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210
A. Lencioni and C. A. Hogan
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19.1 Introduction
Surgical treatment of osteoarthritis (OA) of the knee
can vary from implant design to surgical technique.
This chapter provides a surgical case with the surgical
technique developed at the authors’ institution. The
role of total knee arthroplasty for the treatment of
knee OA, including measured resection and gap balancing techniques along with their comparative outcomes, are also discussed. The goal of maintaining
mechanical versus kinematic alignment with regard to
technique and outcomes in relation to each other is
illustrated. In addition, the use of unicompartmental,
bicompartmental, and tricompartmental knee arthroplasty with comparative outcomes for the treatment of
unicompartmental and tricompartmental knee OA is
covered.
19.2 Case Example
We present a case of a 66-year-old male who presented
to our clinic with advanced right knee arthritis
(. Figs.19.1 and 19.2). He had a long standing history
of right knee pain. Prior to presentation in our clinic, he
underwent extensive conservative treatment with physical therapy, activity modications, anti-inammatories,
cortisone, and viscosupplementation. At the time of
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. Fig. 19.1 Weight-bearing AP X-ray demonstrating advanced
medial compartment degenerative changes including joint space narrowing, subchondral sclerosis, and marginal osteophytes
. Fig. 19.2 Lateral X-ray demonstrating tibiofemoral arthritis
mentioned above but also posterior femoral osteophytes and degenerative changes of the patellofemoral compartment
evaluation, the patient elected to pursue operative management of his knee arthritis. This case highlights our
surgical technique for total knee arthroplasty.
19.3 Surgical Technique
At our institution, we use the following preparation,
positioning, and surgical technique for cemented total
knee arthroplasty. If possible, all patients undergo a
single-shot adductor canal block with the regional anesthesia team in the preoperative bay. Once complete, the
patient is moved to the operating room and a single-shot
short acting spinal is performed. The patient is then
placed in a supine position, a formal time-out is held,
and the patient is prepped and draped is a standard
fashion. We use a double prep with chlorhexidine and a
tourniquet is placed but typically not used. Once the
drapes are in place, a De-Mayo surgical knee positioner
is placed onto the eld.
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A standard midline incision is used for the surgical
approach. Effort is made to ensure that the distal portion
of the incision is medial to the tibial tubercle (potentially
helps with kneeling pain). Next, a standard medial parapatella arthrotomy is used. Once the arthrotomy is complete we perform a subtotal synovectomy along the
medial side and the supra-patellar pouch, and remove
the retro-patellar fat pad in its entirety. Then, a complete
subperiosteal dissection medially on the proximal tibia is
performed to release the deep medial capsule, deep MCL
back to the mid- coronal plane (note this release is signicantly less for valgus knees).
> Note this is done in exion with 90° Homan retrac-
tors protecting the collateral ligaments.
Next, using a measured resection technique we prepare
the femur. Using an intramedullary guide, the distal
femur cut is made either in 5° of valgus or 4° of valgus
(for a valgus knee). The thickness of this cut is 9mm for
our system. Following this and using a posterior refer-
encing system, the femur is sized and rotation is set to
be parallel to the transepicondylar axis and perpendicular to Whiteside’s axis (.
Fig. 19.3). The order of
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19
. Fig. 19.3 A bovie is used to mark out the Whiteside’s (anteropos-
terior) and transepicondylar axis. Note these lines should be perpendicular to one another
. Fig. 19.4 The box cut is made for a posterior stabilized femoral
component. This will set the medial-lateral position of the femoral
component, and in general a more lateral position optimizes patellar
tracking
these cuts is anterior, posterior, posterior chamfers,
anterior chamfers. The box cut is made using the boxcut guide for a posterior stabilized knee system
(.
Fig. 19.4). After all the femoral cuts are made, the
tibia is then subluxed forward with a posterior retractor. Medial and lateral 90° Homan retractors protect
the collaterals.
> Please ensure the lateral retractor is anterior to the
midline of the tibia to protect the common peroneal
nerve.
