Knee Arthroplasty: New and Future Directions

Foreword
Foreword
Preface
Acknowledgements
Contents
Contributors
About the Editor
Part I: Primary Total Knee Arthroplasty
1: Pre-operative Planning in Primary Total Knee Arthroplasty
1.1 Introduction
1.2 History and Physical Examination
1.3 Indications
1.4 Imaging
1.4.1 Anteroposterior View
1.4.2 Lateral View
1.4.3 Axial View
1.4.4 Long-Leg Standing Radiograph
1.4.5 Stress Tests
1.4.6 Laboratory Test
1.5 Templating
1.5.1 Femoral Templating in Coronal Plane
1.5.2 Tibial Templating in Coronal Plane
1.5.3 Templating in the Sagittal Plane
1.6 Planning in Complex Primary Knee Arthroplasty
1.6.1 Ligamentous Instability
1.6.2 Extra-articular Deformity
1.6.3 Bone Loss
1.7 Selecting the Right Implant Size
1.8 Summary
References
2: Surgical Exposures in Total Knee Arthroplasty
2.1 Introduction
2.2 Anteromedial Parapatellar Approach
2.3 Alternate Approaches
2.3.1 Subvastus Approach
2.3.2 Midvastus Approach
2.4 Anterolateral Approach
2.5 Quadriceps Snip
2.6 Summary
References
3: Implant Evolution and Design Rationale in Total Knee Arthroplasty
3.1 Introduction
3.2 History of TKA
3.2.1 Early Prosthetic Models
3.2.1.1 Interposition and Resurfacing Prostheses
3.2.2 Cruciate Excision, Retention, and Substitution
3.3 Cruciate Retaining (“PCL Retaining,” CR-TKA)
3.4 Highly Congruent Liner (Anterior Stabilized)
3.5 Bicruciate Retaining (BCR-TKA)
3.6 Mobile Bearing Versus Fixed Bearing Total Knee Arthroplasty
3.7 Non-cemented Versus Cemented Knee Prostheses
3.8 Constrained Condylar Knee Prosthesis
3.9 Polyethylene in TKA
3.10 Metals Used in TKA
3.11 Summary
References
4: Basics in Total Knee Arthroplasty: A Step-by-Step Approach to a Varus Knee
4.1 Introduction
4.2 Preoperative Planning
4.3 Surgical Considerations
4.3.1 Exposure
4.3.2 Proximal Tibial Preparation
4.3.3 Femoral Preparation
4.3.4 Femoral Sizing
4.3.5 Ligament Balancing
4.3.6 Tibial Preparation
4.3.7 Patella Resurfacing
4.4 Discussion
4.5 Summary
References
5: Total Knee Arthroplasty in Knees with Fixed Flexion Deformity
5.1 Introduction
5.2 Preoperative Patient Evaluation
5.3 Intraoperative Steps
5.3.1 Flexion Deformity Assessment After Anaesthesia
5.3.2 Surgical Technique
5.3.2.1 Grade I: Mild Deformity <15°
5.3.2.2 Grade II: Moderate Deformity >15° and <30°
5.3.2.3 Grade III: Severe Deformity >30°
5.4 Post-operative Rehabilitation
5.5 Complications of Residual Fixed Flexion Deformity
5.6 Summary
References
6: Total Knee Replacement in a Valgus Arthritic Knee
6.1 Introduction
6.2 Patho-Anatomy of a Valgus Arthritic
6.3 Classification
6.4 Principles of Correction
6.5 Preoperative Planning
6.6 Surgical Technique
6.6.1 Approaches
6.6.2 Bone Resection
6.6.3 Gap Assessment and Soft Tissue Balancing
6.7 Complications Following TKR in a VAK
6.8 Results
6.8.1 Results Based on the Surgical Approach Employed
6.8.2 Results Based on the Technique of Soft Tissue Balancing
6.9 Summary
References
7: Mobile Bearing Unicompartmental Knee Arthroplasty
7.1 Introduction
7.2 History of Unicompartmental Knee Arthroplasty
7.3 Indications for Medial Compartment Unicompartmental Arthroplasty
7.4 Surgical Procedure of Mobile Bearing Medial UKA (Oxford Phase 3 with Microplasty Instrumentation)
7.4.1 Position
7.4.2 Approach
7.4.3 Tibial Cut
7.4.4 Femoral Preparation
7.4.5 Cementation of Components
7.5 Post-operative X-Rays
7.6 Rehabilitation
7.7 Complications of Mobile Bearing Unicondylar Arthroplasty
7.8 Results of Mobile Bearing Unicondylar Knee Arthroplasty
7.9 Summary
References
8: Fixed Bearing Unicondylar Knee Arthroplasty
8.1 Introduction
8.2 Evolution of UKA
8.3 Indications
8.4 Preoperative Assessment and Planning
8.5 Surgical Approach
8.5.1 Incision and Exposure
8.5.2 Proximal Tibial Resection
8.5.3 Distal Femoral Resection
8.5.4 Tibia Preparation and Implantation
8.6 Discussion
8.7 Case Illustration
8.8 Summary
References
9: Radiological Assessment of Total Knee Arthroplasty
9.1 Introduction
9.2 Radiological Modalities
