ankle AP weight-bearing radiographs in a patient difference between the mechanical
with a varus knee deformity. A, The mechanical axis is represented by a line axis and the anatomic axis of the
drawn from the center of the femoral head to the center of the talus. A neutral femur, can be used (Figure 2). This
mechanical alignment should bisect the center of the knee (asterisk). B, The angle most commonly measures
tibiofemoral angle is determined by measuring the angle between the anatomic
axis of the femur (ie, a line bisecting the intramedullary canal of the femur) and between 5 and 7 of valgus. In one
the anatomic axis of the tibia (ie, a line bisecting the intramedullary canal of the report, however, Mullaji et al13
tibia). The neutral tibiofemoral angle is 76 1 of valgus. C, The hip-knee-ankle showed that this angle can vary from
angle is determined by measuring the angle between the mechanical axis of the 3 to 11 of valgus. The authors
femur (ie, a line from the center of femoral head to the center of the knee joint)
and the mechanical axis of the tibia (ie, a line from the center of the knee to suggested using an individualized
center of the talus). The neutral hip-knee-ankle angle is 0. femoral resection angle rather than a
fixed resection angle, such as those
measuring 5, 6, or 7.
extension and with the patients digital radiographic templating. The tibial bone cut is perpendicu-
knees placed 18 inches apart. The Adding a calibrated reference lar to the mechanical axis of the
rotational position of the lower marker, such as a ball or coin at the tibia. The amount of resection
extremity may influence the reli- level of the joint line, can increase required usually is based on the
ability of the measurements; there- the accuracy of the sizing of the combined thickness of the tibial
fore, it is important to have the tibial and femoral components component and the thinnest
patellae facing forward. The AP during templating. Using this tech- available polyethylene component
weight-bearing view of the knee nique, preoperative planning accu- thickness for the implant system
typically is obtained with the x-ray rately predicts the component size being used, typically 10 mm. This
beam focused at the knee joint and within one size larger or smaller amount of bone resection should be
the patella, facing directly anteri- 100% of the time for the tibia and performed on the unaffected side of
orly. The true lateral view can be 90% of the time for the femur.4 the tibial plateau or, if both sides are
verified if no overlap is present Knowing the expected implant size affected, from the level of the pre-
between the medial and lateral is beneficial for ensuring the arthritic tibial plateau (Figure 3).
femoral condyles. Finally, the tan- availability of the implant, partic- The AP weight-bearing view of the
gential axial view of the patello- ularly if extreme sizes will be used. knee is scrutinized to detect medial
femoral joint is performed with the and/or lateral osteophytes and bone
knee in 30 of flexion. Radiographic Landmarks and defects. The lateral knee view typically
The surgeon must know the Templating is used to detect posterior osteophytes
magnification of the radiographs to Before templating, the radiographs and to measure the tibial slope and the
perform adequate conventional or should be reviewed to confirm the patellar height (Figure 4). The skyline

