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Indications for Knee Arthroplasty

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Indications for TKA
Relieve pain caused by osteoarthritis of the knee (the most common).
Deformity in patients with variable levels of pain:
o Flexion contracture > 20 degrees.
o Severe varus or valgus laxity.

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Osteoarthritis
American College of Rheumatology classification criteria:

Knee pain and radiographic osteophytes and at least 1 of the following 3


items:

o Age >50 years.


o Morning stiffness <=30 minutes in duration.
o Crepitus on motion.

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Contraindications for TKA
Recent or current knee sepsis.
Remote source of ongoing infection.
Extensor mechanism discontinuity or severe dysfunction.
Painless, well functioning knee arthrodesis.
Poor health or systemic diseases (relative contraindications).

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Indications:
Younger patients with unicompartmental disease instead of HTO.
Elderly thin patient with unicompartmental disease (shorter rehabilitation, greater
ROM)
Contraindications:
Flexion contracture >= 5 degrees.
ROM < 90 degrees.
Angular deformity >= 15 degrees.
Cartilaginous erosion in the weight-bearing area of the opposite compartment.

Unicondylar Knee Arthroplasty

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Patellar Resurfacing
Indication for leaving the patella unresurfaced:
o Congruent patellofemoral tracking.
o Normal anatomical patellar shape.
o No evidence of crystalline or inflammatory arthropathy.
o Lighter patient.

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Classification
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Classification
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3
1- Cruciate retaining
2- Cruciate substituting
3- Mobile bearing
4- Unicondylar
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2

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Biomechanics of Knee Arthroplasty

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Kinematics
The TRIAXIAL motion of the knee:
o Articular geometry
o Ligamentous restraints
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Degrees of Freedom

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Degrees of Freedom
Constrained Prostheses
Non-constrained Prostheses
Intermediated Prostheses

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Constrained Prostheses
Hinged implants.
One degree of freedom.

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Non-constrained Prostheses
Ideal implants.
5 degrees of freedom.
Intact ligamentous system.
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Intermediated Prostheses
Anterior-posterior stability.
Two types:
o FREEMAN (a cylinder in a non conforming trough).
o INSALL (posterior stabilized knee).

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Intermediated Prostheses
Freeman
Insall

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Longitudinal Alignment Of Knee
Tibial components are implanted perpendicular to the mechanical axis.
Femoral component is implanted in 5 6 degrees of valgus.

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Longitudinal Alignment Of Knee
Posterior tibial tilt is about 5 7 degrees.
Usually depend on the articular design.

Anatomic tilt 5 degrees

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Rotational Alignment Of Knee
Create a rectangular flexion space.
External rotation of the femoral component 3 degrees.

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Role of PCL Femoral Roll-Back

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Role of PCL Femoral Roll-Back

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PCL retaining prostheses:
Better ROM (roll-back, flat tibial surface).
More symmetrical gait (stair climbing).
Less femoral bone resection is required.
PCL needs to be accuracy balanced.
PCL substituting prostheses:
Easier surgical exposure.
See-saw effect prevention.
Lower tibial polyethylene contact stress
Posterior tibial component displacement.
Patella clunk syndrome.

PCL-retention or PCL-substitution ?

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PCL-retention or PCL-substitution ?

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PCL-retention or PCL-substitution ?

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Patella Clunk Syndrome

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Patellofemoral Joint
The patella acts to lengthen extensor lever arm.
This arm is greatest at 20 degrees of flexion.

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Patellofemoral Joint
Changes in the patellar area of contact can leads to eccentric loading of the
patellofemoral joint.

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Patellofemoral Joint
Limb with larger Q angle has a greater tendency for lateral subluxation.
Preventing subluxation:
o Prosthetic component.
o Vastus medialis (in early flexion).

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Polyethylene Issues
1- Dished polyethylene avoids the edge loading. (as PCL substitution)
2- Minimal polyethylene thickness >= 8 mm to avoid higher contact stress.

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Surgical Technique for Primary TKA

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Preoperative Evaluation
Soft tissue defects around the knee.
Vascular status to the limb.
Extensor mechanism.
Preoperative range of motion.
Standing (AP) view, a lateral view of the knee, and a skyline view of the patella.

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Surgical Preparation
Administer a dose of a 1st generation cephalosporin (or vancomycin,
clindamycin)
Avoid pressure on peripheral nerves.

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Surgical Approaches
Medial parapatellar retinacular approach.
Subvastus approach.
Midvastus approach.
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Subvastus approach:
Intact extensor mechanism.
Decreasing pain.
More limited.
Postoperative hematoma.
Midvastus approach:
Preserve genicular a. to the patella.
Contraindication in limited preoperative flexion.
Postoperative hematoma.

Surgical Approaches

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Surgical Approaches
Lateral parapatellar retinacular approach:
o In valgus knees.
o Improve patellar tracking and ligamentous balancing.

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Bone Preparation IM Femoral Guide
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Bone Preparation Gap Technique

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Bone Preparation Tibial Resection
The guide is aligned with the anterior tibial tendon and first web space of the
toes.

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Balancing of The Knee

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Varus Deformity
1st Osteophytes must be removed.
2nd Release the deep MCL.
3rd Release semimembranosus and pes anserinus insertion.
4th release posterior capsule and PCL.
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Varus Deformity

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Valgus Deformity
1st Remove all osteophytes.
2nd release lateral capsule.
3rd
o Lesser deformity: release Iliotibial band.
o Greater deformity: release LCL +/- PCL.
Valgus deformity + flexion contracture >> release posterior capsule.

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Valgus Deformity

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Flexion Contracture
Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule
release.
Flexion gap < Extension gap >> larger tibial insert.
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Flexion Extension Balancing

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Computer Assisted Surgery in Total Knee Arthroplasty

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Management of Bone Deficiency

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Patellofemoral Tracking
Internal rotation of tibial component increases the tendency to lateral patellar
subluxation.
Prosthetic patella should be medially positioned.

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Postoperative Management
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Roentgenographic Evaluation

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Total knee replacement exercise protocol
Postoperative day 1
o Bedside exercises (e.g. ankle pumps, quadriceps exercises)
Postoperative day 2
o Exercises for active ROM and terminal knee extension
o Gait training with assistive device
Postoperative day 3-5
o Progression of ambulation on level surfaces and stairs (if applicable)
Postoperative day 5 to 4 weeks
o Stretching of quadriceps and hamstring muscles
o Progression of ambulation distance

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Specific Disorders

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Previous HTO
Difficult surgical exposure.
Lateral ligamentous laxity.
Difficult stem placement.
Patella infera.

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Previous Patellectomy
PCL retaining arthroplasty for better results.

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Complications of Total Knee Arthroplasty
Thromboembolism.
Infection.
Neurovascular complications.
Patellofemoral complications.
Periprosthetic fractures.

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Patellofemoral Complications
Patella clunk syndrome.
Patellar component failure.
Rupture of patellar ligament.
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Periprosthetic Fractures

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