History

• 1860 (Fergusson)  resection arthroplasty of

the knee for arthritis
• Verneuil  interposition arthroplasty using joint
capsule.
• 1940  The first artificial implants were tried as
molds fitted to the femoral condyles
• 1950  Combined femoral and tibial articular
surface replacements as simple hinges
• 1971  Gunston polycentric knee
replacement improved kinematics
over hinged implants.
• 1973  Constrained Geomedic knee
arthroplasty introduced at the Mayo
Clinic.
• 1973  The total condylar prosthesis by

Insall at the Hospital for Special

Surgery.
• 1993  Ranawat reported a rate of survivorship
of 94% at 15 years of follow-up.
 Indication
• Relief of pain  severe daily pain, fail on
non operative management
• Restore stability
• Restore deformity  BMI>30%
• Radiological anomaly  x ray evidence of
narrowing of the joint space
 Contra Indication
• Absolute contraindications to total knee replacement :
1. Knee sepsis including previous osteomyelitis,
2. Remote source of ongoing infection,
3. Extensor mechanism dysfunction,
4. Severe vascular disease,
5. Recurvatum deformity secondary to muscular weakness,
6. The presence of a well functioning knee arthrodesis.

• Relative contraindications :
1. Medical conditions that preclude safe anesthesia,the demands of
surgery and rehabilitation.
2. Skin conditions within the field of surgery e.g psoriasis
3. Neuropathic joint and obesity.
4. The absence of Anterior Cruciate Ligament (ACL).
Riaz S & Maistrelli GL, Unicompartmental Knee Arthroplasty and its Minimally Invasive Version, Pakistan
Journal of Medical Science: 2005; 21(3); 237-246
 Indication
1) Arthritis involving single, medial or lateral
compartment of the knee.
2) Erosion of Patellofemoral joint especially the
medial facet, the medial margin of the lateral
femoral condyle
3) Fibrillation of cartilage of lateral condyle
4) The fixed flexion deformity should not be more
than 15 degrees11.
5) There should be adequate range of motion12
of the knee which should be at least 90°.
 Type of prostheses
• There are 3 different types of knee replacement
prostheses.
1. Non-constrained prostheses use the patient’s
ligaments and muscles to provide the stability for the
prosthesis.
2. Semi-constrained prostheses provide some stability for
the knee and do not rely entirely on the patient’s
ligaments and muscles to provide the stability.
3. Constrained prostheses are for patients whose
ligaments and muscles are not able to provide stability
for the knee prosthesis.
RS Laskin, J Bone Joint Surg Am, 1976;58;766-773
 Timing of surgery
• In terms of the timing of TKR surgery, 2 studies found
that the severity of osteoarthritis does not predict
outcome, but 1 study was found that higher functioning
patients had significantly less pain and better function up
to 2 years after surgery compared with lower functioning
patients.
• It is important to note that the patients in the low and
high function groups were evenly matched on comorbid
conditions.
• In terms of age, 40% of TKR surgeries were performed
in patients aged 65 to 74 years, 8% were performed in
patients younger than 55 years, and 3% were for
patients older than 85 years.
 Time of surgery
• The clinical history in a patient with arthritis of the knee is dominated
by pain. This predominantly occurs on weight-bearing but in the end
stages may be constant and unrelieved by rest. Night pain is a
particularly disabling symptom that demands urgent attention. The
pain may be localised to one compartment or maybe diffuse.
• Other symptoms include stiffness, swelling, locking and giving way.
• It is useful to try and quantify the level of pain on a simple scale ( e.g
mild, moderate, severe or a numerical scale of 1 to 10) and to
assess how the patient’s activities of daily living (ADL) are affected.
• The patient should be asked questions on maximum walking
distance, recreational sporting ability and aspirations, stair climbing
(which often gives clues about patellofemoral disease), the need for
walking aids, the ability to dress and perform self-care and the
ability to perform activities that require knee flexion. Some patients
may have considerable interference with social interaction, sexual
function and sleep deprivation and may experience exhaustion and
even depression from their disease.
• There are 3 options for holding the knee
replacement prosthesis in place: the
prosthesis can be cemented, non-
cemented or attached using a hybrid
fixation procedure.
 Results based on objective and functional
assessments
Before and after knee replacement

Knee score
Maximum possible Before knee replacement At 2 years

Function 100 46.6 74.6

Pain 50 12.7 42.7

Overall* 100 47.3 83.0

John A L Hart Bone and Joint Disorders: Prevention and Control Joint replacement surgery : MJA2004;
180 : S27-S30
 indica
• The primary diagnosis leading to TKR is
degenerative osteoarthritis (93%).
• Other diagnoses are inflammatory arthritis
(5%), post-traumatic osteoarthritis (2%),
and osteonecrosis (when bone dies due to
blocked blood supply; 1%).
 Indication of total joint replce
• Pain
• Deformity
• Radiographic evidence of OA
 indi
• Patients with painful, deformed and
unstable knees secondary to degenerative
or inflammatory conditions need a
prosthesis that ill provide reproducible
relief of pain and improvement in function.
 indicat
• OA
• RA
• Gout
• Sero negative arthritis
• Post traumatic arthritis