Basics

of
Total Knee Replacement
 History of orthopedics

1895: Dawn of orthopedic industry by Revera DePuy

1926: Zimmer was founded by Justin O Zimmer, who was the sales person of
DePuy
1950: First hip prosthesis was introduced by Zimmer
1959: Sir John charnley introduces low friction arthroplasty
1977: Biomet was founded by four young scientists, with Dane A Miller being
the prime founder
1994: Launch of Nexgen
2003: Zimmer acquires centerpulse
2016: Zimmer acquires Biomet
Evolution of knee
• 1890 by Dr Theophilus Gluck, implant made up of ivory and fixed with
plaster of paris

But failed due to poor

material, inadequate
fixation & infection
Early 1950- Dr Waldier introduced hinged knee system, made up of cocr

1968- Dr Frank gunston, a canadian implanted his first poly centric knee with
less constrained version

Failed due to:

Minimum contact
area & unforgiving
surgical technique

Dr John Insall, Dr Ranawat in early 1970 introduced Total condyler & PS

knee system
Terminology
Ortho: To correct
Paedics: Paediatrics
Arthro : Joint
Plasty : Repair
Osteo: Bone
Auto: Within
Allo: External source
Itis: Inflammation
Otomy: Resection
Ectomy: Surgical removal
Scope: Thru camera
 Types of Knee Replacement
a) Uniknee- Replace only
Partial knee one condyle
replacement b) PFJ- Resurface PFJ &
Patella

Total Knee Replacement of Femor,

Replacement Tibia, Patella

Revision knee Re- Do of primary with

replacement implants to fill in bone &
soft tissue defect
 Concepts in TKR

Fixed platform Rotating platform

Cruciate Posterior Cruciate Posterior

retaining stabilized retaining stabilized

• CR- Retain PCL OR ACL & PCL

• PS- Sacrifice both ACL & PCL
• AS- Anterior stabilized
• Fixed platform- Insert is fixed to tibial tray
• Rotating platform- Insert rotates on tibial
tray
 Concepts in Revision knee

Fixed platform Rotating platform

Constrained
Femor
Semi constrained
Tibial tray
Insert
Stem extension Femor
Femoral Tibial tray
augments Insert
Tibial wedges Stem extension
TM-S Femoral
augments
Tibial wedges
Metaphyseal
sleeve
TM-S
 Implant selection

Factors to consider:
• Bony defect?
• Soft tissue defect?
• Bone conserving?
• Fixed or Rotating?
• CR or PS?
• Semi constrained or Constrained?
 Metallurgy

Femor- Cobalt chrome

Tibia- Titanium, Cobalt chrome

Insert & Patella- Polyethylene

But Why???
Basic design rationale -implants
Femor:
• Always side specific
• Multi, single, infinite radii
• Trochlear groove
• Cement pocket
• Lugs in CR & Notch in PS

Insert:
• Both universal & side specific
• CR,PS,AS, Constrained…
• Cross link, DCM

Tibia:
• Both universal & side specific
• Polished & Mat finish
• Fixed or Rotating platform
• Option for stem or no stem…
 Science of Polyethylene

• Hip & knee behave differently hence the wear pattern of PE

• Hip fails due to abrasive wear, Knee- Fatigue

Cross- linking – A solution?

• Cross linking of poly can be achieved through gamma radiation
• But leaves behind huge free radicals
• Free radicals can be reduced by remelting & annhealing

But what happen’ s?

• Compromises the mechanical strength
 PE - Pyramid

Mechanical
Low wear
strength

Bermuda’ s
triangle???

Oxidative stability

Solution: Passive & Active stabilization

 Disease states- Knee joint

Arthritis:
• Inflammatory joint disease, associated with swelling, redness, pain

Osteoarthritis:
• Sometimes called degenerative arthritis, osteoarthritis is the most common
type of arthritis. It's a wear-and-tear condition that occurs when the cartilage
in your knee deteriorates with use and age.

Rheumotoid arthritis:
• The most debilitating form of arthritis, rheumatoid arthritis is an autoimmune
condition that can affect almost any joint in your body, including your knees.
Although rheumatoid arthritis is a chronic disease, it tends to vary in severity
and may even come and go.

Contd…
Septic arthritis
• Sometimes your knee joint can become infected, leading to swelling, pain
and redness. There's usually no trauma before the onset of pain. Septic
arthritis often occurs with a fever.

Ankolysis:
• Adhesions between the articulating members and the resulting fusion with
loss of mobility

Other conditions:
Gout.
• This type of arthritis occurs when uric acid crystals build up in the joint. While
gout most commonly affects the big toe, it can also occur in the knee.

Pseudogout
• Often mistaken for gout, pseudogout is caused by calcium-containing
crystals that develop in the joint fluid. Knees are the most common joint
affected by pseudogout.
Basic principles of instruments

Ask Yourself:
• Why do we need
instruments
• Do we need so many
instruments
• Is it not confusing

Every instrument has

a reason & a role to
play
 Steps in TKA

• Distal femoral resection

• Femoral sizing
• 4 in 1 femoral resection
• Notch cut
• Proximal tibial cut
• Spacer
• Tibial preparation
• Patella preparation
• Trial
• Cementing
• Implantation
Instruments- Design rationale

Objective:
• Perpendicular distal cut to the
mechanical axis

Why
• 9mm distal cut
• 5 – 7 deg of valgus angle
• Verify with alignment rod

How
• Demonstrate
Femoral sizing

Ask yourself:
• Why external
rotation
• Right & left
• Sizing AP or ML
• In between size
• Positioning stylus
Femoral preparation

Ask Yourself:
• Why I have to use angel wing
• What can I achieve using 4 in 1 block
• When do I use notch cutting block
Tibia - Resuction

Ask yourself:
• Why do I need this jig
• Does slope matters
• How to measure & resect
• How to ensure perpendicular cut
Tibial preparation

Ask yourself:
• Does tibial tray rotation
matter
• How to get it right
• Why preparation
Using Spacer

Ask yourself:
• Why do we use
spacer
• What do you infer
• What are we trying
achieve

Let’s discuss!!!
Patella

Ask yourself:
• Do I need to replace
patella
• How much to retain/
resuct
• Does positioning of
patella matters
Trial before implant

Ask yourself:
• Why trialing
• What do I understand
 Cementing & Implantation

Cementing:
• Use of appropriate bone cement is critical for successful
outcome of any TKA
• Cement application matters like vaccum mix, pulse lavage
• Remove excess bone cement

Implantation:
• Femor first or tibia first
• Do I use trial spacer during implantation
• Knee in flexion or extension
 Managing Complexity

Let’s Discuss
What to expect?
• Severe Varus Instability
• Severe valgus
• FFD???
• In Rheumotoid arthritis
• In Ankolosis
• ACL Absent
• PCL Absent
• LCL Absent
• MCL Absent
 Thank you

Happy selling!!!