TKA Total Knee ARTHROPLASTY Replacement TKR Conf 5

TKA total knee ARTHROPLASTY replacement TKA conf
5
TKA- BONE PREPARATION
Bone surface preparation is based on the following principles:
1. appropriate sizing of the individual components,
2. alignment of the components to restore the mechanical axis,
3. balanced soft tissues
4. balanced gaps in flexion and extension,
5. optimal patellar tracking.

TKA- BONE PREPARATION-BONE CUTS
distal femoral cut
When you cut the Distal Femur you are affecting 3 things:
1) Mechanical Alignment;
2) Extension gap;
3) the Joint Line Height

distal femoral cut
Mechanical Alignment.
• The goal is to place the TKA in neutral mechanical alignment.
• The knee neutral mechanical alignment or the "knee angle" (tibio-femoral
angle) is 6° valgus.
• The tibial is cut at 0° relative to both the mechanical axis and the anatomic
axis (they are parallel).
• The femur is classically cut based on an intramedullary referencing system
(the same as the anatomic axis.)
• The difference between AA - MA is 6°, and guide is set to.
• The exact measurements should be calculated preoperatively as part of the
templating.
distal femoral cut
TECHNIQUE
distal femoral cut

• Cut at a valgus angle (usually 5 to 7 degrees),
• more accuracy this angle can be measured off of a long-standing radiograph
• perpendicular to MA
distal femoral cut
Extension Gap.
Correct cuts (0 for tibia and 6 for femur),
are parallel to form a rectangle,
• indicating a balanced extension gap.
Trapezoidal gap
• indicates soft tissue imbalance
distal femoral cut
distal femoral cut
distal femoral cut
distal femur joint orientation line
• (line drawn between the most distal points of each femoral condyle)
proximal tibia joint orientation line
• (line drawn along the tibial plateaus).

distal femoral cut
Distal Femur Joint Line Cut

The femoral implant of every company... the depth of the
distal femur is 9 mm (and thats is also consistent for every
femoral implant size: 1 - 10...small, medium, and large...a larger
femoral implant does not affect the size of the distal femoral
condyle). Therefore the target depth for the distal femoral cut is 9
mm.
You will take 9 mm of bone and replace it with 9 mm of metal.

distal femoral cut
distal femoral cut
change the distal femur cut,

affecting the joint line.
Cutting a little extra bone form the distal femur,

raise the joint line...
• the implant will always be 9 mm, so if you cut 11 mm and replace

it will 9 mm of metal, you have raised the joint line 2 mm
TKA- BONE PREPARATION distal femoral cut
TECHNIQUE
distal femoral cut

• The amount of bone removed generally is the same as that to be replaced by
the femoral component
• elevation of the joint line over 4 mm should be avoided

distal femoral cut
TECHNIQUE
distal femoral cut
preoperative flexion contracture

• additional resection to correction of the contracture,
• enlarge the extension gap (without affecting the
flexion gap) and will allow more knee extension.
In PS prosthesis,
• an additional 2 mm of distal femoral resection can be performed to
equal the increase in the flexion gap that occurs when the PCL is
sacrificed.
distal femoral cut
distal femoral cut
significant bone loss

take less then 9 mm of bone from the distal femoral cut
• will restore the normal joint line.
pre-existing "patella baja

the joint line is too high relative to the patella, then taking 7 mm of bone,
and adding the 9 mm of component, will lower the joint line by 2 mm.
TKA- BONE PREPARATION-BONE CUTS anterior and posterior femoral cut
anterior and posterior femoral cut

determine
1. the rotation of the femoral component
• Excessive external rotation widens the flexion gap
medially and may result in flexion instability.
• Internal rotation of the femoral component can cause

lateral patellar tilt or patellofemoral instability.
2. the shape of the flexion gap.