Next, using an extramedullary tibia guide set perpendicular to the mechanical axis of the tibia and in 3° of
posterior slope, the tibia cut is made (. Fig.19.5). This
bony fragment and the medial and lateral menisci are
removed (. Fig.19.6). The knee is then brought to 90°
of exion and a laminar spreader is used to assess the
exion gap (. Fig. 19.7). Additionally, this allows
access to the posterior compartment to remove osteophytes. A portion of our peri-articular joint cocktail is
then inltrated into the posterior medial capsule. Once
adequate exion balance is obtained the tibia is then
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. Fig. 19.5 An extramedullary guide is used to make the proximal
tibial resection with attention placed on both coronal and sagittal
alignment as well as depth of resection
sized and prepped. Rotational alignment of the tibia is
set to the medial third of the tibial tubercle. At this
point, trial implants are used to assess motion and stability in exion and extension, varus and valgus instability. At this point, if stability is not adequate, further soft
tissue releases are performed to obtain excellent stability. The patella is addressed last. The patella is everted
and measured for composite thickness. The patellar cut
is then made again using measured resection. This allows
to prevent overstufng the patellar femoral compartment.
> Ensure that a residual thickness of minimum 12mm
is left to protect against fracture.
At times I will accept slightly increased composite thickness if the cut necessary would leave less than 12mm of
residual thickness. All attempts are made not to change
the initial thickness more than 20%. At this point, patellar tracking is checked with trials in place. This is done
with a freehand technique.
Once the correct component size is set, balance has
been determined and trialed, all trial implantsare
removed. The bony surfaces are copiously irrigated with
. Fig. 19.6 After proximal tibial resection, the menisci are removed
a pulse lavage and sterile saline (
Fig. 19.8). The
.
cement is prepared in standard vacuum environment
and I use a medium-viscosity cement which has been
prewarmed to speed curing time. We rst cement the
tibial component (. Figs. 19.9 and 19.10) and then
cement the femoral component (. Figs. 19.11 and
19.12), inset the formal polyethylene and fully extend
the knee while the patellar button is cemented. All excess
cement is removed in standard fashion.
During cement curing, I place the foot on my stomach and apply a constant pressure. I feel this helps to
prevent the slight changes that can occur during expansion of a curing cement. During this, the remainder of
the peri-articular joint cocktail is placed in the synovium,
medial/lateral periosteum of the femur, retropatellar
area, and medial tibia including the pes complex. Once
fully cured a nal range of motion and stability is
checked to ensure no changes. The knee is brought into
exion for closure.
The arthrotomy is closed with a unidirectional
barbed suture (number 1). This is also oversewn at the
same time by an assistant with interrupted #1 braided
suture in gure-of-eight fashion. The subcutaneous tissues are closed with a 2.0 buried monocryl and the skin
is approximated with standard skin staples. The dressing
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. Fig. 19.7 The exion gap is assessed using a laminar spreader.
Ideally, if the bones have been resected appropriately, this will create
a rectangle that will accept at least the minimum composite thickness
of the tibial tray and smallest insert
consisted of adaptic, gauze, cast padding, and a bias
wrap from ankle to mid-thigh. This allows some mild
compression.
19.4 Gap Balancing Versus Measured
Resection
When treating patients with end-stage knee OA the goal
is to get patients to return to activities that their arthritis
has been preventing them from participating in. Over
time TKA engineers have modied the materials and
designs of TKA to achieve this goal with the hopes to
achieve stable knee implants with full exion and extension. Two approaches for the implementation of TKA
implants, gap balancing and measured resection, have
been developed and popularized to achieve soft-tissue
balance along with implant alignment, size, and rotation
in hopes to help patients achieve their goals. While many
surgeons will say they use one or the other, most surgeons actually will fall somewhere in the middle of the
two methodologies. Surgeons have started using more of
. Fig. 19.8 The bony surfaces are irrigated clean of all blood and
bone marrow to maximize cement interdigitation
a hybrid technique in hopes to avoid the individual pitfalls of each specic technique (Sheth etal. 2017).
