Primary TKAPrimary TKA

Beom Koo Lee, M.D.Beom Koo Lee, M.D.Dept. of Orthopaedic Surgery Dept. of Orthopaedic Surgery Gachon University, Gil Medical CenterGachon University, Gil Medical Center

CR or PSCR or PS

Advantage of CRAdvantage of CR

• Maintain central stabilizer• Maintain joint line• Conservation of bone• Patella clunk syndrome• Avoidance of the Stress Inherent in Posterior Cruciate-Substituting Knees• Ease of Management of

Supracondylar Femur FracturesInsall surgery of knee

Trend in USATrend in USA

CR PS• 1995 85%

• 2001 46%

Draw back of CRDraw back of CR

• Perfect PCL balance can’t be obtained predictably

Dennis1996 CORR 331

Shearing in deep flexionShearing in deep flexion

Shearing in CR

after PCL excisionafter PCL excision

• PCL function is compromized as a result of the degenerative process involving knee

Drawback of CRDrawback of CR

Lombardi CORR 2001 ;392:75-87Ranawat CORR 1994;309:131

• Dennis CORR 410’2003 P 114

Drawback of CRDrawback of CR

Marked lift off in CR

• paradoxical sliding and opposite rotation in CR

• near normal roll back in PS

Dennis CORR 410’03 P114

Fluoroscopic exam of fixed bearing TKA

Drawback of CRDrawback of CR

Draw back of CRDraw back of CR

• Early loosening with osteolysis in CR

Which is very rare in PS

Agilietti 1996 AJKS Colizza 1995 JBJS 77-A;1713

Drawback of CRDrawback of CR

• Better ROM in PS Delp1995 ,Kochmond 1995 J

Arthroplasty

• Easy rehab in PS type 정현기

• TKA CR In RA

instability in 15%   (posterior instability, recurvatum,

mediolat instability)

(Meding 2004 CORR428 P146)

Drawback of CRDrawback of CR

서재곤 슬관절 전치환술에서 경골 후방 경사각이 인공 슬관절의 안정성에 미치는 영향

Hyperextension and anterior displacement in CR

Drawback of CRDrawback of CR

Advantage of PSAdvantage of PS• The deformity can be corrected easily. • Minimal tibial resection is possible. This allows placement of the tibial component in stronger host bone • Knees have more normal kinematics• Polyethylene wear is decreased when a conforming articular

John J. Callaghan Insall Surgery of knee

• patients with PS knees reported greater functional limitations in squatting, kneeling, and gardening.

• Our results suggest that with the specific implant used in this study, substitution for the PCL with a spine and cam mechanism may not fully restore the functional capacity of the intact PCL, particularly in high-demand activities that involve deep flexion. 

Conditt J Arthroplasty Oct‘2004 P 107

Advantage of CRAdvantage of CR

AlgorithmAlgorithm

• RA, prior patellectomy

Prior HTO prev PCL rupture• Grade II-III flexion

contracture• Deformity greater

than 15• Severe disease• Incompetent PCL• deformed,deficient,

contracted, laceration, excessive recession

Lombardi CORR 2001 ;392:75-87

PS

Grade I flexion contracturedeformity less than 15Moderate diseaseCompetent PCLIntact , balanced PCL

CR

Joint space narrowing (+) Femoral & tibial condyle erosion (+)

Bony spurs: +

PS

Posterior contact

Moderate deformity

Post slope more than 7

PS

CR

Tibia posterior slope less than 7Contact point more than posterior 1/3Less deformity

Patella resurfacing or Patella resurfacing or notnot

Patellar resurfacing, perhaps more Patellar resurfacing, perhaps more

than any other area of TKA, than any other area of TKA,

as been surrounded by as been surrounded by controversycontroversy

in the 30 years of its existencein the 30 years of its existence

3 camp3 camp

• patellar resurfacing as a routine part of TKA,

• others continue to avoid resurfacing the patella,

• "selective resurfacing of the patella

Favor resurfacingFavor resurfacing

•Better pain relief

Extensor mechanism complication after TKA (James Rand ICL'05 P241)

Long-Term Changes of the Nonresurfaced Long-Term Changes of the Nonresurfaced Patella After Total KneeArthroplastyPatella After Total KneeArthroplasty

•Progressive degenerative changes of the nonresurfaced patella in 40%

Hsin-Nung Shih, J. Bone Joint Surg. Am., May 2004; 86: 935 - 939.

