Deformity Correction of Total Knee Arthroplasty

Deformity
Correction in Total
Knee Arthroplasty
Arun B. Mullaji
Gautam M. Shetty
123
Deformity Correction in Total Knee
Arthroplasty
Arun B. Mullaji • Gautam M. Shetty
Deformity Correction in
Total Knee Arthroplasty
Arun B. Mullaji, FRCS Ed, MCh Orth, Gautam M. Shetty, MS Orth
MS Orth Consultant Arthritis Care and Joint
Consultant Joint Replacement Surgeon Replacement Surgery
Department of Orthopaedic Surgery Asian Orthopedic Institute
Breach Candy Hospital Asian Heart Institute and Research Center
Mumbai, Maharashtra, India Mumbai, Maharashtra, India
ISBN 978-1-4939-0565-2 ISBN 978-1-4939-0566-9 (eBook)

DOI 10.1007/978-1-4939-0566-9
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014939034
© Springer Science+Business Media New York 2014

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To Shati, Nini, Mom and Dad
Arun B. Mullaji
To Priyanka. Thank you for everything

To my Parents for their inspiration, guidance and patience
To all my teachers
Gautam M. Shetty
Foreword
It is my pleasure and honour to write the Foreword for this book, Deformity
Correction in Total Knee Arthroplasty, written by Drs. Arun Mullaji and
Gautam Shetty. I have long admired their surgical expertise in the manage-
ment of patients with severe angular deformity.
In 12 chapters, this book gives comprehensive and practical instruction to
surgeons in the management of varus and valgus deformity, contracture and
hyperextension, stiffness and instability and rotational and extra-articular
deformity.
The text begins with advice regarding preoperative planning and ends with
postoperative pain management and rehabilitation. Each chapter, when
appropriate, includes the application of computer navigation techniques.
This book is clearly written, well illustrated, practical and comprehensive.
The technical tips provided are numerous and indispensable to any surgeon
who treats patients with the severest of angular deformities and instabilities.
I congratulate the authors on their profound contribution to the field of
total knee arthroplasty.
Boston, MA, USA Richard D. Scott, MD
vii
Preface
With rapid advancement in technology and materials in total knee arthro-

plasty (TKA), long-term survival and function of the total knee are now more
and more dependent on restoring accurate limb alignment, precise compo-
nent position and optimum soft-tissue balance. Furthermore, a large number
of early revisions in TKA are related to causes such as malalignment, malpo-
sition and instability.
Correct technique is the key to ensuring optimum function and long-term
survival of the knee. This is all the more crucial and challenging to achieve in
arthritic knees with severe and complex deformities. Many patients in the
developing world present for TKA after years of neglect of their knee arthri-
tis. The number of TKAs being performed in these nations is escalating in
exponential fashion. Hence, correction of severe knee deformities forms an
important part of TKA for orthopaedic surgeons working in these regions and
also those in developed nations occasionally treating such patients.
This book outlines the basic principles of deformity correction in total
knee arthroplasty with a special focus on severe and complex deformities.
Starting with the initial key step of preoperative planning, this volume goes
on to specifically describe how to deal with different types of deformities
encountered in patients who undergo TKA. This book is more of a “how-to-
do” manual, replete with specific tips on deformity correction in primary
TKA rather than an exhaustive presentation on TKA. It does not deal with
general issues related to TKA such as anatomy, kinematics, complications
and revision surgery which are well covered in standard texts. With a focussed
approach to the basic purpose and premise of this book, we have steered clear
of controversial debates commonly encountered in TKA. However, with the
experience of nearly 10,000 TKAs (including over 3,000 computer-assisted
TKAs) behind us, we have distilled the lessons we have learnt with the use of
both conventional surgery and computer navigation in TKA to further refine
our technique. Hence, several chapters in this book have a concluding section
describing the technique of deformity correction using computer navigation.
This book is aimed at orthopaedic surgeons and joint replacement sur-
geons who need to understand the principles of deformity correction espe-
cially in arthritic knees with severe and complex deformities before embarking
on TKA (whether conventional or computer assisted) and will be useful in
fine-tuning their planning and surgical technique.
We are grateful to Dr. Richard Scott, MD, a teacher, researcher and pioneer
in the art and science of joint replacement surgery, for writing the foreword.
ix
x Preface
We thank Dr. Fahad Shaikh, DNB Orth (fellow in Joint Replacement Surgery,
Breach Candy Hospital, Mumbai, India), for helping us obtain clinical and
radiographic images of patients. We thank Dr. Vipul Chavda, BPT, MPT
(Sports Medicine), Consultant Physical Therapist, Prakruti Sports Science &
Physiotherapy Clinic Pvt. Ltd., Mumbai, India for providing clinical images
for the Postoperative Rehabilitation section of Chapter 12. We also would
like to thank the associate editor Kristopher Spring and the developmental
editor Kevin Wright for their invaluable assistance in the preparation and
publication of this book.
Mumbai, India Arun B. Mullaji

Mumbai, India Gautam M. Shetty
Authors
Arun B. Mullaji, FRCS Ed,

MCh Orth, MS Orth,
Consultant Joint Replacement Surgeon,
Department of Orthopaedic Surgery,
Breach Candy Hospital,
Mumbai,
India
Gautam M. Shetty, MS Orth

Consultant Asian Orthopedic Institute,
Asian Heart Institute
and Research Center,
Mumbai,
India
xi
Contents
Part I Preoperative Planning and Basic Technique of Total Knee

Arthroplasty
1 Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Plain Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Computed Tomography (CT) Scan . . . . . . . . . . . . . . . . . . . . 13
Magnetic Resonance Imaging (MRI). . . . . . . . . . . . . . . . . . . 13
Electromyography and Nerve Conduction Studies
(EMG-NCV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Selection of Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Constraint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Extras . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Appendix 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Appendix 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2 Basic Technique of Total Knee Arthroplasty. . . . . . . . . . . . . . . 23
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
“Disclaimer” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Ligament Balancing: The “Kaizen” Approach . . . . . . . . . . . . . . . 24
How to Assess Soft-Tissue Tension? . . . . . . . . . . . . . . . . . . . 24
What to Release? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
When and How Much to Release?. . . . . . . . . . . . . . . . . . . . . 26
Equalising Medial and Lateral Gap in Extension . . . . . . . . . 26
Equalising Medial and Lateral Gap in 90° Flexion . . . . . . . . 26
Equalising Flexion Gap to the Extension Gap. . . . . . . . . . . . 26
Surgical Approach and Exposure. . . . . . . . . . . . . . . . . . . . . . . . . . 29
Tibial Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Balancing in Extension and Distal Femoral Resection . . . . . . . . . 33
Balancing in Flexion, Femoral Sizing and Rotation . . . . . . . . . . . 34
xiii
xiv Contents
Tibial Sizing and Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Patella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Cementing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Technique of Computer-Assisted TKR . . . . . . . . . . . . . . . . . . . . . 36
Appendix Surgical Technique Workflow Chart for TKA . . . . . . . 40
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Part II Coronal Plane Deformities
3 Varus Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Knee Deformity <10°. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Knee Deformity 10–20°. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Knee Deformity >20°. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Computer-Assisted Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4 Valgus Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Severe Valgus Deformities (Type 5 and 6) . . . . . . . . . . . . . . 67
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Part III Sagittal Plane Deformities
5 Flexion Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6 Hyperextension Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Part IV Complex Deformities
7 Rotational Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Contents xv
8 Extra-Articular Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Femoral Extra-Articular Deformities. . . . . . . . . . . . . . . . . . . 105
Tibial Extra-Articular Deformities. . . . . . . . . . . . . . . . . . . . . 105
Femoral Extra-Articular Deformities. . . . . . . . . . . . . . . . . . . 107
Tibial Extra-Articular Deformities. . . . . . . . . . . . . . . . . . . . . 110
Post-HTO Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
9 The Stiff Knee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
10 The Unstable Knee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Pathoanatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Type 1 Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
11 Osteotomies in Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . 139
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Types of Osteotomies and Technique . . . . . . . . . . . . . . . . . . . . . . 139
Reduction Osteotomy of the Tibia . . . . . . . . . . . . . . . . . . . . . 139
Sliding Medial Condylar Osteotomy (SMCO) . . . . . . . . . . . 142
Lateral Epicondylar Osteotomy (LEO) . . . . . . . . . . . . . . . . . 147
Corrective Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Tibial Tubercle Osteotomy (TTO) . . . . . . . . . . . . . . . . . . . . . 150
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
12 Postoperative Pain Management and Rehabilitation . . . . . . . . 155
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Pain After TKA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Multimodal Pain Management Protocol . . . . . . . . . . . . . . . . . . . . 156
Preoperative Patient Education . . . . . . . . . . . . . . . . . . . . . . . 156
Pre-emptive Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Intraoperative Local Infiltration . . . . . . . . . . . . . . . . . . . . . . . 156
Postoperative Analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
xvi Contents
Rehabilitation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Goals of Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Postoperative Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . 158
Special Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Part I
Preoperative Planning and Basic
Technique of Total Knee Arthroplasty
Preoperative Planning
1
Introduction are coming up for total knee arthroplasty (TKA)

[1–3]. Patient satisfaction regarding TKA is pri-
Preoperative planning is paramount before marily based on postoperative pain, ROM and
undertaking any surgical procedure. This cannot functional ability and absence of complications
be overemphasised for a procedure like total related to TKA. An initial assessment of the
knee arthroplasty (TKA) where the goals include patient should address issues related to patient’s
accurate restoration of limb alignment, optimum expectations and apprehensions regarding the
soft-tissue balancing and achieving a satisfac- surgical procedure. Studies have shown that
tory range of motion (ROM). The use of com- patients with high somatisation and depression
puter navigation during TKA does not diminish scores preoperatively continue to remain dissatis-
the role of preoperative planning. The first fied with the outcome of joint replacement
important step in preoperative planning is proper despite lack of clinical or radiographic reasons
selection of the patient and a thorough physical for it [4–6]. Although the presence of psycho-
examination. This step gives important clues logical disorder is not a contraindication for sur-
regarding patient complaints and disability and gical intervention, these issues need to be
the expectation which a patient may have from considered by the surgeon. With simultaneous
the procedure. Physical examination may reveal bilateral TKAs, issues that frequently concern
clues as to what to expect during surgery in patients are whether the procedure will be more
terms of pathoanatomic changes in the arthritic painful, the postoperative functional recovery
joint and how to plan for it during surgery. slower and if they have to be dependent on others
Imaging using plain radiographs helps in con- for their daily activity after surgery compared to
firming the extent of knee arthritis and severity staged bilateral TKAs (SBTKAs) or unilateral
of deformity and is useful for planning the pro- TKAs. An uneventful postoperative recovery and
cedure. This chapter elaborates on physical the risk of complications after SBTKA are also
examination and imaging for a patient who is to major concerns with patients. The authors in a
undergo TKA. prospective study conducted at their centre found
that pain, function and complication rates in
patients who underwent simultaneous bilateral
The Patient computer-assisted TKA were comparable to
those who underwent unilateral TKA [7]. Hence,
Studies have shown that patient demographics the surgeon needs to address these issues before
are changing and increasingly younger, heavier, surgery so that patients can take an informed
and more active patients with higher expectations decision.
A.B. Mullaji, G.M. Shetty, Deformity Correction in Total Knee Arthroplasty, 3

DOI 10.1007/978-1-4939-0566-9_1, © Springer Science+Business Media New York 2014
4 1 Preoperative Planning
Physical Examination severe flexion deformity indicates the need for a

thorough posterior clearance or release with more
Before examining the knee, an assessment of gait liberal bone cuts to correct the deformity. In cases
and functional disability of the patient is invalu- with severe stiffness or flexion deformity, quadri-
able. An abnormal gait with severe waddling or ceps function may be difficult to assess, and any
knee instability may be one of the features in weakness will be revealed only after the TKA.
patients with arthritic knee pain. Evidence of lat- Hence, such patients may require prolonged
eral thrust of the tibia or knee hyperextension aggressive physiotherapy with or without splints
during gait may indicate severe laxity or incom- (e.g. push-knee splint) postoperatively. Apart
petence of the lateral collateral ligaments and from the knee, a thorough examination of the
posterior capsule, respectively (Fig. 1.1). Patients entire lower limb is also warranted. Abnormal tor-
walking with severe intoeing or outtoeing may sion of the tibia using the two malleoli as land-
indicate a torsional abnormality in the limb. marks helps in deciding the rotational position of
Examination of the knee per se includes noting the tibial tray during TKA. Abnormal torsion in
the type and degree of knee deformity, joint range the tibia needs to be taken into account while
of motion, instability, patellar tracking and condi- determining rotational placement of the tibial
tion of the skin over the knee joint. A combination component, or a mobile-bearing design may have
of severe flexion or hyperextension deformity to be used in order to avoid femoral and tibial
along with varus or valgus deformity adds to the rotational mismatch and postoperative gait abnor-
complexity of the surgical technique (Fig. 1.1). malities. Examination of the hindfoot similarly
Knees with severe instability or recurvatum defor- should be part of patient assessment. Both varus
mity entail minimal bony resection and the possi- and valgus knees may be commonly associated
bility of using constrained prosthesis. The with hindfoot valgus (Fig. 1.1). This tends to per-
presence of knee recurvatum should alert the sur- sist even after accurately correcting the knee
geon about the possibility of a neurological condi- deformity and influences the weight-bearing axis
tion. This should be investigated and documented [8]. Hence, in cases with severe flat feet and hind-
whenever necessary. Severe knee stiffness or foot valgus, a medial arch support may be needed
a b c d e
Fig. 1.1 Clinical photographs of various types of deformi- stretched lateral soft-tissue structures. (c, d) Patient has a
ties encountered in knee arthritis. (a) Patient has a combi- combination of valgus and fixed flexion deformity of the
nation of severe bilateral varus and fixed flexion deformities knee. The patient also has severe bilateral flatfeet and hind-
of the knees. (b) Note the lateral subluxation of the tibia on foot valgus. (e) An uncommon recurvatum deformity of the
the left side (arrow) on weight bearing indicating over- knee
Imaging 5
after surgery in order to improve the stance and Weight-Bearing Full-Length

gait of the patient. Proximally, the hip needs to be Hip-to-Ankle Radiograph
examined to rule out any hip pathology which Controversy surrounds the use of weight-bearing
may contribute to referred pain in the knee. hip-to-ankle radiographs in planning TKA. The
A fixed external rotation deformity of the hip use of these radiographs in cases with extra-
especially in the very obese may lead to technical articular deformities is generally accepted.
difficulties during the surgical procedure. Apart Although their use in uncomplicated cases has
from these, a general assessment of peripheral been disputed [10–12], several reports have advo-
limb circulation and neurological assessment and cated their use routinely [13–16]. The authors
an assessment of the lumbar spine are important obtain a weight-bearing long hip-to-ankle radio-
as any pathology related to these regions may graph in all cases for TKA routinely not only to
have an effect on the postoperative functional and rule out extra-articular pathologies or deformities
pain outcome of TKA. In fact it has been shown but also since most of the planning and radio-
that nearly half the dissatisfied patients with an graphic assessment such as degree of deformity,
otherwise satisfactory TKA actually have symp- plane of bone resection, amount of joint laxity
toms related to the spine [9]. and position of the femoral and tibial compo-
The condition of the contralateral limb and nents in the coronal plane are done with respect
knee and that of the other joints as well as overall to the mechanical axes of the femur and tibia.
general physical condition of the patient needs to The following angles and radiographic features
be assessed as these also influence postoperative can be determined with this radiograph:
satisfaction [9]. Overloading of the contralateral Frontal or Coronal Alignment – Relying on
knee may predispose it to accelerated degenera- standard knee anteroposterior radiographs may
tive changes, while presence of fixed flexion or grossly underestimate the knee deformity when
varus deformity may require compensatory foot- compared to long hip-to-ankle radiographs espe-
wear to correct limb length. Severe deformities cially in cases with severe coronal bowing of the
may require bilateral TKAs to be performed. femur (Fig. 1.2) which is common in patients
with knee osteoarthritis [16–18]. The long hip-to-
ankle radiograph helps in accurate estimation of
Imaging preoperative knee deformity measured as the hip-
knee-ankle (HKA) angle. This is defined as the
Plain Radiographs angle between the mechanical axis of the femur
(centre of the femoral head to the centre of the
Patients being considered for total knee arthro- knee) and mechanical axis of the tibia (centre of
plasty (TKA) need to be investigated primarily the knee to the centre of the tibial plafond).
using plain radiographs (either conventional or Distal Femoral Resection – The distal femoral
digital) such as the weight-bearing full-length valgus correction angle (VCA) decides the valgus
hip-to-ankle radiograph, weight-bearing antero- angle at which the distal femur needs to be cut in
posterior view and lateral and skyline views of the coronal plane in order to align the femoral
the knee. These radiographs help in assessing the component perpendicular to the mechanical axis
type and extent of knee deformity, the degree of of the femur. This is calculated as the angle
joint space loss and bone loss, the amount of between the mechanical axis of the femur and the
lateral or medial laxity, the distribution and distal anatomic axis of the femur (Fig. 1.3).
amount of osteophytes and loose bodies, the Although the VCA is commonly believed to be
presence of extra-articular deformities or pathol- between 5° and 7°, a recent study by the authors
ogies and the general bone quality in the patient. involving 503 arthritic limbs has shown wide
Preoperative radiographs are also invaluable in variation in its value among patients with knee
planning the procedure and determining the tech- arthritis [18]. It may vary between 2.6° and 11.4°
nical difficulty that the surgeon may encounter. with 56 % of the limbs having a VCA outside the
a b
Fig. 1.2 Short films can be misleading! (a) A standing deformity is approximately 20° when calculated using the
anteroposterior knee radiograph shows 4° varus deformity mechanical axes (hip-knee-ankle or HKA angle). Note the
of the knee when calculated using the anatomic axes extra-articular deformity caused by severe coronal bow-
(femorotibial angle or FTA). (b) Weight-bearing long hip- ing of the femur (arrow)
to-ankle radiograph of the same patient shows that the
5–7° range [18]. The percentage of limbs with cases, a shorter guide rod needs to be used, and
VCA >7° was significantly more in varus knees owing to such great variability among limbs, the
and with VCA <5° more in valgus knees. VCA should be selected in each limb based on
Preoperative deformity showed significant corre- measurements done on preoperative long films.
lation with VCA. The VCA can also be affected Although extremes of VCA or extra-articular
by excessive coronal bowing of the femoral shaft deformity are irrelevant when placing the femoral
or variation in the femoral neck shaft angle. component in computer-assisted TKA (as the
Excessive coxa vara and lateral femoral bowing software uses only the centre of the femoral head
both increase the VCA, and excessive coxa valga and centre of distal femur to plan the distal cut),
and medial femoral bowing have the reverse effect these findings on the long weight-bearing radio-
[18]. During conventional TKA, extremes of graph may indicate the need for extensive soft-
VCA will render use of an intramedullary femoral tissue releases for restoration of limb alignment
guide rod difficult due to distortion of the femoral and optimum gap balancing during TKA irrespec-
canal and may lead to error in placement of the tive of the technique used (Fig. 1.4). When knee
distal femoral cutting block. Hence, in these varus is associated with minimal osteophytes and
Imaging 7
Fig. 1.3 Distal femoral valgus correction angle (VCA). Fig. 1.4 Extreme of distal femoral valgus correction
Distal femoral valgus correction angle (VCA) decides the angle (VCA). A case of extreme distal femoral valgus cor-
valgus angle at which the distal femur needs to be cut in rection angle (angle ABC) of 17° due to a malunited fem-
order to align the femoral component at 90° to the oral fracture. The distal femoral cut (line DE) drawn
mechanical axis of the femur. This is calculated as the perpendicular to the mechanical axis of femur (line AB)
angle (angle ABC) between the mechanical axis of the endangers the femoral attachment of lateral collateral lig-
femur (line AB) and the distal anatomic axis of the femur ament. Hence, a corrective osteotomy of the extra-articular
(line CB) deformity is warranted
a high VCA due to excessive femoral bowing, proximal tibial cuts are drawn perpendicular to
extensive soft-tissue release may have to be com- the mechanical axes of the femur and the tibia.
bined with a sliding medial condylar osteotomy The angle formed by the proposed tibial and
during TKA [19]. femoral resections (preoperative JDA) will give a
Preoperative Joint Divergence Angle (JDA) – fair estimation of the site (medial or lateral) and
Varus knee deformities are associated with tight degree of soft-tissue contracture and the extent
medial and lax lateral and soft-tissue structures. of soft-tissue release that may be required.
A fair indication of these soft-tissue changes can Similarly, it will also give a fair estimation of the
be obtained on a weight-bearing full-length degree of laxity in the opposite compartment and
radiograph. The proposed distal femoral and how much bone resection may be required.
a b c
Fig. 1.5 Preoperative joint divergence angle (JDA). (a) laxity due to severe varus deformity. This case will require
Mild varus deformity on the right side where the distal substantial medial release in order to balance it with the
femoral and proximal tibial resection planes are parallel lateral side especially due to the associated femoral shaft
to each other (JDA almost zero) implying that minimal bowing present. (c) Here the lateral laxity is very severe
medial soft tissue is needed for gap balancing; on the left with associated lateral subluxation of the tibia despite the
side with moderate varus deformity, the lateral side shows degree of varus deformity being lesser than in patient (b)
moderate laxity (arrow). (b) An example of severe lateral creating a large JDA
Lesser the angle or more parallel the lines, lesser stress fractures or an implant in situ. Excessive
will be the amount of release required for correc- coronal bowing of the femur is a common cause
tion (Fig. 1.5a, b). Similarly greater the angle or of extra-articular deformity in arthritic knees
more divergent the lines, greater will be the undergoing TKA [16, 17]. Mullaji et al. [16]
amount of release required and more conserva- have reported that up to 20 % of varus arthritic
tive the bone cuts (Fig. 1.5c). knees have significant femoral bowing in the
Extra-Articular Deformities or Implant In coronal plane in Asian patients. Stress fractures
Situ – A full-length radiograph will also reveal although uncommon are an important cause of
any extra-articular deformity (EAD) in the limb, extra-articular deformity [20]. Depending on the
hip pathology, prior trauma/surgery, associated type seen on preoperative radiographs, TKA
Imaging 9
may have to be combined with long tibial stem

extenders, metal augments or corrective osteoto- What to Look for in a Weight-Bearing Long
mies [20]. Similarly, in the tibia, extra-articular Hip-to-Ankle Radiograph?
deformity due to malunited or ununited frac- • Degree of limb malalignment or defor-
tures, stress fractures, post-high tibial osteotomy mity based on hip-knee-ankle (HKA)
or excessive tibial bowing may be present. angle.
Although most of these cases of knee arthritis • Distal femoral valgus correction angle
with extra-articular deformities can be managed (VCA) – the greater the angle, the greater
by extensive intra-articular soft-tissue releases, a the need for an extensive soft-tissue
corrective osteotomy may be rarely required release with or without an osteotomy.
[17]. This is discussed in detail in Chap. 8 on • Extra-articular deformity – is a correc-
EADs. tive osteotomy required?
The presence of implants will warrant the • Stress fractures, prior trauma.
need to use computer navigation which will • Prior surgery with implant in situ and
bypass the hardware or extramedullary cutting hip pathology.
guides as use of intramedullary jigs may not be
possible (Fig. 1.6a). However, in some cases
where the implant may be close to the knee joint, Weight-Bearing Knee Anteroposterior
they may have to be removed before implantation (AP) Radiograph
of the prosthesis especially the tibial component The knee AP view is probably the most com-
(Fig. 1.6b). We have shown that navigation is monly used radiograph for diagnosis of knee
useful in cases of altered hip centre [21]. arthritis and planning for TKA. It is important
a b
Fig. 1.6 Implant in situ. (a)