222 Journal of the American Academy of Orthopaedic Surgeons

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Figure 2
Full-length hip-to-ankle AP weight-
bearing radiograph demonstrating
the femoral resection angle, which is
the difference between the
mechanical axis (line A) and the
anatomic axis (line B) of the femur. In
this case, the distal femur should be
resected in 5 of valgus, when using
an intramedullary distal femoral
cutting jig, to achieve a perpendicular
cut to the mechanical axis of the
femur (line A).
view of the patella is used to mea-
sure patellar shift and patellar tilt
and to evaluate the extent of ero-
sion of the patellofemoral joint
(Figure 5). Chia et al14 showed that
a preoperative lateral patellar shift
.3 mm was an independent risk
factor for patellar maltracking
during TKA.
Lastly, the femoral and tibial com-
ponent sizing is performed (Figure 6).
The templating is dictated most
commonly by the anterior-posterior
dimensions of the femur and tibia.
Various digital and acetate templat-
ing techniques have been investi-
gated and shown to be effective and
reliable, and they reduce surgical
April 2016, Vol 24, No 4
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc
Figure 3
Full-length hip-to-ankle AP weight-
bearing radiograph demonstrating a
planned tibial resection for primary
TKA. The tibial cut should be made
perpendicular to the tibial
mechanical axis. In this patient, the
tibial resection of the unaffected side
will be 10 mm.
time and cost.4,15 In this step, the
surgeon must carefully assess the
implant location and anticipate any
potential intraoperative adjustments,
such as the resection of an osteo-
phyte, to accurately estimate the
implant location.
Advanced Imaging
CT or MRI is rarely indicated dur-
ing planning for primary TKA.
When the use of an extreme implant
size is planned, CT can be invalu-
able in determining the size and
whether a custom implant is
required. A preoperative CT or
MRI of the knee is obtained when
patient-specific instrumentation
and/or custom implants will be
used.16
Figure 4
Lateral radiograph of the knee
illustrating the posterior slope angle,
which can be determined by drawing
a line (A) over the anterior cortex of
the tibia and then a perpendicular
line (B) extending to it. Finally, a line
(C) is drawn to connect the articular
surface of the knee and line A. The
posterior slope angle is measured
between lines B and C. Note the
posterior femoral osteophytes
(arrow).
Laboratory Tests
Routine preoperative laboratory test-
ing, including a complete blood count
and electrolyte levels, must be per-
formed. Additional laboratory tests
should be guided by the patients
medical condition. Although having
tight glycemic control with the goal of
obtaining a hemoglobin (Hb) A1c
(HbA1c) test result of #7% is desir-
able, Giori et al17 recently proposed
that achieving a HbA1c level of #8%
is acceptable to avoid substantial
delays in performing the TKA. A low
Hb level is an independent predictor
for the need for a perioperative blood
transfusion. The risk of transfusion is
increased 3.7-fold for each 1 g/dL
decrease in the Hb level below the
threshold of 13 g/dL preoperatively.18
Various options are available to treat
223
Preoperative Planning in Primary Total Knee Arthroplasty

Figure 5 Figure 6

Skyline radiographs of the patella showing patellar tilt (A) and patellar shift (B).
A, Patellar tilt is the angle between the horizontal axis of the patella (line A) and
the anterior intercondylar line (line B). The angle is positive when the patella is
tilted laterally. B, The patellar shift is the lateral displacement (asterisk) of the
median ridge of the patella from the intercondylar sulcus of the femur (arrow),
which is positive when the patella is lateral to the sulcus. The distance (double-
ended arrow) between the two vertical lines indicates the amount of patellar shift. Digitally templated lateral radiograph
of a right total knee arthroplasty
created with templating software. A
a low preoperative Hb level, including is 7 6 1 of valgus.11 Restoration of standard 20-mm calibration marker
was used to increase accuracy.
iron supplementation, recombinant neutral knee alignment with TKA
human erythropoietin administra- distributes the weight-bearing loads
tion, and tranexamic acid (ie, a an- equally across the medial and lateral
tifibrinolytic agent) administered compartment of the knee joint, releases are performed to balance the
intraoperatively. thereby minimizing the risk of knee.22
implant wear and aseptic loosening.
Achievement of a neutral anatomic Preservation of the Joint Line
Surgical Principles of alignment between 2.4 and 7.2 of
Primary Total Knee The preservation or restoration of the
valgus has been shown to sub- anatomic position of the joint line is
Arthroplasty stantially improve implant survival an important factor for a successful
following primary TKA.20 To achieve primary TKA. This measure can be
An understanding of implant designs
mechanical alignment, the femoral achieved if bone cuts are so accurate
used in primary TKA, as well as the
and tibial cuts are made perpendicular that the amount of bone eroded pre-
technical principals of the procedure,
to the mechanical axis, and soft-tissue operatively and the amount of bone
is crucial to help the surgeon success-
releases correct any coronal defor- resected at the time of TKA identi-
fully reconstruct the knee (Table 1).
mity. Bellemans et al21 questioned this cally match the thickness of the
Technical principles of TKA include
concept and reported that a portion of prosthesis. Proximal elevation of the
restoration of neutral mechanical
the normal population does not have joint line leads to pseudopatella baja,
alignment, preservation of the joint
a neutral mechanical alignment at which is associated with high contact
line, restoration of coronal and sag-
skeletal maturity, but rather has $3 forces at the patellofemoral joint and
ittal balance, maintenance of patellar
of varus. The authors termed this dysfunction of the extensor mecha-
tracking, and restoration of the pos-
observation constitutional varus. nism. Shifting the joint line distally
terior tibial slope.
The clinical disadvantages of restor- can lead to patellar subluxation and
ing patients with constitutional varus retropatellar pain.23
Restoration of Neutral to neutral alignment at the time
Mechanical Alignment of TKA are unknown. In the last
Neutral mechanical alignment is ach- decade, the concept of achieving a Restoration of Coronal and
ieved when the mechanical axis of the kinematically aligned knee has Sagittal Balance
lower extremity passes through the emerged and involves resection of the Postoperative knee instability is a
center of the knee joint or when the bone to restore the prearthritic state major cause of premature failure
anatomic axis of the lower extremities and anatomic angle while soft-tissue following primary TKA.24 This

