FUNCTIONAL AND RADIOGRAPHIC

SHORT-TERM OUTCOME EVALUATION

OF THE TOTAL KNEE ARTHROPLASTY
IN PANTI RAPIH HOSPITAL YOGYAKARTA

Arif A*,Rhatomy S*,Kisworo B**

*Fellow of Indonesian Hip and Knee Fellowship
Program
**Staff of Orthopaedic and Traumatology
department, Panti Rapih General
Hospital,Yogyakarta

Background
TKA : standard treatment for end stage
knee arthritis : degenerative, post-
traumatic or metabolic causes.
1
Generally relieves pain, improves physical
function, and has a high level of patient
satisfaction, especially in the elderly.
1

1.Hawker G, Wright J, Coyte P, et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am.
1998; 80(2):163-173. 1
There have been many reports of the
long-term outcome of cemented TKA
2,3,4


We did not have report about the
functional and radiographic outcome of
TKA in Indonesian people.

2.Forster MC. Survival analysis of primary cemented total knee arthroplasty: which designs last? J Arthroplasty
2003;18:265-70.
3. Ranawat CS, Flynn WF Jr, Saddler S, Hansraj KK, Maynard MJ. Long-term results of the total condylar knee
arthroplast: a 15-year survivorship study. Clin Orthop1993;286:94-102.
4.Falatyn S, Lachiewicz PF, Wilson FC. Survivorship analysis of cemented total condylar knee arthroplasty. Clin Orthop
1995;317:178-84.



Patient and Methods
Jan 2003-Dec 2012
330 TKAs on 294 patients
PCL retaining TKA and PCL- sacrificing (J&J,
Zimmer, Stryker)
Retrospective cohort study
Patient come in to the clinic for evaluation
24 patient (37 knees)
Pre op diagnosis : severe OA, RA.
Demographics of the study
population
Surgical Technique and Postoperative
Care
Standard length medial parapatellar approach
Wheater or not a lateral/medial release
Did not performed patellar resurfacing for all cases
Femoral and tibial components : cement, doughy.
Torniquet release after cementation : hemostasis
Closure : interupted nonabsorbable sutures to
closure retinaculum.

DVT prophylaxis LMW heparin
Weight bear as tolerated 1 day after
surgery
Discharged 3 days after surgery
Outpatient physiotherapy 4-6 weeks after
hospital discharge
Routinely follow up at 10 days, 3 months,
and 1 year and periodically year after
Clinical Assesment
Post Operative evaluation :
Knee Society Function Score
Knee Society Rating score
ROM by goniometer
Early postoperative and final follow-up
evaluations were assessed during the clinical
follow-up.




Clinical assessment
KSS Rating System
5
KSS Function Score
6

5. Reference for Rating: Asif S , Choon DS . Midterm results of cemented Press Fit Condylar Sigma
total knee arthroplasty system. J Orthop Surg (Hong Kong). 2005 Dec;13(3):280-4.
6. Reference for score: Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical
rating system. Clin Orthop Relat Res. 1989 Nov;(248):13-4. link to pubmed. Link SF36, SF12

Clinical assessment
ROM by
goniometer

Early postoperative
and final follow-up
evaluations were
assessed during the
clinical follow-up.


Anteroposterior view :
measure femoral angle
(), tibial angle () and
total valgus angle ( +
)
Lateral view : Femoral
implant flexion (), tibial
angle/posterior slope ()
Skyline view : Patellar
tilt, patellar shift
Lucency : femoral
implant and tibial implant
anterior and lateral.

Radiographic Analysis
7. Lippincott Williams & Wilkins. This article originally appeared in Clin
Orthop. 1989 Nov;(248):9-12. PMID: 2805502)

AP View
7. Lippincott Williams & Wilkins. This article originally appeared in Clin
Orthop. 1989 Nov;(248):9-12. PMID: 2805502)

The mechanical axis cannot be accurately measured using short AP
radiographs of the knee.
7

In such cases, the compo- nent positions can be assessed with
reference to the anatomical axes of the femur and tibia instead
7

the femoral angle (the medial angle between the femoral anatomical
axis and a tangent to the distal ends of the femoral condyles) should
be about 95 degree.
7,8

The tibial angle (the medial angle between the tibial anatomical axis
and a line along the tibial base plate) should be about 90.
7,8
The overall femorotibial angle is the sum of the femoral and tibial
angles, and should be about 185.
7,8
In other words, the replaced knee should be in about 5 valgus.
It should be emphasised that this is only a surrogate measure for the
mechanical axis.
7

If there is significant bowing of the femur or tibia in the coronal plane,
such angles may not reflect the actual lower limb mechanical axis.
7. Lippincott Williams & Wilkins. This article originally appeared in Clin
Orthop. 1989 Nov;(248):9-12. PMID: 2805502)