A case with intramedullary
nail in the femur which will
not interfere during CAS
TKA. (b) A case with
proximal tibial plating with a
malunited fracture. Implant
needs to be removed and a
corrective osteotomy may be
required
a b c
Fig. 1.7 Centre of putative tibial base. (a) Proximal end of through the centre of the tibial spine with an inclined tibial
the tibial medullary axis passing through the centre of the articular surface (I). (c) Proximal end of the tibial medul-
tibial spine (C) with a horizontal tibial articular surface (H). lary axis passing lateral to the tibial spine (L) with a hori-
(b) Proximal end of the tibial medullary axis passing zontal tibial articular surface indicating proximal tibia vara
that the knee AP view is obtained while the achieve correction. By marking out these
patient is weight-bearing as a supine view may resections, the surgeon can get a good idea of the
underestimate the degree of arthritis, deformity amount of bone being resected, and if the relative
and instability. This view allows a closer look at thickness of the medial and lateral tibial plateau
the knee in the coronal plane and is an important and distal femur condyles matches the preopera-
part of the preoperative planning process for tive markings.
TKA. As previously mentioned, although this Centre of Putative Tibial Tray – In most cases
view may underestimate the degree of knee this point on a knee AP radiograph is the proxi-
deformity and will not show extra-articular bony mal end of the tibial medullary axis and is also
deformity, it is invaluable in assessing certain noted during registration in CAS (Fig. 1.7a, b).
features around the knee joint which gives an However, in varus knees with proximal tibia vara
idea of what to expect during TKA. or other extra-articular deformities, the proximal
Tibial and Femoral Resection – Tibial and end of the tibial medullary axis may lie lateral or
femoral resections are performed perpendicular medial to the tibial spines (Fig. 1.7c). In such
to their respective mechanical axes. Traditionally, limbs this lateral or medial point should be
the amount of tibial resection is primarily based marked on x-rays and also for registering the
on the actual thickness of the thinnest tibial com- tibial centre point instead of the midpoint of the
ponent. If the composite thickness is 8 mm, then tibial spines. This will ensure central placement
generally 8 mm of the less affected tibial plateau of the stem of the tibial tray which is especially
should be resected. However, both tibial and fem- important when a tibial stem extender is being
oral resections need to be conservative in cases used. This is also the case in post-high tibial oste-
with severe bone loss, severe lateral or medial otomy (HTO) knees where the registration point
laxity in varus or valgus, recurvatum deformity may be medial or lateral, and using this point will
and in knees with gross instability. More than centralise the tibial component without the need
usual distal femur may have to be occasionally for an offset stem. Lateralisation of the tibial cen-
resected in knees with fixed flexion deformity to tre registration point, commonly seen in limbs
Imaging 11
a b c d e
Fig. 1.8 Grades of bone defects. (a) Moderate medial bone loss with severe lateral laxity. (d) The true extent of
tibial bone loss with moderate lateral laxity. This can be bone defect in patient (c) can be seen on the MRI. Minimal
tackled with bone cement. (b) Moderate medial tibial bone bone cuts and severe lateral laxity in this case will leave a
loss with severe lateral laxity. Tibial cut needs to be mini- substantial bone defect which may need a metal augment.
mised in view of severe lateral laxity and hence the bone (e) Severe lateral femoral condyle bone defect which will
defect may require bone grafting. (c) Severe medial tibial need a lateral distal femoral augment with a femoral stem
with tibia vara, indicates that the tibial tray may and lateralisation of the tibial tray with a reduc-
have to be lateralised and the soft-tissue release tion osteotomy. The subsequent bone defect may
may have to be combined with a reduction oste- be filled with bone cement (Fig. 1.8a). However,
otomy in order to achieve correction of malalign- the amount of tibial cut may have to be minimised
ment and medio-lateral balance. This is significant in cases with severe instability or recurvatum
in a case where metaphyseal tibia vara may be the deformity. In such cases the bone defect may
main cause of knee varus deformity (Fig. 1.7c). have to be filled with bone grafts (Fig. 1.8b).
Osteophytes – Medial or lateral tibial and Cases with substantial bone defect need to be
femoral osteophytes are commonly seen in knee treated with metal augments (Fig. 1.8c, d).
arthritis especially in severe cases where they Rarely, severe bone loss may be seen in the femo-
may be abundant. The presence of osteophytes ral condyles where a metal augment and femoral
indicates that their excision will offer a certain stem may have to be used (Fig. 1.8e)
degree of correction and correspondingly less
soft-tissue release may have to be performed.
Similarly in cases of mild to moderate knee What to Look for in a Weight-Bearing Knee
deformity but with significant lateral laxity or AP Radiograph?
with extra-articular deformity where osteophytes • Relative amounts of medial and lateral
may be minimal or absent, extensive soft-tissue tibial and femoral resections
release may be required in order to correct defor- • Centre of the putative tibial tray, espe-
mity and balance the medio-lateral gaps. cially if a longer stem is to be used
Bone Defect – Severe varus or valgus knees • Osteophytes (especially posterior femo-
may be associated with medial or lateral tibial ral, medial femoral and tibial)
and femoral bone loss. These bone defects usu- • Bone defects
ally occur in long-standing severe knee arthritis.
However, bone loss may be substantial in knees
associated with intra-articular stress fractures. Knee Lateral Radiograph
Depending on the severity, bone defects may be Lateral knee radiograph gives a clear sagittal pic-
dealt with using cement, bone graft or metal aug- ture of the knee joint. This view gives a fair esti-
ments. Large bone defects may be reduced in size mation of the posterior osteophytes, joint line and
during surgery by taking a thicker tibial bone cut patellar position and tibial slope.
a b
Fig. 1.9 Posterior osteophytes. (a) Numerous osteo- covering the entire posterior surface of the femoral con-
phytes on the posterior aspect of the femur and tibia dyle. This needs to be removed prior to registration to
(arrows). (b) A single large posterior femoral osteophyte avoid error
Osteophytes – Posterior osteophytes are com- occasionally seen with patella baja and is often
monly seen in knee arthritis and are the most seen in knees with a prior high tibial osteotomy.
common cause of a fixed flexion deformity in an This can be measured on the lateral radiograph
arthritic knee. Ensuring complete excision of using the tip of the fibular head as reference
these posterior osteophytes helps in achieving (Fig. 1.10). If there is significant alteration of
substantial correction of a fixed flexion deformity the joint line, achieving flexion-extension gap
and reducing the need for an extensive soft-tissue balance and accurate sizing and placement of
release and additional bone resection. These femoral component is crucial during TKA.
osteophytes need to be removed prior to assess- Conservative bone cuts and proper gap balancing
ing the extension gap. Rarely these osteophytes may help in avoiding the use of a thicker insert
may grow large to cover the entire posterior con- which may further elevate the joint line.
dyle of the femur (Fig. 1.9). Femoral registration Tibial Slope – The tibial slope may be altered
prior to removal of such osteophytes may cause in knees with severe bone defects and in post-
error and result in the computer suggesting an HTO knees. This should be noted in the preop-
oversized femoral component. erative lateral knee radiograph so that angle of
Joint Line and Patella Height – Preoperative tibial slope may be correspondingly adjusted dur-
alteration of patellar height and joint line is ing surgery.
Imaging 13
used as an approximate guide. However,

Peek et al. [23] in a retrospective study using
digital templating reported better reliability
with 71 % of the femoral components and
60 % of the tibial components correctly tem-
plated to the exact size. They concluded that
digital templating with a calibrating device
can be useful for preoperative planning of
total knee arthroplasty. The authors do not
perform preoperative templating for compo-
nent size. The gap-balancing technique used
by us relies on medio-lateral and flexion-
extension gap balance to determine the tibial
and femoral component size. However, we
do make sure that extremes of component
sizes are made available during surgery
when such a situation is anticipated based on
the built of the patient and the skeletal built
on radiographs. Hence, a tall well-built male
patient may be expected to have a larger than
Fig. 1.10 Joint line and patellar height. Distance AB, usual femoral and tibial component size.
patellar height; Distance BC, joint line
Computed Tomography (CT) Scan

What to Look for in a Knee Lateral
Radiograph?
This investigation is rarely indicated as part of
Posterior osteophytes
the preoperative evaluation in TKA. It may be
Joint line and patellar height
performed to assess any torsional abnormalities
Tibial slope
in the femur or tibia due to malunited fractures or
osteotomies.
Preoperative Templating for

Component Size Magnetic Resonance Imaging (MRI)
Similar to total hip arthroplasty, preopera-
tive templating on radiographs is an option An MRI scan may be required rarely in anky-
in TKA to determine femoral and tibial losed knees to assess the condition of the quadri-
component size. Aslam et al. [22] in a ceps muscle and patellar tendon. It may also be
retrospective study using manual templating done to confirm the diagnosis of an impending
on radiographs reported that 49 % of the stress fracture [20] which may not be obvious on
femoral components and 67 % of the tibial plain radiographs (Fig. 1.11). It may also be use-
components were correctly templated to the ful in cases with an intra-articular stress fracture
exact size with fair to moderate agreement to delineate the size of bone defect and the vascu-
between templated size and actual implant larity of an ununited fragment. It is helpful in
size. Hence, they concluded that templating patients being considered for unicompartmental
for TKA is prone to error and can only be arthroplasty – those with involvement of other
compartments would be more suitable for a TKA.
a b
Fig. 1.11 MRI to detect stress fracture. (a) Plain radiograph is normal, whereas (b) the MRI shows an impending stress
fracture (arrow)
Electromyography and Nerve especially the ones with severe deformities, show
Conduction Studies (EMG-NCV) significant degeneration of the posterior cruciate
ligament (PCL) [24, 25]. Hence, in this situation
An EMG-NCV study of the lower limb may need the PCL cannot be relied on to achieve gap bal-
to be done in cases with long-standing fixed flex- ancing and is best substituted. Hence, the authors
ion deformity to determine the status of the quad- have elaborated here only on variations of
riceps and hamstring muscles and in cases with cruciate-substituting designs.
knee recurvatum deformity to rule out neurologi-
cal causes. It may also be performed in chronic
uncontrolled diabetics with neuropathy and in Design
patients with chronic low back pain and radicu-
lopathy to document the extent of neuromuscular The two primary designs commonly used in pri-
involvement as their symptoms due to the under- mary TKA are a fixed-bearing or a mobile-
lying condition may persist even after TKA. bearing design. The decision to use either one is
primarily based on the surgeon. Several studies
have reported on the benefits of using a mobile-
Selection of Implants bearing design in terms of improved wear resis-
tance and postoperative function such as knee
The authors use a cruciate-substituting design flexion [26, 27]. However, the authors primarily
during TKA in all their patients. The rationale use a fixed-bearing design in most of their
behind this is that a majority of arthritic knees, patients and have specific indications for a
Selection of Implants 15
mobile-bearing knee. First, an active patient who components with these high-flexion designs [30,
wants and expects to perform activities involving 31]. The authors have not used this design in their
high flexion of the knee such as sitting cross- patients since there does not seem to be any sig-
legged on the floor or squatting postoperatively nificant improvement in function and the risks in
may benefit from a mobile-bearing design due to terms of early revision seem to far outweigh the
a certain degree of extra rotation that the implant benefits.
may provide when knee is placed in the cross-
legged position [28]. Second, in cases with rota-
tional deformities of the tibia, a mobile-bearing Constraint
design may mitigate and compensate for the rota-
tional mismatch between the tibia and the implant Most knees undergoing primary TKA can be
position. However, the surgeon needs to be aware managed using prostheses with the least
that an optimally balanced knee is an absolute constraint, i.e. either a cruciate-retaining or a
prerequisite to the use of a mobile-bearing design. cruciate-substituting design. Rarely is a more
Any compromise on this aspect will result in constrained design or hinge prosthesis needed. A
complications such as instability and bearing proper clinical and radiographic evaluation will
“spin-out” with the use of a mobile-bearing indicate the need of a constrained implant during
design. Hence, the authors feel that a surgeon TKA. A constrained design (such as the TC3)
should use a mobile-bearing design only when may be indicated in cases where the opposite col-
one has achieved optimum soft-tissue balance, lateral may be excessively lax (i.e. the medial
especially in flexion. collateral in valgus knees and the lateral collat-
On the tibial side in fixed-bearing designs, eral in varus knees) and the knee unstable
the surgeon has two options – a modular design (Fig. 1.12). A hinge design may be rarely indi-
and an all-polyethylene monoblock design. cated when the knee is grossly unstable, and liga-
Modern all-polyethylene tibial components have ment balancing may not be possible due to
shown comparable results in mid- to long-term soft-tissue incompetence (Fig. 1.12).
follow-up studies and offer several advantages
[29]. These include lower cost, avoidance of
locking-mechanism issues and backside wear Extras
and increased poly-thickness after identical bone
resections. However, there are certain disadvan- Additional components may sometimes be
tages with this tibial design which include lack of required while using a regular cruciate-substituting
modularity which restricts intraoperative options (CS) design. These include the following.
and during early revision TKAs when a liner Long Stem Extenders: Tibial stem extenders may
exchange is indicated [29]. The authors use an all- be required in cases with large tibial bone
polyethylene tibial component whenever the bone defects where bone graft or metal augments
quality is found to be good and the knee well bal- are used in order to provide additional stability
anced and well aligned intraoperatively. A metal- to the tibial component. It may also be used
backed tibia is used when the bone quality is poor, when a corrective tibial osteotomy is
patient is heavy, additional components such as a anticipated or in cases with acute or impend-
stem or augment needs to be used and if the bal- ing stress fracture. Long femoral stem extend-
ance is suboptimal with lateral laxity. ers are rarely used to supplement fixation
Recently an added dimension to the femoral when a distal metal augment is used for severe
component design has been the “high-flexion” femoral bone loss or to stabilise a distal femo-
feature. Although advocates of this design have ral corrective osteotomy.
reported benefits in terms of improved flexion, Augments/Wedges: Metal augments may be used
the reported literature is not very convincing on in knees with substantial bone loss in profound
this. Recent reports have also shown increased arthritic deformities especially when associ-
incidence of early loosening of the femoral ated with an intra-articular stress fracture.
a b c
Fig. 1.12 Different types of implant. (a) Case 1 where laxity warranted the use of a TC3 insert. (c) Case 3
despite severe varus deformity a standard cruciate- showed gross instability and dislocation of the arthritic
substituting design was adequate. (b) Case 2 where the joint which required a hinge prosthesis
presence of severe varus deformity and excessive lateral
Selection of Implants 17
Computer Navigation (c) Instruments:

Although the authors follow a similar surgi- Reflective arrays which are attached to the
cal technique workflow for both conven- femur and tibia and whose position is
tional and navigated TKA, computer-assisted tracked during navigation.
TKA requires the use of additional instru- Marker spheres which are attached to the
ments for registration, navigation and verifi- arrays and which reflect back the infra-
cation during the procedure. Different red beams emitted by the camera.
navigation systems for TKA use different Pointer with attached marker spheres is
types of technical workflow depending on used to register various anatomic land-
the manufacturer and the version of software marks, lines and surfaces during the reg-
being used. The surgeon needs to be well istration process.
versed with the instruments, hardware and Cutting block adaptor helps to verify posi-
computer software workflow of the system tion of cutting blocks and the bone cuts.
before using navigation for TKA. The Schanz pins which help fix arrays to the
authors use the image-free Ci navigation femur and tibia.
system (Brainlab, Munich, Germany) for all The basic setup of the camera and monitor
their TKAs where the surgeon can not only unit with respect to the surgeon and the limb
quantify the alignment of limb and compo- being operated needs to be determined by the
nent but also determine gaps throughout the surgeon beforehand (Fig. 1.13). The camera
entire range of motion. A well-trained tech- unit needs to be placed in such a manner that
nician who can operate the navigation sys- both femoral and tibial arrays are in range and
tem during surgery can be very helpful to easily tracked throughout the entire procedure.
ensure smooth operability of the system. The monitor unit needs to be in full view so that
Broadly, the components of this navigation the surgeon can visualise and control the navi-
system include: gation process. The reflective arrays need to be
(a) Infrared-emitting camera unit fixed to the tibia and femur at a proper angle
(b) Computer monitor unit with the naviga- and distance in such a way that their tracking is
tion software not hindered during the surgical procedure. The
Fig. 1.13 Navigation

system setup during
total knee arthroplasty
(TKA). Setup for a
left side TKA where
the arrays are fixed on
the medial side of the
femur and tibia and
the camera and
display unit are placed
on the right side. Note
the surgeon holding a
pointer with marker
spheres for
registration
surgeon needs to ensure that the arrays are tive site (preferably closer to the diaphysis of
securely fastened to the Schanz pins and the the bone). The Schanz screws must be firmly
marker spheres fully tightened to the arrays fixed to the bone, and we use two screws each
before the start of the procedure. Whenever an for the femoral and tibial arrays and these have
additional procedure maybe indicated such as a a unicortical purchase. In poor-quality bone,
corrective or an epicondylar osteotomy or a bicortical fixation is preferred. At any stage if
long stem is likely to be used, pins for fixing the the arrays/Schanz screws loosen out, the navi-
arrays should be placed away from the opera- gation process has to be abandoned.
tibial cut each drawn perpendicular to their

Glossary respective mechanical axes. This generally
equals the HKA angle.
Coronal component malalignment Components Joint line This is the distance between the tip
outside the acceptable ±3° range from a neu- of the fibula and the tangent drawn to the
tral alignment of 90° in the coronal and sagit- distal end of the femoral condyles on lateral
tal plane. radiographs.
Coronal limb malalignment Postoperative Mechanical axis of the limb Line passing from
HKA angle outside the acceptable ±3° range the centre of the femoral head and the centre
from a neutral alignment of 180°. of the ankle plafond.
Femoral anatomic axis Mid-diaphyseal line of Patellar height This is the distance between
the femur passing proximally from the pirifor- the distal tip of the patellar component and
mis fossa just medial to the greater trochanter the tangent drawn to the distal part of the
distally just medial to the intercondylar notch femoral component on lateral radiographs.
of the femur. Intraoperatively, this distance is assessed as
Femoral mechanical axis Line passing from the gap between the distal tip of the patel-
the centre of the femoral head to the apex of lar component and the tibial polyethylene
the intercondylar notch on the femoral articu- insert when the knee is put through an arc of
lar surface. flexion.
Femorotibial angle (FTA) Medial angle formed Tibial mechanical axis Line passing from the
by the distal femoral anatomic axis and the midpoint between the tibial spines to the cen-
proximal tibial anatomic axis. tre of the talar dome.
Hip-knee-ankle (HKA) angle Medial angle Valgus correction angle (VCA) Angle formed
formed by the mechanical axis of the femur by the mechanical and distal anatomic axes
and the tibia and denotes the coronal align- of the femur and denotes the amount of val-
ment of the limb. gus angulation required for the distal femoral
Joint divergence angle (JDA) Angle formed by cut.
the proposed distal femoral cut and proximal
Appendix 1 19
Appendix 1
The Arthritis Clinic

CLINICAL PREOPERATIVE CHECK LIST
MIND Expectations, Mental/

Psychological health ALLERGIES
DRUGS Anti-coagulants, Steroids,
Immunosuppressant
CARDIAC Status
RENAL Status SPINE Stenosis, Scoliosis, Ankylosis,
URINARY Infection, Prostate Neurodeficit, Claudication
SKIN & NAIL Lesions, Bleeding HIP Range, Abductors

tendencies
CIRCULATION Varicosities, Distal
pulses, H/o DVT
RECURVATUM Neurological?
OPPOSITE KNEE Varus/valgus or FIXED FLEXION Quadriceps
fixed flexion/hyperextension deformity strength?
VALGUS Patellar tracking?
INSTABILITY Neurological?,
Constraint?
PREVIOUS injections,
FEET Flatfeet, In/Out-toeing scars, sugeries
GAIT Waddling, Lateral thrust
Appendix 2
THE ARTHRITS CLINIC

RADIOGRAPHIC
PREOPERATIVE
CHECK LIST
Hip-Knee-Ankle Angle
Valgus Correction Angle
Joint Divergeence Angle
Femoral/Tibial Bowing, Tibia Vara,

Extra-articular Deformity
Osteophytes/Loose bodies
Bone defect
Extremes of implant size
Implant in-situ, prior Osteotomy
Patella position
Condition of hip joints

References 21
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Basic Technique of Total
Knee Arthroplasty 2
Introduction “Disclaimer”
With rapid advancement in technology and • Only posterior cruciate-substituting (CS)

materials in total knee arthroplasty (TKA), long- TKAs have been used by the authors. The
term survival and function of the total knee are rationale of using only CS knees is based on
increasingly more dependent on optimum sur- the finding that the posterior cruciate ligament
gical technique [1–3]. Adherence to basic sur- may undergo marked structural and functional
gical principles ensures a successful outcome. deterioration in arthritic knees especially in
Surgical technique in TKA is akin to a game severe grades of arthritis [4–7] and that the
of chess where every move has predictable and functional outcome and kinematics may be
logical consequences. Hence, every step of the more predictable with a CS knee [8–10].
surgical technique needs to be well thought of • Tibial preparation is performed as the first
before execution. The aim of the authors, like step in the majority of the knees.
most surgeons, is to ensure a well-aligned, well- • The gap-balancing technique has been used in
balanced and well-fixed TKA. Ligament balanc- all knees. Ligament balancing and gap balanc-
ing is an integral part of TKA, and soft-tissue ing are done with balancing in extension first
release should follow a functional and anatomic followed by femoral sizing and creating a flex-
rationale to achieve correct alignment and liga- ion gap equal to the extension gap.
ment balance throughout the range of flexion and • Ligament balancing is predictable and can be
extension. Any deviation from this principle may ensured throughout the full knee range of motion
lead to stiffness, imbalance or instability during in most knees. The authors mainly check liga-
TKA. ment balance in full extension and at 90° flexion
The two basic techniques commonly used in (and can also now quantify it throughout knee
TKA are the measured resection technique and range of motion using navigation). However,
the gap-balancing technique. The authors have balancing around deep knee flexion is still an
successfully used the gap-balancing technique area of controversy and is unclear [11].
in all their cases. This technique has proved reli- • Only cemented components have been used in
able to achieve a well-aligned and well-balanced all knees, and all knees undergo patellar
knee across various types and severity of knee resurfacing.
deformity. The present chapter aims to outline • Standard approach with medial parapatellar
the basic principles of TKA being followed by arthrotomy has been used in all knees.
the authors. The chapter begins with a brief “dis- • Computer navigation described here is not
claimer” listing the characteristic features of sur- only utilised to ensure accurate limb and com-
gical technique being followed by the authors. ponent alignment but also to quantify ligament

24 2 Basic Technique of Total Knee Arthroplasty
balancing and the amount of bone resection as a tool for verification where the computer
and soft-tissue release performed. Hence, navigation system provides real-time feed-
navigation has been used by the authors more back of various surgical steps.
Ligament Balancing: The How to Assess Soft-Tissue Tension?

