Prakash Knee Book PDF
Prakash Knee Book PDF
Prakash Knee Book PDF
Total Knee
Replacement
No sponsorship or benefits have been received from any
commercial organization or company for production of this
book.
This book does not advocate or propagate any particu-lar
brand, design or company or their total knee joints or brand of
bone cement. That choice is left to the reader.
All profits from the sale of this book would be used for pure
and applied research into normal and abnormal joints, and for
performing surgeries on economically underprivileged patients.
L. Prakash
June 2016
A Beginner’s Guide to
Total Knee
Replacement
A Beginner’s Guide to
Total Knee
Replacement
ISBN: 978-93-85915-??-?
Copyright © Author and Publisher
First Edition: 2017
All rights reserved. No part of this book may be reproduced or transmitted in any
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or any information storage and retrieval system without permission, in writing, from
the author and the publisher.
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Printed at
Dedicated to
Dr KH Sancheti
The inventor of Indus Knee, my knee Guru and the person who
taught me many things about knee joint.
Dedicated to
Dr Raymon Gustilo, MD
The Inventor of Genesis Knee, my old friend and a brilliant
Orthopaedic teacher.
Foreword
pictures and 10% text, this book is a pleasure to read, while full of
knowledge. Dr L Prakash has himself painted water colours for all
pictures and the photos are from his own cases taken by his assistant.
He has himself edited the videos, and done part of the formatting
and design of the book. I was envious that one man could do so
many different things!!
This book is a must-read for a surgeon planning to embark on
the arduous but fascinating journey of becoming a primary knee
arthroplasty surgeon. It is also an essential read for those doing
knee replacements, sporadically or occasionally. For those doing it
regularly, this will be an exceptional refresher, while it will be an
invaluable addition to any operation theatre library. Even an
experienced arthroplasty surgeon like me could glean many
valuable tips from this fascinating book. Combining illustrations,
photographs, videos and multimedia content is a brilliant idea and
this book shows years of hard work and ceaseless toil to write.
It is with pride and pleasure that I write this foreword and dedi-
cate the book to the orthopaedic fraternity.
S. Venkateswaran
Consultant Orthopaedic Surgeon
North East London NHS Treatment Centre,
King George Hospital, Ilford, Essex.IG3 8YY.
Ph: 0208 598 4600.
Consulting Rooms in London & Birmingham
10 Harley Street, London, W1G 9PF. Phone 02074678301
Guildhall Back Care Centre, Navigation Street,
Birmingham B24BT. Phone: 0121632 5332
Contents 9
Acknowledgements
Foreword xiii
Acknowledgements xiii
1. Introduction 1
5. Biomechanical considerations 92
Conclusions 439
Bibliography 441
1
Introduction
2
Historical Aspects and
Design Criteria of
Total Knee Arthroplasty
Gluck’s classic paper describing his ivory hinge fixed with pumice
and POP as cement.
8 Guide to Total Knee Replacement
The original Gunston Knee. Copied from the internet and not from
the author’s personal collection.
Historical Aspects and Design Criteria ... 13
MacIntosh buttons.
femoral flange, made of COP alloy (Co, Cr, Ni, Mo, C, and P).
There was a one-piece, mildly dished polyethylene tibial
component with a central cutout for preservation of both cruciate
ligaments. He also designed an instrumentation set to give
perfect reproducible cuts.
Others authors who followed the same approach were Waugh
(in 1973 at the University of California UCI), Townley (in 1974
with the cemented anatomical knee) and Sheedom (who
designed the Leeds knee around the same time).
Each of these prostheses had a horseshoe shaped tibial
component with a space behind and centrally for the retention
of both anterior and posterior cruciate ligaments.
The principal aspect of this new concept was that the bone
and cartilage removed were to equal the thickness of the
prosthetic material replacing them.
The drawings submitted by Dr Kenna for his US Patent are
extremely interesting are reproduced below.
Until this time, fixation of the condylar total knee was
primarily achieved with cement.
Historical Aspects and Design Criteria ... 27
The IB II prosthesis.
Historical Aspects and Design Criteria ... 33
The high femur and a deep notch is friendly to all patellar situations.
