total knee arthroplasty
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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

Total Knee Arthroplasty


Dr. Rami Eid

  • 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
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.
  • 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
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

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
patellar resurfacing
Patellar Resurfacing
  • Indication for leaving the patella unresurfaced:
    • Congruent patellofemoral tracking.
    • Normal anatomical patellar shape.
    • No evidence of crystalline or inflammatory arthropathy.
    • Lighter patient.



1- Cruciate retaining

2- Cruciate substituting

3- Mobile bearing

4- Unicondylar



  • The TRIAXIAL motion of the knee:
    • Articular geometry
    • Ligamentous restraints
degrees of freedom14
Degrees of Freedom
  • Constrained Prostheses
  • Non-constrained Prostheses
  • Intermediated Prostheses
constrained prostheses
Constrained Prostheses
  • Hinged implants.
  • One degree of freedom.
non constrained prostheses
Non-constrained Prostheses
  • Ideal implants.
  • 5 degrees of freedom.
  • Intact ligamentous system.
intermediated prostheses
Intermediated Prostheses
  • Anterior-posterior stability.
  • Two types:
    • FREEMAN (a cylinder in a non conforming trough).
    • INSALL (posterior stabilized knee).
longitudinal alignment of knee
Longitudinal Alignment Of Knee
  • Tibial components are implanted perpendicular to the mechanical axis.
  • Femoral component is implanted in 5 – 6 degrees of valgus.
longitudinal alignment of knee20
Longitudinal Alignment Of Knee
  • Posterior tibial tilt is about 5 – 7 degrees.
  • Usually depend on the articular design.

Anatomic tilt 5 degrees

rotational alignment of knee
Rotational Alignment Of Knee
  • Create a rectangular flexion space.
  • External rotation of the femoral component 3 degrees.
pcl retention or pcl substitution
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
Patellofemoral Joint
  • The patella acts to lengthen extensor lever arm.
  • This arm is greatest at 20 degrees of flexion.
patellofemoral joint29
Patellofemoral Joint
  • Changes in the patellar area of contact can leads to eccentric loading of the patellofemoral joint.
patellofemoral joint30
Patellofemoral Joint
  • Limb with larger Q angle has a greater tendency for lateral subluxation.
  • Preventing subluxation:
    • Prosthetic component.
    • Vastus medialis (in early flexion).
polyethylene issues
Polyethylene Issues

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

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

preoperative evaluation
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
Surgical Preparation
  • Administer a dose of a 1st generation cephalosporin (or vancomycin, clindamycin)
  • Avoid pressure on peripheral nerves.
surgical approaches
Surgical Approaches
  • Medial parapatellar retinacular approach.
  • Subvastus approach.
  • Midvastus approach.
surgical approaches36
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
surgical approaches37
Surgical Approaches
  • Lateral parapatellar retinacular approach:
    • In valgus knees.
    • Improve patellar tracking and ligamentous balancing.
bone preparation tibial resection
Bone Preparation – Tibial Resection
  • The guide is aligned with the anterior tibial tendon and first web space of the toes.
varus deformity
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
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
Flexion Contracture
  • Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule release.
  • Flexion gap < Extension gap >> larger tibial insert.
patellofemoral tracking
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
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
Previous HTO
  • Difficult surgical exposure.
  • Lateral ligamentous laxity.
  • Difficult stem placement.
  • Patella infera.
previous patellectomy
Previous Patellectomy
  • PCL retaining arthroplasty for better results.
complications of total knee arthroplasty
Complications of Total Knee Arthroplasty
  • Thromboembolism.
  • Infection.
  • Neurovascular complications.
  • Patellofemoral complications.
  • Periprosthetic fractures.
patellofemoral complications
Patellofemoral Complications
  • Patella clunk syndrome.
  • Patellar component failure.
  • Rupture of patellar ligament.
mokazem com
  • 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