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Daniel H. Williams, MSc, FRCS (Tr & Orth), Donald S. Garbuz, MD, MPH, FRCSC, B.A.

Masri, MD, FRCSC

Total knee arthroplasty:


Techniques and results
Providing a patient with a pain-free, stable knee joint that will last a
long time can be achieved by focusing on five surgical goals.

ajor joint arthroplasty is allowed the centre of rotation to change

M
ABSTRACT: While osteoarthritis re-
mains the most common indication undoubtedly one of the with flexion of the knee.5 The metal-
for total knee replacement, the num- surgical success stories on-polyethylene condylar design—
ber of primary total knee arthroplas- of modern times. The completely replacing the femoral and
ties performed annually has increas- number of primary knee arthroplas- tibial articulating surfaces—was pur-
ed exponentially over the last 55 ties performed annually increased sued throughout the early 1970s at
years. Outcomes have improved exponentially over the last half of the centres across the world.6-11 The result
with the use of careful preoperative 20th century and increased between was an implant relying on component
assessment, a range of component 16% and 44% during the first 5 years geometry and soft tissue balance to
options, and operative technique of the 21st century.1,2 The history of provide stability, with a large articu-
guided by clear surgical goals. total knee arthroplasty began back lating surface area to spread load and
Informed consent of any patient con- in 1860, when the German surgeon minimize polyethylene wear. Incre-
templating total knee arthroplasty Themistocles Gluck implanted the mental improvements in component
must be obtained by discussing the first primitive hinge joints made of materials, geometry, and fixation
risks and benefits and explaining that ivory. Development really took off continued throughout the 1970s and
between 80% and 85% of patients following the introduction of the 1980s. More accurate sizing, the
are satisfied after the procedure. Walldius hinge joint in 1951: initially option of patellafemoral replacement,
manufactured from acrylic and later, better instrumentation, and compo-
in 1958, from cobalt and chrome.3 nents that allowed an increased range
Unfortunately, this hinge joint suffer- of motion and a lower wear rate have
ed from early failure. since been developed.
In the early1960s, John Charnley’s Unicompartmental knee arthro-
cemented metal-on-polyethylene total plasty developed in parallel with total
hip arthroplasty inspired the develop- knee replacement from the early efforts
ment of the modern total knee replace-
ment.4 Gunston, from the same centre Dr Williams is a fellow in the Division of
as Charnley, went on to design an Lower Limb Reconstruction and Oncology
unhinged knee that replaced both the in the Department of Orthopaedics at
medial and lateral sides of the joint the University of British Columbia. Dr Gar-
with separate condylar components. buz is an associate professor and head of
Improved biomechanics resulted from the Division of Lower Limb Reconstruction
the preserved intact cruciate and col- and Oncology in the Department of Ortho-
lateral ligaments, which maintained paedics at UBC. Dr Masri is a professor and
the stability of unlinked femoral and head of the Department of Orthopaedics at
tibial components, and a design that UBC.

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Total knee arthroplasty: Techniques and results