Materials
Metals, plastic and acrylic cement form the three common
materials used in arthroplasty. Ceramics have now made their
appearance on the scene. This chapter will give you enough
knowledge not to be fooled by snake oil salesmen, the employees
of multinational companies selling those exotic high priced knees
at 50 plus times the manufacturing cost!
The materials for knee arthroplasty were based on the
materials successfully used in total hip replacements, so let us
begin with the common origins. In the beginning, when hemi-
arthroplasties were done, the implant material varied from heat
cured acrylic to resins, then to stainless steel. Stainless steel
showed less wear than acrylic and soon replaced it. The fact
that the non-replaced acetabulum showed significant wear
prompted research into total joints. Charnley’s work laid the
foundation of modern arthroplasty. In spite of continuing
research in implant materials, the time-honoured combination
of metal articulating with ultra high molecular weight
polyethylene is yet to be challenged. However, the choice of
metal has changed from stainless steel of Charnley’s time to
stronger steel alloys, then to cobalt-chromium and titanium-
aluminium-vanadium. Ceramics are also used because of their
excellent frictional and wear characteristics, but have their own
disadvantage of brittleness.
There is a lot of confusing terminology whilst describing
materials, e.g. yield strength, toughness, ultimate tensile
strength, ductility, elasticity, and fatigue strength. This book is
55
56 Guide to Total Knee Replacement
Metals
Stainless steel: This no doubt the cheapest material, tried and
tested for a long period (since 1900). 316L stainless steel is
popular for implants as it is the most corrosion resistant when
in direct contact with biological fluids. What makes 316L ideal
as an implant material is the lack of inclusion. Alloys with
inclusion contain sulphur, which is a key ingredient in
accelerating metallic corrosion.
Stainless steel is an iron alloy. By adding 16% chromium it
becomes corrosion resistant stainless steel. The addition of 7%
nickel helps stabilize the austenite to stainless steel. Type 316L
stainless steel selected for surgical implants contains
approximately 17–19% chromium and 14% nickel. Molybdenum
added to the alloy forms a protective layer, sheltering the metal
Biomaterials of the Artificial Knee 57
The ASTM F75 standard specifies that the alloy should contain
cobalt as its principal element, with 27 to 30% chromium, 5 to
7% molybdenum, and limits on other important elements such
as manganese and silicon, less than 1% iron, less than 0.75%
nickel, less than 0.5% of nitrogen, tungsten, phosphorus, sulphur,
boron, etc.
Besides cobalt-chromium-molybdenum (CoCrMo), cobalt-
nickel-chromium-molybdenum (CoNiCrMo) is also used for
implants. The possible toxicity of released Ni ions from CoNiCr
alloys and also their limited frictional properties are a matter of
concern in using these alloys as articulating components. Thus,
CoCrMo is usually the dominant alloy for total joint arthroplasty.
Titanium knee implants are still being evaluated and are not widely used.
60 Guide to Total Knee Replacement
bio-degradation of the implants fixed not too snugly has not only
led to early loosening, but also to massive osteolysis, migration
of the titanium particles, and even black stained lymph nodes at
sites distant from the joint, which confirms that inertness may be
a more important factor than higher elasticity and lower weight.
Early Muller cups showed much greater wear for two reasons. Thin
cup due to large head and gamma radiation.
Alumina and zirconia ceramics are not too different in look and feel
on the operating table.
70 Guide to Total Knee Replacement
Argentinian black market cement used in USA when FDA had not
yet approved the use of bone cement.
The original low viscosity cement, best for injection under pressure.
cement is not glue and does not have any adhesive qualities. As
a matter of fact, it is a grout or a filler to enable a more uniform
transmission of forces.
As it sets and is mouldable, it is distributed uniformly all over
the surfaces transmitting weight proportionately across all
dimensions of the implant. Due to the absence of mechanical
bonding properties, the cement does not adhere to the polished
surfaces of the prosthesis. However, it does slightly bond to the
rough metallic surfaces or the plastic tibia. Some manufacturers
choose to precoat the surface of the implant with a thin coat of
PMMA to enhance its bonding qualities. However, since the time
of Sir John, cement was never intended to be glue; it was never
intended to bond either the prosthesis or the cup to the body.
