Download the Take Home Message Book in PDF format

The Osteoarthritic Knee
Best Current Practice in Europe (2nd BCPE)
Florence 3-5 April 2013
TAKE HOME MESSAGE BOOK

CONTENTS
SESSION 1
OSTEOTOMIES AND PARTIAL KNEE SOLUTIONS
Chairman: J.-N. Argenson (France)
Load absorption - a solution to delay arthroplasty in younger patients page 7
N. London (United Kingdom)
The role of high tibial osteotomy page 9
P. Lobenhoffer (Germany)
Unicompartmental knee arthroplasty is a successful procedure page 10
C. Dodd (United Kingdom)
Patients expectations and outcome after HTO and UKA page 11
S. Tòksvig-Larsen (Sweden)
The role of patello-femoral arthroplasty page 12
D. Barrett (United Kingdom)
SESSION 2
CROSSFIRE ON CASES INDICATION
Chairman: R. Becker (Germany)
Case 1: Osteoarthritis grad II medial compartment and neutral alignment page 13
Grade II OA neutral alignment in active 45 yrs old man page 14
Biologic treatments
M. Marcacci (Italy)
Grade II OA neutral alignment in active 45 yrs old man page 15
Conservative options
P.S. Sussmann (Switzerland)
Case 2: Osteoarthritis grad II medial compartment and varus malalignment page 16
Grade II medial OA in active 55 yrs old man page 17
Joint distraction
F. Almqvist (Belgium)
Grade II medial OA in active 55 yrs old man page 18
HTO
R. Van Heerwaarden (The Netherlands)
Case 3: Osteoarthritis grad III medial compartment page 19
Grade III medial OA in active 55 yrs old man page 21
TKA
A.D. Hanssen (USA)
Grade III medial OA in active 55 yrs old man page 22
UKA
O. Kessler (Switzerland)
Case 4: Osteoarthritis grad III lateral compartment page 23
Grade III lateral OA in active 60 yrs old woman page 24
TKA
S. Tarabichi (United Arab Emirates)
Grade III lateral OA in active 60 yrs old woman page 25
UKA
C.O. Tibesku (Germany)
Case 5: Patellofemoral + medial osteoarthritis page 26
2

Patellofemoral + medial OA in a 60 years old woman page 27
TKA
T. Wilton (United Kingdom)
Patellofemoral + medial OA in a 60 years old woman page 28
Bicondylar
F. Benazzo (Italy)
SESSION 3
ICL PRIMARY TKA - 10 BASIC PRINCIPLES
Chairman: J. Bellemans (Belgium)
Indication + implant page 29
A. Ferretti (Italy)
Planning + approach page 30
R. Becker (Germany)
Bone cuts + rotational position page 32
N. Confalonieri, A. Manzotti (Italy)
Soft tissue balancing + patellar tracking page 34
R. Strachan (United Kingdom)
Blood management + pain control & rehab page 36
M. Denti, P. Volpi (Italy)
SESSION 4
CURRENT CONTROVERSIES IN TKA
Chairman: E. Thienpont (Belgium)
Who will pay the costs of new technologies in arthroplasty page 37
J.-N. Argenson (France)
Who will pay the costs of new technologies in arthroplasty page 38
R. Vermeulen (Belgium)
How to improve patello-femoral tracking with current TKA design page 39
Trochlear constraint role
A. Amis (United Kingdom)
How to improve patello-femoral tracking with current TKA design page 40
Trochlear orientation role
N. Verdonschot (The Netherlands)
Ideal postoperative alignment for TKA page 41
Restore it to neutral
A. Mullaji (India)
Ideal postoperative alignment for TKA page 43
Anatomical is better
H. Vandenneucker (Belgium)
Planning with conventional X-ray or intraoperative technology for a better alignment in TKA page 44
I prefer high-tech
J. Cobb (United Kingdom)
Planning with conventional X-ray or intraoperative technology for a better alignment in TKA Page 45
I prefer conventional plan
N.P. Thomas (United Kingdom)
Multimodal approaches for a shorter hospital stay page 46
EU trends
D. Kohn (Germany), M. Brockmeyer (Germany)
3

Multimodal approaches for a shorter hospital stay page 47
US trends
G.R. Scuderi (USA)
SESSION 5
VIDEO PEARLS - PRIMARY TKA
Chairman: T. Wilton (United Kingdom)
Staying out of trouble at primary TKR page 48
R. Rossi (Italy)
Gap balancing technique and stability assessment page 50
J. Romero (Switzerland)
Measured resections with PSI in a fixed valgus deformity page 51
E. Thienpont (Belgium)
“Adapted” measured resection technique for TKA page 52
J. Victor (Belgium)
Soft tissue balancing in varus deformity: an algorithmic approach page 53
P. Verdonk (Belgium)
Patellar resurfacing technical tips page 54
W.N. Scott (USA)
SESSION 6
CASE CHALLENGE - PRIMARY TKA
Chairman: J. Victor (Belgium)
Acute primary TKA for peri-articular knee fractures page 55
S. Eggli (Switzerland)
TKA in post-traumatic osteoarthritis page 56
P. Adravanti (Italy)
TKA in the stiff knee page 58
M. Bonnin (France)
TKA plus simultaneous HTO for severe metaphyseal varus deformities page 59
P. Hernigou (France)
SESSION 7
DIFFICULT PRIMARY TKA
Chairman: N. Thomas (United Kingdom)
How do I manage severely deformed knees page 60
A. Mullaji (India)
Mid-flexion instability in fixed flexion contracture cases page 61
A.B. Wymenga (The Netherlands)
TKA post-osteotomies. Difficulties that the surgeon can predict page 63
E. Servien (France)
Planning and correction of extra-articular deformities with TKA page 64
A. Baldini (Italy)
How to regain motion in stiff or ankylosed arthritic knees page 65
S. Tarabichi (United Arab Emirates)
Dealing with torsional deformities in TKA procedures page 67
S. Hofmann (Austria)
4

SESSION 8
INFECTION
Chairmen: S. Hofmann (Austria), A. Trampuz (Germany)
Infection diagnosis - A European perspective page 68
C.L. Romanò (Italy)
New diagnostic tools for biofilm infection page 69
A. Trampuz (Germany)
Management early wound healing complications page 70
J.A.N. Verhaar (The Netherlands)
Case challenge therapy page 71
S. Hofmann (Austria)
Debridement and polyethylene liner exchange in infected TKA - The early chance page 72
R.S.J. Burnett (Canada)
Single stage - An attractive alternative page 73
H. Winkler (Austria)
Two stage still for all patients page 75
A.D. Hanssen (USA)
SESSION 9
ICL REVISION TKA - 10 BASIC PRINCIPLES
Chairman: G. Van Hellemondt (The Netherlands)
Failure analysis + patient selection page 76
C. Zorzi (Italy)
Planning + excluding infection page 77
P. Ritschl (Austria)
Approach / implant removal + 3 steps technique page 78
F. Giron (Italy)
Dealing with bone defects + implant fixation page 79
J.F. Salreta (Portugal)
Diaphyseal fixation with straight and offset stem extensions page 81
M. Innocenti (Italy)
Level of constraint + extensor mechanism page 82
S. Zaffagnini (Italy)
SESSION 10
CURRENT CONTROVERSIES IN REVISION TKA
Chairman: A. Baldini (Italy)
Which is the best stem extension for revision page 84
Cemented
T. Fehring (USA)
Which is the best stem extension for revision page 86
Cementless
A. Franz (Germany)
Filling the defect. Metaphyseal solutions page 87
Sleeves
C.C. Castelli (Italy)
5

Filling the defect. Metaphyseal solutions page 88
Tantalum cones
G.R. Scuderi (USA)
The best spacer for the infected TKA page 89
In favour of static
T. Pfitzner (Germany)
The best spacer for the infected TKA page 90
In favour of mobile
A. Schiavone Panni, M. Vasso, S. Cerciello (Italy)
Exposure for revision TKA: how do you set your threshold for a TTO page 91
Pretty high
A. Porteous (United Kingdom)
Exposure for revision TKA: how do you set your threshold for a TTO page 92
Very low
S. Romagnoli (Italy)
Use of hinges in revision total knee page 93
As less as possible
F. Catani (Italy)
Use of hinges in revision total knee page 94
More useful than you think
S. Fuchs-Winkelmann (Germany)
SESSION 11
VIDEO PEARLS - REVISION TKA
Chairman: A. Wymenga (The Netherlands)
Enhanced metaphyseal fixation in revision TKA page 95
F. Benazzo (Italy)
Implant removal and antibiotic-loaded cemented spacer preparation for infected TKA page 97
C. Perka (Germany)
Diaphyseal preparation and fixation with stem extensions page 98
T. Fehring (USA)
Dealing with a large flexion gap page 99
G. Van Hellemondt (The Netherlands)
How to treat a damaged patella during revision TKA page 100
P. Chapman-Sheath (United Kingdom)
SESSION 12
CASE CHALLENGE - REVISION TKA
Chairman: P. Adravanti (Italy)
Skin problems in revision TKA page 101
P. Massin (France)
Revision TKA with associated extra-articular deformity page 102
J-L. Briard (France)
Dealing with patellar bone loss page 103
F. Montserrat (Spain)
Management of bilateral TKA infection page 104
R.S.J. Burnett (Canada)
6

LOAD ABSORPTION - A SOLUTION TO DELAY ARTHROPLASTY
IN YOUNGER PATIENTS
Nick London
United Kingdom
Key points
Joint unloading validated, but room for innovation
KineSpring procedure: > 300 pts, > 50 surgeons, > 10 countries
Safety and efficacy positive
Standardization phase: early/mid results (4.5 yrs)
Load absorption is a solution for many patients
Joint unloading validated, but there is room for innovation
Joint unloading clinically demonstrated:
-normal load maintains healthy tissues
-excessive load initiates or accelerates knee OA [1-4]
-unloading concept clinically validated: bracing, HTO
Why consider new technologies:
-bracing has poor patient compliance and short term benefit (when evaluated at 2.7 years - 24% had
undergone arthroplasty) [5]
-HTO may impact return to work status (Median duration of incapacity of work (87 days) - 9.4% of the
patients could not work at the same level of work load after the surgery) [6]
KineSpring Procedure: >300 patients, > 50 surgeons, > 10 countries
New technology introduction phases (from Seil, van Heerwaarden, Lobenhoffer, Kohn) [7]:
-pioneering
-procedure development; Early results
-standardization
-use by other surgeons; Technique refinement; Strategies
for remaining issues
-outcome assessment
-mid/long term results
-general acceptance
-global confirmation
New load absorber option: KineSpring System:
-joint preserving
-no penetration of joint capsule
-superficial to medial collateral ligament
-no bone resection or alteration
-effectively reversible
-unloads in knee extension, passive in knee flexion (i.e. absorbs load during stance)
KineSpring pioneering phase (2008-2011) - 100 patients enrolled in three clinical studies
Australia, 2008: David Hayes, Craig Waller
UK/Belgium, 2010: Nick London, Rhys Williams, Mark Blyth, Bryn Jones, Tim Wilton, James Richardson,
Rene Verdonk, Fredrik Almqvist
Procedure/product development: smaller implant, > ROM
KineSpring standardization phase (2011-2013)
Use by other surgeons:
Over 300 total patients treated
Over 50 surgeon implanters
Over 10 countries
Technique refinement: single use instruments and streamlined procedure
Regular user-group meetings continue procedure advancement
7

Safety and efficacy positive
-Patient expectations and recovery
-Phase I: wound healing
-Phase II: improve ROM and return to ADLs
-Phase III: return to sport
-Outcomes compare favorably to HTO [8-15], UKA [16-21]
Load absorption is a solution for many patients
Effective treatment option
-Significant pain relief and functional improvement
-Solution for many pts, don’t limit to young
-Extra-capsular, reversible procedure
-Credible alternative to HTO / UKA
-Delay need for arthroplasty
References
1. Andriacchi, et al. J Rehab Res Dev. 2000; 37(2): 163-170.
2. Messier, et al. Arthritis Rheumatism 2005; 52(7): 2026-2032.
3. Gunther, et al. Best Practice Res Clin Rheum. 2004; 15(4): 627-43.
4. Sharma, et al. JAMA 2001; 286(2): 188-195.
5. Wilson et al. Long-term results of unloader brace in patients with unicompartmental knee osteoarthritis. Orthopedics Aug
2011. doi: 10.3928/01477447-20110627-07.
6. Schröter et al. Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Traumatol Arthrosc. DOI
10.1007/s00167-012-2129-9.
7. Seil et al. Rapid Evolution of HTO. Knee Surg Sports Traumatol Arthrosc 2013;21:1-2.
8. Brouwer RW et al. The Cochrane Collaboration 2007: 1-37.
9. Stukenborg-Colsman C et al. Knee 2001; 8(3): 187-194.
10. Gaasbeek RD et al. 2009 International Orthopaedics 2009; 34: 201-207.
11. Ivarsson I et al. J Bone Joint Surg 1990; Br-72: 238-244.
12. Luites JW et al. J Bone Joint Surg 209; Br-91: 1459-1465.
13. Hoell S et al. Arch Orthop Trauma Surg 2005; 125: 638-643.
14. Robinson, et al. J Bone Joint Surg 2010; Br 92-B: 404-b.
15. Asik M et al. Knee Surg Sports Traumatol Arthrosc 2006; 14: 948-54.
16. Emerson et al. J Bone Joint Surg 2008; Am-90: 118-122.
17. Stukenborg-Colsman et al. Knee 2001; 8(3):1 87-194.
18. Ivarsson et al. J Bone Joint Surg 1990; Br-72: 238-244.
19. Pandit et al J Bone Joint Surg 2011; Br-93: 198-204.
20. Conditt et al. MAKO Surgical White Paper 2011: 1-12.
21. Luscombe et al. Int Orthop 2007; 31(3): 321-4.
8

THE ROLE OF HIGH TIBIAL OSTEOTOMY
Philipp Lobenhoffer
Hannover, Germany
1. HTO efficiently unloads the medial compartment in varus overload
Several biomechanical studies have proven the effect of HTO on cartilage load under static and dynamic
conditions. The total load is reduces and the peak load areas are shifted from anteromedial before to
posterolateral after the procedure. The edge load on cartilage defects of the involved compartment is
reduced significantly after HTO.
2. HTO is mainly indicated for frontal plane varus malalignment caused by an extraarticular
metaphyseal deformity of the proximal tibia
The results of HTO are strongly depending of the correct indication. An extraarticular bony varus
deformity (TBVA > 5°) is an important predictor for long term success of the procedure. HTO is not
indicated for pure intraarticular abrasion type of medial osteoarthritis. Extraarticular valgus correction
would lead to a pathological joint line (MPTA > 93°) which usually is correlated with impaired results of
the procedure.
3. HTO can be safely performed as biplanar open wedge procedure with fixation by a
subcutaneous plate fixator
There is a swing from closed wedge lateral procedures to open wedge medial osteotomies for valgus
correction of the proximal tibia. The complication rate is lower and the technique is easier and more
versatile. A biplanar osteotomy technique and a plate fixator for fixation allow for immediate loading of the
leg without loss of correction. The elastic-stable fixation principle induces spontaneous bone healing so no
bone graft or substitute is necessary.
4. HTO is an efficient treatment for combined ACL/PCL insufficiency and varus osteoarthritis
Biomechanical studies have proven the enormous impact of tibial slope on anterior/posterior knee stability.
Combining valgus correction with slope increase/decrease improves stability and function of these knees
significantly. Slope should be increased in PCL deficiency and reduced in ACL deficiency. Open wedge
osteotomy allows to alter the tibial slope easily.
5. HTO induces regenerative processes in the involved compartment
Results in osteochondritis dissecans and in osteonecrosis of the medial compartment demonstrate a
significant healing response in the lesions after the compartment is unloaded. Osteotomy stimulates
regeneration of the tissues thus being the ideal base for biological reconstruction of osteochondral and
chondral defects.
References
1. Knee Surgery Sports Traumatology Arthroscopy Volume 21 Number 1 January 2013 Special Issue Knee Osteotomies
2. Lobenhoffer Ph et al (ed.): Osteotomies around the Knee AO Publishing Thieme International 2008
3. Lobenhoffer Ph et al (ed.): Kniegelenknahe Osteotomien Thieme Verlag Stuttgart 2006
9

UNICOMPARTMENTAL KNEE ARTHROPLASTY IS A SUCCESSFUL PROCEDURE
Chris Dodd
Nuffield Orthopaedic Centre, Oxford, United Kingdom
• All joint registers show higher failure rate of UKR compared to TKR
• There are many advantages of UKR over TKR
• The indications are well defined and UKR/TKR ratio is up to 50%
• Usage is an important determinant of outcome
• Surgeons should either embrace UKR or abandon the procedure.
10

PATIENTS EXPECTATIONS AND OUTCOME AFTER HTO AND UKA
Sören Tòksvig-Larsen
Sweden
Take home message
1. early intervention, as osteotomy and uniknee is underutilized
2. excuses not to do early intervention
3. satisfaction depends on expectation, patient and doctor’s
4. revision easy, one more opportunity for surgical treatment
5. economic benefit
6. patients demands increase
11

THE ROLE OF PATELLOFEMORAL ARTHROPLASTY
David Barrett
Southampton University Hospital, United Kingdom
Take home message
1. Patellofemoral arthritis is symptomatic in a young, high demand group of patients.
2. Design of patellofemoral arthroplasty is changing to be more aware of the soft tissue demands of the
patellofemoral articulation.
3. Operative technique for patellofemoral surgery is much more aligned to sport surgery considerations
rather than the lessons we have learnt for total knee replacement.
4. Functional results from patellofemoral arthroplasty are proven to be very high and long term studies of
patellofemoral arthroplasty show survival ship figures approaching that of total knee arthroplasty.
5. There is a recognized progression of tibiofemoral arthritis following patellofemoral arthroplasty in a
small group of patients.
12

CASE 1
OSTEOARTHRITIS GRAD II MEDIAL COMPARTMENT AND NEUTRAL
ALIGNMENT
History
O/E:
- Male, age: 45 yrs
- BMI 25kg/m 2
- Engineer (75% sitting position)
- Pain during activity
- Unable to run and to continue other sports activities
- Pain medial joint line
- ROM: 0-0-140°
- no effusion
13

CASE 1
GRADE II OA NEUTRAL ALIGNMENT IN ACTIVE 45 YRS OLD MAN
BIOLOGIC TREATMENTS
Maurilio Marcacci
Italy
1. Several treatment options are currently available for medial osteoarthritis in under 40 patients with
neutral alignment, but literature reveals controversial findings. Although traditionally not indicated for the
treatment of osteoarthritis (OA), regenerative procedures are becoming a focus of increased interest due to
their potential to provide pain relief and alter the progression of degenerative diseases.
2. Regenerative procedures have been introduced as ambitious techniques that aim at restoring the articular
surface with a hyaline-like tissue, and improvement in tissue engineering with new scaffolds as well as new
regenerative options involving growth factors or MSCs are currently being investigated as promising
solutions to further improve the treatment of cartilage lesions.
3. Randomized controlled trials are necessary to evaluate the new regenerative approaches, to show
advantages and disadvantages clearly with respect to the more traditional procedures, besides their
potential, limits, and indications to improve the treatment of patients affected by chondral and
osteochondral lesions
References
1. Marcacci M, Zaffagnini S, Kon E, Marcheggiani Muccioli GM, Di Martino A, Di Matteo B, Bonanzinga T, Iacono F, Filardo
G. Unicompartmental osteoarthritis: an integrated biomechanical and biological approach as alternative to metal resurfacing.
Knee Surg Sports Traumatol Arthrosc. 2013 Jan 31.
2. Gomoll AH, Filardo G, de Girolamo L, Espregueira-Mendes J, Marcacci M, Rodkey WG, Steadman JR, Zaffagnini S, Kon E.
Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures. Knee Surg Sports Traumatol Arthrosc. 2012
Mar;20(3):450-66.
3. Gomoll AH, Filardo G, Almqvist FK, Bugbee WD, Jelic M, Monllau JC, Puddu G, Rodkey WG, Verdonk P, Verdonk R,
Zaffagnini S, Marcacci M. Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures. Knee Surg
Sports Traumatol Arthrosc. 2012 Mar;20(3):468-86.
14

CASE 1
GRADE II OA NEUTRAL ALIGNMENT IN ACTIVE 45 YRS OLD MAN
CONSERVATIVE OPTIONS
Patrick S. Sussmann
Switzerland
1. Patient expectations: Often very high in the 45-55 year old active patient with high functional demand.
Not always can surgical options meet the actual patient expectations best.
2. Patient education: well informed patients take more mileage out of conservative options.
3. Optimal conservative management of knee OA: combination of non-pharmalogical and pharmalogical
treatment. Line out different advantages and expected gain.
In summary, there are a large variety of conservative treatment options in cases where there are no surgical
options or surgical options cannot meet patient expectations.
Reference
K M Jordan et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report
of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum
Dis 2003; 62: 1145-1155
15

CASE 2
OSTEOARTHRITIS GRAD II MEDIAL COMPARTMENT
AND VARUS MALALIGNMENT
History:
O/E
- 55 yrs of old gentleman
- Labourer
- BMI 23 kg/m2
- Pain during weight bearing at the medial compartment
- Pain going up- or down stairs
- Pain medial joint line
- McMurray negative
- No effusion
- Full range of motion
16

CASE 2
GRADE II MEDIAL OA IN ACTIVE 55 YRS OLD MAN
JOINT DISTRACTION
Fredrik Almqvist
Belgium
OA of the knee joint is increasing significantly in the young active population.
After failed conservative treatment options the tendency is to be more aggressive in the treatment, although
there is a treatment gap for medial OA where less aggressive interventions could be proposed.
An unloading extra-capsular treatment could be in favour because of:
1. Short hospital stay and rehabilitation;
2. Indicated in the normoaxial leg;
3. Good clinical outcomes until now;
4. It does not burn any bridges for further solutions in the young active patient.
So, be open for new treatment options!
References
1. London et al. Clinical and economic consequences of the treatment gap in knee osteoarthritis management. Medical
Hypotheses 2011; 76: 887-892
2. London, Nick. Closed Meeting of the European Knee Associates. Oxford, 2012
3. Rand, J. ISAKOS meeting on the management of osteoarthritis of the knee prior to total knee arthroplasty. ISAKOS
Congress 2005.
4. Bonnin, M et al. Can patients really participate in sport after high tibial osteotomy Knee Surg Sports Traumatol Arthrosc
2011. DOI 10.1007/s00167-011-1461-9.
5. Schröter, S et al. Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Trauatol Arthrosc 2012;
DOI 10.1007/s00167-012-2129-9.
6. Amis, A. Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc:2012; DOI:10.1007/s00167-012-2122-
3.
17

CASE 2
GRADE II MEDIAL OA IN ACTIVE 55 YRS OLD MAN
HTO
Ronald Van Heerwaarden
The Netherlands
1. The natural history of medial compartment overload in the presence of cartilage degeneration as well as
the joint preservation effect of an unloading High Tibial Osteotomy are evidence based knowledge.
2. Current HTO techniques including accurate re-alignments without overcorrection, cartilage unloading
through MCL release and immediate full weight bearing create predictable good outcomes.
3. Evidence based joint preservation techniques like HTO and new techniques like knee joint distraction
should be a (future) routine treatment option for a knee surgeon.
18

CASE 3
OSTEOARTHRITIS GRAD III MEDIAL COMPARTMENT
History:
O/E
- 55 yrs old gentleman
- BMI 24 kg/m2
- Weight bearing painful
- Unable to go hiking or to do gardening
- Severe knee swelling
- Grade I opening at the medial side
- ROM: 0 - 5 - 120°
19