Favor resurfacingFavor resurfacing

FavorFavor non resurfacingnon resurfacing

Scott F. Dye, Geoffrey L. Vaupel, and Christopher C. Dye Am J Sports Med  Nov 1998 26: 773-777.

Favor non resurfacingFavor non resurfacing

• No significant difference was found regarding these revision rates or the Knee Society clinical rating scores, functional scores, patient satisfaction, anterior knee pain, or radiographic outcomes

Burnett RS, Haydon CH, Rorabeck CH, et al. Clin Orthop 428:12, 2004.

Feller JA, Bartlett RJ, Lang DM:. J Bone Joint Surg Br 78:226, 1996

Barrack RL, Wolfe MW, Waldman DA, et al:

J Bone Joint Surg Am 79:1121, 1997

Favor nonresurfacingFavor nonresurfacing

•High complication rate and questionable benefits associated with resurfacing

John Gallagher Insall surgery of knee

James Rand ICL'05 P241 Extensor mechanism complication after TKA

Favor selective resurfacingFavor selective resurfacing

• Progressive degenerative changes of the nonresurfaced patella (mainly on the lateral facet) and patellar maltracking were the most common abnormal radiographic changes.

• Patients with preoperative patellar maltracking were at risk for the development of these changes and clinical symptoms. • Resurfacing of the patella during total Knee arthroplasty may benefit such patients.

Hsin-Nung Shih, J. Bone Joint Surg. Am., May 2004; 86: 935 - 939.

Selective resurfacingSelective resurfacing

Pre-op ant knee pain Inflammatory arthritis Advanced chondromalacia Obesity Malalignment Lack of congruency

Extensor mechanism complication after TKA (James Rand ICL'05 P241)

Bone

Inactive patientMinimal OASmall patella

Patella unresurfacing

BoneTibiofemoral

F/53 RA

Patella resurfacing

Pat grade IV OA with painMaltracking

Active age

Patella resurfacing

Tibia 1 st or femur 1 stTibia 1 st or femur 1 st

Gap techn or Gap techn or

Measured resectionMeasured resection

Gap techniqueGap technique

Essential philosophy of the Essential philosophy of the gap gap techniquetechnique

• It builds on the state of the soft tissues

• The soft-tissue correction is performed first and the measured gap resection is performed next.

Insall 4th

Gap techn; Tibia cutGap techn; Tibia cut

• cut at right angles to the long axis in the coronal plane (A)

• Posterior slope; 0-5

Insall 4th

posterior femoral cut;posterior femoral cut; Size and rotation Size and rotation

After tensioning, the size and rotation is determined

Distal femoral cut; alignment Distal femoral cut; alignment controlcontrol

Classic measured Classic measured resection techniqueresection technique

Replace a bone with prosthesis

So the cut bone should be identical size with prosthesis thickness

Insall 4th

Distal femoral cut; alignment

90 to mechanical axis from the center of the femoral head to the center of the knee

In practice the intramedullary alignment rod is inserted and distal cutting guide matching the pre-op determined angle ( normally aligned in 6 to 7 degrees of valgus) is applied.

Measured resection techn

Distal femoral cut ;depth of cut Distal femoral cut ;depth of cut

• Prosthesis thickness

(9mm)

Insall 4th

Figure 84-24 Ideally, the amount of distal femoral resection should be judged from the normal side.