80 Guide to Total Knee Replacement
83
84 Guide to Total Knee Replacement
These wax patterns are coated with layers of fine ceramic clay and
dried to form clay moulds with the pattern inside.
The Making of a Knee Prosthesis 87
Irrespective or the metal used for casting, this step remains the same.
Ceramic shell trees being air dried and fired to make one time
ceramic dies.
Radiological and other tests are done to choose the approved castings.
Biomechanical Considerations
The resultant force R in a varus knee passes fully through the medial
compartment.
98 Guide to Total Knee Replacement
mm. Just imagine sliding a brick on the table, first wide side
down, and then on its edges. Naturally the same load distributed
over a wider area will be lesser per square mm.
However, the exact opposite is true of friction-induced wear.
Larger the contact area, greater the surfaces rubbing against one
another, more the friction and more the wear. These points
should receive very careful consideration while a knee implant
is being designed.
In addition to the nature of the articulating surfaces, loading
depends on the surface area. To give a simple example, it is easier
to push a brick that lies flat, than when it is standing upright.
As the material that is going to be used is a constant, the design
of the knee must provide minimal contact surfaces to produce
lowest friction possible.
Friction on the contrary depends on the area of contact; thus,
a smaller contact area will have a lower friction than a larger
area of contact, the bearing surfaces being constant! By these
statements it is apparent that friction and wear are independent,
and both are of concern to the surgeon.
A newer design knee allowing limited contact in full flexion, but rather
full contact in extension.
Biomechanical Considerations 101
6
Knee Design Considerations and
Types of Knee Replacements
Genesis II knee.
110 Guide to Total Knee Replacement
Disadvantages:
1. Need for greater surgical skill for precise alignments.
2. Patellar tracking is not as good as anatomic knees.
3. Prosthesis cannot have inbuilt features for left and right.
Consequently bone cuts should differ on left and right side to
allow for a valgus positioning of the prosthesis.
Anatomic femoral components: Advantages:
1. Better patellar tracking.
2. Prosthesis insertion is easy.
3. Instrumentation needs much less eye balling.
4. Designs can have a thicker medial and thinner lateral part of
the femoral component, needing a much lesser amount of bone
to be removed.
Disadvantages:
1. Increased inventory and costs.
2. More (number) and more complicated instrumentation.
These are very recent designs in which the medial and lateral
tibial articulations differ in shape and size. The medial aspect is
larger and slightly deeper compared to the lateral side. It has a
lot of theoretical advantages, but the follow-up is short and it is
much more expensive.
Nonmetal-backed tibial component: Studies have shown that
a metal-back in tibia dissipates forces much better, leading to
much lesser stresses and lesser plastic deformation. However,
the thickness of the plastic should be a minimum of 5 mm in the
thinnest part. Otherwise if the plastic wears out over the years,
there will be a severe metallosis by the grinding between the
femoral component and the tibial metal base plate.
There is an increasing interest and resurgence of studies
towards nonmetal-backed tibial components now. All poly tibias
have now made a comeback and still have a place in the very
elderly low demand knee.
Metal-backed fixed and modular tibial components: Most tibial
components presently available are metal-backed. More recent
ones are all modular. However, there are a few designs that still
have a fixed metal-back. The modular design has an advantage
of greater control, especially in the final stages of surgery. Here
if one finds that after cementation, the knee is a bit tight or loose,
one can just change the polyethylene liner to get a better fit.
Modular designs: Here the modularity pertains to the
interchangeability between the tibial and femoral components.
In the first generation knees, one could use only the same-sized
femur with the same-sized tibia. Later designs became
compatible one size up or down. The present generation modular
knees are practically universal, where one can allow articulation
with any femur and tibia.
7
Indications and Contraindications of
Total Knee Replacement
116
Indications and Contraindications of Total Knee ... 117
Contraindications
Absolute Contraindications
1. Active sepsis, either in the knee or elsewhere in the body.
However an old septic arthritis is not a contraindication as
mentioned above, so long as the infection has been eradicated.
2. Charcot’s disease with absent joint proprioceptive function
is doomed for failure because of abnormal and un-mechanical
loading of the joint.
3. Absent quadriceps mechanism likewise is an absolute
contraindication.