CASE 3
GRADE III MEDIAL OA IN ACTIVE 55 YRS OLD MAN
TKA
Arlen D. Hanssen
Rochester, USA
Although UKR has enjoyed another resurgence, there are a number of realities that should give pause to
those who have embraced this trend.
1. Published results reveal that TKR has better survival, particularly beyond 10 years.
2. Traditionally, UKR has been used in the elderly and most published results are in the elderly.
3. Recent registry data show alarmingly high failure rates of UKR in patients less than 65 yrs age. This
makes UKR less cost-effective for overall global care of a specific patient group.
4. UKR is more technically difficult than TKR and in the presence of technical errors, UKR is less
forgiving than TKR.
5. One common cause of UKR failure is progression of arthritis in the contralateral compartment which
does not occur in TKR.
6. Revision of a failed UKR is not always routine and often requires revision TKR components.
7. The ideal candidate for UKR is distinctly uncommon.
8. Revision of enigmatic pain following UKR is universally unsuccessful.
Concerns
1. The concept that unicompartmental arthroplasty is a temporizing (prearthroplasty) procedure is not a
valid one in that the patient has to undergo another arthroplasty with all the risks of revision
arthroplasty surgery.
2. The treatment outcome of an infected UKR is similar to that of the infected TKR.
3. The change toward more liberal indications for UKR will not satisfy the expectations of many patients
requesting these procedures. Unfortunately, subsequent TKR will not be a good alternative or solution
for many of these patients. In one series, the most common causes of failure were: 1) a disputable
indication, or 2) suboptimal operative technique.
Conclusion
Based all available information, TKR is a more reliable, durable and more cost-effective option than UKR.
References
1. Hang JR, Stanford TE, Graves SE, Davidson DC, de Steiger RN, Miller LN. Outcome of revision of unicompartmental knee
replacement. Acta Orthop. 2010 Feb;81(1):95-8
2. Koskinen E, Eskelinen A, Paavolainen P, Pulkkinen P, Remes V.Comparison of survival and cost-effectiveness between
unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: a follow-up study of 50,493 knee
replacements from the Finnish Arthroplasty Register. Acta Orthop. 2008 Aug;79(4):499-507
3. W-Dahl A, Robertsson O, Lidgren L, Miller L, Davidson D, Graves S. Unicompartmental knee arthroplasty in patients aged
less than 65. Acta Orthop. 2010 Feb;81(1):90-4.
21

CASE 3
GRADE III MEDIAL OA IN ACTIVE 55 YRS OLD MAN
UKA
Oliver Kessler
Zurich, Switzerland
Surgical treatment options for medial compartment osteoarthritis of the knee include total knee
arthroplastey (TKA) or unicompartmental knee arthroplasty (UKA), depending on the patient's age, level of
physical activity and the degree of deformity. Following arthroplasty of the knee, the patient's perception of
improvement in symptoms is fundamental to the assessment of outcome.
The rate of excellent and good outcome are similar in TKA group.
In UKA group, the patients have lesser blood loss and a faster recovery.
UKA is more minimally invasive and protects the soft tissue in a higher degree than TKA.
Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there
is considerable controversy regarding how best to treat patient with advanced arthritis.
In the younger patient group, UKA compared to TKA allow them to maintain an active, healthy lifestyle.
Preserving both cruciate ligaments in unicondylar knee arthroplasty likely provides more normal knee
mechanics and contributes to enhanced patient function.
Preserving both cruciate ligaments UKA maintain some basic features of normal knee kinematics.
A disadvantage of TKA is the arduous rehabilitation and bone loss, opting for UKA, especially in young,
high-demand patients.
TKA procedures demonstrate more problems with the patella in regards of anterior knee pain.
In TKA it’s still an unsolved poroblem wether to replace the patella or not.
UKA treated patients show less problems with patella compared to TKA treated patients.
References
1. Berger, R. A. et al. Unicompartmental knee arthroplasty. Clinical experience at 6- to 10-year followup. Clin.Orthop.Relat
Res.367 (1999): 50-60
2. Deshmukh R V and Scott R D: Unicompartmental knee arthroplasty: long-term results. Clin. Orthop.Relat Res. 392 (2001):
272-78
3. Faour-Martín O et al.Oxford phase 3 unicondylar knee arthroplasty through a minimally invasive approach: long-term results.
Int Orthop. 2013 Mar 17
4. Baker PN et al.Comparison of patient-reported outcome measures following total and unicondylar knee replacement. Bone
Joint Surg Br. 2012 Jul;94(7):919-27.
22

CASE 4
OSTEOARTHRITIS GRAD III LATERAL COMPARTMENT
History:
O/E:
- 60 yrs. old lady
- BMI 35kg/cm2
- Pensioner
- Daily pain
- No sports activities
- Mild Effusion
- Full ROM
- Collateral ligaments stabile
- Pain at the lateral side and at the patellofemoral compartment
23

CASE 4
GRADE III LATERAL OA IN ACTIVE 60 YRS OLD WOMAN
TKA
Samih Tarabichi
United Arab Emirates
Total knee replacement has more dependable and predictable outcome in 60 years old active patients. Our
experience confirm that full flexion after total knee replacement can be achieved for active patient. Uni
knee replacement has inferior results as compared to TKA the survival ship is less. Lateral Uni replacement
has inferior result if compared to medial uni. In 60 years old active female the outcome of total knee
replacement is more predictable if compared to the uni.
24

CASE 4
GRADE III LATERAL OA IN ACTIVE 60 YRS OLD WOMAN
UKA
Carsten Oliver Tibesku
Straubing, Germany
1. Invasiveness
UKA provide a less invasive approach than TKA, including less blood loss, less infections, a shorter
hospital stay, and a faster recovery. UKA is less expensive than TKA [1].
2. Patient satisfaction
The perceived patient satisfaction is higher in UKA than TKA [2, 3].
3. Function
Although deep flexion can also be achieved with modern TKA, the following parameters are more normal
and closer to the healthy knee in UKA than TKA: kinematics of the knee [4], ap- and ml-stability [5],
restoration of joint line, muscle activity (EMG) [6-8], muscle strength [6], proprioception [6-8], and gait [6-
8].
4. Longevity
Long-term survival of lateral UKA and TKA are comparable, with newer lateral UKA implants achieving a
10-year-survival of 92% and 16-year-survival of 84% [1, 9].
5. Ease of revision
Lateral UKA can easily be revised to primary total knee replacements. Revision of UKA is cheaper than of
TKA. The results of revision TKA after UKA appear to be better than after HTO or TKA [1, 10].
References
1. Heyse TJ, Tibesku CO. Lateral unicompartmental knee arthroplasty: a review. Arch Orthop Trauma Surg. 2010;130(12):1539-
48
2. Laurencin CT, Zelicof SB, Scott RD, Ewald FC. Unicompartmental versus total knee arthroplasty in the same patient. A
comparative study. Clin Orthop Relat Res. 1991 (273): 151-6
3. Rougraff BT, Heck DA, Gibson AE. A comparison of tricompartmental and unicompartmental arthroplasty for the treatment
of gonarthrosis. Clin Orthop Relat Res. 1991 (273): 157-64
4. Argenson JN, Komistek RD, Aubaniac JM, Dennis DA, Northcut EJ, Anderson DT, et al. In vivo determination of knee
kinematics for subjects implanted with a unicompartmental arthroplasty. J Arthroplasty. 2002; 17(8): 1049-54
5. Becker R, Mauer C, Starke C, Brosz M, Zantop T, Lohmann CH, et al. Anteroposterior and rotational stability in fixed and
mobile bearing unicondylar knee arthroplasty: a cadaveric study using the robotic force sensor system. Knee Surg Sports
Traumatol Arthrosc. 2012
6. Fuchs S, Frisse D, Laass H, Thorwesten L, Tibesku CO. Muscle strength in patients with unicompartmental arthroplasty. Am
J Phys Med Rehabil. 2004; 83(8): 650-4; quiz 5-7, 62
7. Fuchs S, Frisse D, Tibesku CO, Laass H, Rosenbaum D. Proprioceptive function, clinical results, and quality of life after
unicondylar sledge prostheses. Am J Phys Med Rehabil. 2002; 81(7): 478-82
8. Fuchs S, Rolauffs B, Plaumann T, Tibesku CO, Rosenbaum D. Clinical and functional results after the rehabilitation period in
minimally-invasive unicondylar knee arthroplasty patients. Knee Surg Sports Traumatol Arthrosc. 2005; 13(3): 179-86
9. Argenson JN, Parratte S, Bertani A, Flecher X, Aubaniac JM. Long-term results with a lateral unicondylar replacement. Clin
Orthop Relat Res. 2008; 466(11): 2686-93
10. Chatain F, Richard A, Deschamps G, Chambat P, Neyret P. [Revision total knee arthroplasty after unicompartmental
femorotibial prosthesis: 54 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2004;90 (1): 49-57
25

CASE 5
PATELLOFEMORAL + MEDIAL OSTEOARTHRITIS
History:
O/E:
- 60 yrs old lady
- BMI 27kg/cm2
- Pensioner
- Moderate exercise
- Pain during activity and rest
- No Effusion
- ROM: 0 - 5 - 120
26

CASE 5
PATELLOFEMORAL + MEDIAL OA IN A 60 YEARS OLD WOMAN
TKA
Timothy Wilton
United Kingdom
The surgical treatment of this patient’s condition would no longer appropriately be by minor interventions
such as arthroscopic surgery. The likelihood of deterioration rather than improvement would be very
significant and IF the patient were to improve the improvement would be likely to be confined to
mechanical symptoms. Any improvement in pain would be likely to be short-lived.
Arthroplasty would therefore be required and this could be by partial multi-compartment replacement or by
Total replacement.
Revision rates for UNI are universally shown to be around 2-3 times higher at 10 years than the revision
rates for TKA in all national registries from around the world [1, 2]. The revision rates for PFJ replacement
alone are higher than those for UNI, the results in the NJR being around 50% worse for PFJ replacement.
In a recent presentation about the Avon PFJ, the PFJ replacement with the best results reported, with over
10 years of follow-up Ackroyd [3] showed significant deterioration in revision rates between 5year and 10
year follow-up.
There is no obvious reason to believe that the results of combined UNI and PFJ replacement would have
anything but higher revision rates than the individual components alone even when used for appropriate
indications, since some of the cases would require revision for failure of BOTH while some would fail in
each of the constituent implants and yet others would fail with progression in untouched compartments.
Finally there would be some revisions because the implants would be easier to revise than a TKA.
Several studies [4] have reported high revision rates with the Deuce implant even in relation to the results
expected with other partial replacements.
On the basis of revision rate there is therefore no contest and it follows that the only justification for
performing a partial replacement would be if that could be shown to give a better clinical or functional
outcome than a TKA.
Evidence that the use of either combined UNI and PFJ, or the Deuce implant, gives predictably better
clinical or functional outcomes is inconclusive at best. What evidence of that kind has been forthcoming
refers to relatively short term data and is currently therefore a poor excuse for using implants with a higher
revision rate.
References
1. 9 th Annual Report of National Joint Registry Available online at ‘njrcentre’
2. 2012 Annual Report of Australian Arthroplasty Register
3. 8-14 year results of Avon PFJ replacement CE Ackroyd at BASK Annual Meeting Derby. March 2012
4. Early Failure using the Deuce arthroplasty White SP, Forster MC, Joshy S. BASK Annual Meeting Cardiff March 2011
27

CASE 5
PATELLOFEMORAL + MEDIAL OA IN A 60 YEARS OLD WOMAN
BICONDYLAR
Francesco Benazzo
Italy
Principles
- type of patient
- level of activity
- what implant she deserves
Pre-op evaluation
X-rays:
- full weight bearing x-rays: indication for uni
- lateral view : pf evaluation
- patellar axial view: evaluation of patellar facet involved
- CT/MRI not really necessary unless particular needs/doubts
Clinical
- “one finger sign”
- anterior knee pain (AKP)
- wich patellar facet is clinically painful
Options for treatment
- Uni solo
- Uni+pf arthroplasty
- TKA
Indications
Uni solo: “one finger sing” + slight AKP with only medial facet involved
Uni+pf arthroplasty: medial pain + AKP with lateral facet involved in patients:
- high demanding patients
- low demanding with need of quicker rehab and/or need of more proprioception (i.e. neurological
problems)
TKA: any contraindication for a Uni implant (i.e obesity, no ACL, major deformity etc)
Surgical technique issues
- approach and exposure
- sequence of surgical steps
- sizing
- rotation of pf component
- limb realignment
References
1. F. Benazzo, S.M.P. Rossi, L. Piovani, A. Combi, S. Perle Bi-uni und bi-uni + femoropatellarer. Gelenkersatz 2012
2. Thienpont, Price Bicompartmental knee arthroplasty of the patellofemoral and medial compartments. Knee Surg Sports
Traumatol Arthrosc. 2012 Nov 25. [Epub ahead of print]
3. F. Benazzo SMP Rossi Unicompartment Knee Arthroplasty From Primary to Revision Surgery G. Bentley (ed.), European
Instructional Lectures, European Instructional Lectures 13, 255 DOI 10.1007/978-3-642-36149-4_21, © EFORT 2013
28

INDICATION + IMPLANT SELECTION
Andrea Ferretti
Italy
INDICATION
1. Pathology
degenerative osteoarthritis (primary or secondary)
- uni/bicompartimental
- tricompartimental
- isolated patello-femoral ()
Inflammatory diseases
Tumors
2. Symptoms
Pain: it is the predominant symptom in patients seeking knee arthroplasty.
Instability: Osteoarthritis (OA) leads to a loss of proprioceptive function and deep sensibility and a loss of
function of several anatomical structures.
Range of motion: Knee stiffness restricts all daily activities (eg. To walk normally, to ascend or to descend
stairs, to get up from a chair…)
Disability: OA can seriously affects daily life activities. Inability to perform sport activity and the aim to
resume it is not a right indication for TKA.
Summary
A right indication is the key of the success in TKA. There is no treatment for a total knee arthroplasty
implanted with a wrong indication.
References
1. Polkowski GG 2nd, Ruh EL, Barrack TN, Nunley RM, Barrack RL. Is pain and dissatisfaction after TKA related to earlygrade
preoperative osteoarthritis Clin Orthop Relat Res. 2013 Jan;471(1):162-8.
2. Russell RD, Huo MH, de Jong L, Jones RE. Preoperative flexion does not influence postoperative flexion after rotatingplatform
total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013 Jan 12.
IMPLANT SELECTION
1. Retaining-cruciare PCL or substuting-cruciate PCL
Retaining the PCL is believed to aid in proprioception and AP stability. On the other hand, ligament
balancing and correction of knee deformity are more difficult with PCL retention. A loose PCL may lead to
instability and pain, whereas a tight PCL may restrict knee flexion and lead to high stress concentration in
the polyethylene liner. CS Prosthesis was designed to improve stair climbing, better range of knee motion
and prevention of posterior subluxation of the tibia.
2. Cement or Cementless TKA
There has been a recent increase in interest for non-cemented fixation in total knee arthroplasty with a
similar survivorship rates. The use of uncemented implants could result in a better alignment, in both the
frontal and the sagittal plane, due to a more precise impaction procedure.
3. Fixed- or mobile-bearing TKA
Features inherent in the design of the tibial component of the rotating-platform knee protect the boneprosthesis
interface from the excessive micromotion. Shear and torque forces at the fixation interface were
minimized through the rotational relief provided by the mobile-bearing configuration. Biomechanical
testing has demonstrated that, under physiological loading, the tibial insert will rotate rather than
transferring those stresses to the tibial base plate.
Summary
Know the implant that you are using. Use the one you Know best.
References
1. Baier C, Springorum HR, Götz J, Schaumburger J, Lüring C, Grifka J, Beckmann J. Comparing navigation-based in vivo knee
kinematics pre- and postoperatively between a cruciate-retaining and a cruciate-substituting implant. Int Orthop. 2013 Mar;
37(3): 407-14.
2. Ranawat CS, Meftah M, Windsor EN, Ranawat AS. Cementless fixation in total knee arthroplasty: down the boulevard of
broken dreams - affirms. J Bone Joint Surg Br. 2012 Nov; 94 (11 Suppl A): 82-4.
3. Iorio R, Bolle G, Conteduca F, Valeo L, Conteduca J, Mazza D, Ferretti A. Accuracy of manual instrumentation of tibial
cutting guide in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012 Apr 24.
29

PLANNING + APPROACH
Roland Becker
Department of Orthopaedic and Trauma Surgery, Hospital Brandenburg, Germany
Surgical planning is crucial for successful total knee arthroplasty (TKA). The planning will improve the
precision of surgery and decreases the OR time. Both the surgeon and the OR staff will work more
efficient during the entire surgical procedure.
The five-step algorithm of surgical planning
1. Decision over type of implants (cruciate retaining, posterior stabilized, total stabilized)
2. Component sizing and placement
3. Patients placement
4. Usage of tourniquet
5. Surgical approach
1. The type of implant might depend from the degree of osteoarthritis and the severity of
malalignment. Spacer should be considered in case the joint line is not preserved. If the knee can not
be balanced during surgery very well you should rather consider a more constrained implant.
2. Templating includes the sizing and positioning of the implants in both the
anteroposterior and lateral view. Standardized X-rays are essential for correct planing, such as: 1.
Anteroposterior long leg weight bearing view
2. Anteroposterior and lateral view with the correct magnification
3. Merchant view in order to assess the shape and degree of degeneration
of the patella
Component sizing and placement is required in the frontal and sagittal plane. Sometimes there is a
mismatch between the anteroposterior and mediolateral dimension. Very few companies provide
asymmetrical tibial components. The major problem with the symmetrical tibial component seems to
be the postereolateral overhang, which may cause impingement of the popliteus tendon during knee
extension.
The planning on X-ray relies on the bony anatomy. Digital planning is nowadays mandatory using
different kind of commercially available software. The components are positioned according to the
anatomical landmarks. The joint line will be placed perpendicular to the mechanical axis. The
amount of bony resection can be determined prior surgery and checked during the operation.
The degree of varus or valgus deformity will provide information about the amount of correction.
Thus soft tissue release can be planed as well.
Patient’s specific instrumentation requires CT-scan or MRI. Component sizing and the positioning
of the component are already planed on the computer. However the planning is outsourced but
needs to be controlled by the surgeon. Some studies have shown very precise component placement.
However there is still a lack or data to support the usage of patient specific technology on a routine
basis.
3. Patient positioning is very important. The exposure of the knee depends from the appropriate
position of the leg. TKA surgery is mainly performed in 60° of knee flexion. A foot support or
better a hydraulic leg holder will keep the knee in the required position. Patient placement in a good
position may safe additional assistance.
4. Surgery under tourniquet does not increase the risk of thromboembolism. The blood loss is
comparable (1). However the tourniquet causes wound hypoxia and may have an impact on early
wound healing (2).
5. The best surgical approach remains debatable. The standard medial approach is most commonly
used. The approach allows an extension very easily. However the midvastus or subvastus approach
has become very popular in primary TKA especially since minimal invasive surgery has been
introduced. No difference in muscle function was found between the subvastus and midvastus
approach (3). Patella mobility is well preserved in both approaches. Patella mobility is one important
factor in order to achieve good range of motion after surgery.
Some authors recommend the lateral approach in valgus knees. The tight soft tissue structures can
be released during the approach. Frequently the approach requires osteotomy of the tibial tubercle in
30

order to get sufficient access to the joint during surgery (4). A complication rat of up to 8% has been
reported with the tibial tubercle osteotomy according to a meta-analysis.
Keeping all these aspects in mind the surgeon might face less unexpected situations during surgery.
Take home message
1. Standard X-rays such as full leg weight bearing view, anteroposterior, lateral and Merchants view
are required.
2. Correct component sizing and placement in the frontal and sagittal plane.
3. Correct patients placement on the OR table using foot support or hydraulic leg holder. Keep in
mind surgery is performed mainly in 60° of knee flexion.
4. The surgical approach does not show significant impact on muscle function
after surgery. Patella mobility seems to be better preserved when the midvastus or subvastus
approach is used.
References
1. Smith TO, and Hing CB. Is a tourniquet beneficial in total knee replacement surgery A meta-analysis and systematic review.
Knee. 2009; 17(2): 141-147.
2. Clarke MT, Longstaff L, Edwards D, and Rushton N. Tourniquet-induced wound hypoxia after total knee replacement.
J.Bone Joint Surg.Br. 2001;83(1):40-44.
3. Berth A, Urbach D, Neumann W, and Awiszus F. Strength and voluntary activation of quadriceps femoris muscle in total
knee arthroplasty with midvastus and subvastus approaches. J Arthroplasty. 2007, Jan;22(1):83-8.
4. Zonnenberg CB, Lisowski LA, van den Bekerom MP, and Nolte PA. Tuberositas osteotomy for total knee arthroplasty: a
review of the literature. J Knee Surg. 2010, Sep;23(3):121-9.
31

BONE CUTS +ROTATIONAL POSITION
Norberto Confalonieri, Alfonso Manzotti
1st Orthop Dept CTO Hospital, Milan, Italy
Key Points
1. There are a total of 7 bone cuts in a typical total knee replacement (TKR):
• Tibia (or femur first)
• distal femur
• anterior femur
• posterior femur
• anterior chamfer,
• posterior chamfer,
• and patella.
Each of these cuts has its own special science, and each cut can affect the other cuts and potentially the
outcome of the TKR.
Aims of bone cuts
• correct mechanical axis
• restoration joint line
• equalizing flexion and extension gaps
• balancing soft tissues
• correct patella-femoral kinematics
Techniques
2. Measured Resection (femur fist):
Basis:
• anatomical reconstruction of the femur
• remove amount of bone as component thickness
• rotation based on anatomical landmarks
Advantages
Maintaining joint line
Minimize mid-flexion instability
May be easier to be performed
Disadvantages
Unpredictable femoral rotation
Asymmetric flexion gap
Predispose to lateral laxity and condylar lift-off
Gap balancing technique (tibia first)
Basis:
• Ligament balanced femoral resection
• Flexion/extension gap determining distal femoral resection
• Flexion gap determine femoral component rotation (irrespective of bone landmarks!!!)
• Parallelism to the epycondilar axis is not the objective (+6°)
Advantages
Create equal and symmetric flexion/extension gaps with
equal symmetric collateral ligaments tensions
Enhances patellar tracking
Disadvantages
More difficult joint line restoration
Depends on accurate tibial cut to create rectangle in flexion
and appropriately roatae the femoral component
More difficult to be performed without any CAS tools
Aims of rotational positionnement:
• Avoid patellar maltracking (abnormal Q angle)
• To achieve a symmetric flexion-extension gap
• To achieve a more “normal” kinematics
• To minimize instability/wear/pain
32

Techniques
Femoral Rotation
• Transepincondylar Axis
• Posterior Condylar Line
• Balanced Flexion Gap
• Whiteside Line
• Functional Flexion axes
Tibial Rotation
• “Rom technique”
• Posterior Lateral corner Lockeh Technique (“PLCL”)
• Anterior tibial tuberosity (1cm medially)
• Posterior tibial margin
• PCL insertion
• Projected tranepycondylar axis
• Center of 2 tibial plateaus
• Akagi line
• Anterior tibial plateau marging (“curve to curve”)
Ancillary Tools:
• Conventional intra/extramedullary guide
• Patient Specific Instrumentation (PSI)
• Computer assisted technique CAS (offers to the surgeon the numbers and a real feed back in O.R.,
without losing his control!)
• Robot (maybe in future)
Pearls
The BONE CUTS CORRECT ARTHRITIS
DEFORMITY and the THICKNESS of
PROSTHESIS BALANCES THE KNEE.
Minimal bone cut rule: prosthesis thickness
(mm) minus arthritis deformity (degrees) = mm
of bone to remove
Navigation offers the numbers to be considered during all the
phases of your procedure to assess alignment, gaps balancing
and rotational aspects
Take home message
• Correct the arthritis deformity by bone cuts
• Remove the minimal bone stock
• Restore the joint line
• Balance the ligament with the same joint spaces and the prosthesis thickness
• Do not accept passively any dogma in rotation (do not rotate the femur, check the piano sign...)
• CAS tools (navigation, psi, robot, ecc.) are not a different technique but an ancillary tool for better
information about your personal procedure
33