Femoral component rotation determination
1. The transepicondylar axis,

2. anteroposterior axis,
3. posterior femoral condyles,
4. cut surface of the proximal tibia
all can serve as reference points
• reliance on a single reference could result in suboptimal femoral

component rotation in the transverse plane
knee with
normal
condylar
shape
transepicondylar axis
• a line drawn between the medial and lateral femoral
epicondyles
o the epicondylar axis is parallel to the cut tibial surface
o make the posterior femoral cut parallel to it will
create the appropriate rectangular flexion gap

anteroposterior axis
a line between the bottom of the sulcus of the femur and the top
of the intercondylar notch,
• make the posterior femoral cut perpendicular to this

axis
posterior femoral cut

posterior femoral condyles axis
make the cut in 3 degrees of external rotation off a line

between them.
the native knee, the posterior femoral condyles are not equal
size and therefore a line across them is not parallel to the tibial
cut, rather they are in 3° of valgus (to match the native tibial
plateau angle of 3° varus).

posterior femoral condyles axis
A valgus knee with a hypoplastic lateral femoral condyle may

lead to an internally rotated femoral component
Hypoplastic lateral condyle
causes relative internal
rotation of the femoral
component
cut surface of the proximal tibia or the “gap” technique
make the posterior femoral cut parallel to the proximal tibial cut after the soft tissues
have been balanced in extension
This technique often is used for mobile-bearing TKA because precise gap balancing in flexion
is necessary to ensure that “spinout” of the polyethylene bearing does not occur

cut surface of the proximal tibia or the “gap” technique
Cautions
reliance on ligaments of nonanatomic length can lead to suboptimal femoral

component rotation in the transverse plane.
the thickness of bone removed from the posterior aspect of the femoral
condyles should equal the thickness of the posterior condyles of the
femoral component
measuring the thickness of the posterior condylar resection with

“posterior referencing” instrumentation.
“Anterior referencing” instruments measure the

anteroposterior dimension of the femoral condyles from an anterior cut
based off the anterior femoral cortex to the articular surface of the
posterior femoral condyles.
The femoral component chosen must be equal to or slightly less than the
measured anteroposterior dimension to avoid tightness in flexion.
• Posterior referencing instruments

• are theoretically more accurate in recreating the
original dimensions of the distal femur;
• anterior referencing instruments

1. Have less risk of notching the anterior femoral
cortex
2. place the anterior flange of the femoral
component more reliably against the anterior
surface of the distal femur.
It is absolutely necessary that the surgeon knows

whether the implant system being used is an anterior or
posterior based
• this will be important when balancing

flexion-to-extension gap inequalities.
TKA- BONE PREPARATION-BONE CUTS anterior and posterior chamfer femoral cut
anterior and posterior chamfer femoral cut
Complete the distal femoral preparation for a PCL-

retaining prosthesis by making anterior and
posterior chamfer cuts for the implant.
A, Chamfer cuts
complete distal
femoral resection in
cruciate-retaining
arthroplasty.
TKA- BONE PREPARATION Intercondylar notch
cut
If a PCL-substituting design is chosen, remove the

bone for the intercondylar box to accommodate
the housing for the post and cam mechanism
B, Intercondylar
notch cut to
accommodate post
and cam mechanism
in cruciate-
substituting
arthroplasty.
TKA- BONE PREPARATION proximal tibia Cut
Cut the tibia perpendicular to its mechanical axis

with the cutting block oriented by an intramedullary
or extramedullary cutting guide.
The amount of posterior slope depends on the

individual implant system being used. Many
systems incorporate 3 degrees of posterior slope
into the polyethylene insert, which allows more
accurate slope to be aligned by the implant
rather than with the cutting block.
The amount of tibial resection depends on which side of the

joint (more or less arthritic) is used for reference.
• unaffected side of the joint, the resection should be

close to the size of the implant, typically 8 to 10 mm.
• arthritic side of the joint, the amount of resection

usually is 2 mm or less.
GAP BALANCING TECHNIQUE

balance the flexion and extension gaps
• placing spacer blocks or a tensioner within the gaps
with the knee in flexion and extension.
Varus-valgus balance can be fine-tuned with further

medial or lateral releases
Before any soft-tissue release,

• remove any medial or lateral osteophytes about the tibia
and femur.
• Remove posterior condylar osteophytes they can

• block flexion
• tent posterior soft-tissue structures in extension,
causing a flexion contracture.
The flexion and extension gaps must be roughly equal
• If extension gap is too small or tight, extension is

limited
• if the flexion gap is too tight, flexion is limited.
• Laxity of either gap can lead to instability.
extension gap is smaller than flexion gap

1. first make certain that all posterior condylar osteophytes
have been removed.
2. remove more bone from the distal femoral cut surface,