of McKeever and Elliott in 1952.12 climb stairs or inclines, use of walk- between 1% and 2% of operations and
However, because the unicompartmen- ing aids or other orthotics, and exac- may require further and repeated major
tal procedure replaces only the dis- erbating or relieving factors all build a joint surgery. Arterial injury compli-
eased part of the joint with more nat- more detailed picture of disability. cates between 0.03% and 0.17% of
ural kinematics or joint movement,13,14 Knee examination should include cases15 and peroneal nerve injury has
the indications for its use are more assessment of gait, surgical scars, loc- been reported in between 0.3% and
limited. alized tenderness, active and passive 2.0% of patients.16 The 20-day post-
range of motion, limb alignment, co- operative mortality rate of 0.2% is
ronal and sagittal plane ligament sta- increased above the age-matched pop-
bility, and neurovascular status of the ulation and is the same as that meas-
limb. Other pathology contributing to ured for total hip arthroplasty. The
symptoms should be excluded by mortality rate normalizes with the
examination of the back, hip, foot, and age-matched population after the 70th
Radiographs should ankle of the same limb. postoperative day.17 Mortality at 1
Up-to-date and serial (if available) year following knee arthroplasty is
always be performed
radiographs of the knee should in- 1.6%, which is half the mortality rate
before MRI is ordered; clude an anteroposterior view as well of the age-matched population, demon-
as true lateral and skyline patello- strating that total knee arthroplasty
in many cases, the
femoral views of the involved knee patients are a highly select group.18
plain radiographic together with full long leg views if
findings will make there is significant deformity, previ- Operative technique
ous fracture, or previous osteotomy of Preoperative radiographic templating
MRI unnecessary. the femur or tibia. An anteroposterior for knee arthroplasty, while not as cru-
pelvis and lateral radiograph of the cial as for hip arthroplasty, does indi-
ipsilateral hip should be sought if there cate the size and shape of the tibial
are symptoms of groin pain or signs of bone to be removed and the compo-
stiffness or pain on rotation of the hip. nent type and size that is likely to be
Magnetic resonance imaging can be required. It is particularly important
used to assess for meniscal or liga- in cases requiring the extremes of
Indications and mentous injury in appropriate cases, implant size to ensure that all likely
preoperative assessment but is generally not required for the sizes are available, in cases of severe
Osteoarthritis, whether primary, post- routine assessment of the painful deformity, and in cases where there is
traumatic, or secondary to avascular arthritic knee. Radiographs should severe bone loss.
necrosis, osteochondritis, or sepsis, is always be performed before MRI is
by far the most common indication for ordered; in many cases, the plain rad- Components
total knee replacement. Inflammatory iographic findings will make MRI Most orthopaedic supply companies
arthritides make up the bulk of the unnecessary. manufacture a range of implant de-
remaining indications. Diagnosis of The option of total knee arthro- signs, from cruciate ligament retain-
the underlying condition allows appli- plasty is typically discussed with pa- ing ( Figure 1 ) and posterior stabilized
cation of appropriate nonoperative tients at the point in their lives when ( Figure 2 ) implants that usually pro-
treatment, while the functional impact knee pain from arthritis is significant- vide sufficient stability in the primary
of disease upon the everyday life of ly interfering with activities of daily setting, through to megaprotheses for
the patient determines the appropriate living. Informed consent requires a replacing tumor or bone.
timing of surgery. Mechanical symp- full discussion of the risks and bene- The level of built-in constraint, or
toms—locking or giving way—may fits of surgery to ensure that patient stability, required by a knee prostheses
be amenable to arthroscopic assess- expectations are realistic. Generally, depends upon whether the posterior
ment and treatment. The severity of between 80% and 85% of patients are cruciate and collateral ligaments are
symptoms are assessed by noting satisfied with their knee arthroplasty. intact. If the posterior cruciate liga-
reduced walking distance, analgesic The most significant complication is ment is compromised, as it is in most
use, and sleep disturbance. Ability to deep infection, which complicates rheumatoid knees, or there is fixed

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Total knee arthroplasty: Techniques and results

coronal plane or significant flexion


deformity, then the PCL is replaced
by a cam and post, the design of which
controls sagittal plane kinematics.
A larger post can provide additional
side-to-side/coronal plane stability
( Figure 3 ). If the medial collateral lig-
ament is compromised, a hinged pros-
thesis is chosen to further improve
coronal plane stability ( Figure 4 ). In-
evitably this puts greater strain upon
the hinge itself and produces increas-
ed shear stresses at the implant inter-
face with the bone. A rotating hinge
allows movement in the axial plane
between the polyethylene and tibial
surface, decreasing these stresses but
producing a secondary surface for the
generation of wear debris. Modular
femoral and tibial stems are added to
the resurfacing implants in this scen- Figure 1. Cruciate ligament retaining Figure 2. Posterior stabilized implant. The
ario to increase the area of fixation, implant. presence of a post (arrow) distinguishes this
design from the cruciate ligament retaining
spreading load and decreasing stress- design in Figure 1, which has no such post.
es at the implant bone interface.
Femoral or tibial stems of varying
lengths may also be added if there are
significant uncontained bone defects.
Generally, a contained bony defect
with an intact cortical rim or an uncon-
tained defect of less than 5 mm can be
filled with cement upon implantation.
Contained defects greater than 5 mm
with an intact cortical rim can be treat-
ed with morcelized impaction bone
allografting. Uncontained defects re-
quire shaping to accommodate the
metal wedges that are added to the
implant. Larger defects are not com-
monly encountered in the primary set-
ting, but when present may require
bulk bone allograft. The addition of a
femoral or tibial stem provides addi-
tional stability and protects supple-
mented defects, minimizing the risk
of long-term implant subsidence.