4. A painless arthrodesis in a good functional position.
Relative Contraindications
1. Young age is a contraindication, as this is at best a salvage
procedure, the reliability and longevity of which are still under
investigation. However, even young patients with very
severely crippling disability and a low life expectancy can be
favourably considered.
2. Obesity is a relative contraindication. Increased body weight
puts an increased demand on the replaced joint, thereby
reducing the life expectancy of the implants. In my setup,
120 Guide to Total Knee Replacement
8
General Principles of
the Surgical Technique
A full length X-ray with hips, knees and ankles in a single frame helps
to plan the surgery properly.
General Principles of the Surgical Technique 125
number of visitors from outside the city rose, the rule was
relaxed. So as many as six observers were inside the theatre
on many occasions without any problems, so long as all
personnel followed the theatre protocol.
8. Special drapes are used. Made of thick cotton, very large
in size, they completely drape the patient and isolate the
operating field from the anaesthesist’s end. Further details
of the type of drapes used and the method of draping is
described in the section on operating technique. The
currently available disposable paper drapes are also good,
so long as one uses large drapes that stretch from floor to
floor on both sides.
It has been found that it is easy to enforce this sort of a
discipline in operation theatres where only orthopaedic
operations are routinely performed. In general nursing homes,
and those with a great turnover, it might be sometimes difficult
to enforce all the above conditions. However, it must be
emphasized that each of the above needs to be followed
religiously to avoid any complications. An infection in an
arthroplasty is a disaster. Sir John spent all his life working
towards 0% infection. We all must treat an infection as our own
personal responsibility, taking all precautions and making all
efforts to minimize it.
Antibiotic prophylaxis: The current pharmacological literature
tells us that airborne bacteria are prone to cause infection only
during the actual surgical period. Sufficient concentrations of
antibiotics present at and immediately after the operation are
sufficient to avoid infection. Prolonged administration of
antibiotics will only encourage resistant strains to grow and
cause problems. Any of the newer wide spectrum antibiotics
can be used. A good rule of thumb is to avoid popular antibiotics
commonly used by general practitioners as rarer the antibiotic,
lesser the chances of resistant strains. Presently we use
Cefuroxime sodium 1.5 gm in 6 doses every 12 hours beginning
from just before anaesthetic induction.
An intravenous administration assures peak serum
concentrations, especially when the joint is open. I do not use
antibiotics in the cement (except in revision cases and tubercular
hips where I add streptomycin to the cement).
General Principles of the Surgical Technique 129
applied for one side but not on the other side during surgery. If
one knee was more severely damaged, surgery without a
tourniquet was done on this knee. This study is still continuing;
its conclusion and results shall be published at a later stage.
However, the preliminary findings of this study reveal that:
1. The average time taken for operation with tourniquet was
55 minutes (63 minutes without tourniquet).
2. Immediate postoperative pain was significantly less on
the side without the tourniquet.
3. Total blood loss was more or less the same with or without
a tourniquet.
4. Intra-operative bleeding was higher without a tourniquet.
5. But drainage was significantly higher when a tourniquet
was used.
6. The sum total of both was more or less the same.
7. Skin problems and delayed healing were significantly
lower in the group without the tourniquet, rather than
the tourniquet group.
Hence I have presently stopped using tourniquet in almost
all cases. However for a beginner, I still recommend the use of a
tourniquet, except in cases of rheumatoids with a very soft and
papery skin.
Surgical Technique
Painting and draping of the limb. Bulky towels should be avoided over
foot, as we need to check toe orientation during surgery.
Surgical Technique 141
Quadriceps tendon is incised in the line of its fibres, and the deep
incision skirts around the medial patellar border straightening down
below it, up to the tibial tuberosity.
Surgical Technique 145
It is usual to make two deep linear incisions, one above and one
below the patella and then curve it around the medial patellar border,
retaining enough soft tissue for subsequent suturing.
146 Guide to Total Knee Replacement
Flexion of the knee shifts the patella further laterally and gives a
decent exposure.
Surgical Technique 149
After soft tissue releases, ensure that all deformities are corrected
before beginning the first bone cut.
The six bone cuts for every knee arthroplasty independent of the
design.
Surgical Technique 167
The distal femoral cut should be parallel to the ground in AP axis and
in 3° to 5° valgus in ML axis.