“Kaizen” Approach
Numerous devices have been described to
Kaizen, Japanese for “improvement”, or assess soft-tissue tension during TKA. We use
“change for the better”, refers to philosophy or a tensioner made up of a single fixed tibial
practices that focus upon continuous improve- plate which sits on the tibial cut surface and
ment of processes and techniques [12]. In sim- two separate moveable plates for the medial
ple language, this concept implies performing and the lateral femoral condyles (Fig. 2.1a).
several small, continuous steps of improve- These two femoral plates can be moved inde-
ment to achieve significant results [12]. The pendently using a screw mechanism to increase
principles of ligament balancing we use during or decrease the tension medially and laterally.
TKA are very similar to the Kaizen concept. In full extension, the aim while assessing liga-
Optimum limb alignment and soft-tissue bal- ment tension is to achieve a limb alignment as
ancing are achieved during TKA by executing close to neutral as possible and equal tension
several small, interrelated steps involving bone both medially and laterally as assessed by the
cuts and soft-tissue release and varying the surgeon (Fig. 2.1b). The final stability is
size and position of the femoral component. checked in full extension using spacer blocks
Basically, soft-tissue balancing in TKA where a valgus and a varus stress are applied to
involves achieving “equality and equipoise” determine the degree of laxity (Fig. 2.1c). This
(i.e. equal width and equal tension) between step is again repeated in 90° flexion using the
the medial and the lateral compartments tensioning device and also using a spacer
within the extension or flexion gap and block with the AP cutting block in place
between the extension and flexion gaps. (Fig. 2.1d, e). The aim is not only to ensure
Hence, the two aims are to achieve a rectangu- that there is optimum stability in full extension
lar extension and flexion gap and a flexion gap and 90° flexion but also to confirm that any
equal in width to the extension gap. Soft- opening on stressing is equal on both sides and
tissue releases to achieve balance in TKA which also springs back equally.
involve deciding what to release, when to
release and how much to release for a given
knee deformity. It is crucial to keep in mind What to Release?
that intra-articular soft-tissue release and bone
cuts are intended to deal with intra-articular Based on the type of knee deformity and the
deformities. Attempts to tackle an associated degree of initial soft-tissue imbalance, the site
extra-articular deformity of the femur or tibia and the structures to be released vary from
using this technique may involve significant knee to knee. A thorough knowledge of what
release of important soft-tissue stabilizers of structures can be released during TKA for any
the knee joint like the collaterals which may given deformity is essential. For a varus knee,
subsequently result in imbalance. Hence, no release on the lateral side should be per-
cases with a concomitant extra-articular defor- formed, and for a valgus knee the opposite is
mity may require an additional procedure like true. Similarly, for a knee with flexion defor-
corrective or epicondylar osteotomy [13]. mity, posterior release is necessary, whereas
Disclaimer 25
a b
c d
Fig. 2.1 Various steps for assessing soft-tissue ten- in full extension. (d) Assessment of medial and lateral
sion during TKA. (a) Soft-tissue tensioner used by the soft-tissue tension using the tensioner with the knee
authors during TKA. It is made up of a single fixed held in 90° flexion. Note that the thigh is supported by
tibial plate which sits on the tibial cut surface and two an assistant to nullify the effect of the weight of the
separate moveable plates for the medial and the lateral limb during the assessment. (e) Assessment of medial
femoral condyles. (b) Assessment of medial and lat- and lateral soft-tissue tension using a spacer block
eral soft-tissue tension using the tensioner with the with the knee held in 90° flexion. This is done before
limb held in neutral alignment and the knee held in full the posterior cut is performed with the femoral AP
extension. (c) Assessment of medial and lateral soft- block pinned in place
tissue tension using a spacer block with the knee held
in a hyperextending knee it should be strictly alignment and medio-lateral balance

avoided. We completely avoid performing any (Fig. 2.2c). The extent of medio-lateral soft-
sort of release of the collaterals and avoid tissue disparity in extension after the bone
completely releasing the pes anserinus or cuts can be predicted using the joint diver-
dividing the popliteus tendon. Most deformi- gence angle on preoperative full-length radio-
ties and imbalance can be corrected releasing graphs (see Chap. 1).
capsular structures and adhesions rather than
the collaterals and supplementing these
releases with osteotomies. It must be pointed Equalising Medial and Lateral
out that the collateral ligaments themselves do Gap in 90° Flexion
not undergo contracture/shortening.
With the knee in 90° flexion, the tibial and
posterior femoral cuts should generally be
When and How Much to Release? parallel to the epicondylar axis and perpen-
dicular to the anteroposterior axis of the femur
We follow a graduated, controlled and step- (Fig. 2.3a). We mark the level of the tentative
wise approach to soft-tissue release during posterior femoral cut after assessing flexion
TKA. Removal of osteophytes as the initial gap balance using the tensioner (Fig. 2.3b, c).
step considerably improves deformity and However, it is very important to achieve good
decreases the quantum of soft-tissue release medio-lateral balance in flexion before deter-
required. A preliminary soft-tissue release is mining the level and performing the posterior
performed as part of exposure and follow- femoral cut. In varus knees, if the posterior
ing osteophyte excision. Rigid deformities femur is cut in the presence of excessive
may not be fully corrected with a prelimi- medial tightness, then the femoral component
nary release. Similarly, although soft-tissue may get placed in excessive external rotation
release may achieve full correction of defor- and vice versa (Fig. 2.3d–e). Similar to when
mity, it may fail to achieve medio-lateral the knee is in full extension, the aim at 90°
balance. Such cases with residual deformity knee flexion is to create a rectangular flexion
or medio-lateral imbalance will require fur- gap equal on both medial and lateral side.
ther, extended releases supplemented by a Hence, the determinants of flexion gap include
reduction osteotomy [14]. distal femoral and tibial cuts, medio-lateral
soft-tissue tension in 90° flexion, femoral
component size and position and the tibial
Equalising Medial and Lateral insert thickness.
Gap in Extension
With the knee in full extension, the tibial and Equalising Flexion Gap
the distal femoral resection are made perpen- to the Extension Gap
dicular to their respective mechanical axes
(Fig. 2.2a). The aim is to create a rectangular Based on our technique of creating the exten-
extension gap equal on both medial and lateral sion gap first, the way to flexion-extension
side. However, despite accurate bone cuts, the gap balancing involves creating a flexion
extension gap may be unequal or quadrilateral gap matching in dimension to the previously
owing to medio-lateral soft-tissue imbalance created extension gap. The key to achieving
as determined by spacer blocks (Fig. 2.2b). this is the size and position of the femoral
This disparity needs to be rectified using component. Using the method previously
appropriate soft-tissue releases to restore limb described, the flexion gap is assessed using
Disclaimer 27
a b c
Fig. 2.2 Equalising medial and lateral gaps in full quadrilateral instead of rectangular due to medio-lat-
extension. (a) The tibial and the distal femoral resec- eral soft-tissue imbalance as determined by a spacer
tions (dotted lines) are made perpendicular to their block. (c) This requires appropriate soft-tissue releases
respective mechanical axes (solid lines). (b) Despite to restore limb alignment and medio-lateral balance
accurate cuts, the resultant extension gap may be and a rectangular extension gap
a spacer block with the AP cutting block of helpful to tackle a flexion gap that exceeds the
the estimated femoral component size pinned extension gap. However, the surgeon needs to
in place. This must have no slots posteriorly. be cautious in not overdoing this and causing
Using a stylus or “angel wing”, we ensure that either anterior notching or post impingement
there is no notching. If the flexion gap is tighter against the box in extension. The AP block
for the corresponding spacer block used previ- is placed accurately before performing the
ously in the assessment of extension gap, the anterior and posterior femoral cuts by using
femoral component needs to be undersized or “combined referencing” where multiple refer-
moved anteriorly in order to equalise the flex- ences are used to ascertain the position of the
ion-extension gaps. Slight flexion or posterior AP cutting block and subsequently the femo-
shift of the femoral component may also be ral component (Fig. 2.4).
X
a b c
LE ME
Y
A B
C D
d e
AP CUTTING AP CUTTING
BLOCK BLOCK
Fig. 2.3 Equalising medial and lateral gaps in 90° previously marked distal cut. Note that the cutting
flexion. (a) Relation of various distal femoral rota- block has been positioned based on “combined refer-
tional axes to the posterior femoral (line AB) and tibial encing”. (d) If the AP cutting block is placed and the
(line CD) cuts with the knee in 90° flexion. The tibial posterior femur is cut in the presence of excessive
and posterior femur cuts should generally be parallel medial tightness, then the femoral component may get
to the epicondylar axis (line LE–ME) and perpendicu- placed in excessive external rotation. (e) Similarly, if
lar to the anteroposterior (AP) axis of the femur (line the AP cutting block is placed and the posterior femur
XY). (b) The tentative posterior femoral cut marked is cut in the presence of excessive lateral tightness,
after assessing flexion gap balance using the tensioner then the femoral component may get placed in
and its relation to the AP axis. (c) The AP cutting excessive internal rotation
block pinned in position and its relation to the
Surgical Approach and Exposure 29
1.WHITESIDE’S LINE 4. ANTERIOR SURFACE
2.EPICONDYLAR AXIS
5.FLEXION GAP USING SPACER
3.POSTERIOR CUT LEVEL BASED ON SOFT TISSUE TENSION
Fig. 2.4 The concept of “combined referencing” and its five components in order to accurately place the AP
cutting block
Surgical Approach and Exposure The tibial cut is always performed first in all
our cases. Using seven simple steps during expo-
The authors use the classical anterior skin inci- sure will help in easily dislocating the knee and
sion with the medial parapatellar arthrotomy to bringing the tibia forwards without having to per-
approach the knee. This approach has served us form excessive, unnecessary soft-tissue release or
well in almost all of our TKA cases. Rare excep- having to apply a Hohmann’s retractor on the pos-
tions where an alternative approach was used terior aspect of the tibia. This approach allows for
include knees with severe valgus arthritis and laterally displacing the extensor apparatus (quad-
patellar maltracking which required a lateral riceps tendon and patella) easily without having to
parapatellar arthrotomy and stiff arthritic knees evert the patella and adequately exposing the tibial
where a tibial tubercle osteotomy was performed articular surface to perform the tibial cut (Fig. 2.5).
to improve exposure. Like any surgical procedure, approaching the knee
We use a pneumatic tourniquet in all our cases to perform TKA is facilitated by using the right
which is inflated before the incision is taken. The surgical instruments. After the medial parapatellar
pressure set is typically 100 mmHg over the sys- arthrotomy, the following seven steps are per-
tolic pressure of the patient in thin or nonobese formed to adequately expose the knee for TKA:
patients or 150 mmHg over and above if the 1. Patella – Division of the patellofemoral
patient is obese. Rarely, if the patient is morbidly ligament, excision of the infrapatellar fat pad
obese and the thigh size is too big for the largest and removal of patellar osteophytes and peri-
cuff, tourniquet is applied but inflated after all the patellar synovium to facilitate lateral displace-
bone cuts have been performed and just before ment of the extensor apparatus and patella for
cementing. resurfacing.
to the laterally displaced patella helps to

completely expose the tibial articular sur-
face (Fig. 2.5).
6. Menisci – Excision of both menisci with cau-
terisation of the lateral genicular vessels.
7. Posterior osteophytes – Excision of postero-
medial tibial osteophytes with a broad flat
osteotome (Fig. 2.6c) and removal of poste-
rior femoral osteophytes using a curved osteo-
tome (Fig. 2.6d). Removal of the medial
meniscus beforehand improves access to the
posterior surface of the femoral condyle for
removal of these osteophytes.
Fig. 2.5 Complete anterior dislocation of the tibia
following excision of cruciates and menisci. The laterally After completing these seven basic exposure
displaced extensor apparatus (quadriceps tendon and steps, the knee is now extended and checked for
patella) is held in place with an angled Hohmann’s retrac- amount of correction achieved with these prelim-
tor without having to evert the patella and adequately inary soft-tissue releases by applying a valgus
exposing the tibial articular surface to perform the tibial
cut stress for a varus knee (and a varus stress for a
valgus knee) and the amount of soft-tissue laxity
present on the opposite side by applying a varus
2. Anterior surface of femur – Elevation of the stress for a varus knee (and a valgus stress for a
synovium, fat and soft tissue from over the valgus knee).
anterior surface of distal femur not only for
registering the surface for CAS but by ade-
quate visualisation notching can be avoided. Tibial Resection
3. Cruciates – Complete excision of both cruci-
ates is essential prior to balancing. The tibial cut affects both the extension and the
4. Anterior osteophytes – Removal of osteo- flexion gaps. How much minimum thickness of
phytes around the distal end of the femur and tibia needs to be resected with reference to the
the medial or lateral aspect of the proximal less involved side is governed by the type and
tibia. Excision of the osteophyte usually pres- severity of knee deformity and the knee prosthesis
ent in the medial corner of the medial femoral design. The standard tibial cut involves resecting
condyle just beneath the femoral attachment of an amount equal to the combined thinnest insert
the MCL is important in varus knees to reduce and tray thickness available with an implant sys-
tenting of the MCL (Fig. 2.6a). Osteophytes tem. However, this needs to be varied depend-
are often seen posteromedially deep in the ing on the type and severity of deformity. More
intercondylar notch and should be excised as severe the coronal plane deformity (varus or val-
well (Fig. 2.6b). gus), less should be the amount of tibial resection.
5. Knee dislocation – The knee is now flexed Similarly, less bone needs to be resected in knees
maximally and the tibia gently externally with severe ligamentous instability or in a hyper-
rotated by an assistant while the surgeon extending knee. More than 8 mm of tibia can
simultaneously releases the deep MCL and occasionally be resected in knees with a severe
capsule along the medial and posteromedial fixed flexion deformity or in knees with a large
edge of the tibial articular surface using dia- defect where resecting an additional few mm may
thermy. This safely dislocates the knee and provide a uniform flat surface.
brings the tibia fully forwards. An angled The coronal plane of tibial resection is based
Hohmann’s retractor then applied to the on using either the mechanical axis of the tibia or
posterolateral aspect of the tibia adjacent the medullary axis of the tibia. The position of
Tibial Resection 31
a b
c d
Fig. 2.6 Removal of osteophytes as part of the exposure osteotome. (c) Excision of posteromedial tibial osteo-
for TKA. (a) Excision of osteophyte usually present in the phytes with a flat broad osteotome. (d) Excision of poste-
medial corner of the medial femoral condyle just beneath rior femoral osteophytes using a curved osteotome. Note
the femoral attachment of the MCL with a flat narrow that the tibia has been displaced anteriorly as much as
osteotome. (b) Excision of osteophytes posteromedially possible to allow better access for the osteotome
deep in the intercondylar notch with a flat narrow posteriorly
a b c d
Fig. 2.7 Reference for tibial cut in the coronal plane. (a) coronal plane of the tibial cut in the presence of tibial
Position of the tibial mechanical axis in a curved tibia. (b) bowing or tibial vara results in shift of the entry point lat-
Position of the tibial tray when the mechanical axis of the erally. (d) This facilitates lateralising the tibial component
tibia is used to decide the coronal plane of the tibial cut in which helps in decreasing the area of medial bone defect,
the presence of tibial bowing or tibial vara. Note that the performing a reduction osteotomy for deformity correc-
entry point and subsequently the tibial tray and stem may tion and ligament balancing and placing the tibial stem at
be placed too medially. (c) Using the medullary axis of the the centre of the proximal medullary canal of the tibia
middle third of the tibial shaft as reference to decide the
tibial tray in the coronal plane and the amount of proximal medullary axis of the tibia is used in a
tibial resection may vary depending on which deformed tibia, the tibial component may be
axis is used. The coronal plane of tibial resection placed too medially. A third way of deciding the
has been classically recommended to be perpen- coronal plane of the tibial cut is based on the
dicular to the mechanical axis of the tibia or the medullary axis of the middle third of the tibial
proximal tibial medullary axis. Although this shaft (Fig. 2.7c). Although using this axis in tibia
may be appropriate in a straight tibia, the same with bowing or varus deformity shifts the entry
may not hold true for tibiae which show coronal point laterally, this facilitates lateralising the
plane bowing (Fig. 2.7). When the mechanical tibial component which helps in decreasing the
axis of the tibia is used to decide the coronal area of medial bone defect, performing a reduc-
plane of the tibial cut in the presence of tibial tion osteotomy for deformity correction and lig-
bowing or tibial vara, the entry point and subse- ament balancing and placing the tibial stem at
quently the tibial tray and stem may be placed the centre of the proximal medullary canal of the
too medially (Fig. 2.7a-b). Similarly when the tibia (Fig. 2.7c-d).
Balancing in Extension and Distal Femoral Resection 33
Fig. 2.8 Variations in the tibial slope based on the design of the insert and tibial tray
Slope of the tibial cut is governed by the the extension gap. If either the medio-lateral gaps
implant being used and the manufacturer’s rec- or the limb alignment in full extension is subop-
ommendation for that implant. Certain designs timal, then additional soft-tissue release needs to
have a built-in slope in the polyethylene insert, be performed to achieve a balanced extension gap
whereas others have a slope built in the cutting and satisfactory limb alignment.
block (Fig. 2.8). The tibia should be cut at neutral The distal femoral cut is made perpendicular to
with respect to the sagittal plane if the implant the mechanical axis of the femur. The thickness of
polyethylene already has an inbuilt slope. Adding distal femoral resection needs to be conservative
a slope to the tibial cut in this situation will in cases with severe bone loss, severe lateral or
increase the flexion gap and also limit terminal medial laxity in varus or valgus, recurvatum defor-
knee extension. Tibial resection affects both the mity and in knees with gross instability. More
extension and flexion gap. Hence, proper execu- than usual amount of distal femur may have to be
tion of the tibial cut in both coronal and sagittal occasionally resected in knees with fixed flexion
plane is crucial to avoid further errors in gap bal- deformity to achieve correction. Conventionally,
ancing. Using the medullary axis of the middle the cut is performed using intramedullary guides
third of the tibial shaft, especially in bowed tibiae, which are commonly set at an angle of 5–7° val-
will not only minimise tibial cutting error but also gus. However, choosing this fixed range for the
component placement errors in the coronal plane. distal femoral valgus cut is fraught with risks
especially in knees with severe deformities. A
recent prospective study [15] done by the authors
Balancing in Extension and Distal has shown wide variations in this angle among
Femoral Resection patients with the distal femoral valgus correction
angle (VCA) varying from 2° to 11° and almost
The distal femoral cut affects only the extension 45 % of limbs having a VCA outside the conven-
gap. After the tibial cut, a soft-tissue tensioning tional 5–7° range [15]. This is commonly due to
device is used to tension the medial and lateral bowing of the femoral shaft in the coronal plane
soft tissues so as to achieve an equal medial and which is frequently encountered in Asian patients
lateral gap while checking the alignment of the undergoing TKA. Evaluation of femoral bowing
limb in full extension (Fig. 2.1b). It is important in our patients undergoing TKA revealed that one
to remove all osteophytes especially from the pos- in five varus limbs had significant femoral bowing
terior aspect of femoral condyle before this step in the coronal plane [16]. Using an intramedul-
as their presence may lead to underestimation of lary guide (straight rod) in a bowed femur (curved
canal) will lead to displacement of the cutting jig and the previously made mark on the posterior
and an inaccurate cut vis-à-vis the mechanical aspect of the distal femoral cut surface based on
axis of the femur. Hence, to avoid malalignment soft-tissue tension. For rotation, the AP cutting
of femoral component in the coronal plane, the block is generally placed parallel to the epicondylar
distal femoral cut should be tailored in each limb axis and perpendicular to Whiteside’s line. After
based on VCA determined on preoperative full- pinning the AP cutting block to the distal femur, the
length hip-to-ankle radiographs. flexion gap balance is assessed using a spacer block
After the tibial and distal femoral cuts, limb (Fig. 2.1e). If the flexion gap seems too tight com-
alignment and medio-lateral extension gap bal- pared to the extension gap, the femur needs to be
ance can be verified using a spacer block downsized or vice versa. Hence, the authors use the
(Fig. 2.1c). Again varus and valgus stressing is concept of “combined referencing” to determine the
performed to assess imbalance. Any soft-tissue position, size and rotation of the femoral component
imbalance and limb malalignment at this stage (Fig. 2.4). Preparation of the distal femur is then
can be addressed with a further release. completed using a notch cutting block of appropri-
ate size to perform the notch and chamfer cuts.
Balancing in Flexion, Femoral