Surgical goals
The clinical aims of knee arthroplasty Figure 3. Posterior stabilized implant Figure 4. Hinged implant for improving
with larger post (arrow) for improving coronal plane stability. The hinge is linked
are to provide the patient with a pain- coronal plane stability. into the femoral component as indicated by
free, stable joint that will last a long the arrow.

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Total knee arthroplasty: Techniques and results

time. To achieve this, the surgical team Rheumatoid arthritis or lateral patella tendon and is a function of
focuses on five surgical goals: femoral condyle hypoplasia can lead the positioning of the tibial, femoral,
• Mechanical alignment of the limb. to a valgus deformity that requires the and, if used, patella component. In
The proximal tibia and the distal following releases to attain satisfac- particular the femoral component
femur are cut so that the mechanical tory balance: requires appropriate positioning in
axis of the limb—from the centre of 1. Lateral osteophyte removal. all three planes to allow the patella
the hip to the centre of the ankle 2. Subperiosteal dissection of the lat- to track correctly.
joint—passes through the centre of eral joint capsule. Each of these goals may not nec-
the knee arthroplasty. This ensures 3. Lateral patellofemoral ligament essarily be addressed in strict order
that forces are transmitted equally release. during surgery. Indeed, some of the
through each side of the new joint, 4. “Pie crusting” of the iliotibial band steps involved during the procedure
optimizing the lifetime of the joint.19 if tight in extension. may address more than one goal at the
Aligning the limb correctly also pro- 5. Popliteus release if tight in flexion. same time. For instance, sizing and
vides the correct starting platform 6. PCL sacrifice requiring the use of a positioning the femur ensures balance
for achieving subsequent surgical posterior stabilized component. of the flexion and extension gaps as
goals. 7. Lateral collateral ligament release well as creating a Q angle that affords
• Joint line preservation. The depth of from its femoral insertion (avoid- correct patella tracking. What is vital
bone removed from the tibia and the ing complete release and subse- is that every goal be considered in
femur should be equal to the height quent varus instability). order to produce a pain-free, stable
of the respective components that • Balance of the flexion and extension joint that will last a long time.
are implanted. By taking out what is gaps in the sagittal plane. This re-
to be put back in, the position of the sults in the knee maintaining stabil- The operation
original joint line is preserved. This ity throughout its full range of mo- Following complete preoperative
optimizes the function of the liga- tion. Flexion instability occurs when assessment and planning to ensure
ments and muscles acting upon the the gap between the tibia and the correct implant availability, a typical
knee. femur is wider in flexion than in total knee arthroplasty would proceed
• Soft tissue balance in the coronal extension and must be corrected to as follows:
plane. Balancing the knee to varus ensure the patient is asymptomatic. • Intravenous antibiotics are given
and valgus stress maintains equal Recurvatum or extension beyond well before inflation of a proximal
load transmission through each side 0 degrees may result from a “loose” thigh tourniquet to 300 mm Hg.
of the knee. Following many years extension gap. A “tight” flexion or • The skin is prepped and draped to
of disease, deformity in the coronal extension gap may restrict the full allow an adequate midline longitu-
plane can become fixed by contrac- range of flexion or extension. Loss dinal incision to access the knee
ture of soft tissues. Osteoarthritis of full range of motion at either joint, usually via a medial parapatel-
most commonly leads to a varus extreme can be disabling. Loss of lar approach.
deformity and tight medial soft tis- full flexion can make stair and hill • Part of the anterior fat pad, remnants
sues, which are released in the fol- climbing difficult. Loss of full ex- of the medial and lateral menisci,
lowing order to attain satisfactory tension makes complete lockout of the anterior cruciate ligament and
balance: the knee impossible and requires the PCL (if a posterior stabilized
1. Medial osteophyte removal. prolonged quadriceps muscle en- implant is to be used) are excised.
2. Proximal subperiosteal stripping gagement—which is tiring for the Osteophytes are excised and the
of the deep medial collateral lig- patient—when standing in one spot. proximal medial soft tissues are
ament. A tibiofemoral gap consistent released to allow visualization of the
3. Posteromedial capsular release. throughout a full range of motion edge of the medial tibial plateau and
4. PCL sacrifice requiring the use of can be achieved by using an appro- forward subluxation of the tibia in
a posterior stabilized component. priately sized tibial insert combined full flexion and external rotation.
5. Distal tibial periosteal stripping with a femoral component implant- Further preliminary soft tissue re-
of the MCL (avoiding complete ed in the correct position. leases are performed at this stage as
release and subsequent valgus • Q angle correction. This is the angle appropriate.
instability). between the quadriceps and the • The tibia is cut at 90 degrees to its