• raising the joint line
3. release the posterior capsule from the distal femur,

flexion gap is smaller than extension gap,
• remove more bone from the posterior femoral condyles by

making appropriate cuts for the next smaller available
femoral component;
• make sure this is done with anterior referencing so
that the posterior condyles are shortened and the
anterior cortex is not notched.
If the flexion and extension gaps are equal, but there
is not enough space for the desired prosthesis,
• remove more bone from the proximal tibia

• bone removed from the tibia affects the
flexion and extension gaps equally.
the flexion and extension gaps are equal but lax,
• a larger spacer block and a thicker tibial polyethylene insert

are required to obtain stability.
TKA- SOFT-TISSUE BALANCING
the bone preparation is completed first, and then the flexion

and extension gaps should be evaluated for symmetry for
equal height in flexion and extension.
This can be done with

1. laminar spreaders,
2. spacer blocks,
3. computer navigation techniques.
Before release of any anatomic soft-tissue supporting structure

about the knee, all peripheral osteophytes should be removed
from the femur and tibia.
The removal of osteophytes alone may be enough to balance

existing coronal plane deformities.
If a tibial resection first (gap balancing) surgical technique is being

used, the osteophytes should be removed before determining any
bony cuts on the femur.
• excessive collateral or PCL tension,
• restricted knee range of motion
• excessive laxity
• clinically unacceptable instability.
1 to 2 mm of balanced varus-valgus opening in the medial and
lateral compartments of the prosthetic knee is a reasonable goal.
over release
• coronal plane instability
• require conversion to an implant with a constrained post
• stability should be checked after each stage of soft-tissue release
VARUS CORRECTION IN POSTERIOR STABILIZED TOTAL KNEE
ARTHROPLASTY
• release of the deep MCL off the tibia to the PMC
• Make the bone cuts using the preferred technique (intramedullary or

extramedullary guide, computer navigation, custom cutting blocks).
ARTHROPLASTY
• Remove all osteophytes on the femur and the tibia because
• tent the medial soft-tissue sleeve

• effectively shorten the medial collateral ligament.
ARTHROPLASTY
• Make sure the PCL is resected

• PCL is a secondary medial stabilizer,
• take care not to release the entire soft-tissue sleeve off the tibia
because it may overshoot the gap
ARTHROPLASTY
• If flexion and extension gaps are tight medially,

• release the appropriate tight portion of the medial soft-tissue
sleeve ( sup MCL)
ARTHROPLASTY
• extension gap is tight only, release in order:

1. posterior oblique ligament POL
2. semimembranosus
3. posteromedial capsule
ARTHROPLASTY
• If the flexion gap is tight,

• anterior aspect of the superficial mcl
• tight bands within the structure
ARTHROPLASTY
• medial gap is still tight (severe varus deformity),

1. advancing the lateral collateral ligament
2. use of a more constrained implant
VARUS CORRECTION IN POSTERIOR CRUCIATE–RETAINING TOTAL KNEE
ARTHROPLASTY
• the release may need to be more significant to effectively balance the

gap since the PCL is a secondary coronal stabilizing structure.
ARTHROPLASTY
• release of the deep MCL off the tibia
• Make the bone cuts using the preferred technique (intramedullary or

extramedullary guide, computer navigation, custom cutting blocks).
ARTHROPLASTY
• Remove all osteophytes on the femur and the tibia because
• tent the medial soft-tissue sleeve

• effectively shorten the medial collateral ligament.
ARTHROPLASTY
• If the extension gap is tight only

1. posterior oblique ligament POL
2. semimembranosus
3. posteromedial capsule
ARTHROPLASTY
• If the flexion gap is tight,
1. anterior aspect of the superficial MCL
2. the pes anserinus insertion
ARTHROPLASTY
• If the entire soft-tissue sleeve is released and the medial gap is still
tight,
• balancing the PCL if it is tight

ARTHROPLASTY
• there is still a tight medial gap,
1. release posterior capsule if it is tight
2. advancing the lateral collateral ligament
3. using a constrained condylar implant
VALGUS DEFORMITY CORRECTION
common in
1. Rheumatoid and inflammatory arthropathies
2. hypoplastic lateral femoral condyle
3. previous trauma
4. reconstructive procedures that change the weight-bearing axis of the lower extremity or tighten the
lateral side of the joint
1. During exposure don’t compromise the medial soft-tissue sleeve,

