Tips and Tricks in HIP AND KNEE ARTHROPLASTY

Tips and Tricks
in
HIP AND KNEE ARTHROPLASTY
Tips and Tricks
in
HIP AND KNEE ARTHROPLASTY
A Practical Approach
Authors
Chandra Shekhar Yadav MBBS MS (Ortho)

Professor
Department of Orthopedics
Knee and Hip Arthroplasty Surgeon
All India Institute of Medical Sciences (AIIMS)
New Delhi, India
Joint Replacement Fellow
The Prince Charles Hospital, Brisbane, Australia
King George Hospital Sydney, Australia
Dartmouth-Hitchcock Medical Center
New Hampshire, USA
Ashok Kumar MBBS MS (Ortho) MRCS

Consultant Orthopedic Surgeon
Department of Orthopedics
(Joint Replacement, Pediatric Orthopedics, Oncology)
Dubai Bone and Joint (DBAJ) Center
Mohammed Bin Rashid Al Maktoum Academic Medical Center (BBRM-AMC)
Dubai Healthcare City (DHCC)
Dubai, UAE
Fellow
Exeter Hip Center, UK
Trauma and Orthopedics
Katharinen Hospital, Germany
Co-Author
Sanjay Yadav MBBS MS (Ortho)

Senior Resident
Department of Orthopedics Surgery
All India Institute of Medical Sciences
New Delhi, India
Foreword
Ross Crawford
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Tips and Tricks in Hip and Knee Arthroplasty: A Practical Approach

First Edition: 2014
ISBN: 978-93-5025-647-3
Printed at
Dedicated to
My patients, well-wishers and family
—Chandra Shekhar Yadav
My parents, loving wife (Sharda)

sons (Anikait and Krish) and elder brother (Subhash)
—Ashok Kumar
My parents, wife (Swati)

teachers and patients
—Sanjay Yadav
Foreword
As hip and knee arthroplasty expands rapidly in India,

it is important that training and junior surgeons develop
an understanding of the principles of surgery. This
book Tips and Tricks in Hip and Knee Arthroplasty:
A Practical Approach offers an excellent introduction
to the concepts and techniques of basic hip and knee
arthroplasty. The book is well laid out with extensive
illustrations, explaining the principles of arthroplasty,
including surgical techniques and complications.
I think, the book will be a very valuable aid for those
developing their skills in hip and knee arthroplasty. I recommend the book to
you as an excellent reference source for understanding hip and knee arthro-
plasty from the fundamental level to dealing with more complex primary
joints replacements.
Both the beginner and experienced surgeons will find much to enjoy
in the book and will gain knowledge in some of the controversies in
joint replacement surgery. The book does not choose to judge or present
opinions on appropriate implant selections or techniques, but does provide
a balanced approach to the pros and cons of different implant selections and
surgical techniques.
Ross Crawford
D Phil (Oxon) FRACS (Ortho) MBBS (Qld)
Professor (Orthopedic Research)
Department of Biomedical Engineering
School of Mechanical, Manufacturing and Medical Engineering
Queensland University of Technology, Australia
Director
Department of Orthopedic Surgery
Mater Adult Hospital
South Brisbane Qld 4101, Australia
Preface
It gives us immense pleasure to introduce the first edition of this book titled
Tips and Tricks in Hip and Knee Arthroplasty: A Practical Approach. There
are so many short books on the arthroplasty in the market, but usually they
are focused in detail on one particular aspect of the arthroplasty. There was a
need for a book which talks about simple practical approach to hip and knee
arthroplasty. A book which gives all information from basic to the recent
advances and current controversies in easily understandable language which
even an orthopedic surgeon working in remote areas can understand and
follow the concepts of the arthroplasty. By keeping these objectives in mind,
the book has been written with sincere efforts. The book would be a great
help for the postgraduates, residents, consultants and other surgeons who
want to understand and learn the art of arthroplasty but may not be having
a good mentor or shy to clear their doubts about arthroplasty because of
their position, age or other reasons. The book cannot replace the standard
textbooks of arthroplasty or orthopedics, but it will be of immense help as a
handbook for the operation theater, indoor, outdoor clinical practice among
budding arthroplasty surgeons.
Chandra Shekhar Yadav

Ashok Kumar
Sanjay Yadav
Contents
Section 1: Hip Arthroplasty
1. Applied Anatomy 3

• Hip Joint 3

2. History and Biomechanics of Hip Arthroplasty 6

• Biomechanics 9

3. Implants and Bone Cements 14

• Femoral Component 14

• Acetabular Component 19

• Ceramic on Ceramic Hips 21

• Metal-on-metal Total Hip Arthroplasty 22

• Hip Resurfacing vs Conventional THR 24

• Bone Cements 24

4. Radiographic Evaluation in Total Hip Arthroplasty 28

• Preoperative Radiological Evaluation 28

• Radiographs 28

• Acetabular Conditions, Precautions and Problem Faced 28

• Femoral Conditions, Precautions and Problems Faced 31

• CT Scan 34

• Magnetic Resonance Imaging 35

• Bone Scan 35

• How to Read Postoperative X-Ray? 35

• Follow-up Radiographs 38

• Aseptic Loosening of Cup 38

5. Surgical Approaches and Indications of

Hip Arthroplasty 41

• Conventional Surgical Approach 41

6. Perioperative Management of Total Hip Arthroplasty 50

• Preoperative Clinical Evaluation 50

• Postoperative Clinical Management 51

7. Primary Total Hip Arthroplasty 54

• Neck Cut 54

• Exposure of Acetabulum 54

xii Tips and Tricks in Hip and Knee Arthroplasty
• Acetabular Reaming 58

• Femur Preparation 58

• Impingement 67

• Wound Closure 70

8. Complex Primary Total Hip Replacement 71

• Total Hip Replacement in Protrusio Hip 71

• Total Hip Replacement in Ankylosed Hip 73

• Dysplastic Hip 76

9. Complications of Total Hip Arthroplasty 79

• Hematoma Formation 79

• Mortality 79

• Thromboembolism 80

• Vascular Injury 81

• Limb Length Discrepancy 81

• Instability (Dislocation and Subluxation) 81

Section 2: Knee Arthroplasty
10. Applied Anatomy of Knee Joint 85

• Knee Joint 85

11. History and Biomechanics of Knee Arthroplasty 90

• Biomechanics of Normal Joint and a Prosthetic Joint 91

12. Implants and Patient Selection 94

• Osteoarthritis of Knee Joint 94

• Treatment 95

• Cruciate Retaining vs Cruciate Substituting 96

• High Flex Design 98

• Fixed vs Mobile Knee 99

• Gender Knees 99

• Cemented vs Noncemented 100

• All Polyethylene vs Metal Backed Tibia 101

• Routine vs Judicious use of Anticoagulant Prophylaxis 102

• Patellar Resurfacing 103

• Extension Rods 106

• Hinged Implants 106

• Various Conditions and Implant Selection 106

Contents xiii
13. Perioperative Management of

Total Knee Arthroplasty 111

• Preoperative Clinical Evaluation 111

• Postoperative Clinical Management 113

14. Surgical Approaches and Technique of Primary

Total Knee Arthroplasty 116

• Surgical Approaches 116

• Tips of Patellar Eversion 123

• Bone Cuts 123

• Tibial Cut 123

• Common Mistakes and their Causes 140

• Criteria for Equalizing Flexion and Extension Gaps
and Bone Cuts 145

15. Complex Primary Total Knee Arthroplasty 146

• Varus Knee 146

• Valgus Knee 147

• Fixed Flexion Deformity of Knee 148

16. Complications of Total Knee Arthroplasty 153

• Complications after Total Knee Replacement 153

Index 157. 157
Section 1
Hip Arthroplasty
1
chapter
Applied Anatomy
Hip Joint
Type: Multiaxial ball and socket variety of the synovial joint.
arts of Bones Forming Hip Joint

P
zz Acetabulum: It lies on the lateral surface of pelvic bone where ilium, pubic
and ischium bone fuse with each other. It has (Fig. 1.1) medial wall (floor, F),
anterior (A), posterior (P) walls and the dome (D weight-bearing area). Inferiorly
it is deficient and is called as the acetabular notch which is traversed by the
transverse acetabular ligament (TAL). Acetabulum is 20° anteverted.
zz Femur: Head of femur (Fig. 1.2) articulates with the acetabular cavity of pelvic
bone. Neck is anteverted (15°) in relation to coronal plane.
zz Capsule: It extends proximally to the acetabulum and transverse acetabular
ligament, surrounds the femoral neck and is attached anteriorly down to the
intertrochanteric line and posteriorly about 1cm above the intertrochanteric
crest.
zz Acetabular labrum: It is a fibrocartilaginous rim which elevates the peripheral
margin of acetabulum and forms the transverse acetabular ligament.
zz Movements: Flexion (0-130°), extension (0-20°), abduction (0-40°), adduction
(0-30°), internal rotation (0-35°), external rotation (0-45°), and circumduction.
zz Blood supply: Hip joint is supplied by the branches of the obturator artery,
medial and lateral circumflex femoral arteries, superior and inferior gluteal
arteries, and first perforating branch of the deep artery of the thigh.
zz Inferior gluteal artery: It leaves behind the piriformis and its branch may be
damaged while splitting the gluteus maximus muscle proximally.
zz Blood supply to quadratus femoris: Branches of the lateral circumflex artery may
bleed while cutting the quadratus femoris muscle.
4 Section 1 Hip Arthroplasty

Fig. 1.1 Anterior (A), posterior (P) walls, dome (D), floor (F) and transverse acetabular ligament
(TAL) of the acetabulum; also the insertion of abductors (AB) at the tip of trochanter (T) and thigh
Fig. 1.2 The head (H, ball), acetabulum (Socket A), neck (N), greater trochanter (GT), lesser
trochanter (LT), gluteus maximus (GM), attachment of the vastus lateralis (VL) at the base of
greater trochanter and abductors (AB) being retracted at its attachment at the tip of greater
trochanter with Hohmann retractor
hapter 1 Applied Anatomy 5
C

Fig. 1.3 Tip of trochanter (TP), piriformis tendon (P), superior gemellus (SG), obturator
internus (OI), inferior gemellus (IG), quadratus femoris (QF) and sciatic nerve (SN)
erve Supply
N
It is supplied by femoral, obturator, superior gluteal nerves and by nerve to the
quadratus femoris.
Sciatic nerve: It leaves the pelvis through the greater sciatic notch and runs down
the back of the thigh on the short external rotator muscles, encased in fatty tissue.
The nerve crosses (Fig. 1.3) the superior gemellus (SG), obturator internus (OI), the
inferior gemellus (IG), and the quadratus femoris (QF) before disappearing beneath
the femoral attachment of the gluteus maximus.
2
chapter
History and Biomechanics of

Hip Arthroplasty
History
There are four different periods in the evolution of arthroplasty:
1. Early stage of total hip arthroplasty:

Emphasis was on how arthroplasty can be performed successfully with different pro-

posed materials (gold, fascia, glass, metal) and methods.
• The first attempt to replace the hip joint was made by Gluck from Berlin

(Germany, 1880) by using an ivory prosthesis.1 It was not successful. Second
attempt was by French surgeon, Jules Pean from Paris (1890) with a platinum
prosthesis. This prosthesis also failed.
• Sir Robert Jones (1912) performed interpositional (using gold foils) hip

arthroplasty.
• Smith-Peterson (1921) performed mold arthroplasty (using glass) to restore

congruous articular surfaces by inducing metaplasia in fibrin clot formed over
exposed bleeding articular cancellous surfaces to fibrocartilage aided by gentle
motion. Problem was glass breakage.2
• Modified Smith-Petersen cup arthroplasty (Aufranc) was the standard hip

reconstruction method during this stage.2
2. Early modern total hip arthroplasty:

Different types of prostheses became available but were associated with high rate

of complications because of poor material and design. Bone cement and high
density polyethylene were introduced.
• Judet used heat-cured acrylic femoral head prosthesis. Problems were fragmen-

tation and wear of acrylic head, tissue reactions and bone destruction.3
• Moore4 and Thompson5 used metallic endoprostheses and these were associ-

ated with acetabular erosion and femoral bone loss (Fig. 2.1).
• Charnley6 introduced the concept of low frictional arthroplasty and used poly-

ethylene with a cemented stem. Initial prosthesis consisted of a Teflon cup and
stainless steel monobloc femoral components. Head size (Fig. 2.2) was 22.2 mm
Chapter 2 History and Biomechanics of Hip Arthroplasty 7

Fig. 2.1 Thompson and AMP prostheses, stem going into varus

Fig. 2.2 Charnley cemented prosthesis Fig. 2.3 28 mm head with cementless total

hip arthroplasty (AML stem-Diaphyseal/
Distal fit)
8 Se tion 1 Hip Arthroplasty
c

and prosthesis was fixed with polymethylmethacrylate (PMMA). Problems were
‘poly’ wear and aseptic loosening.6
3. Standard total hip arthroplasty:

Metal on ultra-high density polyethylene with cementless (Fig. 2.3) or cemented

stem became the standard modern THR implants:
• Improved cementing technique

• Large diameter heads were introduced (Fig. 2.4)

• Press fit or porus coated, hydroxyapatite coated cementless stem were

introduced.
4. Current total hip arthroplasty:

Emphasis is on improving the bearing surfaces (metal, ceramic, highly crossed

linked poly):
• Metal-on-metal (cup, liner, head—all are metallic) (Fig. 2.4)

• Metal-on-poly (metallic cup with highly crossed linked polyethylene liner on a

metallic head) (Fig. 2.5)
• Ceramic-on-poly (metallic cup, highly crossed linked polyethylene liner with

ceramic head)
• Ceramic-on-ceramic (ceramic liner with ceramic head with metallic cup)

(Fig. 2.5).
Fig. 2.4 Large head Metal on Metal cementless THR


Fig. 2.5 Ceramic-on-ceramic, metal-on-poly coupling with metaphyseal/proximal fit stem

Biomec anics
h
Load on Hip
Body weight acting on the hip in a single leg stance phace should be counterbal-
anced by the abductors by generating 2.5 times more force to maintain the position
of pelvis.
zz Normal hip: Ratio of the lever arm of the body weight to that of the abductors:
2.5:1
zz Arthritic hip: May be up to: 4:1
zz Prosthetic joint: Can be reduced up to 1:1 and it offloads hip up to 30% of the
total load. Increasing the abductor lever arm reduces stress on joint.
otational tability
R
S
Rounded cemented femoral stem, broad proximal part, distal flutes, surface impres-
sions and extensive porous coating improve rotational stability.
enter of Head (Hip enter)

C
C
The anatomic position of center of head is most desirable position due to minimum
stress on the joint. Medial or superolateral center of head produces more stress than
the anatomic position.
Center of rotation of head is determined by following three factors:
1. Vertical offset (Vertical height): Vertical distance from the center of the head to

lesser trochanter (Fig. 2.6). Shortening of affected lower limb can be calculated by
comparing this distance to opposite normal side in unilateral pathology.
2. Offset (Horizontal offset): Horizontal distance from the center of the femoral head

to a line through the axis of the distal part of the stem or canal (Figs 2.7 and 2.8).
c

Fig. 2.6 Vertical offset (distance) from center of femoral head to lesser trochanter

Fig. 2.7 A = Horizontal offset, B = Vertical offset

Fig. 2.8 Horizontal offset (distance) from center of femoral head to tip of greater trochanter

at right angle to axis through stem or canal

3. Version of neck (Anterior offset): Position of neck in relation to the coronal plane.

Normal anteversion: 10-15° (prosthetic joint should have the normal anteversion).
Varus hips have reduced vertical offset and increased horizontal offset while

valgus hip has increased vertical offset and reduced horizontal offset.
Head Diameter
Large Diameter Head
zz More range of motion: Around 8-10° more flexion with 32 mm head than 28 mm.7
zz More stable: Has to move more distance before dislocation—‘jump distance’.
zz Large head with trapezoidal neck (all current modern implants) produces less
impingement than the 28 mm head with thick neck or skirted head (Plus size
head) on a thick neck (circular or nonoval or nontrapezoidal neck).
Current socket has a depth equal to radius of head and has beveled edges (both are

absent in Charnley cup). So with large head, impingement is less and movement is more.
oefficient of Friction
C
It indicates amount of the resistance produced in moving one object over another.
The coefficient of friction for normal joints: 0.008 – 0.02; metal-on-metal: 0.8;
metal on high-density polyethylene: 0.02; ceramic-on-polyethylene is low; ceramic-
on-ceramic is nearly equal to normal joint.
Wear
It is the loss of material from the moving surfaces of the prosthetic joint. It can be
abrasive, adhesive and fatigue (more important in TKR).
Three-body (third body) wear8 is an abrasive wear and occurs due to retention of

debris particles between the sliding surfaces. Linear wear is measured by serial X-rays
and better by digital radiographs and computer-assisted wear measurement. Cobalt-
chromium alloy head with a UHMWPE acetabular component usually has average
wear of 0.10 mm/year.
Polywear
Poly having a thickness below 5 mm usually has high risk of premature wear. Bigger
head produces more volumetric wear and small head produces more point contact
wear. But large head with highly crossed linked poly produces minimal poly wear.
Cross-linking of polyethylene molecules by gamma radiation or electron beams is
now known to substantially reduce wear of polyethylene bearings, with wear reduc-
tion proportional to the amount of cross-linking achieved. Second generation highly
cross-linked poly like X3 poly (Stryker) uses sequential annealing to help saturate
free radicals and EPoly (Biomet, Warsaw, IN) that uses vitamin E as a free radical
scavenger have been introduced in the market. Advantages9 of highly cross-linked
polyethylene include improved wear resistance, improved oxidative resistance, poten-
tially lower susceptibility to third body wear, and maintenance of handling proper-
ties similar to the existing UHMWPEs. Reported mean wear rate with highly cross-
linked poly is 0.022 and with UHMWPEs are 0.085 mm/y.9
c

Metal wear: Metal undergoes oxidative wear due to formation of surface passive oxide
film, and with joint motion this film is repeatedly removed and reformed, with grad-
ual roughening of the surface. Linear wear/year rate for metal-on-metal is 0.004 mm
and metal-on-poly is 0.1 – 0.4 mm.
Ceramic wear: Alumina and zirconia ceramics are harder than metal and exist in an
oxide state; therefore, are not susceptible to oxidative wear. Linear wear/year rate for
ceramic-on-poly is 0.05 – 0.1 mm and ceramic-on-ceramic is 0.002 mm.
Lubrication: A thin film of fluid between metallic head and cup (boundary lubricant)
reduces friction between the surfaces.
Periprosthetic bone loss (Stress shielding): (Fig. 2.9) It is an adaptive bone remod-
eling occurring during first two years due to stress shielding (load is taken more by
implant than the bone). It produces loosening (Fig. 2.9) and may predispose to frac-
ture of the implant or of femur. It usually occurs around the proximal part of stem,
stem with extensive porous coating or along the distal part of long stem. It is best
detected by measurement of bone mineral density by DEXA scan. BMD shows a rapid
fall around prosthesis during first 3-4 months and reaches a plateau around one year.
Then it remains the same for next 5-6 years.10 Alendronate11 has been shown to reduce
the periprosthetic bone loss. Preservation of subchondral bone, poly of more than
5 mm thickness and metal backed poly socket reduces acetabular component
loosening.
Fig. 2.9 Gruen zones of osteolysis around proximal femoral prosthesis (zone 1 to 7)


e erences
R
f
1. Fischer LP, Planchamp W, Fischer B, Chauvin F. The first total hip prostheses (1890) Hist

Sci Med 2000; 34:51-70.
2. Smith-Petersen MN. Evolution of mould arthroplasty of the hip. J Bone Joint Surg 1948;

30:59-70.
3. Judet R, Judet J. Technique and results with acrylic femoral head prosthesis. J Bone

Joint Surg Am 1952; 34:173-9.
4. Moore AT. The self-locking metal hip prosthesis. J Bone Joint Surg Am 1957; 39:811-20.

