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Total Knee Arthroplasty. 06/06/2006. Dr. Rami Eid. Introduction. TKA is one of the most successful and commonly performed orthopedic surgery. The best results for TKA at 10 – 15 yrs. compare to or surpass the best result of THA. Indications for Knee Arthroplasty. Indications for TKA.

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Total knee arthroplasty l.jpg

Total Knee Arthroplasty


Dr. Rami Eid

Introduction l.jpg

  • TKA is one of the most successful and commonly performed orthopedic surgery.

  • The best results for TKA at 10 – 15 yrs. compare to or surpass the best result of THA.

Indications for tka l.jpg
Indications for TKA

  • Relieve pain caused by osteoarthritis of the knee (the most common).

  • Deformity in patients with variable levels of pain:

    • Flexion contracture > 20 degrees.

    • Severe varus or valgus laxity.

Osteoarthritis l.jpg

  • American College of Rheumatology classification criteria:

    Knee pain and radiographic osteophytes and at least 1 of the following 3 items:

    • Age >50 years.

    • Morning stiffness <=30 minutes in duration.

    • Crepitus on motion.

Contraindications for tka l.jpg
Contraindications for TKA

  • Recent or current knee sepsis.

  • Remote source of ongoing infection.

  • Extensor mechanism discontinuity or severe dysfunction.

  • Painless, well functioning knee arthrodesis.

  • Poor health or systemic diseases (relative contraindications).

Unicondylar knee arthroplasty l.jpg


Younger patients with unicompartmental disease instead of HTO.

Elderly thin patient with unicompartmental disease (shorter rehabilitation, greater ROM)


Flexion contracture >= 5 degrees.

ROM < 90 degrees.

Angular deformity >= 15 degrees.

Cartilaginous erosion in the weight-bearing area of the opposite compartment.

Unicondylar Knee Arthroplasty

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Patellar Resurfacing

  • Indication for leaving the patella unresurfaced:

    • Congruent patellofemoral tracking.

    • Normal anatomical patellar shape.

    • No evidence of crystalline or inflammatory arthropathy.

    • Lighter patient.

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1- Cruciate retaining

2- Cruciate substituting

3- Mobile bearing

4- Unicondylar



Kinematics l.jpg

  • The TRIAXIAL motion of the knee:

    • Articular geometry

    • Ligamentous restraints

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Degrees of Freedom

  • Constrained Prostheses

  • Non-constrained Prostheses

  • Intermediated Prostheses

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Constrained Prostheses

  • Hinged implants.

  • One degree of freedom.

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Non-constrained Prostheses

  • Ideal implants.

  • 5 degrees of freedom.

  • Intact ligamentous system.

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Intermediated Prostheses

  • Anterior-posterior stability.

  • Two types:

    • FREEMAN (a cylinder in a non conforming trough).

    • INSALL (posterior stabilized knee).

Intermediated prostheses18 l.jpg
Intermediated Prostheses



Longitudinal alignment of knee l.jpg
Longitudinal Alignment Of Knee

  • Tibial components are implanted perpendicular to the mechanical axis.

  • Femoral component is implanted in 5 – 6 degrees of valgus.

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Longitudinal Alignment Of Knee

  • Posterior tibial tilt is about 5 – 7 degrees.

  • Usually depend on the articular design.

Anatomic tilt 5 degrees

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Rotational Alignment Of Knee

  • Create a rectangular flexion space.

  • External rotation of the femoral component 3 degrees.

Pcl retention or pcl substitution l.jpg

PCL retaining prostheses:

Better ROM (roll-back, flat tibial surface).

More symmetrical gait (stair climbing).

Less femoral bone resection is required.

PCL needs to be accuracy balanced.

PCL substituting prostheses:

Easier surgical exposure.

See-saw effect prevention.

Lower tibial polyethylene contact stress

Posterior tibial component displacement.

Patella clunk syndrome.

PCL-retention or PCL-substitution ?

Patellofemoral joint l.jpg
Patellofemoral Joint

  • The patella acts to lengthen extensor lever arm.