Sizing and Rotation Tibial Sizing and Rotation
After achieving a well-balanced extension gap, After the femoral chamfer and notch cuts, limb
the flexion gap is assessed using a soft-tissue ten- alignment, extension and flexion gap balance are
sioner. The aim is to achieve a flexion gap equal to assessed using trial components. In varus knees
the previously created extension gap. Medio- showing excessive medial tightness and/or exces-
lateral soft-tissue tension is assessed at 90° flex- sive lateral laxity, additional soft-tissue release
ion with an assistant supporting the weight of the with or without a reduction osteotomy and down-
limb at the proximal thigh (Fig. 2.1d). Ideally the sizing of the tibial component may be needed. In
medial and the lateral gaps should have equal ten- such a situation, a thicker insert will have to be
sion. However, arthritic knees in general, based used to achieve soft-tissue stability.
on the authors’ experience, tend to be more lax Tibial component rotation is determined by put-
laterally. Hence, 2 mm of disparity between the ting the knee through an arc of flexion and exten-
medial and lateral gaps (lateral more lax than the sion, and the optimum position of the tray is marked
medial side in varus knees) may be accepted and using cautery on the anterior aspect of the tibia.
does not seem to affect the overall function of the Tibial tray size is governed by its compatibility with
knee. This rectangular gap achieved after soft- the femoral component size (some systems require
tissue tensioning is marked on the distal femoral both to be matched, others allow one and two sizes
cut surface to denote the posterior femoral cut up or down) and the need for a reduction osteotomy
(Fig. 2.3b). In varus knees, the presence of exces- which consequently calls for downsizing of the
sive medial tightness may encourage the femoral tibia. The tibial tray is placed along the lateral cor-
component to get placed in excessive external tex of the tibial surface. Uncapped bone medially
rotation and vice versa. may be removed with an osteotome to prevent tent-
The AP cutting block equivalent to the femoral ing of the medial soft-tissue sleeve. Tibial torsion
component size estimated is now selected and may be seen with severe deformity. Tibial torsion
placed in the AP axis. The surgeon references the calls for greater caution in accurately rotating the
anterior cortex of the distal femur to avoid notching tibial component so as not to result in in-toeing [17].
Closure 35
Patella cases where the tourniquet has not been used

and the field is excessively bloody. The bone
The authors resurface the patella in all cases surfaces need to be inspected for any cysts
of TKA. A rare exception includes a very thin which need to be curetted out and any loose can-
native patella where leaving behind at least cellous bone from the canal needs to be removed.
12 mm thickness of patellar bone is not feasible. Most small to medium well-contained cysts or
The aim is to leave behind at least 12–14 mm small to medium uncontained cysts can be tack-
of patellar bone with the component placed led by a bone cement fill. However, large cysts
slightly more medially and superiorly. Usually need to be grafted using cancellous bone pieces
more thickness of bone is removed medially obtained from the femoral cuts. A large periph-
than laterally (as the patella is asymmetric in eral defect should be first refashioned using a
thickness) so as to end up with a symmetrically saw to prepare a step-cut defect in which one
thick remnant. A thorough excision of peripatel- can ensure good fit of the solid bone graft which
lar synovium is performed at the outset during should be then fixed using Kirschner wires [19].
exposure, and peripatellar cauterisation is per- This construct should then be supplemented
formed before patellar implantation to prevent with a long stem to ensure additional stability of
postoperative patellar crepitus or clunk. The the tibial component.
authors use an onlay-type, oval dome, 3-pegged,
all-polyethylene, cemented patellar component
in all cases. After implantation, excessive patel- Closure
lar bone around the component is removed using
a large bone rongeur or bone cutter to obtain an We deflate the tourniquet after the cement has
even slope around the patella so as to prevent hardened. While the cement is setting, excessive
crepitus or impingement. cement around the components is curetted out,
and the periarticular soft-tissue sleeve is infil-
trated with an analgesic “cocktail” [20]. Once the
Cementing cement is set, the tourniquet is deflated, and the
knee is put through a range of flexion and exten-
The authors use cemented components in all sion to check patellar tracking. Any sign of lat-
TKAs. A thorough preparation of femoral, tibial eral maltracking or patellar component lift-off is
and patellar cancellous bone surfaces is essen- dealt with by a lateral retinacular release. The
tial to ensure good penetration of bone cement authors perform this with an inside-out tech-
and fixation of the components. The authors use nique. The knee is then dislocated to remove any
normal saline sprayed with a 50-cc syringe cementophytes around the posterior aspect of the
along with an ETO-sterilised toothbrush to knee. After a thorough haemostasis with special
clean and prepare the cancellous bone surface care to cauterise the superior lateral genicular
[18]. This has proved to be an effective and vessels which may get transected during the lat-
inexpensive alternative in our setup where using eral release, the incision is closed in layers over a
pulse lavage adds to the cost of the procedure. negative suction drain placed within the knee
Besides, using pulse lavage in patients with joint. After closure of the capsule, the knee is
poor bone quality (which is often the case in our again put through a range of flexion and exten-
patients) may result in inadvertent surface sion to check patellar tracking, maximum flexion
removal of fragile bony trabeculae. However, obtained on table, watertight closure of the cap-
pulse lavage may have to be used in certain sule and the patency of the drain tube.
Technique of Computer-Assisted TKR
The basic surgical technique followed by the

authors is the same as described above when
computer navigation is used. Navigation
acts as a verification tool during bone cuts,
soft-tissue release and implant positioning
to achieve accurate and consistent results.
However, it is important to note that when
computer navigation is being used, the surgeon
needs to be aware about its limitations and
may have to override some of its recommen-
dations whenever required. It may be unwise
to use computer navigation on an “auto-pilot
mode” with the surgeon’s experience and clin-
ical judgement taking a back seat. Although
it does involve a learning curve and may
add to surgical time initially, in the authors’
experience the surgical time during computer-
assisted TKA quickly becomes equivalent
to conventional TKA technique with experi-
ence. This section gives a brief overview of
the basic setup of computer navigation and
its use during TKA. The authors have used
the image-free Ci navigation system with its Fig. 2.9 The position of the array pins confined to the
proximal third of the tibia and the distal third of the
software (Brainlab, Munich, Germany) for all femur within the surgical incision
their cases. The computer navigation system
consists of a camera unit, a computer screen
and the arrays. The Ci navigation system is impede the cutting blocks or the compo-
based on infrared technology where infrared nents. For the tibial pins, the authors fix the
light emitted by the camera unit is reflected first pin one thumb below the tibial articu-
back by tibial and femoral reflective arrays lar surface with both the pins directed away
and is detected by two cameras. The use of from the position of the tibial stem. For the
computer navigation system involves the fol- femur, the distal-most pin is placed mid-
lowing basic steps: way between the articular cartilage margin
Fixation of Arrays: The tibial and femoral and the medial epicondyle.
arrays, each with three reflective spheres, Registration: Registration is done in the stan-
are fixed to the bone using two 4-mm dard fashion as described for the navigation
Schanz pins placed unicortically. The posi- system. Registration starts by kinematic
tion of the pins is usually confined to the identification of the centre of the femoral
proximal third of the tibia and the distal head, mapping of the lower femur, upper
third of the femur (Fig. 2.9). The arrays tibia and bony landmarks of the ankle. The
may be fixed within the surgical wound or centre of the femoral head is computed by
outside of it using small stab incisions. pivoting the femur and moving the entire
When placed within the surgical wound, limb in a circular motion while the pelvis
care should be taken so that the pins do not is steadied. It is accepted if the accuracy
Closure 37
Fig 2.10 Registration of surfaces on the distal femur and upper tibia
is within 3 mm. The computer calculates are verified using the flat verification
the centre of the femoral head as the apex arrays. The surgeon can choose to alter
of a cone described in space by the arrays the thickness and orientation of the cuts if
as the leg is pivoted. This is followed by desired.
registration of bony landmarks, lines and Verification of Bone Cuts: After initial regis-
surfaces on the distal femur and upper tibia tration, different steps of TKA can be veri-
(Fig. 2.10). The initial mechanical axis of fied using computer navigation. The
the lower limb is then determined by the amount and plane of tibial, distal femoral
computer using the centre of the femoral cut and anterior femoral cut are verified
head, centre of the knee and the centre of (Fig. 2.11b) and can be compared to the
the ankle. desired settings.
Navigating Cutting Blocks: Conventional Gap Balancing in Extension and Flexion: In
cutting blocks for the tibial, distal femo- extension, navigation allows quantification
ral and anteroposterior femoral cuts can of medial and lateral gaps and the limb
be navigated in position (Fig. 2.11a) to alignment for a given spacer. It also allows
match the default recommendations of visualising the degree of medio-lateral lax-
the computer in order to obtain the desired ity present for a given spacer. In flexion,
cuts. The positions of these cutting blocks medio-lateral gap balance can be assessed
Fig. 2.11 Verification

a
of cutting block position
and bony cut accuracy
with navigation using a
flat pointer. (a) The
distal femoral cutting
block is pinned in
position while
simultaneously
verifying its position
with navigation. (b) The
distal femoral cut is
verified for accuracy
with navigation
with respect to the position of distal femoral components and again after implantation
bony landmarks such as the transepicondy- of the prosthesis especially when the
lar line, Whiteside’s line and the posterior cement is setting. Holding the limb in the
condylar axis. The optimised version of the appropriate position while the cement is
Ci navigation software allows the surgeon setting is crucial to avoid malalignment
to simulate the effect of change in rotation, of tibial and femoral components due to
flexion or extension, upsizing or downsiz- an uneven cement mantle or incomplete
ing of the femoral component on the flexion seating of the components. Navigation
gap vis-à-vis the extension gap (Fig. 2.12) allows for real-time continuous visuali-
without actually performing the cuts. sation of the limb position in both the
Final Alignment: The final alignment of the coronal and sagittal plane while the
limb and gaps can be confirmed with trial cement is curing.
Closure 39
Fig. 2.12 Optimised

version of the Ci
navigation software
allows the surgeon to
simulate the effect of
change in rotation,
flexion or extension,
upsizing or downsizing
of the femoral
component on the
flexion gap vis-à-vis
the extension gap
before performing any
cuts on the femur
Appendix Surgical Technique Workflow Chart for TKA
Clinical and Radiographic assessment
Exposure and preliminary release
Assessment of correctibility and gap imbalance
Tibial Cut
Assessment of extension gap balance and alignment
Distal femoral cut
Assessment of flexion gap balance
Femoral sizing and rotation and equalizing flexion gap to extension gap
Alignment and balance using trial components
Patella preparation
Cementing of final implants
Closure
References 41
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Part II
Coronal Plane Deformities
Varus Deformity
3
Introduction principles of dealing with a varus deformity, both

mild to moderate and severe deformities, during
Varus deformity, the most commonly encoun- TKA.
tered deformity in patients undergoing total knee
arthroplasty (TKA), is associated with a limb
alignment (hip-knee-ankle angle) of less than Pathoanatomy
180° and varying degrees of contracture of
medial soft-tissue structures, laxity of the lateral Stability and function of the knee joint involve a
soft-tissue structures, flexion deformity and dynamic interplay of various soft-tissue struc-
medial bone erosion at the knee joint. Medial tures around the knee joint. A sound knowledge
osteophytes cause tethering and functional short- of these structures, both under normal and dis-
ening of the medial soft-tissue structures in a eased conditions, is crucial to achieve optimum
varus deformity; posterior osteophytes exert the alignment, balance and kinematics after TKA for
same effect on the posterior capsule leading to the arthritic knee. The issue of stability and bal-
flexion contracture and obstruction to deep flex- ancing of soft tissues around the knee joint dur-
ion. There may also be associated lengthening ing TKA is compounded by the fact that ligaments
and attenuation of the lateral soft-tissue struc- and muscles around the knee joint are dynamic
tures especially in severe varus deformities [1]. structures which behave differently in knee
Hence, the challenges in performing TKA in a extension and flexion.
varus arthritic knee include restoration of limb A sequential release of soft-tissue structures
alignment, balancing the medial and lateral soft- has been recommended to achieve equal medial
tissue tension, equalising flexion and extension and lateral gaps during TKA [1, 6–9]. It is hence
gaps and restoring medial bone loss. Severe varus important to know the soft-tissue structures
deformities may be associated with malrotation around the medial aspect of the knee joint and the
of the distal femur and tibia which makes con- effect of release of these structures on gaps and
ventional bony landmarks less reliable to deter- alignment.
mine rotational alignment of the femoral and Traditionally, medial soft-tissue structures of
tibial components [2–4]. Furthermore, severe the knee joint have been described in three lay-
varus deformities may also be associated with ers [10–12]. The first and most superficial layer
extra-articular deformities such as excessive cor- consists of the deep crural fascia of the knee
onal bowing of the femoral shaft and proximal joint including the retinacula and the pes anse-
tibia vara which makes TKA technically chal- rinus (sartorius, gracilis and semitendinosus)
lenging [5]. The current chapter describes the attachment on the anteromedial aspect of the

46 3 Varus Deformity
Fig. 3.1 Medial soft-tissue

structures of the knee joint
Superficial medial
collateral ligament
Posteromedial capsule
Deep medial Posterior oblique
collateral ligament ligament
Pes anserinus
proximal tibia distally. The second layer consists the clinicoradiographic features presented by
of the superficial part of the medial collateral each varus arthritic knee, the surgeon will have to
ligament (MCL) which also gives rise to the pos- individualise the amount of bone resection, soft-
terior oblique ligament (POL) posteromedially tissue release and component size and position for
(Fig. 3.1). The third and the deepest layer con- each TKA in order to achieve optimum limb align-
sists of the deep part of MCL, the deep capsular ment and gap balance. Based on our experience of
layer and the insertion of the semimembranosus nearly 10,000 TKAs over the last 20 years, the
tendon at the posteromedial corner of the tibia authors have identified several clinical and radio-
just below the joint line. We performed a cadav- graphic features in varus arthritic knees which
eric study to quantify the effect of sequential pos- form the basis of their surgical technique.
teromedial release on flexion and extension gaps The three principal clinical features of varus
using an image-free computer navigation system deformity on clinical examination (under anaes-
[13]. Our study demonstrated that sequential thesia) which need to be noted are (1) correctibil-
soft-tissue releases led to an incremental and ity of the deformity (rigid, partially correctible,
differential effect on flexion and extension gaps fully correctible and unstable) with knee in maxi-
[13]. Hence, judicious and titrated use of this mum extension, (2) associated sagittal plane
posteromedial soft-tissue releases sequence and deformity (fixed flexion or hyperextension) and
following an algorithmic approach will help in (3) extent of lateral side soft-tissue laxity (mild,
correcting deformity and restoring limb align- moderate or severe) (Fig. 3.3). The degree of cor-
ment and balance during TKA. Although sev- rectibility of deformity will decide the amount of
eral authors have described different sequence soft-tissue release required medially in order to
of soft-tissue release for varus deformities [1, achieve correction and balance. Similarly,
6–9], we follow our technique of sequential soft- amount of soft-tissue laxity on the lateral side of
tissue release as described here for a cruciate- the knee in a varus deformity decides the extent
substituting TKA (Fig. 3.2). of medial soft-tissue release required in order to
As described in Chap. 1 , a lot of informa- equalise the medial and lateral soft-tissue gaps.
tion can be derived about the pathologic soft- Any associated sagittal plane deformity will
tissue and bony changes which have occurred require titrating the amount of tibial and distal
in an arthritic knee based on preoperative radio- femoral bony resection and posterior soft-tissue
graphic features and examination of the knee release to achieve deformity correction and
under anaesthesia during TKA. Depending on flexion-extension gap balance.
Pathoanatomy 47
Varus Deformity
Excision of osteophytes; release of anteromedial capsule and deep MCL

(to facilitate forward dislocation of tibial plateau)
<10° varus 10°−20° varus° >20° varus°
Fully correctible Partially Fully Partially Fully Partially

correctible correctible, correctible, correctible, correctible,
lateral laxity lateral laxity lateral laxity lateral laxity
TKA
Further release Further release Further release
(semimembranosus, (semimembranosus, (semimembranosus,
posteromedial capsule) posteromedial capsule) posteromedial capsule)
+
Reduction osteotomy
Medio-lateral Medio-lateral
balance imbalance
Medio-lateral Medio-lateral
balance imbalance
TKA Reduction
osteotomy
TKA Sliding medial condylar
osteotomy (SMCO)
Fig. 3.2 Algorithmic approach to achieve limb alignment and soft-tissue balance in varus deformity during TKA
Preoperative radiographic features will usually deformities, excessive lateral laxity, abundant
provide hints as to what manoeuvres need to be osteophytes and severe medial bone loss are
carried out to correct the deformity and achieve more commonly seen in knees with severe long-
optimum soft-tissue balance and can also help standing varus deformities (especially ≥20°)
predict the difficulty a surgeon may face in achiev- than in knees with mild to moderate varus defor-
ing these goals. The five radiographic features of mities [4]. In some knees, where the degree of
varus arthritic knees which need attention are (1) arthritic involvement and the amount of intra-
degree of deformity (as measured on full-length articular deformity is less severe, the above fea-
hip-to-ankle radiographs), (2) amount of lateral tures may be absent. However, in these knees the
laxity (based on joint divergence angle and lateral degree of deformity may be confounded by the
translation of tibia), (3) presence of extra-artic- presence of an extra-articular deformity (com-
ular deformity (coronal femoral bowing based monly excessive coronal bowing of the femur)
on valgus correction angle, tibia vara based on which adds to the overall severity of limb defor-
tibial plateau angle), (4) medial bone loss (mild, mity and makes the case more challenging to
moderate, severe) and (5) presence of osteophytes treat (Fig. 3.5). Furthermore, increase in varus
(minimal, moderate, abundant) (Fig. 3.4). deformity may also cause variation in the distal
Several of the above features may be present valgus correction angle (VCA) and rotational
or absent primarily based on the severity of profile of the distal femur and the tibia which
arthritic involvement and the degree of knee needs to be accounted for while positioning the
deformity. Rigidity, associated sagittal plane femoral and tibial components [2–4, 14–19].
Fig. 3.3 The three principal

clinical features of varus
arthritic deformity which
needs to be noted during
TKA (shown here using
computer navigation screen
shot images). (a) Maximum
varus deformity (using a
varus stress at the knee joint
in maximum extension) and
maximum knee deformity in
the sagittal plane (flexion).
(b) Maximum correctibility
of varus deformity (using a
valgus stress at the knee joint
in maximum extension).
(c) Maximum lateral
soft-tissue laxity (using a
varus stress at the knee joint a
in maximum extension)
c
Pathoanatomy 49
3. EXTRA-ARTICULAR DEFORMITY
1. DEGREE OF DEFORMITY
4. MEDIAL BONE LOSS
2. LATERAL LAXITY
5. OSTEOPHYTES
Fig. 3.4 The five principal radiographic features of varus arthritic deformity which needs to be noted on preoperative
full-length hip-to-ankle radiographs
Based on radiographic analysis of 1,500 features put the knee at greater risk for malalign-
computer-assisted TKAs [5], the authors have ment after TKA [5]. Hence, the surgeon should
described features of an “at-risk” knee which identify such “at-risk” knees, and every measure
can be identified on preoperative standing, must be undertaken to ensure optimum limb and
full-length hip-to-ankle radiographs (Fig. 3.6). component alignment and soft-tissue balance
The presence of these preoperative radiographic during TKA.
Fig. 3.5 Extra-articular

deformity confounding the
severity of deformity in an
arthritic knee.
(a) Preoperative standing
knee radiograph showing
mild changes in terms of
deformity, bone loss,
osteophytes and lateral laxity.
Dotted line shows femoro-
tibial angle. (b) Preoperative
standing, full-length
hip-to-ankle radiograph of the
same patient (a) showing
significant coronal bowing
of the femoral shaft (arrow)
because of which the distal
femoral valgus correction
angle (VCA) in this patient
is almost 10.5°. Dotted line is
the anatomic axis of the distal
femur and the black line
shows the femoral mechani-
cal axis; the angle formed by
the two lines is the VCA
Surgical Technique ancing where bone resection and soft-tissue

release are tailored to each individual knee based
The surgical technique followed by the authors on the presence or absence of the above clinico-
for varus TKA is based on the presence of any radiologic features. The varus arthritic knee is
combination of the three clinical and five radio- treated with progressive release of medial soft-
graphic features present in the arthritic knee. tissue structures to achieve full correction of
The basic technique followed is one of gap bal- deformity and to achieve “equipoise” with the
Surgical Technique 51
4. SIGNIFICANT
CORONAL BOWING OF
FEMORAL SHAFT
1. SEVERE DEFORMITY (34°)
5. MEDIAL BONE LOSS
2. LARGE LATERAL
DIVERGENCE ANGLE
3. LATERAL
SUBLUXATION OF
TIBIA
Fig. 3.6 The “at-risk” knee showing five features on preoperative full-length hip-to-ankle radiographs which may
increase the risk of malalignment in this patient
lateral soft-tissue structures. However, this soft-tissue release. Based on whether the defor-
release of medial soft-tissue structures needs to mity is fully correctible, partially correctible,
be controlled and measured to avoid overcorrec- rigid or unstable, further soft-tissue release may
tion or instability. be required in order to correct the deformity.
The first step to achieve these goals is to Most partially correctible deformities get fully
remove all osteophytes around the knee joint corrected with removal of osteophytes and the
which will not only free the tethered soft-tissue preliminary soft-tissue release (deep MCL and
structures but also helps avoid unnecessary soft- semimembranosus) performed for exposure of
tissue release. Following this principal step, the the joint and anterior dislocation of tibia.
surgeon can accurately assess in full extension However, the medial release required may be
how much residual deformity and soft-tissue extensive (posteromedial capsular attachment to
tightness persists and which may require a formal proximal tibia and segmental excision of the
posteromedial capsule) in cases with rigid defor- (osteophyte excision and capsular release) and as
mities or knees with severe medio-lateral soft- a last resort resecting additional distal femoral
tissue imbalance and may also require performing bone. However, when an associated hyperexten-
a reduction osteotomy of the tibia (see Chap. 11 sion deformity is present, conservative tibial and
for technique) with or without undersizing the distal femoral bone resection should be per-
tibial component [20]. In contrast, soft-tissue formed and posterior soft-tissue release avoided.
releases should be restricted and controlled in Rarely, some of these knees may have an associ-
knees which are unstable in coronal and or sagit- ated “reverse” bowing of the femoral shaft
tal planes. (Fig. 3.7) when analysed on preoperative full-
The next step after achieving deformity cor- length hip-to-ankle radiograph. This puts the
rection is to assess how lax the lateral soft-tissue knee at greater risk for overcorrecting the limb
structure vis-à-vis the medial structures. This is axis into valgus alignment. In such cases, the sur-
best done by giving a varus stress with a spacer geon should strictly avoid over-release on the
block placed in the extension gap to determine medial side and reduce the valgus correction
how much the LCL is elongated. Although a angle (VCA) for the distal femoral cut.
varus deformity may appear to be fully cor-
rected with medial soft-tissue release as evi-
denced by correct alignment being achieved Knee Deformity 10–20°
with a spacer block in extension with a valgus
stress being applied, medio-lateral soft-tissue Such varus deformities are commonly associated
balance may still prove to be elusive due to with mild to moderate degree of lateral laxity,
excessive lateral soft-tissue laxity. Similarly, in medial bone loss, sagittal plane deformity or
the presence of an extra-articular deformity, extra-articular deformity. The amount of osteo-
achieving optimum deformity correction and phytes present may vary from mild to moderate.
soft-tissue balance may not be possible despite Again, although most of these deformities can be
extensive medial release. Both these scenarios easily tackled using the standard procedure, an
warrant performing either a sliding medial con- associated extra-articular deformity either in the
dylar osteotomy or a corrective osteotomy of the femur (excessive coronal bowing) or the tibia
extra-articular deformity (see Chap. 11 for tech- (proximal tibia vara) may make deformity cor-
nique) [21, 22]. rection and soft-tissue balancing a challenge. The
presence of such extra-articular deformity will
require more than the usual medial soft-tissue
Knee Deformity <10° release to achieve limb realignment and gap bal-
ance. Rarely, when even extensive soft-tissue
Typically, knees with mild deformities (<10° release fails to achieve the surgical goals (due to
varus or HKA angle >170–180°) have minimal or excessive lateral laxity with or without excessive
no osteophytes, medial bone loss or extra- medial tightness), a sliding medial condylar oste-
articular deformities and no associated sagittal otomy (SMCO) may be required. The need for
plane deformities. Such knees are easily cor- SMCO in such cases can usually be predicted on
rectible with a preliminary medial soft-tissue preoperative radiographs by the presence of an
release and standard bone cuts. However, these extra-articular deformity confounding the lesser
deformities may be sometimes associated with degree of intra-articular knee deformity, often in
mild to moderate lateral laxity or an associated combination with the presence of excessive
sagittal plane deformity. Excessive lateral laxity lateral laxity of the knee joint (lateral divergence
maybe dealt with by proportionately extending angle), lateral translation of the tibia and lack of
the amount of medial soft-tissue release. An osteophyte, excision of which would otherwise
associated fixed flexion deformity may get contribute to deformity correction without the
corrected by a thorough posterior clearance need for excessive medial release.
Fig. 3.7 Reverse bowing

a b
of the femoral shaft in
the coronal plane.
(a) Preoperative standing,
full-length hip-to-ankle
radiograph showing mild
varus deformity of the left
knee. Failure to recognize
reverse bowing has led to
valgus malalignment of the
right knee. Dotted black line
shows mechanical axis of
lower limb. (b) An enlarged
view of the femoral shaft
shows reverse bowing in the
coronal plane. Red line shows
reverse bowing angle of the
femoral shaft
Knee Deformity >20° ment (MCL), posteromedial capsule and

semimembranosus) is performed as per the tech-
Severe varus deformities pose several challenges nique previously described by the authors
during TKA including severe extra-articular (Fig. 3.2). Excision of osteophytes along the pos-
deformity, severe lateral laxity, medial bone loss teromedial tibia and medial femoral condyle is
and associated moderate to severe sagittal plane initially performed. Tibial resection is restricted
deformities. The degree of soft-tissue release is at approximately 6–7 mm of bone with respect to
governed by the amount of soft-tissue tightness the lateral tibial condyle when the deformity is
assessed using a tensioning device. An extensive, associated with excessive lateral laxity or an
graded, stepwise soft-tissue release (subperios- associated hyperextension deformity [23]. In the
teal elevation of the deep medial collateral liga- presence of a medial tibial bone defect, this cut
12
discrepancy is address with additional soft-tissue
VALGUS CORRECTION ANGLE
10 release and reduction osteotomy. Usually the

flexion gap may be larger than the extension gap
8
(due to extensive soft-tissue release), and the
(degrees)
6 femoral component may have to be upsized,