5. Thompson FR. Two and a half years’ experience with a Vitallium intramedullary hip

prosthesis. J Bone Joint Surg Am 1954; 36:489-99.
6. Charnley J. Arthroplasty of the hip: a new operation. Lancet 1961; 1:1129-36.

7. Burroughs BR, Hallstrom B, Golladay GJ, et al. Range of motion and stability in total hip

arthroplasty with 28, 32, 38 and 44 mm femoral head sizes: an in vitro study. J Arthropl
2005;20:11.
8. Bragdon CR, Jasty M, Muratoglu OK, et al. Third body wear of highly cross-linked

polyethylene in a hip simulator. J Arthropl 2003;18:553.
9. Rajadhyaksha AD, Brotea C, Cheung Y, Kuhn C, PA-C, Ramakrishnan R, Zelicof SB. Five-

year comparative study of highly cross-linked (crossfire) and traditional polyethylene.
The Journal of Arthroplasty 2009; 24( 2): 161-7.
10. Venesmaa PK, Kröger HP, Jurvelin JS, et al. Periprosthetic bone loss after cemented total

hip arthroplasty: a prospective 5-year dual energy radiographic absorptiometry study
of 15 patients. Acta Orthop Scand 2003;74(1):31–6.
11. Tapaninen TS, Venesmaa PK, Jurvelin JS, Miettinen HJA, Kröger HPJ. Alendronate

reduces periprosthetic bone loss after uncemented primary total hip arthroplasty –
a 5-year follow-up of 16 patients. Scandinavian Journal of Surgery 2010; 99: 32–7.
3
chapter
Implants and Bone Cements
Femoral Component
Femoral components are broadly divided into cemented and noncemented variety.
Noncemented stems may have a porous surface for bone ingrowth or may be of press-
fit varieties with surface impressions for macrointegration of bone with the implant.
Vertical offset: It is determined by base length of the prosthetic neck plus the length
added by the modular head (‘plus head’ increases and ‘minus head’ decreases the
length). It is also affected (more in cemented hip) by the level of neck osteotomy and
depth of stem inserted in femoral canal.
Offset (horizontal offset): It is primarily a function of stem design. Some stems come
in 132° (normal) and 127° (high) offsets.
Anteversion: It is determined in relation to lesser trochanter and is less likely to
change in cementless implant than cemented stem. Anatomical stem have some
degree of inbuilt anteversion.
Cemented Stems
Most commonly used stems are made up of cobalt-chrome alloy which has a high
modulus of elasticity and it reduces stress in the proximal cement mantle. Lateral
broad cross section of stem, loads the proximal cement mantle in compression.
Collared stems are believed to help in deciding the depth of insertion. Initially
stems having rough surface or impressions were believed to help in improving cement
and implant bonding, but were later found to produce more debris and loosening.
Currently polished collarless stems are the standard cemented femoral implant. Exeter
stem is a polished collarless double tapered implant. Exeter stem is gold standard
among the cemented stems. Examples of cemented stems are shown in (Fig. 3.1).
Stems should occupy approximately 80% of the cross section of the medullary canal
with an optimal proximal 4 mm and distal 2 mm of cement mantle (Fig. 3.2).
Distal cement restrictor (usually 12-14 mm) or distal medullary plug and centralize
Chapter 3 Implants and Bone Cements 15

Fig. 3.1 Different cemented stems

Fig. 3.2 A well-fixed cemented exeter stem
c

able 3.1 eported advantages and disadvantages of cemented and cementless
T

R
hips
Cemented hip Cementless hip
dvantages • Gives immediate stability • Allows fixation by
A

• Allow immediate to early mobilization direct bone-to-implant

• Cement can fill the minimal femoral osteointegration

or acetabular bone loss/defects • Revision is easy
without need of bone grafting • Cement related problems

• Less expensive are not present
• Limb length and femoral anteversion

can be adjusted at the time of setting
of bone cement
Disadvantages • Technically demanding (requires • More expensive than

expertise in cementing techniques) cemented hip
• Aseptic loosening (Fig. 3.3 ) • 3-6 weeks of nonweight

B

• Cement fracture /breakage bearing mobilization is
• Cement related problem: Fat required for osteointegration

embolism • Sometimes stem removal

• Revision becomes difficult due to difficult than cemented stem

removal of cement and bone loss
A B
Figs 3.3A and B (A) Septic loosening of the cemented hip stem; (B) Aseptic loosening of

the acetabular (arrow) and femoral components

the stem in the femoral canal and help in achieving uniform cement mantle. Usual
length of currently available stem designs varies from 120 to >200 mm. Long stems
are required in revision hip, or to bypass a cortical perforation, fracture or weak
bone due to removal of screw or internal fixation devices. Advantages and disad-
vantages of cemented and cementless hip are given in Table 3.1. Figures 3.3A and B
shows septic and aseptic loosening.
Cementless Stem
It is indicated in active young adults, middle age and elderly patients with good
bone stock. Definitive stability is provided by ingrowth of bone around the stem
in the femoral canal. Most of them are proximal fitting stems. Very long stems
(Fig. 3.5B) are distal fitting stem (used for revision hip). Two prerequisites for bone
ingrowth include immediate implant stability at the time of surgery and intimate
contact between the porous surface and viable host bone. Figure 3.4 shows various
cementless stems.
Uncemented porous coating: Commonly coated surface include titanium alloy with a
porous surface of commercially pure titanium fiber-mesh or beads and cobalt-chromium
alloy with a sintered beaded surface. Titanium has superior biocompatibility, high fatigue
strength, and lower modulus of elasticity. But it is notch sensitive hence the porous coat-
ing should be restricted to large proximal part of the stem and should be avoided on
Fig. 3.4 Different cementless stems

A B
Figs 3.5A and B (A) AML stems; (B) Solution stem
lateral tensile border of the stem. Problems include fatigue strength of porous implants,
ion release, and adverse femoral remodeling. Extensive coating produces adverse femoral
remodeling, stress shielding and thigh-pain (AML and Solution stems). Hence, it should
be restricted to proximal portion only specially in primary arthoplasty).
But fully coated stems are very useful in revision and osteoporotic bone where proximal
or metaphyseal fitting is doubtful (Figs 3.5A and B).
Cementless stems come in two following basic shapes:
Anatomical femoral stem: It has a posterior metaphyseal bow and a variable anterior
diaphyseal bow according to the geometry of the femoral canal. Anteversion must be
built into the neck segment of separate right and left stems and slight overreaming
is required for good fitting of implant. They are believed to transfer stress to large
priority areas of contact mimicking the normal strain transfer patterns of the femur
so have the long-term fixation.
Straight femoral stem (Fig. 3.4): It has a symmetrical cross section and fit on either
side. They may have proximal tapered large canal filling portion or may have par-
allel-sided, less proximal canal filling to achieve good fit (proximal and distal) and
axial/rotational stability by virtue of their shape. They are believed to have better fit
because of extra preparation of femoral canal.
Uncemented Press-fit Stems

They have rough surface or surface impression that promotes macrointerlocking with
bone after initial immediate surgical stability. They do not promote bone ingrowth
without additional hydroxyaptite coating.
Modular Femoral Stem (Fig. 3.6)

These stems are required for mismatch in fit at the proximal and distal part of stem.
They have separate metaphyseal and neck part independent of diaphyseal portion.
Fig. 3.6 Versatile modular and custom made hip system
They are used in deformity of proximal femur due to surgery, trauma and congenital
bowing and revision hip replacements.
Custom-made Femoral Components (Fig. 3.6)

Patients having bony deformity or bone loss from trauma, tumor, congenital condi-
tions (DDH requires small stems) or revision surgery (calcar replacement prosthesis)
require custom made or specialized femoral components.
Acetabular component
Broadly divided into cemented or cementless cup.
Cemented Cup (Fig. 3.7)

Long-term survivorship is still questionable especially in beginners. Hence, these are
preferred in elderly low demand patients, tumor surgery, severe osteopenic bone and
revision surgery (requiring extensive bone grafting). But this is used in all age groups in
many parts of the world. Cup has thick ultra high density (UHD) polyethylene with
peripheral flange to pressurize the cement mantle, vertical and horizontal grooves on
external surface to stabilize cement mantle and wire marker embedded in the plastic for
assessomg the cup position in postoperative radiographs. Surface PMMA spacer of 3
mm helps in formation of a uniform cement mantle and prevents “bottoming out phe-
nomenon” (cement gets pushed out below the cup and results in thin cement mantle).
Fig. 3.7 Exeter cemented cup with raised PMMA spacers
Fig. 3.8 Cementless acetabular cup
Cementless Acetabular Components (FIg. 3.8)

Porus coated cementless cup with a UHD polyethylene or crossed linked polyethyl-
ene have become the standard in current modern cementless total hip arthroplasty.
Bone integration is facilitated by initial fixation (integration occur maximum around
this) with screw, peg/spikes, or by enlarged peripheral press fitted rim without screw.
Size ranges from 40 to 75 mm with polyethylene to articulate with different head
diameters (22 to 36 mm). Polyethylene is secured with the cup by plastic flanges and
metal wire rings that lock behind elevations or ridges in the metal shell, and peripher-
ally placed screws. Thickness of the polyethylene should be > 5 mm to reduce wear
hence acetabular loosening. Usually, polyethylene has a posterosuperior elevation
(flanged portion of polyethylene liner) which gives additional stability. It should be
positioned in either posterosuperior or superior position.
Ceramic on Ceramic Hips (FigS 3.9A and B)

Materials related advantages and problems in old and current designs with ceramic
implants are shown in Table 3.2.
Squeaking Sounds
The incidence of squeaking with alumina-ceramic devices reported in the literature
varies widely (0.3 to 20.9% ).4,5,7
Basic etiology: Study of the retrieved implants have shown microseparation, edge load-
ing, and the development of stripe wear as three possible reasons for squeaking sound.8
Table 3.2 Reported material related advantages and problems with ceramic
implants
Old design Current design (1994 onward; third generation)
Material Faulty materials1,2 Better materials3
• High porosity • Higher density
• Larger grain size • Higher purity
• Low density of the ceramic • Smaller grains
Problems • High fracture rate (13.4%) • Low fracture rate (4:100 000 or 0.004%.)3
• Osteolysis2 • Squeaky sound (0.3%–20.9% )4,5
• Osteolysis (1.4%)6
Fig. 3.9A Ceramic on ceramic hip Fig. 3.9B Ceramic on polyethylene hip
Following three factors may contribute to the above three basic reasons for produc-
tion of squeaking sound:9
zz Surgical technique related factors: Improper orientation of the component may
lead to decreased lubrication at the articulating interface or cause an obstruction

leading to sound due to contact stress vibrations. This sound may be further
exaggerated due to insufficient anteversion of the cup, impingement, or third-
body debris in the interface.
zz Patient related factors: These include younger age, increased height and weight,
and high physical activity.

zz Implant related factors: Implant design and the material also play an impor-
tant role. Delta (Ceramtec) has been shown to produce less sound than Forte
(Ceramtec) ceramic.
Click Sounds
Possible causes include movement of a hard-on-hard bearing, soft tissue impinge-
ment, or shifting.7
Metal-on-Metal Total Hip Arthroplasty (Fig. 3.10)

Potential advantages of metal-on-metal hips include use of large head (better sta-
bility and improved range of motion) and reduced rate of wear and osteolysis.10,11
Disadvantages includes elevation of serum and urine metal ion levels, possible risk
of carcinogenicity and teratogenic effects in human beings,12 metal induced hyper-
sensitivity13 reactions and diffuse or perivascularity oriented lymphocytic infiltration
with early local inflammation and pain (ALVAL-Aseptic Lymphocyte-Dominated
Fig. 3.10 Resurfacing (MOM) implants

Table 3.3 Reported advantages and disadvantages of the hip resurfacing vs

conventional THR
Hip resurfacing Conventional THR
Advantages • Preservation of bone stock • Technically less demanding
on femoral side 14,15 • Problems of head retention are
• Less stress shielding 16,17 not seen (fracture neck of femur,
• Less thigh pain 18 osteonecrosis of head of femur)
• Reduced dislocations 18 • Less expensive (some implants)
• Reduced osteolysis 19 • Large head (36 mm) with highly
• Improved biomechanics 19 cross linked polyethylene give
• Retention of proprioception comparable hip movements,
• Easy revision on femoral side stability and durability
Disadvantages • Learning curve • Range of motion is less than surface

• Fracture of neck of femur replacement in < 36 mm head
(0 to 4%) • More possibility of dislocation in
• Malalignment small heads (0.4% to 5%)
• Aseptic loosening
• Unexplained hip pain
• Increased revision rate due
to complications associated
with learning curve
• Osteonecrosis of head of femur
• Problems of metal-on-metal
articulation
A B
Figs 3.11A and B Complications of resurfacing
Vasculitis-Associated Lesion) and ultimately metallosis and failure. ASR (DePuy

Orthopedics) has been withdrawn from the market.20
Hip Resurfacing vs Conventional THR (FIg. 3.11)

Initial reports of metal-on-metal hips were dramatic but slowly the faults associated
with this technique started appearing in the literature. Initial literature was more in
favor of resurfacing but now sufficient literature shows either a comparable or infe-
rior result in comparison to conventional THR (Table 3.3). Now these implants have
been withdrawn from the market.
Fracture neck of femur: It is a very disturbing complication (Figs 3.11A and B) of
surface replacement. Surgeon’s experience appears to be the most important factor
for this complication. Other contributing factors include age, sex, body mass index,
femoral neck notching, cysts on the femoral head, neck lengthening, and varus align-
ment of the femoral component.21
Bone Cements (Figs 3.12a and b)

There are following three types of bone cement based on their viscosity:
1. Low viscosity: It has a long waiting phase (sticky phase) of 3 minutes; viscosity rapidly
increases during the working phase and has a hardening phase of about 1-2 minutes.
Surgeon has to act quickly for cementing.
2. Medium viscosity: It has a long waiting phase of 3 minutes; viscosity increases
slowly during working phase and has a hardening phase between one minute 30
seconds and two minutes 30 seconds.
3. High viscosity: It has a short waiting phase followed by a long working phase.
Viscosity remains same till the end of the working phase. Surgeon gets more time
for cementing.
The green color of Palacos Cement is believed to have reduced waiting time
for dough-up and its green color gives better visibility. Simplex P is believed to
have a better fatigue strength and Simplex P Speed Set cement has better strength
and a faster setting time. Low viscosty cements are used in THR with cement gun
A B
Figs 3.12A and B Cement mixing technique
(CMW 3). High viscosity cements are used in TKR with digital application (CMW
1). Low temperature (during storing and mixing) and high humidity prolongs set-
ting time while high temperature speeds up the setting of bone cement. Temperature
during hardening phase may increase up to 70°C to 120°C (in vitro) and up to 56°C
(in vivo for 2-3 minutes).
A
Fig. 3.13A Distal medullary plug
B
Fig. 3.13B Distal centralizer in femoral cemented stem
C
Fig. 3.13C Use of cement gun, retrograde filling
Functions of bone cement: It helps in fixation of components, reinforces the bone

structure, transfers the mechanical stress to bone and may deliver antibiotic (if
impregnated with cement).
Modern cementing techniques (Figs 3.13A to C) include pulsatile lavage, medullary
brush (to remove free bone, blood or debris), cement restrictor (for distal block-
age of cement) Fig. 3.13A, packing of medullary canal with gauze tape soaked in
hydrogen peroxide, medullary centralizer over distal tip of stem (to centralize stem
in the canal) Fig. 3.13B, cement preparation (reduction of porosity by vacuum
mixing, centrifugation), and cement gun for retrograde insertion and pressurization
Fig. 3.13C. Complications of bone cement includes pulmonary embolism due to
fat or cement pressurization (more in elderly patient or having patent foramen ovale);
aseptic loosening and breakage.
References
1. Nizard R, Sedel L, Hannouoche D, et al. Alumina pairing in total hip replacement. J Bone
Joint Surg Br 2005;87B:755.
2. Sedel L, Nizard R, Bizot P. Osteolysis and ceramic bearing surfaces. Clin Orthop 1998;349:273.
3. Joseph W. Greene, Arthur L. Malkani, Frank R. Kolisek, Nenette M. Jessup, MPH, Dale L,
Baker BA. Ceramic-on-ceramic total hip arthroplasty. The Journal of Arthroplasty Vol. 24
No. 6 Suppl. 1 2009.
4. Walter WL, O’toole GC, Walter WK, et al. Squeaking in ceramic-on-ceramic hips: the
importance of acetabular component orientation. J Arthroplasty 2007;22:496.
5. Keurentjes JC, Kuipers RM, Wever DJ, et al. High incidence of squeaking in THAs with
alumina ceramic-on-ceramic bearings. Clin Orthop Relat Res 2008;466:1438.
6. D’Antonio JA, Capello WN, Manley MT. Alumina ceramic bearings for total hip
arthroplasty: five-year results of a randomized study. Clin Orthop 2005;436:164.
7. Jarrett CA, Ranawat AS, Bruzzone M, et al. The squeaking hip: a phenomenon of
ceramic-on-ceramic total hip arthroplasty. J Bone Joint Surg Am 2009;91:1344.
8. Glaser D, Komistek RD, Cates HE, et al. Clicking and squeaking: in vivo correlation of sound
and separation for different bearing surfaces. J Bone Joint Surg Am 2008;90 (Suppl 4):112.
9. J Wesley Mesko, James A D’Antonio, William N Capello, Benjamin E Bierbaum, Marybeth
Naughton. Ceramic-on-ceramic hip outcome at a 5- to 10-year interval has it lived up
to its expectations? The Journal of Arthroplasty Vol. 00 No. 0 2010.
10. Schmalzried TP, Peters PC, Maurer BT, et al. Long duration metal-on-metal total hip
arthroplasties with low wear of the articulating surfaces. J Arthroplasty 1996;11:322.
11. Sieber HP, Rieker CB, Kottig P. Analysis of 118 second-generation metal-on-metal
retrieved hip implants. J Bone Joint Surg 1999;80B:46.
12. Brodner W, Bitzan P, Meisinger V, et al. Serum cobalt levels after metal-on-metal total
hip arthroplasty. J Bone Joint Surg Am 2003;85-A:2168.
13. Willert HG, Buchhorn GH, Fayyazi A, et al. Metalon- metal bearings and hypersensitivity
in patients with artificial hip joints. A clinical and histomorphological study. J Bone
Joint Surg Am 2005; 87:280.
14. Mont MA, Ragland PS, Etienne G, et al. Hip resurfacing arthroplasty. J Am Acad Orthop
Surg 2006;14: 454.
15. Crawford JR, Palmer SJ, Wimhurst JA, et al. Bone loss at hip resurfacing: a comparison
with total hip arthroplasty. Hip Int 2005;15:195.
16. Harty JA, Devitt B, Harty LC, et al. Dual energy X-ray absorptiometry analysis of peri-
prosthetic stress shielding in the Birmingham resurfacing hip replacement. Arch
Orthop Trauma Surg 2005;125:693.
17. Little JP, Taddei F, Viceconti M, et al. Changes in femur stress after hip resurfacing
arthroplasty: response to physiological loads. Clin Biomech (Bristol, Avon) 2007;22:440.
18. Wagner M, Wagner H. Preliminary results of uncemented metal-on-metal stemmed and
resurfacing hip replacement arthroplasty. Clin Orthop Relat Res 1996(329 Suppl);S78
19. Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A
minimum follow-up of five years. J Bone Joint Surg Br 2005;87:167.
20. Marker DR, Seyler TM, Jinnah RH, et al. Femoral neck fractures after metal-on-metal
total hip resurfacing: a prospective cohort study. J Arthroplasty 2007;22(Suppl 3):66.
www.depuy.com/asr-hip-replacement-recall. Accessed on 17-10-2013.
4
chapter
Radiographic Evaluation in Total