Radiolucency
7. Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al, Reading radiograph after total
knee arthroplasty.Hongkong J Orthop Surg.2010;14(1):225-39
Radiolucency
The width of the radiolucent line for each of
the zones is measured in mm and these widths
are added together to give a total score.
7
For a tibial component with a central stem (7
zones:
7
a score of 4 is probably insignificant;
closely followed for progression : score is 5-9
a score of 10 signifies possible or impending
failure regardless of symptoms.
A stable radiolucent line at the cementbone
interface of <2 mm in width is frequent and
has no clinical significance.
7


7. Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al, Reading radiograph after total
knee arthroplasty.Hongkong J Orthop Surg.2010;14(1):225-39
Skyline View
7. Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al,
Reading radiograph after total knee
arthroplasty.Hongkong J Orthop
Surg.2010;14(1):225-39
Result Clinical Outcome

The Mean KS Function Score: 80,77(range: 69-88)
The Mean KS Rating Score: 85,57 (range: 55-100)
The Mean ROM : 106,9 (SD 13,5, range 70-125)
2 patient failed to achieve 90 ROM at final visit
Complications
No infections or observed deep vein
thrombosis
Radiographic Outcome
AP View

Femoral (): 93,89
(range, 90 112).
Mean of tibial angle
() : 89,04 (range 85
95)
And mean of valgus
angle : 3,55 (range, -
2 17)

Knee Lateral
mean of femoral fn
() 1,53 (range, 0
5)
tibial angle ()
4,31 (range, 80
92)

Skyline View
Mean patellar tilt: 37,
5 (range, 22 60)
Mean patellar shift:
3,05 mm (range, 0
14)
most of case (84,25)
shift to lateral.
Radioluscence
Femoral Zone
Minor non-progressive
radiolucent on both of
implant.
On femoral implant:
most of case have
luscence at zone 1,2,3
and 5


Tibial implant AP Zone
Luscence of most
case at zone
1,2,3,4,5 and 7.
Tibial Implant lateral Zone
luscence most of
case at zone 1 and
2

Discussion
Total knee arthroplasty is a well-
established procedure for the elderly that
generally relieves pain, improves physical
function, and has a high level of patient
satisfaction.
15


The indication for TKA has expanded
because of these good results.
Clinical Result
The clinical result based on the Knee Society score
excellent for the mean Knee Society Functional
Score was 80.77 (range, 69-88),

the mean Knee Society Rating Score was 85,57
(range, 55-100).

Ranawat et al reported in patient after TKA with
Press- Fit Condylar, The mean of knee society
functional score was 73 points (range, 50 to 100
points) and the mean clinical score was 88 points
(range, 50 to 100 points).
9


9.Ranawat,C.S.,Rasquinha,V.J.,Cervieri,C.L.,et al.The Press-Fit Condylar Modular Total Knee System with a
Posterior Cruciate-Substituting design.JBJS 2006;88-A:1006-1010

ROM
The mean ROM at the time of the latest follow up
was 106.9 (range, 70-125).

2 knees (5,4 %) failed to achieve 90 ROM at final
visit.

Ranawat et al reported that the mean ROM was
108 (range, 60-135), and eleven knees (10%)
had < 90 of motion.
9

The other study describes that ROM has correlation
with functional outcome. Ritter et al reported that
patient with 128 to 132 of motion and without a
flexion contracture or without a hyperextension
deformity appears to obtain the best functional
results following a posterior cruciate-retaining TKA
10
9. Ranawat,C.S.,Rasquinha,V.J.,Cervieri,C.L.,et al.The Press-Fit Condylar Modular Total Knee System with a Posterior
Cruciate-Substituting design.JBJS 2006;88-A:1006-1010
10.Ritter ,M.A., Lutgring,J.D.,Davis.,K.E.,et al. The effect of postoperative range of motion on functional activities after posterior
cruciate-retaining total knee arthroplasty.JBJS 2008;90:777-84.
Radiographic View

The ideal of the femoral angle: about 95.
7
We

usually set for mechanical axis when
femoral distal cut on 5 degree valgus
The ideal of the tibial angle: about 90.
7

Mean of valgus angle was 3,55 (range, -2 17),
The femorotibial angle should be about 185, in
other words, the replaced knee should be in
about 5 valgus.
7
7. Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al, Reading radiograph after total knee arthroplasty.Hongkong J
Orthop Surg.2010;14(1):225-39


Tew and Waugh : postoperative limb alignment was
one factor for determining durability, factors other
than alignment might be more important for
determining long-term survival following total knee
arthroplasty.
11

Sikorski : need for studies that measured alignment
soon after the initial procedure to 10-15 years of
clinical follow-up to confirm the relationship between
alignment and implant longevity following
contemporary total knee arthroplasty.
11