224 Journal of the American Academy of Orthopaedic Surgeons

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 Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

Table 1
Types of Knee Implant Designs in Total Knee Arthroplasty19
Implant Design (Example) Advantages Disadvantages

Unconstrained knee (cruciate-retaining Increased quadriceps muscle strength, Risk of postoperative PCL rupture,
design; PCL is preserved) lower shear forces at tibial component- potential loss of femoral rollback with
host bone interface, preserved bone some current designs
stock on the femoral side, improved
stair climbing
Semiconstrained knee (posterior Potential ease of ligament balancing, Risk of cam-post impingement or
stabilized design; PCL is substituted) no need to correct a contracted PCL, dislocation, increased constraints in
suitable after patellectomy and for varus or valgus direction compared
PCL-deficient knees, great versatility with cruciate-retaining knee design,
for different types of substantial knee risk of tibial post polyethylene wear
deformities from cam-post mechanism, risk of
patellar clunk syndrome
Constrained knee (varusvalgus- Coronal stability in severe coronal bone Decreased femoral bone stock,
constrained design, also known as deformities potentially higher rate of aseptic
condylar constrained knee) loosing from increased constraint in
younger and active patients, risk of
tibial post polyethylene wear and/or
fracture from cam-post mechanism
Highly constrained knee (rotating hinge Highly constrained implants typically Potentially high rate of aseptic loosing
design) reserved for complex instability cases, from increased constraint, substantial
when gaps are greater than the largest reduction of bone stock
available polyethylene liner and/or for
substantial bone loss