9.3 Conventional or Plain Radiography
9.3.1 How to Obtain the Ideal AP and Lateral X-Rays After TKA
9.3.1.1 Proper Patient-Positioning for AP View of the Knee Joint
9.3.1.2 Patient Positioning for Lateral View of the Knee Joint
9.3.1.3 How Should Ideal Post-operative X-Rays Look?
9.3.2 What to Look for in Post-operative Radiographs?
9.3.3 Long-Knee Films Versus Short-Knee Radiographs for Assessment of Alignment After TKA
9.3.4 Evaluation of the Patella After TKA
9.3.5 Assessment of the Joint Line
9.3.6 Assessment of Component Sizing
9.4 Fluoroscopy
9.5 Computed Tomography (CT) Scanning
9.5.1 Role of Computed Tomography in the Painful Total Knee Arthroplasty
9.5.2 Metal Artifact Reduction in Computed Tomography
9.5.3 Assessment of Radiolucencies After TKA
9.6 Magnetic Resonance Imaging (MRI) After Total Knee Arthroplasty
9.6.1 Recent Developments in Magnetic Resonance Imaging
9.6.2 Merits and Demerits of Magnetic Resonance Imaging
9.7 Radiostereographic Analysis (RSA)
9.8 Nuclear Medicine and Bone-Scintigraphy Scans
9.8.1 Three-Phase Bone Scintigraphy
9.8.2 Phases of Bone Scans
9.8.3 Recent Advances in Scintigraphy Scanning
9.9 Role of Ultrasound in the Post-operative Evaluation of TKA
9.10 Summary
References
Part II: Total Knee Arthroplasty in Complex Primary Situations
10: Total Knee Arthroplasty in Stiff/Ankylosed Knees
10.1 Introduction
10.1.1 Aetiology
10.1.2 Patho-Anatomy
10.2 Definition of a Stiff Knee
10.2.1 Ankylosed Knee
10.2.2 Muscle Function After TKA Conversion in Bony Ankylosis
10.2.3 Bone Quality
10.2.4 Patello-Femoral Ankylosis
10.3 Pre-operative Evaluation
10.4 Surgical Planning
10.5 Surgical Approach
10.5.1 Extensile Exposures
10.5.1.1 Quadricep Snip (Insall 1993 for Stiff Knee)
10.5.1.2 V-Y Quadricep Turndown (Coonse and Adam for Stiff Knee 1943)
10.5.1.3 Tibial Tubercle Osteotomy (TTO): (First by Dolin Modified by Whiteside 1983)
10.5.1.4 Femoral Peel
10.6 Steps for Bony Ankylosis Conversion to TKA
10.6.1 Patellar Ankylosis Clearance
10.6.2 Lateral Mobilisation of Patella and Quadricep
10.6.3 Tibio-Femoral Osteotomy
10.7 Selection of Implants
10.8 Case Discussion
10.8.1 Case 1: Bilateral Ankylosed Knee in Case of Rheumatoid Arthritis
10.8.2 Case 2: Bilateral Knee Bony Ankylosis 90 Post RA
10.8.3 Case 3: OA Bilateral Knee Subluxation, Osteophytes, Loose Bodies and Stiffness
10.8.4 Case 4: OA with Osteophytes with Mechanical Block
10.8.5 Case 5: Post RA Stiff Knee with Fracture While Attempted Manipulation
10.8.6 Case 6: Stiff Knee with Stress Fracture in Post Patellectomy
10.8.7 Case 7: Stiff Knee with Non-union Fracture Tibia
10.8.8 Case 8: Stiff Knee with Extension Stem Tip Cut Out Due to Loss of Medial Pillar
10.9 Post-operative Management
10.10 Management of Residual Flexion Deformity in Ankylosed Knee
10.11 Discussion
10.11.1 Comparative Results Stiff and Ankylosed Knee
10.11.2 Complications
10.12 Summary
References
11: Total Knee Arthroplasty in Extra-Articular Deformity
11.1 Introduction
11.2 Causes of EAD [4, 5]
11.3 Radiographic Evaluation [4, 5, 8, 9]
11.4 Preoperative Planning
11.5 Surgical Options
11.6 Implant Choice for Osteotomy Fixation
11.7 Implant Choices for TKA
11.8 Role of Computer Navigation in TKA Associated with EAD
References
12: Post-High Tibial Osteotomy Total Knee Arthroplasty
12.1 Introduction
12.2 Pathoanatomy
12.3 Preoperative Evaluation
12.4 Procedure
12.4.1 Exposure
12.4.2 Proximal Tibial Cut
12.4.3 Ligament Balancing
12.4.4 Proximal Tibial Preparation
12.4.5 Patellar Preparation
12.4.6 Closure
12.4.7 Postoperative Rehabilitation
12.5 Discussion
12.6 Summary
References
13: Total Knee Arthroplasty in Osteoarthrosis Complicated with Stress Fractures
13.1 Introduction
13.2 Pathophysiology
13.3 Presentation
13.4 Risk Factors
13.5 Differential Diagnosis
13.6 Preoperative Planning
13.7 Treatment Options
13.7.1 Nonoperative Treatment
13.7.2 Operative Treatment
13.8 Surgical Technique
13.8.1 Intra-articular Fracture
13.8.2 Extra-articular Fracture
