Knee Arthroplasty – Types, Indications, Contraindications

Anatomy and Physiology of Knee Arthroplasty

The knee is a synovial hinge joint with minimal rotational motion. It is comprised of the distal femur, proximal tibia, and the patella. There are 3 separate articulations and compartments: medial femorotibial, lateral femorotibial, and patellofemoral. The stability of the knee joint is provided by the congruity of the joint as well as by the collateral ligaments. The capsule surrounds the entire joint and extends proximally into the suprapatellar pouch. Articular cartilage? covers the femoral condyles, tibial plateaus, trochlear groove, and patellar facets. Menisci are interposed in the medial and lateral compartments between the femur and tibia which act to protect the articular cartilage? and support the knee.

The mechanical axis of the femur, defined by a line drawn from the center of the femoral head to the center of the knee, is 3 degrees valgus to the vertical axis. The anatomic axis of the femur, defined by a line bisecting the femoral shaft, is 6 degrees valgus to the mechanical axis of the femur and 9 degrees valgus to the vertical axis.[rx] The proximal tibia is oriented to 3 degrees of varus. The varus position of the proximal tibia, along with the offset of the hip center of rotation, results in the weight-bearing surface of the tibia is parallel to the ground. The sagittal alignment of the proximal tibia is sloped posteriorly approximately 5 to 7 degrees. The asymmetry of the natural bony anatomy maintains the alignment of the joint and ligamentous tension.

Indications of Knee Arthroplasty

TKA is a well-described treatment option for patients suffering from knee pain? secondary to stiffness?. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।" data-rx-term="osteoarthritis" data-rx-definition="Osteoarthritis is wear-and-tear joint disease causing pain and stiffness. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।">osteoarthritis? who have failed conservative treatment measures. It is a reliable procedure that provides pain relief and improves the patient’s functional status.[rx] Furthermore, the need for correction of a significant or progressive deformity at the knee with evidence of pain? and stiffness?. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।" data-rx-term="osteoarthritis" data-rx-definition="Osteoarthritis is wear-and-tear joint disease causing pain and stiffness. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।">osteoarthritis? can also be an indication for a TKA. A patient with persistent knee pain without radiographic evidence of knee osteoarthritis should have further workup to exclude other possible sources of their pain.

Clinical symptoms of pain? and stiffness?. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।" data-rx-term="osteoarthritis" data-rx-definition="Osteoarthritis is wear-and-tear joint disease causing pain and stiffness. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।">osteoarthritis? include

• Knee pain?
• Pain? with activity and improving with rest
• The pain gradually worsens over time
• Decreased ambulatory capacity

Clinical evaluation includes

• Full knee exam including a range of motion and ligamentous testing
• Knee radiographs include standing anteroposterior, lateral, 45-degree posteroanterior, and skyline view of the patella

Radiographic evidence of pain? and stiffness?. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।" data-rx-term="osteoarthritis" data-rx-definition="Osteoarthritis is wear-and-tear joint disease causing pain and stiffness. সহজ বাংলা: বয়স/ক্ষয়ের কারণে জয়েন্টের ব্যথা।">osteoarthritis? include[rx]:

• Joint space narrowing
• Subchondral sclerosis?
• Subchondral cysts
• Osteophyte? formation

Conservative treatment includes

• Non-steroidal infection?, or irritation, often causing pain?, swelling?, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation?, pain, or swelling. সহজ বাংলা: প্রদাহ/ফোলা/ব্যথা কমায়।" data-rx-term="anti-inflammatory" data-rx-definition="Anti-inflammatory means reducing inflammation, pain, or swelling. সহজ বাংলা: প্রদাহ/ফোলা/ব্যথা কমায়।">anti-inflammatory? medication
• Weight loss
• Activity modification
• Bracing
• Physical therapy?
• Viscosupplementation
• Intra-articular steroid? injection

Contraindications of Knee Arthroplasty

Absolute

• Active or latent (less than 1 year) knee sepsis
• Presence of active infection? elsewhere in the body
• Extensor mechanism dysfunction
• Medically unstable patient

Relative

• Neuropathic joint
• Poor overlying skin condition
• Morbid obesity
• Noncompliance due to major psychiatric disorder, alcohol, or drug abuse
• Insufficient bone stock for reconstruction
• Poor patient motivation or unrealistic expectation
• Severe peripheral vascular disease

Equipment of Knee Arthroplasty

A TKA system will consist of instrumentation that helps the surgeon prepare the ends of the femur, tibia, and patella to receive an implant.  The instrumentation will be specific to the brand and type of implant being used with each company and model having specific intricacies.

In general, the instrumentation will consist of:

• Intramedullary femoral guide to help establish the distal femoral alignment
• The distal femoral cutting guide
• Femoral sizing guide
• The 4-in-1 femoral cutting guide
• The extramedullary or intramedullary tibial guide
• The proximal tibial cutting guide
• Patella sizing guide
• Femoral component trial
• Tibial baseplate trial
• Patellar button trial
• Trial plastic bearing

The final implants will come in individual sterile packages and will consist of:

• Femoral component, typically made of cobalt-chrome
• Tibial component, typically made of cobalt-chrome or titanium
• Tibial polyethylene bearing, made of an ultra high molecular weight (UHMW) polyethylene
• Patellar button, made of UHMW polyethylene

Personnel

• Anesthesia team
• Operating room nurse
• Surgical technician
• Surgical assistant

Preparation

• Full medical and drug history before surgery
• Appropriate pre-surgical workup, clearance, and optimization
• Pre-operative radiographs of the affected knee
• Pre-operative templating of the affected knee to estimate the component size
• Primary TKA system of choice
• Have various final implant sizes ready and available in the hospital
• Have increasing prosthesis constraint options ready and available in the hospital
• Have revision total knee replacement system of choice ready and available if needed
• +/- bacterial? infections. সহজ বাংলা: ব্যাকটেরিয়ার সংক্রমণের ওষুধ।" data-rx-term="antibiotic" data-rx-definition="An antibiotic is a medicine used to treat bacterial infections. সহজ বাংলা: ব্যাকটেরিয়ার সংক্রমণের ওষুধ।">antibiotic? cement, surgeon preference

The Technique of Knee Arthroplasty

The goal of TKA is the same regardless of surgeon, implant, or technique. The variability in the procedure lies in the technique.  Some of the variations in operative technique for TKA are listed below.

• General anesthesia versus regional anesthesia
• Tourniquet versus tourniquet-less surgery
• Standard versus patient-specific instrumentation
• Standard versus patient-specific implants
• Traditional versus robotic-assisted TKA
• Traditional versus navigation-assisted TKA
• Traditional versus sensor-assisted TKA
• Measured resection versus gap balancing
• Cruciate-retaining implant versus cruciate stabilized the implant
• Resurfaced versus non-resurfaced patella
• Cement versus cement-less (press fit) TKA

Complications of Knee Arthroplasty

Potential complications include:[rx][rx]

• Infection, superficial and deep
• Blood clot
• Pulmonary embolism
• Fracture
• Dislocation
• Instability
• Osteolysis resulting in component loosening
• Pain
• Stiffness    
• Vascular injury
• Nerve injury