Measured resection techn

prosthesis size and depth of prosthesis size and depth of posterior femoral cutposterior femoral cut

• Bone size determined by sizer

• The size usually match to Prosthesis thickness (9mm)

Insall 4th

Measured resection techn

Posterior Slope of Tibia CutPosterior Slope of Tibia Cut

gap technique measured resection technique

0- 5 Original slope should be less than 7

Femur rotationFemur rotation

Gap techn Measured resection

Collateral lig tension 3 E/RAP axisEpicondylar axis

My practice; combinationMy practice; combination

• Measured Resection; proximal tibia and distal femur• Ligament balance in extension

• Gap Techniques rotation & size

My practiceMy practice

Femur 1 st

Huge posterior bone spur that block anterior displacement of tibia

High flex or notHigh flex or not

AdvantageAdvantage of high flexionof high flexion

• although the degree of postoperative knee flexion did not affect patient satisfaction, it did influence fulfillment of expectations, functional ability, and knee perception.

Brandon N. Devers, Michael A. Conditt, Miranda L. Jamieson, Matthew D. Driscoll, Philip C. Noble, Brian S. ParsleyDoes Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee Arthroplasty? JA feb 2011 Pages 178-186

AdvantageAdvantage of high flexionof high flexion

Brandon N. Devers, Michael A. Conditt, Miranda L. Jamieson, Matthew D. Driscoll, Philip C. Noble, Brian S. ParsleyDoes Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee Arthroplasty? JA feb 2011 Pages 178-186

Increased tibial Increased tibial internal rotation internal rotation with deep flexion with deep flexion

• Posterolateral subluxation and posterior impingement in lateral side

Nagawa JBJS 2000

Stress in high flexionStress in high flexion

Ephrat Most J arthropplastyEphrat Most J arthropplasty20052005Bank CORR2003Bank CORR2003

Early Impingement

Late Impingement

Polymer insert stress in TKA during high Polymer insert stress in TKA during high flexion activityflexion activity

Morra EA, JBJS(Am), 2005Morra EA, JBJS(Am), 2005

The kirschner arthroplasty with an internally The kirschner arthroplasty with an internally rotated tibial component at 120 flexion.rotated tibial component at 120 flexion.

The The posterolateral edge of theposterolateral edge of the post impinge on post impinge on the medial edgethe medial edge of lateral femoral condyle of lateral femoral condyle

NakayamaNakayamaJ arthroplasty 2005J arthroplasty 2005

Newer prosthetic design that allow for greater range of motion will further test

the critical posterior condylar bone interface

higher incidence of femoral component loosening may be seen

ThomasV.King CORR 1990ThomasV.King CORR 1990

Clinical study of high flexion Clinical study of high flexion knee.knee.

• Early failure

조성도 , 슬관절 2006

Much larger quadriceps forceMuch larger quadriceps force is needed is needed for weight bearing in hyperflexed kneefor weight bearing in hyperflexed knee

• Is High Flexion Following Total Knee Arthroplasty Safe? :Evaluation of Knee Joint Loads in the Patients During Maximal Flexion  ARTICLEPages 647-651JA aug'05• Takeo Nagura, Toshiro Otani, Yasunori Suda, Hideo Matsumoto and Yoshiaki Toyama

the patients following TKA are not capable to use 100% range of passive motion because of the limitation in the quadriceps force when performing high flexion such as rising from the floor

Is High Flexion Following Total Knee Arthroplasty Safe?: Evaluation of Knee Joint Loads in the Patients During Maximal Flexion 

• ARTICLEPages 647-651JA aug'05Takeo Nagura, Toshiro Otani, Yasunori Suda, Hideo Matsumoto and Yoshiaki Toyama

Excessive wear at Post-op 10 YrExcessive wear at Post-op 10 YrIn full flexed knee.In full flexed knee.