Hip Arthroplasty
Preoperative radiological evaluation
Radiographs
zz Anteroposterior radiograph of pelvis with both hips and proximal two-third of femur
zz Lateral radiograph of hip with femur.
Confirm the diagnosis and assess the extent of pathology.
Acetabular Conditions, Precautions

and Problem Faced
Dysplasia (Fig. 4.1)
Dysplastic small shallow acetabulum with deficient roof. There is lateral uncovering
of femoral head due to absence of bone in posterosuperior part of acetabulum with
or without evidence of previous iliac surgery (Salter’s/Pemberton osteotomy or com-
monly done shelf procedure).
Think of using small cup with or without posterosuperior bone graft, medializa-
tion of hip center and difficulty in reduction.
Protrusio (Fig. 4.2)

It is the projection of medial acetabular wall beyond the ilioischial line (Kohler line).
Assess the degree (type 1: < 5 mm, type 2: 5-10 mm, type 3: >15 mm) of protrusion.
Think of difficult dislocation of hip, lateralization of hip center with bone grafting
of medial wall. Use the cup with wider periphery like PSL cup of stryker.
Chapter 4 Radiographic Evaluation in Total Hip Arthroplasty 29
Fig. 4.1 Dysplastic left hip with short limb (SL), upridden greater trochanter (UT), shallow
acetabulum, increased acetabular index (AI), uncoverage of the head and sciatic nerve
proximity
Fig. 4.2 Protrusion of medial wall (thin white arrow) of acetabulum beyond Kohler line (blue
line). Severity is assessed with its distance (red line) from Kohler line
Bone Quality (Fig. 4.3)

Whether it is good or poor (osteopenia/osteoporosis).
Think of gentle reaming, gentle impaction of the trial or definitive cup with or
without bone grafting in osteoporotic hips.
Bone Loss
Small or large cystic cavities.
Think of curettage and bone grafting (simple/impacted).
Infection (Healed; Fig. 4.3)

May have poor bone quality, bone loss, wandering acetabulum (high hip center),
limb length discrepancy, protrusion with or without dysplasia.
Old Surgically Treated or Conservatively Treated Fracture of

Acetabulum (Figs 4.4A and B)
May have protrusion, poor bone quality, bone loss, medial or high hip center with or
without limb length discrepancy.
Think of above-mentioned problems and corrective measures including nor-
malization of hip center and limb length discrepancy, need of mesh or antiprotrusio
devices, evaluation for sciatic nerve injury and CT with 3D reconstruction (for col-
umns and walls).
Exposure of cup may be difficult due to tough fibrous tissue. Acetabular wall may
be deficient or nonunited. Reduction may be difficult.
Fitting of cup may be difficult. Metal cutting rasp to remove previous hardware
may be required.
Fig. 4.3 Tuberculosis of left hip with wandering acetabulum (WA), resorption of femoral
head and poor bone quality
Femoral COnditions, Precautions and

Problems Faced
Old Surgically Treated or Conservatively Treated Fracture of
Proximal part of Femur (Figs 4.5A and B)
Calcar is absent. Upper part of femur is deformed. Vertical offset is reduced. Problems
faced are removal of hardware, difficulty in making entry hole and judging the proper
anteversion and difficulty in reduction.
Think of using calcar replacement prosthesis and distal fitting stem (Solution);
hardware removing rasp (Midas Rex), cutting less neck in femoral cut and taking
care of greater trochanter to avoid intraoperative fracture in poor quality bone.
Limb Length (Fig. 4.6)

Distance between two fixed bony points above the acetabulum and below on the
proximal femur. Usually distance between a transverse line joining the lower most
part of two ischial tuberosities (some people use transverse line joining the lower
most part of two tear drops) and a transverse line joining the two lesser trochanter
(mid or just above) is compared on both hips (in unilateral hip pathology) to calcu-
late the shortening.
Think of correct level of neck cut, proper use of head size (plus or minus), offset
(127° or 132°) and restoring center of hip.
A B
Figs 4.4A and B (A) Old neglected central fracture dislocation with poor bone quality;
(B) Postoperative X-ray
A B
Figs 4.5A and B (A) Head in varus with resorption of calcar; (B) Postoperative X-ray
(Solution stem)
Fig. 4.6 Limb length discrepancy (left side lesser trochanter is at the level of left tear drop).
Also, note the poor bone quality
Bowing of Femur
Best seen in lateral radiograph. Mild: careful reaming and component impaction;
Severe: may require osteotomy.
Center of Hip
Horizontal and Vertical Offset
Neck Shaft Angle
Whether normal 130°, coxa vara (may have short limb); or coxa valga (may have
long limb).
Think of restoration of leg length and proper hip center. Use proper offset fem-
oral stem.
Anteversion
Normal is 10 to 15°. Difficult to measure on plain radiographs (need CT); increased
anteversion (risk of anterior dislocation)/decreased anteversion (risk of posterior dis-
location). Keep combined antiversion from 30 to 40° (about 20° acetabulum and 10°
femoral stem). In posterior approach never reduce combined anteversion. Instead, it
is safer to increased combined anteversion by 5 to 10°.
Fig. 4.7 Acetabular templating

Templating for Prosthesis

Determine the center of head, offset (vertical and horizontal), limb length discrep-
ancy, size and position of femoral component, cup (size, position and cement mantle).
Cup (Fig. 4.7): Center of acetabulum is marked through the template over radio-
graph (corrected for magnification) and it should correspond to the new center of
rotation of hip.
The template cup is placed at a 45° angle to the inter tear drop axis and is posi-
tioned with its medial part at tear drop, superior edge at superolateral acetabu-
lar margin, inferior edge at obturator foramen and it should overlap the minimal
subchondral bone of cup.
Center of acetabulum marked through the template corresponds to the new center
of rotation of hip.
Femur (Figs 4.7 and 4.8): Keep tip of neck of template stem at level of tip of greater
trochanter and body of stem within the endosteal dimensions of the femoral diaphy-
sis and metaphysis in both anteroposterior and lateral radiograph of hip with thigh.
Diaphyseal measurements are scaled for magnification, decreasing the likelihood of
undersizing or oversizing the femoral component.
CT Scan
Indications of CT scan include dysplastic hip, old fracture dislocation of acetabu-
lum, sequele of septic arthritis. Assess the configuration of acetabulum (walls, column,
medial bone of acetabulum) and proximal femur (antevesion, deformity, dysplasia).
Fig. 4.8 Templating for femoral stem; 1. level of greater trochanter; 2. matching the medial
inner cortex; 3. matching the lateral inner cortex; 4. at the center of femoral head.
Magnetic resonance imaging

To rule out infection in some cases.
Bone scan
To rule out infection.
how to read postoperative x-ray?

X-ray of pelvis with both hips anteroposterior view and hip joint with thigh lateral
view is required.
Acetabular Component (Figs 4.9 to 4.11)

Look for cup position (anteroinferior edge should be above and lateral to the tear
drop, no space behind the cup if impacted till it touches the floor, medialization or
lateralization), abduction angle (horizontal cup if: < 35°: vertical cup if: > 50°), screw
position, size of cup (over or under size), status of bone graft (osteopenia, bone loss,
DDH) and cavities (well filled with grafts or still prominent), cement mantle (at least
3 mm).
Fig. 4.9 Postoperative AP view after bilateral THR with good cup abduction (around 40 deg-
rees), ITL (Inter-tear drop line), equalized limb length (LL) and well placed screws
Fig. 4.10 Lateral view of the hip with well Fig. 4.11 Vertical cup with high
centered stem and cup (without any gap abduction angle
between cup and acetabulum)
Fig. 4.12 Varus placement of stem leading Fig. 4.13 Wiring around the diaphysis.
to lateral cortical perforation and extra- Minimal calcar with diaphyseal fit using
medullary cement extravasation fully coated long stem prosthesis
Fig. 4.14 Valgus stem Fig. 4.15 Varus stem
Fig. 4.16 Aseptic loosening of the Fig. 4.17 Well fixed cemented femoral stem
acetabular and femoral components (5 years follow-up)
Femoral Component (Figs 4.10 to 4.15)

Look for size of head, center of rotation of head, offset, length of calcar, limb length
discrepancy, varus or valgus position of stem, part of prosthesis above the neck (up
to 1 cm acceptable without significant limb length discrepancy), cement mantle
(4 mm proximal and 2 mm distal), any TBW for trochanteric fracture.
Lateral view (Fig. 4.11): Look for intramedullary central position of stem, antever-
sion of femur, graft and cysts.
Follow-up Radiographs (Figs 4.16 to 4.19)

Look for osteoingration of cup (absence of radiolucent lines between cup and parent
bone, presence of superolateral and inferomedial buttress, medial stress-shielding,
radial trabeculae), change in position, aseptic loosening, subsidence of stem and
changing position of tip of stem.
Aseptic Loosening of Cup (Table 4.1)

Definite Migration
Horizontal or vertical migration >2 or 3 mm, change in opening angle of >5°.
Fig. 4.18 Septic loosening of the Fig. 4.19 Dislocation of femoral head
cemented hip stem
Table 4.1 Comparison of septic and aseptic loosening of joint prosthesis

Parameter Septic loosening Aseptic loosening
Defining the problem Loosening from joint Loosening from other (noninfectious
infection is referred to as reasons) such as bone fracture,
septic failure brittle bones that cannot hold the
implant, or some other mechanical
problem like osteolysis is aseptic
(without infection)
Pain More Less
Inflammatory More elevated Less elevated
markers- CRP, ESR (CRP>10mg/L;
ESR>30mm/hr)
Cytokine levels in More elevated Less elevated
synovial fluid
Radiograph Osteitis Osteolysis
Histology- PMN ≥ 5/hpf (97.8%) ≤ 5/hpf (99%)
infiltrates
Microbiology Culture positive (89%) Culture negative
FDG-PET scan 82.8% sensitivity; 87.3% specificity in septic loosening
Treatment options • Systemic antibiotics • Loosening from bone fracture
with or without surgical around the implant or fracture
irrigation may be the of the implant itself may require
first line of treatment surgery
• Implant removal may be • Failed implant may need revision
required
Hypersensitivity — Hypersensitivity may lead to early
loosening
Septic revisions Suboptimal results Better results
Probable Loosening
Presence of a radiolucent zone at the cement-bone interface around the periphery of
the entire component on at least one radiograph, extending for more than 50% of
the stem circumference.
Possible Loosening
Presence of a radiolucent zone at the cement-bone interface extending for more than
50% but less than 100% of the periphery of the component, and less than 50% of
the stem circumference.
Other Criteria for Radiolucency

Radiolucent lines appearing after 2 years and progressing in all 3 zones (≥ 2 mm
in any zone). Causes may be graft related (migration, incorporation or resorption),
Fig. 4.20 Assessment of acetabular cup positioning
polyethylene wear (decreased distance from head margin to articular margin at any
point), instability (subluxation/dislocation).
Femoral Component (Fig. 4.20)

Look for aseptic loosening, radiolucency, stem migration (compare the position of
shoulder of prosthesis), varus/valgus, offset, center of head, limb length discrepancy,
periprosthetic fracture, cement loosening, broken implant and dislocation. Increasing
migration on serial X-rays is suggestive of stem failure.
5
chapter
Surgical Approaches and

Indications of Hip Arthroplasty
Conventional Surgical approach

zz Posterior approach
zz Anterior or anterolateral approach.
zz Mini or minimal invasive approach
Posterior Approach
Check the correct side for surgery and position the patient in lateral and stable posi-
tion with affected side up after induction of anesthesia.
Use posterior support over sacrum avoiding any obstruction to hip movement.
Patient should be in strict lateral position including the shoulder of affected side
(Figs 5.1A and B). Drape the limb (Fig. 5.2).
A
Fig. 5.1A Lateral position with anterior support
B
Fig. 5.1B Lateral position with posterior support
Fig. 5.2 The draped limb
Flex the affected hip up to 45° and give a straight skin incision (9-10 cm) starting
5-6 cm proximal to tip of greater trochanter extending through the tip and down
along the shaft of femur (Fig. 5.3).
Chapter 5 Surgical Approaches and Indications... 43
Fig. 5.3 Incision with knee flexed at 45°, centered over the tip of the greater trochanter (TGT;
Curved line) extending down over the lateral shaft of femur and proximally with slight curve
posteriorly
Divide subcutaneous tissue and deep fascia along the line of incision down up to
gluteus maximus. Lift the tendinous (Fig. 5.4) distal part of maximus and cut by
cautery or knife and proximally by blunt dissection (Fig. 5.5). This exposes the
Fig. 5.4 Raising the lower part of the tendinous part of the gluteus maximus and separating
the muscular part
Fig. 5.5 The exposed part of the trochanter after blunt separation of the muscular part proximal
to the tendinous portion of the gluteus maximus
Fig. 5.6 Trochanteric bursa after retracting the separated gluteus maximus with Charnley
retractor
Fig. 5.7 Cutting the trochanteric bursa to expose the external rotators and quadratus femoris
muscle
trochanteric bursa (Fig. 5.6) which is incised transversely (Fig. 5.7) over the poste-
rior border of greater trochanter and dissected down by pressing with a sponge in
hand to expose the short external rotators and quadratus femoris (Fig. 5.8). At this
stage sciatic nerve can be felt or seen with fat on the posterior aspect of quadratus
femoris (Fig. 5.8). A Hohman retractor is passed below the abductors just above the
tip of greater trochanter and piriformis tendon with few fibers of gluteus minimus
Fig. 5.8 Tip of trochanter (TP), piriformis tendon (P), superior gemellus (SG), obturator
internus (OI), inferior gemellus (IG), quadratus femoris (QF) and sciatic nerve (SN)
Fig. 5.9 Stay suture applied over the piriformis tendon, superior gemellus, obturator internus,
inferior gemellus and part of quadratus femoris
Fig. 5.10 Raising a capsulomuscular sleeve with cautery starting from the attachment of
external rotator with the trochanter and proximally extending it into the capsule over the
middle of the head of femur
Fig. 5.11 Already raised capsulomuscular sleeve and showing the exposed head
adherent to posterior capsule over exposed head (Fig. 5.8). Two to three stay sutures
are applied in the piriformis tendon, short external rotators and proximal part of
quadratus muscle (Fig. 5.9). Raise a conjoint-myocapsular sleeve (Figs 5.10 and 5.11)
by starting cutting (with cautery) linearly over the capsule to piriformis tendon, short
external rotators and part of quadratus. If patient has flexion deformity extend the
dissection up to iliopsoas tendon attached to lesser trochanter; and tranverse and
longitudinal fibers of gluteus maximus attached to posterolateral aspect of proximal
femur. Dislocate hip by flexion, adduction and internal rotation of hip.
Anterior Approach
It is in existence since last 40 yrs. It provides adequate and safe exposure to the hip.
Low hip dislocation rate is a major advantage. It does not require any special table/
instruments (Table 5.1).
The patient is placed in a supine (more common) or, if desired, a lateral position
on the operating table. A straight lateral incision is made, and dissection is done up
to fascia lata. The interval between the vastus lateralis and abductors is developed.
The abductors can be released and repaired later. The hip capsule is identified and
opened, and the hip is dislocated by traction and external rotation. The femoral head
is then removed, allowing direct access to the acetabulum. The femur is placed into a
figure-of-four position for broaching.
Few patients can have a limp which lasts for 3-4 weeks due to abductor retraction.
Limb length equality is better appreciated with stable hip.
Mini or Minimal Invasive Approach

It adds to other existing controversial issues in total joint replacement. Following
advantages and disadvantages of MIS have been described in the literature (Table 5.2).
Table 5.1 Approaches to THR

Anterior/Anterolateral approach* Posterior approach
Patient positioning Lateral or supine Lateral

Incision Lateral Postero-lateral
Abductor dysfunction More muscle damaging Less muscle damaging
(Main disadvantage) (Abductor sparing)
Dislocation Less chance of dislocation More chances of posterior
(Main advantage) dislocation
(Main disadvantage)
Limp More common Less common
Familiarity Currently less common More common
Myocapsular repair Less important Very important
Revision surgery Posterior approach preferred Can be done through
Same approach
Cosmesis Less More
Bilateral Thr Does not need change of Needs change of position for
position if supine the other hip
*Both anterior/anterolateral and posterior surgical approaches have strong advocates,
and the choice of approach is best left to the surgeon.
Table 5.2 Advantages and disadvantages of minimal invasive surgeries

Advantages1–3 Disadvantages
• More of theoretical value Problems
except cosmesis • Technically demanding
• Decreased tissue damage • Need special instrumentation and image assistance
• Decreased blood loss • Poor visualization
• Less postoperative pain • Difficulty in assessing the implant positioning and
• Faster postoperative stability
recovery • Tissue damage may be more than the conventional
• Shortened length of stay long incision
• Improved cosmetic results Results4
• Malpositioned components
• Instability
• Dislocation
Indications for THR

Total hip arthroplasty is usually indicated in osteoarthritis (trauma, septic or tuber-
cular arthritis, avascular necrosis of hip, Perthes, DDH), and inflammatory arthritis
(rheumatoid, ankylosing spondylitis, seronegative disease or psoriatic arthritis):
zz Progressive original joint pathology despite conservative measures
zz Pain and limitations of function affecting quality of life
zz Rest or night pain
zz Stiff hips
zz Severe unacceptable deformity.
Absolute Contraindications
Recent or current hip or distant infection, medically unfit patient.
Relative Contraindications
zz Deficient or absent abductors function
zz Neuropathic joint
zz Progressive neurological disease.
References
1. Berger RA. Total hip arthroplasty using the minimally invasive two-incision approach.
Clin Orthop Relat Res 2003;417:232-41.
2. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip
arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-24.
3. Wright JM, Crockett HC, Delgado S, et al. Mini incision for total hip arthroplasty: a
prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty
2004; 19(5):538-45.
4. Woolson ST, Mow CS, Syquia JF, et al. Comparison of primary total hip replacements
performed with a standard incision or a mini-incision. J Bone Joint Surg Am 2004;
86(7):1353-8.
6
chapter
Perioperative Management of Total

