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Posterior Stabilized
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Total Knee Arthroplasty
MusaB.Zaid andThomasP.Vail
Contents
28.1 Introduction – 318
28.2 Case Example – 318
28.3 Surgical Technique – 318
28.3.1 Positioning – 318
28.3.2 Exposure – 319
28.3.3 Distal Femoral Preparation – 319
28.3.4 Tibial Preparation – 320
28.3.5 Extension Gap Balancing – 321
28.3.6 Femoral Sizing andRotation – 322
28.3.7 Patellar Preparation – 323
28.3.8
Trialing andTibial Sizing – 323
28.3.9 Cementation andFinal Component Placement – 323
28.3.10 Closure – 324
317
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28.4 Literature Review – 324
References – 325
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_28
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M. B. Zaid and T. P. Vail
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28.1 Introduction
The decision to utilize a cruciate-retaining versus a posterior stabilized total knee arthroplasty continues to be
an area of debate as one technique has not separated
itself from the other in achieving optimized pain relief
and functional outcome. While current literature suggests that posterior stabilized knee arthroplasty may
provide increased postoperative range of motion, there
is minimal difference in rates of aseptic loosening or
patient-reported outcomes when compared to cruciateretaining total knee arthroplasty. The purpose of this
chapter is to highlight the surgical technique of performing a cemented posterior stabilized total knee
arthroplasty as well as to briey discuss the kinematic
considerations of a posterior stabilized knee arthroplasty and explore some of the recent literature examining functional and patient-related outcomes between
cruciate-retaining and posterior stabilized implant
designs.
28.2 Case Example
On examination, her body mass index is 26 kg/m3.
She walks with an antalgic gait, valgus thrust. She has
full painless passive and active range of motion of her
bilateral hips with no pain on active straight leg raise.
Examination of her knees is signicant for mild medial
and lateral joint line tenderness and no effusion. The
patient has bilateral, left greater than right, valgus knee
alignment with a symmetrical range of motion of
0–130°. She is stable to anterior–posterior stress exam
and her valgus deformity is passively correctable with
solid endpoints on collateral ligament testing. She is
neurovascularly intact.
Anterior–posterior, sunrise, lateral, and Rosenberg
view radiographs of the bilateral knees demonstrate valgus alignment with bone-on-bone lateral joint space
narrowing and associated subchondral sclerosis
(. Fig.28.1).
Given the severity of the patient’s symptoms, the
associated limitation of her activities, and impact on her
quality of life, staged bilateral total knee arthroplasty is
recommended. As her left knee is more symptomatic,
the patient elects to have a left total knee arthroplasty
rst. Postoperative results are shown in .
Fig.28.2.
A 75-year-old female with a past medical history of
hypertension has been followed in the arthroplasty clinic
with bilateral, left greater than right, knee pain that has
progressively worsened over the last year. She describes
activity-related, dull-aching pain located in her anterior
knees that gets worse with using stairs, prolonged standing, and walking. Additionally, she has noticed increased
bowing of her knees. The patient currently can ambulate
greater than six blocks and does not use any assistive
devices. She has previously attempted oral antiinammatories and intra-articular cortisone injections
experiencing mild relief of her symptoms. Her review of
systems is notable for joint pain; she denies back pain or
other signicant joint symptoms.
28.3 Surgical Technique
28.3.1 Positioning
The patient is placed supine on a standard operating
room Table. A well-padded, high-thigh tourniquet is
placed on the operative extremity and is only inated
during nal component cementation. The operative
extremity is prepped and draped in the usual sterile fashion and then placed in a knee positioning device and
secured. The ankle is left free to allow for visualization
of the malleoli during placement of the extramedullary
tibial alignment guide.