The anterior and posterior femoral cuts should exactly match the inner
dimensions of the prosthesis to be used.
168 Guide to Total Knee Replacement
The upper tibial cut should be parallel to the floor front side-to-side
and in a 3° to 5° posterior slope in the anterioposterior axis.
Surgical Technique 169
The chisel hole opening will guide the drill bit for intramedullary
instrumentation.
174 Guide to Total Knee Replacement
The jigs ensure that the distal femoral cut is parallel to the floor in AP
axis, and in 3° to 6° of valgus in the ML direction.
Surgical Technique 183
The distal femoral cutting block is now pinned to the anterior aspect
of distal femur.
Surgical Technique 187
The cutting slot in this block will be in correct relation to the long axis
of femur because of the intramedullary guide.
188 Guide to Total Knee Replacement
It is better to err on the side of thinner cuts initially, which can be subse-
quently refined.
Surgical Technique 191
The block pins should be retained in place because after the tibial
cut, if an additional femoral cut is needed, the distal cutting block
can be reinserted over the same pins.
194 Guide to Total Knee Replacement
Some devices are simple while others are complicated. This step tells
us the correct size of the femoral component that will eventually be
used.
196 Guide to Total Knee Replacement
After the correct sized block is pinned, the anterior and posterior distal
femoral cuts are made. Thin slivers should be removed, especially
anteriorly, to avoid femoral notching.
198 Guide to Total Knee Replacement
Each company has its own design for the block. If the saw blade is
not passing through the slot, one should keep it flush with the block
to ensure the correct axis of the cut.
Surgical Technique 199
The next step is chamfer cutting. This block can either be a prismatic
wedge or a solid block with beveled slots.
200 Guide to Total Knee Replacement
These cuts are in the precise angle to match the interior of the femoral
component and will ensure a perfect fit, especially in a cementless
implant.
Surgical Technique 201
After the distal bone cuts, the femoral surface should match the
interior of the prosthesis perfectly.
202 Guide to Total Knee Replacement
The slot in the jig ensures that the upper tibia is in 3° to 5° of posterior
slope.
204 Guide to Total Knee Replacement
One should attempt to take the thinnest possible wafer thin cuts. It is
always safer to err on the side of thinner cuts, which can later be
improved upon if needed.
Surgical Technique 205
The combined thickness of the femoral and tibial cuts should match
the thickness of the two components combined.
206 Guide to Total Knee Replacement
The earlier soft tissue releases will ensure that the gaps in flexion and
extension are equal. This is the most important step in a knee
replacement.
Most gap balancers also measure the gap to indicate the correct
size of HDPE insert thickness.
208 Guide to Total Knee Replacement
The next step is insertion of the trial implants and a trial reduction.
212 Guide to Total Knee Replacement
Extremes of flexion should not open the clips. If they do, additional
soft tissue releases may be required.
214 Guide to Total Knee Replacement
After the notch cut, a posterior stabilized implant is put through the
same range of motions.
218 Guide to Total Knee Replacement
If the design of femoral components has pegs, now is the time to make
peg holes.
220 Guide to Total Knee Replacement
Depending on the design, the proximal tibial notches are drilled and
slotted.
224 Guide to Total Knee Replacement
The next step is patellar shaving. One can either replace patella or
just resurface and trim the edges.
226 Guide to Total Knee Replacement
In case of a cemented knee, this is the time to open and mix the
cement.
230 Guide to Total Knee Replacement
The surfaces should be clean and dry. Liquid cement is poured over
the tibial cancellous surface and the component pressed in.
Surgical Technique 231
Liquid cement is now poured over the lower femoral cut surfaces.
Nonantibiotic loaded cements are more liquid in the initial stages
and provide better cancellous integration.
Surgical Technique 233
Flexion and extension gap balance is the most important step of total
knee replacement.
240 Guide to Total Knee Replacement
Towel clips will confirm that the patella does not tend to snap out
during flexion.
242 Guide to Total Knee Replacement
The knee can be put through a full range of motion at this stage.
Surgical Technique 243
The knee is now inspected carefully, washed thoroughly and all loose
cement bits removed patiently.