SOFT TISSUE BALANCING + PATELLAR TRACKING
Robin Strachan
United Kingdom
SOFT TISSUE BALANCING
Planning and measured resection
Planning and templating is not enough to guarantee adequate soft tissue balancing, particularly in severe
deformity. Variation in patient morphology both in the limb and the knee itself, when associated with bone
deficiency and ligament laxity and/or contracture means that each case is an individual exercise. Tensions
within the ligaments and capsular envelope must be matched to the size and position of the components.
Bone cut basics
The aim of the initial bone cuts is to match ligament and capsular tensions to the size and positions of the
components, throughout a full range of motion in order to optimise stability, motion, function and wear.
These initial cuts are however only the starting point. To rely solely upon bone cuts and in particular
femoral rotation to achieve gap balance may not be enough to achieve optimal balancing and dynamics.
Initial balancing and sequential releases
Various algorithms for sequential release of valgus and varus knees have been described starting usually
with fixed and then dynamic structures. The sequences can be somewhat variable but do fall into logical
sequences. Some danger lies in over-release and the creation of instabilities which then requires more
constrained components, thereby leading to more stress on the bone-implant interface. Under-release leads
to tightness and restriction of motion. Both tightness and instability can increase component wear.
Motion and the Cruciates
Balancing the PCL in cruciate retaining knees and countering the effect of ACL section is highly important
in terms of improving ROM, function and wear. The PCL can be sacrificed as a resort when deformity is
otherwise uncorrectable or the PCL is degenerate.
Intra-op testing of motion
There is no substitute for experience and surgical feel for any excess laxity or tightness in different
directions or at different degrees of flexion, in order to be able to optimise function of the final TKA
construct. Intra-operative testing regimes should try to identify any deficiencies within 6 degrees of
freedom in order to fully assess knee stability at each stage of the ligament balancing process. Valgus-varus,
antero-posterior and axial stress must be applied. ‘Drop testing’ the knee also ensures that flexion is
adequate. Care must be taken to look out for mid-flexion tightness or instability. Surgical navigation can
assist with quantification of motion during such assessments.
Changing a Component or it‘s position
There should be no hesitation in considering adjustments to size and position of components by such
manoeuvres as fine tuning of bone cuts, particularly in situations where further soft tissue releases will lead
to instability and a requirement for more constrained components.
Final synchronisation
Indeed, final synchronisation of the TKA construct should probably always involve consideration of
adjustments to distal cuts, slopes, component sizes and offsets at the same time as assessing how much
release of soft tissue would be required to achieve the same effect. Therefore a graduated approach to both
bone cuts and releases appears to be required, particularly in cases with complex deformities.
Summary
• Planning is necessary in complex cases
• Consider bone cuts and releases together
• Test joint dynamics after every adjustment
• Be prepared to change a component
• Small adjustments can have large effects
• Don’t forget the extensor mechanism.
34

PATELLAR TRACKING
Tibio-femoral dynamics
Patellar motion is highly dependent upon tibio-femoral motion and may be highly abnormal even before
TKA is attempted. Chronic retinacular contracture can lead to poor patellar tracking, restricted flexion, pain
and wear.
Iatrogenic factors
There has been an extensive and well-documented history of failure to adequately address patellar tracking.
Even in recent analyses, over 15 percent of patellae have been shown to track abnormally. Iatrogenic
factors including mal-positioning of components have been important in the past, but recent improvements
in the understanding of trochlear shape and positioning have helped greatly. Too thick a patella, oblique
patellar cuts and mal-positioned buttons can lead to pain and impingements. Overstuffing of the extensor
compartment can arise from anterior femoral positioning and oversizing.
Deformity and contracture
However, even when tibio-femoral joint dynamics have been optimised there remains a cohort of patients
of about 6% in an average knee arthroplasty practice, who will require some degree of soft tissue balancing
of the extensor mechanism. This is particularly so in cases where the primary abnormality has been within
the extensor mechanism and has led on to contracture of the lateral retinacular structures and collapse of
lateral patellar or lateral femoral bone.
Assessment of tracking and its correction
Intra-operative testing should always include temporary partial closure of the medial parapatellar incision
and stress testing of the whole knee construct while carefully observing patellar tracking including with the
tibia externally rotated. Staged lateral release can be performed using various techniques such as ‘piecrusting’
and ‘inside-to-out’ cuts. It is the authors preference however to use a staged , ‘proximal-to-distal’,
‘outside-to-in’ method in order to minimise risk of damage to the geniculate vessels and keep the knee
cavity sealed from the subcutaneous plane. Once again, surgical navigation can assist with quantification of
the severity of the problem and the efficacy of correction. Medial plication may be required, but must not
be used in isolation against tight lateral structures.
Summary
• Be aware of morphological variation in the knee and severe deformities
• Optimise all component positions
• Test and adjust tibio-femoral dynamics
• Then test patella tracking
• As a last resort, re-balance the soft tissues of the PFJ.
35

BLOOD MANAGEMENT + PAIN CONTROL & REHAB
Matteo Denti, Piero Volpi
Humanitas Institute, Milan, Italy
Blood management, pain management and rehabilitation are important aspects during for fast recovery
after total knee arthroplasty (TKA).
1. Blood management
The risk of bleeding is between 500-700 ml but the total true blood loss following TKA
is twice the volume of the visible loss (drainage).
We could have different strategies:
Pre-operative strategies
* Erythropoietin supplementation
* Preoperative autologous donation
High costs (Erythropoietin supplementation) Wastage up 55% of autologous blood when routinely used
(reinfusion) Decreased preoperative Hb levels (preop donation)
Intra-op. and Post-op. Strategies
* Surgical techniques to minimize blood loss (cemented component, careful homeostasis, etc..)
* Perioperative blood salvage
The use of Tranexamic acid reduce in a significant way the risk of blood transfusion in TKA. The use of
fibrin sealant did not show any reduction in the transfusion rate.
2. Pain management
The pain could be control with:
Epidural analgesia
Epidural catheter infusion of Ropivacaine: 2 or 3mg /millilitre.
Maximum 28mg /hour
Ropivacaine is a god sensory blocker but realises less motor blocking effects
Femoral nerve block
Local anesthetic blockade of femoral nerve, is an excellent technique for anaesthesia of the knee
Continuous femoral nerve block (perineural catheter), provides postoperative analgesia after knee
arthroplasty.
Endovenouse analgesia
Continuous endovenouse analgesia with oppioid and NSAIDs
Patient controllaed analgesia
PCA morphine pump is programmed to give an intravenous bolus of morphine (2mg/dose) on demand,
with a lock out time of 6 minimum and maximum dose of 35mg over 4 hours.
In addition to PCA, patients may receive NSAIDs i.v, Paracetamol (1gr x 4).
3. Rehabilitation
- full weight bearing as early as possible
- crutches related to the patient and without as soon as possible
- CPM only during the hospitalization
- Quadriceps exercises
- Lymph drainage
36

WHO WILL PAY THE COSTS OF NEW TECHNOLOGIES IN ARTHROPLASTY
Jean-Noël Argenson
France
1. The economic and medical challenge for TJA
- increasing life expectancy
- growing demand for TJA procedures
- increased cost related to new technologies
2. Increased projected OA knee younger patients
- the less than 65 to represent 60% of all TKA in 2030
- average 25% increase life expectancy with implant
- active life style
- increased expectations
- more likely to use more costly premium implants
3. Reasons for increased TKA utilization
- increased population
- epidemic obesity
- sport-related injuries
- newer components to last longer and accommodate high activity
- better preoperative health to provide better outcome
4. Cost-effectiveness analysis of TJA
- quality adjusted life gained
- cost per quality of life gained
- TJA is effective clinically and in terms of effectiveness
5. Payers for new technologies in TJA
- patients
- hospitals
- national systems
- private insurance
- health suppliers
References:
1. Bozic JJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effectiveness analysis to evaluate new technologies in
orthopaedics. J Bone Joint Am.2006; 88-A:706-14
2. Kurtz SM, Lau ED, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint
replacement. Clin Orthop. 2010; 467:2606-12
3. Gioe TJ, Sharma A, Tatman P, Mehle S. Do “premium” joint implants add value Clin Orthop 2010; 469:48-54
4. Losina EL, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the
United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am. 2012;
94-A:201-7.
5. Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR. Predicting the cost-effectiveness of total hip and
knee replacement. Bone Joint J 2013; 95-B:115-21
6. Kremers MH, Visscher SL, Moriarty JP, Reinalda MS, Kremers WK, Naessens JM, Lewallen DG. Determinants of direct
medical costs in primary and revision total knee arthroplasty. Clin Orthop 2013; 471:206-14
37

WHO WILL PAY THE COSTS OF NEW TECHNOLOGIES IN ARTHROPLASTY
Renaat Vermeulen
Eucomed and EHTI Board Member, Belgium
Paying for “New Technology” in arthroplasty is just one element of a broader challenge that Health Care
faces today. The real question is how innovation will be funded when less means are available.
Innovation runs in cycles, driven by a need. Competition between both researchers and companies may
lead to an invention. The earliest applied versions of the invention are typically expensive. When the
technology and manufacturing methods mature, the prices come down substantially and the technology
becomes part of basic offering. New or incremental innovation is the next step in the cycle, which is
illustrated with the case of PSI (Patient Specific Instruments)
Medical Innovation however is under threat in Europe because of a large funding gap in Health Care
systems around Europe. The question is raised whether innovation should be stopped and it is commented
as to why that is not a desirable solution. Four things need to happen in a sustainable funding model.
- Industry should behave socially responsible; several examples of Industry’s recent contributions to
funding are illustrated
- Early adopters should be supported and with their co-operation better clinical and economical
evidence of innovative devices should be collected
- A dramatic reduction of the inefficiencies in the Health Care system needs to happen. A few
examples are given to illustrate the potential of efficiency gains
- Funding of innovation with Community money is crucial to avoid cost of opportunity and to
maintain Industry competitiveness with other world regions
Conclusion: there is no straight-forward answer to the title question. There is a shared responsibility of all
stakeholders, but as a Society we have an overwhelming duty to continue to fund innovation.
38

HOW TO IMPROVE PATELLO-FEMORAL TRACKING WITH CURRENT TKA DESIGN
TROCHLEAR CONSTRAINT ROLE
Andrew Amis
Imperial College, London, United Kingdom
Key points
1. Near knee extension, patellar tracking and stability are controlled mainly by the soft tissues – the
quadriceps and retinacula – and not by the trochlear geometry. Therefore, good tracking in early knee
flexion depends primarily on soft tissue balancing.
2. The natural trochlear groove has a prominent lateral facet which controls patellar lateral translation
when the patella enters the groove around 20 degrees knee flexion.
3. In general, there will be a higher constraint to control the patellar tracking when the trochlear groove is
deeper and has a steeper slope on the articular facets.
4. Patellar tracking follows the natural trochlear groove, which is aligned with the mechanical axis of the
femur.
5. Modern prostheses with grooves which are lateral near extension and medial near deep flexion are not
anatomical and do not offer more physiological tracking or medial-lateral stability than did the older
designs.
6. Patellar tracking is also influenced by the position of the prosthetic femoral component: external
rotation causes the patella to be carried laterally and to be tilted laterally.
7. We may conclude that patellofemoral joint function after TKA depends on accurate implant alignment
and soft tissue balancing. These surgical factors may be more important than the geometry of the
implant!
39

HOW TO IMPROVE PATELLO-FEMORAL TRACKING WITH CURRENT TKA DESIGN
TROCHLEAR ORIENTATION ROLE
Nico Verdonschot
The Netherlands
Key points
1. Prosthetic groove is longer than femoral trochlea
2. TKA changes patella-femoral kinematics
3. Trochlea is usually medialized after TKA
4. Symmetric or asymmetric groove hardly affects patella kinematics
5. No tilt and no displacement after TKA does not mean that the patella is in its natural position
40

IDEAL POSTOPERATIVE ALIGNMENT FOR TKA
RESTORE IT TO NEUTRAL
Arun Mullaji
India
1. Better survivorship for neutral knees: Most long-term studies show better implant survivorship for
neutrally aligned knees. Recent publications (see References) will be discussed.
2. Better function for neutral knees: has been demonstrated in several recent studies which have focused
on outcomes vis-à-vis alignment.
3. Lower failure of neutral knees in patients with higher BMI: Obesity is increasing all over the world.
Higher BMI has been shown in some studies to result in higher mechanical failure rates. The incidence
is reduced in neutrally aligned knees.
4. Anatomical or kinematic alignment is hazardous if extra-articular deformity exists. Several Asian
surgeons have published data on the high prevalence of extra-articular deformity such as femoral and
tibial metaphyseal bowing in patients undergoing TKA. These patients will be at high risk for
significant malalignment if anatomical alignment is sought.
5. There is a paucity of randomized, long-term studies till date to show superiority of anatomical
alignment with regards to either short-term benefits in terms of improved kinematics and enhanced
patient satisfaction or long-term survivorship. In fact most studies strongly caution against excess varus
of the tibial component and excess valgus of the femoral component.
Till such time as convincing long-term data and evidence emerges that it is safe to place the components in
anything but neutral alignment, surgeons should continue to aim for neutral alignment to ensure longevity
of the implant. However, it must be stated that coronal alignment is not the only contributing factor to
durability and success; correct sizing of components, rotational alignment, joint line restoration, soft-tissue
balance, cementing techniques, BMI, gait, patient expectations and activity level are also some of the other
crucial factors that can influence outcomes.
References
1. Shetty GM, Mullaji A, Kanna R, Vadapalli R. Variation in valgus correction angle and factors affecting it: analysis of 503
navigated total knee arthroplasties J Arthroplasty 2013; 28: 20-27
2. Mullaji A, Shetty GM. Persistent hindfoot valgus causes lateral deviation of weight-bearing axis after total knee arthroplasty.
Clin Orthop Relat Res 2011; 469:1154-60.
3. Mullaji A, Lingaraju AP, Shetty GM. Alignment of computer-assisted total knee arthroplasty in patients with altered hip
center. J Arthroplasty 2011; 26:1072-7
4. Mullaji AB, Marawar SV, Mittal V. A Comparison of Coronal Plane Axial Femoral Relationships in Asian Patients With Varus
Osteoarthritic Knees and Healthy Knees. J Arthroplasty 2009; 24(6): 861-7
5. Mullaji A, Shetty GM. Computer-assisted TKA: Greater Accuracy, Doubtful Clinical Efficacy (Orthopedic Crossfire:
Opposes) Orthopedics 2009 Sep; 32(9): 1-4
6. Mullaji A, Kanna R, Marawar S, Kohli A. Comparison of limb and component alignment using computer-assisted navigation
versus image intensifier-guided conventional total knee replacement: A prospective randomised single-surgeon study of 467
knees. J Arthroplasty 2007; 22(7): 953-959
7. Bonner TJ, Eardley WGP, Patterson P, et al. The effect of post-operative mechanical axis alignment on the survival of
primary total knee replacements after a follow-up of 15 years. J Bone Joint Surg Br 2011;93:1217
8. Choong P, Dowsey M, Stoney J. Does accurate anatomical alignment result in better function and quality of life comparing
conventional and computer-assisted total knee arthroplasty. J Arthroplasty 2009;24:560.
9. Huang NFR, et al. Coronal Alignment Correlates With Outcome After Total Knee Arthroplasty: Five-Year Follow-Up of a
Randomized Controlled Trial. J Arthroplasty 2012; 9: 1737-41
10. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it J Arthroplasty.
2009;24(6 Suppl):39-43.
11. Ritter MA et al. The Effect of Alignment and BMI on Failure of Total Knee Replacement. J Bone Joint Surg Am. 2011;93:1588-
96
How do I manage severely deformed knees
1) Decide whether there is associated extra-articular deformity or not based on full-length standing
radiographs.
2) Plan whether correction is to be done intra-articular IA or extra-articular EA. On the femoral side this
is determined by noting whether the putative femoral resection (perpendicular to its mechanical axis)
will compromise either collateral ligament attachment if correction was planned IA, in which case an
EA correction would be prudent. On the tibial side if the proximal extension of the mid-axis of the
tibia distal to the deformity falls outside the tibial plateau then an extra-articular correction would be
required.
3) Purely intra-articular release will require lesser bony resections but larger soft-tissue releases which will
lead to larger flexion than extension gaps, requiring adjusting of femoral component size (upsizing) and
41

placement (in flexion and posterior translation) to equalize gaps. Reduction osteotomy is a useful
manoeuvre to achieve further correction and balance of ligaments.
4) Extra-articular correction may be required on the femoral side or tibial side; it may entail performing a
concomitant sliding medial or lateral femoral condylar osteotomy, transverse corrective femoral or
tibial osteotomy. Screws, plates or locking IM nails, stems or sleeves may be required to fix the
osteotomy.
5) Associated bone defects on the tibial plateau may need to be addressed by autologous grafting or metal
augments with additional stems.
6) Most deformities can be treated with a posterior-stabilized device. Additional constraint in the form of
a varus-valgus constrained implant may occasionally be deployed if there is residual ligament imbalance
or a larger flexion gap; rarely a hinge may be used if there is significant stretching/lack of integrity of
the medial collateral ligament or a flexion gap that is too large to be dealt with using a vvc implant.
References
1. Mullaji A, Shetty GM. Surgical Technique: Computer-assisted Sliding Medial Condylar Osteotomy to Achieve Gap Balance in
Varus Knees During TKA Clin Orthop Relat Res Jan 2013
2. Mullaji A, Shetty GM, Lingaraju AP Computer-assisted total knee replacement in patients with arthritis and a recurvatum
deformity J Bone Joint Surg Br 2012; 94-B 5: 642-647
3. Mullaji A, Shetty G. Total knee replacement for arthritic knees with tibio-fibular stress fractures: Classification and treatment
guidelines J Arthroplasty 2010; 25(2): 295-301
4. Mullaji A, Shetty GM. Lateral Epicondylar Osteotomy Using Computer Navigation in Total Knee Arthroplasty for Rigid
Valgus Deformities J Arthroplasty 2010; 25(1):166-9
5. Mullaji A, Shetty G. Computer-Assisted Total Knee Arthroplasty for Arthritis With Extra-articular Deformity J Arthroplasty
2009; 24 (8): 1164-1169
6. Mullaji AB, Marawar S, Sharma A. Correcting varus deformity. J Arthroplasty 2007; 22(4) 15-19.
7. Mullaji AB, Padmanabhan V, Jindal G. Total Knee Arthroplasty for Profound Varus Deformity: Technique and radiological
results in 173 knees with varus more than 20 degrees. J Arthroplasty 2005; 20(5): 550-561.
42

IDEAL POSTOPERATIVE ALIGNMENT FOR TKA
ANATOMICAL IS BETTER
Hilde Vandenneucker
UZ KU Leuven, Belgium
1. Tradition = neutral mechanical alignment /Nowadays trend to anatomic restoration
2. Is neutral = anatomical = natural /normal
For an important fraction of normal population (M 32% / F 17%) is natural ≥ 3°varus. Restauration of
neutral alignment might be unnatural, with need for release of medial soft tissue, in this population
group
3. Is neutral important for long-term survival
Growing evidence that mild residual varus is not biomechanical harmful
43

PLANNING WITH CONVENTIONAL X-RAY OR INTRAOPERATIVE TECHNOLOGY
FOR A BETTER ALIGNMENT IN TKA
I PREFER HIGH-TECH
Justin Cobb
United Kingdom
Introduction
Surgical precision affects the clinical outcomes in technically demanding procedures such as knee
arthroplasty. Implant placement can affect limb alignment, wear, loosening and revision. The exact
technical result required for ideal implant placement can be difficult to achieve. While skilled surgeons
rarely make mistakes that are clinically important, when changing to a new device with different
instrumentation, there is a learning curve. As the world becomes more risk averse, modern and superior
knee arthroplasty systems may be hard to gain widespread adoption without some way of helping surgeons
up that learning curve.
3D planning may be cost effective
3D reconstructions of axial images can now be carried out on most mobile phones. This approach is now
normal practice in dental, craniofacial and neurosurgery. Arthroplasty surgeons should take advantage of
this cheap and accessible imaging. They allow a level of precision in planning that is impossible using
conventional radiographs. Detailed plans should be cost neutral by reducing both inventory and
instrumentation associated with precisely planned cases.
However, plans require implementation, and failure to achieve detailed plans may cause more problems
than not having plans at all.
3D surgical assistants: robots vs PSI
Three technologies now exist that help the surgeon implement plans – navigation/robotics, patient specific
instrumentation, and conventional instruments. Semi-active robotic systems combine elements of both
navigation and fully autonomous systems. They offer surgeons constraint outside of a pre-set zone of safety
rather than simply providing them with the information. Rapid prototyped cutting guides made to match
the anatomy of the patient provides an alternative method of carrying out the same task. These cutting
guides, or patient specific instrumentation (PSI), offer a simpler embodiment of the many of the steps
involved in the procedure and achieve a plan without the use of a robotic system. By reducing the number
of steps needed, PSI technology may reduce the time taken.
How can we measure surgical accuracy
Surgical precision may be determined simply by comparison between the planned implant position and
orientation and the position and orientation actually achieved. This should be balanced with the time taken
to achieve that level of accuracy, and the cost of delivery.
What level of accuracy matters
No consensus exists on the level of accuracy actually needed for clinically satisfactory results. Good
surgeons achieve as good results as robots. There is only weak evidence that error is associated with poorer
outcomes. We suggest that it is possible to plan an operation in detail, and that failure to achieve that plan
may result in a poor outcome. So technology may have a role to play.
Take home messages:
3D plans should save money by reducing risks and operating costs
Robotics and PSI produce expert level skill in less experienced surgeons
PSI should be cost neutral, a fraction of the cost of most robotic systems
Novel arthroplasty systems should be adopted with a PSI
44

PLANNING WITH CONVENTIONAL X-RAY OR INTRAOPERATIVE TECHNOLOGY
FOR A BETTER ALIGNMENT IN TKA
I PREFER CONVENTIONAL PLAN
Neil P. Thomas
Hampshire Clinic, North Hampshire and Wessex Nuffield Hospitals, United Kingdom
Key points
1. TKR results in good outcomes in the majority
2. Highly cost effective, but increasing demand
3. Mechanical alignment does not correlate well with implant longevity or clinical outcome
4. CAS and other technologies may result in improved alignment but NO difference in outcomes
References
1. Bonner TJ et al. 2011. The effect of postoperative mechanical axis alignment on the survival of primary total knee
replacements after a follow up of 15 years. BJJ 93(9):1217-1222
2. Colebatch AN et al. 2009. Effective measurement of knee alignment using AP radiographs. Knee 16(1): 42-45
3. Dakin H et al. 2012. Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set. BMJ
Open2:e000332
4. Deakin AH et al. 2012. Natural distribution of the femoral mechanical-anatomical angle in an osteoarthritic population and its
relevance to total knee arthroplasty. Knee 19(2): 120-123
5. Gbejuade H et al. 2013. Measurement of knee alignment: a comparison of long leg CT scanograms and weight bearing long
leg X-Rays. BJJ 95 suppl 9
6. Harvie P et al. 2012. Computer navigation vs conventional total knee arthroplasty: Functional results of a prospective
randomised trial. J Arthroplasty 27(5): 667-672
7. Hoffart HE et al. 2012. A prospective study comparing the functional outcome of computer-assisted surgery and
conventional total knee replacement. BJJ 94(2):194-199
8. Huang TW et al. 2011. Total knee arthroplasty with use if computer assisted navigation compared with conventional guidings
ystems in the same patient: Radiographic results in Asian patients. JBJS Am 93(13): 1197-1202
9. Kim et al. 2007. Alignment and orientation of the components in total knee replacement with and without navigation support:
A prospective randomised study. BJJ 89(4): 471-476
10. Lombardi AV et al. 2011. Neutral mechanical alignment: a requirement for successful TKR: Affirms. Orthop 34(9): e504-506
11. Lutzner J et al. 2008. Computer assisted and conventional total knee replacement: A comparative, prospective,
randomised study with radiological and CT evaluation. BJJ 90(8): 1039-1044
12. Mahaluxmivala J et al. 2001. The effect of surgeon experience on component positioning in 673 press fit condylar posterior
cruciate-sacrificing total knee arthroplasties. J Arthrop 16(5): 635-640
13. Mason JB et al. 2007. Meta-analysis of alignment outcomes in computer assisted total knee arthroplasty surgery. J
Arthroplasty 22(8):1097-1106
14. NJR (National Joint Registry) 9th Annual Report, 2012
15. Parratte S et al. 2010. Effect of postoperative mechanical axis alignment on the fifteen year survival of modern, cemented total
knee replacements. JBJS Am 92(12):2143-2149
16. Petersen TL & Engh GA. 1988. Radiographic assessment of knee alignment after total knee arthoplasty. J Arthrop 3(1): 67-72
17. Xie C et al. 2012. Clinical outcomes after computer –assisted versus conventional knee arthroplasty. Orthopaedics 35(5): e647-
653
45