  • This arm is greatest at 20 degrees of flexion.

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Patellofemoral Joint

  • Changes in the patellar area of contact can leads to eccentric loading of the patellofemoral joint.

Patellofemoral joint30 l.jpg
Patellofemoral Joint

  • Limb with larger Q angle has a greater tendency for lateral subluxation.

  • Preventing subluxation:

    • Prosthetic component.

    • Vastus medialis (in early flexion).

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Polyethylene Issues

1- Dished polyethylene avoids the edge loading. (as PCL substitution)

2- Minimal polyethylene thickness >= 8 mm to avoid higher contact stress.

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Preoperative Evaluation

  • Soft tissue defects around the knee.

  • Vascular status to the limb.

  • Extensor mechanism.

  • Preoperative range of motion.

  • Standing (AP) view, a lateral view of the knee, and a skyline view of the patella.

Surgical preparation l.jpg
Surgical Preparation

  • Administer a dose of a 1st generation cephalosporin (or vancomycin, clindamycin)

  • Avoid pressure on peripheral nerves.

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Surgical Approaches

  • Medial parapatellar retinacular approach.

  • Subvastus approach.

  • Midvastus approach.

Surgical approaches36 l.jpg

Subvastus approach:

Intact extensor mechanism.

Decreasing pain.

More limited.

Postoperative hematoma.

Midvastus approach:

Preserve genicular a. to the patella.

Contraindication in limited preoperative flexion.

Postoperative hematoma.

Surgical Approaches

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Surgical Approaches

  • Lateral parapatellar retinacular approach:

    • In valgus knees.

    • Improve patellar tracking and ligamentous balancing.

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Bone Preparation – Tibial Resection

  • The guide is aligned with the anterior tibial tendon and first web space of the toes.

Varus deformity l.jpg
Varus Deformity

  • 1st Osteophytes must be removed.

  • 2nd Release the deep MCL.

  • 3rd Release semimembranosus and pes anserinus insertion.

  • 4th release posterior capsule and PCL.

Valgus deformity l.jpg
Valgus Deformity

  • 1st Remove all osteophytes.

  • 2nd release lateral capsule.

  • 3rd

    • Lesser deformity: release Iliotibial band.

    • Greater deformity: release LCL +/- PCL.

  • Valgus deformity + flexion contracture >> release posterior capsule.

Flexion contracture l.jpg
Flexion Contracture

  • Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule release.

  • Flexion gap < Extension gap >> larger tibial insert.

Patellofemoral tracking l.jpg
Patellofemoral Tracking

  • Internal rotation of tibial component increases the tendency to lateral patellar subluxation.

  • Prosthetic patella should be medially positioned.

Total knee replacement exercise protocol l.jpg
Total knee replacement exercise protocol

  • Postoperative day 1

    • Bedside exercises (e.g. ankle pumps, quadriceps exercises…)

  • Postoperative day 2

    • Exercises for active ROM and terminal knee extension

    • Gait training with assistive device

  • Postoperative day 3-5

    • Progression of ambulation on level surfaces and stairs (if applicable)

  • Postoperative day 5 to 4 weeks

    • Stretching of quadriceps and hamstring muscles

    • Progression of ambulation distance

Previous hto l.jpg
Previous HTO

  • Difficult surgical exposure.

  • Lateral ligamentous laxity.

  • Difficult stem placement.

  • Patella infera.

Previous patellectomy l.jpg
Previous Patellectomy

  • PCL retaining arthroplasty for better results.

Complications of total knee arthroplasty l.jpg
Complications of Total Knee Arthroplasty

  • Thromboembolism.

  • Infection.

  • Neurovascular complications.

  • Patellofemoral complications.

  • Periprosthetic fractures.

Patellofemoral complications l.jpg
Patellofemoral Complications

  • Patella clunk syndrome.

  • Patellar component failure.

  • Rupture of patellar ligament.

Mokazem com l.jpg

  • هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي.

  • الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة.

  • This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali.

  • This site is not responsible of any mistake may exist in this lecture.

Dr. Muayad Kadhim

د. مؤيد كاظم