19.4.1 Gap Balancing
Gap balancing is a technique using the tension of the
soft tissue to make bony cuts with the goal to have symmetric, rectangular exion, and extension gaps. Making
the assumption that the soft tissue tension of the
patient’s knee is “normal” and “un-altered”, the goal is
to cut the femur parallel to the tibial cut. This relies on a
precise tibia cut which is typically perpendicular to the
anatomic and mechanical axis of the tibia. The initial
tibial cut acts as the foundation for soft tissue tensioning
which allows one to place the guide for the posterior and
distal femoral cuts. Before any femoral cut is made all
tensioning is completed, including posterior osteophyte
removal and soft tissue releases (Jaffe etal. 2018).
When using gap balancing for TKA implantation
you want to have symmetric tension of the soft tissues in
extension before setting femoral rotation and creating
your exion gap. Once extension tensioning is achieved
with soft tissue release and osteophyte removal; the
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. Fig. 19.9 First, cement is applied to the proximal tibia w/ nger
packing of the tibial keel. It is important to avoid blood and cement
on this surface
proximal tibia and distal femur cut can be made using
the tibia and femur mechanical axis as your guide. This
allows you to make the proximal tibia and distal femur
cuts and then using soft tissue releases to create a balanced extension gap (Sheth etal. 2017). Next, you set
the femoral rotation and exion gap by balancing the
soft tissue in 90° of exion using laminal spreaders or a
system-specic soft tissue tensioner device to assist in
measuring the posterior femoral condyle cut and distal
femur rotation. This creates a rectangle with the bone
removed from your posterior femoral condyles. Gap
balancing and soft tissue tensioning will ideally restore
the anatomic rotation of the knee and make balanced
exion and extension gaps.
> As with measured resection, gap balancing is not per-
fect. The gap balancing technique has been criticized
for incorrect condylar offset, and impingement leading to diminished knee exion (Sheth etal. 2017).
While attempting to balance the exion and extension
gaps surgeons can incidentally raise the joint line, or
. Fig. 19.10 Cement is applied to the undersurface of the tibial
component to improve cement-to-cement bond and avoid fat interposition
alter the anatomic femoral rotation, which can lead to
instability to mid-range motion (Sheth etal. 2017; Babazadeh etal. 2014; Lee etal. 2010; Martin and Whiteside
1990; Tigani etal. 2010). Elevation of the joint line in
gap balancing technique occurs when the surgeon is
attempting to balance the extension gap and will resect
more distal femur and then insert a bigger implant in
hopes to improve the extension gap tension. Mid-exion
instability occurs with an elevated joint line because of
an altered patella femoral mechanics. Additionally, surgeons can sacrice femoral rotation for balanced exion
gaps which will lead to internal rotation of the distal
femur and mal-tracking of the patella, increasing the
risk of patella fracture and other complications (Sheth
etal. 2017).
> Making any alteration to the soft tissue tension,
including removing osteophytes, releasing IT band
and popliteus, does not alter the exion and extension
gaps symmetrically. Also, anything done after the
femoral cuts can ultimately affect nal balancing of
the knee and riskinstability.
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. Fig. 19.11 A horseshoe-shaped layer of cement is placed on dis-
tal and anterior femoral surfaces. Note, cement is not applied to the
posterior condylar surfaces so as to avoid excess posterior cement,
which is more difcult to remove
19.4.2 Measured Resection
On the other hand, the goals of the measured resection
technique are to replace the amount of bone resected
with an equal thickness of prosthesis implanted and use
anatomic landmarks to determine appropriate component position and rotation (Sheth etal. 2017). This technique relies on the ability of the surgeon to appropriately
identify anatomic landmarks and size the implants.
Measured resection allows for maintenance of the joint
line, restoration of posterior condylar offset, and optimization of knee kinematics (Sheth etal. 2017). Using
measured resection, the surgeon must rely on anatomic
landmarks including the transepicondylar axis (TEA),
the AP axis (Whiteside‘s line), and the posterior condylar axis to set the correct femoral rotation. When correctly identied, this technique allows for maintenance
of the joint line, neutral femoral rotation, and appropriate exion–extension gaps.
> Similar to gap balancing, measured resection has
been criticized for some of the pitfalls associated with
the technique, most notably relying on the anatomic
. Fig. 19.12 Cement is applied to the anterior and posterior sur-
faces of the femoral component. This helps prevent cement–bone
interface gaps anteriorly and minimizes the occurrence of excess
cement posteriorly
landmarks for setting rotation of the femoral compo-
nent (Sheth etal. 2017).