MULTIMODAL APPROACHES FOR A SHORTER HOSPITAL STAY
EU TRENDS
Dieter Kohn, Matthias Brockmeyer
Germany
No evidence for an ideal length of stay
There are no scientific data that define an ideal length of stay
In Europe length of stay varies between 4 and 14 days
Median is 7 days (2008 data)
• Most surgical variables do not influence length of stay.
Postoperative blood transfusion is connected with longer LoS
Poor anaesthetic fitness is connected with longer LoS
MIS could not be connected to a shorter length of stay
• Most outcome variables are not influenced by length of stay
Less hospital aquired infections with shorter LoS
Increased patient satisfaction with shorter LoS
• With short length of stay higher readmission rate is a concern
• With short length of stay manipulation rate increases
46

MULTIMODAL APPROACHES FOR A SHORTER HOSPITAL STAY
US TRENDS
Giles R. Scuderi
USA
Take home message
1. The goal of post-operative pain management is to provide improved patient outcome and
satisfaction without undue complications
2. The right option depends on an interaction between the surgeon, anesthesiologist, pain
management service, nursing staff, and patient.
a. Reduce the adverse opioid related side effects
3. Multimodal approach
a. Pre-operative pre-emptive analgesia
i. Celecoxib
ii. Acetamenophin
iii. Oxycodone SR
b. Regional anesthesia
i. Pre-operative placement provides pre-emptive analgesia
ii. Meta-analysis comparing regional anesthesia vs. general anesthesia demonstrated a
30 % reduction in morbidity and mortality in orthopedic patients (Rodgers BMJ
2000).
iii. Regional anesthesia decreased incidence of pulmonary embolus, DVT, respiratory
depression and transfusion (Hu JBJS Br.2009)
c. Post-operative analgesia
i. Poorly-controlled postoperative pain is associated with an increased incidence of
cognitive dysfunction, especially in elderly patients.(Lynch Anesth Analg 1998).
ii. Femoral nerve block
1. Single shot
2. Continuous
iii. Sciatic nerve block
iv. Break through pain
1. Oxycodone
2. Hydromorphone
4. Improved analgesic efficacy allows earlier and more intensive rehabilitation, resulting in a decrease
in length of stay (Chelly et. Al: J Arthroplasty 2001)
a. Better patient satisfaction
47

STAYING OUT OF TROUBLE AT PRIMARY TKR
Roberto Rossi
Mauriziano Umberto I Hospital, University of Turin, Italy
Introduction
TKA is a reproducible surgical technique. The power point video illustrates some technical points during
standard procedure. The aim of this video is to show how to prevent common errors in knee replacement.
We considered a series of chronological steps as the exposure and surgical approaches, the tibial and femur
cuts and the position of the prosthesis. We highlight the importance of the rotation of the tibia and femur,
femoro-patellar mal-tracking, the size of the components. Hence, this video includes a number of tips and
pearls to facilitate the procedure, avoiding several surgical complications during a standard TKA. This
video is particularly intended for young or unpractised surgeons interested in learning TKA basics surgical
technique.
Surgical approach
-Before proceeding parapatellar medial arthrotomy is useful to mark with a marking pen the quad and the
patellar tendon at the level of the superior and inferior border of the patella, just to avoid a patella baja or
alta during the closure.
-It is important to find the interval between the patellar tendon anteriorly and the Hoffa fat pad directly
posterior: you can use a finger between tendon and fat pad to clearly identify the interval and protect
patellar tendon from the electrocautery, with the knee in full extension
- We recommend to use a pin into the tendon to prevent a partial detachment.
Once the exposure of the tibial plateau is complete we suggest to 1) remove the menisci and the
osteophytes, 2) identify and coagulate the lateral inferior geniculate vessels.
Bone cuts
There are five basic principles for TKR
1. Restoration of the mechanical axis
2. Restoration of the joint line
3. Balancing of the soft tissues
4. Equalizing flexion and extension gaps
5. Restoration of patella-femoral alignment and mechanics
The surgical procedure comprises five essentials bone cuts, whether the prosthesis is cemented or press-fit.
An additional sixth cut for the removal of intercondylar notch is performed in PCL sacrifice prosthesis.
These cuts are the same regardless for the amount of bone loss, presence of osteophyte, and soft tissues
balance.
The essential bone cuts for any TKR are:
- Transverse osteotomy of the proximal tibia
- Resection of the distal femoral condyles angulated at 4° to 6° of valgus alignment
- Anterior and posterior condylar resection according to the selected size of prosthesis
- Anterior and posterior chamfers for the distal femur depending on prosthetic design
- Retropatellar osteotomy
- Optional resection of intercondylar notch for PCL substituting prosthesis
There is no-fixed order to perform the bone cuts, because the tibial and distal femoral osteotomy are
independent of each other. We usually begin with the tibial cut; nevertheless in tighter knee or in presence
of important posterior osteophytes, it is preferable to start with distal femoral osteotomy to gain space,
allowing a better view of tibial plateau.
Proximal tibial osteotomy
-The extramedullary guide should be pointed proximally on tibial spines and distally, at the ankle, on tibialis
anterior tendon, and run parallel to the anterior tibial crest.
Once you have positioned the tibial guide, you have to decide the level of tibial osteotomy. The depth of
the tibial cut should correspond to the thickness of the tibial insert. This cut is usually 10 mm below the
level of normal tibial plateau. During osteotomy two Hohmann retractors are placed medially and laterally
to protect medial and lateral collateral ligament and patellar tendon.
Tips and pearls of Proximal Tibial Osteotomy
1. Most of the time we observe cases with a varus proximal tibial alignment (meta-diaphysis angle
average of 3-4° of varus). If we want to obtain a perpendicular proximal tibial cut, we need to use
the extramedullary guide with a slightly valgus alignment (medializing the guide close to ankle of 4-
5 mm)
48

2. In obese patients we suggest to use the tibialis anterior tendon as distal reference for alignment,
since it is easy to palpate at the distal 1/3 of the tibia.
3. The position of the mask determines the direction of the tibial slope. The mask must be positioned
perpendicularly to the tibial intercondylar line to avoid an obliquely sloped cut.
4. Especially in loose knees, we recommend to cut less then 10 mm (7-8 mm): the remaining
necessary space will be obtained through the soft-tissues release.
5. We suggest to remove the tibial resected bone just in one piece rotating from medial to lateral.
Distal femur osteotomy
The distal femur osteotomy is performed in the most of the cases with an intramedullary guide. The entry
point for the femoral rod is few millimeters medial to the midline and just anterior to the origin of PCL. A
large drill hole is made at this point to allows the rod insertion. During the drilling you should place the
fingers on anterior shaft of the femur to estimate the correct direction. Before inserting the rod, we suggest
to insert suction inside the femoral canal to avoid excessive increase of intramedullary pressure during rod
insertion.
You should resect an amount of bone equivalent to that which is replaced by the prosthesis, generally from
8 to 12 mm. After a correct cut it is possible to see a “figure of eight” configuration on the cut surface.
If the cut is too distal you can see two ovals, whereas if the cut is too proximal you will see a surface with
all contiguous bone.
At this stage you can evaluate and if necessary correct the extension gap with the spacer block and check
the alignment with the spacer in place associated with alignment rods.
Tips and Pearls of Distal femoral cut:
1. To evaluate the correct position of the entry point of the rod you can observe a reversed V shaped
sign on the lateral condyle that indicates the height of the entrance point in the femoral canal.
2. Once the cutting block is pinned on the anterior aspect of the femur you can check the correct
amount of resection inserting the sickle in the slot between the two condyles: when it results
tangent to the cartilage, the resection is about 10 mm.
Anterior and posterior femoral condylar osteotomy
-These cuts determine the rotation and the dimension of the prosthesis and the knee balancing in flexion.
The femoral component rotation influence the flexion gap, the knee stability and the patello-femoral
tracking.
-There are several methods to determine the correct rotation of femoral component, none of which is
perfect, so the surgeon have to familiarize with all of them to double- or triple-check. The most important
are: measured 3° to 5° of external rotation to posterior femoral condyles, tension technique to obtain
rectangular flexion gap (parallel-to-tibial-cut technique), the transepicondylar axis and perpendicular to
trochlear notch line of Whiteside.
49

GAP BALANCING TECHNIQUE AND STABILITY ASSESSMENT
José Romero
Endoclinic Zurich, Zurich, Switzerland
Symmetrically balanced collateral soft tissues in extension and in flexion 1, 2 and alignment of the tibial and
femoral components perpendicular to the mechanical axis in the coronal plane 3 are identical goals for both
methods, the “femur first technique” and the “tibia first technique”. The major difference between the two
methods is on how rotation of the femoral component is determined to achieve these goals.
The “femur first technique” addresses the femur before the tibial plateau is resected. Rotation of the
femoral component is referenced on bony landmarks, and there are three methods accepted. The first
method is historically known as the measured resection technique because it removes a determined amount
of bone of the posterior condyles with a routine 3° external rotation. The second method resects the
posterior condyles perpendicular to the trochlear groove (Whiteside line), and the third methods resects the
posterior condyles parallel to the transepicondylar axis. The remaining ligamentous imbalance in flexion is
corrected by selective soft tissue releases. However, such releases in flexion affect the balance in extension
to a unknown extend 5,6 . It may therefore be difficult in some cases to achieve symmetric balance in flexion
and extension if the releases are performed at the end after having performed all bony cuts.
The first step of the “tibia first technique” is the resection of the tibial plateau perpendicular to the tibial
long shaft axis, the second step is the distraction of the flexion gap and the third step is the resection of the
posterior condyles parallel to the tibial resection plane according to the ligamentous tension in flexion.
Then the extension gap is addressed: The distal femur is resected perpendicular to the line connecting the
center of the distal femur and the center of the femoral head. If the extension gap is released at the end to
correct for remaining ligamentous balance imbalance it may affect the balance of the flexion gap.
A combination of both methods may overcome the problem of such unequal effects of ligamentous
releases for the flexion and extension gap. The first step of this method, called the balanced flexion gap
technique, resects the proximal tibia and the distal femur perpendicular to the tibial and femoral mechanical
axis. Then the extension gap is analysed using a distractor. If a ligamentous imbalance of the extension gap
exists it is released until a rectangular extension gap is achieved under distraction. The flexion gap is then
also set under distraction and the posterior condyles are resected parallel to the tibial resection plane. The
extension gap stays rectangular since the resection of the posterior condyles which determines rotational
alignment of the femoral component has only an impact on the flexion gap selectively without changing the
balance in extension 6 .
It has been shown that an asymmetric flexion gap is associated with a clinically inferior outcome and that it
is correlated to femoral component rotation 7. The balanced flexion gap technique is a useful method
particularly for a fixed varus or valgus deformation that determines the rotation of the femoral component
individually each patient. However, until know, no comparative studies exist to prove which method
provides superior patient satisfaction and longevity of the implant.
References
1. Freeman MAR: Anonymous Arthritis of the knee: Clinical features and surgical management. Springer-Verlag, New York,
1980.
2. Insall JN: Choices and compromises in total knee arthroplasty. Clin Orthop 226:43, 1988.
3. Insall JN: Surgical techniques and instrumentation in total knee arthroplasty. In Insall JN, Windsor RE, Kelly MA, Scott WN,
Aglietti P (eds): Surgery of the knee. Churchill Livingstone, New York, Edinburgh, London, Madrid, Melbourne, Tokyo, 1993,
pp. 739.
4. Krackow AK, Mihalko WM: The effect of medial release on flexion and extension gaps in cadaveric knees. Am J Knee Surg
12:222–228, 1999.
5. Krackow AK, Mihalko WM: Flexion-extension joint gap changes after lateral structure release for valgus deformity correction
in total knee arthroplasty. J Arthroplasty 14:994–1004, 1999.
6. Romero J, Duronio JF, Sohrabi A, et al: Varus and valgus flexion laxity of total knee alignment methods in loaded cadaveric
Knees. Clin Orthop 394:243, 2002.
7. Romero J., Stähelin T., Binkert C., Pfirrmann C.W., Hodler J., Kessler O.: The clinical consequences of flexion gap asymmetry
in total knee arthroplasty. J Arthroplasty 22(2):235-40, Feb 2007.
50

MEASURED RESECTIONS WITH PSI IN A FIXED VALGUS DEFORMITY
Emmanuel Thienpont
Saint Luc University Hospital, Brussels, Belgium
Introduction
Valgus knees are less frequent then varus knees and therefore we as surgeons are less experienced. The
valgus knee is not just an inversed varus knee. We should distinguish in between the iatrogenic valgus knee,
which exists after complete lateral meniscectomy, after overcorrected high tibial osteotomy and after
trauma.
This talk will cover the intrinsic valgus knee, which is a question of dysplasia. We shall cover how Patient
Specific Instruments (PSI) can help us obtain reproducible results.
Key points
Place for the far medial subvastus approach in valgus knee
The problem of valgus knees is dysplasia
- Of the MCL
- Of the posterolateral condyle
- Of the trochlea
- Of the patella with extreme bone loss sometimes
- Of the posterior capsule with hyperextension and medial laxity
Release of the soft tissues (fixed valgus knee)
Contracture of the ITB in extension
Why PSI in valgus knees
- Preoperative mechanical axis analysis
- Idea about the levels of resections and need for CCK implants
- Idea about the sizes
- Helps determine the epicondylar axis since PCA and AP-axis are not reliable because
of dysplasia
- Helps correct HKA to 180° despite intrinsic valgus of femoral/tibial bones
Pitfalls
- Check the Ir planning
- Often ML size is narrow compared to AP size in valgus knees
- Default planning of 10 mm resection of lateral side is NOT allowed of course
- Beware of the hyperextension in valgus and often need of less proximal femoral
resection
Conclusions
PSI can have a place to improve accuracy in the valgus knee, if the planning is checked by an experienced
surgeon that understands the secrets of valgus knees.
Especially on the femoral side PSI guides can have some added value.
PSI is not a substitute for good surgical technique and soft tissue balancing in these often complicated
knees
51

“ADAPTED” MEASURED RESECTION TECHNIQUE FOT TKA
Jan Victor
Ghent University, Belgium
Key points
1. All possible references for sizing and aligning the implants should be taken into account and used.
2. There is no dogmatic advantage of measured resection over ligament balancing, or vice versa, both
have flaws and potential pitfalls
3. Knee kinematics should direct surgical decisions. Remember that the medial side of the knee is
most stable and isometric side, whereas the lateral side is more mobile and anisometric.
Take home message
Try to restore the joint line level on the medial side of the knee. This can easily be achieved by
compensating for lost cartilage or bone on the distal and posterior part of the medial compartment when
using referencing instruments. For sizing, posterior referencing should be used. Rotation of the femur
should be decided upon based upon bony landmarks in combination with ligament assessment. When
rotation is applied on cutting blocks, make sure to rotate around the posteromedial condyle and not around
the centre of the block.
References
1. Victor J, Van Doninck D, Labey L, Van Glabbeek F, Parizel P, Bellemans J. A common reference frame for describing
rotation of the distal femur. J Bone Joint Surg 2009; 91-B: 683-690.
2. Victor J. Rotational alignment of the distal femur. A literature review. Orthop Traumatol Surg Res 2009; 95:365-72
3. Victor J, Wong P, Witvrouw E, Vander Sloten J, Bellemans J. How isometric are the medial patellofemoral, the superficial
medial collateral and the lateral collateral ligament of the knee Am J Sports Med. 2009.
52

SOFT TISSUE BALANCING IN VARUS DEFORMITY: AN ALGORITHMIC APPROACH
Peter Verdonk
Antwerp Orthopaedic Center, Monica Hospitals, Belgium
A certain order exists in addressing the varus deformity of the knee with intra-articular ligamentous balance.
The first step is removing the osteophytes from the femur and tibia as they tether the medial capsula and
the medial collateral ligament . The osteophytes must be removed from the entire margin of the medial
femoral condyle and from the tibia (step 1). Subsequently the deep MCL is released from the tibia in all
total knee arthroplasty procedures as part of the surgical approach (step 1’).
The superficial MCL is generally the major restraining anatomical structure in the varus knee. The
anteromedial and posteromedial part of the superficial MCL should be identified and can be release at the
level of the jointline using the so-called pie crusting technique (step 2) OR it can be release more distal on
the tibia (step 3).
If lengthening of the MCL of less than 6-8 mm is necessary to establish balanced gaps, pie crusting (step 2)
using an 11-blade from the inside out or using a 18G needle from the outside in can be performed aiming
to section the tightest fibers of the ligament. A progressive and controlled lengthening can thus be obtained
either in flexion (anteromedial fibers) or in extension (posteromedial fibers) or a combination of both. If
the varus is combined with an fixed flexion deformity, a selective release of the semimembranous tendon in
the posteromedial corner 1cm under the jointline can be performed using sharp transection (step 2’).
In the case of a severe varus with need for lengthening of the superficial MCL more than 6-8 mm, the
release of the MCL should be performed on the distal aspect of its tibial insertion (step 3). A periosteal
elevator can be used to strip the superficial MCL from tibia. This is done distal to the pes anserine
insertion, usually raising a periosteal sleeve down the diaphyseal region of the proximal tibia. However, one
should avoid over release resulting in medial instability.
In severe varus, the medial aspect of the tibia can also be trimmed down and the tibial implant downsized
and lateralized. With this ‘bony release’, one can avoid the necessity for a distal MCL release in selected
cases.
Occasionally a contracted PCL can be partially responsible for a varus deformity. This can be addressed
either by excising the PCL and using a PCL-substituting implant or by selectively balancing the PCL.
53

PATELLAR RESURFACING TECHNICAL TIPS
W. Norman Scott
Insall Scott Kelly ® Institute, New York, USA
The decision whether to resurface the patella in Total Knee Arthroplasty is often based on geographical
location and surgeon experience. In general, the outcome studies looking at patella resurfacing agree that
patella resurfacing results in less anterior knee pain and fewer re-operations of the patella. Whereas leaving
the patella unresurfaced, results in increased anterior knee pain and more re-operations for patella pain. 1-9, 11
The outcomes of patella resurfacing are to an extent affected by the design of the femoral component.
Newer “patella friendly” designs appear to diminish the incidence of of anterior knee pain for both
resurfaced and un-resurfaced patellae. 10
Past problems with patella resurfacing were essentially caused by metal-backed patella components and
inadequate surgical techniques, which required too many lateral patella releases. 12-13
Currently the main complications are caused by problems with surgical technique. Essential “patella
friendly” surgical techniques: 14-15
- The femoral component rotation should be set using the Epicondylar axis and the AP axis.
- The tibial component rotation should be set on the medial third of the Tibial Tubercle, which is
15° of external rotation.
- Patella bone resection should restore (with the component in place) the pre-operative AP
dimension.
- The patella component should be positioned superior and medial on the patella, with no overhang
of the component.
- A bevel cut of the uncovered lateral bone surface of the patella helps with clearance and tracking. 16
- The patellar tendon should be debrided of soft tissue that might otherwise impinge in the PF joint.
- The patellar tracking is tested in a “No Thumb” fashion with proximal traction. The patella should
track level in the trochlea with no tilting.
- Using proximal-to-distal oblique sutures in closing the joint helps prevent Patella Baja.
In summary, the complications of patellar resurfacing have been minimized by improved surgical and
rotation techniques, so that we now see a revision rate of only ~1% 17-18
References
1. Scott, WN, Rozbruch, J, Otis, J, Insall, JN, Ranawat, C, Burnstein, A: Clinical and Biomechanical Evaluation of Patella
Replacement in Total Knee Arthroplasty. Orthopaedic Transactions, 1978, vol 2 page 203
2. Burnett RS, Haydon CM, Rorabeck CH, Bourne RB. Patella resurfacing versus nonresurfacing in total knee arthroplasty:
results of a randomized controlled clinical trial at a minimum of 10 years' followup. Clin Orthop Relat Res. 2004
Nov;(428):12-25.
3. Nizard RS, Biau D, Porcher R, Ravaud P, Bizot P, Hannouche D, Sedel L. A meta-analysis of patellar replacement in
total knee arthroplasty. Clin Orthop Relat Res. 2005 Mar;(432):196-203.
4. Parvizi J, Rapuri VR, Saleh KJ, Kuskowski MA, Sharkey PF, Mont MA. Failure to resurface the patella during total knee
arthroplasty may result in more knee pain and secondary surgery. Clin Orthop Relat Res. 2005 Sep;438:191–196.
5. Emilios E. Pakos, MD; Evangelia E. Ntzani, MD; Thomas A. Trikalinos, MD Patellar Resurfacing in Total Knee
Arthroplasty: A Meta-Analysis. J Bone Joint Surg Am, 2005 Jul 01;87(7):1438-1445
6. Bourne RB, Burnett RS. The consequences of not resurfacing the patella. Clin Orthop Relat Res. 2004 Nov;(428):166-9
7. Campbell DG, Duncan WW, Ashworth M, Mintz A, Stirling J, Wakefield L, Stevenson TM. Patellar resurfacing in total
knee replacement: a ten-year randomised prospective trial. J Bone Joint Surg Br. 2006;88:734-9
8. Burnett RS, Boone JL, McCarthy KP, Rosenzweig S, Barrack RL. A prospective randomized clinical trial of patellar
resurfacing and nonresurfacing in bilateral TKA. Clin Orthop Relat Res. 2007 Nov;464:65–72.
9. R. Stephen J. Burnett, MD, FRCS(C); Julienne L. Boone, MD; Seth D. Rosenzweig, MD; Karen Steger-May, MA; Robert
L. Barrack, MD. Patellar Resurfacing Compared with Nonresurfacing in Total Knee Arthroplasty: A Concise Follow-up
of a Randomized Trial. J Bone Joint Surg Am, 2009 Nov 01;91(11):2562-2567
10. J. Tabutin, F. Banon, Y. Catonne, J. Grobost, J. L. Tessier, B. Tillie. Should we resurface the patella in total knee
replacement Knee Surgery, Sports Traumatology, Arthroscopy, October 2005, Volume 13, Issue 7, pp 534-538
11. Clements WJ, Miller L, Whitehoulse SL, Graves SE, Ryan P, Crawford RW. Early Outcomes of Patella Resurfacing in
Total Knee Arthroplasty. Acta Orthopaedica, Volume 81 (1): 108-13, February 2010
12. Scuderi, Giles; Scharf, Stephen; Meltzer, Lon and Scott, W. Norman: The Relationship of Lateral Releases to Patella
Viability in Total Knee Arthroplasty. Journal of Arthroplasty, Vil. 2, No. 3, p. 209-214, 1987
13. Scuderi, Giles; Scharf, Stephen; Meltzer, Lon; Nisonson, Barton and Scott, W. Norman: Evaluation of Patella Viability
after Disruption of the Arterial Circulation, American Journal of Sports Medicine, Vol. 15, No. 5, p. 490-493, October
1987
14. Insall & Scott: Surgery of the Knee, 3 rd Edition. Churchill Livingstone, 2001
15. Insall & Scott: Surgery of the Knee, 5 th Edition. Elsevier, 2012
16. Rosen AL, Scuderi GR. Patella Resurfacing. Techniques in Knee Surgery 1(1):72-76, 2002
17. Boyd AD Jr, Ewald FC, Thomas WH, Poss R, Sledge CB. Long-term complications after total knee arthroplasty with or
without resurfacing of the patella. J Bone Joint Surg Am. 1993;75:674-81.
18. Robert L. Barrack, MD, Alexander J. Bertot, MD, Michael W. Wolfe, MD, Douglas A. Waldman, MD, Matko Milicic,
MD, And Leann Myers, PhD. Patellar Resurfacing in Total Knee Arthroplasty. A Prospective, Randomized, Double-
Blind Study With Five To Seven Years Of Follow-Up. J Bone Joint Surg Am. Vol 83-A no 9 Sept 2001:1376-81
54