PCL = posterior cruciate ligament

outcome can be prevented with ad-
equate preoperative assessment and
careful intraoperative soft-tissue
releases performed to achieve in-
traoperative stability throughout
the ROM. Patients with coronal
knee deformities typically have tight
soft-tissue structures, such as liga-
ments, on the concave side of the
deformity and stretched out soft-
tissue structures on the convex side.
A stepwise approach must be con-
sidered for soft-tissue releases when
managing coronal deformities. It is
recommended that osteophyte
removal and all bone cuts should be
performed first. A prosthetic trial or
spacer blocks are then inserted to
evaluate the medial and lateral gaps
during flexion and extension. If the
medial or lateral gaps are not bal-
anced, then sequential soft-tissue
releases should be performed. The
soft-tissue releases should be per-
formed with caution; overly zealous
releases on the contracted side of the
joint can lead to instability, and
subsequent conversion to a con-
strained knee design might be
required.
The aim of sagittal balance is to
achieve equal flexion and extension
gaps. Intraoperatively, these gaps
can be achieved by soft-tissue
releases, adjusting the tibial or
femoral resections, or changing
component size. It is important to
correct a fixed flexion contracture
because it can adversely influence
functional outcomes after TKA.
Although existing evidence shows
that, in TKAs with a cruciate-
retaining implant, residual flexion
contracture may improve with time
after surgery, it is imperative that all
the necessary releases and osteo-
phyte resections be addressed in-
traoperatively.25 This also has been
shown to be required in patients
with flexion contractures at the
time of TKA performed with a
posterior-stabilized (PS) implant.26
Maintenance of Patellar
Tracking
Patellofemoral complications are
responsible for approximately 8% of
primary TKA failures.14 Alteration
in knee kinematics, such as an
increased Q angle (normal Q angle =
15) and an imbalance of peri-
patellar soft-tissue structures, can
produce a laterally directed muscle
vector that can lead to patellofemo-
ral instability.14,27 Several factors
influence the Q angle, including
component malposition and limb
malalignment. For example, internal
rotation and medialization of the
femoral or tibial components, as well
as a femoral component positioned
in .7 of valgus, can increase the Q
angle during TKA.27 When patellar
resurfacing is planned, improper
patellar preparation, such as under-
resection or an asymmetric patellar
cut with a thick lateral facet,
and lateralization of the patellar

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226

Preoperative Planning in Primary Total Knee Arthroplasty

Figure 7
Journal of the American Academy of Orthopaedic Surgeons

Algorithm demonstrating the key elements required for the clinical approach, choice of implant design, and techniques used during primary total knee arthroplasty. For
radiographic templating, the hip-knee-ankle (HKA) angle or the tibiofemoral angle and the femoral resection angle should be measured on the full-length HKA weight-
bearing AP radiograph to plan for the tibial and femoral resection. The weight-bearing AP radiograph is scrutinized to detect bone defects and medial or lateral
osteophytes and to estimate the size of the bone resections. The tibial slope and patellar height should be measured on the patellofemoral view. CR = cruciate-
retaining, MCL = medial collateral ligament, PS = posterior stabilized, RH = rotating hinge, TKA = total knee arthroplasty, VVC = varusvalgus constrained.

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 Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

component also can increase the Q Figure 8

angle. Additionally, a patellar bone-
prosthesis construct that is thicker
than the native patella results in an
increase in the lateral tilt and con-
tributes to patellar maltracking.28

Restoration of Posterior
Tibial Slope
The normal posterior slope angle
(PSA) is highly variable, with a re-
ported range of 5 to 15.29 Although
restoring the PSA should be consid-
ered when cutting the proximal tibia
to optimize ROM, some authors
recommend reducing the PSA in
TKAs with PS knee implants to pre-
vent cam-post impingement.9,19,29,30

