TOTAL KNEE REPLACEMENT ARTHROPLASTY

Dr Debashish Chanda Final year postgraduate student Moderated by Prof P. K. Baruah Department Of Orthopedics Guwahati Medical College

INTRODUCTION
TKA

is one of the most successful and commonly performed orthopedic surgery. best results for TKA at 10 15 yrs. compare to or surpass the best result of THA.

The

BIOMECHANICS OF KNEE JOINT

BIOMECHANICS OF KNEE JOINT

Motion in knee occurs in three separate planes

TRIAXIAL These

MOTION

are& extension, & adduction

Flexion

Abduction

Rotation

around long axis of the limb

FEMORAL ROLL-BACK: Knee does not rotate on a single axis like a hinge, but rather the femoral condyles roll and glide on the tibia with a changing center of rotation.

AXES OF LOWER LIMB

Mechanical axis of lower limb Mechanical axis of tibia Anatomical axis of femur

Articular surface of tibia has a posterior tilt of 9

HISTORY

EVOLUTION OF TKR

Development of TKR

History dates back to 1861 Fergusson reported resection arthroplasty of knee for arthritis

Membrane interposition arthroplasty proved the feasibility of knee arthroplasty

1863- Verneuil. (Capsular interposition) 1888- Kaga. (published series with fascia lata)

Linked hinged arthroplasty 1949- Shiers. Advantage - Correction of deformity plus good stability. Disadvantage - Large bone resection for bulky prosthesis. Most successful was Guepar prosthesis.

EVOLUTION

Femoral mould arthroplasty: earliest use of metal in knee arthroplasty 1940, Campbell (contoured vitalium plate). Tibial mould arthroplasty: 1951: Townley . Acrylic and metal interposition arthroplasty: half circle metallic implants for the most affected tibial condyle. Rotationally non-constrained hinge arthroplasty: tried to overcome the inability of the tibia to rotate on femur during flexion, of earlier hinged prosthesis.
1973: Spherocentric knee. 1978: Kinematic rotating hinge prosthesis.

EVOLUTION OF TKR
Bicondylar

knee prosthesis: basic concept was to join two unicondylar replacements to be able to provide complete coverage of femoral and tibial articular surfaces.
1974: Duocondylar total knee. (Insall) 1980: Geomedic total knee.

Features: Larger and thicker tibial components to improve survival. Problem: Initial designs retained both cruciate ligaments resulted in kinematic conflict.

BASIC DESIGN OF MODERN TKR PROSTHESIS

MODERN TKR PROSTHESIS

1973:

Insall developed total condylar prosthesis at the Hospital for Special Surgery. Advantage: 1. Higher conformity with less wear. 2. Less flexion range. Concept of patellar resurfacing is part of modern prosthesis

Total condylar prosthesis introduced by Insall in 1973

Femoral component
Made

of Cobalt-Chrome alloy Two separate medial and lateral unicondylar pieces on distal and posterior aspects, joined anteriorly to a flatter, wider surface The distal and the posterior aspects of femoral and tibial components articulate together during whole ROM

Tibial component

Initially made of polyethylene (UHMWP) metal backing was added in 1980s to allow more uniform stress transfer to the underlying cancellous metaphyseal bone and to prevent polyethylene deformation

Kinematic condylar prosthesis

Posterior cruciateretaining total knee arthroplasty

Total condylar design is limited in flexion by posterior impingement of femur on tibial polyethylene component

Insall-Burstein II posteriorstabilized knee

With

central cam mechanism PCL Sacrificing knee

PCL Retaining vs PCL Substituting

PCL Retaining type - Merits:
Longer lateral distal femoral condyle in AP- direction facilitates femoral rollback and screw-home movement in final degrees of extension. PCL restricts translational displacement of knee reduces stress on prosthetic construct More symmetrical gait, esp. stair climbing (better rollback and proprioceptive roll of PCL). No cut-out required on the femoral side for any cam mech. Technically more demanding. Does not tolerate joint line change.