ACUTE PRIMARY TKA FOR PERI-ARTICULAR KNEE FRACTURES
Stefan Eggli
Switzerland
1. Analysis of fracture type
2. Analysis of deformity
3. Aim for intramedullary stabilization
4. Aim for early full weight bearing (spacers – stems)
4. Femorotibial articulation - as less constraint as possible
5. Stabilize the fracture first
6. Intraoperative x-rays
7. Orientation of femur in accordance with fracture reduction
References
1. Karpman RR, Del Mar NB. Supracondylar femoral fractures in the frail elderly. Fractures in need of treatment. Clin Orthop
Relat Res 1995; 316
2. Ajay Malviya, Mike R. Reed, Paul F. Partington, Acute primary total knee arthroplasty for peri-articular knee fractures in
patients over 65 years of age. Injury, Int. J. Care Injured 42 (2011); 1368-1371
55

TKA IN POST-TRAUMATIC OSTEOARTHRITIS
Paolo Adravanti
Parma, Italy
Keypoints
1. Etiology of the stiff knee
2. Pre-operative planning
3. Skin problems
4. Exposure
5. Restore the joint line and balance the space
6. Patient expectation
7. Post-op recovery
1. Etiology of the stiff knee
A stiff knee by description is defined as a knee with less than a 50° arc of movement [1], ankylosed in
flexion or in extension. Post-traumatic stiff knee remains a severe and quite frequent complication,
primarily due to intra- and extra-articular fibrosis and scarring adhesions in the quadricepsfemoral
apparatus, including fibrosis and shortening of the medial and lateral parapatellar retinaculum, adhesions
from the deep surface of the patella to the femoral condyles, fibrosis of the vastus intermedius with
adhesion to the rectus femoris muscle and the front of the femur, and actual shortening of the rectus
femoris (whole quadriceps extensor). In addition, fractures of the callus and adherence of the skin to
underlying muscle can be involved. In such case intrarticular and extrarticular malunion can be combined.
2. Pre-operative planning
The approach to total knee arthroplasty in a patient with stiff knee is similar to planning the revision of a
total knee arthroplasty. Radiographic assessment should include standard knee radiographs, full-length A-P
view, a Rosenberg’s view and skyline views of the patella. Moreover, CT scan can help to detect possible
meta-epiphyseal deformities.
3. Skin problems
Prior scars should be used when possible to preserve vascularity to the soft tissues and minimize the risk of
skin necrosis. The risk of skin edge necrosis can be reduced by careful handling of the skin flaps. Trial
incisions and/or soft-tissue expanders can be used preoperatively in patients with stiff knee, especially in
the presence of multiple prior incisions and adherent skin [2,3]. Sometimes it can be useful to consider flap
before surgery.
4. Exposure
After elevation of full thickness skin and subcutaneous flaps, most of stiff knee can be exposed through a
conventional medial parapatellar arthrotomy. Removal of scar tissue from periphery of the patellar
component and lateral gutter and lateral retinacular release can also improve mobilization of the extensor
mechanism [4]. Subperiosteal dissection of the medial tibial soft tissue sleeve permits tibial external rotation
and relative lateralization of the tibial tubercle which also reduces tension on the patellar ligament during
lateral retraction of the patella. If the knee cannot be flexed more than 40-50°, it is better to perform a
quadriceps snip or tibial tubercle osteotomy.
5. Restore the joint line and balance the space
A challenge in stiff knee arthroplasty is to restore the joint line and to equalize the space in flexion and in
extension; in particular it is important to find an appropriate compromise between the flexion space, which
is larger in this type of knee, and the rising of the joint line. At the end of the procedure if the extensor
mechanism is still tight does not allow 40-50° of flexion with the implant in place, even with the tourniquet
released, further controlled Z lengthening of the quadriceps has to be done. It is important to consider the
possible instability: in that case adding constraint can be appropriate.
6. Patient expectation
Although TKA provides substantial gains in flexion, together with a significant pain reduction, patients
affected by stiff knee must know that they will not recover a normal ROM, in particular if the pre-operative
stiffness was severe. Indeed, most knees still cannot flex more than 90° However, in these patients the
gains in flexion, usually up to 40-50°, appear very considerable given the scarce re-operative flexion [5-7].
56

7. Post-op recovery
To reduce peri-operative and immediate post-operative pain the use of perineural catheter is suggested.
Rehabilitation protocol must be very slow and adapted to each patient ability, since insisting to gain more
flexion can cause post-operative complications, especially related to the extensor mechanism and to skin.
References
1. Aglietti P, Windsor RE, Buzzi R, et al. Arthroplasty for the stiff or ankylosed knee. J Arthroplasty
2. 1989;4:1.
3. Mahomed N, McKee N, Solomon P. Lahoda L, Gross AE. Soft tissue expansion before total knee arthroplasty in arthrodesed
joints. J Bone Joint Surg Br. 1994;76:88–90
4. Manifold SG, Cushner FD, Craig-Scott S, et al. Long term results of total knee arthroplasty after the use of soft tissue
expanders. Clin Orthop 2000:133
5. Judet R, Judet J, Lagrange J. A technique for freeing the extensor apparatus in cases of stiffness of the knee. Mem Acad Chir
1956;82:944-7.
6. Massin P, Bonnin M, Paratte S, Vargas R, Piriou P, Deschamps G; French Hip Knee Society (SFHG). Total knee replacement
in post-traumatic arthritic knees with limitation of flexion. Orthop Traumatol Surg Res. 2011; 97:28-33.
7. Bhan S, Malhotra R, Kiran EK. Comparison of total knee arthroplasty in stiff and ankylosed knees. Clin Orthop Relat Res.
2006;451:87-95
8. McAuley JP, Harrer MF, Ammeen D, Engh GA. Outcome of knee arthroplasty in patients with poor preoperative range of
motion. Clin Orthop Relat Res. 2002;404:203-7.
57

TKA IN THE STIFF KNEE
Michel Bonnin
France
Take home message
1. Analyse the etiology of the stiffness
• Intra vs extra articular
• Multioperated vs non noperated
• Post-traumatic vs rheumatoïd
2. Check the feasibility of a TKA
• Extensor apparatus
• Bone quality
3. Prevention of complications
• Skin necrosis: ask plastic surgeon
• Infection: ask infectiologist
• Patellar tendon: osteotomy of tibial tuberosity
58

TKA PLUS SIMULTANEOUS HTO FOR SEVERE METAPHYSEAL VARUS DEFORMITIES
Philippe Hernigou
Hopital Henri Mondor, Creteil; France
Total knee arthroplasty (TKA) in patients with established knee osteoarthritis and major varus, mostly due
to constitutional proximal deformity, remains a challenging procedure. Orthogonal cuts result in
asymmetric bone resection and subsequent bone related laxity in the convex side.
TKR plus osteotomy would be indicated if the preoperative workup suggests that the extraarticular
deformity is such that resection-related laxity would cause a ligament-balancing problem or excessive softtissue
slackness (with adverse effects on the extensor mechanism, the collateral ligaments, and the level of
the joint line) once the necessary bone cuts will have been made. The bone contribution to the deformity is
suspected when it is not correctable on clinical examination and is measured on valgus stress radiographs as
the remaining malalignment. To our way of thinking, a combined procedure would be indicated once the
extraarticular deformity exceeds 15 degrees.
The technique that combines high tibial osteotomy and TKA in the same sitting to address such major
deformities is described in this presentation. It allows achievement of good realignment without excessive
release. Opening osteotomy is performed first and the TKA is then placed, with stem augmentation, to
ensure stability of the construct. Preliminary results of this original demanding method are encouraging,
and it is suggested that this option be considered in severe varus osteoarthritic knees. The results obtained
in patients with this technique are explained.
59

HOW DO I MANAGE SEVERELY DEFORMED KNEES
Arun Mullaji
India
1) Decide whether there is associated extra-articular deformity or not based on full-length standing
radiographs.
2) Plan whether correction is to be done intra-articular IA or extra-articular EA. On the femoral side this
is determined by noting whether the putative femoral resection (perpendicular to its mechanical axis)
will compromise either collateral ligament attachment if correction was planned IA, in which case an
EA correction would be prudent. On the tibial side if the proximal extension of the mid-axis of the
tibia distal to the deformity falls outside the tibial plateau then an extra-articular correction would be
required.
3) Purely intra-articular release will require lesser bony resections but larger soft-tissue releases which will
lead to larger flexion than extension gaps, requiring adjusting of femoral component size (upsizing) and
placement (in flexion and posterior translation) to equalize gaps. Reduction osteotomy is a useful
manoeuvre to achieve further correction and balance of ligaments.
4) Extra-articular correction may be required on the femoral side or tibial side; it may entail performing a
concomitant sliding medial or lateral femoral condylar osteotomy, transverse corrective femoral or
tibial osteotomy. Screws, plates or locking IM nails, stems or sleeves may be required to fix the
osteotomy.
5) Associated bone defects on the tibial plateau may need to be addressed by autologous grafting or metal
augments with additional stems.
6) Most deformities can be treated with a posterior-stabilized device. Additional constraint in the form of
a varus-valgus constrained implant may occasionally be deployed if there is residual ligament imbalance
or a larger flexion gap; rarely a hinge may be used if there is significant stretching/lack of integrity of
the medial collateral ligament or a flexion gap that is too large to be dealt with using a vvc implant.
References
1. Mullaji A, Shetty GM. Surgical Technique: Computer-assisted Sliding Medial Condylar Osteotomy to Achieve Gap Balance in
Varus Knees During TKA Clin Orthop Relat Res Jan 2013
2. Mullaji A, Shetty GM, Lingaraju AP Computer-assisted total knee replacement in patients with arthritis and a recurvatum
deformity J Bone Joint Surg Br 2012; 94-B 5: 642-647
3. Mullaji A, Shetty G. Total knee replacement for arthritic knees with tibio-fibular stress fractures: Classification and treatment
guidelines J Arthroplasty 2010; 25(2): 295-301
4. Mullaji A, Shetty GM. Lateral Epicondylar Osteotomy Using Computer Navigation in Total Knee Arthroplasty for Rigid
Valgus Deformities J Arthroplasty 2010; 25(1):166-9
5. Mullaji A, Shetty G. Computer-Assisted Total Knee Arthroplasty for Arthritis With Extra-articular Deformity J Arthroplasty
2009; 24 (8): 1164-1169
6. Mullaji AB, Marawar S, Sharma A. Correcting varus deformity. J Arthroplasty 2007; 22(4) 15-19.
7. Mullaji AB, Padmanabhan V, Jindal G. Total Knee Arthroplasty for Profound Varus Deformity: Technique and radiological
results in 173 knees with varus more than 20 degrees. J Arthroplasty 2005; 20(5): 550-561.
60

MID-FLEXION INSTABILITY IN FIXED FLEXION CONTRACTURE CASES
Ate B. Wymenga
Knee Reconstruction Unit, Department for Orthopedic Surgery,
Sint Maartenskliniek, Nijmegen, the Netherlands
Definition, etiology natural course functional consequences FFC
Definition of FFC: > 10 dgr extension deficit is mild, > 20 dgr extension deficit is severe
Incidence preoperative FFC varies from 20 – 60% in the literature
Etiology of FFC: Posterior osteofytes, medial and lateral osteofytes femur and tibia, tight posterior capsule,
tight PCL, bony impingement.
Quadriceps force in increased with FFC, 22 % more with 15 degrees and 50% with 30 degrees of FFC.
Ambulation is slower, increased energy is used, ability to walk is reduced.
Natural history is benign if FFC is not corrected completely during surgery and gradually decreases.
Postoperative incidence varies around 3-5%, risk factors for a postoperative FFC are a preoperative FFC,
male, age and anterior knee pain. If the postoperative FFC is more than 15 degrees after 3 months the risk
for definitive FFC is increased.
Flexion contractures of a ipsilateral arthritic hip can induce and maintain a FFC in the knee. In case of
bilateral FFC of the knee the not operated side should be treated within a few months and leg length
discrepancy can be corrected with a shoe lift.
Patients with a TKA and FFC have no pain, a risk for anterior knee pain and lower Womac scores and
smaller ROM.
Traditional treatment algorithms with additional distal resection femur
Classical surgical algorithms: first remove posterior and medial and lateral osteofytes, then release posterior
capsule at femur condyles, at the tibia edge or centrally in the capsule. After that an additional distal femur
cut is made to facilitate implant space in extension.
Whiteside approach: prevent additional distal femur cut, use larger femur component to fill flexion space and
decrease tibial slope with tibia cut which increases extension space and decreases flexion space
Analysis of midflexion laxity in FFC
Reasons midflexion laxity 1) inadequate release posterior capsule, this causes tensioning of the extension gap
with relative loose collateral ligaments 2) increase of the jointline causes a change of center of rotation with
the use of a smaller component. This will create a stable flexion and extension gap but increases midflexion
with 5 degrees laxity
Proposed approach for FFC preventing midflexion laxity
How to prevent midflexion laxity 1) prevent increase of the jointline on the femur 2) use if possible a larger
femur component and use a flexed position to fill the flexion gap 3) decrease the slope of your tibia cut
61

which will create easier extension and filling of the flexion space.
References
1. Bellemans et al. Flexion contracture in total knee arthroplasty. Clin Orthp Rel Res. 452, 78-82, 2006
2. Su. Fixed flecture deformity and total knee arthropasty. J Bone and Joint Surg Br 2012-94B , 112-15
3. Berend et al. Total knee arthroplasty in patients with greater than 20 degrees flexion contracture. Clin.Orthop Rel Res. 2006,
452, 83-87.
4. Cross et al. Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in midflexion.
The Knee, 2012, 19 (6), 875-9
5. Meftah et al. Correcting fixed varus deformity with flexion contracture during total knee arthroplasty, the inside out technique.
J Bone and Joint Surg vol 94A, 10 e66 (1-6) 2012.
6. Quah et al. Fixed flexion deformity following total knee arthroplasty. A prospective study of the natural history. The Knee, 19,
(2012) 519-521.
7. Koh et al. Incidence, predictors and effects of residual flexion contracture on clinical outcomes of total knee arthroplasty. J
Arthr. 2012 in press.
8. Tanzer et al. The natural history of flexion contracture in total knee arthroplasty. Clin Orthop Rel Res. 248, 129-134, 1989.
9. Whiteside et al. Surgical procedure for flexion contracture and recurvatum in total knee arthroplasty. Clin Orthop Rel Res.
404, 189-195, 2002.
62

TKA POST OSTEOTOMIES. DIFFICULTIES THAT THE SURGEON CAN PREDICT
Elvire Servien
Department of orthopaedic surgery, Centre Albert Trillat, Hopital de la Croix-Rousse - Lyon University,
France
Take home message
Some technical difficulties have to be taken into account before performing a TKA post osteotomy:
exposure and patella eversion may be unseasy, But the main issue is to determine the proper tibial cut level
because of the proximal tibia deformity and the joint line obliquity.
References
1. Parvizi et al. (2004) Total knee arthrosplasty following proximal tibial osteotomy: risk factors for failure. JBJS Am
2. Piedade et al.(2012) TKA outcomes after prior bone and soft tissue surgey. KSSTA
63

PLANNING AND CORRECTION OF EXTRA-ARTICULAR DEFORMITIES WITH TKA
Andrea Baldini
Florence - Italy
Key points
• Deformity analysis & Trigonometric rules (femur and tibia)
• Preoperative planning
• Intra-articular correction vs Combined osteotomies simultaneous or staged)
Deformity analysis
Establish the Center of Rotational Angulation (CORA) and the degree of deformity at that level
Femural side: Evaluate angular correction need (distal femoral anatomical axis /femoral mechanical axis
relationship)
Tibial side: distal tibia anatomical axis and its relationship with tibial plateu width (proximally prolonged
distal tibial anatomical axis should fit within the width of the tibial plateau)
“ The closer the deformity to the knee the greater the importance” (more difficult to be corrected by intraarticular
resections only). True for the femur, debatable for the tibia
Preoperative planning
Perpendicular lines (mimicking the distal femoral resection) to the ideal mechanical axis of the femur
should not arm collateral ligaments insertions at the epicondyles
Calculate the distal femoral offset (distance between medial and lateral condyle in the coronal plane to the
tangent line perpendicular to the mechanical axis.
Be prepared for extensive ligamentous release to elongate the concave side to correct the intra+extraarticular
deformity
Femoral deformities are more difficult to be managed because the wedge resection creates instability only in
extension (coronal plane deformity)
Assuming that neutral mechanical axis is reached, correction of varus deformities may leave some lateral
laxity which is better tolerated by the patient than medial laxity after valgus correction.
Be prepared to torsional deformities (internal rotation for the adductors pull of distal femoral fractures)
Intra-articular correction vs Combined osteotomies
Plan the limits of intra-articular correction (close to the joint and > 20°)
Intra-articular corrections with residual moderate laxity is well compensated by semiconstrained implants
(stemless or short cemented stems fixation possible)
Simultaneous osteotomies can be technically demanding - consider to stage the procedure
Tibial side - Combined TTO helps visualizing the osteotomy plane
Femoral side - Stem as an internal fixation device if deformity is distal (need for design with rotational
stability)
References
1. Baldini A and Traverso F. Radiographic evaluation of total knee arthroplasty in improving accuracy in knee arthroplasty.
Jaypee Brothers Medical Publishers (P) Ltd 2012
2. Baldini A, Adravanti P. Less invasive TKA: extramedullary femoral reference without navigation. Clin Orthop 466(11):2694-
2700, 2008.
3. Lonner JH, Siliski JM, Lotke PA. Simultaneous femoral osteotomy and total knee arthroplasty for treatment of osteoarthritis
associated with severe extra-articular deformity. J Bone Joint Surg Am. Mar;82(3):342-8. 2000
4. Paley D, Herzenberg JE, Tetsworth K,McKie J, Bhave A Deformity planning for frontal and sagittal plane corrective
osteotomies. Orthop Clin North Am 25:425–465, 1994.
5. Paley D. Principles of Deformity Correction. Springer ed New York 2003.
6. Constrained condylar knee without stem extensions for difficult primary total knee arthroplasty.
7. Anderson JA, Baldini A, MacDonald JH, Tomek I, Pellicci PM, Sculco TP. J Knee Surg. Jul;20(3):195-8. 2008
8. Wang JW, Wang CJ. Total knee arthroplasty for arthritis of the knee with extra-articular deformity. J Bone Joint Surg Am.
Oct;84-A(10):1769-74, 2002.
9. Wang JW, Chen WS, Lin PC, Hsu CS, Wang CJ. Total knee replacement with intra-articular resection of bone after malunion
of a femoral fracture: can sagittal angulation be corrected J Bone Joint Surg Br. Oct;92(10):1392-6, 2010.
10. Koenig JH, Maheshwari AV, Ranawat AS, Ranawat CS. Extra-articular deformity is always correctable intra-articularly: in the
affirmative. Orthopedics. Sep;32(9). 2009
11. Wolff AM, Hungerford DS, Pepe CL. The effect of extraarticular varus and valgus deformity on total knee arthroplasty. Clin
Orthop Relat Res. Oct;(271):35-51. 1991
64

HOW TO REGAIN MOTION IN STIFF OR ANKYLOSED ARTHRITIC KNEES
Samih Tarabichi
Tarabichi Institute for Joint Surgery, Dubai, United Arab Emirates
The numerous benefits of attaining a substantial post-operative range of motion (ROM) in patients with
osteoarthritis undergoing total knee arthroplasty (TKA) has been extensively discussed and well
documented [1-3]
Patients with advanced osteoarthritis retain a restricted ROM even when placed under
general anesthesia, suggesting the causative factors to be permanent pathological changes in the knee.
Sources of the restriction have been hypothesized to include osteophytes, irregularities in the bone surface,
synovitis, adhesive capsulitis, restrictive soft tissues and adhesions of the quadriceps muscle, and/or tendon
to surrounding structures [4,5].
Stiffness after periods of limited activity is characteristic of the arthritic knee as well as the posttraumatic
knee, highlighting a potentially shared etiology for both. Structural pathologies that may limit flexion in the
stiff posttraumatic knee have been discussed in the literature and include adhesions from the deep surface
of the patella to the femoral condyles, fibrosis, and shortening of the lateral expansions of the vasti and
their adherence to the femoral condyles, fibrosis of the vastus intermedius, and shortening of the rectus
femoris [6]. All of these restrict flexion by blocking the normal distal excursion of the quadriceps, which
Wendt et al [7] reported to be an average of 6.62 cm for flexion up to 90° and [6] reported to be up to 9 cm
for “full flexion” to occur.
In our study, we considered, tethering adhesions of the quadriceps muscle to be the major pathological
structures responsible for limited ROM in the stiff arthritic knee, as is the case in the posttraumatic stiff
knee. There were a total of 42 quadriceps releases carried out on 24 fully consenting patients (10 men and
14 women) by the same practicing surgeon. Of the 24 patients, 18 had a bilateral TKA, whereas 6 had only
a unilateral TKA. The mean patient age was 68 years (range, 58-83 years), and the mean weight was 77.7 kg
(range, 65-94 kg).
Our intraoperative procedure was designed to assess the direct effect of the release of adhesions tethering
the quadriceps muscle to the femur and its surrounding structures. The rationale behind this is
demonstrated in Fig. 1. As can be inferred from Fig. 1B, removal of the supra-patellar pouch is necessary to
gain access to the inferior aspect of the quadriceps muscle. Once access is gained, the adhesions may be
systematically resected until the quadriceps muscle is freed enough to allow a greater degree of flexion to
occur.
The singular effect of the quadriceps release was demonstrable by the immediate and successive
improvement in ROM as the release was continued proximally in all patients. Range of motion improved in
all patients at an average 34.2° (SD 7.8, P < 0.001) post release before any soft tissue balancing, bone
resection or resurfacing, or any other surgical interventions were applied. In fact, any knee deformities,
including the presence of large osteophytes in 6 of the 42 cases, seemed to hinder the improvement in
ROM post release (Fig. 2).
The success in obtaining an immediate and significant improvement in ROM by releasing only the
quadriceps muscle from its tethering adhesions and keeping other pathological changes such as large
osteophytes, severe knee deformities, and irregular articular surfaces intact clearly demonstrates that the
inadequate excursion of the quadriceps muscle and tendon is the main limiting factor to better knee flexion.
Fig. 1. Simplified illustrations demonstrating the basic principle of our approach.
65