Hip Arthroplasty
Preoperative clinical evaluation

Assess the hip pain: It is usually in the groin, sometimes referred to anterior thigh or
knee, is increased by activity or weight-bearing and may be partially relieved by rest
or restricted weight-bearing. Pain in the buttock or lower posterior pelvis may be
from lumbosacral spine, sacroiliac joint or sacrum.
Assess the patients expectation, occupation and discuss the needed lifestyle modifica-
tion after hip arthroplasty.
Assess the range of motion, deformity, adductor contracture and limb length
discrepancy.
Look for movements and deformities of affected knee and spinal deformity.
Abductor strength: Trendelenburg’s test.
Stop aspirin/disprin 7-10 days before surgery.
Stop oral anticoagulants 48 hours before surgery.
Start insulin for uncontrolled diabetes/omit morning dose of oral hypoglycemic on
the day of surgery for NIDDM(Type 2 DM).
Control hypertension,
Stopping of anti-rheumatoid drugs before surgery is controversial (some suggest
to stop it as it increases the risk of wound problems/infection; others say to con-
tinue: as it will reduce the postoperative pain and activity of disease by reducing the
inflammation).
Rule out hip infection by (ESR, CRP, TLC, bone scan, MRI) or treat infection
before surgery (Normal ESR, CRP, Bone scan and TLC).
Informed and written consent for surgery (explain alternative treatment, advantages/
disadvantages, result of THR; do not give assurance of absolute equal limb length).
One dose of intravenous antibiotics (cefotaxime/ceftriaxone) in the morning or one
hour before starting the surgery. Avoid aminoglycosides (gentamycin, amikacin) in
renal disease.
Chapter 6 Perioperative Management of Total Hip Arthroplasty 51
Bilateral THR in one sitting: Medically fit patient with bilateral severe arthritis of
joints, or stiff hip/flexion deformity for better rehabilitation.
Postoperative Clinical Management
Shifting of patient to bed or trolley: Both lower limbs should be in abducted and
externally rotated position with a pillow (Charnley pillow) between legs (Fig. 6.1).
While shifting from operation table to trolley or bed, adduction and internal rotation
should be avoided to prevent dislocation. One person should focus on the hip area
and other on holding lower limbs in abduction and external rotation.
Immediate postoperative care: Check for vital sign, soakage of dressing (do supra-
bandaging), pulse, BP, respiratory rate, O2 saturation; blood in suction drain (one
ring is roughly around 100 ml) and replace accordingly; distal pulses (dorsalis pedis
and posterior tibial artery); color (should be pink) and capillary refill (normally <2
seconds) of foot and toes; and extension of toes and foot (sciatic nerve).
Wound inspection: Can be done on 2nd postoperative day and debulk dressing. Any
suspicious looking discharge should be sent for culture and sensitivity.
Analgesic: Morphine top up (12 hourly) through combined spinal epidural (CSE)
or epidural catheter for 2-3 days with injection. Diclofenac sodium (renal, asthmatic
or allergic disease: pethidine + phenargen/tramodol) SOS basis followed by oral
Diclofenac/aceclofenac sodium (renal, asthmatic or allergic disease: tramodol with or
without paracetamol) till suture removal.
Antibiotic and prophylaxis for DVT (Fig. 6.2): See Chapter on Complications of
TKR.
Immobilization: Nonweight-bearing mobilization for next 3-4 weeks in cementless
or hybrid THR (cemented stem with cementless cup). Allow partial to full weight-
bearing from 2nd to 3rd postoperative day in cemented hip.
Suture removal and mobilization: Static hip exercises and gradual mobilization of
hip in bed in cementless hip. Hip mobilization and abductor strengthening exer-
cise in cemented hips. Suture/staples removal on 14th postoperative day after close
inspection for healing to avoid gaping (if still wide gaping, delay for 5-7 days, if
minimal or doubtful gaping, remove alternate sutures) (Figs 6.3A and B).
Anticoagulant Prophylaxis
It is a controversial issue. Most arthroplasty surgeons routinely use low molecular
weight heparin in patients undergoing total hip replacement. While some surgeons
believe that the incidence of DVT and fatal pulmonary embolism has decreased due
to better defined surgical and anesthetic techniques and early mobilization of the
patients.1 They further believe that heparin use is associated with a number of com-
plications (see Chapter in TKR section).
Fig. 6.1 Charnley’s pillow
Fig. 6.2 Pneumatic compression device

Chapter 6 Perioperative Management of Total Hip Arthroplasty 53
A
Fig. 6.3A In-bed mobilization-flexion
B
Fig. 6.3B In-bed mobilization-abduction
Reference
1. Lassen MR, Borris LC. Mobilization after hip surgery and efficacy of thromboprophylaxis.
Lancet 1991;337:618.
7
chapter
Primary Total Hip Arthroplasty
Primary total hip arthroplasty consists of following steps:
Neck cut
After exposure and dislocation of hip hold the limb in a position with knee in 90°
flexion then adduct and internal rotate at hip so that articular surface of distal tibia
and knee becomes parallel with ground. Try to keep the head and neck parallel to
the ground. Put one Hohmann retractor on superior and one on inferior border of
neck to protect acetabulum and one Langenbeck retractor (small) near the tip of
trochanter to protect the abductors.
Place neck resection guide (Fig. 7.1) with tip at the level of greater trochanter,
mark (with cautery or osteotome) according to preoperative templating or leave
around 1-1.5 cm medial calcar (Fig. 7.2). It should start at the lateral top most part
of neck just above the piriformis fossa and should extend vertically making it 45° to
long axis of femur (Fig. 7.3). After the neck cut release the transverse and longitudi-
nal fibers of gluteus maximus attached to the posterolateral aspect of shaft of femur,
anterior capsule (Fig. 7.4) to correct flexion deformity of hip (if present), and then
iliopsoas if needed.
Exposure of Acetabulum
Femur is retracted anteriorly by placing the anterior retractor between anterior lip of
acetabulum and the psoas tendon. Second Hohmann retractor is placed below the
transverse acetabular ligament (6 o’ clock position) and 3rd retractor on the posterior
aspect of acetabulum. Remove the capsule, labrum and osteophytes from the rim
(edge) of acetabulum and also the soft tissue from the floor of acetabulum with the
Capener gouge or bone nibbler.
Chapter 7 Primary Total Hip Arthroplasty 55
Fig. 7.1 Alignment guide placed on the lateral surface of shaft of femur with its tip at the
level of greater trochanter
Fig. 7.2 Neck cut after removal of femoral head with residual calcar (1-1.5 cm)
Fig. 7.3 Marking for neck cut making 45° angle with axis of shaft of femur (arrow mark)
Fig. 7.4 Release of anterior capsule towards the floor with cautery
Fig. 7.5 Well exposed acetabulum with Hohmann’s retractor (one for retracting greater
trochanter and one below transverse acetabular ligament)
Fig. 7.6 The reaming of the acetabulum

Acetabular Reaming
After adequate exposure of the acetabulum (Fig. 7.5), start reaming (Fig. 7.6) with
a reamer 4-8 mm smaller than templated size of acetabular component directed
towards the medial wall and aim to remove the cartilage and align the raised ante-
rior and posterior walls of the horse shoe shaped part of acetabulum with the lower
central part of floor to convert it into a hemispherical shape. Use increasing size
of reamer (1-2 mm increments) in the direction of original cup (35-45° abduc-
tion from the horizontal (Fig. 7.7), 10-20° anteversion (Fig. 7.8) from the coronal
plane) till the largest reamer makes close contact with the anterior wall, posterior wall
and the dome of acetabulum providing a hemispherical bleeding acetabular cavity
(Fig. 7.9). If floor is sclerotic, use drill (Fig. 7.10), ring curette or osteotome to remove
the sclerotic bone to get a bleeding cancellous surface. Trial cup with size 1-2 mm
more than the last reamer should be inserted by learning arthroplasty surgeon or just
put on the top and see whether it will fit by the experienced surgeon. Sometimes
reaming of the peripheral rim of acetabulum by reamer (size same as definitive cup)
may be required. Acetabular floor may need impaction bone grafting to enhance
stability and osteointegration (Figs 7.11 and 7.12).
Femur Preparation
Again position the leg as for cutting the neck, put one broad Hohmann retractor
below the lesser trochanter and one Langenbeck retractor near the tip of trochanter
to protect the abductors. Remove the soft tissue, osteophytes from the medial surface
of trochanter (Fig. 7.13). Use box chisel (Fig. 7.14) to open the canal and to remove
the bone from medial surface of trochanter by putting it close to it (like pushing the
medial surface of trochanter laterally) and medial edge of box should be either paral-
lel or slightly inferior to the medial most surface of inferior calcar (toward floor for
anteversion). Open the canal with canal opener by directing it close to medial surface
of trochanter in to the piriform fossa, use one size large hand reamer to further open
the canal deep in the femur. Use a bone file, curette or the lateral border of smallest
reamer to rub against the medial surface of trochanter for removal of medial bone to
prevent the varus position of femoral component. Some surgeons make a lateral bone
trough for the same purpose (Fig. 7.15).
Start with smallest size broach pushing against (Fig. 7.16) the medial surface of
trochanter (to remove medial bone to prevent varus) with medial edge of broach
(Fig. 7.17) either parallel or slightly inferior (toward floor for anteversion) to the
medial most surface of inferior calcar. Increase the size of broach further till largest
broach starts getting resistance to hammering and goes down in to the canal up to
desired position (mark on the broach) and does not move on twisting or vertically
pulling the handle of broach. Try to take rest of few seconds in between hammering
to insert the proximal part of broach and if it is not progressing down at all, stop
hammering to prevent fracture and use the one size small broach as the definitive
femoral size.
Fig. 7.7 Ideal abduction angle (ABA: 45°) for acetabular reamer from the horizontal or ground
Fig. 7.8 Ideal anteversion for acetabulum reaming (AV A: 15° from the line along the axis of
the body plane of the body)
Fig. 7.9 Well prepared bleeding acetabulum
Fig. 7.10 Walls of acetabulum are sclerotic then drilling can be done
Fig. 7.11 Impaction of morselized cancellous bone graft
Fig. 7.12 Well prepared acetabulum after impaction bone grafting

Fig. 7.13 Removal of tissue or osteophytes from the trochanteric fossa
Fig. 7.14 Entry point for femur using the box chisel, it should be flushed against the medial
trochanter wall and the medial edge of chisel should be parallel with the medial most curved
femoral calcar
Fig. 7.15 Lateral bone trough (some surgeons make it, others try to remove the lateral
trochanter bone by rubbing the lateral bone with lateral aspect of the small rasp to prevent the
varus position of the femoral stem)
Fig. 7.16 Reaming of the canal starting with the smallest size of broach (lateral border of the
broach should be flushed and held tight against the lateral trochanteric bone while maintaining
the anteversion)
Fig. 7.17 Last broach in situ (it should not rotate in the canal and should be inserted fully) with
preserved medial cancellous calcar bone (arrow mark)
Trial Reduction
Attach the neck with the broach and trial liner (according to the system). Trial head
is attached (start with standard, zero head), hip is reduced by applying traction to
extremity with hip in slight flexion (try to avoid external rotation).
Neck length is adjusted by changing the size of femoral head (–, 0, +) or offset.
(Normal: 132°; High: 127°).
Check: Range of motion, stability, limb length, impingement and abductor tight-
ness. (on finger should be taut).
Stability of Hip
Posterior stability is assessed with the hip in flexion, adduction, and internal rota-
tion. Hip should be stable (head should not dislocate or subluxate) when flexed 90°,
adducted 20°, internally rotated at least 45° (Fig. 7.18) and when hip is flexed 40°
with adduction and axial loading (the so-called position of sleep). If the hip dislo-
cates easily, and the head can be manually distracted from the socket more than a few
millimeters (the so-called shuck test, normal 2-4 mm), use a longer neck length to
increase the stability of hip. After the surgery, joint may appear loose, but limb length
equality is more important than a loose joint after shuck test. Even if shuck test is
positive, with good component positioning and meticulous posterior myocapsular
repair, chances of instability/dislocation is almost nil.
Fig. 7.18 Assessment of the stability of joint by Ranawat technique
Anterior stability is checked by feeling anterior dislocation or subluxation with

fingers on the anterior aspect of the head and neck of femur with hip in full extension
with external rotation.
Try with standard (0) head size, if not stable (longitudinally excessive movement
on telescopy or dislocating on flexion/adduction/internal rotation) or limb length is
short; use successive large (+) head. If stability improves but limb length increases
(minimum lengthening on the cost of stability should be accepted), then stability can
be improved by changing horizontal offset (if available change 132° to 127° offset).
Most common causes of instability are combined anteversion < 40°, impingment
because of osteophytes and soft tissue slackness and weakness of abductor.
Length of Both Limbs

Push the pelvis posteriorly (if no iliac support) and keep the side being operated with
other lower limb in same position with both knees at same level [in anteroposterior
plane. Limb length can be checked by vertically putting a flat Hohmann or oste-
otome on the anterior surface (Fig. 7.19) of both knees]. Both knees at same position
with both feet at same level suggest either equal length (if using iliac support) or
the lengthening of side being operated (if no iliac support, patient is falling forward
due to flexion of pelvis). Limb length can also be assessed by measuring [before dis-
locating the hip for neck cut (Fig. 7.20) and after trial reduction or with definitive
head (Fig. 7.21)] the distance between two fixed bony points above and below the
acetabulum. Ranawat et al used a pin below the infracotyloid groove and measured
the distance between it and a mark on the greater trochanter transosseous pins placed
above and below the hip joint and a measuring device between the pins.
Fig. 7.19 Assessment of the limb length after putting the knee and foot at same level
(Hohmann retractor is placed on the anterior aspect of knee of nonsurgical side then see
whether it is touching the surgical side or not; here it is not touching that’s mean it is short on
the side being operated)
Fig. 7.20 Measurement of distance (vertical offset) from center of femoral head to lesser
trochanter before neck cut
Fig. 7.21 Length from center of head to lesser trochanter
Significant shortening or instability can be corrected by successive increasing (+)

the head size or increasing horizontal offset without increasing the length. If limb is
long with standard (0) head then go with minus head and check stability, if slight
instability then increase the horizontal offset (132° to 127°) and recheck the limb
length.
Impingement
After the incorrect version, this is most common cause of dislocation. Look for
impingement of neck or shoulder of prosthesis against head, osteophytes (remove
anteroinferior: predispose to dislocation in extreme range of flexion and internal rota-
tion) or soft tissue attached with anterior capsule.
Definitive Prosthesis
Remove the trial components. Wash the acetabulum, fill the small cavities with mor-
cellized bone graft (use head or bone removed with box chisel).
Fix the cup on inserter with alignment guide, insert it at 45° of abduction from
horizontal, 10-15° of anteversion with alignment limb parallel to ground with ham-
mer. Cup (Fig. 7.22) should be fully seated on the floor (check with artery forceps),
lower edge should be close to the outer margin of transverse acetabular ligament,
version should be adequate and should not move on moving the handle of inserter
(mediolateral or superoinferior movements).
Fig. 7.22 Well fixed acetabulum on prepared acetabulum after reaming and impaction grafting
Cup Fixation
If cup is stable and press fit: Screws may not be required (Surgeon preference-may
use screw for additional fixation).
If doubtful stability, poor bone quality, elderly patients: Fix with 2-3 screw in safe
zone (10’ clock–2’ clock of cup) decribed by Wasielewski et al.1 Safest is posterosu-
perior quadrant with maximum pullout strength (length > 25 mm may be used).
Posteriorinferior quadrant has inferior gluteal and internal pudendal neurovascular
structures (length should be < 25 mm). Anterosuperior quadrant have external iliac
artery and vein while anteroinferior quadrant have obturator neurovascular bundle
(length < 20 mm in anterior quadrant). Avoid prominence of screw head to prevent
back wear of polyethylene liner.
Liner (Fig. 7.23): Edges of the cup should be free from osteophytes and soft tissues
for proper placement of liner. Hood (elevation) of polyethylene liner should be kept
posterosuperiorly or superiorly (if abduction is more). Proper placement should be
checked by attempting the extraction of liner with extractor.
Femoral stem: Insert the definitive stem (with same precautions for anteversion and
prevention of varus position) initially by manual pushing then with hammer (take
same care as while with broach) up to the desired length. If its proximal part does not
go up to the desired point: hand reamer or flexible reamer should be passed to remove
any distal bone followed by removal of proximal bone by curette, or small thin oste-
otome. Mostly stem sinks after proximal and distal bone removal, if it remains few
mm protruded from the canal: can be left and head size adjusted accordingly (trial
with one size small head).
Fig. 7.23 Definitive liner in situ
Fig. 7.24 Passing of the sutures through greater trochanter for rotator repair
Fig. 7.25 Completed rotator repair
Attach trial head and again check ROM, stability, limb length. Then insert defini-
tive head and reduce the hip. Again check ROM, instability, limb length and abduc-
tor tightness.
Wound closure
Reattach the piriformis tendon, external rotators and part of quadratus femoris by
passing the sutures (surgeon’s preference: Non-absorbable monoacryl/ethibond (num-
ber 2 or 5) sutures through posterolateral aspect of greater trochanter and muscles with
limb in position of abduction and external rotation (Figs 7.24 and 7.25).
Reattach the distal part of gluteus maximus (longitudinal, if possible transverse
fibers also), suture tendinous part of gluteus maximus with monoacryl/ethibond
(cross horizontal mattress suture) and proximally with vicryl. Close deep fascia with
vicryl, and subcutaneous tissue (if excessive subcutaneous fat: close fat in two lay-
ers) with vicryl. Skin is closed by staple or monocryl and may be left if subcuticular
sutures have been applied.
Postoperative skin traction: May be applied for mild residual flexion (10-15°)
deformity of hip for 3-5 days.
Reference
1. Wasielewski RC, Cooperstein LA, Kruger MP, et al. Acetabular anatomy and the
tranacetabular fixation of screws in total hip arthroplasty. BJS 1990;72 A:501.
8
chapter
Complex Primary Total

Hip Replacement
Primary total hip arthroplasty may be difficult and requires experience in certain
primary pathologies like protrusio, dysplastic or ankylosed hips and in the presence
of an implant in situ for proximal hip or acetabular fractures.
total hip replacement in Protrusio Hip
Problems
zz Medial migration of the hip center
zz Superior and medial migration of the head making acetabulum—oblong
zz Difficult dislocation
zz Risk of spiral fracture of femur while dislocating the femoral head
zz Deficient medial support for cup
zz Shortening of the affected limb
zz Sciatic nerve: Close to the joint.
Tips and Tricks for THR

zz A good preoperative templating for limb length inequality
zz Either dislocate the hip by extra soft tissue release and excision of posterior osteo-
phytes. If not possible then do in situ neck osteotomy
zz Lateralization of acetabular cup (Figs 8.1 and 8.2) with medial bone grafting
(morcellized cancellous)
zz Careful reaming to create convergence of the acetabular rim without preferentially
reaming the superior rim and causing an iatrogenic superior segmental defect or
high hip center.
zz Never ream/deepen the medial wall
zz Peripheral reaming to obtain a good peripheral fit.