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Total knee arthroplasty: Techniques and results

mechanical axis using an extra - are made to match the inside of the assessment—usually up until the 10th
medullary or intramedullary jig. femoral component, and a drill hole day postoperatively to ensure optimal
Tibial bone is removed from the is made in each condyle to accom- thromboprophylaxis. The patient is
normal side of the joint to the same modate the two femoral pegs.The mobilized, fully weight bearing in the
depth—usually 10 mm—as the trial components are inserted with majority of cases, as soon as the gross
height of the tibial component to be the appropriate tibial spacer. The effects of the anesthetic have worn off.
implanted, with the aim of preserv- patella is prepared if it requires Patients are encouraged to maximize
ing the position of the original joint replacement, and is rechecked prior knee extension and flexion at every
line.
• The femoral intrameduallary canal
is entered and the appropriate jig
is used to cut the distal femur in
between 5 and 7 degrees of valgus
relative to the anatomical axis. This
The patient is mobilized, fully weight
ensures the bone is cut at 90 degrees
to the mechanical axis of the femur, bearing in the majority of cases, as
thus satisfying the first surgical
soon as the gross effects of the
goal of knee arthroplasty. Femoral
bone is removed to the same depth— anesthetic have worn off.
again, usually 10 mm—as the height
of the femoral component to be im-
planted, with the aim of preserving
the position of the original joint line.
• The extension gap is checked to
ensure a 10-mm spacer can be insert- to final implantation. The optimum stage of their recovery to ensure opti-
ed. If it cannot, the tibia or femur, as position of the tibial component is mal outcome. Exercises are commen-
appropriate, are recut by an appro- marked and preparation of the tibial ced to ensure full recovery of quadri-
priate amount—usually 2 to 4 mm. keel is completed. ceps tone and strength and analgesia
Overall alignment of the bony cuts • The cancellous bone surface is clean- is provided to ensure the best possible
is checked to ensure the limb is ed and the real components cement- results from physiotherapy. Discharge
straight and the soft tissues balance ed with antibiotic-loaded cement. from hospital is allowed when the
to varus and valgus stress. Further Compression is applied with the knee wound is dry and the patient is safe
adjustments of the bony cuts and in extension through a trial insert. ascending and descending stairs.
further soft tissue releases proceed Once the cement has hardened any Sutures or skin clips are removed at
if required. loose cement is removed and the 10 to 14 days. A walking aid may be
• The femoral size is measured (in appropriate real polyethylene insert required for several weeks following
the anteroposterior and mediolateral is implanted. surgery. The literature supports driv-
plane) and correct position of • The tourniquet is released to con- ing from 8 weeks, so long as the pa-
the femoral cutting block in the firm hemostasis. A single drain is tient is clear of opiod analgesia and
sagittal (anteroposterior transla- used and the retinacular-tendinous can perform an emergency stop.20 Fol-
tion), the coronal (mediolateral layer is closed with interrupted sut- low-up appointments are scheduled at
translation), and axial plane (rota- ures. The subdermal tissues and skin 6 to 8 weeks, 1 year, 5 years, and every
tion) is ensured. are closed and dressings applied. subsequent fifth year thereafter. Earli-
• The posterior femoral condylar cut er follow-up should be requested if
is made to enable trialing of the 10- Postoperative care there is any sign of infection or other
mm spacer block at 90 degrees of Two further intravenous doses of anti- significant concern. Over 85% of total
flexion to confirm that the flexion biotics are given to cover the first 24 knee arthroplasty patients will recover
gap matches the extension gap be- hours. Low molecular weight heparin knee function following a general
tween the tibia and the femur. or a similar suitable anticoagulant is rehabilitation protocol. The remain-
• The remaining femoral bony cuts prescribed—according to patient risk ing 15% of patients will have difficul-