Metallosis andMetallosis andbone defectbone defect

MIS or notMIS or not

Limited ArthrotomyLimited Arthrotomy

• Minimal Incision Approach– Mini-median Parapatellar– Mini-midvastus– Mini-subvastus

• Quadriceps Sparing Approach

(Scuderi, 2004, CORR)

Pitfalls of MIS Pitfalls of MIS InstrumentationInstrumentation

• Greater Errors in MIS Instruments– Femur: Variable Placement & Cutting Block

Movement– Tibia: Tendency of Varus Cut d/t Medial

Placement of Cutting Block

(Stulberg, 2005, AAOS)(Stulberg, 2005, AAOS)

Minimal Incision Surgery as Minimal Incision Surgery as a Risk Factora Risk Factorfor Early Failure of Total Knee Arthroplastyfor Early Failure of Total Knee Arthroplasty

Robert L. Barrack, MD,* C. Lowry Barnes, MD,† R.

J Arthroplasty June 2009

Time to revisionTime to revision,,

• which was significantly shorter for the MIS group (14.8 vs 80 months, P < .001).

• The MIS group was much more likely to fail at less than 12 months (37% vs 5%, P < .001) and at less than 24 months (81% vs 22%, P < .001).

Robert Barrack, C. Lowry Barnes, Derek Miller, Stephen Burnett, John Clohisy and William MaloneyJ Arthroplasty feb 2008 Page 316

ComplicationsComplications After Minimally Invasive Total After Minimally Invasive Total Knee Arthroplasty as Compared With Knee Arthroplasty as Compared With

Traditional Incision Techniques: Traditional Incision Techniques: A Meta-A Meta-Analysis Analysis

Rajiv Gandhi MD,, , Holly Smith, Kelly A. Lefaivre MD, J. Rod Davey MD, and Nizar N. MahomedJA January 2011, Pages 29-35

MIS vs StandardMIS vs Standard

Rajiv Gandhi MD,, , Holly Smith, Kelly A. Lefaivre MD, J. Rod Davey MD, and Nizar N. MahomedJA January 2011, Pages 29-35

Mobile or fixedMobile or fixed

3.9

60

50

40

30

20

10

POINT(Total Condylar)

LINE(PCA)

QUASI-LINE(Whiteside)

CO

NT

AC

T S

TR

ES

S M

Pa

2529

32

Rapid Failure

Danger

Caution

Safe

2200 N@15°

Flexion

AREA(LCS)

(Rotating Platform)

CompressiveYield Stress32 MPa

Industrial Limit10 MPa

Medical Limit5 MPa

CONTACT STRESSES vs GEOMETRY IN TKRCONTACT STRESSES vs GEOMETRY IN TKR

DURING HEEL STRIKE OF GAIT CYCLE

mobile bearing TKA

Greenwald P195 ICL'05

John Fisher Eng, CORR (2010) 468:12–18

JamesB.Stiehl ICL'05 P233)

Dennis, Douglas A MD CORR 2006 Nov.

Polyethylene Wear

PFC sigma rotating platform mobile-bearing knee

BuechelThe Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1

June 2004 (Buechel CORR404 2002 P40)

Mobile-Bearing Total Knee Mobile-Bearing Total Knee Arthroplasty: Better Arthroplasty: Better

Than a Fixed-Bearing? Than a Fixed-Bearing?

• We found no difference in survivorship at 12 to 23 years.

Zachary D. Post MDa, JA September 2010, Pages 998-1003

• Patients with cementless mobile-bearing TKA also had a significantly lower KSCS (161 versus 184, P<.05), significantly higher incidence of pain rated more than mild (23% versus 7%, P<.01)

• and a trend toward less arc of motion (1060 versus 1150 , P<.2).