Complex Primary Total

Knee Arthroplasty

In complex cases, a specific implant
design or surgical technique might be
preferred over another. Several con-
ditions, including severe coronal
deformities and instability, extra-
articular deformities, severe bone
deficiency, and previous patellec-
tomy, warrant careful preoperative
consideration and selection of the
optimal implant design and surgical
technique. The surgeon must be
aware of the various options avail-
able to manage such conditions dur-
ing TKA to increase the likelihood of
optimal outcomes (Figure 7).
Severe Coronal Deformities
and Ligamentous Instability
Management of a coronal deformity
requires a planned, stepwise approach
to achieve a balanced knee intra-
operatively. This approach includes
removing the osteophytes, sequential
soft-tissue balancing, and if necessary,
adjusting the bone cuts. In the setting
of severe varus deformity, however,
the surgeon may not be able to achieve
the desired intraoperative stability
in rare instances and must anticipate
A, Preoperative AP weight-bearing radiograph of the knee demonstrating a
severe valgus deformity. B, Postoperative AP radiograph of the knee after the
implantation of a varusvalgus-constrained knee design.
the conversion to a constrained knee implant with MCL advancement,
implant.31 repair, or reconstruction.32,33 How-
Similarly, in knees with severe ever, these procedures have been
valgus alignment, intraoperative criticized for their potentially
attempts should be made to balance adverse influence on the ligaments
the knee in flexion and extension isometricity.34 In a study on the use
before considering the use of a con- of lateral epicondylar osteotomy in
strained implant. Several stepwise TKA for rigid valgus deformities,
lateral releases and ligament balanc- Mullaji and Shetty35 reported no
ing strategies can be used when a complications. In elderly and low-
cruciate-retaining or PS implant is demand patients with severe valgus
selected.32 However, when the and MCL deficiency, the surgeon
medial collateral ligament (MCL) is may consider performing a TKA
extremely attenuated and extensive with a constrained knee implant.32,36
lateral releases have been performed, Although some surgeons have ex-
balancing the coronal plane may fail pressed concern that TKAs with
to correct the deformity and balance constrained implants will transfer
the knee. In addition, extensive lat- stresses to the implant-bone inter-
eral releases may result in flexion face, which can result in premature
instability and/or a postoperative loosening, studies have shown that
peroneal nerve palsy. This problem the survivorship of these implants is
can be avoided by converting intra- .96% at long-term follow-up.37
operatively to a varusvalgus-con- Nevertheless, surgeons should
strained knee implant (Figure 8). attempt to reconstruct the knee using
Some authors prefer to use a PS knee nonconstrained knee implants and

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Preoperative Planning in Primary Total Knee Arthroplasty
Figure 9
Full-length hip-to-ankle AP weight-
bearing radiograph demonstrating
the lower extremities of a 57-year-
old woman known to have rickets
who underwent bilateral femoral
and tibial corrective osteotomies
during childhood. The hip-knee-
ankle angle (not drawn) on the
left lower extremity is 33, with
substantial (30) extra-articular
deformity of the left femur. In the
left femur, the apex of the
deformity (arrow) is determined
by drawing two bisecting lines
through the anatomic axis. In this
patient, the deformity is relatively
close to the joint. When templating
the distal femoral valgus cut
(line A), it became clear that the
insertion site of the lateral
collateral ligament would have to
be sacrificed. Therefore, a
corrective osteotomy at the apex of
the deformity was considered in
this patient.
be prepared preoperatively to ensure
that constrained devices are readily
available when the intraoperative
assessment indicates that they are
necessary.
Extra-articular Deformity
Previous osteotomies, metabolic
bone disease, malunion of fractures,
228
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Figure 10
AP radiograph of the knee
demonstrating a medial tibial plateau
bone defect (double arrows)
measuring 6 mm.
and bone tumors can lead to bowing
or angulation of the femur or tibia.
In the setting of extra-articular
deformities in the coronal plane,
the goal of TKA is to achieve a
neutral mechanical alignment to
optimize long-term results.20 How-
ever, the standard preoperative
templating, bone incisions, and
conventional instruments, such as
an intramedullary guide, may be
ineffective because of the bone
deformity. Rotational and sagittal
deformities also can add to the
complexity of these cases.
Preoperatively, the surgeon can
anticipate the impact of the deformity
based on its distance from the knee
joint. The closer the deformity is to
the joint, the greater its impact on
knee alignment. For example, if the
apex of a femoral or tibial deformity
is located at a distance from the joint
that corresponds to 25% of the
length of the bone, the effect of the
deformity will be twice that of a
Journal of the American Academy of Orthopaedic Surgeons
deformity located at a distance cor-
responding to 50% of the length of
the bone.38 The magnitude of the
deformity plays an equally impor-
tant role in its management. The
greater the deformity, the greater the
impact on knee alignment.
Preoperative templating allows the
surgeon to anticipate whether an in-
traoperative intra-articular compen-
satory correction is achievable or if
an extra-articular corrective osteot-
omy is required (Figure 9). In general,
an intra-articular compensatory
correction can be achieved if the
deformity is far from the joint and
limited to ,20 in the coronal plane
on the femoral side and ,30 on the
tibial side.39 This technique might
require extensive soft-tissue releases
secondary to the asymmetric oblique
cuts. Therefore, the surgeon should
be prepared to reconstruct and/or
advance the affected collateral liga-
ment or convert to a constrained
knee design. In contrast, if the
deformity is severe and close to the
joint or if preoperative templating
indicates that the intra-articular
bone resection will include the
attachment sites of the MCL and/or
lateral collateral ligament, an extra-
articular corrective osteotomy (per-
formed in a staged fashion or at the
time of primary TKA) is recom-
mended.40 Although this technique
is appealing and preserves ligamen-
tous stability, it is associated with
high rates of nonunion, infection,
and arthrofibrosis.
Recent advances in computer-
assisted navigation for TKA have
expanded the indications for its use
in patients with severe extra-
articular deformities. Although
computer-assisted surgery (CAS) has
not been found to be superior to
conventional techniques in routine
TKA, Catani et al41 suggested that
CAS has a definite advantage in
patients with severe extra-articular
deformities. The use of CAS can
sometimes obviate the need for a