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Total knee arthroplasty: Techniques and results

ty obtaining proper knee function sec- 1969 and 1995, 89% of the condylar survivorship rates of 100% at 10 years
ondary to significant pain, limited pre- designs had survived 10 years and are seen with the Miller-Galante II
operative motion, or the development between 78% and 89% had survived knee, which was redesigned to solve
of arthrofibrosis. This subset of 15 years.22 Survivorship rates, however, the high rate of patellofemoral compli-
patients will require a more specific varied considerably among different cations seen with the Miller-Galante I
prolonged rehabilitation program that implant designs. The corresponding (which still had an 84.1% survivorship
may involve ongoing oral analgesia, rates for some, now discontinued, rate at 10 years).28 Studies comparing
continued physical therapy, additional designs in this same study were the results of different design options
manufactured by the same company
are now also available: the 10-year
Genesis knee results for the (posteri-
or) cruciate retaining knee reveal 97%
survival compared with the Genesis
Improved survivorship rates of 100% at
posterior stabilized knee, which has
10 years are seen with the Miller-Galante II 96% survival—an insignificant differ-
ence.29 The results of unicompartmen-
knee, which was redesigned to solve the
tal knee arthroplasty have been as
high rate of patellofemoral complications good as total knee arthroplasty in pub-
lished individual series, with sur-
seen with the Miller-Galante I.
vivorship rates of 98% at 10 years.30,31
It is arguably the recent registry
data for newer generation knee im-
plants that apply most readily to the
average patient considering total knee
diagnostic studies, and occasionally between 43% and 63% at 10 years arthroplasty. The 8-year survivorship
manipulation. Controlling pain is the and between 28% and 59% at 15 rate for the eight most common knee
mainstay of any such treatment plan.21 years.22 Further studies have confirm- joints in current use in Norway is
ed clinical survival of the total condy- between 89% and 95%1 and the 7-year
Results lar knee design of 94% at 15 years23 rate in Australia is 95.7%.2 Of note,
The survivorship rate is the percent- and between 77% and 91% at 21 to 23 purely in terms of survival, these reg-
age of total knee arthroplasties that years.24,25 For this reason the total istries have found inferior results for
have not been revised in any given condylar design has endured. Perhaps even the best-performing unicompart-
series of patients. It is generally the the best long-term published results mental knee arthroplasties when these
most often quoted outcome in the joint are for the Anatomic Graduated Con- are compared with total knee arthro-
arthroplasty literature. Survivorship dylar (AGC) knee arthroplasty, the plasty. The cumulative survival at 7
is arguably the most useful outcome success of which is attributed to a years for unicompartmental knees in
when distinguishing between differ- straightforward design that utilizes Australia is only 88.1% compared
ent prosthetic designs and also helps carefully manufactured materials. The with 95.7% for total knees.1,2 This may
answer the patient question, “How AGC knee has a published survivor- relate to issues of patient selection or
long will the knee last?” ship rate of 98.9% in 4583 knees at 15 reflect the increased technical expert-
The pioneers of total knee arthro- years26 and a rate of 97.8% in 7760 ise required for this procedure. Con-
plasty saw early failures that quickly knees at 20 years—quite impressive version of unicompartmental knee
led to the use of more durable materi- survivorship. The number of knees arthroplasty to total knee replacement
als, better fixation, and improved de- that reach long-term follow-up in such is relatively straightforward, so appro-
sign.5-11 Published longer-term results series are, however, often small; only priate patients seeking a partial knee
have shown markedly differing sur- 36 of the 7760 knees in this study replacement should not be discour-
vivorship rates between more subtle made it to the 20-year point.27 aged by the slightly lower long-term
differences in arthroplasty design. In Medium-term follow-up is becom- survivorship seen in registry data.
a recent study looking at 3234 knee ing available on updated versions of Several knee scores have been
arthroplasties performed between the total condylar design. Improved developed to assess outcome follow-