Given the wide range of femoral anatomy between
patients, this results in a wide range of femoral component nal rotation. In addition to variability of the anatomy, critics point out the poor interobserver reliability
to correctly identify the anatomy (Sheth etal. 2017).
The TEA is traditionally described as the line connecting the prominence of the lateral epicondyle to the
sulcus of the medial epicondyle (Sheth etal. 2017) and is
thought to be the most reliable landmark for assessing
the femoral rotation (Sheth etal. 2017; Jaffe etal. 2018).
Intraoperatively the TEA is not easily identied, or
reproducible, most notably difculty identifying the
medial epicondylar sulcus, where the MCL originates
from (Sheth et al. 2017; Jaffe etal. 2018), and proper
identication may require more soft tissue dissection.
Whiteside‘s line has been described as the AP axis and is
a line starting anterior at the trochlear sulcus and runs
posterior through the deepest part of the trochlea to the
midpoint of the intercondylar notch. In studies, the AP
axis has been shown to be a more consistent predictor of
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the patient’s natural external rotation than the PCA
(Jaffe etal. 2018; Arima etal. 1995). Lastly, and according to critics as the least reliable landmark is the posterior condylar axis, connecting the posterior aspects of
the femoral condyles. Traditionally the TEA and
Whiteside’s lines are perpendicular and the posterior
condylar axis is thought to be 3–6° of internal rotation in
relation to the TEA (Sheth etal. 2017; Jaffe etal. 2018).
When placing the femoral guides using the measured
resection technique, the guide can be anterior- or
posterior- referenced. With anterior referencing the sur-
geon will x the guide to the anterior femur to ensure
that femoral component sizing changes will not remove
any additional anterior bone, while a differential amount
of bone is cut from the posterior femoral condyles,
which can affect the exion gap. Posterior referencing
sets the posterior femoral condyle cut with the jig pinned
in place, and sizing changes take more or less bone from
the anterior femur which could lead to notching and the
risk of stress-riser fracture or overstufng the patellofemoral joint, respectively (Jaffe etal. 2018).
Finally, proponents of gap balancing have pointed
out the difculty of adequate ability to perform soft tissue release to balance the exion and extension gaps
which can lead to coronal instability, and variability of
the bony anatomy and difculty identifying landmarks
can lead to internal rotation of the femoral components
which effectively lateralize the patella tracking.
the two main ways surgeons have approached TKA
alignment.
19.5.1 Mechanical Alignment
> Mechanical alignment in TKA is based on the
thought that restoring the normal mechanical alignment will provide better outcomes.
To do this the surgeon will make the bone cuts in the
femur and tibia perpendicular to the mechanical axis
and parallel to each other removing the 3° of valgus and
varus, respectively. The femur is cut with an intramedullary guide using the anatomic axis as a reference and the
guide is set to cut the distal femur, an angle (usually
3–6°) that represents the difference of the mechanical
and anatomic axis on plain lms making a cut that is
perpendicular to this axis. On the other side, the tibia’s
mechanical and anatomic axis are the same. The tibial
cut is made using an extramedullary guide placed in the
anatomic/mechanical axis and then the cut is perpendicular to this axis. The hopes of making the cuts parallel is to produce equal load distribution across the new
joint line (Schiraldi etal. 2016). While making the tibial
cut perpendicular to this axis there is a worry that this
will remove too much lateral tibia and cause laxity which
is managed with soft tissue balancing.
19
19.4.3 Comparison ofOutcomes
> At this time, there is no clear conclusion on which
technique provides better patient outcomes.
In one study looking at TKA in patients who had both
knees replaced, one using gap balancing and the other
measured resection had no difference on 2-year outcomes (Tapasvi et al. 2020). Another study looked at
prosthesis survivorship, patient outcomes, and complications, and in 214 patients both techniques provided
excellent survivorship at 3 years along with excellent
patient outcomes (Churchill etal. 2018).
