Surgical Techniques in Total Knee Arthroplasty (TKA) and Alternative Procedures

First Edition

Saverio Affatato

Table of Contents

Cover image

Title page

Copyright page

List of contributors

Woodhead Publishing Series in Biomaterials

Part One: Fundamentals in total knee arthroplasty and alternative procedures

1: The history of total knee arthroplasty (TKA)

Abstract

1.1 Knee anatomy

1.2 History of total knee arthroplasty (TKA)

1.3 Indications for a TKA

1.4 Biomaterials used in TKA

1.5 Operative procedure for TKA

1.6 Surgical techniques

1.7 Improvements and modern surgical TKA operations

1.8 Alternative techniques to TKA operations

Acknowledgement

2: Biomechanics of the knee

Abstract

2.1 Knee joint anatomy

2.2 Analysis of motion

2.3 Knee biomechanics

2.4 Knee kinematics

2.5 Knee statics

2.6 Knee dynamics

2.7 Biomechanical model of the knee

2.8 Kinematics models

2.9 Static or nearly static models

2.10 Dynamic models

2.11 Knee pathologies

2.12 Knee prosthesis

2.13 Knee biomechanics after knee replacement

Acknowledgements

3: High tibial osteotomy (HTO) surgery

Abstract

3.1 Introduction

3.2 Biomechanical principles

3.3 Patient selection and preoperative evaluation process

3.4 Selection process criteria

3.5 Surgical technique

3.6 Postoperative complications

3.7 Revision surgery for late failure of HTO

Acknowledgement

4: Arthroscopic débridement in total knee arthroplasty (TKA)

Abstract

4.1 Introduction

4.2 Intra-articular lesions in knee osteoarthritis

4.3 Preoperative considerations

4.4 Imaging

4.5 Knee osteoarthritis: definition

4.6 Historical evolution of arthroscopic débridement

4.7 Indications and contraindications of arthroscopic débridement

4.8 Operative techniques

4.9 Role of arthroscopy as an adjunct to open surgery

4.10 Results

4.11 Future perspectives

4.12 Conclusions

Part Two: Surgical techniques and considerations for total knee arthroplasty (TKA)

5: Challenges in total knee arthroplasty (TKA)

Abstract

5.1 TKA in sequelae of poliomyelitis

5.2 TKA after high tibial osteotomy

5.3 TKA after varus distal femoral osteotomy

5.4 Primary TKA in stiff and ankylosed knees

5.5 Primary TKA in knees with bone loss

6: Preoperative planning in total knee arthroplasty (TKA)

Abstract

6.1 Introduction

6.2 Preoperative evaluation of the patient

6.3 Indications and contraindications of TKA

6.4 Preoperative radiographic analysis

6.5 Planning femoral and tibial cuts

6.6 Templating

6.7 Preoperative planning based on exam findings

6.8 Conclusion

7: The first surgical approach for total knee arthroplasty (TKA)

Abstract

7.1 Introduction

7.2 Historical notes and medical use

7.3 Indications for total knee arthroplasty (TKA)

7.4 Standard approaches for primary total knee arthroplasty (TKA)

7.5 Pre-operative preparation

7.6 The traditional anterior surgical approach

7.7 Partial knee replacement

7.8 Minimal invasive surgery (MIS)

7.9 Computer assisted surgery and custom made knee replacement

7.10 Rehabilitation

Acknowledgement

8: Surgical exposure in total knee arthroplasty (TKA)

Abstract

8.1 Surgical exposure in total knee replacement (TKR)

8.2 Medial parapatellar approach

8.3 Subvastus approach

8.4 Midvastus technique

8.5 Lateral parapatellar approach

9: Ligament balancing techniques in total knee arthroplasty (TKA)

Abstract

9.1 Objectives and implications of ligament balancing

9.2 General prosthetic considerations about ligament balancing: wear, loosening and proprioception

9.3 Surgical techniques

9.4 Management of instability or deformity

9.5 Surgical tools for ligament balance assessment

Acknowledgement

10: Correcting varus and valgus knee in total knee arthroplasty (TKA)

Abstract

10.1 Correcting varus knee in TKA

10.2 Correcting valgus knee in TKA

10.3 Conclusion

11: Mini-invasive approach in total knee arthroplasty (TKA)