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Total knee arthroplasty: Techniques and results

ing total knee arthroplasty. These tools than in the normal-weight group. opments over the last half century
produce numbers that correspond to Additionally, survivorship rates in have resulted in 10-year survivorship
excellent, good, fair, or poor outcome. obese patients were not significantly rates of 90% and higher, and between
For example 92% of knees were as- lower than in patients who were not 80% and 85% of patients have been
sessed as good or excellent in one obese at 10 years follow-up.35 There satisfied with their total knee replace-
study, with 1.6% fair and 6.5% poor.23 was, however, a greater proportion of ment. Further incremental improve-
Between 96% and 98% of knees were
assessed as good or excellent in anoth-
er study.29 However, more recently it
has been shown that the views of sur-
geons and their patients regarding the
outcome of surgical interventions do
Survivorship rates in obese patients
not always correlate well—especially
with respect to function and pain. were not significantly lower than in
Patient questionnaires are thought to
patients who were not obese at
better assess patient outcome, and in a
recent study 81.8% of 8095 patients 10 years follow-up.
were satisfied, 11.2% (906 of 8095)
were unsure, and 7.0% (566 of 8095)
were not satisfied with their new knee
joint.32
With regard to younger patients
under the age of 55 years, a survivor- lucent lines seen on the radiographs ments in knee arthroplasty engineer-
ship rate of 96% of 93 knees was around the implants of the obese ing, implant design, and material
observed at 10 years,33 and of 90% of patients23,35 and in the morbidly obese science will continue to improve bear-
108 knees at 18 years;34 94% of pa- the complication rates are higher and ing surface tribology, implant fixa-
tients in the latter study had good or the implant survivorship rate is lower. tion, and implant longevity. These
excellent function and all but two The final objective measure of advances will all help meet the main
patients had improvement in their outcome perhaps most relevant to the surgical goals of total knee arthro-
activity score postoperatively. Fur- individual patient is range of flexion. plasty: to correct limb alignment, pre-
thermore, 24% regularly participated This has gradually improved from a serve joint line position, balance the
in activities such as tennis, skiing, mean of 99 degrees23 to between 114 soft tissues in the coronal plane, bal-
bicycling, or strenuous farm or con- and 117 degrees with newer genera- ance the flexion/extension gap in the
struction work.34 This suggests that tion designs.29 Postoperative range of sagittal plan, and create a Q angle that
the traditional practice of withholding motion largely depends on the preop- facilitates satisfactory patella track-
knee replacement until patients are erative range of motion. Generally, ing. Preoperative assessment and
over 65 or over is not warranted, and what the patient has before the opera- planning will also help meet these
replacement should proceed when tion is what the patient can expect to goals by ensuring patient expectations
clinically appropriate. achieve after surgery and rehabilita- are realistic and informed consent has
It was traditionally thought that tion.36 Patients seeking knee replace- been obtained after a full discussion
obese patients do not fare as well as ment should be counseled that their of the risks and benefits of surgery.
normal-weight patients following postoperative knee will not be “nor-
joint replacement. Postoperative out- mal,” but it will feel and function Competing interests
come scores for obese patients, how- much better than their preoperative None declared.
ever, were found to be comparable to arthritic knee.
scores for patients who were not obese References
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all improvement was actually greater plasty. Fortunately, technical devel- 2. The Australian National Joint Replace-

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Total knee arthroplasty: Techniques and results

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