Early failure in cementless Early failure in cementless mobile TKAmobile TKA

(Barrack JA oct'04 101)(Barrack JA oct'04 101)

LCS mobile bearing TKA (Hartford JA Dec'01 P 977)

Early clinical outcomes of floating platform mobile-Early clinical outcomes of floating platform mobile-bearing TKA:bearing TKA:

longitudinal comparison with fixed-bearing TKAlongitudinal comparison with fixed-bearing TKA

• More patients preferred knees implanted with the FB prosthesis at 12 and 24 months

Tae Kyun KimKnee Surg Sports Traumatol Arthrosc (2010) 18:879–-888

• Average pain score was 44 for RP and 48 for FB (P = .002).

• Average function scores was 72 for RP and 87 for FB (P =.0001).

• Average total Knee Society score was 91 for RP and 96 for FB (P = .03).

MOBILE BEARING KNEES PROVIDE MOBILE BEARING KNEES PROVIDE NO EARLY CLINICAL NO EARLY CLINICAL BENEFIT BENEFIT AT MINIMUM FIVE-YEAR FOLLOW-UPAT MINIMUM FIVE-YEAR FOLLOW-UP

J. Bohannon Mason, MD

The Journal of Arthroplasty, Volume 23, Issue 2, February 2008, Page 330

   Decreased in mobile

--ROMROM

Dennis ICL'05 P207;

Iglietti JA Feb'05 P145

Stiehl ICL 2005 P234

• The wear rate for the FB averaged 8.14 ± 2.63 mg/million cycles and the RP averaged 6.78 ± 1.74 mg/million cycles..

• • We concluded polyethylene

wear was similar for both designs.

An In Vitro Study of Wear An In Vitro Study of Wear

Hani Haider and Kevin Garvin 

CORR nov 2008-

Rotating Platform versus Fixed-bearing Total Knees:

• rotating+translate> rotate only> fixed

Gravimetric wear

• There was no statistical difference between pitting and scratching, but burnishing was twice as much for MB inserts (P = .003).

Gerard A. Engh, MD, Rebecca L. Zimmerman, MS, Nancy L. Parks, MS, and C. Anderson Engh,

MDThe Journal of Arthroplasty Vol. 24 No. 6 Suppl. 1

sept 2009

Articular surface wear

• There was a minimal amount of pitting for both, but the scratching score was twice (P = .000) and the burnishing score was 3 times greater for MB inserts (P = .000).

Gerard A. Engh, MD, Rebecca L. Zimmerman, MS, Nancy L. Parks, MS, and C. Anderson Engh,

MDThe Journal of Arthroplasty Vol. 24 No. 6 Suppl. 1

sept 2009

Backside wear

Wear Damage in Mobile-bearing TKA is Wear Damage in Mobile-bearing TKA is as as

SevereSevereas That in Fixed-bearing TKAas That in Fixed-bearing TKA

Natalie H. Kelly BS, Rose H. Fu BS,Timothy M. Wright PhD, Douglas E. Padgett MDClin Orthop Relat Res (2011) 469:123–-130

• Radiographic evaluation showed a 27% incidence of radiolucent lines for the femur and a 31% incidence of radiolucent lines

for the tibia.

LCS mobile bearing TKA (Hartford JA Dec'01 P 977)

• Rotating platform dislocation(3.2%)

Diadvantage or Problems of MBDiadvantage or Problems of MB

JamesB.Stiehl ICL'05 P233)

John Calahan CORR 392 P221

Problems of Mobile BearingProblems of Mobile Bearing

Prevalence of Osteolysis After Simultaneous Bilateral Fixed- and Mobile-Bearing Total Knee

Arthroplasties in Young Patients J Arthroplasty September 2009, Pages 932-940

(Otto CORR410'03P181

did not decrease did not decrease

lateral release lateral release

raterate

Rotating platform did not improve Rotating platform did not improve patella trackingpatella tracking

(Pagnano 2004 CORR428 P221)(Pagnano 2004 CORR428 P221)

(SigmaPress-Fit Condylar, DePuy, Warsaw, IN)

mobilemobile

Minimal deformityYoung age

FixedFixed

Complicated case age over 70