Fig. 2. Case number 10, a 74-year-old woman who underwent bilateral quadriceps release prior to commencing TKA. Despite the
large posterior osteophytes that can be seen in the prerelease lateral x-ray (left), we were able to dramatically improve flexion from
105 to 140° as shown in the postrelease lateral x-ray (right).
References
1. Ritter MA, Campbell ED. Effect of range of motion on the success of a total knee arthroplasty. J Arthroplasty 1987;2:95.
2. Schurman DJ, Rojer DE. Total knee arthroplasty: range of motion across five systems. Clin Orthop Relat Res 2005;132.
3. Chiu KY, Ng TP, Tang WM, Yau WP. Review article: knee flexion after total knee arthroplasty. J Orthop Surg 2002;10:194.
4. McGinty JB, Tippet JW. Operative arthroplasty. 2nd ed. 1996. p. 411.
5. Jung-Man K, Myung-Sang M. Squatting following total knee arthroplasty. 
Clin Orthop Relat Res 1995;313:177.
6. Nicoll EA. Quadricepsplasty. J Bone Joint Surg 1963;45-B:183.
7. Wendt PP, Johnson RP. A study of quadriceps excursion, torque, and the 
effect of patellectomy on cadaver knees. J Bone
Joint Surg Am 1985;67:726.
66

DEALING WITH TORSIONAL DEFORMITIES IN TKA PROCEDURES
Siegfried Hofmann
Austria
1. Definition and challenge
- torsional deformities in TKA are common (10-15%)
- represents axial plane deformity (third dimension of knee joint)
- not correcting torsional deformity with TKA leads to malrotation components
- malrotation femur and/or tibia component cause patellofemoral maltracking
2. Rotational alignment landmarks
- femur three bony landmarks or balanced gap technique
- still not clear which works better
- external rotation femur > 3° common in valgus but also in varus knees
- tibia several landmarks described but still controversial
- geometric (anatomical) axis new landmark for tibia
- tibia tubercle is not linked to the geometric axis in torsional deformities
3. Modified surgical technique
- femur “extension gap first” combines landmarks and soft tissues
- femur valgus positioning and internal malrotation leads to patella maltracking
- tibia positioning with maltorsion of tibia 2 options:
1. proximal tibia landmarks – fits to tibiofemoral joint but leads to patella maltracking
2. TT & excessive external rotation- functional derotation & good patella tracking
4. Results literature
- femur hypoplastic lateral condyle common in torsional deformities
- femur more >3° external rotation in valgus but also possible in varus knee
- tibia proximal torsional deformity with lateral TT very common Middle East & Asia
- solutions: functional derotation, mobile bearing or derotation osteotomy
5. Own results
- tibiofemoral and patellofemoral joint are not linked
- recurrent dislocators 50 % normal tibia & torsional deformity femur only
- 32 patients with dislocated / subluxed patella underwent TKA
- correction of torsional deformity at femur & tibia with
- extension gap first technique
- functional derotation with tibia component & PS
- all perfect patella tracking & no problems with tibiofemoral joint
Summary
- torsional deformities are common in patients for TKA
- not correcting leads to malrotation of components & patella maltracking
- femur rotation parallel to epicondylar line well accepted
- torsional deformity tibia main problem and still controversial
- excessive external rotation tibia component & functional derotation works well
References
1. Cameron, MB (2005) A Comedy of Errors: The Bad Knee. J Arthroplasty 20:18-222.
2. Cobb JP et al (2008) The anatomical tibial axis: reliable rotational orientation in knee replacement. JBJS Br 90:1032-10383.
3. Hofmann S et al (2011) Bone Cuts and Implant Positioning to Achieve High Flexion. Tech Knee Surg 10:77-864.
4. Nagamine R et al (2003) Medial Torsion of the Tibia in Japanese Patients With OA of the Knee. CORR 408:218-2245.
5. Seitlinger G and Hofmann S (2012) Tibial Tubercle-Posterior Cruciate Ligament Distance: A New Measurement to Define the
Position of the Tibial Tubercle in Patients With Patellar Dislocation. Am J Sports Med 40:1119-11256.
6. Victor J, et al (2009) A common reference frame for describing rotation of the distal femur JBJS Br 91:683-690
67

INFECTION DIAGNOSIS - A EUROPEAN PERSPECTIVE
Carlo L. Romanò
Centro di Chirurgia Ricostruttiva e delle Infezioni Osteo-articolari
IRCCS Galeazzi, Milan, Italy
1. Peri-prosthetic infections require a multimodal approach
No single test is 100% sensitive and specific for peri-prosthetic infections.
A multi-modal approach is therefore necessary.
More than 20 diagnostic tests, including laboratory, imaging, microbiological and histological findings have
been proposed.
2. New serum markers
In this evolving panorama, new serum markers, are under study and have proven their efficacy in research
and early clinical trials.
3. Biofilm chemical debonding
Bacteria detection is difficult in biofilm-related infections.
Sonication has been proven to increase bacteria retrieval.
New biofilm chemical debonding techniques may now offer another way to obtain similar bacterial
detection rate.
4. Digital telethermography
Imaging techniques do play a key role in implant-related infections.
Digital telethermography is a new non-invasive, low-cost, easy to do assessment for peri-prosthetic knee
infections.
5. Combined diagnostic tool
Old and new diagnostic approaches do offer peculiar sensitivity and specificity as to regard implant-related
infection detection, but what if various tests gives conflicting results and what is the synergy of two or
more positive tests
Computerized calculation of the combined diagnostic power of two or more tests is possible, thanks to a
simple algorithm, that may in the near future be ready as an App on your smartphone…
68

NEW DIAGNOSTIC TOOLS FOR BIOFILM INFECTION
Andrej Trampuz
Berlin, Germany
Challenge
- diagnosis of low grade PJI is difficult
- pathogens are mainly staphylococci with biofilm production
- sessile forms of pathogens are difficult to be identified
Classical infection diagnostic tests
- laboratory tests with ESR & CRP
- aspiration with cell count & PMN
- microbiological evaluation with minimum 10 days incubation
- sonication of retrieved implants
New diagnostic procedure
- molecular diagnosis using PCR
- identify DNA of pathogens
- very expensive
- high sensitivity but clinical relevance still unclear
Key points of this lectures will be:
- Definition
- microbiology vs molecular diagnosis
- clinical significance of molecular diagnosis
- future perspective
References
1. Jacovides CL et al (2012) Successful Identification of Pathogens by Polymerase Chain Reaction (PCR)-Based Electron Spray
Ionization Time-of-Flight Mass Spectrometry (ESI-TOF-MS) in Culture-Negative Periprosthetic Joint Infection. J Bone Joint
Surg Am 94:2247
2. Kobayashi N et al (2008) Molecular Identification of Bacteria from Aseptically Loose Implants. Clin Orthop Relat Res
466:1716-1725
3. Parvizi J et al (2011) Aseptic loosening of total hip arthroplasty: infection always should be ruled out. Clin Orthop Relat Res
469:1401-1405
4. Parvizi J et al (2010) AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip
and knee. J Am Acad Orthop Surg 18:771-772
5. Puig-Verdie L et al (2013) Implant sonication increases the diagnostic accuracy of infection in patients withdelayed, but not
early, orthopaedic implant failure. J Bone Joint Surg Br 95:244-249
6. Trampuz A et al: Sonication of removed hip and knee prostheses fordiagnosis of infection. N Engl J Med 2007; 357(7): 654-
663
69

MANAGEMENT EARLY WOUND HEALING COMPLICATIONS
Johannes A.N. Verhaar
Rotterdam, The Netherlands
Keynotes
1. The number of wound complications after TKA can be reduced by specific measures.
2. Preoperative reduction of wound complication:
- By optimising the patient’s medical conditions
- Evaluation of previous incisions
- Nasal contamination ()
3. At surgery:
- Antibiotics
- Using the right incision
- Adequate soft tissue handling
4. Postoperatively:
- Prevention of hematoma
- Adequate surgical dressing
- Prompt reaction in case of wound problems
5. Management of wound problems:
- Don’t miss a deep infection
- Always aspirate and culture the joint fluid before antibiotics are given
- Early surgical debridement may be indicated
Take home message
1. Wound problems can be reduced by measures to be taken preoperatively, at surgery and postoperatively.
2. Aspiration synovial fluid from the joint for culture is necessary before antibiotics are given
postoperatively.
3. A wound with either persisting drainage or skin necrosis usually benefits from surgical debridement. In
case of skin necrosis, consult the plastic surgeon before surgical debridement.
References
1. Hierner R, Reynders-Frederix P, Bellemans J, Stuyck J, Peeters W. Free myocutaneous latissimus dorsi flap transfer in total
knee arthroplasty. Journal of plastic, reconstructive & aesthetic surgery: JPRAS 2009;6 2 (12): 1692-700.
2. Moucha C, Clyburn T, Evans R, Prokuski L. Modifiable risk factors for surgical site infection. The Journal of Bone and Joint
Surgery. 2011; 93(4): 397-404.
3. Ries MD. Skin necrosis after total knee arthroplasty. The Journal of Arthroplasty. 2002; 17(4): 74-77.
4. Vince K, Chivas D, Droll KP. Wound complications after total knee arthroplasty. The Journal of arthroplasty. 2007; 22 (4
Suppl 1): 39-44.
5. Vince KG. Wound closure: healing the collateral damage. The Journal of bone and joint surgery. British volume. 2012; 94 (11
Suppl A): 126-33.
70

CASE CHALLENGE THERAPY
Siegfried Hofmann
Austria
Case presentation of an early infected TKA within 4 weeks
Questions
1. Further diagnosis and imaging
2. What to offer patient
3. Time frame & indication for I&D
4. Indications for implant removal
5. Preference for single or two stage revision
71

DEBRIDEMENT AND POLYETHYLENE LINER EXCHANGE IN INFECTED TKA -
THE EARLY CHANCE
R. Stephen J. Burnett
Canada
Introduction
The use of debridement and polyethylene liner exchange (DPLE) remains controversial with variable and
often poor results in the literature.
Indications for DPLE and antibiotic therapy
This treatment may be considered in patients with acute postoperative and acute hematogenous infections,
provided the duration of symptoms is acute & without chronicity. In addition, if a patient is a poor
medical candidate for a two-stage exchange procedure (or 1-stage exchange) or longer anesthetic duration,
and symptoms are acute weeks then this procedure is an option. If preoperative cultures are negative but
suspicion is high (elevated cell count, ESR, CRP) for infection and components are well-fixed, then this
procedure may also be considered. Contraindications include loosening of tibial or femoral components,
chronic infections, infections with a draining sinus tract, and virulent infections (mycobacteria, fungal,
VRE, MRSA) with resistant organisms or infections which will likely require suppressive treatment with
long-term antibiotics which are frequently poorly tolerated by patients. Inadequate soft-tissue for wound
closure or the need for muscle flaps, wound-vacs, or skin grafting are contraindications.
Technique
This procedure is not just a ‘simple liner exchange’, rather, a combination of steps to optimize treatment
of an acute infection. Preoperative planning must ensure availability of appropriate implant specific
polyethylene. Preoperative antibiotics should not be withheld unless there is uncertainty about the
infecting organism. Synovial fluid should be sent for cell count with differential, crystals, and multiple (>3-
5) cultures (routine, mycobacterial, and fungal). Synovial tissue in representative areas of inflammation
should be sent for frozen sections and for tissue cultures. Any inflamed synovium should be debrided -
typically the medial & lateral gutters, suprapatellar pouch, and posterior aspect of the knee. A generous
medial exposure is required, non-eversion of the patella, external rotation of the foot and leg, and
protection of the extensor mechanism. The PCL may need to be released for exposure. The polyethylene
must be removed without damaging the tibial baseplate and locking mechanism. Extensive irrigation and
debridement of any devitalized or abnormal tissue should be performed, without compromising the
extensor mechanism collateral ligaments, or neurovascular structures. Adequate exposure to insert a new
polyethylene liner must be achieved. We prefer to deflate the tourniquet prior to closure to ensure
hemostasis. A drain is always used for 48-72h.
Summary of results
The success rate of DPLE varies from 20-60% [1], with often quoted < 50% [2], and averaging 32% (1/3)
in the literature. Improving outcomes with this procedure has been described in an algorithm [3] which
includes the following factors for success: (1) acute hematogenous infections, (2) TKA implanted for <
3months, (3) poor results with gram-negative infections, (4) duration of symptoms < 3 weeks, (5) no
abscess or sinus tract, and (6) stable implants. TKA infections with MRSA, VRE, MRS-Epi have inferior
results compared to MSSA and MS-coagulase negative staphylococcus with this procedure. Culture
negative infections similarly have poor results. Patients and surgeons must understand that DPLE while
initially attractive, may lead to high failure rates (1/3; 34%) of subsequent 2-stage reimplantation [4] and
potentially increased overall cost. This procedure should be used with caution, utilizing strict criteria, and
with patient education about the inherent limitations of DPLE and need for possibly further surgery.
References
1. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, Osmon DR. Outcome of
prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. Feb 15 2006;42(4):471-478.
2. Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum WK. The preoperative prediction of success following irrigation and
debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty. Jun 2012;27(6):857-864
e851-854.
3. Martel-Laferriere V, Laflamme P, Ghannoum M, Fernandes J, Di Iorio D, Lavergne V. Treatment of prosthetic joint
infections: validation of a surgical algorithm and proposal of a simplified alternative. J Arthroplasty. Mar 2013;28(3):395-400.
4. Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, Kalore N. The Chitranjan Ranawat Award: fate of
two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. Jan
2011;469(1):18-25.
72

SINGLE STAGE - AN ATTRACTIVE ALTERNATIVE
Heinz Winkler
Austria
Key points
1. Is two stage more safe than single stage
a. NO significant difference with regard to infection control [1]
b. Two stage only 55-80% success when including cases without re-implantation or death
[2, 3]
c. Single-stage much better results with regard to patients’ function [4], quality of life [5]
and mortality [6]
2. The role of AB loaded cement (AB-PMMA, spacers) in septic revisions
a. No effect on biofilm remnants
b. Spacers >20% complication rates
c. Increased bone loss
d. Reduced mechanical strength – increased loosening rate
3. How can we improve results in PJI
a. Single stage revision – improve conditions for the patient
b. Increase local antibiotic concentrations – eliminate biofilm remnants
c. Avoid cement
d. Biologically restore bone stock
4. Why use Antibiotic impregnated bone grafts in septic revisions
a. Provide sufficiently high local AB-concentrations for elimination of biofilm remnants
[7]
b. May restore bone stock
c. May favourably be combined with uncemented implants
a. Enabling One stage approach avoiding bone cement
b. “Potentially permanent spacer” - easy re-revision
c. Improved conditions in case of failure
d. Improved long term results
5. Technique [8]
a. ALWAYS remove ALL implants + cement
b. Radical debridement
c. Jet-lavage
d. Re-drape and wash
e. Fill osseous defects with morsellized antibiotic impregnated bone graft [9]
f. Impaction grafting of defects on the femoral and tibial side [10]
g. Use implants featuring cementless stems with good contact to cortical bone [11]
Summary
• No reason to believe in inferiority of one stage procedures regarding infection control
• One stage clearly shows better results than multiple stage, regarding costs, patient’s burden, quality of
life, functional outcome and mortality.
• For reducing re-infection rates the issue of biofilm remnants must be addressed.
• Biofilm remnants require much higher local antibiotic concentrations than feasible with systemic
application or antibiotic loaded cement
• Antibiotic impregnated bone grafts are likely to provide AB-concentrations sufficient for elimination of
biofilm remnants, without side effects.
• Antibiotic impregnated bone grafts may restore bone stock
• They may be combined with uncemented implants, granting easy removal under possibly improved
conditions in case of failure (“potentially permanent spacer”), and possibly improved long term results
in case of success.
• Impaction grafting in combination with uncemented stems is a safe and reliable technique for single
stage revision.
References
1. Jamsen E, Stogiannidis I, Malmivaara A, Pajamaki J, Puolakka T, Konttinen YT. Outcome of prosthesis exchange for infected
knee arthroplasty: the effect of treatment approach. Acta Orthopaedica 2009;80:67-77.
2. Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty:
predictors of failure. Clinical orthopaedics and related research 2011;469:3049-54.
3. Jamsen E, Sheng P, Halonen P, et al. Spacer prostheses in two-stage revision of infected knee arthroplasty. Int Orthop
2006;30:257-61.
73

4. Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M. Patient satisfaction and outcome after septic versus aseptic
revision total knee arthroplasty. J Arthroplasty 2000;15:990-3.
5. Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of One and Two-Stage Revision of Total Hip
Arthroplasty Complicated by Infection: A Markov Expected-Utility Decision Analysis. J Bone Joint Surg Am 2011;93:631-9.
6. Berend KR, Lombardi AV, Jr., Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage Treatment of Hip Periprosthetic
Joint Infection Is Associated With a High Rate of Infection Control but High Mortality. Clin Orthop Relat Res 2013;471:510-
8.
7. Winkler H, Janata O, Berger C, Wein W, Georgopoulos A. In vitro release of vancomycin and tobramycin from impregnated
human and bovine bone grafts. J Antimicrob Chemother 2000;46:423-8.
8. Winkler H. One-Stage Exchange of Infected Total Knee Arthroplasty: Effective Antimicrobial Treatment and Biological
Reconstruction Using Antibiotic Impregnated Allograft. In: Parvizi J, ed. The Knee: Reconstruction, Replacement, and
Revision. Brooklandville, Maryland: Data Trace Publishing Company; 2013:109:1-9.
9. Winkler H, Kaudela K, Stoiber A, Menschik F. Bone grafts impregnated with antibiotics as a tool for treating infected
implants in orthopedic surgery - one stage revision results. Cell Tissue Bank 2006;7:319-23.
10. Ghazavi MT, Stockley I, Yee G, Davis A, Gross AE. Reconstruction of massive bone defects with allograft in revision total
knee arthroplasty. J Bone Joint Surg Am 1997;79:17-25.
11. Whiteside LA. Cementless revision total knee arthroplasty. Clin Orthop Relat Res 1993:160-7.
74

TWO-STAGE IS STILL FOR ALL PATIENTS
Arlen D. Hanssen
Mayo Clinic, Rochester, USA
Although it seems attractive to consider one-stage reimplantation for an infected TKR, the literature,
clinical experience and old-fashioned common sense dictate that a two staged approach remains the gold
standard for successful eradication of infection. In the following table, a compilation of the world’s
literature, the superiority of infection control with a two-stage approach is easily demonstrated and it is
important to recognize that the success with one-stage approach is less even when the “best” and least
virulent cases have been preferentially selected for this approach while all other cases, including the most
severe cases, have been treated with the two-stage approach.
Table 1. Results of reimplantation TKR
Spacers/Beads Prosthesis Fixation Success
Direct-Exchange Plain cement 58%
Direct-Exchange Ab-PMMA 74%
Two-Stage no Plain cement 88%
Two-Stage no AbPMMA 92%
Two-Stage yes Ab-PMMA 94%
In addition to infection control, there are a number of other reasons for using a two-staged approach.
1. The soft-tissue envelope around the knee joint is much more susceptible to scarring and wound
necrosis and often a period of immobilization after implant removal with spacer placement allows
better wound healing than efforts to obtain early ROM associated with final prosthesis
implantation.
2. Increasingly, more infections are becoming multi-drug resistant and sometimes with polymicrobial
infections not all micro-organisms are identified until the postoperative time period. A two-stage
approach allows for individualized treatment in these difficult cases.
3. The indications for reimplantation have broadened significantly in the past three decades so that
patients with multiple comorbidities, severe bone loss, are soft-tissue damage are now acceptable
candidates. Treatment for these variables is optimized with a two-stage approach and fewer bridges
are burned using this approach. For example, in the setting of severe bone loss, use of biologic
fixed devices for prosthetic fixation are often very difficult to remove if infection recurs.
References
1. Burnett RS, Kelly MA, Hanssen AD, Barrack RL. Technique and timing of two-stage exchange for infection in TKA. Clin
Orthop Relat Res. 2007 Nov;464:164-78
2. Leone JM, Hanssen AD. Management of infection at the site of a total knee arthroplasty. Instr Course Lect. 2006;55:449-61.
3. Mabry TM, Hanssen AD. Articulating antibiotic spacers: a matter of personal preference. Orthopedics. 2007 Sep;30(9):783-5.
75

FAILURE ANALYSIS AND PATIENT SELECTION IN REVISION TKA
Claudio Zorzi
Ospedale Sacro Cuore, Verona - Italy
Revision TKA should be performed only after etiology of failure is assessed
Diagnosis and failure analysis are very demanding.
Failure analysis should be conducted according to a predefined protocol:
1. Thorough anamnesis and clinical history
2. Evaluation of the pain pattern
3. Psychological examination
4. Accurate clinical examination
5. Laboratory test
6. Joint aspiration
7. Radiographic analysis
8. Imaging
9. Response to conservative therapy
Surgeons should expect different improvements and final functional scores depending on the cause of
revision.
Revision in early failures, expecially for atrhrofibrosis, have been shown to yield less satisfactory results.
Age, BMI, psychiatric disorders are highly correlated with the outcome.
High-risk patients should have more detailed pre-operative education on achieving realistic
expectations
References
1. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies
Nawfal Al-Hadithy, Department of Trauma and Orthopaedics, Lister General Hospital, Stevenage, UK Int Orthop
36:1185-9. 2012
2. Reason for revision influences early patient outcomes after aseptic knee revision.Paul P Baker, Paul P Cowling, Steven S
Kurtz, Simon S Jameson, Paul P Gregg, David D Deehan Clin Orthop Relat Res 470(8):2244-52 (2012)
3. The aetiology of total knee arthroplasty failure influences the improvement in knee function Ralf Bieger, Thomas Kappe,
Christian R. Fraitzl, Heiko Reichel Archives of Orthopaedic and Trauma Surgery February 2013, Volume 133, Issue 2,
pp 237-241
4. Predisposing factors which are relevant for the clinical outcome after revision total knee arthroplasty. Francois
Hardeman, Knee Surg Sports Traumatol Arthrosc (2012) 20:1049-1056
5. Revision after early aseptic failures in primary total knee arthroplasty. Sergio Rocha Piedade, Knee Surg Sports Traumatol
Arthrosc (2009) 17:248-253
6. Early mechanical failure in total knee arthroplasty. Marc-Antoine Rousseau, International Orthopaedics (SICOT) (2008)
32:53-56
7. Causes of failure and etiology of painful primary total knee arthroplasty. Romain Seil, Dietrich Pape; Knee Surg Sports
Traumatol Arthrosc (2011) 19:1418-1432
76

PLANNING + EXCLUDING INFECTION
Peter Ritschl
Austria
Take Home Message
The diagnosis of PJI can be difficult and utilizes many different diagnostic modalities including
• Clinical, serologic, radiographic, szintigraphic and microbiologic tests.
• Optimal diagnostic strategies of PJI remain unanswered.
Any chronic painful prosthesis can represent a PJI
There is a need of strong collaboration between all involved medical and surgical specialists:
• Orthopedic-, Plastic surgeons,
• Infectious disease specialists
• Microbiologist / Pathologist
PJI: Periprosthetic Joint Infection
77