A basic premise that has been used to justify computer
navigation systems has been that restoring limb
alignment to a neutral mechanical axis of 0 3 will
improve the durability of the implant.
11

11.Baldini,A.,Anderson,J.A.,Mariani,P.C., et al. Patellofemoral evaluation after total knee arthroplasty.JBJS.2007;89:1810-17

Parratte et al
Demonstrated that alignment was defined as a traditional
broad target of a neutral mechanical axis 0 3,
No marginal improvement in terms of survival at 15 years
when that target was hit (mechanically aligned group) as
compared with when it was missed (outlier group).
11

It may be that the traditional definition of a well-aligned total
knee implant (mechanical axis, 0 3) is simply too broad
and imprecise to be clinically meaningful in the setting of
contemporary total knee arthroplasty.
Current-generation knee instrumentation allows most
surgeons to achieve a mechanical axis of 0 3 in the
majority of patients, with most of the remaining outliers
positioned just 1 or 2 from those boundaries.
11


11.Baldini,A.,Anderson,J.A.,Mariani,P.C., et al. Patellofemoral evaluation after total knee arthroplasty.JBJS.2007;89:1810-17

However, any individual patient may have a
combination of muscular issues (e.g., frank
weakness), skeletal issues (e.g., fixed pelvic
deformity), or neurologic issues (e.g., balance or
proprioception loss) that impact gait and thus alter
the dynamic loading of the knee joint.
11

If ideal alignment is influenced by an individual
patients dynamic gait pattern, one can quickly
understand the limitations of defining alignment as
a dichotomous variable .
11

11.Baldini,A.,Anderson,J.A.,Mariani,P.C., et al. Patellofemoral evaluation after total knee arthroplasty.JBJS.2007;89:1810-17

Lateral View
the sagittal alignment of the femoral and tibial component
can be assessed
the femoral component may be in extension, neutral
position or flexion.
If the femoral component is in too much extension, the risk
of notching the anterior femoral cortex is increased.
If the femoral component is in excessive flexion , knee
extension may be blocked in TKA prosthesis designs that do
not permit too much hyperextension.
7

This study, the mean of 1,53 (range, 0 5) in flexion position.

7. Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al, Reading radiograph after total knee arthroplasty.Hongkong J Orthop Surg.2010;14(1):225-39


Lateral View
Posterior slope of the tibial component, some authors
have suggested that ideal posterior tibial slope should
be 0-3 degree.
7
.
In our study the mean of tibial angle () was 4,31
(range, 80 92).
In general, more posterior slope is needed with PCL-
retaining TKA prosthesis than with posterior-stabilised TKA
prosthesis.
Excessive posterior flexion instability
Inadequate posterior slope or anterior slope
tightening of the collateral ligament with knee flexion,
thus limiting knee flexion.
7

7.Chiu,K.Y.,Cheng,H.C.,Yau.W.P., et al, Reading radiograph after total knee arthroplasty.Hongkong J Orthop Surg.2010;14(1):225-39

Patellar tilt&shift
In our study, mean of patellar tilt was 37,5
(range, 22 60)

patellar shift was 3,05 mm (range, 0 14),
most of case (84,25%) shift to lateral

Baldini et al reported that patellar tilt and
subluxation were considered major only when
they measured > 5 degree or > 5 mm.
12

12.Paratte.S.,Pagnano.M.W.,Trousdale.R.T., et al.Effect of postoperative mechanical axis
alignment on the fifteen-year survival of modern,cemented total knee
arthroplasty.JBJS.2010;92:2143-9

Radiolucency
Lateral view femoral component
Our Study: Patil et al : PFC-TKA
14 years follow-up

12.Patil,S.S.,Branovacki.G.,Martin,M.R.,et al.14-Year Median Follow-Up Using the Press-Fit Condylar Sigma Design for Total Knee
Arthroplasty.Arthroplasty.2013;1-5
Radioluscence
Tibial implant AP View
Our Study

Patil et al : PFC TKA
14 years follow up
12.Patil,S.S.,Branovacki.G.,Martin,M.R.,et al.14-Year Median Follow-Up Using the Press-Fit Condylar Sigma Design for Total
Knee Arthroplasty.Arthroplasty.2013;1-5
Weaknesses of the study
Weaknesses of the study are its retrospective
nature, short-term follow up and small population.
The latest developments in TKA are high-flex knees
and sex-specific knees specifically developed
to achieve more range of motion, potentially
allowing a higher level of activity for patients.
An increased range of motion in high-activity
young patients may result in early loosening.
Future research will show us the long-term results of
the new TKA designs
Conclusion
Our experience with TKA in our hospital has
been encouraging.
The risks of implant loosening and wear in our
study are low.
This type of TKA seems to be an effective and
safe treatment for patients.
Functional and radiographic outcome were
comparable to other published studies
Most patients do well after a short-term follow-
up period.


THANK YOU