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