13.9 TKA as a Treatment of Stress Fracture in OA: A Review of Current Literature
13.9.1 Author’s Recommendation: Single-Stage TKA with a Long Stem
13.10 Complications
13.11 Summary
References
14: Management of Bone Defects in Primary Total Knee Arthroplasty
14.1 Introduction
14.2 Classification
14.3 Management of Bone Defects
14.4 Pre-Operative Planning
14.5 Surgical Considerations
14.6 Complications
14.7 Tips and Pearls
14.8 Current Concept
14.9 Discussion
14.10 Summary
References
15: Total Knee Replacement in Obese Patients
15.1 Introduction
15.1.1 Survival of TKA
15.1.2 Basic Science
15.2 Obesity and Total Knee Arthroplasty
15.3 Considerations in TKA in Obese Patient
15.4 Summary
References
16: TKA in Post-Trauma and Failed Fixations
16.1 Introduction
16.2 Challenges in Post-Trauma Situation
16.3 Preoperative Planning
16.3.1 Radiological Evaluation
16.3.2 Blood Investigations
16.3.3 Role of Preoperative Knee Aspiration
16.4 Surgical Considerations
16.4.1 Incision and Exposure
16.4.2 Hardware Removal and Timing of Surgery
16.4.3 Joint Reconstruction and Bone Loss Management
16.4.4 Implant Selection
16.5 TKA After Intramedullary Nailing
16.6 Computer-Assisted Surgery (CAS)
16.7 Primary Arthroplasty for Acute Fractures Around the Knee
16.8 Complications: How to Avoid and Tackle Them?
16.8.1 Infection
16.8.2 Skin Problems
16.8.3 Postoperative Knee Stiffness
16.8.4 Instability
16.8.5 Extensor Mechanism Disruption
16.8.6 Malalignment
16.9 Clinical Outcomes and Survivorship
16.10 Summary
References
17: Sliding Condylar Osteotomy for Managing Severe Deformities in Total Knee Arthroplasty
17.1 Introduction
17.1.1 The Varus Knee Deformity
17.1.2 The Valgus Knee Deformity
17.2 Pre-Operative Planning
17.2.1 History-Taking
17.2.2 Physical Examination
17.2.3 Radiological Evaluation
17.2.4 Indications for SCO
17.2.5 Contraindications for SCO
17.2.6 Pre-Operative Implant Planning
17.3 Surgical Technique of Various Types of SCO
17.3.1 Medial Condylar Downsliding Osteotomy (MCDO) for Severe Varus Deformity
17.3.2 Lateral Condylar Downsliding Osteotomy (LCDO) for Severe Valgus Deformity
17.3.3 Lateral Condylar Upsliding Osteotomy (LCUO) for Severe Varus Deformity
17.3.4 Medial Condylar Upsliding Osteotomy (MCUO) for Severe Valgus Deformity
17.4 Discussion
17.4.1 Complications, and How to Avoid and Manage them
17.5 Current Concepts and Recent Advances
17.6 Clinical Cases
17.6.1 Case 1
17.6.2 Case 2
17.6.3 Case 3
17.7 Summary
References
18: Total Knee Arthroplasty in Genu Recurvatum
18.1 Introduction
18.2 Etiology
18.3 Management
18.4 Basic Surgical Pearls
18.5 Discussion
18.6 Summary
References
19: Total Knee Arthroplasty in Persons with Haemophilia
19.1 Introduction
19.2 Indications of TKA in Haemophilia
19.3 Administration of Factor
19.3.1 First Option
19.3.2 Second Option
19.3.3 Inhibitors of Factor
19.4 Preoperative Care
19.5 Intraoperative Considerations
19.5.1 The Femur
19.5.2 The Tibia
19.5.3 The Patella
19.6 Post-operative Care
19.7 Discussion
19.8 Complications
19.9 Summary
References
20: Total Knee Arthroplasty in Patient with History of Previous Knee Sepsis
20.1 Introduction
20.2 Preoperative Planning
20.3 Scenario 1: Single-Stage TKA
20.4 Scenario 2: Two-Stage TKA
20.5 Discussion
20.6 Summary
References
Part III: Managing Complications Post Total Knee Arthroplasty
21: Periprosthetic Fractures Following TKR
21.1 Introduction
21.2 Risk Factors for Periprosthetic Fractures Around TKR
21.3 Classification
21.4 Evaluation and Planning
21.5 Supracondylar Periprosthetic Fracture Femur
21.5.1 Non-operative Treatment
21.5.2 Operative Treatment
21.5.2.1 Plate Fixation
21.5.2.2 Intramedullary Nails
21.5.2.3 Revision Total Knee Replacement
21.6 Tibial Periprosthetic Fractures
21.6.1 Treatment
21.7 Periprosthetic Fractures of the Patella
21.7.1 Risk Factors
21.7.1.1 Vascular Compromise
21.7.1.2 Patellar Thickness
21.7.1.3 Implant Design
21.7.1.4 Limb Alignment