Surgical Technique 245
The joint is again put through full range of movements with and without
the towel clips.
246 Guide to Total Knee Replacement
The joint is again put through full range of movements with and without
the towel clips.
Surgical Technique 247
10
Instruments for Primary
Total Knee Replacement
253
254 Guide to Total Knee Replacement
These blocks can vary from simple Freeman and Insall designs (top
and bottom) to the complex fourth generation magnetic snap-on
jigs.
258 Guide to Total Knee Replacement
The upper tibial cutting guides too come in various designs. They cut
7 mm of upper tibia with a slight posterior slope.
Instruments for Primary Total Knee Replacement 259
The dynamic gap balancers expand the gap with a turn screw and
even mid-range gaps can be measured. Long-term success of a
knee depends on proper gap balancing and equalization of tension
in all quadrants.
Instruments for Primary Total Knee Replacement 261
Each implant design has its own femoral size template. It is useful to
have a metal scale to correctly measure the cut dimensions and
ensure that the right size implant is used.
262 Guide to Total Knee Replacement
Each design is different, but they are all based on the same scientific
principles and produce the same end result. The one in blue is a light
titanium cutting block designed by me in 1994.
264 Guide to Total Knee Replacement
TIBIAL SIZERS
Tibial sizers match the implant and differ from company to company.
Instruments for Primary Total Knee Replacement 265
Each set comes with its own tibial trials, some in 1 mm difference,
others in 2, 3 and 5 mm differences. Separate trials exist for CS and
CR designs.
Instruments for Primary Total Knee Replacement 269
TRIAL REDUCTION
Other designs use box chisels or broaches to match the tibial metal-
back.
274 Guide to Total Knee Replacement
Block pins, extractors, angle strips, and other nuts and bolts.
276 Guide to Total Knee Replacement
11
Postoperative Treatment,
Mobilization and Physiotherapy
276
Postoperative Treatment, Mobilization and Physiotherapy 277
Most patients climb stairs on the fifth day and go home by the sixth.
12
Fixed Varus and
Valgus Deformities
279
280 Guide to Total Knee Replacement
contract too much and we should never cut them. Simple erasure
from the bony attachments with a sharp chisel or periosteal
elevator will provide sufficient laxity to allow for correction of
deformities.
The following steps need to be followed to correct the fixed
varus deformity:
1. Exposure as described in the previous chapter.
2. All the osteophytes from the femur are removed using a
nibbler. One must ensure that after this is done, the true
confines for the distal femur are visible.
3. All the osteophytes from the tibia are now removed as far
as the exposure will allow.
10. The next step depends upon the type of the tibial implant
that one plans to use. If using a posterior stabilized implant,
one can resect the posterior cruciate ligament with impunity
and be at ease.
11. If one is using a posterior cruciate retaining prosthesis, it is
better to scrape the posterior cruciate off the back of the tibia!
A very gross varus managed with graft and screw, and using an 8 mm
insert, avoiding a tibial stem or wedges.
Fixed Varus and Valgus Deformities 291
4. The patellar fat pad is now excised, and all the capsular
attachment from the lateral part of upper tibia is scraped
using a sharp chisel or a periosteum elevator.
5. All the attachments and adhesions between the iliotibial
band and the lateral tibial plateau are detached. This will
allow for freeing of the lateral structures.
Precise and adequate soft tissue releases will correct the most
stubborn deformities.
13
Tricks and Tips with
Mediolateral Deformities
301
302 Guide to Total Knee Replacement
14
Fixed Flexion and
Recurvatum Deformities
Stretching the knee under anaesthetic will reveal the true extent of
fixed flexion deformities.
304 Guide to Total Knee Replacement
The large anterior osteophyte on the tibia is the main culprit for
causing fixed flexion deformities.
out on the other side. This will protect the vessels. The
capsule is now resected.
10. The knee is straightened and the deformity correction is
assessed. In majority of cases, this is enough to get a full
correction. However, if full correction is not achievable, one
must resect an extra amount of distal femur. This will result
in a superior displacement of the femoral component and
will lead to a laxity in the quadriceps mechanism. The
resulting extensor lag will take a few months to disappear.
This final step is necessary only if the fixed flexion deformity
is more than 60° or in nonambulant patients.