4 flexed 2–5° and translated posteriorly to achieve
balance. If the flexion gap is still larger than the
2
extension gap, additional resection of distal
0
1 51 101 151 201 251 301 351 401 451
femur is needed to accommodate a thicker
NUMBER OF LIMBS spacer.
Despite associated femoral and tibial extra-
Fig. 3.8 Graph showing distribution of the valgus correc- articular deformities and excessive lateral lax-
tion angle (VCA) in our series of 459 varus limbs. The
VCA in 47 % of varus limbs was >7° ity, the above technique of bone resection and
soft-tissue release results in well-aligned and
balanced knees in majority of limbs with severe
usually passes some distance above it and not varus deformity undergoing TKA. However, in
through its base. An additional 1–2 mm is a few cases of rigid deformities, medial tight-
resected if it reduces the size of the bone defect. ness may persist even after extensive medial
By lowering the tibial surface with this additional soft-tissue release, and a sliding medial condy-
resection, a smaller tibial component could be lar osteotomy (SMCO) may be required. This
used, which in turns helps in increasing the involves distalising and fixing the medial femo-
amount of reduction osteotomy which can be ral condylar fragment using cancellous screws
performed for deformity correction and/or after the implant has been cemented (see Chap.
medio-lateral soft-tissue balancing [20]. 11 for technique). Rarely, in cases with persis-
The distal femur is cut at a valgus correction tent and severe lateral side soft-tissue laxity and
angle (VCA) determined on preoperative long severe instability, a constrained implant may
hip-to-ankle radiographs for each individual limb have to be used.
since this may show wide variation among indi- Medial tibial bone defects may be significant
viduals (Fig. 3.8). The thickness of the distal cut is even after the tibial cut has been performed. Bone
determined by the extent of medial femoral con- defects are dealt with based on their size and
dylar bone defect and the severity of the flexion position (Fig. 3.9). Usually, uncontained medial
contracture. The thickness must be reduced if the tibial bone defects less than 10 mm deep are
medial condyle shows significant bone loss or in filled with bone cement, whereas defects ≥10 mm
the presence of an associated hyperextension are filled with autologous bone graft (typically
deformity or severe instability. Additional bone using bone from the notch cut). The bone defect
may have to be resected from the distal femur in should be first gently fashioned into a step-cut
the presence of a significant flexion deformity defect using a saw and then the bone block
which has not improved with removal of posterior shaped to match the defect. The graft is usually
osteophytes and release of posterior capsular punched into position or fixed into place using
adhesions. In the presence of excessive coronal 2-mm K-wires or cancellous screw if the size of
bowing of the femur, a short intramedullary guide the graft is large (Fig. 3.9). These should be
rod should be used to avoid malposition of the dis- directed parallel to the tibial surface to avoid the
tal cutting block with respect to the mechanical peg or stem of the tibial component. A tibial stem
axis of the femur, or computer navigation should extender is usually used in cases with large
be used to accurately align the cutting block and to medial bone defects of >10 mm (Fig. 3.9). Rarely,
bypass the extra-articular deformity in the femur. significant medial femoral bone defects may
The medio-lateral gap balance in knee exten- require the use of metal augments supplemented
sion is assessed with a spacer block, and any with a femoral stem (Fig. 3.10).
a c
d e f g
Fig. 3.9 Medial tibial bone defect in varus arthritic knees large enough to warrant grafting and hence was filled with
undergoing TKA. (a) Preoperative anteroposterior stand- bone cement (arrow) and supported with a long stem tibial
ing knee radiograph showing significant medial tibial bone implant. (f) Preoperative anteroposterior standing knee
defect. (b) Intraoperative photograph of the same patient radiograph showing significant medial tibial bone defect.
(a) showing the medial tibial bone defect. Note that the (g) Postoperative anteroposterior standing knee radiograph
tibial cut passes much above the deepest point of the bone of the same patient (f) where the tibial bone defect was
defect. (c) Postoperative anteroposterior standing knee large enough to require bone grafting and fixation with
radiograph of the same patient (a) where the tibial bone wires (arrow) and supported with a long stem tibial
defect was treated with autograft punched in position with- implant. (h) Preoperative anteroposterior standing knee
out fixation (arrow) and supported with a long stem tibial radiograph showing significant medial tibial bone defect
implant. (d) Preoperative anteroposterior standing knee and subluxation of the knee joint. (i) Postoperative antero-
radiograph showing significant medial tibial bone defect. posterior standing knee radiograph of the same patient (h)
(e) Postoperative anteroposterior standing knee radiograph where a constrained design was used and the tibial bone
of the same patient (d) where the tibial bone defect was not defect was treated with bone grafting and screw fixation
h i
Fig. 3.9 (continued)
a b c d
Fig. 3.10 Lateral femoral condyle bone defect in a varus metal augment along with a femoral stem was used in the
arthritic knees undergoing TKA. (a) Preoperative antero- same patient (a) to treat the bone defect. (c) Postoperative
posterior standing knee radiograph showing substantial anteroposterior standing knee radiograph of the same
lateral femoral and tibial bone defect. Arrow shows sub- patient (a). (d) Postoperative lateral knee radiograph of
stantial lateral femoral bone loss. (b) A distal femoral the same patient (a)
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Valgus Deformity
4
Introduction Pathoanatomy
A valgus arthritic knee, compared to a varus Valgus arthritic deformities commonly present
knee, offers its own challenges during total knee with tightness of lateral soft-tissue structures
arthroplasty (TKA). A valgus knee is less com- which may be associated with varying degrees of
monly encountered in arthritic knees undergo- laxity of the medial structures. Contracture of the
ing TKA and involves a distinctly different set iliotibial (IT) band, popliteus tendon, posterolat-
of pathoanatomic structural changes when com- eral capsule and popliteofibular ligament may be
pared to a varus knee. The incidence of valgus encountered in these knees (Fig. 4.1). We do not
arthritic knees in patients undergoing TKA is less believe that the lateral collateral ligament (LCL)
than 10 % in the senior surgeon’s series [1, 2]. undergoes contracture and shortening. The sur-
Restoration of optimal limb alignment and gap geon should be aware which soft-tissue structures
balance after TKA in valgus knees can be a for- are taut in different positions of knee flexion and
midable challenge because of several reasons. extension so that a calibrated, stepwise approach
First, a surgeon may be less familiar with the sur- is followed during release and imbalance or
gical technique and soft-tissue releases involved instability avoided. Essentially, the LCL and pop-
and there is a paucity of soft-tissue structures liteus tendon are taut in both flexion and exten-
available for release on the lateral side compared sion, the IT band and posterolateral capsule are
to the medial side. Second, there is a higher risk taut only in extension, and the popliteofibular
of common peroneal nerve palsy due to its prox- ligament is taut only in flexion [3].
imity to lateral soft-tissue structures and stretch- In addition, there may be asymmetric wear
ing that may occur in correcting long-standing or hypoplasia of the posterior condyles with
valgus deformity especially if associated with excessive wear of the posterolateral condyle of
flexion deformity. Finally, osseous defects in the femur and/or tibia (Fig. 4.2a, b) [4]. This is
the posterolateral aspect of the femur and tibia; important to note intraoperatively as using the
hypoplastic lateral femoral condyle, an associ- posterior femoral condyles as a reference to place
ated external rotation deformity of the distal the AP cutting block may cause excessive resec-
femur or proximal tibia, and patellar maltracking tion from the posterior femoral condyle laterally,
may also be commonly encountered in valgus thereby resulting in excessive internal rotation
arthritic knees. Hence, a valgus knee is a differ- of the femoral component and patellar maltrack-
ent ball game when compared to varus arthritic ing. Using the AP axis (as described by Arima
knees, and this chapter aims to outline the man- and Whiteside [5]) as an alternative to achieving
agement of the same with TKA. proper femoral component rotation is also fraught

60 4 Valgus Deformity
FEMUR
a b
4 c
LCL
P 2 A
Fig. 4.2 Common pathoanatomic findings in a valgus

arthritic knee. (a) Hypoplasia and distortion of the lateral
femoral condyle (solid arrow) with associated patellar
FIB TIBIA maltracking (dashed arrow) as seen on an anteroposterior
standing knee radiograph. (b) Significant bone loss from
Fig. 4.1 Soft-tissue structures on the lateral and postero- the lateral tibial condyle (arrow) as seen on an anteropos-
lateral aspect of the knee joint which may require release terior standing knee radiograph. Note the large osteophyte
during TKA in a valgus arthritic knee. 1 Iliotibial band, 2 on the lateral margin of the tibial plateau which must be
popliteus tendon, 3 popliteofibular ligament, 4 posterolat- excised before any soft-tissue release. (c) Intraoperative
eral capsule. A anterior, P posterior, LCL lateral collateral finding showing significant erosion and distortion of the
ligament femoral trochlear groove (arrow) due to severe patello-
femoral arthritis and significant patellar maltracking.
with risk especially if the patella is maltracking Using the anteroposterior axis as reference to determine
and leads to more lateral wear of the trochlear femoral rotation in this case is risky
groove (Fig. 4.2c). Hence, the transepicondylar
axis (TEA) is preferred by the authors in severe deformity such as flexion or hyperextension
valgus deformities as a landmark for determining deformity or an extra-articular deformity which
femoral rotation. Patellar maltracking, commonly may further complicate the surgical technique.
seen in severe valgus deformities (Fig. 4.2a), is Most patients with a valgus deformity at the
usually the consequence of an excessive Q angle knee have associated hindfoot valgus (flatfeet)
due to valgus malalignment, excessive external (Fig. 4.3) and even distortion of the midfoot [7, 8].
tibial torsion and excessive tightness of the lat- The authors have reported that despite restoring
eral retinaculum [6]. Valgus knees may also be the hip-knee-ankle (HKA) axis in such patients,
associated with external rotation deformity of the the ground mechanical axis may still pass lateral
proximal tibia due to a tight iliotibial tract [6]. to the centre of the knee joint, and this may need
Lastly, the valgus arthritic knee just like the varus to be factored in while deciding what should be
knee may also be associated with a sagittal plane the final knee alignment during TKA [7].
Pathoanatomy 61
Valgus knees form a spectrum of deformities are typically knees where the valgus deformity
with important differences which impact surgi- present in extension disappears on flexing the knee
cal technique. All valgus knees are not alike! (type 1) (Fig. 4.4). Type 2 knees are those in which
Ranawat et al. [9] had classified valgus arthritic
knees into three major variants based on the
a b
degree of deformity, status of medial collat-
eral ligament (MCL) and the amount of lateral
release required – variant 1 showing minimal val-
gus deformity and medial soft-tissue stretching;
variant 2 showing substantial deformity (>10°),
bone loss and medial stretching; and variant 3
showing severe deformity and osseous deficiency
with an incompetent medial soft-tissue sleeve.
The authors have modified this classification to
include six types of valgus knees based on (1)
severity and correctibility of valgus deformity,
c
(2) associated flexion, hyperextension or extra-
articular deformity and (3) status of the medial
collateral ligament (MCL) (Table. 4.1, Figs. 4.4,
4.5, 4.6, 4.7, 4.8 and 4.9).
The majority of valgus knees are correctible
under anaesthesia with a varus stress. These
d e
Fig. 4.3 Bilateral valgus knees associated with signifi-

cant hindfoot valgus
Table 4.1 Classification of valgus knees Fig. 4.4 Type 1 valgus deformity. (a) Clinical photo-
Type 1: Correctible valgus, no associated deformity, graph showing maximum valgus deformity with a valgus
MCL intact stress applied with patient under anaesthesia. (b) Clinical
Type 2: Rigid valgus, no associated deformity, MCL photograph showing complete correctibility of valgus
intact deformity with a varus stress applied with patient under
anaesthesia. (c) Clinical photograph showing no associ-
Type 3: Valgus with hyperextension deformity, MCL ated flexion or hyperextension deformity with patient
intact under anaesthesia. (d) Preoperative standing anteroposte-
Type 4: Valgus with flexion deformity, MCL intact rior knee radiograph showing the valgus deformity. (e)
Type 5: Severe valgus with incompetent MCL Postoperative standing anteroposterior knee radiograph
Type 6: Valgus with extra-articular deformity showing restoration of knee alignment with a cruciate-
substituting design
a b d e
Fig. 4.5 Type 2 valgus deformity. (a) Clinical photograph (d) Preoperative standing anteroposterior knee radiograph
showing maximum valgus deformity with a valgus stress showing the valgus deformity. (e) Postoperative stand-
applied with patient under anaesthesia. (b) Clinical pho- ing anteroposterior knee radiograph showing restoration
tograph showing partial correctibility of valgus deformity of knee alignment with a cruciate-substituting design.
with a varus stress applied with patient under anaesthesia. A lateral epicondylar osteotomy (LEO) was required in
(c) Clinical photograph showing no associated flexion or this case due to the rigid nature of the deformity
hyperextension deformity with patient under anaesthesia.
the valgus deformity is rigid in both extension and Although the classical medial parapatellar
flexion and are most likely to be associated with a approach is effective in the majority of valgus
hypoplastic lateral femoral condyle (Fig. 4.5). In knees for TKA, a lateral parapatellar approach
type 3 knees, the deformity is usually correctible is indicated in cases where severe valgus defor-
(Fig. 4.6), while in type 4 there may be a trapezoi- mity is associated with patellar maltracking. This
dal flexion gap due to contracture of posterolateral approach provides greater access to lateral soft-
structures (Fig. 4.7). Any long-standing valgus tissue structures in severe valgus since a medial
deformity which is severe may develop attenua- approach and lateral displacement of the quadri-
tion of the MCL (type 5) (Fig. 4.8). ceps complex here will externally rotate the tibia,
pushing the contracted posterolateral corner of
the tibia away from the operative field. Besides,
Surgical Technique a lateral release is a part of this approach which
will help in restoring normal patellar tracking.
The authors follow an algorithmic approach Advocates of this approach have also cited bet-
to deal with a valgus knee during TKA princi- ter preservation of blood supply to the exten-
pally based on their classification (Fig. 4.10). sor mechanism with a lateral arthrotomy as
a c d e
Fig. 4.6 Type 3 valgus deformity. (a) Clinical photo- anteroposterior knee radiograph showing the valgus defor-
graph showing maximum valgus deformity with a valgus mity. (d) Preoperative lateral knee radiograph showing
stress applied with patient under anaesthesia. (b) Clinical hyperextension at the knee joint. (e) Postoperative stand-
photograph showing associated hyperextension deformity ing anteroposterior knee radiograph showing restoration
with patient under anaesthesia. (c) Preoperative standing of knee alignment with a cruciate-substituting design
a c d e
Fig. 4.7 Type 4 valgus deformity. (a) Clinical photo- large posterior femoral osteophyte. (e) Postoperative
graph showing maximum valgus deformity with a valgus standing anteroposterior knee radiograph showing restora-
stress applied with patient under anaesthesia. (b) Clinical tion of knee alignment with a cruciate-substituting design.
photograph showing associated fixed flexion deformity A lateral epicondylar osteotomy (LEO) was required in
with patient under anaesthesia. (c) Preoperative standing this case to achieve correction of valgus and flexion defor-
anteroposterior knee radiograph showing the valgus deformity and achieve medio-lateral soft-tissue balance
mity. (d) Preoperative lateral knee radiograph showing
a b c
Fig. 4.8 Type 5 valgus deformity. (a) Clinical tent medial collateral ligament (MCL). (c) Postoperative
photograph showing severe valgus deformity of the knee. standing anteroposterior knee radiograph showing
(b) Preoperative standing anteroposterior knee radiograph restoration of knee alignment with a constrained design.
showing severe valgus deformity with a large medial joint Note the subperiosteal excision of fibular head to reduce
space opening indicating an extremely lax or incompe- risk of peroneal nerve palsy
compared to a medial arthrotomy combined with and femur should be removed (Fig. 4.2a, b).
extensive lateral retinacular release for patellar Although removal of lateral tibial or femoral
maltracking [10, 11]. However, an inherent risk osteophytes has minimal effect on the LCL, this
of this approach is the difficulty of achieving helps in reducing the tethering of posterolateral
closure because of post-release deficiency of the capsule. In severe valgus deformities, a subperi-
flimsy soft-tissues inferior to the patella later- osteal excision of the fibular head, made easier
ally. This may require achieving closure using through a lateral arthrotomy, helps in signifi-
a fat pad flap harvested from the infrapatellar cantly reducing the tenting of LCL and also
fat pad [10]. Another disadvantage is the diffi- reduces the risk of stretching of the common
culty in accessing the medial aspect of the knee peroneal nerve after the deformity has been fully
which may sometimes necessitate the need for a corrected (Fig. 4.11). After excision of the PCL,
tibial tubercle osteotomy which carries the risk of an initial release of the IT band with the knee in
patellar tendon failure and non-union. full knee extension helps in reducing lateral
The knee should be dislocated after excision tightness. The IT band is typically released from
of the cruciates with minimal or no release on the Gerdy’s tubercle but can also be lengthened
the medial side. Any release here will only add using multiple small incisions at the level of the
to the excessive laxity of medial soft-tissue knee joint with the knee placed in full extension
structures and will make medio-lateral soft-tis- with a varus stress to feel the taut IT band.
sue balancing more difficult subsequently. Prior Lateral tightness in full extension can be further
to any lateral soft-tissue release, all osteophytes reduced by releasing the posterolateral capsule.
from the lateral and posterolateral aspect of tibia The authors perform this as close to the tibia as
a b c
Fig. 4.9 Type 6 valgus deformity. (a) Preoperative stand- nail had to be removed before starting the total knee
ing hip-to-ankle radiograph showing valgus deformity arthroplasty (TKA) procedure in order to accommodate
with an associated extra-articular deformity at the mid- the stem of the tibial tray. (c) Postoperative standing knee
shaft of the right tibia (arrow) due to malunited fracture radiograph showing restoration of the knee alignment
with an intramedullary nail in situ. (b) Postoperative with a cruciate-substituting design. A lateral epicondylar
standing hip-to-ankle radiograph showing complete res- osteotomy (LEO) was performed in this case to achieve
toration of the hip-knee-ankle axis. The intramedullary deformity correction and medio-lateral soft-tissue balance
possible using electrocautery. Another method lesser than for varus knees and is typically set at
is by using multiple stab incisions with the knee 3°. However, in an analysis of 503 limbs under-
placed in full extension. However, this technique going TKA by the authors, the mean VCA in 44
is fraught with risk of damaging the common valgus limbs was found to be 5.9° ± 1.9° (range,
peroneal nerve [12] which maybe between 7 and 3.5–10°) [1]. Although the mean VCA in valgus
9 mm from the posterolateral capsule in full limbs was significantly lesser when compared
extension [13]. to mean VCA in varus limbs, 70 % of valgus
The tibial and distal femoral cuts are typically limbs had a VCA of >5° (Fig. 4.12). Hence,
decided based on the degree and complexity of owing to wide variation, VCA for distal femo-
deformity with the medial side as reference. ral cut needs to be individualised for each case
Minimal amount of bone needs to be resected based on preoperative full-length hip-to-ankle
in both severe valgus deformities and in knees radiographs.
with associated instability or hyperextension. Lateral tightness in flexion is reduced by
The valgus correction angle (VCA) for distal freeing the popliteus tendon from surrounding
femoral resection in valgus knees may be much fibrous tissue and releasing the popliteofibular
VALGUS Knees
(examined under anaesthesia)
RIGID
CORRECTIBLE
(Type 1)
LATERAL approach
MEDIAL approach
No With With Lax/Incompetent

assiciated Fixed flexion Hyperextension MCL
Deformity Deformity Deformity (Type 5)
(Type 2) (Type 3) (Type 4)
Minimum Constrained
Graduated Graduated
distal femur implant
lateral release lateral release
with or without LEO with or without LEO resection
(distal shift) (posterior shift)
Fig. 4.10 Algorithm (based on the type of deformity) used by the authors to treat valgus deformity during TKA. LEO
lateral epicondylar osteotomy
ligament. The popliteofibular ligament is a thin and position of the femoral component may have
structure which runs from the inferior margin of to be altered based on the extension gap previ-
the popliteus ligament to the head of the fibula. ously achieved. The final alignment and balance
This structure is released by running the tip of are then checked using trial components. In full
the electrocautery below the inferior border of extension, a medial or lateral opening of >2 mm
the popliteus tendon along the posterolateral cor- is considered abnormally lax. Similarly, in 90°
ner of the knee joint (Fig. 4.13). If the posterior flexion, a medial opening of >2 mm and a lateral
femur is resected in the presence of excessive lat- opening of >4 mm are considered abnormally lax.
eral tightness, then the femoral component may Patellar tracking is then checked through-
get placed in excessive internal rotation. Hence, out the knee range of motion with the trial
lateral tightness in flexion needs to be addressed components in place. Both abnormal track-
and soft-tissue balance achieved before performing and lateral tilt of the patella are dealt with
ing the posterior cuts. by serial, graduated release of the lateral reti-
The AP cutting guide is placed perpendicu- naculum till the tracking is normal and there
lar to the transepicondylar axis (TEA). The size is no tilt. Very rarely, persistent maltracking of
Fig. 4.11 Subperiosteal

excision of the fibular head. a c
(a) Preoperative standing
knee radiograph showing
severe valgus deformity.
The fibular head adds to the
tenting of the lateral collateral
ligament (LCL).
(b) Intraoperative photograph
showing the exposed fibular
head (arrow) which needs to
be excised. A lateral approach
was used in this case.
(c) Postoperative standing
anteroposterior knee
radiograph showing
restoration of knee alignment
with a cruciate-substituting
design. A lateral epicondylar
osteotomy (LEO) along with
subperiosteal excision of the
fibular head (arrow) was
required in order to restore
alignment and balance in this
rigid valgus deformity
b
the patella despite extensive lateral retinacular excessive tightness laterally, severe bone loss
release may require plication and double breast- on the lateral side and an associated extra-artic-
ing of the medial retinaculum during closure of ular or sagittal plane deformity. Excessive val-
the arthrotomy. gus deformity may warrant the use of a lateral
approach to facilitate easy access and release
of lateral soft-tissue structures (Fig. 4.14).
Severe Valgus Deformities Excessive femoral bowing in the coronal plane
(Type 5 and 6) commonly seen in severe varus deformities may
also be present in severe valgus arthritic knees.
Profound valgus deformities of ≥15° pres- However, in valgus knees the bowing may be in
ent with their own challenges during TKA. the reverse direction (i.e. excessive curvature of
Similar to profound varus knees, these can be the femoral shaft medially) which may result in
associated with excessive laxity medially or a low valgus correction angle (VCA) [1]. This
Fig. 4.12 Graph showing 12