APPROACH / IMPLANT REMOVAL + 3 STEPS TECHNIQUE
Francesco Giron
Florence, Italy
Approach: Revision requires wide exposure.
Skin incision: In the knee blood supply of the skin is from medial to lateral. Consider risks related to
patient and those related to previous surgeries. An existing surgical incision should be used whenever
possible. If multiple longitudinal incisions are present, is preferably to utilize the more lateral one. Avoid
large lateral flaps and acute corners. In unusual situations consider sham incision, tissue expanders or
muscle flap.
Extensor mechanism: Standard medial parapatellar approach is the "gold standard". Do not be hurried to
flex the knee, work in extension. Perform synoviectomy; reestablish medial and lateral gutters; release of
scar between the anterior femur and the deep quadriceps (Tarabichi technique); free patellar tendon from
the scar; dissect around medial proximal tibia (external rotation); remove articular polyethylene. Attention
to details in the surgical exposure has made more aggressive manoeuvres such as tibial tubercle osteotomy
and quadriceps turn-down largely obsolete.
Component removal: Almost any component can be removed by sawing through the fixation interface
(with a reciprocating saw) followed by insertion of multiple osteotomes between the component and bone.
Remove femoral and tibial component hammering a punch on the edge of component. Removal of
cemented, stemmed components may be challenging. Remove any screw that locks the component to the
stem so that the component can be removed independently, and the fixation interface of the stem can be
exposed. Fully cemented diaphyseal length stems should be avoided when possible because of the
difficulties with removal, which may necessitate an anterior femoral “window” or an extended tibial
tubercle osteotomy.
Three step technique: Three sequential steps in revision arthroplasty technique gradually construct a knee
that is stable from flexion to extension, with a reasonable reconstitution of the three dimensional joint line.
Step 1: Re-establish the tibial “platform”. Create a flat platform, resect the least amount of bone to
preserve the bone stock, accommodate wedges and stems to fill the bone defects and to align the tibial
component.
Step 2: Balance the flexion gap. Choose the correct femoral size. Adjust femoral component rotation.
Restore distal and posterior joint line. Choose poly insert.
Step 3: Stabilize the knee in extension. Fill the extension space. Work in proximo-distal dimension.
Build-up or recut.
References
1. Vince KG, Droll K, Chivas D. New concepts in revision total knee arthroplasty. J Surg Orthop Adv. 2008 Fall;17(3):165-72.
2. Jacofsky DJ, MeneghiniRM, Sporer SM, Della Valle CJ. Revision total knee arthroplasty; What the practicing orthopaedic
surgeon needs to know. 77th AAOS Annual Meeting, New Orleans, ICL 222.
3. Dennis DA, Berry DJ, Engh G, Fehring T, McDonald SJ, Rosenberg AG, Scuderi G. Revision total knee arthroplasty. J Am
Acad Orthop Surg. 2008; 16: 442-454.
78

DEALING WITH BONE DEFECTS + IMPLANT FIXATION
José Filipe Salreta
Portugal
DEALING WITH BONE DEFECTS
The management of bone defects in total Knee replacement remains a challenging clinical problem despite
several surgical treatment options available to the surgeon.
1. Etiology
It’s crucial to determine the mechanism of failure in order to correct previous mistakes. The
etiology is multifactorial and includes aseptic loosening of the implants, periprosthetic osteolysis,
stress shielding, and infection.
2. Preoperative planning
Revision Total knee replacement is a complex surgery where the surgeon has to deal with several
aspects at the same time, osseous reconstruction, joint line restoration, flexion-extension balance.
With that purpose a careful preoperative planning is of paramount importance in order to
anticipate all these aspects.
Standard radiographs of the knee to be operated on and of the contra-lateral Knee will provide
important information for intra-operative guidance during revision as alignment, joint line,
posterior condylar offset.
3. Classification
Just after implant removal and debridement, a fully assessment of the location, size and extent of
bone damage can be achieved.
Bone defects are divided in contained and uncontained defects, whether the cortical rim is intact or
interrupted.
The most commonly-used classification system is the one of Andersen Orthopaedic Research
Institute (AORI) which classifies the femur and tibia defects separately as follows:
Type 1- minor bone defects which will not compromise the stability of standard implants
Type 2 - damaged metaphyseal bone. Loss of cancellous bone will need to be filled by cement,
bone graft or metal augments to restore the joint line. Type 2A defects occur in just one femoral
condyle or tibial plateau while Type 2B occurs in both condyles or plateaux.
Type 3 - deficient metaphyseal bone. Severe cancellous bone loss and cortical rim damage.
Occasionally associated with detachment of the collateral ligaments and/or patellar ligament.
Usually requires long-stemmed or custom- made hinged prosthesis.
4. Surgical options
The options available for the reconstruction of the bone defects include:
1. Cement
2. Autologous bone graft
3. Morsellised or impacted allograft
4. Structural allograft
5. Modular metal augments
6. Porous tantalum metal cones
7. Metaphyseal sleeves
8. Custom-made hinged prosthesis
The method of reconstruction is directly related to the severity of the bone loss encountered
during surgery. It should also take into account the life expectancy and functional demand of the
patient as well as the quality of the bone, grafts and implants available.
The best treatment method for large bone defects remains controversial and therefore has not yet
been established.
79

References
1. Meneghini RM, Lewallen DG, Hansen AD: Use of porous tantalum metaphyseal cones for severe tibial bone loss during
revision total knee replacement. J Bone Joint Surg Am 2008;90(1):78-84
2. Jones RE, Skedros JG, Chan AJ, Beauchamp DH, Harkins PC: Total knee arthroplasty using the S-Rom mobile bearing hinge
prosthesis. J Arthroplasty 2001; 16 (3) : 279-287
3. Clatworthy MG, Balance J, Brick GW, Chandler HP, Gross AE: The use of structural for uncontained defects in revision total
knee arthroplasty :A minimum five- year review. J Bone Joint Surg Am 2001; 83(3): 401-411
4. Engh GA, Ammeen DJ: Bone loss with revision total knee arthroplasty: Defects classification and alternatives for
reconstruction. Instr Course Lect 1999; 48: 167-175
5. Toms AD, Barker RL, McClelland D: Repair of bone defects and containment in revision total knee replacement. A
comparative biomechanical analysis. J Bone Joint Surg (Br) 2009,91-B: 271-7
6. Whittaker JP, Dharmarajan R, Toms AD: The management of bone loss in revision total knee replacement. J Bone Joint Surg
(Br) 2008; 90-B:981-7
7. Scuderi GR. Complications after total knee arthroplasty. How to manage patients with osteolysis. J Bone Joint Surg Am
2011;93:2127-35
IMPLANT FIXATION
The implant fixation with stems in revision total knee replacement is almost universally accepted by surgeons,
particularly in most severe osseous deficiencies cases.
The use of intramedullary stems has an offload effect on the damaged metaphyseal bone increasing the mechanical
stability of the construct. Several biomechanical aspects of the different fixation techniques are still under study, thus
the optimal fixation technique remains controversial.
Stem fixation can be cemented, hybrid or cementless.
Cemented stems provide in short-term a more rigid construct. The indications for cemented stems include wide
intramedullary canal, malalignment of the femur or tibia, bad quality of bone, elderly patients and infection.
Press-fit stems provide a more equitative distribution of the load on the cortical, cancellous bone and stem. Press-fit
stems in addition with offset extensions permit an adequate alignment and an enhanced endosteal diaphysis-fit.
Hybrid fixation is the most used method in which the base plate of the components are fixed with cement to the
host bone and the stem is press-fit engaged into the endosteal diaphysis.
The fixation method is directly related to the bone defect reconstruction achieved, and should take into account the
degree of the constraint of the prosthesis.
Tantalum Trabecular Porous Cones and Metaphyseal Sleeves are very attractive reconstructive and fixation methods,
considering that they provide a metahyseal-filling of the femur or tibia, promoting a biological integration of the
implant, and in addition they provide more rigid and stable constructs through the long press-fit stem. This concept
has changed the philosophy of the bone fixation.
Well-designed studies and longer follow-up are needed to determine whether these new techniques will provide
durable reconstruction in such challenging cases.
References
1. Bourne RB, Finlay JB. The influence of tibial component intramedullary stems and implant- cortex contract on the strain
distribution of the proximal tibia following total knee arthroplasty. Clin Orthop Relat Res 1986; 208:95-99.
2. Completo A, Duarte A, Fonseca F, Simões JA, Ramos A, Relvas C. Biomechanical evaluation of different reconstructive
techniques of proximal tibia in revision total knee arthroplasty: an in vitro and finite element analysis. Clinical Biomechanics.
2013.Article in Press.
3. Completo A, , Simões JA, Fonseca F. Revision total knee arthroplasty: the influence of load sharing and instability. Knee
2009;16:275-279.
4. Fehring TK,Odum S, Olekson C, Griffin WL, Mason JB, McCoy TH. Stem fixation in revision total knee arthroplasty: a
comparative analysis. Clin Orthop Relat Res 2003; 416:217-24.
5. Meneghini RM, Lewallen DG, Hanssen AD. Use of porous tantalum metaphyseal cones for severe tibial bone loss during
revision total knee replacement. J Bone Joint Surg Am.2008; 90: 78-84.
6. Radnay CS, Scuderi GR. Management of bone loss: augments, cone, offset stems. Clin Orthop Relat Res 2006; 446:83-92.
80

DIAPHYSEAL FIXATION WITH STRAIGHT AND OFFSET STEM EXTENSION
Massimo Innocenti
Florence, Italy
1. Cement or cementless stems
- No single answer for all patients
- Advantages and disadvantages of both
- Comparable survivorship of press-fit stems and cemented stems
- Increased interest in uncemented fixation with new generation ingrowth surface and new stem
design
2. How fit give to the stem
- High fit allow better alignment and high stability instead of stress shielding and end of stem
pain
- Give the lower fit necessary to stabilized enough the implant
- Increase fit in case of methaphyseal bony defects
3. How long
- Remains an open question
- Consider bowed shape of femur and tibia
4. Straight or offset stem
a. TIBIA:
- Consider the methaphyseal/dyaphyseal anatomical mismatch
- Choose straigh or offset to optimize the tibial coverage
b. FEMUR:
- Consider systematical use of posterior offset stem:
to restore posterior condylar offset
to allow better stem alignment into the canal
to restore desired joint line
81

LEVEL OF CONSTRAINT + EXTENSOR MECHANISM
Stefano Zaffagnini
Istituto Ortopedico Rizzoli, Bologna, Italy
LEVEL OF CONSTRAINT
1. The principle: the less constraint according to the degree of laxity
- Super stabilized models
- Semi-constrained models
- Constrained models
2. Indications for super-stabilized:
- primary revision
- collateral ligaments present
- no severe bone loss
3. Indications for semi-constrained:
- collateral ligaments laxity
- moderate bone-loss
- neuropathic patient
4. Indications for constrained:
- collateral ligaments absent
- severe bone loss
- multiple revision
References
1. Dennis DA, Berry DJ, Engh G, Fehring T, MacDonald SJ, Rosenberg AG, Scuderi G. Revision total knee arthroplasty. J Am
Acad Orthop Surg. 2008 Aug;16(8):442-54.
2. Lee JK, Kim SJ, Choi CH, Chung HK. Revision Total Knee Arthroplasty Using a Constrained Condylar Knee Prosthesis in
Conjunction with A Posterior Stabilized Articular Polyethylene. J Arthroplasty. 2012 Nov 9.
3. Barrack RL, Lyons TR, Ingraham RQ, Johnson JC. The use of a modular rotating hinge component in salvage revision total
knee arthroplasty. J Arthroplasty. 2000 Oct;15(7):858-66.
4. Kim YH, Kim JS. Revision total knee arthroplasty with use of a constrained condylar knee prosthesis. J Bone Joint Surg Am.
2009 Jun;91(6):1440-7.
EXTENSOR MECHANISM
1. Extensor mechanism problems
- Tendon ruptures (quadriceps or patella tendon)
- Patella baja
- Stiff tendons
- Patellar fractures
2. Tendon ruptures:
- Direct suture repair
- Augmentation with autologous tendon
- Augmentation with allograft tendon
3. Patella baja:
- Soft tissue release
- Tibial tuberosity elevation
- Patellar tendon lengthening
4. Stiff tendons:
- Soft tissue and capsular release
- Quadriceps snip
- Tibial tuberosity osteotomy
82

5. Patellar fractures:
- Synthesis
- Fragment removal
- Partial\total patellectomy
- Complete extensor apparatus transplantation
References
1. Rosenberg AG. Management of extensor mechanism rupture after TKA. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):116-
9. doi: 10.1302/0301-620X.94B11.30823.
2. Zanotti RM, Freiberg AA, Matthews LS. Use of patellar allograft to reconstruct a patellar tendon-deficient knee after total
joint arthroplasty. J Arthroplasty. 1995 Jun;10(3):271-4.
3. Busfield BT, Ries MD. Whole patellar allograft for total knee arthroplasty after previous patellectomy. Clin Orthop Relat Res.
2006 Sep;450:145-9.
4. Bruni D, Iacono F, Sharma B, Zaffagnini S, Marcacci M. Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage
Revision for Prosthetic Knee Infection A Randomized Prospective Study. Clin Orthop Relat Res. 2013 Apr;471(4):1305-18.
5. Laskin RS. Management of the patella during revision total knee replacement arthroplasty. Orthop Clin North Am. 1998
Apr;29(2):355-60.
83

WHICH IS THE BEST STEM EXTENSION FOR REVISION
CEMENTED
Thomas Fehring
OrthoCarolina Hip and Knee Center, USA
Key Points
1. Metaphyseal engaging cemented stems are satisfactory in most simple revisions.
2. Metaphyseal engaging cementless stems are rarely indicated.
3. Canal filling cementless stems can create joint line malalignment.
4. Offset cementless stems can help prevent this, but extraction can be difficult.
5. Cemented stems are biomechanically superior to cementless stems with less micromotion.
6. Cementless stems can be effective provided they are diaphyseal engaging in patients with good bone
stock.
Biomechanics of Stem Fixation
Stem Micromotion:
Stern et al. Clin Orthop Rel Research 1997
• cadaveric study
• micromotion and migration significantly less in cemented stems versus cementless stems
Bert et al. Clin Orthop Rel Research 1998
• biomechanical study
• fully cemented implants have less micromotion than implants where tray cemented and stem press fit
Jazrawi et al. J Arthroplasty 2001
• cemented metaphyseal engaging stems have less micromotion than cementless stems of same length
Clinical Studies
Cemented Stems
Murray et al. Clin Orthop Rel Research 1994
• 40 patients fully cemented revision TKA’s
• only one loose femoral component at 5 year follow up
• durability of cementless stems must be compared to these results
Whaley et al. J Arthroplasty 2003
• 38 fully cemented revision TKA’s
• clinical follow-up 10.1 years
• 11 year survivorship for aseptic loosening 95.7% ( revisions)
• 1 loose tibia (standard length)
• no loose femurs
Cementless Stems
Shannon et al. J Arthroplasty 2003
• 60 patients uncemented intramedullary stems of variable lengths
• mean follow-up 5.7 years
• 12 re-revisions (10%) for aseptic loosening
• 4 radiographically loose tibial components
• overall mechanical failure rate of 16%
• radio-opaque lines present in 90% and 97% of remaining femoral and tibial stems
84

Peters et al. J Arthroplasty 2009
• 184 knees
• cortically contracted metadiaphyseal stems
• 49 months follow up
• 9 re-revisions for infection
• No re-revisions for aseptic loosening
Wood et al. J Arthroplasty 2009
135 knees
• press-fit diaphyseal fixation with proximal cementation
• 5 year mean follow-up
• 6 revisions
• 98% survival
Fehring et al. Clin Orthop Rel Research 2003
“Stem Fixation in Revision Total Knee Arthroplasty: A Comparative Analysis”
Conclusion
implants implanted with cementless stems were significantly more unstable than those implanted with
cemented stems (p = .0001)
- Caveat!
All the cementless stems were only metaphyseal engaging.
85

WHICH IS THE BEST STEM EXTENSION FOR REVISION
CEMENTLESS
Alois Franz
Hospital for Orthopedic Surgery and Sports Medicine, Siegen - Germany
Cementeless stems
Principles and biomechanics
Increased area of fixation reduced micromotion of wedges/augments at interface. Off-load interface stress
and protect damaged metaphyseal fixation area reduce bone stress 30%
Alignment of components: offset stems often to align better the implant on the metaphysis increased
support to axial and bending loads
Requirements
Length: stem length defines the length of stress shielding and potential bone loss (as short as possible to
prevent stress shielding, but long enough to reach press-fit) (Bourne 1986).
Width / Thickness: 30mm of parallel engagement is necessary to ensure reduced micromotion (Conditt J.
Arthroplasty 2004).
Results
Beckmann J et al. Fixation of revision TKA: a review of the literature. Knee Surg Sports Traumatol
Arthrosc 2011; 19:872-79.
A literature review was carried out in the main medical databases from 1980 to 04/2010. Hybrid and
cemented techniques are comparable regarding:
• the survival of arthroplasties;
• the rate of aseptic loosening;
• the clinical outcome.
Advantages
• Easier, faster to implant
• Guarantee axial alignment if they fill canal
• Excellent results and good 10 year survivorship
• Easier to remove and less bone loss
Summary
1. Use long enough stems to reach enough press fit
2. Use off-set stems to achieve best intra-medullary alignment
3. Provides ease of another revision
4. Achieves clinical results comparable to full cementation
5. Reaches survival rates as good as full cementation
86

FILLING THE DEFECT. METAPHYSEAL SOLUTIONS
SLEEVES
Claudio Carlo Castelli
Azienda Ospedaliera Papa Giovanni XXIII - Bergamo, Italy
1 Alternatives methods of managing large defects in revision TKA:
- structural allograft
- trabecular metal cones
- metaphyseal sleeves
2 Sleeves are not just an alternative methods or device but offer a different solutions and surgical
procedure
- specific surgical technique allows that metaphysis become best reference for
alignment
fixation
joint line reconstruction
3 Assist in restoring the joint line (3D) and provide a stable methaphyseal base for the
components: build up implant on sleeve
- efficient and utilitarian acting both as trials and cutting guide
- intramedullary guides and blocks often unstable because difficult to secure in the remaining bone
- on femoral side assist in proper cutting guide and component positioning to manage large flexion
gaps:
conventional intramedullary ( all case but mainly in bowing femur) road fixation produces a too
anteriorized and too extended position
4 Sleeves fix implant on metaphysis and compressively load the bone
- metaphyseal region generally has intact and well vascularized bone even in the setting of severe
bone loss
- good surface for osseous integration of porous coated components. Load produces beneficial
remodelling at the implant bone interface
- defect can be filled relatively independently on femoral and tibial component rotation : adress bony
defect managing without sacrifice additional bone
- are system specific and connected with a morse taper to the revision implant
- are to be associated wiht short cementless or cemented stems . Even appliable with no stem at all
- faster straight forward surgical procedure
5. Indication-contraindication and clinical results
- metaphyseal bony defects both contained and uncontained (AORI II a-b and III)
- contraindicated in active infection and unsupportive metaphysis that does not allow for initial
sleeve ( implant ) stability
- Short-medium term follow up is encouraging and supportive for their continued application.
6. Summary
- Sleeves are not an alternative device to fill bone loss but requires a different surgical procedure
- Implant size and position are build up on sleeves
- Fix implant on metaphysis and compressively load the bone
- Are system specific and connected with a morse taper to the revision implant
- Faster straight forward surgical procedure
87

FILLING THE DEFECT. METAPHYSEAL SOLUTIONS
TANTALUM CONES
Giles R. Scuderi
USA
Take home message
1. In revision TKA, metaphyseal defects of the proximal tibia and distal femur are commonly
encountered and impact component fixation. These defects may cause difficulties with fixation.
2. A successful revision TKA requires reconstitution of the bone defects to establish a stable
platform for the final implant.
3. Trabecular metal (TM) cones are available in multiple shapes and sizes and eliminate the concerns
associated with allogenic bone graft (Scuderi. JBJS 93A, 2011).
4. Trabecular metal tibial cones establish a stable base for the tibial component by re-establishing the
cortical rim. The TM cone is securely impacted into the host bone defect in a cementeless pressfit
manner. The core implant is cemented to the tibial cone.
a. Additional augments can be added to the tibial baseplate to restore the mechanical
alignment
b. The use of cemented or cementless tibial stem extensions is dependent upon the severity
of tibial bone loss and the ability to obtain diaphyseal fixation.
5. Trabecular metal femoral cones establish a stable base for the femoral component. The TM cone is
securely impacted into the host bone defect in a cementeless pressfit manner. The core implant is
cemented to the femoral cone.
a. Additional augments can be added to the femoral component to restore the distal joint line
and the posterior condyles.
b. The use of cemented or cementless tibial stem extensions is dependent upon the severity
of femoral bone loss and the ability to obtain diaphyseal fixation.
6. Clinical Results with TM tibial cones
a. Meneghini, et al. JBJS 90A, 2008.
b. Long and Scuderi. J Arthroplasty, 2009
7. Clinical results with TM femoral cones
a. Howard et al. JBJS 93A, 2011
88

THE BEST SPACER FOR THE INFECTED TKA
IN FAVOUR OF STATIC
Tilman Pfitzner
Center for Musculoskeletal Surgery, Charité, Universitätsmedizin, Berlin, Germany
1. Infection treatment
- two stage exchange still golden standard
- mobile and static spacers equal in infection control
- mobile spacers superior in ROM after reimplantation
2. Feasibility of mobile spacers
- at risk in excessive soft tissue infection with tissue defects
- not possible in excessive bone defects
- not possible in insufficient ligaments
3. Wear of PMMA - PMMA articulation
- PMMA not made for articulation
- hard, abrasive wear
- problem of 3 rd body wear after reimplantation
4. Reduction of static spacer problems
- increase of stability with supportive rush-pins / AO-rods
- full weight bearing possible
5. Own results
- 16 static spacers with rush pin vs. 17 spacers with AO-Rods
- no significant difference in infection control
- less complications due to migration/bone loss/fracture
- no significant difference in clinical outcome after reimplantation
Summary
- static spacer superior in infection and bone loss/instability
- shorter exchange intervals reduce problems due to joint immobilization
References
1. Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA. Minimizing Dynamic Knee Spacer Complications in Infected
Revision Arthroplasty. Clin Orthop Relat Res. 2012; (470): 220-227.
2. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-Joint Infections. N Engl J Med 2004; (351): 1645-1654.
3. Jaekel DJ, Day JS, Klein GR, Levine H, Parvizi J, Kurtz SM. Do Dynamic Cement-on-Cement Knee Spacers Provide Better
Function and Activity During Two-stage Exchange Clin Orthop Relat Res 2012; (470): 2599-2604
4. Fink B, Rechtenbach A, Büchner H, Vogt S, Hahn M. Articulating spacers used in two-stage revision of infected hip and knee
prostheses abrade with time. Clin Orthop Relat Res. 2011; (469): 1095-102.
5. Park SJ, Song EK, Seon JK, Yoon TR, Park GH. Comparison of static and mobile antibiotic-impregnated cement spacers for
the treatment of infected
total knee arthroplasty. International Orthopaedics 2010; (34): 1181-1186
89

THE BEST SPACER FOR THE INFECTED TKA
IN FAVOUR OF MOBILE
A. Schiavone Panni, M. Vasso, S. Cerciello
Italy
1. Three types of articulating spacers: molded in surgery room, preformed and composite.
2. Recently mobile spacers have been demonstrated more effective in infection eradication than fixed
spacers.
3. Dynamic spacers allow (partial) weight bearing, flexion of the knee thus avoiding arthrofibrosis and
stiffness. The capability of bending the knee between stages improves patient satisfaction and the final
result.
4. Mobile spacers avoid osteopenia by disuse, and better suit to the bone contours so obtaining less
osteopenia by spacer friction or migration. Removal of articulated spacers is less invasive than block
spacers ( preserving bone stock) and doesn’t require special instrumentation.
5. Reimplantation is facilitated by decreased quadriceps scarring, maintenance of collateral ligaments
integrity and preserved bone stock. Dynamic spacers also facilitate knee exposure at reimplantation
6. Mobile spacers present less complications than fixed spacers. However, articulating spacers may be not
appropriate in case of extensor mechanism disruption, severe ligamentous instability, or important
bone loss because of the risk of dislocation or wound dehiscence. Moreover, weight-bearing and
movement can cause breakage, fragmentation, and displacement of the dynamic spacers with possible
reactive synovitis and compression of the neurovascular structures of the knee.
References
1. Jaekel DJ, Day JS, Klein GR, Levine H, Parvizi J, Kurtz SM. Do Dynamic Cement-on-Cement Knee Spacers Provide Better
Function and Activity During Two-stage Exchange Clin Orthop Relat Res (2012) 470:2599–2604
2. Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA. Minimizing Dynamic Knee Spacer Complications in Infected
Revision Arthroplasty. Clin Orthop Relat Res (2012) 470:220–227
3. Kalore NV, Maheshwari A, Sharma A, Cheng E, Gioe TJ. Is There a Preferred Articulating Spacer Technique for Infected
Knee Arthroplasty A Preliminary Study. Clin Orthop Relat Res (2012) 470:228–235
4. Romanò CL, Gala L, Logoluso N, Romanò D, Drago L. Two-stage revision of septic knee prosthesis with articulating knee
spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports
Traumatol Arthrosc. 2012 Dec;20(12):2445-53
90