15
Recurvatum
Deformity of the Knee
308
Knee Replacement in Osteoarthritis 309
16
Knee Replacement in
Osteoarthritis
A tibial defect has been grafted with bone from distal femur and
affixed with a screw.
312 Guide to Total Knee Replacement
A typical OA knee.
Knee Replacement in Osteoarthritis 315
17
Knee Replacement in
Rheumatoid Arthritis
18
Total Knee Replacement in
Old Tuberculous Knees
Postoperative radiograph.
Good power and ability to straight leg raise within a few days of
surgery.
334 Guide to Total Knee Replacement
19
Total Knee Replacement in
the Haemophillic Knee
Pronto came the factor and the surgery went on well. The first
patient was followed up for nine years and did well.
After that I have had three more patients—two classical
haemophiliacs and one with Christmas disease—and all have
gone home without problems, except one patient with Christmas
disease who had a large haematoma that had to be drained. The
re-operation caused some infection in the knee and this persisted
for some time. The patient eventually ended up with an
arthrodesis after removal of the implants.
Total Knee Replacement in the Grossly Unstable Knee 337
20
Total Knee Replacement in
the Grossly Unstable Knee
21
Unicompartmental
Knee Arthroplasty
Introduction
In most cases, arthritis of the knee first starts in one compartment.
Depending on the axis and loading, an uneven force distribution
across the joint will cause one-half of the joint to wear out first.
This will secondarily lead to a deformity on the side of
degeneration and consequently exaggerate the wear to that side.
As a consequence, the degenerated side continues to wear; in
the initial stages, the eccentric loading of the joint actually
protects the opposite compartment! Once the cartilage on medial
side is fully worn off, the opposite side starts wearing too and
the arthritis proceeds from a uni- to a bi- and tri-compartmental
damage!
The idea of just replacing the damaged compartment seems
very attractive in theory and looks more sensible than osteotomy
and realignment to bring the forces to act upon the undamaged
side. However, a protracted and difficult history of unicompart-
mental knees with a lot of initial failures has put this procedure
into disrepute!
Relevant Biomechanics
The knee joint, unlike the hip, is a very complex articulation
indeed. To simplify our understanding, we can consider the knee
as made up of three different joints: the medial compartment,
the lateral compartment and the patellofemoral compartment.
The medial compartment has the medial collateral as its
medial stabilizer and the anterior cruciate as its lateral stabilizer,
with the patella and the posterior structures as the saggital
anteroposterior stabilizers.
341
342 Guide to Total Knee Replacement
Once the skin is incised, the fat and the subcutaneous tissue
are separated by a pad to allow for a correct and proper
visualization of the patellar tendon and the patella.
Unicompartmental Knee Arthroplasty 345
This guide ensures that the medial portion of the upper tibia
is cut exactly parallel to the floor in mediolateral direction and
in a 3° posterior slope.
348 Guide to Total Knee Replacement
The posterior soft tissues are excised, taking due care to ensure
that the medial collateral and anterior cruciate remain
undisturbed.
354 Guide to Total Knee Replacement
Trial femoral and tibial components are now placed over the
cuts. It is ensured that the undersurfaces of both components
exactly match the bone cuts and the components seat perfectly.
Unicompartmental Knee Arthroplasty 355
Femoral anchorage holes are now made using the special jig.
Unicompartmental Knee Arthroplasty 357
The jig ensures that the pegs on the underside of the actual
tibial metal-back seat perfectly on the cut surface of upper tibia.
The joint is now put through the full range of motion and its
stability checked in flexion, extension and mid-range.
The knee is once again put through the full range of motion.
Unicompartmental Knee Arthroplasty 369
22
Complications of Knee
Replacement and their Management
LATE COMPLICATIONS
Delayed infection: These occur spontaneously months or years
after the replacement in a normal and functioning knee. The
source is usually haematogenous and secondary to throat, chest,
tonsils or bladder infection. The patient suddenly develops
severe pain and swelling. The function is dramatically affected
and initial radiographs may not present any abnormality. It is
very important to diagnose the problem early by an aspiration
under aseptic conditions in the operating theatre, and start an
aggressive management after proper cultures have been done.
The sequence of events in managing late infections is identical
to that of early infections and the same steps should be followed.