distribution of the valgus
correction angle (VCA) in our
10
series of 44 valgus limbs. The
VCA in 70 % of valgus limbs
was >5° 8
0
0 10 20 30 40 50
Fig. 4.13 Intraoperative photograph showing technique

of releasing the popliteofibular ligament using cautery just
below the popliteus tendon (P) close to the tibial cut
surface
needs to be determined on preoperative full-

length radiographs and the calculated VCA used Fig. 4.14 Lateral approach to the knee used in rigid
severe valgus deformities
intraoperatively to execute the distal femoral
cut. Similar to varus knees, in knees with severe
valgus deformity, the amount of resection of the be ideally done under the guidance of computer
proximal tibia and distal femur needs to be kept navigation as this allows for accurate measure-
at a minimum especially when associated with ment of difference between the medial and
severe ligament laxity or an associated recurva- lateral gaps and the amount of residual limb
tum deformity. deformity and helps execute precise, controlled
Very rarely, when substantial soft-tissue and quantitative lengthening of the lateral soft-
release laterally fails to correct deformity or tissue structures (lateral collateral ligament and
achieve medial-lateral soft-tissue balance, a popliteus tendon) (Fig. 4.16). Another alterna-
sliding lateral epicondylar osteotomy (LEO) tive for dealing with excessive laxity medially
may be indicated (Fig. 4.15) [14]. This should in a valgus knee is to shorten the medial soft-
b c
Fig. 4.15 Lateral epicondylar osteotomy (LEO). the lateral epicondylar block (arrow) held with a towel
(a) Intraoperative photograph of the lateral epicondylar clip after the femoral component has been cemented.
block (arrow) with its soft-tissue attachment separated (c) Intraoperative photograph of the lateral epicondylar
from the lateral femoral condyle after all the femoral cuts block fixed in position using cancellous screw
have been performed. (b) Intraoperative photograph of
tissue structure. This can be performed using incompetent and is a cause of significant insta-
several methods. These include MCL advance- bility, a constrained prosthesis (with a taller post
ment from the tibial side or midsubstance divi- and deeper box) may be needed. However, every
sion and imbrication of MCL [6]. Both these attempt must be made to balance the soft tissues
procedures have the disadvantage of affecting so as not to excessively load the post leading to
ligament strength and isometricity. Healy et al. post wear and fracture.
[15] described a technique of detaching the Severe valgus knees with associated flexion
femoral origin of the MCL with an epicondylar deformity carry a high risk of postoperative
bone block. This medial epicondylar osteotomy common peroneal nerve palsy. Although this
(MEO) has the advantage of not causing direct may be transient due to stretching of the nerve on
damage to the MCL. The authors perform a full correction of the valgus and flexion deformi-
sliding medial condylar osteotomy (SMCO) in a ties, this may cause considerable disability and
valgus knee whenever necessary using the tech- distress in the patient causing delay in postopera-
nique described in the Chap. 3. Similar to the tive recovery. In knees with profound valgus
LEO, the authors prefer using computer naviga- deformity with associated significant fixed flex-
tion for performing SMCO in all their cases (for ion deformity (≥20°), the authors undercorrect
complete description of both these osteotomies, the flexion deformity to approximately less than
see Chap. 11). However, these procedures are 10°, keep the knee in flexion over a pillow for the
rarely indicated and most severe and rigid val- first 48 h postoperatively to avoid undue stretch-
gus knees can be dealt with using a graduated ing of the nerve and gradually correct it postop-
lateral release with or without a LEO. Under eratively using physiotherapy and occasionally a
certain rare circumstances when the MCL is too push-knee splint.
a b c d e
Fig. 4.16 Severe, rigid valgus deformity treated with (d) Postoperative standing hip-to-ankle radiograph of
computer-assisted TKA combined with lateral epicon- the same patient (a) showing complete restoration of the
dylar osteotomy (LEO). (a) Preoperative clinical pho- right knee alignment after computer-assisted TKA com-
tograph of a patient showing severe valgus deformity of bined with LEO. (e) Postoperative standing anteroposte-
the right knee. (b) Preoperative standing hip-to-ankle rior knee radiograph of the same patient (a) at 4 years
radiograph of the same patient (a) showing severe val- follow-up showing complete restoration of the right knee
gus deformity of the right knee. (c) Postoperative clini- alignment. (f) Postoperative lateral knee radiograph of the
cal photograph of the same patient (a) at suture removal same patient (a) at 4 years follow-up showing cancellous
showing complete restoration of the right knee alignment. screws used for LEO
Computer-Assisted Technique lengthening of the tight lateral soft-tissue

structures and proper restoration of limb
The basic technique of computer-assisted alignment and soft-tissue balance [14].
TKA in valgus knees is similar to the one
previously described for varus knees. Apart
from assisting in performing precise bone
cuts and graduated soft-tissue release and
References
verification of limb alignment, bone cuts 1. Mullaji AB, Shetty GM, Kanna R, Vadapalli RC. The
and soft-tissue tension, the optimised gap- influence of preoperative deformity on valgus correc-
balancing feature of the computer software tion angle: an analysis of 503 total knee arthroplasties.
helps in equalising the flexion gap to the J Arthroplasty. 2013;28:20–7.
2. Mullaji AB, Shetty GM, Lingaraju AP, Bhayde S.
extension gap by adjusting the level of dis- Which factors increase risk of malalignment of the
tal femoral resection and the femoral com- hip-knee-ankle axis in TKA? Clin Orthop Relat Res.
ponent size and position. In limbs where 2013;471:134–41.
an additional lateral epicondylar osteot- 3. Whiteside LA. Selective ligament release in total knee
arthroplasty of the knee in valgus. Clin Orthop Relat
omy (LEO) may be required, navigation Res. 1999;367:130–40.
allows for precise, controlled, quantitative 4. Matsuda S, Miura H, Nagamine R, Mawatari T,
Tokunaga M, Nabeyama R, Iwamoto Y. Anatomical
References 71
analysis of the femoral condyle in normal and two-year follow-up evaluation. Clin Orthop Relat
osteoarthritic knees. J Orthop Res. 2004;22:104–9. Res. 1991;271:52–62.
5. Whiteside LA, Arima J. The anteroposterior 11. Sekiya H, Takatoku K, Takada H, Sugimoto N,
axis for femoral rotational alignment in valgus Hoshino Y. Lateral approach is advantageous in total
total knee arthroplasty. Clin Orthop Relat Res. knee arthroplasty for valgus deformed knee. Eur J
1995;321:168–72. Orthop Surg Traumatol. 2014;24:111–5.
6. Favorito PJ, Mihalko WM, Krackow KA. Total knee 12. Bruzzone M, Ranawat A, Castoldi F, Dettoni F,
arthroplasty in the valgus knee. J Am Acad Orthop Rossi P, Rossi R. The risk of direct peroneal nerve
Surg. 2002;10:16–24. injury using the Ranawat “inside-out” lateral
7. Mullaji A, Shetty GM. Persistent hindfoot val- release technique in valgus total knee arthroplasty.
gus causes lateral deviation of weightbearing axis J Arthroplasty. 2010;25:161–5.
after total knee arthroplasty. Clin Orthop Relat Res. 13. Jia Y, Gou W, Geng L, Wang Y, Chen J. Anatomic
2011;469:1154–60. proximity of the peroneal nerve to the posterolateral
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hindfoot alignment before and after total knee 2012;19:766–8.
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2004;19:211–6. osteotomy using computer navigation in total
9. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, knee arthroplasty for rigid valgus deformities.
Rossi R, Babhulkar S. Total knee arthroplasty for J Arthroplasty. 2010;25:166–9.
severe valgus deformity. J Bone Joint Surg Am. 15. Healy WL, Iorio R, Lemos DW. Medial recon-
2005;87 Suppl 1:271–84. struction during total knee arthroplasty for severe
10. Keblish PA. The lateral approach to the valgus knee. valgus deformity. Clin Orthop Relat Res. 1998;356:
Surgical technique and analysis of 53 cases with over 161–9.
Part III
Sagittal Plane Deformities
Flexion Deformity
5
Knees with degenerative or rheumatoid arthritis Flexion deformities in arthritic knees may result
may have associated intra-articular inflamma- from intercondylar notch osteophytes which act
tion and effusion because of which they may as a mechanical block preventing full extension
assume a position of flexion in response to the [7], whereas posterior osteophytes cause tenting
pain and increased intra-articular pressure. of the posterior capsule which can enhance this
Posterior femoral and tibial osteophytes along deformity (Fig. 5.1). In long-standing cases,
with those in the intercondylar notch in OA may these osteophytes are associated with secondary
enhance the deformity by tenting the posterior contracture and shortening of soft-tissue struc-
capsule or blocking full extension. This, in the tures such as the posterior capsule, posterior
long run, becomes a fixed flexion deformity, oblique ligament, semimembranosus (in varus
adding to the disability of the patient. Knee knee) and popliteofibular ligament (in valgus
arthritis with a fixed flexion deformity interferes knee) which add to the deformity. In severe cases,
with ambulation causing increased energy the hamstrings and gastrocnemius may also be
expenditure, decreased stride length and veloc- affected. Rarely in patients with inflammatory
ity, decreased endurance and inability to stand arthritis, neuromuscular disorders, haemophilia
for long periods [1–5]. Flexion deformities are or long-standing immobility, flexion deformity is
commonly encountered in knees with varus or primarily the result of isolated soft-tissue con-
valgus deformities. Isolated flexion deformities tractures, and minimal osteophytes may be pres-
in knee arthritis are rare, although in some knees ent (Fig. 5.2).
fixed flexion deformity may be the predominant Consequences of long-standing flexion defor-
deformity when compared to coronal plane mities in arthritic knees include bone loss on the
deformities. It is estimated that flexion contrac- posterior aspect of the tibial plateau and reduction
tures may occur in up to 60 % of knees undergo- of quadriceps strength leading to persistent exten-
ing TKA [4]. Griffin et al. [6] reported the sor lag postoperatively. The latter is typically
incidence of flexion contractures as 62 % in masked preoperatively due to the flexion defor-
varus knees, 31 % in valgus knees and 26 % in mity and becomes obvious once the flexion defor-
neutral knees. This chapter aims to discuss the mity has been fully corrected with TKA. It is
management of fixed flexion deformities in necessary to keep this in mind and inform the
TKA. patient regarding the possible need for extensive

76 5 Flexion Deformity
Fig. 5.1 Osteophytes in knees with flexion deformity Lateral radiograph of the knee showing a large posterior
undergoing TKA. (a) Lateral radiograph of the knee femoral osteophyte (arrow) which should be completely
showing anterior tibial or “anvil” osteophyte (white removed to not only achieve correction of flexion defor-
arrow) and posterior tibial and femoral osteophytes mity but also prevent postoperative restriction of termi-
(black arrows). Osteophytes at all these three locations nal flexion. (c) Lateral radiograph of the knee showing
can contribute to flexion deformity, anterior tibial osteo- large osteophytes all around the knee joint including
phyte by mechanically blocking knee extension and pos- large, multiple osteophytes in the patellofemoral joint
terior osteophytes by tenting soft-tissue structures. (b) (arrow)
a b
Fig. 5.2 Fixed flexion deformity of the knee due to con- the same patient showing absence of osteophytes around
tracture of soft-tissue structures. (a) Intraoperative clini- the knee joint. The flexion deformity in this patient with
cal photograph of a patient showing fixed flexion rheumatoid arthritis was purely due contracture of soft-
deformity of almost 30°. (b) Lateral knee radiograph of tissue structures
Table 5.1 Classification of flexion contractures sometimes when the posterior osteophytes are
Grade 1: <10° too large, these can be better accessed and
Grade 2: 10°–30° removed only after the tibial cut has been per-
Grade 3: >30° formed or by performing a preliminary freehand
resection of the posterior femoral condyle.
Removal of the posterior osteophytes prior to
postoperative physiotherapy not only to maintain performing the distal femoral resection is impor-
correction of the flexion deformity but also to tant; it reduces the need for excess distal femoral
strengthen the quadriceps. Lombardi et al. [8] resection and obviates or minimises the need for
have divided flexion deformities encountered in soft-tissue release thereby reducing the likeli-
patients undergoing TKA into three grades based hood of mid-flexion instability.
on the severity of deformity (Table 5.1). The pri- The tibial cut needs to be adequate since the
mary step in correcting flexion deformity is to extension gap in arthritic knees with associated
remove all osteophytes whenever present in order flexion deformity tends to be smaller when com-
to remove their tenting effect on soft tissues. This pared to the flexion gap. This discrepancy will get
usually takes care of most mild to moderate defor- more pronounced after a medio-lateral soft-tissue
mities. However, severe deformities may require release is performed to address an associated
an additional soft-tissue release posteriorly. varus/valgus deformity or if an additional poste-
The flexion gap is much larger than the exten- rior release is performed for the flexion deformity.
sion gap in an arthritic knee with flexion defor- The authors typically remove 8–10 mm of the
mity. This mismatch is further increased when proximal tibia with reference to the unaffected
there is an associated severe coronal plane side (Fig. 5.3). Before assessing medio-lateral gap
deformity requiring extensive medial or lateral balance in full extension, the surgeon needs to
soft-tissue release. This mismatch can be make sure that all posterior osteophytes and loose
addressed to a certain extent with a posterior soft- bodies have been removed so that the extension
tissue release. However, if the extension gap con- gap can be accurately judged. Any retained poste-
tinues to be small, 2 mm of additional bone may rior osteophytes will result in an underestimation
need to be resected from the distal femur. Another of the extension gap (Fig. 5.4). Rarely, if the flex-
method is to upsize the femoral component so as ion deformity persists despite complete posterior
to close the flexion gap relative to the extension clearance, a posterior soft-tissue (posterior cap-
gap. sule, medial and lateral head of gastrocnemius)
release is required. The authors perform this using
a broad gouge which is applied flush to the femo-
Surgical Technique ral condyles and the soft tissues are gently stripped
from their femoral attachment (Fig. 5.5). In severe
The first step, after exposure, to deal with flexion cases, the capsule is divided with cautery midway
deformity is to remove all osteophytes. The between the femoral and tibial attachments on
medial and posteromedial tibial and medial fem- either side of the midline (so as not to damage the
oral osteophytes need to be excised first followed neurovascular bundle) with the knee held dis-
by posterior femoral osteophytes. These poste- tracted with laminar spreaders in extension. The
rior osteophytes can be approached and removed amount of distal femoral cut is decided based on
using a curved osteotome after subluxating the the severity of associated coronal plane deformity
tibia forwards and placing the osteotome between and soft-tissue laxity. If there is an associated
the posteromedial corner of the tibia and the severe varus or valgus deformity, less bone may
medial femoral condyle. The osteotome can also need to be resected from the distal femur. Leaving
be inserted through the intercondylar notch at an the pins that hold the distal cutting block behind
oblique or transverse angle around the lateral till after the extension gap has been assessed
edge of the medial femoral condyle. However, allows one to revisit the cut if inadequate.
Varus/Valgus Resect High Resect Low Slope
Planned 0.0° Var 8.5 mm 2.0 mm 3.0° Post
Verified 0.5° Var 8.5 mm 2.0 mm 3.5° Post
Deviation 0.5° Var 0.0 mm 0.0 mm 0.5° Post
Varus/Valgus Resection Flexion/Extension
Planned 0.0° Var 10.0 mm 1.5° Flex
Verified 0.5° Var 9.5 mm 1.5° Flex
Deviation 0.5° Valg -0.5 mm 0.0° Flex
Fig. 5.3 Intraoperative computer screen snapshots of flexion deformity tends to be smaller when compared to
TKA performed in a patient with flexion deformity. The the flexion gap. (a) Thickness of proximal tibial resection
proximal tibial and distal femoral cuts need to be adequate is 8.5 mm. (b) Thickness of distal femoral resection is
since the extension gap in arthritic knees with associated 9.5 mm
Subsequent assessment of the flexion gap help in closing the large flexion gap and equalis-
usually shows that the extension gap previously ing it to the extension gap (Fig. 5.6c). Rarely,
achieved is much smaller than the flexion gap slight flexion deformity may persist despite all
(Fig. 5.6a, b). This mismatch is addressed by the above measures when the limb is assessed
adjusting the size and position of the femoral using trial components. We address this by
component. Upsizing, posteriorly shifting and resecting 2–3 mm from the distal femur.
slightly flexing the femoral component usually However, this should be performed cautiously as
Fig. 5.4 Effect of posterior a

osteophytes on the extension
gap during TKA. (a) Posterior
tibial and femoral osteophytes
cause tenting of posterior
soft-tissue structures adding to
the flexion deformity. (b)
Incomplete removal of these
posterior osteophytes can cause
underestimation of the
extension gap and may lead to b
error in flexion-extension gap
balancing. (c) Complete
posterior clearance (of
osteophytes and loose bodies)
is necessary with or without
additional posterior soft-tissue
release to ensure accurate
assessment of the extension gap
Although seen very rarely, long-standing flex-

ion deformities may be sometimes associated
with severe contracture and shortening of the
hamstring tendons. These shortened tendons can
be felt on the posteromedial aspect of the knee
joint as chords which typically get taut when the
knee is extended. We usually address this after
the trial implants are in place by doing a frac-
tional lengthening of the contracted tendons
using a separate incision on the posterior aspect
of the knee directly over the taut, palpable ten-
don. Postoperative management is based on the
Fig. 5.5 Posterior soft-tissue release. Whenever required,
this can be performed using a broad gouge (padded by a
degree of correction achieved and the amount of
sponge) applied flush to the femoral condyles to gently residual flexion contracture at the end of the pro-
strip soft tissue from their femoral attachment. Note that cedure. A postoperative residual flexion contrac-
this is best performed after the tibial cut to allow easy ture of <5° can be managed with routine
access posteriorly
physiotherapy (Fig. 5.7). However, any cor-
rectible residual contracture between 5° and 10°
excessive resection from the distal femur may at the end of the procedure, especially in patients
cause elevation of the joint line and mid-flexion where the flexion deformity was long-standing or
instability. exceeding 15–20°, will require application of an
a b c
Fig. 5.6 Flexion-extension gap balancing during TKA in knees with flexion deformity. This difference is further
a patient with flexion deformity. (a) The extension gap increased when there is an associated severe coronal
tends to be smaller in knees with flexion deformity due to plane deformity requiring extensive medial or lateral
tautness of the posterior soft-tissue structures. Posterior soft-tissue release. (c) Upsizing, posteriorly shifting and
release and additional resection of 2 mm from distal slightly flexing the femoral component usually help in
femur helps to increase this gap. (b) The flexion gap closing the large flexion gap and equalising it to the
tends to be much larger compared to the extension gap in extension gap
above-knee plaster splint for 48 h postoperatively Another common feature in patients with long-
in order to maintain the knee in maximum correc- standing flexion contracture is an associated sig-
tion. These patients may subsequently require a nificant quadriceps weakness. This is usually not
push-knee splint or a long knee brace while walk- obvious preoperatively and gets unmasked post-
ing in order to maintain correction of the flexion operatively after the flexion contracture has been
contracture. However, irrespective of the amount corrected. This may require prolonged physio-
of residual flexion contracture at the end of the therapy in order to strengthen the quadriceps.
procedure, these patients need careful surveil- Most patients with >20° of FFD preoperatively
lance during the postoperative rehabilitation are given a push-knee splint for 30 min three
period for signs of recurrence of flexion contrac- times a day and while walking in the initial
ture which needs to be addressed aggressively 2–4 weeks along with electrical stimulation of
using appropriate splints and physiotherapy. the quadriceps to strengthen them.
Fig. 5.7 Severe flexion a b

deformity. (a) Preoperative
clinical photograph of a
patient showing severe
bilateral flexion deformity.
(b) Postoperative clinical
photograph of the same patient
(a) at suture removal showing
complete correction bilateral
flexion deformities with TKA
and routine postoperative
physiotherapy
Computer-Assisted Technique ral component size and position (Fig. 5.8).

The basic surgical technique for computer- Commonly, upsizing, posteriorly shifting (by
assisted TKA in knees with flexion contrac- 2–3 mm) and slightly flexing (usually 3–5°)
tures is similar to the one previously described the femoral component may be required to
for conventional TKA. As previously close the larger flexion gap and equalise it to
described, adequate bone needs to be resected the extension gap.
from both the proximal tibia and distal femur. Navigation, as always, allows for measured
Complete posterior clearance of osteophytes and controlled soft-tissue release and bone
and loose bodies is necessary before assessing cuts as per the amount of deformity and soft-
and recording the extension gap. The flexion tissue imbalance present in each knee.
gap is expected to be greater than the exten- Navigation also helps the surgeon quantify the
sion gap, especially in knees with severe flex- final extension alignment of the limb in the
ion deformity. The optimised gap-balancing sagittal plane and ensure that the limb is not
feature of the computer software can be used left in residual flexion deformity at the end of
to simulate equalisation of flexion gap to the the procedure which may persist and then
extension gap by simultaneously adjusting the limit patient function and satisfaction
level of distal femoral resection and the femo- postoperatively.
Fig. 5.8 Intraoperative computer screen snapshot show- adjusting the level of distal femoral resection and the
ing the optimised gap-balancing feature of the navigation femoral component size and position. Note the large dis-
software. This can be used to simulate equalisation of crepancy between the flexion and the extension gap typi-
flexion gap to the extension gap by simultaneously cally seen in arthritis knees with flexion deformity
References 83
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J Bone Joint Surg Br. 2012;94(11 Suppl A):112–5.
5. Krych AJ, Pagnano MW. Flexion contractures: get-
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ting it straight. Semin Arthroplasty. 2009;20:38–9.
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6. Griffin FM, Insall JN, Scuderi GR. Accuracy of soft
Am. 1975;57:961–7.
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2. Harato K, Nagura T, Matsumoto H, Otani T, Toyama
Y, Suda Y. Knee flexion contracture will lead to
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8. Lombardi AJ, Mallory T, Adams J. A stepwise algo-
Y, Suda Y. A gait analysis of simulated knee flexion
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Hyperextension Deformity
6
Introduction and using a constrained prosthesis [1–3, 7].

