Steps total knee replacement

basic steps in TKA

1. BASIC SURGICAL
TECHNIQUE –TKA
Dr Aditya Apte
Sunshine hospitals

5. MEDIAL PARAPATELLAR
APPROACH

6. Originally described by Von Langenback
later modified by Robert jones and Insall
* Proximal medial border of quadriceps
tendon –medial border preserved
* Point halfway between medialis
insertion and superomedial pole of patella
* Medial border of tibial tubercle

8. Patello-femoral Ligament

9. AFTER ARTHROTOMY

10. STEP 1 : REMOVAL OF OSTEOPHYTES UNDER MCL

11. STEP 2 : CLEARING FEMORAL NOTCH

12. STEP 3 : REMOVAL OF INFRAPATELLAR PAD OF FAT

13. STEP 4 : CLEARING SUPRAPATELLAR SYNOVIUM

14. STEP 5-Inverted Isosceles Triangle

15. STEP 6: CLEARING OF
PATELLOFEMORAL OSTEOPHYTES
+ DEBULKING

16. ALIGNMENTS IN TKR
1.ANATOMICAL ALIGNMENT
2.MECHANICAL ALIGNMENT
•MEASURED RESECTION
•GAP BALANCING
3.KINEMATIC ALIGNMENT

17. ANATOMICAL ALIGNMENT
• Hungerford and Krackow
• Anatomically recreate the joint line
• Femoral cut at 8-9°of valgus combined with the 2-3°
varus tibial cut

18. Anatomic alignment (a) attempts to mimic the natural knee by cutting the tibia at 3°varusto the mechanical axis
of the tibia and a distal femoral cut that is 9°valgus to the mechanical axis of the femur to recreate a 6°valgus joint
line. Mechanical alignment (b) involves a tibial cut that is perpendicular to the mechanical axis of the tibia and a
distal femoral cut 6°valgus to the anatomic axis (perpendicular to the mechanical axis) of the femur

19. MECHANICAL ALIGNMENT
Insall -Femoral and Tibial cut perpendicular to the
mechanical axis
Insall -1.the knee joint aligned through the anatomical
alignment may be loaded more medially with a medial tibial
plateau fixation failure.
2. cuts perpendicular to mechanical axis

20. a. measured resection-bony
landmarks ( preserve joint line )
b. gap balancing-ligament
tension
c. combined / modern

21. T-F CORRELATION

22. STEP 6:DISTAL FEMUR CUT

23. ENTRY
''Starting point for femoral IM rod
insertion is made 8-10mm anterior
to the origin of the PCL,
And slightly medial to the
midportion of the
intercondylar notch''
''A correct thickness of distal
femoral cut just skims the
roof of intercondylar notch''
Operative techniques in Orthopaedic Surgery Sam W.Wiesel
(publisher) Lippincott Williams & Wilkins 1 st Edition (2011)
Tips and tricks in total knee arthroplasty
BhavukGarg*, GauravSharma**, RajeshMalhotra***

25. INTRAMEDULLARY GUIDE
•AIM is for DFC to be
perpendicular to Mechanical
axis
•Identify the VCA
•General –
•Varus –5 to 7 degree
valgus cut
•Valgus knees –0 to 3
degree valgus cut

26. Distal Femur Cut
Anterior
Chamfer Cut
Posterior
Cut
Anterior
Cut
Posterior
Chamfer Cut
•-Distal femur cut corelates
with thickness of metallic
femoral component provides
-Varus/ valgus alignment
-Flexion/ extension
-Proximal/ distal position

27. Femur
component
aligned in
varus
Femur
component
aligned in valgus
Femur
component
aligned in neutral
varus/ valgus
position
Distal femur cut in frontal view

28. Femur
component
aligned in
extension
Femur
component
aligned in
flexion
Femur
component
aligned in
0°flexion/ extension
Distal femur cut in Sagittal view

29. Proximal
Distal
Resection level
of distal femur cut

30. In general, for each 10°of flexion
contracture -additional 2mm resection
Severe FFD

31. STEP 7: FEMUR SIZING

32. POSTERIOR REFERENCING -RISKS ?
ANTERIOR REFERENCING -RISKS ?

33. PLACING OF THE 4 IN 1
CUTTING BLOCK
AIM –Prosthesis must be in External rotation

35. •TRANSEPICONDYLAR AXIS :
Lateral epicondyle -apex of bony prominence
Medial epicondyle:
Apex of the medial prominence -Anatomical TEA
Medial sulcus -Surgical TEA .
. POSTERIOR CONDYLAR AXIS :
in 3-5 degree of IR / valgus

36. •ANTEROPOSTERIOR AXIS(WHITESIDES LINE):
1. Line connecting the lowest point of the patellar
groove and the top of the intercondylar notch.
2. Femoral component rotation is oriented perpendicular
to it
3. easily identified / reproducible

37. CONFIRMATION OF
EXTERNAL ROTATION

38. STEP 8 : 4 IN 1 block
1.ANTERIOR AND
POSTERIOR FEMUR
CUTS –DETERMINE
ROTATION, FEMORAL
COMPONENT POSITION
2.ANTERIOR AND
POSTERIOR CHAMFER
CUTS –For
accomodation of
prosthesis

39. 1.Anterior –notching , piano sign
2.Posterior –protect mcl, popliteus

40. STEP 9 : BOX CUT

41. •COMPONENTS
–SUBPERIOSTEAL ELEVATION OF DEEP MCL
–HYPERFLEXION OF KNEE
–EXTERNAL ROTATION OF LEG
–DELIVERING TIBIA FORWARD
RANSALL MANOUVRE
RANAWAT+INSALL