Fig. 8.1 Left side protrusio hip
Fig. 8.2 The well-incorporated medial bone graft after THR

Chapter 8 Complex Primary Total Hip Replacement 73
Total Hip Replacement in Ankylosed hip

Problems
Faber (Flexion, abduction and external rotation) deformity is not uncommon.
zz Exposure is very difficult in these deformities.
zz These hips are difficult to dislocate (Figs 8.3 and 8.4A and B).
zz Require in situ provisional neck cut followed by reaming of the in situ head till
acetabular surface becomes visible then do definitive neck osteotomy (Fig. 8.5).
zz Cementless hips may be the best option for these young active patients
zz These patients tend to have external rotation deformity and increased anteversion
of the femur.
zz Bone is osteoporotic due to disuse so acetabular over-reaming should be avoided
and leaving a spike of bone at the superolateral acetabular margin may support
cementless cup1.
zz Patients tend to have anterior instability or dislocation due to various reasons
including hyperextension1 at the hip predisposing a more anteverted and more

vertical inclination of the acetabular cup, external rotation and increased femoral
anteversion causing impingement of the prosthetic neck or the greater trochanter
posteriorly or difficulties in the placement and/or reduction of the hip.2
zz High rate of heterotopic ossification.
Fig. 8.3 FABER deformity

A
Fig. 8.4A A case of bilateral ankylosed hip
B
Fig. 8.4B Postoperative radiograph after bilateral total hip arthroplasty
Fig. 8.5 Definitive osteotomy of neck

For neck resection, approach the inferior neck and feel the lesser trochanter and
pubo-femoral arch. Osteotomy of neck may require two stages.
zz In situ provisional neck osteotomy is performed (Avoid cutting into greater tro-
chanter, calcar and posterior acetabular wall). Then finally do definitive osteotomy.
zz Leave the superolateral acetabulum bone spike during reaming which will provide
support to cementless cup and avoid tendency of vertical inclination of the cup.
zz Remove the remaining femoral head piecemeal.
zz Ream medially with sequential reamers till foveal soft tissue which defines original
joint plane. Avoid over reaming of anterior and posterior wall. Use of small cups
is advisable.
zz Soft tissue release: For flexion deformity release anterior and superior capsule,
iliopsoas and rectus femoris (if needed).

zz For severe deformities (Consider two stage surgery or two incision techniques):
Anterior approach for image guided osteotomy of neck in supine position, fol-
lowed by usual posterior approach.
zz Trochanteric osteotomy or slide may be required but should not be routinely done.
zz Postoperatively indomethacin for 2 weeks to prevent heterotopic ossification.

Dysplastic Hip
Problems
zz Dysplastic acetabulum with sloping walls (Fig. 8.6).
zz Usually anterolateral and superior bone are deficient
zz Difficult acetabulum exposure due to severe soft tissue contractures and prior
childhood pelvic osteotomies

zz Up ridden trochanter (high dislocations), increased neck shaft angle and increased
femoral anteversion
zz Proximal femur may have a narrow canal or may be distorted due to prior femoral
osteotomies
zz Adductor contracture.

zz Aim should be to place the cup in true acetabulum having maximum bone stocks
with anatomic hip center
zz Usually a small size cup should be used
zz Start with the smallest size reamer and do not over ream the lateral most acetabulum wall
zz Bone graft: If coverage is > 70%: No graft is required. If uncoverage of head is
> 30%: Use contoured femoral autograft fixed with lag screw (Figs 8.7 to 8.9).
Fig. 8.6 The dysplastic hip with deficient posterosuperior acetabular wall
Fig. 8.7 A provisional fixation of the bone graft prepared from head with K wires
Fig. 8.8 A definitive fixation of the bone graft prepared from head with screws
Fig. 8.9 Postoperative radiograph of hip arthroplasty
If uncoverage is > 45 %: Use cemented cup with femoral head supported with a
auto/allograft
zz Femur: Good soft tissue release- anterior capsule, iliopsoas, gluteus maximus and
even rectus femoris muscle in some cases for flexion deformity or to bring down
the femur after neck osteotomy.
zz Use specially designed short/low offset CDH stem
zz In high dislocation: Subtrochanteric femoral shortening may be required
zz Modular or cemented stem should be used for extreme anteversion.
References
1. Kilgus DJ, Namba RS, Gorek JE, et al. Total hip replacement for patients who have
ankylosing spondylitis: the importance of formation of heterotopic bone and of the
durability of fixation of cemented components. J Bone Joint Surg Am 1990;72:834.
2. Tang WM, Chiu KY. Primary total hip arthroplasty in patients with ankylosing spondylitis.
J Arthroplasty 2000;15:52.
9
chapter
Complications of Total
Hip Arthroplasty
Hematoma Formation
It is commonly seen due to injury to first perforating branch of the profunda femoris
artery deep to the gluteus maximus insertion (during release for flexion deformity)
or to branches of the obturator artery (when osteophytes are removed from inferior
acetabular margin or incision is made to release hypertrophic transverse ligament
obstructing the cup vision).
Prevention is by adequate homeostasis with closed suction drain (controversial)
and treatment includes correction of the predisposing factors (coagulopathy, drugs),
compression dressing and occasionally by surgical drainage (for wound gaping or
necrosis, infection, compartment syndrome) and use of closed suction drain.
Mortality
In hospital mortality: 0.16 to 0.52%.
At 90 days: Primary total hip arthroplasty-1% and 2.5% for revision hip.
Heterotopic Ossification (Fig. 9.1)

It occurs in up to 10% of cases. It is more common in post-traumatic
secondary osteoarthritis (hypertrophic osteophytes) and in patients with previous
history of heterotopic ossification. It is also seen in cases of ankylosing spondylitis,
diffuse idiopathic skeletal hyperostosis, Paget disease, and unilateral hypertrophic
osteoarthritis.
Common site is area of adductors and iliopsoas muscles in the form of calcifica-
tion around 3-4 weeks after surgery and treatment includes NSAID (Indomethacin)
or low dose (500 cGy) radiotherapy (Preoperative and postoperative).
Fig. 9.1 Heterotopic ossification in a case of THR
Thromboembolism
The risk of fatal PE (Pulmonary embolism) following primary hip or knee replace-
ment has been consistently reported to be between 0.1 and 0.2%, regardless of the
chemoprophylactic agent employed for prophylaxis.1,2 Better postoperative care, pain
management and early mobilization has reduced the incidence of thromboembolic
phenomenon drastically.
Nerve Injury
Primary THR: 0.7 to 3.5%.
Revision THR: 3.2 to 7.5 %.
Sciatic nerve may be injured during exposure (nerve is close in protrusion, revi-
sion, DDH, external rotation deformity, resorption of head and neck, due to vigor-
ous retraction of soft tissue on the posterior aspect of acetabulum, due to cement,
subgluteal hematoma or excessive lengthening (> 4 cm). Incomplete recovery is very
Chapter 9 Complications of Total Hip Arthroplasty 81
common and complete recovery is seen only in few patients. Give patient foot drop
splint to prevent equinus of foot. Femoral nerve may be injured by retractors placed
anterior to the iliopsoas, during excision of anterior capsule or femoral retraction for
acetabular preparation. Complete recovery is quite common and patient should be
given knee immobilizer/support till nerve recovery. Obturator nerve may get injured
due to screw in the anteroinferior quadrant, extruded cement or by retractors.
Vascular injury
These are very rare (0.2% to 0.3%) and are usually seen in revision surgery (due to
direct injury by screw, cement, cage or due to retractor placed anterior to iliopsoas).
Limb Length Discrepancy

Patient are more worried for lengthening (particularly for unilateral hip disease) than
shortening. Lengthening up to 1 cm is well tolerated but excessive lengthening may
cause limping or sciatic nerve injury (> 2.5-4 cm). Preoperative templating in asso-
ciation with intraoperative measurement is the most accurate method for equalizing
limb length.
Instability (Dislocation and Subluxation)

Risk of dislocation after primary arthroplasty is about 2-5%.3 More than half of all
dislocations occur within the first three months after surgery and more than three
quarters within one year.4 Factors predisposing to instability include malpositioned
components (excessive ante or retroversion, inadequate offset or center of head),
inadequate soft tissue tension, abductor insufficiency, impingement (extreme move-
ments of flexion, internal rotation) of neck of femoral component and femur over
cup margin or femur on pelvis (or osteophytes), trauma, extreme position of limbs,
posterior approach, revision surgery, trauma and small size of head. Posterior dis-
location usually occurs due to decreased anteversion (by flexion, adduction, inter-
nal rotation of hip) and anterior dislocation occurs due to increased anteversion
(by flexion, abduction and external rotation) of components. Anterior dislocations
are very uncommon in posterior approach. Diagnosis is on the basis of attitude of
limbs and radiographs (AP and lateral). Treatment is to evaluate the cause and closed
reduction (traction with hip and knee at 90° with downward counter traction on
pelvis assisted by mild abduction of thigh or by Allis or Stimson method) under seda-
tion or GA. If closed reduction (due to soft tissue interposition, displaced liner, lax
soft tissue or unstable reduction) fails; plan for open reduction with preparation for
possible replacement of culprit components (liner/head/cup/femur). Recurrent dislo-
cation usually occurs due to malposition of the components, abductor insufficiency
or lax soft tissues and is better managed by revision surgery.
References
1. Douketis JD, Eikelboom JW, Quinlan DJ, et al. Short-duration prophylaxis against venous
thromboembolism after total hip or knee replacement: a meta-analysis of prospective
studies investigating symptomatic outcomes. Arch Intern Med 2002; 162(13):1465-71.
2. Brookenthal KR, Freedman KB, Lotke PA, et al. A meta-analysis of thromboembolic
prophylaxis in total knee arthroplasty. J Arthroplasty 2001;13(3):293-300.
3. Mahoney CR, Pellicci PM. Complications in primary total hip arthroplasty: avoidance
and management of dislocations. Instr Course Lect 2003;52:247-55.
4. Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am 1982;
64:1295-1306.
Section 2
Knee Arthroplasty
10
chapter
Applied Anatomy of
Knee Joint
Knee joint
Largest synovial joint of the body.
Parts of the Joint

Distal end of femur, proximal tibia and articular surface of patella (Figs 10.1A and B).
Menisci: There are two menisci. Medial one is attached at its periphery to the cap-
sule and tibial collateral ligament. Lateral meniscus is attached to the tendon of the
popliteus. Both the menisci are interconnected anteriorly by the transverse ligament
(Fig. 10.2).
Infrapatellar fat pad: It separates the synovial membrane from the patellar ligament.
It has to be partially excised for eversion of the patella (Fig. 10.3).
Ligamentum patellae: It is the continuation of quadriceps tendon below the patella
(Fig. 10.4), it is attached above to the apex of patella and below to the tibial tuber-
osity. Care should be taken to prevent any injury to it during soft tissue release and
eversion of patella.
Lateral collateral ligament: It is attached above to the lateral epicondyle and below
to the lateral surface of head of fibula.
Medial collateral ligament (Fig. 10.5): It is attached above to the medial femoral
epicondyle just distal to the adductor tubercle and below to the medial edge and
medial surface of tibia above and behind the attachment of sartorius, gracilis and
semitendinosus tendons. It should be protected with medial soft tissue sleeve while
taking the femoral and tibial bone cuts.
Anterior cruciate ligament: It is attached below to a facet on the anterior part of
the intercondylar area of the tibia and above to a facet on the posterior aspect of the
lateral wall of intercondylar notch of femur.
86 Section 2 Knee Arthroplasty
A B
Figs 10.1A and B The knee joint in AP and lateral view
Fig. 10.2 Photograph of meniscus, popliteus, cruciate ligaments

Chapter 10 Applied Anatomy of Knee Joint 87
Fig. 10.3 The exposed knee joint
Fig. 10.4 The quadriceps tendon, patella, ligamentum patellae

Fig. 10.5 Medial collateral ligament (at the tip of artery forceps)
Fig. 10.6 The Q angle between the line through center of patella (CPO) and tibial tuberosity
(TT) and line from center of patella to the anterior-superior iliac spine (ASIS)
Chapter 10 Applied Anatomy of Knee Joint 89
Posterior cruciate ligament: It is attached below to the posterior aspect of the inter-
condylar area of the tibia and above to the medial wall of the intercondylar notch of
femur.
Blood supply: It is supplied from the descending and genicular branches from femo-
ral, popliteal and lateral circumflex femoral artery.
Nerve supply: It is supplied by the branches from obturator, femoral, tibial and com-
mon peroneal nerve.
Q angle: It is the angle (Fig. 10.6) between the extended anatomical axis of the femur
and the line between the center of patella and the tibial tubercle. Large Q angle tends
to cause lateral subluxation of patella.
11
chapter
History and Biomechanics of

Knee Arthroplasty
zz Fergusson (1861): Treated knee arthritis by resection arthroplasty.

zz Campbell (1930): Established interposition knee arthroplasty (using free fascial
grafts) in arthritic joints.
zz Campbell and Boyd (1940) and Smith-Petersen (1942) performed mould arthroplasty.
zz A Canadian orthopedist, Frank Gunston (1960-68), from Sir John Charnley’s
Hip Center, developed and used the first metal on plastic knee replacement
secured to the bone with cement.
Total condylar prosthesis (TCP) (Zimmer, Warsaw, IN): Insall introduced it in 1974.
It was cemented cruciate sacrificing knee prosthesis with a relatively conforming tibio-
femoral articulation. Stability depended on soft tissue balance in flexion and extension,
along with moderate articular conformity in the coronal and sagittal planes. But it had
problems like posterior subluxation of the tibia, decreased range of motion (90-100°
flexion), poor stair climbing and impingement of posterior femoral metaphysis against
tibial articular surface (at 95° of flexion). To solve these problems, new design (modified
TCP), Insall Bernstein posterior stabilized prosthesis (IB-I) was introduced in 1978. It
had femoral cam (to function as mechanical PCL) to articulate with a tibial spine as
a substitute for the excised PCL. It had originally all polyethylene tibial components
which were later fabricated with metal backing (1981). A new modular design, IB-II
(1987) was introduced to accommodate modular tibial inserts, wedges, stems and aug-
ments. Further changes in this design by Insall led to two new designs, Legacy posterior
stabilized knee prosthesis (LPS) (Zimmer, Warsaw, IN) and the LPS-Flex (it has both
fixed and mobile bearing tibial component).
Differences between normal and prosthetic joint are given in Table 11.1.
Chapter 11 History and Biomechanics of Knee Arthroplasty 91
Table 11.1 Differences between normal joint vs prosthetic joint

Normal joint Prosthetic joint
Tibial articular • At 3° varus from the true • At 90° to long axis of tibia
surface vertical axis of body • 10 mm tibia is cut to accommodate
minimum thickness of tibial plate
(10 mm) from the least affected tibial
plateau
• Extramedullary rod in internal
rotation leads to posterolateral
slope and external rotation results in
posteromedial slope
Distal femoral • Distal femoral articular surface • Since tibia is at 90° (not in 3° varus),
articular is in 9° valgus (anatomical axis femoral valgus should be reduced to
surface (valgus) 6° valgus to mechanical axis 6° (to achieve neutral mechanical axis)
+ tibia articular surface in 3° • Distal femoral cut thickness should
varus) in relation to tibia be equal to thickness of prosthesis
Distal femoral • In flexion, articular surface (line) • At 90° tibial articular surface, lateral
articular remains parallel to ground gap is more than medial
surface because of asymmetry of • For balancing this femur has to be
(rotation) posterior femoral condyle in cut in 3° external rotation in relation
relation to varus tibial articular to posterior condylar axis (cut more
surface (medial condyle thickness of medial than lateral in
extends 2 mm more on the posterior cut)
articular surface than lateral
condyle)
Patella • Medialized, 12-15 mm of host patella
should be left after resection for
prosthesis
Femoral • 6° valgus, 3° external rotation, 90° to
component long axis of femur in sagittal plane
and should be in the centre or
lateralized
Biomechanics of normal joint

and a prosthetic joint
Anatomical axis of lower limb (Fig. 11.1): A line drawn along the long axis
of femur extending down along the long axis of tibia. It forms 6° valgus angle
with mechanical axis and forms 9° valgus angle from true vertical axis of body.
Mechanical axis (Fig. 11.1): A line extending from the center of the femoral head
to the center of the talar dome on a standing long leg anteroposterior radiograph.
Neutral mechanical axis passes from center of femoral head to the center of ankle
joint (center of tibial plafond and center of dome of talus) through center of knee
joint (center of intercondylar notch and center of tibial plateau).
Fig. 11.1 The mechanical axis Fig. 11.2 Change of instant center of rotation
(MA), vertical axis (VA) and (ICR) in flexion from 0-120° forming J curve
femoral shaft axis (FSA)
Fig. 11.3 Femoral rollback on tibia with flexion

Chapter 11 History and Biomechanics of Knee Arthroplasty 93
Screw home mechanism: It is external rotation of tibia over femur during extension
of knee (opposite occurs during flexion of knee).
J curve (Fig. 11.2): Transverse axis of flexion and extension constantly changes and
follows a J shaped curve around the femoral condyle.
Femoral rollback (Fig. 11.3): With increasing flexion, femur rolls back over the tibial
condyle.
Polyethylene
Polyethylene liner in TKR usually comes in following three shapes:
1. Flat polyethylene surface: Flat articular surface gives areas of high contact stress
due to less conforming articulation with femur in sagittal plane.
2. Polyethylene with a post: For cam mechanism and femoral rollback where PCL is
sacrificed.
3. Polyethylene with dished surface: More conforming in coronal and sagittal
planes.
12
chapter
Implants and Patient Selection
Osteoarthritis of Knee joint

It is most common in Indian female patients.
Clinical Features
zz Pain during movement, weight bearing, climbing stairs and after prolong sitting
zz Deformity
zz Crepitus
zz Instability
zz Stiffness.
Radiological Features
Staging of Osteoarthritis (Fig. 12.1) of the Knee48 (Kellgren)
Stage 0
No abnormality.
Stage 1
Incipient osteoarthritis, osteophytes on the eminences.
Stage 2
Moderate joint space narrowing, moderate subchondral scelerosis.
Stage 3
>50% joint space narrowing, rounded femoral condyle, extensive subchondral scle-
rosis, extensive osteophyte formation.
Chapter 12 Implants and Patient Selection 95
Fig. 12.1 Kellgren stages of osteoarthritis of knee
Stage 4
Joint destruction, obliterated joint space, subchondral cysts in the tibial and femoral
condyle, joint subluxation.
Treatment
Conservative
It includes modification of life styles (avoid cross legged sitting, squatting, prolong
climbing of stair and use of English toilet), analgesics (Non steroidal anti-inflam-
matory drugs, opioids), Physiotherapy (quadriceps exercise, local ultrasound, inter-
ferential therapy) and walking aids (crutches walking stick, shoe wedges), Diacerin,
intra-articular steroid and hyaluronic acid injections.
Surgical49-51
Joint sparing options: Symptomatic:
zz Arthroscopic lavage, shaving, debridement
zz Bone-stimulating: Microfracture, drilling, abrasion arthroplasty
zz Joint surface restoration: Autologous osteochondral transplantation (OCT),
autologous chondrocyte transplantation (ACT)

zz Corrective osteotomy near the joint: High tibial osteotomy.
Joint Replacements
zz Partial: Unicondylar knee arthroplasty, patellofemoral arthroplasty
zz Total knee arthroplasty.
Ideal Patient for Total Knee Arthroplasty

zz Thin built
zz Minimal comorbidities
zz Moderately active
zz Good range of motion
zz Not too old
zz Not too young.
Indications of Total Knee Arthroplasty

zz Progressive original joint pathology despite conservative measures
zz Pain and limitations of function affecting quality of life
zz Rest or night pain
zz Deformity and instability in arthritic joint.
Contraindications
zz Recent or current knee or distant infection
zz Medically unfit patient
zz Discontinuity or severe dysfunction of extensor mechanism
zz Recurvatum due to muscle weakness
zz Neuropathic arthropathy
zz Morbid obesity.
Unilateral vs bilateral TKR: It remains controversial and literature is also divided.
Different studies report the following advantages and disadvantages of the single
stage bilateral TKR (Table 12.1).
Cruciate Retaining VS Cruciate