. Fig. 28.1 Preoperative radiographs demonstrating valgus alignment with medial-sided bone-on-bone arthritis and osteophyte formation
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. Fig. 28.2 Postoperative radiographs demonstrating a well-sized, well-xed, cemented posterior stabilized total knee arthroplasty
28.3.2 Exposure
With the knee in a 40–45° exed position, a curved
medial peripatellar skin incision, avoiding the tibial
tubercle and other bony prominences, is used. A capsular incision is then performed starting distally using a
knife, proceeding from the medial one-third of the tibial
tubercle, incorporating the medial 6–8 mm of the
infrapatellar ligament, creating a cuff of tissue around
the medial aspect of the patella, and then proceeding
proximally in the medial 6–8mm of the quadriceps tendon to a distance of about one patella diameter above
the superior pole of the patella. The patella is then
reected laterally and the fat pad is excised.
An “internal release of the patella” is performed by
elevating the capsular attachment to the patella along
the lateral patellar border at the osteochondral junction.
The lateral patellofemoral ligament is divided sharply. A
limited synovectomy is performed (this can be more
extensive if there is extensive synovitis or synovial thickening). Exposure in standard varus or valgus knee with
a correctable deformity (as opposed to a more severe,
xed deformity required a greater release of contracture) includes minimal elevation of the deep MCL to
allow visualization of the proximal tibia sufcient to
perform a proximal tibial resection.
Once this standard exposure is completed, the knee
is exed with the patella subluxated to the lateral gutter.
This allows sufcient visualization of the distal femur
and proximal tibia to begin the bone resection and
assessment of the exion and extension gaps.
28.3.3 Distal Femoral Preparation
The knee is brought into exion and a rongeur is used to
remove any osteophytes that may be present along the
articular cartilage edges sufciently large to interfere
with the assessment of the joint line using the distal femoral resection guide. For intramedullary guidance of the
distal femoral cut, the diaphysis of the distal femur is
then opened above the notch toward its medial border at
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M. B. Zaid and T. P. Vail
. Fig. 28.3 Intraoperative photograph demonstrating exposure of
the distal femur as well as marking the start site for the intramedullary alignment guide located 7–10mm anterior and just medial to the
femoral origin of the posterior cruciate ligament
a location 7–10mm anterior and just medial to the femoral origin of the posterior cruciate ligament
(. Fig. 28.3). The intramedullary alignment rod is
inserted into the distal femur with the attached distal
femoral cutting block preset at the desired valgus angle
relative to the anatomic axis. This desired angle can be
determined with preoperative imaging. The resection
level is set such that the resected bone matches the thickness of the prosthesis, thereby preserving the joint line.
Once positioned, the cutting jig is secured with pins
allowing removal of the alignment rod and creation of
the distal femoral using an oscillating saw through the
jig (. Fig.28.4).
> Care should be taken to assure that the cutting instru-
ment does not deviate off of sclerotic bone thereby
moving the cut off of the desired angle.
. Fig. 28.4 Intraoperative photograph demonstrating placement
of the distal femoral cutting guide followed by removal of the intramedullary alignment guide. Note the entry position of the intramedullary guide just above the notch and slightly medial to the mid-line.
An oscillating saw is used to make this cut through the guide
28.3.4 Tibial Preparation
Following distal femur preparation, the knee is brought
into 90° of exion to prepare the proximal tibia. While it
is possible to create both the distal femoral and proximal tibial cuts with navigation or custom blocks, most
often an extramedullary tibial guide is used. Likewise, it
is also acceptable to make the proximal tibial cut rst,
and the distal femoral cut next, using the proximal tibia
to guide the femoral cut. In either workow, the extramedullary guide is secured to the leg via pins at the joint
line and clamps that reach around the tibial at or above
the lateral and medial malleoli. The position of the jig
proximally sets the relationship of the proximal tibial
cut to the mechanical and anatomic axes. Some surgeons
prefer a predetermined proximal tibial angle, others use
Posterior Stabilized Total Knee Arthroplasty
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. Fig. 28.5 Intraoperative photograph demonstrating placement
of the extramedullary tibial alignment guide. The resection stylus is
placed on the tibial plateau to set the proper level of proximal tibial
bone resection. The amount of resection correlates with the combined thickness of the metal prosthetic tray and tibial insert
surface anatomy such as the intermalleolar position distally and the medial third of the tibial tubercle proximally, and others choose to make the proximal tibial cut
perpendicular to the mechanical axis.