Abstract

11.1 Introduction

11.2 General observations

11.3 Limited medial parapatellar arthrotomy (LMPA)

11.4 Limited subvastus (LS) approach

11.5 Limited midvastus approach

11.6 Quadriceps-sparing (QS) approach

11.7 Is MIS really MIS?

11.8 Conclusion

Part Three: Future trends and challenges in total knee arthroplasty (TKA)

12: Applications of computer-assisted surgery (CAS) in total knee arthroplasty (TKA)

Abstract

12.1 Introduction

12.2 Total knee arthroplasty

12.3 Unicompartmental knee arthroplasty

12.4 Revision total knee arthroplasty

12.5 Knee ligament reconstruction

12.6 Osteochondral lesion

12.7 High tibial osteotomy

13: Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA)

Abstract

13.1 Introduction

13.2 Patient-specific instrumentation – the impetus for its development

13.3 Using patient-specific instrumentation: from the office to the operating room

13.4 Patient-specific instrumentation – a review of the current literature

13.5 Future directions

14: Revision total knee arthroplasty (TKA)

Abstract

14.1 Introduction

14.2 Indications for revision

14.3 Preoperative assessment

14.4 Approach and skin incision

14.5 Removal of the components

14.6 Three step technique

14.7 Postoperative rehabilitation

14.8 Conclusion

15: Diagnosis and management of infection in total knee arthroplasty (TKA)

Abstract

15.1 Introduction and pathogenesis

15.2 Risk factors and clinical evaluation

15.3 Diagnosis

15.4 Treatment options

15.5 Conclusions

Index

Copyright

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List of contributors

R. Adala     Fortis Hospital, Bangalore, India

S. Affatato     Istituto Ortopedico Rizzoli, Bologna, Italy

L. Amendola     Maggiore Hospital, Bologna, Italy

A. Anand     Fortis Hospital, Bangalore, India

R.B. Ayad     Oil Clinic Hospital, Tripoli, Libia

S. Battaglia     Istituto Ortopedico Rizzoli, Bologna, Italy

C. Bettuzi     Maggiore Hospital, Bologna, Italy

F. Catani     University of Modena and Reggio Emilia, Modena, Italy

E. Castiello     Istituto Ortopedico Rizzoli, Bologna, Italy

S. Comitini     Maggiore Hospital, Bologna, Italy

M. Commessatti     Maggiore Hospital, Bologna, Italy

D. Devoti     Suzzara Hospital, MN, Italy

N. Dilip     Fortis Hospital, Bangalore, India

C. Faaborg-Andersen     Georgetown University, Washington, DC, USA

M. Fosco     Suzzara Hospital, MN, Italy

P. Gentile     Maggiore Hospital, Bologna, Italy

A. Graceffa     Clinica Ortopedica Universita' di Catania, Italy

P. Hernigou     Hopital Henri Mondor, Créteil, France

P.F. Indelli     Stanford University in Florence, Italy; Clinica Ortopedica Universita' di Firenze, Italy

M. Innocenti     Clinica Ortopedica Universita' di Firenze, Italy

D. Leonetti     Maggiore Hospital, Bologna, Italy

M. Marcucci     Clinica Ortopedica Universita' di Firenze, Italy

R. Mugnai     University of Modena and Reggio Emilia, Modena, Italy

D. Nam     Washington University Orthopedics, St. Louis, MO, USA

G. Pipino     Ospedale Villa Regina, Bologna, Italy; Stanford University in Florence, Italy

P. Poli     Clinica Ortopedica Universita' di Firenze, Italy

R. Ravindran     Fortis Hospital, Bangalore, India

J.V. Srinivas     Fortis Hospital, Bangalore, India

D. Tigani     Maggiore Hospital, Bologna, Italy

Y.A. Veerappa     Fortis Hospital, Bangalore, India

D. Vitantonio     University of Modena and Reggio Emilia, Modena, Italy

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Part One

Fundamentals in total knee arthroplasty and alternative procedures

1

The history of total knee arthroplasty (TKA)

S. Affatato    Istituto Ortopedico Rizzoli, Bologna, Italy

Abstract

The knee is a diarthrosis joint composed of four bones: the femur, the tibia, the patella, the proximal part of the fibula. Articular conformity between the femur and the tibia is provided by two fibrocartilagineous discs: the external and internal menisci. The knee ligaments are the anterior and posterior cruciate ligament, the internal and external collateral ligaments, and the patellar tendon.

Current total knee arthroplasty is made up of a femoral component and a tibial component of cobalt–chromium alloys, and a platform/insert of polyethylene.