21.7.2 Classification of Patellar Periprosthetic Fractures
21.7.3 Treatment
21.8 Summary
References
22: Management of Extensor Mechanism Disruption in Total Knee Arthroplasty (Primary and Revision)
22.1 Introduction
22.2 Anatomy
22.3 Clinical Features
22.4 Classification
22.5 Quadriceps Tendon Ruptures
22.5.1 Surgical Technique of Using a Marlex Mesh for Extensor Mechanism Reconstruction [27, 28]
22.5.2 Patellar Tendon Ruptures
22.5.3 Surgical Technique of Patellar Tendon Reconstruction Using a Quadriceps Tendon-Bone Graft Augmented with ST [15]
22.5.4 Surgical Technique of Extensor Mechanism Reconstruction Using an Allograft
22.6 Summary
References
23: Painful Total Knee Arthroplasty: An Algorithmic Approach
23.1 Introduction
23.2 History
23.3 Evaluation of Psychological and Mental Health
23.4 Physical Examination
23.5 Imaging
23.6 Laboratory Tests
23.7 Intra-Articular Causes of Pain Following TKA
23.7.1 Aseptic Loosening
23.7.2 Instability
23.7.3 Patellofemoral Dysfunction
23.8 Implant Malposition
23.9 Popliteal Tendon Dysfunction
23.10 Hypersensitivity to Metal or Cement
23.11 Complex Regional Pain Syndrome (CRPS)
23.12 Extra-Articular Cause of Pain
23.13 Summary
References
24: Management of the Stiff Total Knee Replacement
24.1 Introduction
24.2 Risk Factors and Aetiology
24.2.1 Preoperative
24.2.2 Intraoperative
24.2.3 Post-Operative
24.3 Evaluating the Stiff Painful TKR
24.4 Management of a Stiff Knee Replacement
24.4.1 Conservative Treatment
24.4.2 Physical Therapy
24.4.3 Manipulation Under Anaesthesia (MUA)
24.4.4 Arthroscopic Arthrolysis
24.4.5 Open Surgery
24.4.6 Revision Knee Arthroplasty
24.5 Summary
References
25: Knee Prosthetic Instability
25.1 Introduction
25.2 Risk Factors and Prevention
25.3 Diagnosing Instability
25.3.1 Physical Examination
25.3.2 Radiological Examination
25.4 Classification of Types of Instability
25.4.1 Flexion Instability
25.4.2 Mid-flexion Instability (MFI)
25.4.2.1 Causes of Mid-flexion Instability
25.4.2.2 Elevated Joint Line
25.4.2.3 Multiradius Design
25.4.2.4 Medial Collateral Ligament (Mcl) Laxity
25.4.3 Extension Instability
25.4.3.1 Acute Instability in Extension
25.4.3.2 Symmetric Extension Instability
25.4.3.3 Asymmetrical Extension Instability
25.4.4 Global Instability
25.4.5 Genu Recurvatum
25.5 Types of Constraint in Knee Implants
25.5.1 Cruciate Retaining (CR)
25.5.2 Ultracongruent Inserts
25.5.3 Cruciate Substituting
25.5.4 Non-linked Hinged
25.5.5 Linked Hinged Implants
25.6 Summary
References
26: Periprosthetic Joint Infection: Diagnosis and Principles of Management
26.1 Introduction
26.2 Classification
26.2.1 Stage 1 (Acute Postoperative Infections)
26.2.2 Stage 2 (Delayed Deep Infections)
26.2.3 Type 3 Infection (Late Hematogenous Infections)
26.3 Diagnosis of PJI
26.4 Principles of Management of PJI
26.4.1 Medical Therapy (Antibiotic Suppression)
26.4.2 Debridement with Implant Retention
26.4.3 Single-Stage Revision
26.4.4 Two-Stage Revision
26.4.5 Knee Arthrodesis
26.5 Summary
References
27: DAIR: Concepts and Results (Debridement, Antibiotics, Irrigation, and Implant Retention)
27.1 Introduction
27.2 When to Proceed with DAIR
27.3 Technical Aspects
27.4 Use of Antibiotics
27.5 Results of DAIR
27.6 Failure of Treatment
27.7 Future Perspective
27.8 Summary
References
28: Single-Stage Revision TKA for Periprosthetic Joint Infection: The New Gold Standard
28.1 Introduction
28.2 Pathogenesis and Diagnosis of PJIs
28.2.1 Diagnosis
28.3 Classification
28.4 Indications of Single-Stage Revision TKA
28.5 Relative Contraindications of Single-Stage Revision TKA
28.6 Surgical Technique
28.7 Advantages of Single-Stage Revision
28.8 Summary
References
29: Revision for Infected Total Knee Replacement
29.1 Introduction
29.2 Burden of the Problem and the Role of Joint Registries
29.3 Classification
29.4 Diagnosis
29.5 Principles
29.6 One-Stage Vs. Two-Stage Revision
29.6.1 One-Stage Revision
29.6.2 Two-Stage Revision
29.7 Authors’ Preferred Technique for First Stage of a Two-Stage Revision