However, the technique of under-resection of tibia
Hyperextension deformity is uncommon in and femur, over-resection of the posterior surfaces
arthritic knees undergoing total knee arthroplasty of the femur, using a smaller femoral size with
(TKA), occurring in less than 5 % of patients bone resection being done first and ligaments
[1–3]. In a recent study by the authors [3], the being balanced later will usually result in a stable,
overall incidence of hyperextension in arthritic well-balanced knee [2, 3]. This chapter aims to
knees undergoing TKA was 3.9 % (45/1,150 outline the means of tackling hyperextension
limbs). Hyperextension can be encountered in deformity during TKA.
patients with valgus deformities and excessive
ligamentous laxity, in patients with rheumatoid
arthritis (RA), in patients post high tibial osteot- Pathoanatomy
omy (HTO) and in patients with neuromuscular
disorders such as poliomyelitis [4–6]. The results Arthritic knees with hyperextension have certain
of our study indicated that the majority of patients characteristic pathoanatomic features which
with hyperextending, arthritic knees suffered need to be considered while performing a TKA.
from primary osteoarthritis (78 %) and 58 % of These are typically soft-tissue and bony abnor-
the limbs had an associated preoperative varus malities. Among the soft tissues, the posterior
deformity compared to 42 % which had a valgus capsule is usually overstretched, causing hyper-
deformity [3]. extension at the knee joint. This is associated
Treating a hyperextending, arthritic knee with with attenuation of the cruciate and collateral
TKA could be challenging due to associated coro- ligaments. These structural changes convert the
nal plane deformities (varus or valgus), bony posterior soft-tissue structures of the knee joint
abnormalities such as reverse sloping of the tibial into a “hammock” (Fig. 6.1a) which needs to be
plateau and significant medio-lateral instability made taut in order to correct this sagittal plane
which may lead to difficulty in achieving a stable, deformity and restore soft-tissue balance. In
well-balanced knee and the possibility of recur- knees with associated valgus deformities, the
rence postoperatively [1–3]. Surgical techniques iliotibial band may be contracted and anteriorly
to deal with hyperextension during TKA includes displaced which may accentuate the hyperexten-
posterior capsular plication, proximal and poste- sion deformity.
rior transfer of the collateral ligaments, tightening Owing to this attenuation of posterior soft-
the extension gap using thicker inserts, under- tissue structures, the resultant extension gap is
resecting the bone, undersizing the femoral com- much larger compared to the flexion gap in
ponent, using distal femoral augmentation blocks hyperextension deformities (Fig. 6.1b). Hence,

86 6 Hyperextension Deformity
a standard resections of proximal tibia and distal

femur will further widen this extension gap,
resulting in severe extension-flexion gap mis-
match and an excessively large extension gap
requiring a very thick insert. Hence, one of the
basic principles of treating hyperextension defor-
mity during TKA is to resect minimal bone from
b
both proximal tibia and distal femur and strictly
avoid release of posterior soft-tissue structures.
Apart from these soft-tissue changes, hyperex-
tension may be accentuated by bony abnormali-
ties such as decreased posterior slope or anterior
sloping of the tibia or significant wear or bone
loss on the anterolateral or medial aspect of the
Fig. 6.1 Effect of posterior soft-tissue laxity and attenua- tibial plateau (Fig. 6.2a). In patients who have
tion (posterior capsule particularly) in hyperextension defor-
mity. (a) Overstretching and attenuation of the posterior undergone a previous high tibial osteotomy,
capsule of the knee joint converts the posterior soft-tissue impaction of the anterior tibial cortex may also
structures into a “hammock” in hyperextension deformities. result in an anterior slope (Fig. 6.2b). In either
(b) Owing to this attenuation of posterior soft-tissue struc- scenario, the surgeon needs to be careful to not
tures, the resultant extension gap is much larger (compared
to the flexion gap) in hyperextension deformity. Note that aggravate the bony abnormality by resecting the
the tibial and the distal femoral bone cuts if too thick will proximal tibia with a neutral slope or, worse, an
significantly add to the already large extension gap anterior slope.
a b
Fig. 6.2 Tibial slope in hyperextension deformity. (a) ing significant anterior sloping of the tibia (arrow). This
Lateral radiograph of the knee in a patient with patient was a case of post high tibial osteotomy TKA
hyperextension deformity shows an almost neutral tibial where significant anterior sloping of the tibia caused
slope (dotted line). (b) Intraoperative photograph show- hyperextension at the knee joint
Rarely, hyperextension may be the consequence based on the standard landmarks. A stylus or
of a neuromuscular disorder such as poliomyelitis “angel wing” is used to ensure that no anterior
with associated bony deformities and muscular notching occurs. If the flexion gap is found to
degeneration. These patients need to be thor- equal the extension gap, the femoral size corre-
oughly evaluated to assess the degree of neuro- sponding to the size of the AP block is confirmed.
muscular deficit as they are at a higher risk for Slight alterations in position of the block can be
poor surgical outcome after TKA due to postop- made if 1–2 mm disparity exists in the gaps (pro-
erative recurrence of hyperextension and instabil- vided that notching will not occur). Large dispari-
ity with a standard posterior cruciate-substituting ties will need upsizing or, more likely, downsizing
prosthesis or even one that is more constrained. of the AP block. Once gaps are balanced, the AP
Such cases may require a linked (hinged) device. cuts are completed; limb alignment and flexion-
We believe however that most of our cases are due extension gap balancing are rechecked with the
to weak quadriceps where patients extend their knee in full extension and 90° flexion using trial
knee to lock it by an altered posture and gait components. By following these basic principles,
pattern. the vast majority of hyperextending knees can be
managed with a regular cruciate-substituting
implant without the need for a constrained pros-
Surgical Technique thesis. From the analysis of our data of 45 TKAs
done for hyperextending knees, most of the knees
The amount of bony resection is governed by the (92 %) were managed using inserts of thickness
severity of the deformity: The greater the recurva- 12.5 mm or less and the remaining 8 % required
tum, the less should be the resection. As per inserts of thickness 15 mm [3]. None of the knees
results of the retrospective study conducted by the required inserts of thickness greater than 15 mm
authors on 45 computer-assisted TKAs done on or constrained prostheses. The aim was to achieve
arthritic knees with recurvatum deformity, the a slight amount of flexion (2°–5°) at the end of the
mean amount of proximal tibial and distal femoral procedure [3].
bone resection was approximately 6.5 mm with The amount of proximal tibial and distal femo-
respect to the good side [3]. Hence, the authors ral resection, the extent of soft-tissue release,
are careful not to resect more than 6–7 mm from femoral sizing and the need for additional proce-
the tibia and femur at the start of the procedure dures (such as epicondylar osteotomy) were based
(Fig. 6.3). By retaining the pins that hold the cut- on the degree of recurvatum deformity and the
ting block in position, further resection is possible type of associated varus and valgus deformity.
if needed to accommodate the thinnest spacer. Postoperatively, the patient was allowed full
Using the gap-balancing technique, the degree of weight-bearing walking and active knee flexion
soft-tissue release is decided by the amount of on the first postoperative day after drain removal.
soft-tissue tightness assessed using a tensioning Patients were encouraged to keep a pillow below
device. Generally these knees are quite lax and the knee for 2 weeks depending on the degree of
guarded releases have to be performed. Medial recurvatum to allow tightening of the posterior
release for varus knees and lateral release for val- soft-tissue structures. In cases with severe preop-
gus knees is performed to restore the mechanical erative recurvatum where the recurvatum at the
axis to 180°. Care is taken to perform no capsular end of surgery was closer to 0°, a long-leg knee
release posteriorly. After the distal femoral and brace was used while walking for 2 weeks. No
proximal tibial resections, a spacer block is used immobilisation was used routinely.
to confirm medio-lateral soft-tissue stability in Hence, adhering to basic surgical principles of
full extension as well as the coronal alignment. A resecting less bone from the proximal tibia and
non-slotted AP cutting block is then positioned on distal femur and strictly refraining from perform-
the distal femur and the flexion gap is assessed ing a posterior release avoid the possibility of
with the same thickness spacer block that gave a postoperative recurrence and ensure a successful
satisfactory extension gap. Rotation is assessed outcome in these patients (Fig. 6.4).
Fig. 6.3 Intraoperative

computer screen snapshots of
TKA performed in a patient
with hyperextension deformity.
(a) Patient has a combination of
valgus (1.5°) and severe
hyperextension deformity (15°).
(b) Thickness of proximal tibial
resection is limited to only
4 mm. (c) Thickness of distal
femoral resection is limited to
only 5 mm. (d) The knee has a
final alignment of 1° varus and
6.5° flexion after components
are cemented in place. (e)
Intraoperative kinematics shows
well-balanced medio-lateral
gaps throughout the knee range
of motion
c
e
a b
c d
Fig. 6.4 Outcome of TKA in a patient with hyperexten- on passive extension of the knee by the examiner. (d)
sion deformity. (a) Preoperative clinical photograph show- Standing anteroposterior and lateral knee radiograph of the
ing severe hyperextension deformity (approximately 20°). same patient at 7 years post TKA showing excellent align-
(b) Clinical photograph of the same patient at 7 years post ment and fixation of the components. Note that the patient
TKA showing no recurrence of hyperextension on straight was successfully treated with a simple, cruciate-substitut-
leg raising. (c) Clinical photograph of the same patient at ing design with a tibial insert thickness of 12.5 mm despite
7 years post TKA showing no recurrence of hyperextension the severe preoperative hyperextension deformity
Computer-Assisted Technique flexion and extension gap balance. The femo-

Conventional TKA lacks quantitative stan- ral component planning feature of the software
dardisation of bone resection, soft-tissue is particularly valuable in determining femoral
release and gap measurements which may component size and position to equalise gaps.
result in some unpredictability in outcome. In addition, CAS enables the surgeon to iden-
Like in any type or degree of knee deformity tify even few degrees of hyperextension early
during TKA, computer-assisted navigation in the procedure (Fig. 6.3). This should imme-
system accurately quantifies the amount of diately alert the surgeon to be cautious with
bone resection and soft-tissue release during resection and releases and perform both in an
TKA which helps to achieve optimum restora- incremental fashion. Revisiting a cut is prefer-
tion of limb and component alignment and able to resecting more bone at the beginning.
References 91
CAS also enables the surgeon to “fine-tune” in obese patients. Using an algorithmic
the final extension alignment of the knee to approach along with computer navigation help
ensure a few degrees (2°–5°) of flexion at the in successfully correcting recurvatum without
end of the procedure (Fig. 6.3). This may be resorting to constrained implants and exces-
difficult to discern by “eye balling” especially sively thick inserts (Fig. 6.5).
Fig. 6.5 Algorithm Hyperextension Deformity

used by the authors to
(examined under anaesthesia)
treat hyperextension
deformity during TKA
Associated Associated UNSTABLE

RIGID CORRECTIBLE knee
varus/valgus varus/valgus
deformity deformity
Preliminary No No
medial/lateral release release
soft-tissue
release
6-8 mm tibial 4-6 mm tibial

6-8 mm tibial and femoral and femoral
and femoral bone resection bone resection
bone resection
Undersize
Graduated femur
medial/lateral release
with or without
epicondylar osteotomy
(distal shift) constrained
implant
Kelly MA, Aglietti P, editors. Surgery of the knee.

References New York: Churchill Livingstone; 1993. p. 891–934.
5. Insall JN. Surgical techniques and instrumentation in
1. Meding JB, Keating EM, Ritter MA, Faris PM, total knee arthroplasty. In: Insall JN, Windsor RE,
Berend ME. Genu recurvatum in total knee replace- Scott WN, Kelly MA, Aglietti P, editors. Surgery of
ment. Clin Orthop Relat Res. 2003;416:64–7. the knee. New York: Churchill Livingstone; 1993. p.
2. Whiteside LA, Mihalko WM. Surgical procedure for 739–804.
flexion contracture and recurvatum in total knee arthro- 6. Giori NJ, Lewallen DG. Total knee arthroplasty in
plasty. Clin Orthop Relat Res. 2002;404:189–95. limbs affected by poliomyelitis. J Bone Joint Surg
3. Mullaji A, Lingaraju AP, Shetty GM. Computer- Am. 2002;84:1157–61.
assisted total knee replacement in patients with arthri- 7. Parratte S, Pagnano MW. Instability after total knee
tis and a recurvatum deformity. J Bone Joint Surg Br. arthroplasty. J Bone Joint Surg Am. 2008;90:184–94.
2012;94:642–7.
4. Insall JN, Haas SB. Complications of total knee
arthroplasty. In: Insall JN, Windsor RE, Scott WN,
Part IV
Complex Deformities
Rotational Deformity
7
The rotational alignment of femoral and tibial The lower extremity from an in utero position of
components in TKA is based on various bony internal rotation slowly undergoes lateral or
landmarks and reference axes around the knee external rotation throughout the growth phase of
joint. However, most of these landmarks and ref- the child till skeletal maturity [9]. Staheli and
erence axes have been derived from normal unaf- Engel [10] in their study of tibial torsion in chil-
fected knees. In knees with arthritis, these dren estimated tibial torsion at 15° of external
landmarks and axes may get distorted due to sig- rotation at skeletal maturity. Based on the orien-
nificant cartilage wear, bone loss, soft-tissue con- tation of the bimalleolar axis with respect to the
tracture and additional extra-articular bony flexion-extension axis of the knee joint, the tibia
deformities frequently associated with severe shows dynamic internal rotation when the knee is
knee deformity [1]. flexed [11, 12]. During gait, the tibia shows
Varus arthritic deformities of the knee are typ- dynamic internal rotation with respect to the
ically associated with increased external rotation femur at mid and terminal stance and dynamic
of the tibia [2]. Similarly, severe arthritis and external rotation from toe off until slightly before
deformity are associated with excessive wear of heel strike [12]. In normal subjects, the tibia is
the femoral condyles, and excessive medial or typically in external rotation with Caucasian
lateral soft-tissue contracture leading to increased limbs showing greater external rotation com-
internal or external rotation of the distal femur pared to Asian limbs [13].
[3]. These pathological changes cause distortion Whether abnormal torsion is a cause or a con-
of standard reference axes and landmarks such as sequence of knee osteoarthritis is still unclear.
the tibial tubercle, posterior condyle angle, epi- Nagamine et al. [14] in their CT scan analysis of
condylar axis and anteroposterior axis. Hence, if normal and osteoarthritic tibiae in Japanese sub-
such torsional deformities are not taken into jects had suggested that the traditional way of sit-
account during TKA, it may result in rotational ting on the floor with the foot internally rotated
malalignment of components which will lead to (tatami position) since childhood may cause
patellar maltracking, abnormal gait, postopera- growth disturbance at the proximal tibial meta
tive pain, poor function and early wear [4–8]. physis, causing tibia vara and medial torsion of
This chapter aims to address rotational deformi- the tibia. Krackow et al. [15] in a recent study to
ties in arthritic knees undergoing TKA. quantify the association between medial knee

96 7 Rotational Deformity
A fact that such bony landmarks show wide varia-

LATERAL MEDIAL tion not only among arthritic knees but even
among normal subjects [2, 18–22]. Furthermore,
use of one specific bony landmark may be unre-
liable to determine femoral component rotation
C
D
and may be affected by severity and type of
B underlying arthritic knee deformity. For exam-
ple, the anteroposterior axis (Whiteside’s line)
may not be reliable in cases with severe patello-
femoral arthritis which may cause significant
P
E trochlear wear and distortion [23, 24], and the
F posterior condylar angle (PCA) may not be reli-
able in knees with severe wear and bone loss of
Fig. 7.1 Distal femoral bony landmarks frequently the posterior condyles [25]. Hence, in such cases
used to determine rotation of the femoral component.
Line AP – Anteroposterior axis or the Whiteside’s line
some other technique must be used to determine
drawn along the deepest part of the trochlear sulcus. femoral rotation. The gap-balancing technique
The femoral component is placed perpendicular to this involves rotating the femoral component so as to
axis. Line BC – Anatomic transepicondylar axis con- achieve medio-lateral flexion gap symmetry
necting the lateral epicondyle (point B) and the medial
epicondyle (point C). Line BD – Clinical transepicondy-
(with the help of a tensioning device such as
lar axis connecting the lateral epicondyle (point B) and laminar spreaders) after having achieved a bal-
the medial sulcus (point D). Line EF – Posterior condy- anced and symmetric extension gap. However,
lar line drawn tangent to the posterior-most point of the the femoral rotation required may vary depend-
medial and lateral posterior femoral condyles
ing on the amount of distal femoral bony loss or
distortion and the extent of medio-lateral flexion
gap asymmetry. Although computer navigation
loading and tibial torsion reported that subjects has proven to improve limb and component
with medial OA and associated tibial intorsion alignment during TKA, studies have reported
walked with significantly greater knee loading malrotation of the femoral component during
compared to controls. Hence, the incidence and CAS TKA when a single anatomic landmark is
pattern of torsional deformity in patients with used as reference [26, 27]. For example, using
knee OA shows wide variation depending on the only the epicondylar axis as reference may lead
ethnicity of the population and severity of to excessive external rotation of the femoral
deformity. component. However, using a combination of
Several techniques are used to determine the anatomic and kinematic data has been reported
rotational position of the femoral component to improve accuracy of rotational alignment of
during TKA. These include using bony land- the femoral component [27].
marks on the distal femur, soft-tissue tension and On the tibial side, options to determine tibial
flexion gap (gap balancing) and computer navi- component rotation include using bony land-
gation [16]. However, no single technique has marks and putting the knee through an arc of flex-
emerged as a clear winner [17], and most sur- ion and extension and positioning the tibial tray
geons use a combination of two or more tech- vis-à-vis the femoral component (the “self-
niques. Distal femoral bony landmarks are most positioning” method) [16]. Traditionally, the tib-
frequently and principally used to determine ial tubercle (junction of the middle and medial
rotation of the femoral component (Fig. 7.1). one-third) has been used as a fixed bony landmark
However, several reports have underlined the to determine the rotational alignment of the tibial
tray. However, similar to distal femoral bony reported that the posterior condylar line with
landmarks, the tibial tubercle may show wide respect to the transepicondylar axis was in 11.5°
variations among patients depending on the sever- internal rotation compared to 6.4° internal rota-
ity of knee deformity and ethnicity [2, 28–30]. tion in normal knees and 6.1° internal rotation in
Sun et al. [29] in a CT scan-based study of varus knees. This is probably due to significant
Chinese osteoarthritic knees reported that the distortion and wear of the lateral femoral condyle
tibial component has a tendency to be placed in in valgus knees.
greater external rotation when the medial one- Owing to wide variations in bony landmarks
third of the tibial tuberosity is used as a landmark in arthritic knees, the authors use the combined
in arthritic knees with varus or valgus deformi- referencing technique to determine femoral com-
ties. Hence, they concluded that the tibial tuber- ponent position during TKA. Using a soft-tissue
osity is an unreliable rotational landmark for tensioner, the medio-lateral gap is first assessed
tibial tray in Asian patients with deformed, with the knee in 90° flexion, and the tentative
arthritic knees [29]. In a similar study on posterior cut is marked (parallel to the cut tibial
European subjects, Bonnin et al. [31] reported surface) on the distal femur surface based on
significant variation in the position of the tibial soft-tissue tension. We use the AP axis as the pre-
tuberosity which caused not only excessive exter- liminary reference to position the AP cutting
nal rotation of the tibial component but also defi- block equivalent to the femoral component size
cient coverage of the tibial cut surface by the estimated. In cases where the femoral trochlea
tibial tray. shows significant wear, the epicondylar axis is
used as the preliminary reference. The surgeon
then references the anterior cortex of the distal
Surgical Technique femur (using a stylus or angel wing) to avoid
notching and the previously made mark on the
Femur posterior aspect of the distal femoral cut surface
based on soft-tissue tension. The AP cutting
The severity and type of knee deformity and the block should be generally parallel to the epicon-
presence of an extra-articular rotational defor- dylar axis and perpendicular to the AP axis
mity must be taken into account before deciding (Whiteside’s line). Appropriate soft-tissue
on the rotational alignment of the femoral com- releases are performed if required to achieve
ponent during TKA. Matsui et al. [2] in a CT scan medio-lateral gap balance. In valgus knees there
study of 150 arthritic knees and 31 normal con- may be excessive tightness laterally, and medi-
trols reported progressive external rotation of the ally in varus knees. This becomes evident if the
distal femur with increasing severity of varus cutting block position deviates significantly from
deformity when compared to rotation in normal any of the chosen references. After pinning the
controls. However, this difference was significant AP cutting block to the distal femur, the flexion
only when the epicondylar axes (either surgical gap balance is assessed using a spacer block. If
or clinical) were compared, whereas there was no the flexion gap seems too tight either medially or
difference when the posterior condylar axes were laterally, the AP block may be slightly externally
compared. Therefore, the distal femoral rotation or internally rotated.
in an arthritic knee with varus <10° is similar to a Rarely, in cases with severe femoral EAD
normal knee, whereas the distal femur may be in where there is also a significant rotational com-
excessive external rotation when the varus defor- ponent (Fig. 7.2), the malrotation may have to be
mity is 20° or more. In valgus knees, Matsuda corrected while performing a corrective osteot-
et al. [3] using MRI analysis of the distal femur omy [32].
Fig. 7.2 Preoperative CT

scan of a patient showing
external rotation deformity of
the distal femur on the left
side (arrow) secondary to a
malunited fracture at the
distal femoral shaft
Tibia the position of both malleoli after the tibial tray

position is finalised using the self-positioning
Similar to the femur, the rotational profile of the technique. In cases where significant malrotation
tibia changes with the severity and type of knee of the tibia (which may be due to an associated
deformity. Greater varus knee deformity may be tibial extra-articular deformity) is present, a
associated with increasing internal rotation of the mobile-bearing design is used to prevent femoro-
tibia (Fig. 7.3). In view of variation in the posi- tibial rotational mismatch and postoperative gait
tion of tibial tubercle among patients, the “self- abnormality. If only a few degrees of intorsion of
positioning” technique to determine tibial tray the tibia is present, the tibial tray is internally
rotation minimises femorotibial rotational mis- rotated by the same amount. This is important
match and maximises coverage of the bony tibial else the patient may walk with a marked
surface by the tibial tray [33]. The authors note intoeing gait.
References 99
a b c
Fig. 7.3 Tibial torsion seen preoperatively in patients the fibula is well seen and the gap between the tibia and
undergoing TKA. (a) Preoperative clinical photograph the fibula is prominent (arrow), implying significant
showing significant bilateral tibial intorsion. (b) intorsion of the leg when the patient is standing with both
Preoperative standing, full-length hip-to-ankle radiograph patella facing forwards. (c) Postoperative clinical photo-
of the same patient (a) showing significant tibial intorsion graph of the same patient showing restoration of rota-
(left more than the right). Note that the complete profile of tional alignment of the lower limb
5. Ghosh KM, Merican AM, Iranpour F, Deehan DJ,