PCL retaining PCL sacrificing

PCL Sacrificing type

Merits

To have near-normal PCL strain, PCL has to be balanced to an accuracy of 1mm. A diseased or contracted PCL is difficult to balance. So substituting PCL is advantageous. More reliably corrects fixed knee deformity. Too tight PCL

Limitation of flexion Excessive femoral rollback Accelerated posterior poly. wear Paradoxical forward translation of femoro-tibial contact point during flexion

Too loose PCL

Insall-Burstein II constrained condylar knee

enlarged

central post of the tibial polyethylene insert

Low Contact Stress (LCS) Prosthesis (meniscal-bearing version)

Cementless knee

press-fit

cementless reconstructions

Kinematic II Rotating Hinge (Howmedica) total knee implant

Indications of hinged knee

patients

with severe ligamentous insufficiency severe flexion or extension gap mismatch recurvatum deformity limb salvage procedures

Patellar component
Three basic designs

Patella with central dome Anatomic shaped dome (Mexican hat pattern)

Rotating bearing fully conforming type.

Central convex dome surrounded by concave peripheral rim. Commonest type. Patellar component is made of polyethylene.

The modern designs have three small pegs for fixation of the prosthesis to the patella.

Unicondylar knee prosthesis

1969:

Gunston 1972: Marmor Gunston prosthesis: polycentric femoral component duplicated normal femoral rollback.

Unicondylar prosthesis
Disadvantage: Difficult to maintain joint line in relation to non-resurfaced component. Not suitable for knees with flexion deformity Progressive wear of non-resurfaced compartment Advantage: revision to TKR is easy preservation of bone stock Possibly it can replace high tibial osteotomy

Prerequisites for using unicondylar prosthesis

Non-inflammatory

arthritis Less than 10 varus or 5 valgus Intact ACL Flexion contracture less than 15 Body weight less than 80-90 kg Patellofemoral changes < grade III Pre operative arc of motion >90 Intact cartilage in opposite compartment

INDICATIONS OF TKR

Prime indications
Severe

Relative indications
Deformity
Instability Loss

pain Functional disability

of motion

o Diagnosis Arthritis OA, RA, Post traumatic, inflammatory, osteonecrosis, tumors or fractures.

CONTRAINDICATIONS OF TKR

Absolute
Recent

or current sepsis. source of ongoing infection.

Remote Extensor

mechanism discontinuity or dysfunction.

deformity secondary to muscle

Recurvatum

weakness.

Presence

of painless, well-functioning knee arthrodesis.

RELATIVE
Medical

contraindications for anesthesia

atherosclerotic disease of limb

Significant Poor

skin condition (e.g., Psoriasis)

Neuropathic
Morbid H/o

arthropathy

obesity urinary tract infections

osteomyelitis in the proximity of the knee

Recurrent

PREOPERATIVE RADIOGRAPHIC ASSESMENT

STANDING AP VIEW

Lateral view
Femoral condyles superimposed on a technically adequate true lateral view

Merchant view

Scano-gram
Standing three-joint view

Templating In TKR in AP view

In lateral view

Surgical Approach

Medial para-patellar approach (von Langenbeck)

Gives the best exposure of the whole joint Most commonly used

Medial para-patellar approach ( von Langenbeck)

SUBVASTUS (Southern) APPROACH (Erkes)

Entire belly of vastus medialis is retracted laterally. Advantage: Reduces patellofemoral mal-tracking / subluxation of patella Reduces AVN of patella (as medial blood supply is preserved).

MIDVASTUS APPROACH (Eugh, 1929)

Advantage: Terminal branches of saphenous nerve which give some motor branches to vastus medialis are spared. The descending genicular artery is spared. Disadvantage: Not suitable If knee flexion range < 80o Previous tibial osteotomy Obese patient

Lateral approach (Cameron & Fedorkow,1982)

Only indication : Valgus knee Advantage: direct exposure of lateral tissues in valgus knee medial vascularity preserved corrects external rotation of tibia associated with valgus knee

SURGICAL STEPS

BONE PREPARATION IN TKR

Principles

Bone cuts are required in a predetermined shape to seat the respective implants. Bone cuts are made using specific cutting zigs. Appropriate sizing of the individual components Alignment of the components to restore the mechanical axis Recreation of equally balanced soft tissues in both flexion and extension Optimal patellar tracking

MANAGEMENT OF BONE DEFECTS

Small

defects (68mm deep): incorporated in the proximal tibial cut.