Fractures: Delayed fractures occur due to trivial trauma in
osteoporotic bones, especially with stemmed or constrained
implants. A femoral fracture may occur near the tip of the stem
in a stemmed implant. Most of these fractures occur in the bone
just adjacent to the prosthesis as the bones here are markedly
weaker than the ones embedded with prosthesis and cement.
Whether to treat these fractures conservatively or operatively
depends on their location and type. Most will heal well when
treated conservatively. However, in the interests of early
mobilization, they are usually fixed with a suitable implant.
Wear
The wear in the total knee components represents a problem
that is fairly recently envisaged because long-term follow-up of
knee replacements is only now being reported. As would be
apparent, wear in the metallic components would seem to pose
a lot less problem than wear in the plastic components. The
following points are of relevance and shall be individually
discussed later:
1. Entrapment of cement particles between the components.
2. Shape of the articular surfaces and their relation to wear.
3. Stress shielding and cold creep.
4. Metal-backing, metallosis and metallic attrition.
5. Optimal HDPE thickness and the relationship of the same to
wear.
6. Gamma sterilization, plastic oxidation and wear.
7. Management of wear and wear related problems.
Cement particle entrapment: Though the friction and wear
between metal and HDPE is quite low and this combination has
proved to last pretty comfortably for a long period, the joker in
the pack is the cement particles. Entrapment of cement particles
is a rule rather than an exception. Despite meticulous lavage
Complications of Knee Replacement and their Management 395
Gross wear of the medial plateau and deformation of the HDPE insert
(after 16 years).
Shape of the articular surface and their relation to wear: Unlike
a congruous hip joint (where there is a full conformity between
the two surfaces), an artificial knee is a large complex
asymmetrical joint with minimal constraint and consequently
low contact! The possibility of increased wear between the
contact points is real because of the minimal surface areas of
contact. As the surfaces adapt to the worn-out shape and get
more congruous, the irregular areas become more prone to wear.
396 Guide to Total Knee Replacement
23
All the cement comes out with the femoral component. The
worn out tibia can be appreciated below.
410 Guide to Total Knee Replacement
Trial femoral and tibial components are now placed over the
surfaces after proper measurement.
416 Guide to Total Knee Replacement
Closure in layers.
426 Guide to Total Knee Replacement
Skin stapling.
Revision Knee Replacement 427
Postoperative X-ray.
of slough and scars. The space between the femur and tibia is
preserved, either with a blob of antibiotic-loaded cement or with
an external fixator. The following are the steps:
1. The patient is informed that the first stage is meant to eradicate
infection. If there is incomplete eradication, the patient may
have to undergo an arthrodesis rather than a knee
replacement.
2. The exposure and component removal are standard as
described above. All the sinuses are excised, and scar tissue
is removed. One may need the assistance of the plastic surgeon
for a good flap coverage in case there is a large skin loss.
4. The two surface are stretched as far apart as possible using
lamina spreaders. Bone cement mixed with appropriate
antibiotic is kneaded to a doughy consistency and packed
into the space. It is a good idea to keep the flat handle of the
Hohman retractor behind the cement blob as the cement sets.
This will prevent thermal damage to the popliteal vessels.
5. In case an external fixator is to be used, the same steps are
employed. But the fixator is used to distract the two joint
surfaces to retain maximum gap. I always prefer the thin pins
of the llizarov type frame to thick Stienman pins.
6. The interval between this and the second surgery depends
on complete eradication of all signs of infection. Once this is
achieved, the second stage is put into action.
7. The steps of reimplanting a fresh knee are similar to those
described for revision of an aseptic loosening. The post-
operative and follow-up are also identical.
Single stage revision for infection: This is the method of choice
in cases with doubtful sepsis, minimal signs of inflammation,
delayed infection, good skin, and absence of bad scars and sinuses.
After a thorough preoperative assessment, the following steps
are employed. These steps are similar to those for revising an
aseptic loosening:
1. The skin incision is straight midline. A thick skin flap is
taken. The debridement of the knee and removal of all
infected material follows.
2. Removal of components and cement is done in a manner
similar to that described under revision for aseptic
loosening.
438 Guide to Total Knee Replacement
Conclusions
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