Recently, oxidized zirconium or ceramic femoral components were used in the development of new TKAs.

Keywords

Knee anatomy

Femur

Tibia

Insert

Prostheses

1.1 Knee anatomy

Due to its anatomical complexity, the knee joint has not been definitively classified. It is widely categorized as a ginglymus (hinge joint). However, another approach is to regard it as two different joints: the tibio-femoral joint and the patello-femoral joint (Fig. 1.1). The tibio-femoral joint can be further sub-divided into two condyle joints between each femoral and tibial condyle.

Figure 1.1 The tibio-femoral joint and the patello-femoral joint.

The patella can be found in front of the knee joint, a flat bone surrounded by the quadriceps tendon. The distal part of this tendon, called the patellar tendon, inserts into the tibial tuberosity connecting the patella with the tibia. The patello-femoral joint, an arthrodial (gliding) joint, allows the articular patella to glide over the patellar groove of the distal femur.

Therefore, in essence, the knee joint is a unique joint with three distinct components:

• the patello-femoral,

• the internal, and

• the external tibio-femoral compartments.

Enclosing the knee is the articular capsule, a fibrous membrane connecting the bones to each other.

Synovial fluid produced in the synovial membrane provides lubrication for the joint and supply of nutrient for the articular cartilage. The synovial membrane can be found on the internal surface of the articular capsule coating the articular cavity and, in particular, in the deep recess beneath the quadriceps tendon. The presence of ligaments and tendons ensures the stability of the joint. The most important ligaments of the knee are the anterior and posterior cruciate ligaments, the internal and external collateral ligaments and the patellar tendon.

The external and internal menisci are two fibrocartilaginous discs above each tibial condyle, which improve congruity between the femur and the tibia. They cover the outer part of the tibial articular facets. The menisci look like a wedge, being thicker toward the periphery of the tibial condyles. While the external meniscus is approximately circular, the internal meniscus has a semicircular shape. The external and internal menisci are connected anteriorly by the transverse ligament. The coronary ligaments, which are part of the articular capsule, connect the menisci with the tibia along its peripheral portion. The menisci cushion the compressive force and increase the stability of the knee, particularly the internal meniscus since it is tightly anchored to the bone (Gray 1918; Kapandji, 1998) (Fig. 1.2).

Figure 1.2 Representation of menisci anchored to the bone.

1.2 History of total knee arthroplasty (TKA)

The first attempt at treating patients affected by knee osteoarthritis was during the mid nineteenth century. This consisted of interposing a soft tissue between the joint surfaces or removing a portion of bone from both the distal femur and proximal tibia.

In 1880 the German surgeon Theophilus Gluck fixed ivory prosthetic components to the bone by means of plaster (Gluck, 1890); this can be regarded as the earliest example of total joint replacement. After that, no notable progress was made until 1973, when the prototype of the modern knee prostheses was proposed by John Insall and his colleagues (Insall et al., 1974). This prototype comprised a metallic femoral component and plastic tibial and patellar components, all fixed to the bone. The geometry of the prosthetic components ensured joint stability even if the cruciate ligaments were both sacrificed. All the components were fixed to the bone with cement, made of colophony, pumice and plaster of Paris.

Further progress occurred over the next few years, leading to the use of a metal back for the tibial component and posterior cruciate ligament retention. In the early twentieth century, interposition arthroplasty using autologous tissue or metallic components came to the fore and in 1950s the first tibia replacement was carried out by McKeever (McKeever, 1960). From then, the vision of knee arthroplasty took two different routes:

• the constrained (or hinged) prosthesis, and

• the condylar replacement.

In the condylar replacement knee prosthesis the distal femoral and proximal tibial bearing surfaces are substituted with unconnected artificial components with no direct mechanical link between them. The original design named the Freeman-Swanson prosthesis and proposed at the end of the 1960s at Imperial College, London, comprised a metal roller placed on the distal femur articulating with a polyethylene tibial tray. This first prototype required a re-section of both cruciate ligaments. Later, uni-compartmental knee arthroplasty was developed, involving the substitution of only one tibio-femoral compartment, with the aim of preserving part of the bone. Recent improvements have introduced newer bearings options and cementless fixing (Ranawat). The surgical performance and clinical outcome of knee replacement surgery is constantly being improved by computer-aided systems which assist the surgeon in accurately positioning the prosthesis. Due to its excellent long-term clinical results, knee replacement is a successful and promising procedure. Consequently, the rate of total knee replacement is expected to increase in the future (Culliford et al., 2010).