corrective osteotomy or implant
removal, thereby reducing the risk
of complications.
Bone Defects
Bone defects on the tibial side com-
monly result from previous trauma,
bone erosion from conditions such as
inflammatory arthritis, and severe
coronal deformities. Varus deformity
typically is associated with medial
tibial bone defects, whereas valgus
deformity is associated with central-
lateral defects. Preoperatively, the
surgeon should determine the extent
of the bone defect because manage-
ment typically is based on its size
(Figure 10). Dorr et al42 determined
that any tibial bone defect that
involves ,50% of the tibial plateau
or is ,5 mm in depth can be filled
with cement. For larger defects,
management options include metal
augments and autogenous bone
grafts, with or without fixation. In
one report, Berend et al43 used
cement and screw fixation to manage
large tibial bone defects and achieved
low failure rates at 20-year follow-up.
Lee and Choi44 and Pagnano et al45
investigated the clinical outcome of
using metal rectangular block aug-
ments at a minimum 5-year follow-
up. The authors reported good to
excellent results with no radiographic
or clinical failures. In these studies,
nonprogressive radiolucent lines were
noted at the metal-cement interface;
the significance of these findings on
the long-term survivorship of the
implant remains to be determined.
Although biomechanical studies have
shown that the tensile stress loads are
reduced and that better stability and
rigidity are achieved with metal block
augments than with metal wedge
augments,46 we are not aware of any
clinical studies that demonstrate the
superiority of one type of augment
over another.
The use of autogenous bone graft
to manage large tibial bone defects
April 2016, Vol 24, No 4
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc
is another option, but variable suc-
cess rates have been reported in the
literature.47,48 Overall, metal aug-
mentation is an attractive option
for managing large bone defects. It
provides immediate support and
satisfactory load distribution with
promising midterm results.44,45
Long-term data are required to
confirm the durability of these
implants, however. Autogenous
bone grafting may be best for
young patients, in whom restora-
tion of the bone stock may be
necessary for future surgeries.
Previous Postpatellectomy
Patients who have undergone a pre-
vious patellectomy lose their exten-
sion strength by 20% to 70%.49 In
addition, in patients undergoing
TKA, the loss of the patella decreases
the stability of the knee and over-
loads the posterior cruciate ligament.
The literature has shown that these
patients achieve the best results when
they undergo TKA with a PS knee
implant.32 Nevertheless, even when
a PS device is used, patients with a
previous patellectomy have less
favorable outcomes than those with
a patella.50
Summary
Preoperative planning is crucial in
primary TKA. The application of
conventional surgical principles dur-
ing this procedure allows the surgeon
to obtain reproducible results. A
thorough preoperative history, physi-
cal examination, and radiographic
templating can result in a precise plan
that helps the surgeon successfully
reconstruct the knee and anticipate
potential complications.
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