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> With any of those choices, it is assumed that the sur-
geon accounts for the variability in individual anatomy and preexisting deformity to achieve the desired
outcome.
When performing a posterior stabilized knee replacement, to accommodate the articular design of the prosthesis, the posterior slope is typically set to 5° or less.
The desired varus and valgus alignment of the extramedullary tibial guide can be checked using a drop rod
from anterior portion of the alignment guide and
adjusted relative to surface landmarks on the tibia such
as the tibial crest or the malleoli. While not critical at
this stage, rotation of the proximal tibial cutting block is
set by aligning the central mark on the cutting block
with the medial third of the tibial tubercle. To the extent
that any slope is incorporated into the cut, the rotation
does become important as rotation of the cutting block
that has a greater anterior than posterior resection can
translate into varus or valgus if rotation is off of the
midline.
Finally, the resection stylus is placed on the tibial
plateau to set the proper level of bone resection
Fig. 28.5). Depending upon the point of reference,
(.
the resection level can vary, with less bone being removed
if the point of reference is from a decient area, and
bone resection commensurate with the implant thickness if the point of reference is taken from the healthy
joint line. The proximal tibia cut is then made using an
oscillating saw.
. Fig. 28.6 Intraoperative photograph demonstrating a balanced
or rectangular extension gap
> Great care should be taken to protect the collaterals,
and to feel the posterior cortex, moving slowly with
the saw as the posterior vascular structures, collater-
als, and capsule are at particular risk when making
the tibial cut.
28.3.5 Extension Gap Balancing
After the distal femur and proximal tibia cuts have been
made, the extension gap is checked. The leg is brought into
a full extension and a spacer block is inserted to evaluate
the balance of the extension gap. Ideally, the extension
gap is close to being rectangular rather than trapezoidal
(. Fig. 28.6). There should be no signicant medial to
lateral laxity, or differences of >2 mm, when the spacer
block is placed and ligament balance is assessed.
> This is a very subjective step in the procedure, as there
is no dened magnitude of varus or valgus stress that
should be applied when assessing the extension gap
balance.
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M. B. Zaid and T. P. Vail
However, if the surgeon determines that the extension
gap is not acceptably balanced, then some soft tissue
releases may be needed (assuming that the desired resection angle of the distal femoral and proximal tibial cuts
has been achieved). Typically for a valgus knee, the lateral capsule at the joint line can be elevated off of the
tibia, followed by elevation of the iliotibial band insertion just above Gerdy’s tubercle, and nally if needed
the popliteobular ligament (capsule complex below the
popliteus). For a varus knee, the medial capsule, the posteromedial corner, and the supercial medial collateral
can be released in sequence to achieve balance in the
extension gap.
28.3.6 Femoral Sizing andRotation
Once optimal extension gap balance has been achieved,
one can proceed with femoral sizing and nishing. This
step can be done either using a measured resection
method or a gap balance method. Some surgeons using
a measured resection technique prefer to start with the
distal femoral cut and then nish the femoral preparation using the epicondylar axis or Whiteside’s line to set
rotation, balancing ligaments at the end after all of the
desired femoral and tibial cuts are made. In the gapbalancing workow, the releases are performed at the
outset once the extension gap cuts have been made.
The femoral nishing, which included the anterior,
posterior, and chamfer cuts, is then made using the tibial
cut and the ligament tension to set the rotation. For the
gap-balancing workow, the knee is brought into 90° of
exion and the femur size is determined. The femoral
component rotation is then set using a ligamenttensioning device or a spacer block that sits on the tibia
and is used as a reference for setting femoral component
rotation (.
Fig. 28.7). At this step, a varus and valgus
force can be applied to check for symmetry and lift off
of the jig from the proximal tibia to assess the exion
gap balance. Adjustments can be made in the size of the
femoral component, the thickness of the polyethylene
insert, or the rotation of the femoral component before
the cuts are made to set the rotation.