Substituting (Fig. 12.2 and table 12.2)
Three bias for posterior cruciate ligament among arthroplasty surgeons:
Always preserve: Believe that it gives more range of motion and symmetrical gait
(especially during stair climbing) due to better controlled femoral roll back.
Table 12.1 Comparison of bilateral and unilateral Tkr

Bilateral Unilateral
Indications Young and elderly fit patients Elderly patients, > 75 years
Advantages • Short hospital stay, better Less complications
rehabilitation, less overall cost1,2
• Better functional outcome and patient
satisfaction score2,3
Disadvantages • High incidence of confusion (usually High cost, delayed
due to lower hemoglobin levels and rehabilitation
the systemic dissemination of fat
emboli4–6, and transient hypoxia
• Increased risk of DVT, pulmonary
embolism, myocardial infarction in
elderly patients2,5,7
Decision should be individualized for the patients and should take into consideration various
factors (age, associated co-morbidities, experience of the surgeon, hospital set up) affecting
the outcomes after TKR.
Fig. 12.2 NRG CS and CR design (Courtesy: Stryker)
Table 12.2 Comparison cruciate substituting and cruciate retaining designs

Cruciate substituting Cruciate retaining
Advantages • Less technically demanding • Useful for young and active patient
• More stable component • Preserves bone stock and
interface8 proprioception
• Better range of motion9 • More symmetrical gait (especially
because of smooth during climbing)
posterior roll back • Better stability (PCL prevents anterior
translation of the femur on the tibia)
All these claimed advantages10 have
been disapproved in different studies
and shows comparable results with
CS design
Disadvantages • Tibial post polyethylene • Can be used only in patients with
wear good bone stock. Healthy ligaments
• More bone resection are required for optimum functional
(for post and cam outcome
mechanism)11 • Not a suitable implant for patients
• Risk of patellar clunk in with severe varus,12 valgus or flexion
deep flexion deformity,11 rheumatoid arthritis,
postpatellectomy, femoral/tibial
osteotomy13,14
• Early tight PCL: Loss of flexion or
ligament rupture15
• Late rupture (common in rheumatoid
arthritis): Pain and flexion instability16
Always substitute: Believe that PCL is already degenerated and does not perform its
function adequately
Intraoperative decision: Decide on the morphology of PCL.
Results are controversial. Different outcomes following merits and demerits of each
design have been reported in the literature. Implant choice should be guided by sur-
geon’s experience, training and pathology of PCL.
High Flex Design (Fig. 12.3)

Deep flexion (High flexion): A flexion of 120° is called deep high flexion. It is
required in Asian population for religious activities, for Indian toilet and professional
activities (manual worker, farmer, plumbers).
New high flex design: These designs have thick posterior femoral condyles with
reduced radii (increases the contact area between the posterior condyles and the tibial
insert in deep flexion) of posterior femoral condyles. They also have modified tibial
and femoral components to improve extensor mechanism in deep flexion and poste-
rior femoral rollback.17
Patient Selection for High Flex Design

zz Preoperative flexion should be 120°
zz Demand of deep flexion activity
zz Thigh-calf index should be more than 90% (Thigh and calf should be thin)
zz Collaterals should be functional and stable.
Fig. 12.3 High flex design

Disadvantages of High Flex Designs

Short radius: It has been shown to increase the polyethylene wear18 due to high
contact stresses during terminal flexion. It may make revision surgery more difficult
due to additional removal of bone from the notch area in cruciate substituting (CS)
design and of 2-4 mm bone from the posterior condyles.19
High flexion: It may lead to increased stress on patellofemoral joint, pain, patellar
fracture and loosening.
Results of High Flex Designs

Results are controversial, some suggest no difference20 in flexion while others show
variable range of flexion (Hy-Flex II21; >120°, NexGen LPSFlex:138°; NexGen1
LPS:135°).22
Fixed VS Mobile Knee (Fig. 12.4)

Fixed bearing knees have shown an excellent survival rate of > 90% at 10–15 years
after the operative procedure.23–25 Proponents of mobile knee say that long term
results have been documented in a relatively older population (> 60 to 65 yrs), a
better polyethylene and stable implant fixation is necessary for the younger patients
and that can be provided by mobile bearing knees only. Literature is again conflict-
ing showing comparable results, but there is no long-term follow-up for younger
patients26,27 showing better results of one prosthesis over another. Following are
described pros and cons of each design (Table 12.3).
Mobile knee: Oxford, LCS, Scorpio Plus, MBK, PFC-Sigma RP, PFC- RPF, LPS
Flex Mobile.
Gender Knees
Zimmer knee: It has a modified ML/AP aspect ratio, decreased thickness of the
anterior flange and increased trochlear groove angle in comparison to the original
NexGen knee (Zimmer, Inc).33
Table 12.3 Comparison of fixed bearing and mobile bearing knee

Fixed knees Mobile knees
Advantages • Long-term survival23,24 • Perhaps higher degree of tibiofemoral
• More stable conformity
• Lower contact stresses
• Lower rotational constraint28
Disadvantages • Rotational constraint of some • Limited indications
designs may lead to increased • Back-side wear
torque to insert-base-plate • Fair possibility of insert subluxation or
interface dislocation.30,31
• Back-side wear29 • Mechanical failure rate high (1-2%)32
Fig. 12.4 Mobile knee design
Triathlon knee system (Stryker Orthopedics, Mahwah, NJ): The femoral com-
ponent is narrowed in the ML dimension, and the 8 sizes grow by no more than
3 mm in the AP dimension. The addition of a 7° anterior flange angle was designed to
minimize the risk of notching the anterior cortex, especially if downsizing is necessary.33
Cemented vs Noncemented
Results are controversial.
Some studies report that there are no differences in the long-term result of cement-
less and cemented TKR.34-36 While others report the advantages and disadvantages of
each procedure.
Cementless TKR
Advantages
zz Avoids toxic effects of cement on the body37
zz Preserves sufficient bone stock for revision38
zz Allow early treatment of postoperative infection.38
Disadvantages
• Weak early fixation
zz Radiolucent lines below the tibial plate (showing absence of bony ingrowth)38
(Tibial tray loosening).
Cemented TKR
Advantages39
zz Documented long-term survival
zz It can interdigitate into both soft and hard bone
zz It can adjust minimal improper bone cuts
Now new designs have less osteolysis due to modular tibial tray with improved
locking mechanism, more wear resistant polyethylene with less abrasive surface.
Disadvantages
zz Revision can be difficult due to cement fixation
zz Theoretically cement complications like emboli can occur.
All POLYETHYLENE VS Metal Backed tibia40,41

Results are controversial. Use minimal thickness >10 mm. One recent study in
Chinese40 population found no significant difference between the two groups (All
polyethylene and metal backed implant with respect to HSS scores, ROM, clinical
and radiographic parameters measured and survival rate) Table 12.4.
Table 12.4 Comparison of metal back tibia and all polyethylene tibia
Metal backed tibia40,41 All polyethylene tibia40,41
Advantages • Liner can be adjusted after • Less expensive
insertion of trial or final • No problem of separate polyethylene
prosthesis and can be changed liner (back-side wear, dissociation)
during revision surgery
• It allows good prosthesis-
primary bone contact interface
with additional modular
augment or stem for bone loss
• Documented excellent survival
Disadvantages • Either more proximal tibial • Once inserted then no further
bone is resected or less adjustment can be done
thickness of polyethylene may • Whole component has to be
be used to restore the stability removed for revision surgery
• Liner dissociation or dislocation • Not suitable for soft bone
in rotating platform
• Expensive
Table 12.5 Comparison of various anticoagulation prophylaxis strategies

Routine prophylaxis Judicious prophylaxis
Advantages • Reduces the incidence of DVT • Wound complications and bleeding
• Probably reduces the related complications can be avoided
incidence of pulmonary • Cost effective
embolism
Disadvantages • Expensive therapy • Asymptomatic DVT may become
• Wound hematoma, increased symptomatic and may lead to
blood loss in drain, delayed pulmonary embolism very very rarely
wound healing, skin staining/ • Epidural/intracranial bleed
discoloration
(Figs 12.5 and 12.6)
• Probably does not alter the
incidence of fatal pulmonary
embolism
Fig. 12.5 Skin staining/discoloration due to low molecular weight heparin
Routine vs Judicious Use of

Anticoagulant Prophylaxis
Routine use of anticoagulant chemoprophylaxis has been questioned lately in few
published studies. Following advantages and disadvantages of routine and judi-
cious of anticoagulant chemoprophylaxis have been described in the literature
(Table 12.5).
Fig. 12.6 Skin necrosis and infection due to low molecular weight heparin
Patellar Resurfacing
Controversial, may be done in following situations:
zz Extensive patellofemoral osteoarthritis with predominantly anterior knee pain
zz Preferable in rheumatoid arthritis
zz History of patellar subluxation/dislocation
zz Intraoperative patellar maltracking or extensive patellar cartilage loss.
Complications of patellar resurfacing: It includes improper size, maltracking, loos-

ening, fracture and osteonecrosis of patella.
If you do not resurface, ensure three things:
zz Excellent patelloplasty
zz Circumcision with cautery
zz Ensure good patello-femoral tracking.
Unicondylar Knee Prosthesis (Fig. 12.7)
One Finger Test (Bert 2005)

Patient should point towards a single compartment of the knee joint when asked for
site of pain. Table 12.6 describes unicondylar knee indications and pros and cons.
Fig. 12.7 Unicondylar prosthesis in situ
Fig. 12.8 Constrained prosthesis

Table 12.6 Unicondylar knee-indications, advantages and disadvantages

Indications42 Advantages42-44 Disadvantages42,45,46
• Nonobese patient with • Less bone is removed for • Poor instrumentation and
sedentary lifestyle implantation of the prosthesis design
• Unicompartmental • Reduced blood loss • More technically
osteoarthritis or • Improved range of motion demanding
post-traumatic arthritis • Reduced hospital stay • Poor fixation
• Varus deformity < 10° • Reduced cost of treatment • Reduced prosthesis survival
• Minimum 90° flexion • Biomechanics is closer to the than TKR prosthesiss
without flexion deformity normal knee • Development of
osteoarthritis in the other
compartment
Contraindication42-47 Complications42
• Rheumatoid arthritis • More chances of failed
• Patients with nonlocalized prosthesis due to various
knee pain reasons including involvement
• Bi/Tricompartmental of the opposite compartment,
disease malaligned tibial or femoral
• Grade IV OA changes with component
medio-lateral subluxation
(> 3-4 mm).
• Symptomatic
patellofemoral arthritis
• < 90° flexion with flexion
contracture
• Active lifestyle with
sporting activities
• Obesity
• Unstable and ACL
deficient knee
• High expectation for
sporting activities and for
increased prosthesis survival
Constrained Prosthesis (Fig. 12.8)

zz Indications: Severe deformity, collateral ligament insufficiency, bone defects.
zz Advantage: Provides excellent stability.
zz Disadvantages
– Decreases bone stock.
– Early aseptic loosening.
– Recurrent instability in frontal plane.
– No long-term follow-up.
Extension Rods (Fig. 12.9)

Indications
zz Used with constrained designs
zz Severe deformity and bone loss
zz Associated fractures
zz Revision surgeries
zz Obese
zz Osteoporotic bone.
Advantages
zz Increases stability
zz Increases longevity of prosthesis
Hinged Implants (Fig. 12.10)

Indications
zz Salvage situations (failed revisions, tumors)
zz Significant bone loss.
zz Unreconstructable ligaments
zz Reconstruction after resection of tumor around the knee joints.
Disadvantages
zz Expensive
zz Early aseptic loosening
zz Large bony resections.
Fig. 12.9 A TKR with tibial extension rod

Fig. 12.10 Hinged knee prosthesis
Various Conditions and Implant Selection

zz Unicompartmental arthritis : Unicondylar knee arthroplasty/
high tibial osteotomy
zz Good bone stock : All polyethylene tibia
zz Young patient with no deformity : Cruciate retaining (CR)
zz Mild deformity : RP (Rotating platform) or RPF or fixed
bearing-posteriorly stabilized (FB-PS)
zz Moderate deformity : FB-PS
zz Severe deformity : FB-PS or constrained
zz Severe deformity with bone loss : Constrained prosthesis with extension
rods
zz No extensor mechanism : Hinged prosthesis
References
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13
chapter
Perioperative Management of
Total Knee Arthroplasty
Preoperative clinical evaluation

zz Thorough clinical history.
zz Assess the indications and contraindications.
zz Assess the patient expectations, occupation and discuss the needed lifestyle modi-
fications after the knee arthroplasty.
zz Assess the range of motion, deformity (varus, valgus, flexion or combined deform-
ity, whether correctable or not) and instability (severe instability may require con-
strained prosthesis). Non-correctable deformities require release.
zz Look for range of movements and deformities of hip on affected site.
zz Informed and written consent for surgery.
zz One dose of intravenous antibiotics (cefotaxime/ceftriaxone) in the morning or one
hour before starting the surgery. Avoid aminoglycosides (gentamycin, amikacin) in
renal disease.
zz Manage medical conditions as described in chapter on perioperative management
of THR.
Preoperative Radiological Evaluation

Radiographs
Standing long-leg anteroposterior radiograph, lateral and skyline view:
zz Standing long-leg anteroposterior radiograph (Figs 13.1A and B)
To assess the deformity, mechanical and anatomical axis, bone defects, mediolat-
eral subluxation, and templating for sizes of components.
zz Lateral view (Fig. 13.2): Subluxation, bone defects, posterior osteophytes and
position of patella.
zz Sky line view: Patellar tilt, hypoplasia of condyle or trochlea.
A B
Figs 13.1A and B Standing AP view of both knees with osteoarthritis with subluxation and
varus deformity
Fig. 13.2 Posterior osteophytes and loose bodies

Chapter 13 Perioperative Management of Total Knee Arthroplasty 113
Postoperative clinical management

Immobilization: Knee brace or cylinder slab may be given for initial 2-3 days.
Immediate postoperative care: Check for soakage of dressing (for mild soakage, do
suprabandaging), pulse, BP, respiratory rate, O2 saturation, blood in suction drain
(one ring ≈ around 100 ml, replace accordingly), distal pulses (dorsalis pedis and pos-
terior tibial artery), color (should be pink) and capillary filing (normally < 2 seconds)
of toes, extension of toes and foot (common peroneal nerve).
Wound inspection: Done on 2nd postoperative day and dressing debulked.
Any suspicious looking discharge should be sent for culture and sensitivity.
Analgesic: Morphine top-up (12 hrly) through epidural catheter for 2-3 days with
injection diclofenac sodium (renal, asthmatic or allergic disease: pethidine + phen-
argen/tramodol) on SOS basis followed by oral diclofenac/aceclofenac sodium (renal,
asthmatic or allergic disease: Tramodol with or without paracetamol) till suture
removal.
Antibiotic and prophylaxis for DVT: See chapter on Complications of TKR.
Suture removal and mobilization: Static quadriceps on first 1-2 days, weight bearing
mobilization with walker (Figs 13.3 to 13.5) on 2nd to 3rd day (depending on the
Fig. 13.3 Venous pump in a patient after bilateral total knee arthroplasty
Fig. 13.4 Patient standing on 3rd postoperative day
Fig. 13.5 Patient sitting on the side of the bed with 90° flexion at 2 weeks after surgery
Chapter 13 Perioperative Management of Total Knee Arthroplasty 115
bone quality, fixation of component, intraoperative bone cracks, soft tissue repair),
knee flexion from 2nd to 3rd day (try to get 90° flexion till suture removal) and
suture/staples removal on 14th postoperative day after wound inspection for heal-
ing to avoid gaping (if still wide gaping, delay for 5-7 days, if minimal or doubtful
gaping, remove alternate sutures). Walking aid preferably walker for first-two weeks
followed by stick for next 2-3 weeks. Start stair climbing after 2 weeks in midvastus or
subvatus approach and avoid cross legged sitting/squatting forever.
14
chapter
Surgical Approaches and

Technique of Primary
Total Knee Arthroplasty
Surgical Approaches
With anterior midline skin incision, medial parapatellar and midvastus approaches
are the most commonly used for primary total knee arthroplasty (Table 14.1).
Basic Principles (Tips and Tricks) of

Soft Tissue Release to Achieve Stable Joint
zz Stepwise sequential release
zz Optimum subperiosteal release with osteotome or cautery
zz Laminar spreaders or spacer block to judge to rectangular and equal flexion and
extension space
zz Achieve full extension and good flexion of knee
zz Achieve good medial-lateral balance at full extension, 90° of flexion and mid-flexion
zz Proper patellar tracking
zz Check balancing at every step (preoperatively, after induction of anesthesia, before
and after bone cuts with insertion of trial and final prosthesis).
Basic Principles (Tips and Tricks) for Optimum Bone Cuts

zz Protect and preserve bone and soft tissues (medial-lateral soft tissue sleeves, liga-
mentum patellae and popliteus tendon).
zz Cross check accuracy of cuts by using multiple references (Angel wing, saw blade,
epicondylar axis, Whiteside line, posterior condylar axis or proximal tibial articu-
lar surface) before cut and accuracy of surface after the bone cut.
zz Consider bone quality (careful bone cutting and impaction during cementing for
soft bones, e.g. rheumatoid arthritis, use sharp new blade for cutting hard bone in
osteoarthritis to prevent wrong cut due to kinking of blade by pressure of hard bone)
zz There are no fixed sequences for bone cuts (tibia first or femur first; distal femur or
anterior femoral cut). But beginner should try to follow one sequence (tibial cut,
Chapter 14 Surgical Approaches and Technique of Primary Total Knee Arthroplasty 117
Table 14.1 Comparison of various surgical appraoches to TKR