29.8 Results
29.9 Summary
References
Part IV: Technology in Total Knee Arthroplasty
30: The Science Behind Computer-Assisted Surgery of the Knee
30.1 Introduction
30.2 Classification
30.2.1 Computer-Assisted Technology
30.2.2 Systems
30.2.3 Modalities
30.3 Principles on Tracking Technology
30.3.1 Simplified Overview [22]
30.3.2 Detailed Principles
30.3.2.1 The Optical Active Technology
30.4 Computer-Assisted Image-Based Systems and Technology
30.4.1 Pre-operative Phase
30.4.1.1 Image Protocol Acquisition
30.4.1.2 Surface Reconstruction
30.4.1.3 Planning and Simulation
30.4.2 Intra-operative Procedure
30.4.2.1 Planning [47, 48]
30.4.2.2 Set-up
30.4.2.3 Registration [20]
Registration Processes
30.4.2.4 Execution: Surgical Execution [1, 20, 40, 41]
30.5 Intra-operative Fluoroscopic Image Technology
30.6 Image-Free Technology [56, 57]
30.6.1 General Remarks
30.6.2 Understanding the Concept of CT-Free TKR
30.6.3 Detailed Principles: Collecting Landmarks of the Lower Limb
30.6.3.1 Hip Centre
30.6.3.2 Knee Centre
30.6.3.3 Ankle Centre
30.6.3.4 Coronal, Sagittal and Transversal Plane of the Femur
30.6.3.5 Anterior Referencing and Notching
30.6.3.6 Anterior and Femur Implant Size
30.6.3.7 Femoral Rotation References
30.6.3.8 Landmark References for Bone Cut Height
30.6.3.9 Coronal, Sagittal and Transversal Plane of the Tibia
30.6.4 Execution
30.7 Summary
References
31: Computer-Assisted Total Knee Arthroplasty: Stepwise Approach
31.1 Introduction
31.2 Rationale of Using CAOS in TKR
31.3 Operative Technique
31.3.1 System Setup
31.3.2 Registration of Biomechanical Axis
31.3.3 Distal Femoral Anatomy Registration
31.3.4 Proximal Tibial Anatomy Registration
31.3.5 Femoral Cuts
31.3.6 Tibial Cut
31.3.7 Component Implantation
31.4 Summary
References
32: Navigation-assisted Unicondylar Knee Replacement
32.1 Introduction
32.2 Surgical Technique
32.2.1 Medial UKA
32.2.1.1 Patient Setup
32.2.1.2 Hardware Setup
Camera
Fluoroscopy System
Trackers
Accelerometer-based Portable Navigation
32.2.1.3 Surgical Approach
32.2.1.4 Registration
32.2.1.5 Planning
32.2.1.6 Execution
32.2.2 Lateral Unicompartmental Knee Replacement
32.3 Results
32.4 Discussion
32.5 Summary
References
33: Patient-specific Instrumentation in Total Knee Arthroplasty
33.1 Introduction
33.2 Evolution of Patient-specific Instrumentation
33.3 Patient-specific Instrumentation in TKA
33.4 Planning PSI in TKA
33.4.1 Medical Image Acquisition
33.4.1.1 Image Spatial Resolution and Slice Thickness
33.4.1.2 Image Data Sharing/Transmission
33.4.2 Image Data Processing and 3D Modeling
33.4.2.1 Software
Open Source Software
Off the Shelf Software
33.4.2.2 Image Segmentation
33.4.3 Virtual Surgical Planning
33.4.3.1 Offline Planning Platforms
33.4.3.2 Online Planning Platform
33.5 Manufacturing of PSI
33.5.1 Materials
33.5.2 3D Printers
33.5.2.1 SLS Machines
33.5.2.2 SLA Machines
33.5.2.3 Fused Deposition Modeling (FDM Machines)
33.5.2.4 3D-printed PSI Guides
33.5.3 Sterilization of PSI Guides
33.6 Surgical Considerations
33.6.1 Learning Curve
33.6.2 Cost-effectiveness of PSI
33.6.3 Blood Loss
33.6.4 Operative Time
33.6.5 Complications
33.7 Discussion
33.8 PSI Versus CAS
33.9 Future
33.10 Summary
References
34: Overview of Robotics in Total Knee Arthroplasty
34.1 Introduction
34.2 The Role of Functional Alignment
34.3 The Process of Robotic-assisted TKA
34.3.1 Pre-operative Planning
34.3.2 Intra-operative Registration
34.3.3 Bone Resections
34.3.4 Knee Balancing and Fine Adjustment
34.3.5 Implantation
34.4 Learning Curve
34.5 Current Evidence Base
34.5.1 Alignment
34.5.2 Soft Tissue Trauma
34.5.3 Functional Outcomes
34.6 Cost-effectiveness and Other Challenges
34.7 Future Direction
34.8 Summary
References
35: Total Knee Arthroplasty Using Robotics (MAKO)
35.1 Introduction
35.2 Pre-operative Planning
35.2.1 CT Landmarks
35.2.2 Resection Landmarks
35.2.3 Implant Positioning (Pre-operative)
35.3 Surgical Technique
35.3.1 Patient Positioning