. Fig. 28.7 Intraoperative photograph demonstrating distal femo-
ral sizing. Subsequent to sizing, the rotational position of the distal
femoral component is established using a ligament-tensioning device
in a gap-balancing workow. This can be accomplished with a lamina spreader, an electronic tensiometer, or a specially designed instrument. In this example, the intramedullary rod serves as the pivot
point, allowing balancing of the medial and lateral exion gaps as
the ligaments are tensioned by the instrument. Once the optimal
rotation and size are established, the femoral cutting guide is pinned
in place and removed
. Fig. 28.8 Intraoperative photograph of the notch cut being per-
formed. The medial–lateral position of the notch cut determines the
ultimate medial–lateral position of the implant. It should be placed
as far lateral as possible without lateral overhang to facilitate patella
tracking
> Ideally, the extension and exion gaps should be close
to equal; if the exion space is too large, upsizing the
femoral component should be considered. If the ex-
ion space is too small, the femoral component can be
downsized.
Once the optimal rotation and size are established, the
femoral cutting guide is pinned in place and removed
(. Fig. 28.7). Retractors are placed to protect soft tissues, and an oscillating saw is then used to cut the anterior, anterior chamfer, posterior, and posterior chamfer
cuts at the distal femur. The notch cut is then completed
Fig.28.8). The medial–lateral position of the notch
(.
cut determines the ultimate medial–lateral position of
the implant. It should be placed as far lateral as possible
without lateral overhang to facilitate patella tracking.
Next, a lamina spreader can be used to distract the exion gap to gain visualization of the posterior femoral
condyles to remove residual osteophytes. Trial implants
can now be inserted and overall balance, t, and range
of motion rechecked.
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. Fig. 28.9 Intraoperative photograph showing tibial sizing. The
tibia is sized by selecting a tibial baseplate that maximizes tibial coverage without overhang. Rotation of the implant is set using anatomic landmarks such as the tibial tubercle and ankle joint
28.3.7 Patellar Preparation
The patella is sized and the cutting guide is set according
to the available patellar bone. Generally, the patella is
cut at its osteochondral border, noting that the lateral
facet is generally longer, thinner, and less steep than the
medial facet of the patella.
28.3.8 Trialing andTibial Sizing
With the trial femoral component impacted onto the
femur and the tibial trial in place, a visual check should
be performed to ensure that the distal femur cuts are
appropriate, tting into the femoral trial. The tibia is
sized by selecting a tibial baseplate that maximizes tibial
coverage without overhang (. Fig. 28.9). Tibial component rotation can be assessed before nalizing the
preparation by putting the trial construct through a
range of motion and marking the tibial component
rotation at the joint line. If the knee is stable and well
balanced, and the desired tibial component rotation is
established, then the nal tibial preparation is performed
using the drill and punch method.
28.3.9 Cementation andFinal Component
Placement
The tourniquet is inated and a pulse lavage is used to
prepare all the bony surfaces which are subsequently
patted dry. First, the tibial component is cemented into
place. Cement is placed and nger-packed (some surgeons use a cement gun) along the proximal tibial surface and the keel hole as well as on the tibial baseplate
(. Figs. 28.10 and 28.11). Cement is placed onto the
. Fig. 28.10 Intraoperative photograph demonstrating nger-
packed cement along the proximal tibial surface. Cement is also
placed along the distal femur prior to placement of the femoral component (not shown). Keeping blood and fat out of the interface
between the implant and the cement is important for optimal implant
xation
. Fig. 28.11 Cement is placed onto the dry implant coating the
cement-facing surface of the tibia (shown) and femur
dry implant coating the cement-facing surface of the
tibia and femur. Similarly, cement is placed on the anterior and distal femoral cuts, and a small amount of
cement is placed on the posterior anges of the implant.
The components are then placed and impacted. Excess
cement is removed. A trial liner is placed and the knee is
brought into extension.
> It is important to keep the knee very still and properly
aligned while the cement cures. Movement of the
knee while the cement is in a plastic phase can lead to
bone–cement or implant–cement radiolucency and
suboptimal cement mantle.