42. STEP 10 : PROXIMAL TIBIAL CUT
1.AIM –Tibial cut must be made
perpendicular to the
mechanical/anatomical axis of tibia
2.Method
a)Intramedullary alignment guide
b)Extramedullary alignement guide

43. •Landmarks
–Proximal landmarks
•Anterior to origin of PCL
•Medial third of tibial tuberosity
–Distal landmarks
•Centre of ankle
•Second Metatarsal
•EHL
EXTRAMEDULLARY
ALIGNMENT GUIDE
''An aid to tibial alignment in total knee
replacement
NJ COOKE, R BURNETT ''

45. IDEAL PROXIMAL TIBIAL
CUT

46. PROXIMAL TIBIA CUT
-Proximal/ distal position
-Varus/ valgus alignment
-Posterior/ anterior slope
KEEL PREPARATION
-Anterior/ posterior position
-medial/ lateral position
-rotation
Proximal
Tibia
Cut

47. Tibia
component
aligned in
valgus
Tibia
component
aligned in neutral varus/
valgus
position
Tibia
component
aligned in
varus
Frontal View

48. Tibia component
with
posterior slope
Tibia component
neutrally aligned,
no slope
Tibia component
with
anterior slope
Sagittal View

49. POSTERIOR TIBIAL SLOPE
•Range –Between 0 to 7
degrees
•Indian population –11.54
degrees Standard
Deviation of 4.5
Exceptions
malunited IA fractures
Post HTO
Mastering techniques in Orthopaedic surgery
Knee arthroplasty
Paul A.Lotke
Correlation of posterior tibial slope with Metadiaphyseal angle in TKA –Indian
population
Shuhrashnu S Mohanty

50. EXTENSION GAP CONFIRMED WITH
SPACER BLOCK

51. FLEXION GAP CONFIRMED WITH
SPACER BLOCKS

52. EQUAL SIZE FLEXION AND
EXTENSION GAPS

53. 9 scenarios!!

54. Rotational alignment of the tibial component in total knee arthroplasty is better at the medial
third of tibial tuberosity than at the medial border
Jörg Lützner,
1
Frank Krummenauer,
2
Klaus-Peter Günther,
1
andStephan Kirschner
1
TIBIAL PREPARATION AND
SIZING
Which Rotational Reference for Tibial Component is optimal in Total Knee Arthroplasty? + 1 Mitsuyasu, H;
1Matsuda, S; 1 Fukagawa, S; 1Miura, H; 1Okazaki, K; 1, 2Tashiro, T; 1Kawahara, S; 1 Iwamoto, Y + 1Department
of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Japan
2Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, Fukuoka, Japan
•Sizing –A-P of lateral plateau of tibia
•Rotation –
•Anatomic landmarks
a)Anteromedial border(if not
involved in disease process)
b)alignment
c)akagi line
d)free floating technique

55. GAP BALANCING

56. •Flexion / extension first
•Proximal tibia + distal femur cut
•Balance gaps and perform releases
•Complete cuts

58. Knee at 90 degrees of flexion and the collateral ligaments equally
tensioned using laminar spreaders. Note the transepicondylar axis
is parallel and anterior-posterior axis is perpendicular to the
resected proximal tibia.

59. Placement of the anteroposterior femoral cutting block parallel to the
resected proximal tibia with each collateral ligament tensioned to create a
rectangular flexion gap.

60. * Precise proximal tibial resection is critical when using a
gap balancing technique
* Varus tibial resection will result in increased internal
rotation of the femoral component
* Valgus tibial cut will lead to excessive external rotation
of the femoral component.
* Over-or under-resection of the femoral or tibial bone
resections can lead to a mismatch of flexion and extension
gap dimensions.

61. •Modern / combined technique-
•1. distal femur cut
•2. proximal tibia
•3. balance in extension
•4. complete femur prep.
•5. balance in flexion

62. TEN COMMANDMENTS

63. 1.CORONAL PLANE
valgus –NA
upto 3deg varus-Accep.

64. 2.SAGITTAL PLANE

65. 3.VARUS AND VALGUS STRESS in ext.

66. 4.FEMOROTIBIAL TRACKING SHOULD BE
UNIFORM AT 0 –90 DEGREES

67. 5.AND 6.POLO in 90. flexion

68. 7.MID FLEXION INSTABILITY

69. 8.EXCESSIVE ROLLBACK

70. 9.SPACER BLOCK-FLEXION TO EXTENSION –
UNAIDED , UNASSISTED AND
UNINTERRUPTED
( rectangular gaps )
( without trial implants )

71. 10.PATELLAR TACKING
patella should glide freely in the trochlear notch

72. ADDITIONAL -WATER TIGHT CLOSURE

73. KINEMATIC ALIGNMENT
Kinematic Alignment in TKA: Definition, Surgical Technique, and Challenging Cases
Article · January 2012
MS Thesis Project View project
Stephen Miller Howell University of California, Davis
Maury L. Hull University of California, Davis

74. •Introduced in 2006 –Howell
•Aim is to restore the 3 axis around which
the knee moves
•Normal knee has single radius from 0-150
flexion

75. 2.The transverse axis in the femur
about which the patella flexes and
extends is proximal, anterior and
parallel to the above
1.The transverse axis in the femur
about which the tibia flexes and
extends passes through the center
of the medial and lateral femoral
condyles, which are symmetric in
the varus and valgus knee
3.Both transverse axes in the
femur are perpendicular to the
longitudinal axis about which
the tibia internally and externally
rotates on the femur

76. Cementing
1.High viscosity cement
2.Tkr –no role of antibiotic cement
3.Under tourniquet
4.Maintain ot temperature, sterility
5.Monitor for adverse reactions
6.Adequate hemostasis –closure

77. Thank you .