35.3.2 MAKO System Setup
35.3.3 Surgical Exposure
35.3.4 Tracker Array Placement
35.3.5 Bone Registration
35.3.6 Intra-operative Planning
35.3.7 Positioning the Robot
35.3.8 Bone Preparation
35.3.9 Trial Reduction and Joint Assessment
35.3.9.1 Soft Tissue Balancing with Trial Implants
35.3.9.2 Soft Tissue Balancing with Tensioner
35.3.10 Final Component Preparation and Implantation
35.4 Discussion
35.4.1 Accuracy of Implant Positioning
35.4.2 Soft Tissue and Bone Preservation
35.4.3 Functional Outcome
35.4.4 Complications and Implant Survivorship
35.4.5 Learning Curve
35.5 Drawbacks
35.5.1 Pin Tracts-related Complications
35.5.2 Radiation Exposure
35.5.3 Operative Time
35.5.4 Cost
35.6 Case Examples Demonstrating the Accurate Execution of Different Alignment Options
35.7 The Future
35.8 Summary
References
36: Robotic-Assisted Unicondylar Knee Arthroplasty
36.1 Introduction
36.2 Patient Selection
36.3 Planning
36.3.1 Preoperative
36.3.2 Intraoperative
36.4 Surgical Approach
36.4.1 Design Approach
36.4.2 Surgical Technique
36.5 Discussion
36.5.1 Implant Positioning
36.5.2 Recovery and Hospitalization
36.5.3 Pain Outcomes
36.5.4 Functional Outcomes
36.5.5 Survivorship
36.5.6 Cost-Effectiveness
36.6 Summary
References
37: Fast-Track Total Knee Arthroplasty
37.1 Introduction
37.2 Components of Fast-Track Protocol
37.2.1 Preoperative Phase
37.2.1.1 Optimization of Comorbidities
37.2.1.2 Patient Education
37.2.1.3 Preoperative Fasting and Nutrition
37.2.2 Intraoperative Phase
37.2.2.1 Anesthesia Approach
37.2.2.2 Surgical Procedure
37.2.3 Postoperative Phase
37.2.3.1 Multimodal Analgesia
37.2.3.2 Prophylaxis Against Thromboembolism
37.2.3.3 Early Mobilization and Rehabilitation
37.3 Protocol at Our Institute
37.3.1 Patient Selection
37.3.2 Preoperative Considerations
37.3.3 Surgical Considerations
37.3.4 Postoperative Rehabilitation
37.3.5 Precautions
37.4 Discussion
37.5 Summary
References
Part V: Revision Total Knee Arthroplasty
38: Mechanisms of Failure in Total Knee Arthroplasty: Diagnosis and Evaluation
38.1 Introduction
38.2 Mechanisms of Failure in Total Knee Arthroplasty
38.2.1 Infection
38.2.2 Aseptic Loosening
38.2.3 Instability
38.2.4 Arthrofibrosis
38.2.5 Polyethylene Wear
38.2.6 Malalignment
38.2.7 Periprosthetic Fractures
38.3 Diagnosis and Evaluation (Table 38.2)
38.4 Investigations
38.4.1 Plain Radiographs
38.4.2 CT Scan
38.4.3 MRI Scan
38.4.4 Bone Scan
38.4.5 SPECT Scan
38.5 Summary
References
39: Exposure Options in Revision Total Knee Arthroplasty
39.1 Introduction
39.2 Surgical Exposure
39.3 Vascular Supply of Anterior Part of Knee [19–22]
39.4 Exposures for Easy Revision
39.4.1 Medial Parapatellar Approach
39.4.2 Lateral Parapatellar
39.4.3 Tissue Sparing Arthrotomy
39.5 Deep Dissection
39.6 Exposures for Difficult Revisions
39.6.1 Quadriceps Snip
39.6.2 Tibial Tubercle Osteotomy (TTO)
39.6.3 Banana Peel
39.6.4 V-Y Turndown
39.7 Alternative Techniques
39.7.1 Medial Epicondylar Osteotomy
39.7.2 Femoral Peel
39.7.3 Extensor Mechanism Tenolysis
39.8 Historical Approaches
39.8.1 Coonse and Adams
39.8.2 Insall’s Patellar Turndown
39.9 Complications and Management
39.10 Summary
References
40: Prosthesis Extraction in Revision Total Knee Arthroplasty
40.1 Introduction
40.2 Preoperative Planning
40.3 Principles of Implant Removal
40.4 Special Considerations
40.4.1 Stem Fractures
40.4.2 Difficult Cement Removal
40.5 Summary
References
41: Prosthesis Selection and Rationale for Use in Revision Total Knee Arthroplasty
41.1 Introduction
41.2 Discussion
41.2.1 Instability
41.2.1.1 Posterior-Stabilized Design Prosthesis
41.2.1.2 Varus-Valgus Constraint Prosthesis
41.2.1.3 Rotating Hinged Knee Prosthesis
41.2.2 Bone Defect
41.2.2.1 Metaphyseal Sleeve and Cone
41.2.2.2 Megaprosthesis
41.3 Summary
References
42: Management of Bone Defects in Revision Total Knee Arthroplasty: Concept of Sleeves
42.1 Introduction
42.2 Preoperative Evaluation and Planning
42.3 Surgical Technique