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M. B. Zaid and T. P. Vail
The patellar component is cemented in place after
the tibia and femur. The knee is once again checked for
a stable range of motion once the cement is allowed to
fully harden. The tourniquet is deated and the polyethylene liner is placed.
28.3.10 Closure
The knee capsule is closed anatomically using monolament absorbable suture on the deep layers, and either
nylon suture, stables, or a running subcuticular closure
on the skin. The wound is dressed with a sterile dressing.
28.4 Literature Review
Introduction
z
For the primary total knee arthroplasty, numerous prosthesis designs exist with the two most common being the
cruciate-retaining (CR) and posterior stabilized (PS).
While the cruciate-retaining implant design relies on the
patient’s native posterior cruciate ligament to allow for
femoral rollback during deep exion, the posterior stabilized design utilizes a central post on the tibial polyethylene insert which engages with a transverse cam
located on the femoral component between the condyles
(. Fig. 28.12). In the PS design, during deep exion,
the cam and post engage, which in theory limits the
degree of anterior femoral translation and leads to subsequent femoral rollback allowing increased knee exion (Insall etal. 1982).
The rst iteration of the posterior stabilized design
was introduced in 1978 by Insall and Burstein and consisted of an all-polyethylene tibial component. Since
that time, the PS design has undergone a variety of
changes to improve kinematics and durability (Insall
and Clarke 1993).
> The posterior stabilized total knee arthroplasty is a
popular implant design with numerous studies dem-
onstrating excellent range of motion, survivorship,
and functional outcomes.
Range of Motion
z
It has been hypothesized that replacing the native posterior cruciate ligament with a cam and post can improve
the range of motion through mechanical enforcement
of femoral rollback (Pagnano etal. 1998; Bercik etal.
2013). Numerous studies have demonstrated the ability
to obtain excellent range of motion with a posterior stabilized knee. In a prospective cohort of over 240 knees,
Hirsch et al. compared range of motion between
posterior- stabilized, cruciate-retaining, and cruciatesacricing knees and found that posterior stabilized
. Fig. 28.12 The posterior stabilized total knee implant utilizes a
central post (*) on the tibial polyethylene insert which engages with
a transverse cam located on the femoral component between the
condyles
knees obtained signicantly increased range of motion
as compared to cruciate-retaining knees (112° vs. 104°)
(Hirsch etal. 1994). This nding of improved range of
motion compared to cruciate-retaining implants has
been reproduced in numerous studies (Maruyama etal.
2004; Yoshiya etal. 2005; Catani etal. 2004) including a
recent meta-analysis by Bercik et al. which concluded
that PS knees had on average an increase of 3.33° of
range of motion as compared to CR knees (Bercik etal.
2013). In addition to improved overall range of motion,
numerous studies have found that posterior stabilized
knees may provide increase exion as compared to
cruciate- retaining knees. Similar to range of motion, the
recent meta-analysis by Bercik etal. showed that patients
were able to obtain signicantly more exion in posterior stabilized knees as compared to cruciate-retaining
knees (Bercik etal. 2013).
Loosening and Survivorship
z
Although early on it was hypothesized that retaining the
native posterior cruciate ligament could mitigate aseptic
loosening by resisting shear forces at the bone–implant
interface (Pagnano et al. 1998), early biomechanical
testing of posterior stabilized knees demonstrated that
articulation of the post-and-cam mechanism on a PS
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knee led to compressive rather than shear forces at the
proximal tibia (Insall etal. 1982). These biomechanical
ndings support today’s clinical results.
In a long-term prospective cohort study of 55 young
patients (<60years at index surgery) undergoing a posterior stabilized knee arthroplasty, Meftah etal. experienced no cases of aseptic loosening at an average
follow-up of 12.3 years (range 11–13) (Meftah et al.
2015). Additionally, the posterior stabilized implants
had excellent survivorship of 98% at nal follow-up
(Meftah et al. 2015). Even at 15-year follow-up,
Lachiewicz etal. experienced an aseptic loosening rate
of <1% and survivorship of 96.8% for a cohort of
patients who underwent a modular posterior stabilized
knee arthroplasty.