2. Make the bone cuts
3. Remove osteophytes
4. order of release, depending on the extent of fixed contracture and associated deformity
both extension and flexion gaps are tight, VALGUS DEFORMITY CORRECTION
feel for the tight structures in both flexion and extension and target the appropriate structure
leave the insertion of the popliteus tendon intact as long as it is not tight (see Fig. 7.49
If only the extension gap is tight,

1. release the tight portions of the iliotibial band
 we recommend pie-crusting
2. evaluate the biceps aponeurosis to make sure it is not involved in the contracture
3. Release of the posterolateral corner

• should be considered before release of the lateral collateral ligament if only a small amount of correction is needed

If only the flexion gap is tight
Release of the popliteus tendon
knee is still not balanced in full extension

4. release the posterior capsule off the lateral femoral condyle;
5. release of the lateral head of gastrocnemius
6. PCL
 Because it is a medial structure, the PCL often is attenuated in a knee with a valgus deformity.
7. advancement of the medial collateral ligament (Fig. 7.50)
8. elevation of the femoral origin and proximal advancement

• elevation of the femoral origin and proximal advancement
If the lateral flexion gap opens more than the extension gap ,
make certain that the “jump height” of a posterior stabilized peg is not exceeded; if this is a possibility, consider using a constrained condylar type of implant.
combined severe valgus and flexion contracture
acute correction
stretching of the peroneal nerve and subsequent palsy.
if a palsy presents
Knee should be flexed to alleviate traction
Another approach
immobilize the knee postoperatively in some degree of flexion to allow gradual stretching of the nerve as the
knee is moved into extension.
Occasionally, because of attenuation of the medial collateral ligament, adequate ligament balance cannot be
obtained.
In elderly patients, a constrained condylar type of prosthesis
medial collateral ligament advancement,
elevation of the femoral origin and proximal advancement

TKA Total Knee ARTHROPLASTY Replacement TKR Conf 5

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TKA total knee ARTHROPLASTY replacement TKA conf

Bone surface preparation is based on the following principles:

1. appropriate sizing of the individual components,

2. alignment of the components to restore the mechanical axis,

3. balanced soft tissues

4. balanced gaps in flexion and extension,

5. optimal patellar tracking.

distal femoral cut

• more accuracy this angle can be measured off of a long-standing radiograph

proximal tibia joint orientation line

• (line drawn along the tibial plateaus).

Distal Femur Joint Line Cut

You will take 9 mm of bone and replace it with 9 mm of metal.

change the distal femur cut,

Cutting a little extra bone form the distal femur,

• the implant will always be 9 mm, so if you cut 11 mm and replace

distal femoral cut

• elevation of the joint line over 4 mm should be avoided

distal femoral cut

preoperative flexion contracture

significant bone loss

pre-existing "patella baja

anterior and posterior femoral cut

• Internal rotation of the femoral component can cause

2. the shape of the flexion gap.

Femoral component rotation determination

1. The transepicondylar axis,

all can serve as reference points

• reliance on a single reference could result in suboptimal femoral

Femoral component rotation determination

Femoral component rotation determination

• make the posterior femoral cut perpendicular to this

posterior femoral cut

make the cut in 3 degrees of external rotation off a line

posterior femoral cut

A valgus knee with a hypoplastic lateral femoral condyle may

posterior femoral cut

cut surface of the proximal tibia or the “gap” technique

posterior femoral cut

reliance on ligaments of nonanatomic length can lead to suboptimal femoral

measuring the thickness of the posterior condylar resection with

“Anterior referencing” instruments measure the

anterior and posterior femoral cut

• Posterior referencing instruments

• anterior referencing instruments

anterior and posterior femoral cut

It is absolutely necessary that the surgeon knows

• this will be important when balancing

anterior and posterior chamfer femoral cut

Complete the distal femoral preparation for a PCL-

If a PCL-substituting design is chosen, remove the

Cut the tibia perpendicular to its mechanical axis

The amount of posterior slope depends on the

The amount of tibial resection depends on which side of the

• unaffected side of the joint, the resection should be

• arthritic side of the joint, the amount of resection

GAP BALANCING TECHNIQUE

Varus-valgus balance can be fine-tuned with further

Before any soft-tissue release,

• Remove posterior condylar osteophytes they can

The flexion and extension gaps must be roughly equal

• If extension gap is too small or tight, extension is

extension gap is smaller than flexion gap

2. remove more bone from the distal femoral cut surface,