The aim of TKA is the re-establishment of joint function and the alleviation of pain. The main cause of joint impairment is primary osteoarthritis, a degenerative condition due to ageing. Another condition necessitating TKA is secondary osteoarthritis as a result of an altered load distribution around the knee, generally due to post-traumatic disorders (fractures of the distal femur or proximal tibia) or congenital anomalies producing varus or valgus alignments. Other indications for TKA include osteonecrosis of the femoral condyles (Radke et al., 2005), rheumatoid arthritis (Meding et al., 2004) and haemophilic arthropathy (Goddard et al., 2010).

1.3 Indications for a TKA

TKA is indicated when the knee joint is severely damaged by osteoarthritis, rheumatoid arthritis or other diseases. The primary purpose of TKA is to restore joint stability and relieve pain caused by severe arthritis. The pain should be significant and disabling. Loss of joint stability and chronic acute pain result in a significant reduction in the quality of life. Correction of significant deformity is another important indication but is rarely used as the primary reason for surgery. Generally, TKA is appropriate for older patients with more modest activities, as the TKA lifetime is finite and is adversely affected by higher activity levels (Ranawat et al., 1993; Ritter et al., 1994), (Canale ST and Beaty; Chapman). However, young patients are not excluded by age if they have limited function because of systemic arthritis with multiple joint involvement (Duffy et al., 1998).

1.3.1 Osteoarthritis

Osteoarthritis is the most common type of arthritis. It is caused by prolonged wear and tear of the joint, leading to inflammation, breakdown and the gradual but eventual loss of cartilage. This type of arthritis is age-related; in fact, the majority of patients affected are over 50. Nevertheless, younger people may also suffer from osteoarthritis.

1.3.2 Rheumatoid arthritis

Rheumatoid arthritis is also known as inflammatory arthritis. When the membrane surrounding the knee joint is inflamed, rheumatoid arthritis occurs. If the inflammation becomes chronic it will damage the cartilage, causing soreness and stiffness.

1.3.3 Post-traumatic arthritis

Post-traumatic arthritis arises from a severe knee injury. When the bones around the knee break or the ligaments tear this affects the knee cartilage. Depending on the surgeon's advice, surgery is sometimes the best option in cases of post-traumatic arthritis.

1.4 Biomaterials used in TKA

Modern total knee prosthesis consists of a femoral component, a tibial component, a tibial platform/insert and a patellar component (Fig. 1.3).

Figure 1.3 Schematic representation of total knee prosthesis: femoral component, a tibial component, a tibial platform/insert and a patellar component.

Femoral and tibial components are usually made of cobalt–chromium alloys. The tibial insert and the patellar component, however, are made of polyethylene. The femoral component has an asymmetrical anterior flange similar to the patellar grove to avoid lateral dislocation of the patella. It reproduces the anatomy and function of the distal femur. The tibial component is stabilized by a short stem inserted into the tibial medullar canal emulating the tibial base. The tibial insert, articulated to the tibial component, has a superior surface congruent with the outer surface of the femoral component, while the patellar is a polyethylene dome. Bone cement, polymethylmethacrylate, is commonly used to attach the component to the bone. Most reports regarding cementless knee prostheses show poorer outcomes (Meneghini and Hanssen, 2008) compared to cemented implants (Callaghan and Liu, 2000). Consequently, unlike total hip arthroplasty, cemented fixation is considered the gold standard for TKA (Scuderi et al., 1989; Malkani et al., 1995; Font-Rodriguez et al., 1997). Currently, there are two possible designs of TKA:

• posterior-stabilized prostheses, and

• cruciate-retaining prostheses.

The posterior-stabilized design involves sacrificing both cruciate ligaments. It has a cam mechanism which reproduces the combined rolling and sliding movement of the distal femur over the proximal tibia. At about 70° flexion, the cam engages a central position in the tibial insert, avoiding dislocation of the femur during flexo-extension.

Cruciate-retaining prostheses are implanted leaving the posterior cruciate ligament in situ. Theoretically, the cruciate-retaining design allows a greater degree of knee flexion. However, no conclusive studies confirming the supposedly superior performance of cruciate-retaining designs have been published (Seon et al., 2011).