19.5 Mechanical Versus Kinematic
Alignment
While the type of implant and surgical approach is
important to the surgery, so is the way the surgeon
decides to ensure proper alignment of the knee after
implantation to restore function and prevent eccentric
wear on the implant leading to better surgical outcomes.
Mechanical and Kinematic (anatomic) alignment are
19.5.2 Kinematic Alignment
> Surgeons utilizing kinematic alignment,on the other
hand, focus on restoring the anatomic alignment of
the knee unlike in the mechanical axis approach.
So instead of femur and tibial bone cuts that ignore the
anatomic access, these surgeons focus on recreating the
3° of femoral valgus and 3° of tibial varus in the hope to
create a more balance knee throughout the entire arc of
motion (Schiraldi etal. 2016).
19.5.3 Comparison ofOutcomes
When historically looking at postoperative TKA alignment the literature supports the notion that greater than 3°
of tibial varus leads to rapid failure due to implant wear,
loosening, and decreased function (Schiraldi et al. 2016;
Lad etal. 2013). Additionally, studies have shown that in
70–80% of patients we were successful in placing the nal
implants with less than 3° of error in the coronal plan thus
placing a fair amount of patients at risk for rapid failure
and less functioning implants (Lad et al. 2013).
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Postoperatively, patients with less tibial varus had higher
Knee Society scores than patients with more varus
(Schiraldi etal. 2016). Schiraldi etal. began to look at longterm follow-up of these patients and found that those who
had mechanical alignment with <3° of variation compared
to those with >3° of variation from the mechanical axis
had no statistically different 15-year implant survival rate,
or revision rates when coronal plane alignment was used to
compare groups (Schiraldi etal. 2016; Hadi et al. 2015).
When Dossett etal. preformed a randomized control trial
using kinematic and mechanical alignment as the two
groups they found that patients randomized to the patientspecic kinematic group reported better pain relief, and
better restoration of function than mechanically aligned
TKA (Dossett etal. 2014). They reported the kinematically
aligned group had WOMAC score 16 points higher
(p<.000) and KSS 25 points better (P= .001) (Dossett
etal. 2014). Additionally, Howell etal. found no difference
in Oxford Knee scores and WOMAC scores in patients
with kinematic-aligned knees regardless of their postoperative varus or valgus alignment (Howell etal. 2013).
While mechanical alignment is still the gold standard; many of the mentioned studies show promising
results coming from small data cohorts and radiographic
reporting of malalignment with noted observer bias.
When the bias was removed, only one known study was
found to have shown that worsening malalignment
increased the risk of revisions (Hadi etal. 2015).
At this time, more studies on larger scales will need to
be conducted as both methods have shown in recent
literature to have successful outcomes and similar revi-
sion rates.
19.6 Unicompartmental, Bicompartmental,
andTricompartmental Knee
Arthroplasty
While the TKA design was developed for tricompartmental OA treatment for patients who exhibited osteoarthritis in a single or two compartments, implants were
developed as well. Traditionally, patients who were
thought to be candidates for a unicompartmental knee
arthroplasty (UKA) were patients with unicondylar
osteoarthritis or osteonecrosis; frontal deformity <15°;
exion contracture <15°; functional integrity of the
anterior cruciate ligament (ACL) and peripheral ligaments of the knee as well as the absence of inammatory arthropathy (Vasso etal. 2018; Kim etal. 2018).
In a study of 106 cases of unicompartmental knee
arthroplasty, evaluating the 10-year outcomes in patients
<60 the implant survival rate was 89.3% when using all
revision surgery as a failure with only 20 cases having
documented complications (Kim etal. 2018). In addi-
tion, patients who underwent UKA in this study went
from an average of 130.7° to 132.8° of ROM with a
p-value of .045, and at the last follow-up 69.2% of
patients reported Knee Society scores (KSS) of 85 or
greater and an additional 26.4% with scores between 70
and 84 (Kim etal. 2018).