EXPOSURE FOR REVISION TKA: HOW DO YOU SET YOUR THRESHOLD FOR A TTO
PRETTY HIGH
Andrew Porteous
Avon Orthopaedic Centre, Bristol, United Kingdom
Adequate access is important when performing Revision TKA, both for implant removal, adequate
debridement in infected cases and for implantation. Inadequate access risks damage to bone and
particularly extensor mechanism during extraction and re-implantation. Methods for achieving access must
weight up risks and benefits. Options for obtaining this exposure include:
- Standard medial parapatellar approach with removal of scar tissue and release of contracted suprapatellar
pouch and gutters, OR
- Quad snip (QS), TTO, V-Y turndown (QT)
Della Valle (CORR 2006) suggests that a standard medial capsulotomy approach is adequate in 92% of
revisions TKA’s. Barrack (CORR 1998) showed no difference in any outcome parameter whether a medial
capsulotomy had an added quads snip or not, but TTO and Quads turndown were significantly worse.
Garvin (CORR 1995) did cybex testing on patients after QS and although they showed significant weakness
of the knee in extension when compared with the contralateral normal side, they found no difference if the
patient had a TKA in the contralateral knee. This suggests that quads snip does confer some extension
power deficit, but no different to a standard TKR. Trousdale (CORR 1993) showed quads strength with
cybex testing to be worse after QT than just QS, but not significantly so.
TTO is not always a benign procedure and does have a reported a serious complication rate of approx. 5 –
10% (Zonnenberg). Mean union time can is 12 weeks, and is increased to 21 weeks if there is intramedullary
extension of the osteotomy (Ries). Stability is improved with a step cut and fixation with screws,
cables, wires or sutures can allow union without modification of rehabilitation.A recent study suggests that
after revisions for infection, re-infection rates did not differ between TTO vs Quads snip, and KSS, ROM
and incidence of residual lag were better after TTO. (Bruni)
I agree that TTO, with a step cut and stable fixation, provides excellent access and rehabilitation is not
compromised. However, in the majority of revisions it is not required and does add extra operative time
and possibility of complications. In a personal series of > 400 revision TKA’s, a normal approach +/-
minor quads snip has been sufficient in +/- 90% of cases, a TTO in < 10% and a V-Y Quads Turndown in
< 2% (usually if a prior quads rupture has occurred.
My indications for TTO include severely reduced flexion particularly if combined with patella baja, or the
need to remove a well fixed stemmed tibial component.
References
1. Bruni D, Iacono F, Sharma B, Zaffagnini S, Marcacci M.Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage
Revision for Prosthetic Knee Infection A Randomized Prospective Study. Clin Orthop Relat Res. 2013 Jan 3. [Epub ahead of
print]
2. Zonnenberg CB, Lisowski LA, van den Bekerom MP, Nolte PA. Tuberositas osteotomy for total knee arthroplasty: a review
of the literature.J Knee Surg. 2010 Sep;23(3):121-9.
3. Whiteside LA.Clin Orthop Relat Res. 1995 Dec;(321):32-5.Exposure in difficult total knee arthroplasty using tibial tubercle
osteotomy.
4. Chalidis BE, Ries MD. Acta Orthop. 2009 Aug;80(4):426-31.Does repeat tibial tubercle osteotomy or intramedullary extension
affect the union rate in revision total knee arthroplasty A retrospective study of 74 patients.
5. Garvin KL, Scuderi G, Insall JN. Evolution of the quadriceps snip.Clin Orthop Relat Res. 1995 Dec;(321):131-7.
6. Trousdale RT, Hanssen AD, Rand JA, Cahalan TD. V-Y quadricepsplasty in total knee arthroplasty. Clin Orthop Relat Res.
1993 Jan;(286):48-55.
91

EXPOSURE FOR REVISION TKA: HOW DO YOU SET YOUR THRESHOLD FOR A TTO
VERY LOW
Sergio Romagnoli
Italy
TTA osteotomy in TKA revisions is reserved to complex cases of stiff. Ankylotic knee
The advantages of TTA osteotomy are:
• possibility of perfect articular exposion
• preservation of patella tendon
• preservating quadriceps integrity
• possibility of correction of lower patella
In order to reduce risks of pseudo arthritis -fracture the minimum dimension of TTA have to be 6 cm x 3
cm x 0.7 mm
92

USE OF HINGES IN REVISION TOTAL KNEE
AS LESS AS POSSIBLE
Fabio Catani
Italy
1. Failure mode of primary TKR
We should consider the balance between bone loss and soft tissue integrity. Less mechanical constrain of
the revision TKR transfers less load to the soft tissue envelope. Moreover, less constrain of the revision
TKR will transfer less load on implant/cement/bone interface. Soft tissue laxity or damage can be treated
only by TKR revision constrain; CCK TKR design gives coronal plane stability only if the extensor
mechanism is efficient. CCK TKR design limitation is on axial rotation (bone/implant loading).
2. Bone stock in TKR revision
When bone loss is severe, use of stem is mandatory. Fixation and dimension of stems are important
features during surgical technique and use of Revision TKR constrain design. When bone loss affects soft
tissue integrity, hinge becomes mandatory.
3. Soft tissue and Revision TKR constrain synergy
Flexion and extension gap stability and extensor flexor muscle function are essential factors for using CCK
revision TKR.
Hinge revision TKR and soft tissue are conflicting.
4. Revision TKR design and freedom of motion
CCK revision TKR design constrains the knee on the coronal plane only if the extensor mechanism is
optimal, flexion/extension is free and axial rotation is highly constrained.
Hinge revision TKR is less constrained than CCK if the mechanism allows freedom for axial rotation.
93

USE OF HINGES IN REVISION TOTAL KNEE
MORE USEFUL THAN YOU THINK
Susanne Fuchs-Winkelmann
Germany
1. Introduction
- use of hinged protheses is controversially discussed
- some surgeons say that they are outdated
- some authors are convinced that it is easier for surgeon and patient in large revision cases especially
in older patients
- there is a vast range of complication rates
2. Swedish knee arthroplasty register, Annual report 2011
- Type of Revisions 18,7 % linked
3. Survival Rate
- most authors describe around 90 % after 10 or 15 years
4. Complications
- Infection rate is higher than in primary TKA
5. Experimental results
- Hinged prostheses restore the quadriceps lever arm in knee flexion and improve the lever arm in
knee extension due to higher constraint and stability
- This would offer a potential advantage for patients with weak quadriceps strength.
6. Summary
- Initial designs were associated with a higher failure rate
- More recent designs have improved the patellofemoral articulation and the hinged mechanism
- Primary indication should be for medial or lateral collateral ligament loss, massive bone loss, severe
flexion gap imbalance, neuromuscular deficit or flail knee who require the hyperextension stop.
- Disadvantages such as increased infection risks, difficult to remove in revision cases have to be
discussed.
References
1. Hassenpflug et al, Orthopade 2003, 32: 484-9
2. Barrack RL CORR 2001, 392: 292-9
3. Ostermeier et al, Acta Orthop 2008, 79:34-8
4. Jones RE, Orthopaedics 2006, 29:S80-2
5. Jämsen et al, JBJS Am 2009, 91:38-47
6. Steckel et al, Z Orthop 2005, 143:30-5
7. Deehan et al, J Arthroplasty 2008, 23:683-8
8. Böhm, Zentralbl Chir 2003, 128:64-9
94

ENHANCED METAPHYSEAL FIXATION IN REVISION TKA
Francesco Benazzo
Italy
3 Principles:
- fill defect
- stabilize the implant
- reconstruct the joint
Analysis preoperatively and classification bone defects
- Use x-rays and CT-scan
Options for bone defects
Titanium augments and cement (cement mantle for implant fixation)
TM augments (screws to increase contact with bone, cemntless) and cones
- Bone ingrowth
- Rough surface
- Primary stability
Advantages of cones in metaphyseal fixation
Femur:
- Reinforce the damaged area of the femoral cavity
- stabilize and reconstruct transfer and distribute load
- Adjustments of rotation to re-establish appropriate epicondylar axis alignment
Tibia:
- Reinforce the medullary cavity of the tibia.
- Fill a proximal tibia bone void
- Provide appropriate support of the tibial baseplate.
Indications for TM cones
Femur
- Dimension of the defect
- Location of the defect
- Type of defect
- Need only to fill and stabilize or also to reconstruct and redistribute load
Tibia:
- Dimension of the defect
- Need to reinforce the cortical rim
- Need to reconstruct
Disadvantages of use of TM cones
- sacrifice of viable bone for correct positioning
- difficult removal
Advantages of use TM cones
vs morselized grafts or bone blocks
- immediate stability of the implant
- quicker rehab
vs metaphyseal sleeves
- bone ingrowth
- less bulky
My personal tips
- preference to primary fixation with TM cones
- bone graft only to fill defects but not to stabilize or reconstruct
- sacrifice viable bone worth if immediate reconstruction and stability
- on the femoral side TM cones help also in diaphiseal defects
95

References
1. Lachiewicz PF. Tantalum Cones Provide Fixation Revision Knee Arthroplasty Clin Orthop Relat Res. 2011 Apr 5.
2. Howard JL. Early results of the use of tantalum femoral cones for revision to arthroplasty. J Bone Joint Surg Am. 2011 Mar
2;93(5):478-84.
3. Meneghini RM. Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement.
Surgical technique JBJS Am, 2009.
96

IMPLANT REMOVAL AND ANTIBIOTIC-LOADED CEMENTED SPACER
PREPARATION FOR INFECTED TKA
Carsten Perka
Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, Germany
1. Preoperative considerations
- analysis of microbial resistance with local and systemic antibiotic therapy
- choice of local antibiotics with regard to thermal resistance
- planning of possible soft tissue defects (be prepared for flaps)
- analysis of expected bone defects and ligament stability for decision of spacer type
- availability of immediate microbiological/histological analysis
- sterile boxes for implant sonication / sonication device
2. Techniques and instruments
- large approach for optimal exposition of the joint
- go for cement – prostheses interface to avoid additional bone loss
- specific instruments for implant disconnection in constraint TKA
- Chisels of different size, thickness and curvation
- Gigli saw
- Pulsatile lavage with antiseptics
- radical debridement of bone and soft tissue
- dead bone is dead bone --> mandatory to be removed
3. Static versus dynamic spacer
- static and dynamic spacers equal in infection control
- dynamic spacers superior in ROM after reimplantation
- “static spacer plus” (PMMA supported by AO external fixation rods)
- static spacers superior in bone defects (revision arthroplasty)
- static spacers superior in instable joints (no partial weight bearing)
4. Complications / Contraindications of spacers
- bone loss / migration in isolated fixed PMMA spacers
- spacer fracture / instability in mobile spacers with bone defects / insufficient ligaments
- contraindication of prefabricated mobile spacers in resistant germs
- contraindication in hypersensitivity against PMMA
- relative contraindication in mycosis (no way of cracking biofilm) --> External fixation
- relative contraindication in persistent infection after numerous spacer revisions --> External fixation
5. Own preferred surgical technique
- two stage exchange protocol
- static spacer supported by AO-external fixation rods
- individual antimicrobial supplements
- in unproblematic bacteria short exchange interval
Summary
- radical surgical debridement and the right antibiotic therapy key to success
- choice of spacer dependent on bone defect, joint stability and soft tissue infection
References
1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-Joint Infections. N Engl J Med 2004; (351): 1645-1654.
2. Whiteside LA, Nayfeh TA, LaZear R, Roy ME. Reinfected revised TKA resolves with an aggressive protocol and antibiotic
infusion. Clin Orthop Relat Res. 2012;470(1):236-43.
3. Jämsen E, Stogiannidis I, Malmivaara A, Pajamäki J, Puolakka T, Konttinen YT. Outcome of prosthesis exchange for infected
knee arthroplasty: the effect of treatment approach. Acta Orthop. 2009;80(1):67-77.
4. Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA. Minimizing Dynamic Knee Spacer Complications in Infected
Revision Arthroplasty. Clin Orthop Relat Res. 2012; (470): 220-227.
5. Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM,
Greenleaf JF, Patel R. Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection. N Engl J Med 2007;
357:654-663.
97

DIAPHYSEAL PREPARATION AND FIXATION WITH STEM EXTENSION
Thomas Fehring
OrthoCarolina Hip and Knee Center, USA
Key points
1. Cemented metaphyseal engaging stems are appropriate for most aseptic revisions.
2. If cementless stems are used, they must engage the diaphysis.
3. Preserve pericortical bone when using cemented stems.
4. Obtain cortical contact with aggressive hand reaming when using cementless stems.
5. Ensure proper component rotation at the initiation of insertion when using cementless stems.
Patella inversion method
Patella inversion method for exposure in revision total knee arthroplasty
Fehring et al., J Arthroplasty Vol 17, No. 1, Jan. 2002
• No attempt is made to evert the patella
• Early lateral retinacular release is performed
• Tibia is gradually externally rotated decreasing stress on patellar tendon
Revision arthroplasty principle
• When revising a cemented intramedullary implant, re-cementing into a sclerotic tube is unpredictable.
Tab. Cementless stem indications
Cementless
Metaphyseal engaging
Diaphyseal engaging
Indications
Rarely, if ever, should you use these
Revision patient with good diaphyseal
Bone stock
Where offset stems prevent joint line malalignment
Bypass cortical defects
Stabilize periprosthetic fractures
Previously infected patient
Reaming technique
Different for cemented and cementless stem fixation
Cementless
Cortical contact is important in cementless stem preparation – hand ream aggressively
Cemented
Preservation of cancellous bone is important for cement interdigitation in cemented stem preparation
Merely sound the canal with reamers
98

DEALING WITH A LARGE FLEXION GAP IN REVISION TKA
Gijs van Hellemondt
St. Maartenskliniek, Nijmegen, The Netherlands
1. Causes of instability in flexion
- mainly medio-lateral and/or AP instability
- Causes are : incompetent soft tissues, insufficient insert thickness,
or inadequate bone resection (ea. overresection posterior condyles/ femoral malrotation)
2. preplanning is paramount
- clinical signs
- physical examination
- Plain radiographs /stress x-rays / CT
3. surgical technique for achieving stability in flexion
• Tibia cut (15 mm above styloid process) + distal femur cut
• Check extension gap with spacer
- Distance medial epicondyle jointline ±25-30 mm
- Patella height ±15 mm
• Measure maximal femur size (AP / mediolateral size femur / restore posterior offset)
• Check correct femoral rotation
• Check flexion stability with spacer
• Trial prosthesis: re-check joint-line, patella height rotation femur / tibia, stability, patella tracking,
rom
4. Technical pittfalls
• Think about: “true” patella height / ligament quality
• Relation between joint-line and patella height
• If flexionspace is too large: largest femur wil be outside ML range
• Then consider using implant with more contraint
References
1. Bellemans J (2004) Restoring the joint line in revision TKA: does it matter Knee 11: 3-5
2. Bonnin M, Deschamps G, Neyret P, et al. (2000) Les changements de protheses totales du genou non infectees. Rev Chir
Orthop Reparatrice Appar Mot 86:694-706
3. Bourne R, Crawford H (1998) Principles of revision total knee arthroplasty. Orthop Clin North Am 29: 331-337
4. Bryan R (1988) Patella infera and fat pad hypertrophy after total knee replacement. Tech Orthop 3: 29-33
5. Chonko D, Lombardi A, Berend K (2004) Patella baja and total knee arthroplasty: etiology, diagnosis, and management.
Surg Technol Int 12: 231-238
6. Grelsamer R (2002) Patella baja after total knee arthro-plasty. Is it really patella baja J Arthroplasty 17: 66–691
7. Hofmann A, Kurtin S, Lyons S, et al. (2006) Clinical and radiographic analysis of accurate restoration of the joint line in
revision total knee arthroplasty. J Arthroplasty 21: 1154-1162
8. Laskin R (2002) Joint line position restoration during revision total knee replacement. Clin Orthop 404:169-171
9. Mason M, Belisle A, Bonutti P, et al. (2006) An accurate and reproducible method for locating the joint line during a revision
total knee arthroplasty. J Arthroplasty 21: 1147-1153
10. 1Partington P, Sawhney J, Rorabeck C, et al. (1999) Joint line restoration after revision total knee arthroplasty. Clin Orthop
367: 165-171
11. Porteous AJ, Hassaballa MA, Newman JH. (2008) Does the joint line matter in revision total knee replacement J Bone
Joint Surg 90-B: 879-84
12. 1Rivat P, Neyret Ph, Ait Si Selmi T (1999) Influence de l’ordre des coupes, Coupes dependantes et independantes, Role du
tenseur. 9emes Journees Lyonnaises de Chirurgie du genou et de l’epaule
13. Van den Broek C. MD, Van Hellemondt G.G. MD, Wymenga A.B. MD PhD Chapter: Technique of revision in TKA; joint
line level The Knee Joint - Surgical Technique and Strategies, editors: Bonin et al 2011
99

HOW TO TREAT A DAMAGED PATELLA DURING REVISION TKA
Philip Chapman-Sheath
University Hospital Southampton, UK
1. Maintain residual bone stock
- should we resurface the patella in primary
- osteoarthritis
- correct component rotation
- careful removal of solid implants
2. Preserve resurfaced patella component
- assess preoperatively
- bone quality and loosening
- PE wear / metal backing
- congruency with revision implant
3. Consider primary implants in revision
- use different designs
- single central peg to three peripheral peg PE button
- trabecular metal primary implant
- bone graft and cement
4. Use of alternative implants
- trabecular metal primary implant
- massive bone loss and trabecular revision implant
- PE alternative implants ( biconvex )
5. Other options to consider
- patelloplasty
- patellectomy
- extensor allograft
- arthrodesis
References
1. Maheshwer CB, Mitchell E, Kraay M, Goldberg VM. Revision of the Patella with Deficient Bone using a Biconvex
Component.Clin.Orthop.Rel.Res. 2005 Nov;440:126-30
2. Maheshwari AV, Tsailas PG, Ranawat AS, Ranawat CS. How to Address the Patella in Revision Total Knee Arthroplasty.
Knee 2009, Mar;16(2):92-7
3. Rorabeck CH, Mehin R, Barrack RL. Patellar Options in Revision Total Knee Arthroplasty. Clin.Orthop.Rel.Res. 2003
Nov;(416):84-92
4. Hanssen AD, Pagnano MW. Revision of Failed Patellar Components. Instr.Course Lect. 2004;53:201-6
5. Kamath AF, Gee AO, Nelson CL, Garino JP, LOtke PA, Lee GC. Porous Tantalum Patellar Components in Revision Total
Knee Arthroplasty minimum 5 year follow-up. J.Arthroplasty 2012 Jan;27(1): 82-7
100

SKIN PROBLEMS IN REVISION TKA
Philippe Massin
France
Consider local muscular flaps as useful adjuvant for the treatment of infected knee prostheses with poor
skin status.
Probably anticipate the soft tissue problem and treat if first under adapted antibiotherapy.
101

REVISION TKA WITH ASSOCIATED EXTRA-ARTICULAR DEFORMITY
Jean-Louis Briard
France
Correction of tibial extraarticular deformity (such as after HTO) inside the joint may require ligament &
posterior capsule release to bring the knee to neutral. Consequences must be anticipated.
Asymetrical tibial cut to be in neutral may create laxity and ligament imbalance inside the joint (so called
laxity of resection) which could have to be solved in revision surgery:
1) with metal augment inside the joint to regain stability and then performance of an extraarticular HTO
(case reported);
2) or with a highly constrained design such as hinge knee.
Tibia valgum deformity (genu valgum type 3) may requires a new tibial osteotomy at the first TKA to
realign the limb and maintain stability.
102

DEALING WITH PATELLAR BONE LOSS
Ferran Montserrat
Spain
The management of patellar component with severe bone deficiency in TKA revision surgery is a challenge
and an essential aspect of this procedure.
Several methods have been described to treat severe patellar bone loss during TKA revision:
1. Resection patellar arthroplasty or leaving a “bony shell” are a surgical options when the existing
bone stock is not sufficient to support a revision patellar implant
2. “Gull-wing” sagittal osteotomy is a technique to improve patellar tracking without restoring the
deficient bone stock
3. Placing cancellous bone allograft into a synovial pouch is a procedure to improve bone stock
4. Total patellectomy is a radical option that can produce several problems with weak quadriceps
function and/or dislocation of the extensor mechanism
The average thickness of the patella is 24 mm, which is important in maintaining effective strength of the
extensor mechanism. However, in these four procedures the full thickness of the patella may not be
restored.
Finally, partial or total extensor mechanism allograft is indicated only in cases with previous total
patellectomy, irreparable fractures or extensor mechanism discontinuity
In this subject, the treatment with Trabecular Metal patella implant is a good option because
1. The patellar height and thickness can be restored
2. There is a biological fixation to the remnant bone in the host patella
Three points are mandatory in this technique
1. The continuity of extensor mechanism with a minimum patellar bone-shell stock preserved
2. The patellar bone-shell stock must cover at least the 50% of tantalum implant
3. This implant never must be fixed over soft tissue (previous total patellectomy)
103

CASE - BILATERAL INFECTED TKA: EVALUATION AND MANAGEMENT
Robert Stephen J. Burnett
University of Victoria, Division of Orthopaedic Surgery, Victoria, BC, Canada
• Host / medical comorbidities – higher rate
• Nutritional status – often compromised (albumin, total protein)
• 2- stage procedure most successful
• Bacterial organism – Gram negative, MRSA, VRE, fungal, culture negative infections : negative
predictors
• Soft tissue quality – consider plastic surgery consultation
• Prior extensor mechanism procedures – beware !
• Duration of immobility – 6 weeks then consider re-implant
• Mobile vs static spacers – mobile ideal for bilateral patients
• Timing of reimplantation – staged surgery (ie days or a week apart)
References
1. Cipriano CA, Brown NM, Michael AM, Moric M, Sporer SM, Della Valle CJ. Serum and synovial fluid analysis for diagnosing
chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am. Apr 4 2012;94(7):594-600.
2. Springer BD, Scuderi GR. Evaluation and management of the infected total knee arthroplasty. Instr Course Lect. 2013;62:349-
361.
3. Munro JT, Garbuz DS, Masri BA, Duncan CP. Articulating antibiotic impregnated spacers in two-stage revision of infected
total knee arthroplasty. J Bone Joint Surg Br. Nov 2012;94(11 Suppl A):123-125.
4. Mahmud T, Lyons MC, Naudie DD, Macdonald SJ, McCalden RW. Assessing the gold standard: a review of 253 two-stage
revisions for infected TKA. Clin Orthop Relat Res. Oct 2012;470(10):2730-2736.
5. Wolff LH, 3rd, Parvizi J, Trousdale RT, Pagnano MW, Osmon DR, Hanssen AD, Haidukewych GJ. Results of treatment of
infection in both knees after bilateral total knee arthroplasty. J Bone Joint Surg Am. Oct 2003;85-A(10):1952-1955.
6. Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty:
predictors of failure. Clin Orthop Relat Res. Nov 2011;469(11):3049-3054.
7. Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB. Functional advantage of articulating versus static
spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. Dec 2007;22(8):1116-1121.
104