> These results suggest that posterior stabilized knees
may not be at an increased risk for aseptic loosening
and have excellent survivorship.
Functional Outcomes
z
Patient-reported outcomes following posterior stabilized knee arthroplasty are similar to those of cruciateretaining knee replacements as demonstrated by
numerous randomized trials. In a recent randomized
controlled trial comparing PS to CR knees, Scott etal.
found no signicant difference in Knee Society pain,
function, and motion scores at a minimum follow-up of
2 years in a cohort of 111 patients (Scott and Smith
2014). Similarly, Maruyama etal. found no signicant
difference in postoperative knee scores at an average
follow-up of 31.7months in a prospective randomized
comparison of patients undergoing posterior stabilized
versus cruciate-retaining total knee arthroplasty
(Maruyama etal. 2004). Additionally, a meta-analysis
of randomized trials comparing posterior stabilized and
cruciate-retaining implants failed to demonstrate a signicant difference in functional outcomes and postoperative Knee Society pain scores at 2- and 5-year average
follow-up (Li etal. 2014).
Kinematics and Gait
z
As previously discussed, it is theorized that the camand- post mechanism on a posterior stabilized knee recreates native femoral rollback and allows for increased
knee exion. Numerous studies have compared the kinematics of cruciate-retaining and posterior stabilized
implants. While initially it was thought that retaining
the PCL would allow for predictable femoral rollback
that mimicked native knee kinematics, this has failed to
be proven. Dennis et al. demonstrated the concept of
“paradoxical anterior femoral translation” where abnormal anterior femoral translation upon the tibia can
occur in cruciate-retaining implants (Dennis etal. 1996).
This abnormal femoral motion can theoretically lead to
increased tibial polyethylene wear and shear forces.
Unlike CR implant designs, posterior stabilized total
knee implants have been shown to restore physiological
femoral rollback. Using in vivo uoroscopy, Fantozzi
et al. have demonstrated that posterior stabilized
implants successfully recreate physiological femoral rollback during activities of daily living such as walking,
going from sitting to standing posture, and during stair
climbing (Fantozzi etal. 2006).
Take-Home Messages
5 Posterior stabilized total knee implants uti-
lize a cam-and-post mechanism to recreate
native femoral rollback.
5 Posterior stabilized total knee implants
have demonstrated excellent 10- and 15-year
survivorship with low rates of aseptic loosening.
5 Posterior stabilized implants may offer
slightly more increased exion as compared
to cruciate- retaining implants.
5 Functional outcomes following posterior
stabilized knee replacement are comparable
to cruciate- retaining implants.
5 Joint kinematics may be more closely
restored with a posterior stabilized implant
as compared to a cruciate-retaining implant.
5 Keeping blood and fat out of the interface
between the implant and the cement is
important for optimal implant xation.
References
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sus posterior-stabilized total knee arthroplasty: a meta-analysis.
J Arthroplasty 28:439–444
Catani F, Leardini A, Ensini A et al (2004) The stability of the
cemented tibial component of total knee arthroplasty. J
Arthroplasty 19:775–782
Dennis DA, Komistek RD, Hoff WA, Gabriel SM (1996) In vivo
knee kinematics derived using an inverse perspective technique.
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Fantozzi S, Catani F, Ensini A, Leardini A, Giannini S (2006)
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Insall J, Lachiewicz P, Burstein A (1982) The posterior stabilized
condylar prosthesis: a modication of the total condylar design.
Two to four-year clinical experience. J Bone Joint Surg Am
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Maruyama S, Yoshiya S, Matsui N, Kuroda R, Kurosaka M (2004)
Functional comparison of posterior cruciate-retaining versus
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19:349–353
Meftah M, White PB, Ranawat AS, Ranawat CS (2015) Long-term
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cruciate ligament in total knee arthroplasty. J Am Acad Orthop
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arthroplasty: a preliminary report with minimum 2-year results.
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