42.4 Discussion
42.5 Summary
References
43: Managing Bone Defects in Revision TKR: Concept and Use of Tantalum Cones
43.1 Introduction
43.2 Porous Tantalum
43.3 Surgical Technique
43.4 Removal of Cones
43.5 Discussion
43.6 Pictorial Case Studies (Figs. 43.9, 43.10, 43.11, 43.12, 43.13, and 43.14)
43.7 Case Examples
References
44: Gap Balancing in Revision Total Knee Arthroplasty
44.1 Introduction
44.2 Steps in the Management of Gaps in Revision TKA
44.2.1 Intraoperative Assessment of Gaps and Ligament Stability
44.2.2 Medial–Lateral Soft Tissue Balancing
44.2.3 Creating a Stable Tibial Platform
44.2.4 Flexion Gap
44.2.5 Extension Gap and Restoration of Joint Line
44.3 Assessment Done Once the Trials Are in Place to Confirm the Stability of the Knee
44.4 Approach to a Situation Where Gaps Cannot Be Balanced
44.5 Summary
References
45: Joint Line Restoration in Revision Total Knee Arthroplasty
45.1 Introduction
45.2 Landmarks for Defining Joint Line
45.3 Preoperative Planning
45.3.1 Assess Ligament Integrity
45.3.2 Assess Preoperative Patellar Height (Radiograph of Contralateral Knee)
45.4 Surgical Technique
45.4.1 Exposure
45.4.2 Implant Removal
45.4.3 Establish the Tibial Platform
45.4.4 Reconstruct the Femur
45.4.5 Insert Polyethylene Spacer
45.4.6 Soft Tissue Balancing
45.5 How Much of Joint Line Elevation Can Be Accepted?
45.6 Discussion
45.7 Summary
References
46: Rotating Hinge Knee in Primary and Revision Knee Arthroplasty
46.1 Introduction
46.2 Implant Design
46.2.1 Evolution of Hinge Knee Devices
46.2.1.1 First Generation Implants
46.2.1.2 Second Generation Implants
46.2.1.3 Third-Generation RHK
46.2.2 Peculiarities of Modern RHK Implants
46.2.2.1 NexGen RHK (Zimmer)
46.2.2.2 S-ROM RHK (Depuy)
46.2.3 Bone Loss
46.2.4 Augments Commonly Used Along with RHK
46.3 Surgical Technique
46.3.1 Surgical Technique Principals of NexGen RHK (Fig. 46.12)
46.3.2 Reconstruction of Bone Defect with T.M. Cones in TKA Revision
46.4 Indications
46.4.1 RHK for Primary Cases
46.4.2 RHK for Revision Situations
46.4.3 Special RHK: Distal Femur Replacing (DFR)
46.5 Complications
46.6 Discussion
46.6.1 RHK in Primary TKA
46.6.1.1 Non-Tumour Conditions
46.6.1.2 Primary RHK in Tumour Conditions
46.6.2 RHK in Revision Scenario
46.7 Summary
References
47: Revision of Failed Unicondylar Knee Arthroplasty to a Total Knee Arthroplasty
47.1 Introduction
47.2 Surgical Aspects: Conversion of Failed UKA to TKA
47.3 Preoperative Planning and Surgical Consideration
47.3.1 Step 1: Exposure
47.3.2 Step 2: Removal of Femoral Component
47.3.3 Step 3: Femur Preparation
47.3.4 Step 4: Tibial Implant Removal
47.3.5 Step 5: Tibial Resection and Preparation
47.3.6 Step 6: Management of Residual Bone Defect
47.3.7 Step 7: Soft Tissue Balancing and Final Implantation
47.4 Tips and Pearls
47.5 Discussion
47.6 Summary
References
48: Re-revision of a Previously Revised Total Knee Arthroplasty
48.1 Introduction
48.2 Indications
48.3 Preoperative Assessment
48.3.1 Patient History
48.3.2 Physical Exam
48.3.3 Laboratory Studies
48.3.4 Imaging
48.3.4.1 AP Knee Radiograph
48.3.4.2 Lateral Knee Radiograph
48.3.4.3 Sunrise or Merchant View
48.3.4.4 Advanced Imaging
48.3.4.5 General Considerations
48.4 Intraoperative Surgical Considerations
48.4.1 Skin Incision
48.4.2 Exposure
48.4.3 Implant Removal
48.4.3.1 Indications for Removal
48.4.3.2 Tools and Instrumentation
48.4.3.3 Order of Implant Removal
48.4.3.4 Removing the Femoral and Tibial Components
48.4.3.5 Removing Metaphyseal Components
48.4.3.6 Cement Removal
48.4.4 Reimplantation
48.4.4.1 Building a Stable Platform
48.4.4.2 Determining Femoral Rotation
48.4.4.3 Determining Size of Femoral Component and Balancing Knee in Flexion
48.4.4.4 Determining the Joint Line and Balancing the Knee in Extension
48.4.4.5 Determining Level of Constraint
48.4.4.6 Managing Bone Loss
48.4.4.7 The Patella
48.5 Postoperative Management
48.6 Salvage Options
48.7 Summary
References