In the patients aged 80–89, one study found good
outcomes for UKA for patients with tricompartmental
OA (TCOA), with predominant medial compartment
OA (MCOA) (Marya and Thukral 2013). Forty-ve
patients with TCOA and predominant MCOA underwent UKA with symptomatic relief and implant survival in 96.4% and 94.9% good or excellent outcomes
(Marya and Thukral 2013). At 1-year follow-up the
patients had an average of 115° of ROM, (100–125),
KSS clinical scores improved from average of 46 (26–70)
preoperatively to 81 (66–90) at the nal follow-up. KSS
functional scores improved from 24 (0–50) to 82 (55–90)
(Marya and Thukral
In a meta-analysis comparing UKA to TKA, 60
studies were evaluated in patients with unicompartmental OA (Wilson etal. 2019). This study found both were
viable options for these patients with higher venous
thromboembolism and mortality rates with TKA, and
higher revision rates with UKA (Wilson et al. 2019).
There was a signicant difference in hospital stay for
UKA, but no signicant difference in pain patientreported outcome measures (PROM), but patients who
underwent UKA reported signicantly better functional
PROMs than TKA patients, which included a combined
score of consisting of the Oxford Knee score, Bristol
Knee score, Western Ontario and McMaster Universities
index, KSS, and Japanese Orthopaedic Association
score (Wilson etal. 2019). In addition, they looked at 17
studies looking at the revision rate at 5years and they
found a risk ratio ranging from 1.29 to 5.95 with UKA
requiring revision when compared to TKA. Again at
10years, they evaluated 13 studies with similar results
having UKA with higher revision rates and risk ratios
ranging from .64 for 3.53, with 11/13 groups having
higher rates of UKA revision (Wilson etal. 2019).
Isolated lateral compartment OA is much less common only compromising about 5–10% of people who
have isolated unicompartmental OA. Lateral UKA has
been preformed successfully in 98% of patients reporting
return to recreational activities (Imarisio and Trecci
2017). Reported postoperative functional outcomes for
lateral UKA have not been proven to be signicantly different when compared to TKA for the same indications.
Lateral UKA has been shown to have survivorship of
around 96% at 10years (Imarisio and Trecci 2017).
Bicompartmental Knee Arthroplasty (BKA) was
also developed for patients with medial and patellofemoral compartmental OA. A study looking at a singlebicompartmental implant system used in 15 patients
2013).
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noted a 60% revision rate at 54-month follow-up
(Dudhniwala et al. 2016). The study also found tibial
component bone–cement interface radiolucency in
73.3% of patients and knee pain in 46.6% of patients at
an average of 18 months postoperatively (Dudhniwala
etal. 2016). BKA knee kinematic studies were also preformed and noted slower motor task cadence compared
to control patients, and that overall knee joint kinematics
following BKA replicate the knee kinematics in the nonoperated contralateral limb (Lefer et al. 2012).
Additionally, BKA was found to correct varus deformity
in 130/137 patients (Rolston and Siewert 2009) with the
mechanical axis passing through the center of the knee.
While, as shown in the current literature, in selected
patient populations UKA can be a successful alternative
which may decrease cost, hospitalization time, and
shorten recovery time. There have not been many studies
showing statistically signicant clinical reported
improved outcome scores for UKA or BKA when compared to TKA.
> In addition, TKA has a lower revision rate at 5 and
10 years than UKA (Vasso et al. 2018; Kim et al.
2018; Marya and Thukral 2013; Wilson etal. 2019;
Imarisio and Trecci 2017; Dudhniwala et al. 2016;
Lefer etal. 2012; Rolston and Siewert 2009) and still
is the gold standard for treating degenerative tricom-
partmental OA as anything less would not address the
potential pain generator from arthritis in the unresur-
faced compartment.
Take-Home Messages
5 Today there are many options for the orthopedic
surgeon to choose from with regard to TKA in a
patient with primary knee OA.
5 They have the options of implant design, surgical
technique, and preoperative templating methods
to provide the patient with improved ROM, function, and longevity of the implant.
5 When looking at the literature there has been no
signicant difference with regard to outcomes or
revision rates for gap balancing or measured resection, or with mechanical or kinematic alignment.
5 When comparing UKA and BKA for knee OA,
there have been some recent studies in the elderly
population with tricompartmental OA; UKA for
the medial compartment has been shown to provide some symptomatic relief with decreased morbidity related to the surgery but should not be used
in younger active patients as this implant design
does not address all the underlying pathology in
these patients.
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