Approaches1,2 Advantages Disadvantages
Subvastus (Southern): (Fig. 14.1)
• Incise the vastus medialis • It does not disturb extensor • Not useful for obese
fascia medial to patella and mechanism patient, revision surgery,
lift it from muscle by blunt •A llows better judgment of previous arthrotomy or
dissection patellar tracking high tibial osteotomy
• L ift the inferior edge of the • L ess anterior knee pain, • Eversion of patella is
vastus medialis muscle from patellar fracture, patellar difficult
the periosteum and medial loosening (due to intact
intermuscular septum patellar blood supply)
proximally and perform • L ess postoperative pain
L-shaped arthrotomy and strong intact extensor
mechanism
Midvastus (Fig. 14.2)
Incision is given in the direction • Insertion of vastus medialis • Difficult for obese,
of fibers and through the into the medial border of previous high tibial
midsubstance of vastus medialis quadriceps tendon is not osteotomy, patient with
starting from the superior disturbed less than 80˚ of flexion
medial border of patella, curving •A voids lateral release
along the anteromedial border •A llows early recovery of
of patella, distally medial to the postoperative extensor
ligamentum patellae on the mechanism
medial surface of proximal tibia • Better patellar tracking
Lateral approach
Incision along the lateral • Indicated in fixed valgus • Technically demanding
border of quadriceps tendon deformity due to unfamiliar anatomy
•A llows direct exposure of • Medial eversion and
the lateral pathology displacement of extensor
• Allows better exposure of mechanism is more
the posterolateral corner difficult than the
due to medial displacement lateral one
or eversion of extensor
mechanism and internal
rotation of tibia
• Intact vascularity and better
patellar tracking
Anteromedial parapatellar (Fig. 14.3)
approach Indicated in patients with • Extensor mechanism is
Incision along the medial knee deformities (varus, affected; patellar
border of quadriceps tendon, valgus, flexed knee) maltracking
curving distally around the Better exposure of distal
medial border of patella up to femur and proximal tibia
tibial tuberosity (try to keep
medial to tibial tuberosity)
V-Y Plasty or Tibial Tubercle Osteotomy

zz Used for stiff knee
zz Tibial tuberosity osteotomy is preferred over V-Y plasty
zz Tibial tuberosity osteotomy have less possibility of extensor lag and other
complications.
anterior cut, distal cut, check extension space, sizing of femur (see the proposed
flexion space), 4 in one jig (posterior cut, posterior chamfer, anterior chamfer, ante-
rior cut), notch cut, tibial sizing, check stability with trial femoral prosthesis, trial
tibia and minimum spacer (8, 10 size), prepare tibia, and patella (patellar cut) only.
Technique for Primary Total Knee Arthroplasty

(Cemented Posterior Stabilized Knee)
zz Drape the knee (Fig. 14.4)
zz Inflate the tourniquet
zz Midline skin incision extending slightly medial to tibial tuberosity in the lower
part (Fig. 14.5)
zz Raise medial and lateral skip flaps deep to deep fascia otherwise flap will necrose
(Fig. 14.6)
Fig. 14.1 Planes of dissection in parapatellar and midvastus approach

Fig. 14.2 Plane of dissection for midvastus approach (arrow mark)
Fig. 14.3 Plane of dissection for medial parapatellar approach

zz Use midvastus approach and before cutting put a marking suture at the angle of
attachment of vastus medialis with patella (Fig. 14.7)
zz Cut the muscle with cautery or knife (Fig. 14.8)
zz Excise the synovium from the suprapatellar pouch (Fig. 14.9)
Fig. 14.4 Draped knee with marked tibial tuberosity (T) and joint line (JC)
Fig. 14.5 Marking for midline skin incision, distal part medial to tibial tuberosity
Fig. 14.6 Lifting the medial and lateral skin flaps
zz Distally do the medial release medial to patellar ligament by rotating the leg exter-
nally. Also release upper border of lateral condyle
zz Evert the patella (Fig. 14.10)
Fig. 14.7 The arrow at the marking suture for the angle of vastus medialis attachment with patella
zz Partially excise the fat from infrapatellar fat-pad (Fig. 14.11)

zz Cut the cruciate ligaments
zz Excise the meniscus (Fig. 14.12)
zz Remove the anterior osteophytes (Fig. 14.13).
Fig. 14.8 Cutting the synovium with cautery
Fig. 14.9 Clean suprapatellar pouch after synovectomy

Fig. 14.10 Eversion of patella with flexed knee and release of lateral border of patella
Tips of patellar eversion

zz Adequently raise lateral skin, subcutaneous and deep fascia flap
zz Release lateral border of patella with cautery
zz Release lateral border of tibia proximally
zz Circumcision of patella.
Bone Cuts
There are total six femoral cuts (anterior, distal femoral, posterior, anterior and pos-
terior chamfer cut, intercondylar notch cut), two tibial cuts (proximal and stem cut)
and optional patellar cut. Over all effects of wrong bone cuts includes pain, decreased
ROM, instability, anterior knee pain with or without patellar maltracking and early
aseptic loosening.
Tibial Cut (Figs 14.14 to 14.20)

Cut is made at 90° to long axis (horizontal to ground) of tibia (and with 0-5° posterior
slope) with exramedullary rod aligning distally along the mid of anterior surface of
ankle joint (distally along the 2nd toe) and proximally at the junction of medial one
third and lateral two-third of tibial tuberosity (for correct rotation, center of tibial tray
should be at this junction,). Excesvsive internal rotation of tibial component lead to
posterolateral slope and excessive external rotation result in posteromedial posterior
slope. This cut affects both spaces (flexion and extension). Anterior, posterior and
distil femoral cuts are parallel to this cut in midflexion and in extension respectively.
Fig. 14.11 Debulking of the infrapatellar fat pad
Fig. 14.12 Removal of the posterior part of medial meniscus

Fig. 14.13 Removal of anterior tibial osteophytes
Fig. 14.14 Extramedullary tibial zig parallel to tibia and pointing towards second toe.
Also note the posteior slope
A B
Figs 14.15A and B Varus/valgus cut or excessive anterior or posterior tibial slope due to
improper mediolateral or anteroposterior placement of extramedullary tibial cutting zig
Fig. 14.16 Stylus on more deformed medial tibial plateau

Cut should remove minimum 8-10 mm thickness of tibia; inadequate bone removal
lead to tightening of both spaces (flexion/extension). Anterior tibial slope contrary to
normal posterior slope reduces posterior flexion space, limit the posterior rollback and
may results in pain and decreased ROM. Excessive posterior slope >5-10° may increase
mid flexion instability. Average increase of 1.7° of flexion for every 1° increase in
Fig. 14.17 Hole of zig in line with medial third of the tibial tuberosity (with blue marker)
Fig. 14.18 Cross-checking of the tibial cut thickness with angel wing
Fig. 14.19 Cut tibial surface with removal of posterior part of medial meniscus with cautery
Fig. 14. 20 Approximate extension space assessment by using the minimum spacer
(18-20 mm)
A B
Figs 14.21A and B Anterior cut (A), the epicondylar axis (E), posterior condylar axis (PC)
and the tibial cut surface are parallel to each other; also shows the whiteside line (W) and
femoral entry point (EP) just anterior to ACL attachment
Fig. 14. 22 Femoral entry in the middle of the distal articular surface of femur
posterior slope is achieved. After tibial cut remove posterior remaining part of menis-
cus and osteophytes (Fig. 14.15).
zz After tibial cut check rough extension space (Fig. 14.16).
Anterior Femoral Cut (Figs 14.21 to 14.27)

It is an important cut to prevent malrotation, notching, anterior overstuffing and
patellar maltracking. Insert the intramedullary rod (long better than the short and
should be in the center of canal) by making an entry point (either 5 mm anterior to
the attachment of PCL or mid point of medial and lateral femoral margin or 5 mm
Fig. 14.23 Intramedullary rod with anterior cutting zig with desired 6° of valgus and adjusted for
right-left should be flushed with the distal articular surface of the femoral condyles
medial to the mid point) with jig in 5-7° valgus and 3-5° external rotation (increased
external rotation causes increased midflexion medial space and internal rotation causes
lateral tilting of patella). Stylus should be touching the prominent lateral most part
of anterior surface of lateral condyle (cross check with the Angel wing touching the
anterior surface of lateral femoral condyle) and cut the bone. Cut surface and the
resected bone looks like a piano (Grand piano sign) with cut lateral condyle thicker
than medial condyle. Extension cut will cause notching while flexion cut will cause
anterior overstuffing.
Distal Femoral Cut (DFC) (Figs 14.28 to 14.31)

Remove the intramedullary rod and attach distal cutting zig to pin over anterior sur-
face. Distal femoral cut thickness should be equal to thickness of prosthesis and at 90°
angle to the mechanical axis of femur. Valgus (usually 5-7°) be taken either according
to neck shaft angle (coxa vara > 5°, coxa valga < 5°). Extra or excessive DFC should be
avoided to prevent joint line elevation, patellar maltracking, extension instability, pain
and decreased ROM (>10 mm joint line elevation decrease flexion by > 25%). In fixed
flexion deformity, extra distal femoral cut up to 4 – 6 mm can be taken.
zz After DFC, put a spacer and check medial and lateral stability
zz Now decide the size mid flexion on space depending on definitive prosthesis (Figs
14.32 and 14.33). Now decide the mid-flexion space depending on the size of
definitive prosthesis.
zz Take the 4 in 1 cutting zig of same size and complete the other cuts (Figs 14.31A
and B)
Fig. 14.24 Checking thickness of the anterior cut with angel wing, it should flush with most
prominent part of the lateral femoral condyle
A B
Figs 14. 25A and B External rotation zig either parallel (A) or slightly in external rotation
(B) to cut tibial surface
Posterior Femoral Condyle Cut (Figs 14.34 and 14.35)

This cut is made by jig with knee in 90° flexion and with 3° external rotation (inad-
equate rotation leads to trapezoidal midflexion space than a rectangular space). There
are following three methods for this cut (combine more than one method for accuracy).
A B
Figs 14. 26A and B Anterior cut has been taken and showing giant piano sign (A) shape of
cut surface and Piano shape of bone removed (B) by the cut
Fig. 14. 27 Cross check the anterior cut with a flat rasp; should be equally flushed on both
cut surfaces of the condyles
Posterior condylar axis: A line (Figs 14.25A and B) passing through the lower most
part of both femoral condyles. Cut is made at an angle of 3° external rotation to
this axis in 90° flexion of knee (it cuts more thickness of medial condyle than lateral
condyle). But this method is not good for valgus knee (rheumatoid arthritis) having
either hypoplastic lateral femoral condyle or extensive wear of both condyles (epicon-
dylar axis may be used for cut).
B
Figs 14. 28A and B Intramedullary rod has been removed and checking the thickness of the
distal femoral cut with an Angel wing (A) after putting the distal cutting zig, it should be flush
with the notch area (B)
Fig. 14.29 The cutting of the distal femoral cut with saw with a broad osteotome protecting the
cutting of the tibial surface. Cut should be away from the medial collateral ligament (shown with
a tip of the artery forceps)
Fig. 14.30 Attached distal femoral zig and distal femoral cut has been taken
B
Figs 14.31A and B The extension gap (A) after putting the spacer and checking the medial
(B) and lateral stability
Epicondylar axis: A line (Figs14.21A and B) joining the most prominent part of two
epicondyles make epicondylar axis. Cut should be made parallel to this line.
Whiteside line: It extends (Figs14.21A and B) from the base of femoral trochlear
groove to the apex of the intercondylar notch. It is not reliable in revision surgery.
Tibial cut surface (gap technique): With jig in situ, take saw blade in hand and align
with the proposed level of cut; this should be parallel to cut surface (Fig. 14.25A &
B) of proximal tibia.
Cut should ensure 3° of external rotation for equalizing the space (lateral is more than
medial due to tibial cut at 90° to horizontal plane). Size of zig should be adequate
(small size cuts more posterior condyle and leads to increased midflexion space with
instability). Magnitude of cut correlates well with final flexion (every 1 mm loss of
PFC offset causes 6° loss of flexion).
Femoral Notch Cut (Figs 14.36 and 14.37)

This cut is lateralized and bone should be cut at right angle close to inner margin of
jig with osteotome or saw.
Fig. 14.32 The sizing with a zig (it should be flushed with anterior and posterior cortex, see
the number against the marker, here it is 9)
Fig. 14.33 Size can be cross checked by taking the prosthesis of measured size (like here
using 7 size; if it is 9 then take 9, should be centered over the notch and should not extend
beyond the outer margin of medial and femoral condyles)
Ligament Release for CR Prosthesis

Measured Resection Technique
Anterior and posterior femoral cuts are taken at fixed measured angles referenced from
anatomical landmarks (transepicondylar axis, Whiteside line and posterior condylar
reference). Ligament release is done after implantation of prosthesis in extension.
Gap Technique
Tight ligaments are released (tightest first) after proximal tibia cut, then a laminar
spreader or a tensor may be used to tension the ligaments and the anterior and poste
rior femoral bone cuts are made parallel to the tibial cut based on the ligament tension.
zz Insert trial femur and tibia with approximate sized liner and check stability and
patellar tracking (Figs 14.38A to D)

zz Now wash the prepared femur and tibia.
Patellar Cut (Figs 14.39 and 14.40)

Circumcision should be done for denervation (less patellar pain) and remove osteo-
phytes to clear the surface for estimating the bone removal with the help of patellar
zig. Patella prosthesis should be medialized on a 12-15 mm of native patella. Patellar
tracking should be checked with no touch technique (no thumb on the patella)
B
Figs 14.34A and B Hohmann retractor with broad osteotome to avoid damage to
MCL and tibial cut
Fig. 14.35 Notch cutting zig in situ (should be flushed over the anterior chamfer and distal
femoral cut, should be centered over the femoral entry point)
Fig. 14.36 Well placed notch cutting zig

Fig. 14.37 Complete notch cut
from extension to flexion of knee (there should be no lateral tilting of patella and
it should remain in contact with anterior surface of medial condyle throughout the
extension and flexion movements) preferably after release of tourniquet. Patellar
maltracking may occur due to internal rotation of components, medialization of
notch cut, lateralization of patella or elevation of joint line. Patellar maltracking
may require lateral release which can be done from inside (release < 5 mm to avoid
injury to common peroneal nerve) or from outside (gentle longitudinal releasing
incision just below the lateral patellar margin till the synovium becomes visible and
it should not extend beyond lateral superior margin of patella to avoid damage to
blood supply of patella). Inadequate bone thickness3 removal form patella leads to
anterior overstuffing (anterior knee pain and 3° decrease in ROM for every 2 mm
thickness).
zz Apply some cement over femur and tibia in early phase and over the implant
(in doughy stage), insert the definitive tibia, femur, patella and check range of
motion, stability and patellar tracking (Figs 14.39 to 14.41).
Common mistakes and their causes

zz Instability in flexion: Undersized femoral component (increase resection of PFC),
anterior translation and flexed anterior femoral condyle, rotational malalignment
of femur and tibial stem, increased tibial posterior slope.
zz Instability in extension: Asymmetric instability due to improper bone cuts or
soft tissue release or both, symmetric instability due to excessive removal of bone
(DFC) or generalized laxity.
Figs 14.38A and B

C
Fig. 14.38C
Figs 14.38A to C (A) Stability in extension; (B) Stability and alignment in flexion;
(C) Alignment in extension
D
Fig. 14.38D Checking patellar tracking. Note the no thumb rule.
B
Figs 14.39A and B (A) Early stage cement applied before putting original femoral component
with drilling of the sclerotic tibial cut surface; (B) Original femoral component in situ and
cement over the tibial surface
Fig. 14.40 All the three definitive components implanted with cement
Fig. 14.41 The well positioned patella (not lifting laterally even without any thumb touch: No
thumb technique for checking patellar tracking)
zz Inadequate post clearance due to reverse tibial slope or posterior osteophytes.

zz Anterior over stuffing due to inadequate anterior femoral cut or over size patella.
zz Patellar maltracking due to internal rotation of components, medialized notch
cut, lateralized patella, elevation of joint line or overstuffing.
Criteria for Equalizing Flexion and Extension

Gaps and Bone Cuts
If both extension and flexion space are tight: Remove tibia
If extension is tight and flexion is normal: Posterior release and remove distal femur
If extension is normal and flexion is tight: ↓ Femur size/ ↑ posterior slope of tibia
If extension is normal and flexion is loose: ↑Femur size or distal femur can be
resected and use thicker tibial insert
If extension is loose and flexion is normal: Distal augmentation of femur or down-
size femur and use thicker tibial insert
If both extension and flexion space are loose: Large tibial insert.
Factors Affecting Flexion after TKR

Preoperative flexion is the single most important factor affecting the postoperative
flexion.4 Others variables reducing postoperative flexion includes female sex, obesity,
previous knee surgeries, associated co-morbidities,5 component malposition, patel-
lofemoral overstuffing, improper size of components, inadequate flexion gap balanc-
ing, posterior tibial or femoral osteophytes.6-8
References
1. Steven H. Stern. Surgical exposure in the total knee arthroplasty in Orthopaedic In:
Robert et al. (Eds). Knowledge Update, Hip and Knee reconstruction 3 (1st edn); 2007
pp. 3-15; Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.
2. Andrew H. Crenshaw Jr. Surgical Techniques and Approaches in Canale ST and Beaty
JH (eds). Camplbell’s Operative Orthopaedics 11th edn; 2008 pp. 4-14; Mosby, Elsevier,
Philadelphia USA.
3. Briard JL, Hungerford DS. Patellofemoral instability in total knee arthroplasty.
J Arthroplasty 1989;4(Suppl): 587-97.
4. Dennis DA, Komistek RD, Scuderi GR, Zingde S. Factors affecting flexion after total knee
arthroplasty. Clin Orthop Relat Res 2007;464:53-60.
5. Fisher DA, Dierckman B, Watts MR, Davis K. Looks good but feels bad: factors that contribute
to poor results after total knee arthroplasty. J Arthroplasty 2007;22(6 Suppl 2):39-42.
6. Sultan PG, Most E, Schule S et al. Optimizing flexion after total knee arthroplasty:
advances in prosthetic design. Clin Orthop Relat Res 2003;416:167-73.
7. Kurosaka M, Yoshiya S, Mizuno K, Yamomoto T. Maximizing flexion after total knee
arthroplasty: The need and the pitfalls. J Arthroplasty 2002;17:59-62.
8. Michael Murphy and Simon Journeaux and Trevor Russell. High-flexion total knee
arthroplasty: A systematic review. International Orthopaedics (SICOT) 2009;33:887-93.
15
chapter
Complex Primary Total

Knee Arthroplasty
Varus Knee
Varus deformity is more common in osteoarthritis of knee. Tissues are contracted on
the medial side and are lax on the lateral side.
Contracted Soft Tissues on the Medial Side

zz Posteromedial corner: Semimembranosus insertion, medial capsule and deep
medial collateral ligament
zz Superficial medial collateral ligament
zz Pes anserinus tendon.
Soft Tissue Release (Tips and Tricks; Fig.15.1)1

zz Initial exposure should include the release of deep collateral ligament from the
tibia up to the posteromedial corner of the tibia.
zz Remove medial osteophytes from tibia and femur to prevent tightness of the
medial sleeve.
zz Excise medial meniscus.
zz PCL tight: Release it.
zz If medial tightness persists: Do the sequential release from tibia further poste-
riorly and inferiorly and recheck the medial tightness after release of each tight
tissue.
zz Flex and externally rotate tibia and release semimembranosus from the postero-
medial corner. Release superficial collateral ligament and pes anserinus insertion.
zz If still tight: Subperiosteal release from the tibia distally up to 4-8 cm (should be
the last option to avoid valgus instability).
zz Sequence of release: Deep MCL and capsule and excision of medial meniscus +
osteophytes from medial side of tibia and femur → PCL → semimembranosus
aponeurosis, superficial collateral ligament, pes anserinus → subperiosteal release
from tibia upto 4-8 cm distally (last resort).
Chapter 15 Complex Primary Total Knee Arthroplasty 147
Fig. 15.1 Complete medial release and lateral release being done
Valgus Knee (Figs 15.1 and 15.2)