49: Bulk Allografts in Revision Total Knee Arthroplasty
49.1 Introduction
49.2 Indication
49.3 Types of Bulk Allografts
49.3.1 Femoral Head Allograft
49.3.2 Distal Femoral Allograft
49.3.2.1 Preparation of Allograft
49.3.2.2 Preparation of Host Bed
49.3.3 Proximal Tibial Allograft
49.4 Summary
References
50: Condylar Replacement Prosthesis as a Salvage in Knee Arthroplasty
50.1 Introduction
50.2 Evolution and Implant Designs
50.3 Indications
50.3.1 Revision Total Knee Arthroplasty
50.3.2 Primary Total Knee Arthroplasty
50.4 Decision-Making
50.5 Preoperative Planning
50.5.1 History and Clinical Assessment
50.5.2 Radiological Assessment
50.6 Surgical Technique
50.6.1 Surgical Approach
50.6.2 Soft Tissue Dissection and Exposure
50.6.3 Removal of Distal Femoral Segment and Well-Fixed Implant in Revision Scenarios
50.6.4 Intraoperative Assessment of Bone Defect
50.6.5 Sequence of Reconstruction
50.6.6 Definitive Implant Fixation
50.7 Case Examples
50.8 Discussion
50.9 Summary
References
Part VI: Advances in Perioperative Management in Total Knee Arthroplasty
51: Managing Soft Tissue Deficiencies in Total Knee Arthroplasty
51.1 Introduction
51.2 Risk Factors
51.3 Classification
51.4 Preventive Strategies for Soft Tissue Management and Wound Complication
51.4.1 Optimization of Systemic Factors
51.4.2 Optimization of Local Factors
51.5 Options to Improve the Soft Tissue Envelope
51.5.1 Tissue Expanders
51.5.2 Prophylactic Flaps: Pedicled or Free
51.6 Intra-operative Management
51.7 Management of Established Soft Tissue Compromise and Infection
51.8 Reconstruction of Skin and Soft Tissue Defects
51.8.1 Secondary Suturing and Secondary Healing
51.8.2 Skin Grafting
51.8.3 Flap Coverage
51.8.3.1 Local Flaps
51.8.3.2 Free Flaps
51.9 Summary
References
52: Multimodal Pain Management in Total Knee Arthroplasty
52.1 Introduction
52.2 Multimodal Analgesia
52.2.1 Preoperative (Preemptive)
52.2.2 Intraoperative
52.2.2.1 General Anesthesia
52.2.2.2 Neuraxial Anesthesia
52.2.2.3 Peripheral Nerve Blocks
Femoral Nerve Block
Adductor Nerve Block
IPACK (Infiltration Between Popliteal Artery and Capsule of Knee Joint)
Local Infiltration Analgesia (LIA)
Sciatic Block
52.2.2.4 Drug Adjuvants
52.2.3 Postoperative Period
52.3 Summary
References
53: Deep Vein Thrombosis: Prophylaxis and Management
53.1 Introduction
53.2 Pathogenesis
53.3 Epidemiology
53.4 Prophylaxis Following Total Knee Arthroplasty
53.5 Mechanical Methods
53.5.1 Pneumatic Compression Boots
53.5.2 Venous Plantar Compression
53.6 Pharmacological Methods (Fig. 53.1)
53.6.1 Low-Molecular-Weight Heparin
53.6.2 Warfarin
53.6.3 Aspirin
53.6.4 Fondaparinux
53.6.5 Newer Agents
53.6.5.1 Rivaroxaban
53.6.5.2 Apaxiban
53.6.5.3 Dabigatran
53.7 Influence of Anesthesia on the Rate of Thrombosis
53.8 Duration of Thromboprophylaxis
53.9 Screening Considerations
53.10 High-Risk Patients
53.11 Recommendations
53.12 Management
53.13 Summary
References
54: Optimal Rehabilitation After Total Knee Arthroplasty
54.1 Introduction
54.2 Rapid Rehabilitation
54.3 Pain Management
54.4 Continued Rehabilitation
54.4.1 Getting in and out of Bed
54.4.2 Standing up and Sitting down
54.4.3 Walking
54.4.4 Stairs
54.4.5 Occupational Therapy
54.4.6 Information for When Patient Goes Home
54.5 Homecare
54.5.1 Exercises
54.5.2 Walking
54.5.3 Gait
54.5.4 Kneeling
54.5.5 Sports/Hobbies
54.5.6 Physiotherapy
54.5.7 Driving
54.5.8 Flying
54.6 Do’s and Don’ts After TKA [18]
54.7 Discussion
54.8 Summary
References
55: Evolving Trends in Total Knee Arthroplasty
55.1 Introduction
55.2 Evolution of Total Knee Arthroplasty
55.3 Cruciate Retention versus Substitution
55.4 Advances in Materials
55.5 Advances in Design and Geometry
55.5.1 The Bicruciate Design Total Knee Replacement
55.5.2 Porous Coating in Cementless Knees
55.5.3 3D-Printing in Orthopaedics
55.5.4 Manufacturing of Cementless Implants using Newer Technologies
55.5.5 Patient-Specific Instrumentation
55.6 Rehabilitation and Recovery
55.7 Summary
References