Resection must not exceed 10mm (otherwise patella baja)

Bone

cement: defects < 5mm Bone grafting: impacted cancellous bone harvested from femoral condyles. Allograft is also an option.

Dorr, Ranawat, Sculco techniques.

Metalic

augmentation with wedges and extended stems (Brand et al. 1989).

Can be used in conjunction with bone cement or bone graft.

PATELLO-FEMORAL TRACKING
Any factor increasing the Q-angle can cause lateral maltracking of patella. Maltracking can be avoided by
a. Medialization

of prosthetic patella to approximate median eminence of normal patella. retinacular release: if patella subluxates laterally. and Tokish found that 48% of knees demonstrated initial maltracking, which reverted to normal after tourniquet release.

b. Lateral

c. Marson

POST OPERATIVE REHABILITATION

3rd

post op day : gravity assisted flexion & active extension started. 4-5 days post op : walking with walker Two weeks: stair climbing

COMPLICATIONS OF TKR
Thromboembolism
Incidence

Wound problems (3 main types )

of DVT without prophylaxis 45%-75% Mortality rate of pulmonary embolism 2%

Prolonged post op. drainage: (1%-3%) Persistent serous discharge for more than 5-7 days is an Superficial

indication for surgical exploration and debridement (Dennis D. 1997).

Full

Smaller and with intact dermis : local wound care and observation. Size more than 3-4 cm : SSG or local fascio cutaneous flap. Catastrophic Early soft tissue reconstruction

skin necrosis:

thickness necrosis:

Patello-femoral complications

Patello-femoral instability Patellar fracture Patellar component failure Patellar clunk syndrome

Neurovascular complications
Peroneal

nerve palsy (0.6%-10%)

Causes are Traction during deformity correction Direct pressure (dressing, hematoma, splint) Ischemia due to stretching of surrounding soft tissue sleeve

Vascular complications are rare (<0.05%). Arterial occlusion/laceration/aneurysm AV fistula formation.

Periprosthetic fractures

Supracondylar # femur : 0.3%-2% cases of TKR.

Classification of periprosthetic fractures by Rorabeck, Angliss and Lewis:

Type I: Undisplaced #, prosthesis stable Type II: Displaced #, prosthesis stable Type III: Unstable prosthesis +/- fracture displacement

Tibial fractures are uncommon

REVISION TKR
Causes of aseptic failure of TKR:

Component loosening

Poly. wear with osteolysis

Ligamentous laxity Periprosthetic fracture Arthrofibrosis Patello-femoral complications

REVISION
Important considerations: 1. Previous TKR incision should be used, if possible. 2. Two previous incisions existing the more lateral one should be selected (better blood supply). 3. Standard medial para-patellar arthrotomy 4. Exposure can be improved by V-Y quadricepsplasty Rectus snip (Insall) Tibial tubercle osteotomy (Dolin) 5. Removal of femoral component first allows better clearance for tibial component extraction.

REVISION TKR
Reconstruction principles:
Level of joint line for revision TKRRoughly 1 finger breadth above the proximal tip of fibula & 1 finger breadth distal to the inferior pole of patella. Extensive bone loss requires Custom tibial component Proximal tibial allograft Laxity in both flexion & extensionA larger femoral component in the APdimension, with distal & posterior metal augmentation.

Technical Goals Of Knee Replacement Surgery

The

restoration of mechanical alignment, Preservation (or restoration) of the joint line, Balanced Ligaments Maintaining or restoring a normal Q angle.

Successful Results Depends upon

Precise

surgical technique Sound implant design Appropriate material Patient compliance with rehabilitation

Thank you