Problems
zz Bone loss or hypoplastic lateral femoral and tibial condyle
zz Soft tissues contracted on the lateral side
zz Lax and weak medial sleeve
zz Patellar maltracking
zz Acute correction of combined flexion and valgus deformities can cause common
peroneal nerve palsy. It can be prevented either by exposure and release of the
CPN or immobilizing the knee postoperatively in some degree of flexion to allow
gradual correction.
Contracted Soft Tissue on the Lateral Side

zz Iliotibial band
zz Lateral collateral ligament
zz Arcuate ligament: Posterolateral capsular complex
zz Popliteus tendon
zz Lateral head of gastrocnemius.
Soft Tissue Release (Tips and Tricks)

zz Minimal medial side release
zz Do sequential release of the tight structure on the lateral side and recheck lateral
tightness after release of each structure on the lateral side
Fig. 15.2 Removal of the lateral femoral osteophytes
zz Incise the arcuate ligament: Posterolateral capsular complex horizontally at the

level of tibial bone cut and divide iliotibial band
zz If PCL tight: Release it
zz If lateral structures are still tight: Release lateral collateral ligament and popliteus
tendon
zz Release the lateral head of gastrocnemius for associated flexion deformity
zz Usually thick insert or constrained implant needed in presence of incompetent MCL.
Sequence of release: Posterolateral capsule → Iliotibial band, and PCL and lateral
collateral ligament → Popliteal tendon → Lateral head of gastrocnemius (for associ-
ated flexion deformity).
Pie crusting technique: Elkus described this technique for severe valgus knee. This
involves sequential palpation of tight soft tissues and release by multiple stab punctures.
Fixed flexion deformity of knee (FigS 15.3 to 15.6)

zz Release the posterior capsule proximally for a small distance above the femoral
condyles after the posterior condylar cut
zz Remove posterior osteophytes from tibia and femur
zz If still less posterior recess: Release posterior capsule further up to posterior surface
of femur
zz Medial head of gastrocnemius or extra distal femoral cut should be the last resort
zz Flexion deformity (> 60°): Two staged procedure.
zz In cases of inflammatory arthritis around 5-10° of flexion deformity can be left
and it corrects well in the postoperative period with physiotherapy.
Fig. 15.3 Removal of the posterior osteophytes to clear posterior recess
Fig. 15.4 Clear posterior recess

Fig. 15.5 Residual flexion deformity after TKR on 2nd postoperative day
Fig. 15.6 Complete correction of flexion deformity at 2 weeks in a rheumatoid patient

Stiff Knee
zz Most difficult knee
zz Proximal soft tissue release (V-Y plasty) and tibial tubercle osteotomy may be
required1
zz Soft tissue release should be gradual and sequential
zz Adequate postoperative physiotherapy and use of CPM machine
zz Postoperative flexion may be < 90°.
Patellar Tracking
zz Preferably checked after tourniquet release
zz Preoperative thickness = Postoperative thickness
zz Circumcision and excision of the osteophytes
zz Should be medialized
zz On table patellar maltracking: Lateral release by inside-out or outside-in tech-
nique (Fig. 15.7) till the synovial layer is exposed. Do not go beyond 5 mm to
avoid injury to common peroneal injury in inside-out method.
Bone Loss
zz Varus and valgus knees have defects on medial and lateral sides respectively
zz Minimal defects (Fig. 15.8) are managed by making drill hole or putting screws
and cement
zz Large defects (Fig. 15.9) are managed by bone grafts or metal wedges
zz It is safer to use extension rods in these situations.
Fig. 15.7 Lateral release from outside, do not divide synovium to avoid damage to blood
supply of patella
Fig. 15.8 Small contained bone defects
Fig. 15.9 Reconstruction of large defects with bone graft fixed with screw
Reference
1. Crockarell JR Jr, Guyton LJ. Arthroplasty of knee in Canale ST, Beaty JH (Eds). Camplbell’s
Operative Orthopaedics 11th edn; Philadelphia: Mosby, Elsevier; 2008 pp. 241-99.
16
chapter
Complications of Total Knee

Arthroplasty
Complications after Total knee replacement

Infection (Fig. 16.1)
A number of comorbidities have been shown to be associated with increased risk of
infection. These include previous open knee surgeries, immunosuppressive therapy,
hypokalemia, poor nutrition, diverticulosis, infection elsewhere, diabetes milletus,
obesity, smoking, renal failure, hypothyroidism, and alcohol abuse.
Diabetes increases the risk of wound complications and infection by following ways:
zz It delays collagen synthesis and decreases wound strength.
zz It impairs the delivery of blood and oxygen.
zz Nicotine and other byproducts of smoking cause vasoconstriction, decreased
proliferation of red blood cells, fibroblasts, and macrophages; decreases oxygen
transport and metabolism; and inhibits enzymes necessary for oxidative
metabolism and cellular transport.
zz Reported rate of infection varies from 1.6 to 3%.
zz Get a good perioperative diabetic control.
zz Perioperative intravenous cefotaxime or ceftriaxone with gentamycin (one
preoperative dose) should be given for next 5 days followed by oral cefixime/
cefuroxime/augmentin till suture removal.
zz Early (< 4 week postoperative) or acutely painful, red, swollen knee should
be opened and thorough debridement should be done. Antibiotics should be
continued for six weeks (2 weeks IV in hospital, 4 weeks oral at home)
zz Radiological changes (bone resorption at bone-cement interface, bone cyst,
periosteal reaction), ESR and CRP (peak reaches 48 to 72 hours after TKR and
return to normal within 3 weeks) help in detection and follow-up during treatment.
Fig. 16.1 Infection in a diabetic patient after TKR
Thromboembolism (Fig. 16.2)

It is less in our setup without any obvious known reasons. Western reports suggest
high prevalence (40-84%) of DVT after TKR due to various predisposing factors
including age > 40 years, previous history of thromboembolism, varicose veins, estro-
gen therapy, hypertension, ischemic cardiac disease, prolong immobilization, obesity
and malignancies. Painful, warm, red, swollen leg with positive calf tenderness or
Homan’s sign (calf pain on dorsiflexion of foot) suggests DVT, which can be con-
firmed by Duplex ultrasound. It can be prevented by prophylactic treatment with low
molecular weight heparin (may cause hematoma, infection, bleeding) or warfarin in
hospital and by oral asprin/warfarin up to 7-10 days. Physical preventive measures
include stocking, foot pump, and early mobilization.
Previous h/o thromboembolism, varicose veins and ischemic cardiac disease are
the three genuine indications of chemoprophylaxis against DVT.
Chapter 16 Complications of Total Knee Arthroplasty 155
Fig. 16.2 Discoloration of the skin after TKR due to low molecular weight heparin
Vascular Insufficiency
Reported rate ranges from 0.03–0.2% and is more in patients with peripheral vas-
cular disease.
Nerve Palsy
Common peroneal nerve palsy is seen 0.3 – 1.8% of rheumatoid patients and in
patients with combined fixed flexion and valgus deformity undergoing TKR.
Periprosthetic Fracture (Fig. 16.3)

Supracondylar fractures (0.3–2%) of the femur tend to occur in patients having osteo-
porosis, rheumatoid arthritis, steroid therapy, femoral notching and trauma. Usually
are treated by ORIF with locking plate, intramedullary nail or revision arthroplasty.
Fracture of tibia is very rare.
Instability
Usually due to wrong bone cuts, malpositioned components and inadequate soft
tissue balancing.
Complications of Patellar Resurfacing

zz Fracture
zz Maltracking/instability
zz Aseptic loosening
zz Polyethylene wear
zz Anterior knee pain due to over or undersized patellar component
zz Avascular necrosis of patella
zz Patellar clunk syndrome.
Fig. 16.3 Periprosthetic fracture after TKR
Patellar Clunk Syndrome

Painful clunk occurring during knee movement from flexion to extension constitutes
patellar clunk syndrome. It is due to formation of a fibrous nodule at the junction
of proximal quadriceps tendon and proximal pole of patella because of impinge-
ment of anterosuperior part of intercondylar notch area of femoral component on the
proximal part of quadriceps tendon. It may be seen in oversized femoral components,
abnormal proximally placed patellar prosthesis or due to irritation of quadriceps ten-
don over the anterior flange of femoral component. Treatment is surgical removal of
fibrous nodule with or without revision of patellar component.
Index
Page numbers followed by f refer to figure and t refer to table
A stimulating 95
Bowing of femur 33
Acetabular
component 19, 35
index 29f C
labrum 3 Cement mixing technique 24f
reaming 58 Cemented
templating 33f cup 19
Acetabulum 3 hip 16, 16t
Allis method 81 posterior stabilized knee 118
Ankylosing spondylitis 49 stems 14
Anterior TKR 101
cruciate ligament 85 Cementless
femoral cut 129 acetabular
knee pain 155 components 20
superior iliac spine 88f cup 20f
Artery forceps 88f, 134f hip 16, 16t
Arthritic hip 9 stem 17, 17f, 18
Aseptic loosening 39, 155 TKR 100
of acetabular and femoral components 16f total hip arthroplasty 7f
of cup 38 Center of
of joint prosthesis 39t head 9
Assessment of hip 33
acetabular cup positioning 40f patella 88f
stability of joint 65f rotation of head 9
Autologous Ceramic
chondrocyte transplantation 95 implants 21t
osteochondral transplantation 95 on ceramic hip 21, 21f
Avascular necrosis of patella 155 on polyethylene hip 21f
Axis of lower limb 91 wear 12
Charnley’s
B cemented prosthesis 7f
pillow 52f
Bilateral retractor 44f
ankylosed hip 74f Circumcision of patella 123
total Complete correction of flexion deformity 150f
hip arthroplasty 74f Complex primary total
knee arthroplasty 113f hip replacement 71
Blood supply 3, 89 knee arthroplasty 146
of patella 151f Complications of
Bone bone cement 26
cements 24 patellar resurfacing 103, 155
cuts 123 resurfacing 23f
graft 76 total
loss 30, 151 hip arthroplasty 79
quality 30 knee arthroplasty 153
scan 35 CT scan 34
158 Tips and Tricks in Hip and Knee Arthroplasty
Cup 34 G
fixation 68
Current total hip arthroplasty 8 Gap technique 136, 137
Custom made femoral components 19 Gluteus maximus 4f, 5, 44f, 54
Cutting synovium with cautery 122f Greater trochanter 4f, 55f
D H
Hematoma formation 79
Debulking of infrapatellar fat pad 124f Heterotopic ossification 79
Deep flexion 98 High
Deformity 94 flex design 98, 98f, 99
Dislocation of femoral head 38f flexion 98, 99
Distal Hinged
centralizer in femoral cemented stem 25f implants 106
femoral articular surface 91 knee prosthesis 107f
femoral cut 130 Hip
medullary plug 25f arthroplasty 6, 41, 41t, 78f
Draped limb 42f center 9
Dysplasia 28 joint 3
Dysplastic hip 76 resurfacing 23
Hohmann’s retractor 4f, 54, 57f
E
Early I
modern total hip arthroplasty 6 Ideal abduction angle 59f
stage of total hip arthroplasty 6 Impaction of morselized cancellous bone
Epicondylar axis 136 graft 61f
Excellent patelloplasty 103 Implants and bone cements 14
Excise medial meniscus 146 In-bed mobilization
Exposed knee joint 87f abduction 53f
Exposure of acetabulum 54 flexion 53f
Extension rods 106 Inferior
External rotation deformity 73 gemellus 5, 45f, 46f
gluteal artery 3
F Infrapatellar fat pad 85
Faber deformity 73f
Femoral J
component 14, 38, 40, 91 J curve 93
condyles 137f Joint
notch cut 136 line 120f
rollback on tibia with flexion 92f replacements 95
stem 18, 34f, 68 sparing options 95
Femur 3, 34, 78 surface restoration 95
Fixed Judicious prophylaxis 102
bearing and mobile bearing knee 99t
flexion deformity of knee 148
knee 99
K
Flat polyethylene surface 93 Kellgren stages of osteoarthritis of knee 95f
Fracture 155 Knee
neck of femur 24, 30 arthroplasty 90
of proximal part of femur 31 joint 85, 86f
Functions of bone cement 26 Kohler line 29f
Index 159
L P
Lateral Parts of
collateral ligament 85 bones forming hip joint 3
femoral condyle 131f joint 85
Left side protrusio hip 72f quadratus femoris 46f
Length of both limbs 65 Patellar
Lesser trochanter 4f clunk syndrome 155, 156
Level of greater trochanter 34f cut 137
Ligamentum patellae 85 tracking 151
Limb length 31 Perioperative management of total
discrepancy 32f, 81 hip arthroplasty 50
Low knee arthroplasty 111
molecular weight heparin 102f, 103f, 155f Periprosthetic
viscosity 24 bone loss 12
fracture 155, 156
M Pes anserinus tendon 146
Pie crusting technique 148
Magnetic resonance imaging 35 Piriformis tendon 5, 45f, 46f
Measured resection technique 137 Pneumatic compression device 52f
Medial Polyethylene 93
cancellous calcar bone 64f wear 155
collateral ligament 85, 88f, 134f Posterior
tightness persists 146 condylar axis 132
Medium viscosity 24 cruciate ligament 89
Metal-on-metal total hip arthroplasty 22 femoral condyle cut 131
Migration 38 osteophytes 112f
Minimal invasive surgeries 48t Posteromedial corner 146
Mobile knee 99, 100f Postoperative skin traction 70
Modern cementing techniques 26 Primary total
Modular femoral stem 18 hip arthroplasty 54
knee arthroplasty 116
N Prosthesis 34, 69
Prosthetic joint 9, 91, 91t
Neck Protrusio 28
cut 54 Protrusion of medial wall of acetabulum 29f
shaft angle 33 Psoriatic arthritis 49
Nerve Pulmonary embolism 80
injury 80
palsy 155
New high flex design 98
Q
Normal Q angle 89
hip 9 Quadratus femoris 3, 5, 5f, 45f
joint 91 muscle 45f
Quadriceps tendon, patella, ligamentum
O patellae 87f
Obturator internus 5, 5f, 45f, 46f

One finger test 103
R
Optimum bone cuts 116 Ranawat technique 65f
Osteoarthritis 112f Reaming of acetabulum 57f
of knee joint 94 Removal of
Osteotomy of neck 75, 75f anterior tibial osteophytes 125f
160 Tips and Tricks in Hip and Knee Arthroplasty
lateral femoral osteophytes 148f replacement in

posterior ankylosed hip 73
osteophytes 149f protrusio hip 71
part of medial meniscus 124f Total knee
Residual flexion deformity 150f arthroplasty 95, 96, 118
Resorption of calcar 32f replacement 153
Results of high flex designs 99 Transverse acetabular ligament 3, 4f
Resurfacing implants 22f Triathlon knee system 100
Rule out hip infection 50 Trochanteric bursa 44f
S U
Sciatic nerve 5, 5f, 45f, 71 Ultra high density 19
proximity 29f Uncemented
Septic loosening of cemented hip porous coating 17
stem 16f, 38f press-fit stems 18
Seronegative disease 49 Unicondylar
Severe unacceptable deformity 49 knee 105t
Skin prosthesis 103
necrosis and infection 103f prosthesis in situ 104f
staining/discoloration 102f Upridden greater trochanter 29
Small contained bone defects 152f
Solution stem 18f
Stability of hip 64
V
Staging of osteoarthritis of knee 94 Valgus
Standard total hip arthroplasty 8 knee 147
Stiff stem 37f
hips 49 Varus
knee 151 deformity 112f
Stimson method 81 hips 11
Straight femoral stem 18 knee 146
Superficial medial collateral ligament 146 stem 37f
Superior gemellus 5, 45f, 46f Vascular injury 81
Vastus lateralis 4f
T Versatile modular and custom made hip
system 19f
Technique of primary total knee V-Y plasty 118
arthroplasty 116, 116t
Tendinous portion of gluteus
maximus 44f
W
Thompson and Amp prostheses 7f Well fixed cemented femoral stem 37f
Tibial Wiring around diaphysis 36f
articular surface 91 Wound
cut 123 closure 70
surface 136 inspection 51, 113
tubercle osteotomy 118
tuberosity 88f, 120f, 127f
Total condylar prosthesis 90 Z
Total hip Zimmer knee 99
arthroplasty 28

Tips and Tricks in HIP AND KNEE ARTHROPLASTY

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Tips and Tricks

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

Jaypee Brothers Medical Publishers (P) Ltd.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Tips and Tricks in Hip and Knee Arthroplasty: A Practical Approach

My parents, loving wife (Sharda)

My parents, wife (Swati)

As hip and knee arthroplasty expands rapidly in India,

Chandra Shekhar Yadav

10. Applied Anatomy of Knee Joint 85

13. Perioperative Management of

arts of Bones Forming Hip Joint

History and Biomechanics of

Fig. 2.4 Large head Metal on Metal cementless THR

enter of Head (Hip enter)

Implants and Bone Cements

Fig. 3.4 Different cementless stems

Uncemented Press-fit Stems

Modular Femoral Stem (Fig. 3.6)

Fig. 3.6 Versatile modular and custom made hip system

Custom-made Femoral Components (Fig. 3.6)

Cemented Cup (Fig. 3.7)

Fig. 3.7 Exeter cemented cup with raised PMMA spacers

Fig. 3.8 Cementless acetabular cup

Cementless Acetabular Components (FIg. 3.8)

Ceramic on Ceramic Hips (FigS 3.9A and B)

lead to decreased lubrication at the articulating interface or cause an obstruction

and high physical activity.

Metal-on-Metal Total Hip Arthroplasty (Fig. 3.10)

Fig. 3.10 Resurfacing (MOM) implants

Table 3.3 Reported advantages and disadvantages of the hip resurfacing vs

Disadvantages • Learning curve • Range of motion is less than surface

Vasculitis-Associated Lesion) and ultimately metallosis and failure. ASR (DePuy

Hip Resurfacing vs Conventional THR (FIg. 3.11)

Bone Cements (Figs 3.12a and b)

Functions of bone cement: It helps in fixation of components, reinforces the bone

Radiographic Evaluation in Total

Preoperative radiological evaluation

Acetabular Conditions, Precautions

Protrusio (Fig. 4.2)

Bone Quality (Fig. 4.3)

Infection (Healed; Fig. 4.3)

Old Surgically Treated or Conservatively Treated Fracture of

Femoral COnditions, Precautions and

Limb Length (Fig. 4.6)

Fig. 4.7 Acetabular templating

Templating for Prosthesis

Magnetic resonance imaging

how to read postoperative x-ray?

Acetabular Component (Figs 4.9 to 4.11)

Fig. 4.14 Valgus stem Fig. 4.15 Varus stem

Femoral Component (Figs 4.10 to 4.15)

Follow-up Radiographs (Figs 4.16 to 4.19)

Aseptic Loosening of Cup (Table 4.1)

Table 4.1 Comparison of septic and aseptic loosening of joint prosthesis

Other Criteria for Radiolucency

Fig. 4.20 Assessment of acetabular cup positioning

Femoral Component (Fig. 4.20)

Surgical Approaches and

Conventional Surgical approach

Fig. 5.2 The draped limb

Mini or Minimal Invasive Approach

Table 5.1 Approaches to THR

Table 3.3 Reported advantages and disadvantages of the hip resurfacing vs

Disadvantages • Learning curve • Range of motion is less than surface

Table 4.1 Comparison of septic and aseptic loosening of joint prosthesis

Table 5.1 Approaches to THR

Table 5.2 Advantages and disadvantages of minimal invasive surgeries