The tibial insert can be fixed or mobile. The mobile inserts, available with both cruciate-retaining and posterior-stabilized knees, have the potential to rotate slightly over the tibial component during flexion and extension. Mobile-bearing prostheses are characterized by high congruence between the femoral component and tibial platform, resulting in lower contact stresses since the load can be distributed over the largest area. This mechanical behaviour should theoretically decrease the rate of polyethylene wear, but there is no supporting evidence reported in the literature (Kelly et al., 2011; Smith et al., 2011).

In the case of difficult knee surgery, specific types of knee prostheses are available. In severe valgus deformity (Sculco, 1989; Stern et al., 1991) or revision surgery (Rand, 1991) the constrained condylar knee should be used. The constrained condylar knee was developed by Insall and colleagues from the traditional total condylar knee (Donaldson et al., 1988). It increases the depth of the femoral cam and enlarges the tibial post. Moreover, a femoral stem and a longer tibial stem were added to control varus and valgus stresses and improve stability.

The hinged prosthesis is an alternative model and is useful in cases of revision surgery. This design incorporates the longest femoral and tibial stems and a central hinge, allowing flexion and rotational movements by means of a rotating platform (Barrack et al., 2000; Jones 2006). A hinged prosthesis, unlike constrained prostheses, completely eliminates the slight tilting movement of varus or valgus.

The current trend toward less invasive, tissue sparing surgery has led to the development of the uni-compartmental knee replacement, where only one damaged component is replaced (Fig. 1.4).

Figure 1.4 Uni-compartmental knee replacement.

The main advantages of uni-compartmental knee replacement are reduced blood loss, faster post-operative recovery and rehabilitation.

This model can be suitable for old patients because of the reduced surgical impact compared to standard TKA, but also for young people with uni-compartmental pathologies, due to the high likelihood of a second operation being needed during their lifetime (Repicci and Hartman, 2004; Vince and Cyran, 2004; McAllister, 2008; Jamali et al., 2009). Also, the bone-preserving nature of uni-compartmental knee replacement involves a more straightforward revision compared to TKA.

1.5 Operative procedure for TKA

Depending on the type of degenerative disease of the knee, different procedures should be considered. Where the degenerative joint disease is mild, with mechanical symptoms and recurrent persistent effusions, arthroscopic débridement is sometimes indicated. In the case of medial tibio-femoral compartment disease with stable collateral ligaments and a correctable varus deformity of the knee joint, proximal tibial valgus osteotomy is indicated.

The type of prosthesis is selected based on the exhibited disease, the condition of the knee joint and the age of the patient. Knee replacement prostheses can be classified into three categories:

• unconstrained,

• semi-constrained, and

• constrained (Tateishi, 2001).

Although knee surgery is recommended for older people, it can also be appropriate for younger adults and teenagers depending on their pathological conditions. The decision whether or not to operate is based on the severity of pain and degree of disability of the patient, but it has also to take into account other conditions (weight, gender, age, etc.).

However, it has to be considered that knee replacement surgery earlier in life usually means further surgery later. Nevertheless, several studies have shown that knee replacement surgery performed before severe stiffness and pain is associated with better outcomes.

1.6 Surgical techniques

Total knee surgery is usually performed through a large open incision over the knee joint. The orthopaedic surgeon drives long intramedullary rods up the femur and sometimes down the tibia to determine a precise plane for cutting the bone (Fig. 1.5).

Figure 1.5 Precise plane for cutting the bone in order to perform a total knee surgery.

This can ensure an accurate cut in the bone to re-sect arthritic deformity and assist the implantation. However, this conventional way of performing total knee surgery leads to greater blood loss and has the potential for inaccuracy. There has been a recent bias toward less invasive TKA surgery with a smaller incision. Here, the surgeon makes a very small incision in the front of the knee rather than the standard large opening. Specific instruments are introduced into this small cut which can be manoeuvred easily around the tissue rather than cutting it (Fig. 1.6).

Figure 1.6 With the introduction of new specific instruments the recent orientation for total knee surgery is a less invasive operation with smaller incision.

The disadvantages of minimally invasive TKA are related to the restricted visibility resulting in tibial component malalignment and a higher early failure rate. Some studies have suggested this technique is less painful and entails shorter post-operative rehabilitation time (Bonutti et al., 2010), but other studies have shown an increased average recovery time in mini-incision TKA. However, the real advantages of small incision TKA compared to the traditional medial parapatellar approach are not yet established and need to be further investigated.

Other alternative approaches exist, such as muscle-preserving quadriceps-sparing, midvastus and subvastus approaches. They show mixed results. The muscle-preserving quadriceps-sparing approach has shown increased potential for causing