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Extra-Articular Deformity
8
Introduction the mechanical axis; help in avoiding excess bone

resection; allow graduated measured soft-tissue
In most total knee arthroplasties (TKAs) for release; and align the femoral component based on
arthritic knees with intra-articular varus or valgus the mechanical axis derived from the femoral head
deformity, both alignment and ligament balance centre and knee centre, bypassing the femoral
can be achieved with appropriate bone cuts and extra-articular deformity. Hence, femoral EAD
soft-tissue releases. However, TKA becomes with distortion of the femoral canal and the pres-
technically challenging when knee arthritis is ence of hardware especially in the distal half of the
associated with an extra-articular deformity femur may be an appropriate indication for com-
(EAD) of either the femur or the tibia. Such defor- puter-assisted surgery in this subgroup of patients
mities are secondary to trauma (malunion or non- undergoing TKA. This chapter aims to outline the
union), previous osteotomy, metabolic causes means of dealing with EADs during TKA.
such as osteomalacia or osteoporosis causing
excessive bowing or stress fractures and congeni-
tal causes (Fig. 8.1) [1–4]. Stress fracture although Pathoanatomy
uncommon is a frequent cause of tibial EAD in
patients with knee arthritis. Extra-articular deformities in knees which
Options for dealing with such EADs during undergo TKA complicate the procedure in a
TKA include intra-articular correction along with number of ways. First, an EAD either in the
bone resection and extensive soft-tissue release tibia or the femur adds to the overall deformity
and staged or simultaneous corrective osteotomy in a limb already deformed due to knee arthritis
at the apex of the EAD along with intra-articular (Fig. 8.3). Hence, realignment in such limbs
correction. Conventional techniques, although will require extensive soft-tissue release and
effective in majority of such cases, may not be achieving medio-lateral balance will be chal-
appropriate in selected limbs where the presence lenging especially if there is a dearth of osteo-
of hardware or excessive distortion of the femoral phytes and excessive lateral laxity (in a varus
canal due to deformity may make the use of an knee, or vice versa) at the knee. Such limbs are
intramedullary femoral guide difficult (Fig. 8.2) therefore cases which may require additional
[4]. Recent reports describing the use of navigated procedures such as lateral epicondylar or sliding
TKA for knee arthritis with EADs have indicated medial condylar osteotomy to achieve optimum
good results with appropriate bone cuts and soft limb alignment and soft-tissue balance [9, 10].
tissue releases [1, 5–8]. Navigation systems use Second, some of these limbs with associated
the centre of the femoral head, the centre of the EAD especially secondary to a previous surgical
knee joint and the centre of the ankle to calculate procedure (high tibial osteotomy or fracture
102 8 Extra-Articular Deformity
fixation) have hardware in situ which makes use corrective osteotomy performed either simulta-
of conventional intramedullary alignment jigs neously with TKA or in a staged manner [1].
challenging and may require hardware removal The most common EAD encountered during
before the start of TKA (Fig. 8.2). Third, an TKA is excessive coronal bowing of the femoral
EAD close to the knee joint may distort local shaft [1] (Fig. 8.3). A study published by the senior
bony anatomy and make optimum component author reports the incidence of excessive coronal
alignment challenging to achieve. Finally, bowing of the femoral shaft at 15 % in arthritic
severe EADs, especially in the proximal tibia or knees which undergo TKA in Indian study popula-
distal femur, may require an additional tion [11]. Similar findings have been reported in
a b c d
Fig. 8.1 Causes of extra-articular deformities in knees (HTO) with implant in situ. (d) Severe bowing of the
undergoing TKA. (a) Post-traumatic deformity in the dis- femoral shaft probably secondary to osteopenia and/or
tal ½ of the tibial shaft with broken nail in situ. (b) Post- osteomalacia compounding the knee deformity. (e) Stress
traumatic deformity in the distal 1/3 of femur due to a fracture in the upper 1/3 of the tibial shaft causing varus
malunited fracture with implant in the proximal ½ of deformity locally. (f) Proximal tibia varus. (g) Bowing of
femur. (c) Severe extra-articular deformity in the proxi- the proximal ½ of the femoral shaft secondary to probably
mal end of the tibia secondary to high tibial osteotomy a congenital cause
Pathoanatomy 103

e f g
Fig. 8.2 Excessive distortion of the femoral canal due to (b) Extra-articular deformity at the distal 1/3 of the femur
extra-articular deformity or presence of hardware makes due to a malunited fracture caused a varus deformity of
the use of an intramedullary femoral guide challenging the distal fragment. Use of an intramedullary femur guide
during conventional TKA. (a) Extra-articular deformity at rod (black line) will cause it to go laterally within the dis-
the distal 1/3 of the femur due to a malunited fracture torted canal. (c) An intramedullary nail previously used to
caused an extension deformity of the distal fragment. Use fix a distal femur shaft fracture. This nail will have to be
of an intramedullary femur guide rod (black line) will removed if an intramedullary femur guide rod needs to be
cause it to go posteriorly within the distorted canal. used during conventional TKA
a b
Fig. 8.3 A common cause of femoral extra-

articular deformity in patients undergoing
TKA – excessive coronal bowing of the femoral
shaft. This adds to the overall deformity of the
limb. (a) Standing knee anteroposterior radiograph
showing a knee deformity of 15° varus (black line).
(b) Standing, full-length hip-to-ankle radiograph of
the same patient shows that the overall limb
deformity (hip-knee-ankle angle) is actually 30°
varus. Excessive coronal bowing of the femoral
shaft (dotted line) at 12° in this case adds to the
overall deformity of the limb which can be easily
missed if only short knee films are used
Preoperative Planning 105
Table 8.1 Classification of tibial stress fractures in balance under anaesthesia is also invaluable
patients undergoing TKA
especially in knees which have been previously
I. Intra-articular operated.
(A) Malunited
(B) Ununited
II. Extra-articular Femoral Extra-Articular Deformities
(A) Impending
(B) Acute
On preoperative standing, full-length hip-to-
(C) United
ankle radiographs, the proposed distal femoral
(D) Malunited
cut is drawn perpendicular to the mechanical
(E) Ununited
axis of the femur. If the EAD is close to the
joint or is more than 20° in the coronal plane or
other study populations especially in Asians. if the plane of the distal cut is likely to compro-
Another common cause of EAD in the femur is a mise the attachment of the lateral collateral
malunited fracture typically with hardware in situ. ligament on the lateral epicondyle, a corrective
Similarly, in the tibia, the common causes of EAD osteotomy is considered (Fig. 8.6) [1, 3]. In the
include proximal tibia vara due to distortion and presence of significant femoral bowing (as evi-
bony adaptation secondary to knee arthritis and/or denced by an increase in the angle between the
metabolic causes, malunited fractures, stress frac- mechanical axis and the distal femoral ana-
tures secondary to metabolic causes and deformity tomic axis), the distal femoral valgus resection
secondary to a previous high tibial osteotomy angle should be measured preoperatively and
(HTO). As per the classification proposed by the proportionately increased during the procedure
authors (Table 8.1), tibial stress fractures in (Fig. 8.7) [14]. Severe femoral bowing with
arthritic knees are primarily intra-articular or minimal osteophytes and severe lateral laxity
extra-articular type (Fig. 8.4) [2]. Based on the with or without rigid medial soft-tissue con-
type of stress fractures, the surgical technique and tracture in varus arthritic knees should alert the
implant used may vary during TKA. surgeon that balancing and realignment may be
Post-HTO is a special category of tibial EAD difficult using only intra-articular correction
which brings its own challenges while perform- and a sliding osteotomy of the medial condyle
ing TKA. The issues which need to be dealt with may be required (Fig. 8.8) [10].
during a post-HTO TKA include a previous skin
incision, periarticular bony distortion, soft-tissue
changes, implant in situ and patellar changes Tibial Extra-Articular Deformities
such as maltracking and patella infera (Table 8.2).
Periarticular bony distortion secondary to a pre- On preoperative standing, full-length hip-to-
vious HTO include medial tibial bone loss and ankle radiographs, the axis of the tibia distal to
lateral femoral condylar deficiency, excessive the deformity is drawn and extended proximally
medial or lateral and/or posterior or anterior slop- towards the knee joint. If the distal tibial axis
ing of tibial plateau, excessive medial or lateral does not pass through the tibial plateau or if the
and/or anterior or posterior translation of the EAD is close to the joint or is more than 30° in
proximal tibia and internal or external torsion of the coronal plane, a corrective osteotomy is likely
the proximal tibia (Fig. 8.5) [12, 13]. to be indicated (Fig. 8.9) [1, 3]. In cases where
TKA is planned in a post-HTO knee, periarticu-
lar bony distortion of the proximal tibia and hard-
Preoperative Planning ware (Fig. 8.5) which may interfere with fixation
of the tibial component should be noted on radio-
A full-length hip-to-ankle radiograph is neces- graphs, and surgical steps to tackle each issue
sary to plan for TKA in cases with femoral or need to be planned. Furthermore, the site of a pre-
tibial EAD. A thorough evaluation of soft-tissue vious skin incision should be noted and the TKA
a b c
d e f
Fig. 8.4 Types of tibial stress fractures seen in knees arrow). Impending stress fractures can be diagnosed clin-
undergoing TKA. (a) Type IA – Malunited intra-articular ically and need an MRI for confirmation. (f) Type IIB –
fracture (arrow). (b) Type IB – Ununited intra-articular Acute extra-articular fracture of the proximal 1/3 of the
fracture (arrow). (c) MRI of the same patient in (b) shows tibial shaft (arrow). (g) Type IIC – United extra-articular
the extent of fracture and medial tibial bone defect (black fracture of the proximal 1/3 of the tibial shaft (arrow)
arrow) caused by it. (d) Type IIA – Impending extra- which has healed without any local residual deformity.
articular fracture which is not obvious on plain knee (h) Type IID – Malunited extra-articular fracture of the
radiograph. The patient had local tenderness on the ante- proximal 1/3 of the tibial shaft causing severe varus
rior aspect of proximal 1/3 of the tibial shaft on clinical extra-articular deformity of approximately 37° at the
examination. (e) MRI of the same patient in (d) shows the fracture site. (i) Type IIE – Ununited extra-articular frac-
stress fracture on proximal 1/3 of the tibial shaft (black ture of the proximal 1/3 of the tibial shaft
g h i
Table 8.2 Changes in the knee frequently encountered incision should be planned such that it does not
during post-high tibial osteotomy TKAs which can pose a jeopardise blood supply of skin flaps.
challenge for the surgeon
Previous vertical skin incisions
Patella maltracking, fibrosis around patellar tendon Surgical Technique
insertion, patella infera
Implant in situ
Femoral Extra-Articular Deformities
Tibial bone loss
Decreased or increased tibial slope
The basic principles for intra-articular correction
Medial or lateral translation of proximal tibia
Anterior or posterior translation of the proximal
of the deformity remain the same as in any routine
tibia case of TKA. However, in order to accommodate
Internal or external torsion of the proximal tibia the EAD, a conservative bone cut and an exten-
Medio-lateral soft-tissue imbalance sive soft-tissue release may be necessary. In case
Excessive posterior soft-tissue laxity of deformity or hardware involving the distal half
Extra-articular deformity of the femoral canal, a shorter intramedullary
a b c
d e
Fig. 8.5 Knee radiograph showing periarticular bony dis- tibia (arrow). (c) Coronal angulation of the tibial plateau
tortion secondary to a previous high tibial osteotomy (HTO). with implant in situ. (d) Severe extra-articular varus defor-
(a) Plain knee radiograph showing medial tibial bone loss mity of the proximal tibia with implant in situ. There is asso-
(dotted arrow), lateral femoral condylar deficiency (dotted ciated excessive lateral side soft-tissue laxity seen here as
arrow) and bony overgrowth of the lateral tibia (solid excessive opening of the lateral joint space (curved arrow).
arrow). (b) Posterior translation of the proximal end of the (e) Reverse sloping of the tibial plateau (dotted line)
femoral guide rod may be used to avoid tightness persists despite the extensive release
malposition of the cutting block. However, if the (after assessment with a spacer block), a reduction
implant or deformity interferes with use of the osteotomy of the posteromedial aspect of the
intramedullary guide rod (Fig. 8.2), either an upper tibia is performed to reduce tenting of the
extramedullary femoral guide rod or navigation superficial MCL [17]. The authors do not per-
must be used. An extensive soft-tissue release is form elevation of superficial MCL and release of
performed in a graded, stepwise (subperiosteal pes anserinus insertion as part of the extensive
elevation of the deep medial collateral ligament release as these can lead to excessively large flex-
(MCL), posteromedial capsule and semimembra- ion and/or extension gaps medially. Femoral
nosus) manner [15, 16]. If medial extension gap component upsizing may be necessary in order to
a b
Fig. 8.6 Preoperative planning in a patient with a femo- line) was 12.5°. However, the proposed distal femoral cut
ral extra-articular undergoing TKA. (a) Preoperative full- (black dashed line) when drawn perpendicular to the
length anteroposterior radiograph of the femur showing mechanical axis of the femur showed that it would have
extra-articular deformity of 15° secondary to malunited compromised the attachment of the LCL on the lateral
fracture of the femoral midshaft. Note that the proposed epicondyle (asterisk). (c) Standing knee radiograph of
distal femoral cut (dashed line) drawn perpendicular to the same patient (b) showing excessive lateral side soft-
the mechanical axis of the femur will not compromise the tissue laxity seen here as excessive opening of the lateral
attachment of the lateral collateral ligament (LCL) on the joint space (arrow) and deficiency of osteophytes.
lateral epicondyle (asterisk) and a corrective osteotomy Considering the severity and proximity of the extra-artic-
is not required here. (b) Preoperative standing, full- ular deformity (dashed line) to the knee joint, possibility
length hip-to-ankle radiograph of a patient with extra- of compromise of LCL with the distal femoral cut, sig-
articular deformity in the distal 1/3 femur due to nificant lateral soft-tissue laxity and the deficiency of
malunited fracture. The limb deformity (hip-knee-ankle osteophytes, a lateral closing wedge corrective osteot-
angle) in this patient was 22.5°, and the deformity in the omy at the distal femur will be required in this patient to
distal 1/3 femur due to malunited fracture (white dashed restore limb alignment
c d
balance the larger flexion gap. In the majority of Tibial Extra-Articular Deformities
limbs with femoral EADs, the above technique of
bone resection and soft-tissue release helps in Similar to femoral EADs, the basic principle of
achieving rectangular gaps and accurately restor- extensive soft-tissue release with or without a
ing limb alignment (Fig. 8.10) [1]. reduction osteotomy works well in restoring limb
However, in cases of varus knee osteoarthritis alignment and soft-tissue balance in most cases
with severe femoral bowing throughout the fem- with associated tibial EADs. However, centralis-
oral shaft (commonly due to osteopenia and/or ing the tibial component with respect to the tibial
osteomalacia) and with no or minimal osteo- mechanical axis can be tricky in the presence of
phytes at the knee and excessive lateral soft- tibial EAD. While using a tibial component with a
tissue laxity, a sliding medial condylar osteotomy stem extender, the component needs to be properly
(see Chap. 11 for description of the technique) placed so that the stem remains centrally within
may be required to achieve a well-balanced and the medullary canal (in both coronal and sagittal
well-aligned knee (Fig. 8.11). Rarely, in cases plane) and there is no abutment of the stem on
with severe deformities where the distal femoral either cortex. Furthermore, the tibial tray should
cut may compromise the femoral attachment of also be fixed perpendicular to the tibial mechani-
the collateral ligaments, a simultaneous correc- cal axis in the coronal plane (so that the tibial tray
tive osteotomy (see Chap. 11 for complete stem is in line with the tibial mechanical axis).
description of the technique) may be necessary at However, due to distortion of the tibia by an EAD,
the apex of the EAD. An intramedullary inter- the mechanical axis and medullary axis of the
locking nailing is appropriate for fixation for this proximal tibia will not overlap (Fig. 8.12a).
osteotomy and a sleeve-stem construct may be Therefore, tibial tray placement must be individu-
useful in distal deformities. alised to achieve optimum placement in both
(such as malunited fractures, tibia vara or rarely

coronal bowing of the shaft), the centre of place-
ment of the tray should be lateralised (Fig. 8.12b–
i). In cases where there is significant EAD and the
tibial mechanical axis is angled away from the
medullary axis of the proximal tibia, the tibial tray
is best aligned to the mechanical axis preferably
with a short-stem component which will minimise
the risk of cortical abutment (Fig. 8.12j–k). Rarely
a corrective osteotomy (see Chap. 11 for complete
description of the technique) may be required if
the extra-articular deformity is significant, close
to the knee joint and where the distal tibial axis
does not pass through the tibial plateau (Fig. 8.9c).
Among the extra-articular deformities encoun-
tered in the tibia, stress fractures are treated based
on their type [2]. Malunited intra-articular frac-
tures can be treated with routine TKA, whereas
united intra-articular fractures may rarely cause
severe medial tibial bone loss where either bone
grafting (with resected bone from the TKA cuts)
(Fig. 8.13a–b) or metal augments may be
required. Impending and united extra-articular
fractures can be treated with routine TKA,
whereas acute fractures may need a tibial stem
extender to improve stability and promote frac-
ture healing (Fig. 8.13c–g). Ununited extra-
articular fractures will require local debridement
Fig. 8.7 Distal femoral valgus resection angle in the and a tibial stem extender in order to stabilise the
presence of significant femoral bowing measured on pre- fracture site (Fig. 8.13h–i). Malunited stress frac-
operative standing, full-length hip-to-ankle radiograph. In
this patient the limb deformity (angle ABC) was 25° varus.
tures can be usually treated by routine TKA, but
Due to an associated femoral shaft bowing (7°), the distal rarely a corrective closing wedge osteotomy and
femoral valgus resection angle in this patient was 9.5° a tibial stem extender may be required.
(angle ABD). Hence, in the presence of significant femo-
ral bowing (as evidenced by an increase in the angle
between the mechanical axis and the distal femoral ana-
tomic axis), the distal femoral valgus resection angle Post-HTO Deformities
should be measured preoperatively and proportionately
increased during the procedure A special category of knees with extra-articular
tibial deformity which are undergoing TKA is the
coronal and sagittal plane (Fig. 8.12b–e). On pre- post-HTO knee. As previously discussed, it poses
operative full-length hip-to-ankle radiographs, the several challenges for the surgeon while
surgeon needs to plan the placement of the tibial performing TKA. Beginning with the skin
component vis-à-vis the tibial mechanical axis incision, a previous horizontal skin incision is
and the proximal medullary canal. The position of less problematic and goes well with a midline
the tibial tray can be decided based on the position vertical incision for the TKA (Fig. 8.14a).
and severity of EAD. In cases where the mechani- However, a previous vertical skin incision espe-
cal axis is shifted medially (but still parallel to the cially if close to the midline may pose a chal-
medullary axis of the proximal tibia) due to EAD lenge, and it is best to use the same incision with
a b c d
Fig. 8.8 Example of limbs with significant coronal bow- excessive opening of the lateral joint space (arrow) and
ing of the femoral shaft where balancing and realignment lack of osteophytes. (c) Preoperative standing, full-length
may be difficult using only intra-articular correction and a hip-to-ankle radiograph of another patient showing limb
sliding osteotomy of the medial condyle (SMCO) is deformity (hip-knee-ankle angle) of 15° with associated
required. (a) Preoperative standing, full-length hip-to- significant coronal bowing (11°) of the femoral shaft
ankle radiograph showing limb deformity (hip-knee-ankle (arrow). (d) Preoperative standing knee radiograph of the
angle) of 35° with associated significant coronal bowing same patient (c) showing excessive lateral side soft-tissue
(6°) of the femoral shaft (arrow). (b) Preoperative laxity seen here as lateral translation of the tibia (arrow)
standing knee radiograph of the same patient (a) showing and lack of osteophytes. This patient also had rigid con-
excessive lateral side soft-tissue laxity seen here as tracture of the medial soft-tissue structures
proximal and distal extensions for TKA. In cases require removal before the start of the TKA. If
where a more extensive exposure is required for there is a possibility that the implant may inter-
the removal of old implant, the new incision fere with fixation of the tibial tray (Fig. 8.14c),
should be merged with the new one if possible so the hardware should be removed either through
as to minimise damage to blood supply of the the same TKA incision if possible or through a
skin flap (Fig. 8.14b–c). Owing to scarring small separate incision. A post-HTO knee may
around the patellar tendon attachment, exposure present with different combinations of coronal
and eversion of the patella may be difficult and (varus or valgus) and sagittal (hyperextension or
will require release and excision of fibrous tissue flexion) plane deformities. Based on the severity
to facilitate lateral displacement of the extensor of deformity and soft-tissue balance, thickness of
mechanism and achieve adequate exposure of the the tibial cut may have to be modified (less bone
tibial surface. Old hardware if present may resected in cases with severe deformities and
Fig. 8.9 Preoperative planning in a a b

patient with a tibial extra-articular
undergoing TKA. (a) Preoperative
standing, full-length hip-to-ankle
radiograph showing limb deformity
(hip-knee-ankle angle) of 25° varus
with associated post-HTO proximal
tibial extra-articular deformity. (b)
Preoperative standing knee radiograph
of the same patient showing extra-
articular deformity of the proximal
tibia of 25° varus (dashed line). Solid
line is proximal extension of tibial
medullary axis. Considering the
severity and proximity of the
extra-articular deformity to the knee
joint, significant lateral soft-tissue
laxity and the deficiency of osteo-
phytes, a corrective osteotomy will be
required in this patient to restore limb
alignment. (c) Preoperative full-length
anteroposterior radiograph of the tibia
showing extra-articular deformity of
20° (dashed line) secondary to c
malunited fracture of the proximal
tibial shaft. Note that the distal tibial
axis does not pass through the tibial
plateau (solid black line) and the
extra-articular deformity is severe and
close to the knee joint, and hence, a
corrective osteotomy is required here
d
Fig. 8.10 Example of limbs with significant coronal full-length hip-to-ankle radiograph showing limb defor-
bowing of the femoral shaft where balancing and realign- mity (hip-knee-ankle angle) of 24° (right side) and 23°
ment was performed using intra-articular corrective mea- (left side) varus with associated significant coronal bow-
sures such as extensive soft-tissue releases and a reduction ing of 6° (right side) and 10° (left side) of the femoral
osteotomy. Note that in the majority of limbs with femoral shaft. (b) Postoperative standing, full-length hip-to-ankle
extra-articular deformities, the above intra-articular tech- radiograph of the above patient showing restoration of
nique helps in achieving rectangular gaps and accurately limb alignment on both sides using only intra-articular
restored limb alignment. (a) Preoperative standing, measures
significant medio-lateral soft-tissue imbalance). geon needs to factor this in while determining the
Furthermore, the tibial slope may be decreased or sagittal plane of the tibial cut.
increased due to the previous HTO which should The surgeon needs to be careful while posi-
be determined on preoperative lateral knee radio- tioning the tibial tray with respect to the tibial cut
graphs and care exercised not to be misled by the surface. Both preoperative planning on knee
altered slope. A closing wedge HTO usually radiographs and intraoperative checking with
causes decrease in slope, whereas opening wedge trial components are crucial to get this right. In
may cause increase in slope [12]. Rarely, a knee the presence of medial or lateral translation of the
will have an anterior slope with resulting proximal tibia, it may be challenging to fully cen-
hyperextension at the knee. Accordingly the sur- tralise the tibial component stem within the
Fig. 8.11 Example of a limb with significant

a b
coronal bowing of the femoral shaft where
balancing and realignment was not possible using
only intra-articular correction and a sliding
osteotomy of the medial condyle (SMCO) was
required. (a) Preoperative standing, full-length
hip-to-ankle radiograph showing limb deformity
(hip-knee-ankle angle) of 35° with associated
significant coronal bowing (6°) of the femoral
shaft. Note that the patient also has excessive
lateral soft-tissue laxity (arrow) and the deficiency
of osteophytes medially. (b) Postoperative
standing, full-length hip-to-ankle radiograph of
the above patient showing complete restoration of
limb alignment after performing a SMCO. (c)
Enlarged radiographic image of the SMCO site of
the above patient where the condylar fragment has
been fixed with cancellous screws. The condylar
fragment is distalised and fixed (dotted arrow) in
order to increase the medial joint space and
equalise the medial gap to the lateral gap
c
medullary canal and also align it with the cle an unreliable landmark to determine the rota-
mechanical axis of the tibia. In such cases it is tional position of the tibial component. The
best to place the component in line with the surgeon therefore needs to verify the rotational
mechanical axis of the tibia to avoid cortical position of the tray with respect to the distal tibia
abutment of the stem, although a lateral or medial (malleoli) and also by putting the knee through
position of the stem within the medullary canal an arc of flexion and extension. Few cases may
may be unavoidable (Fig. 8.15a–d). The surgeon present with a large medial tibial bone defect sec-
may use tibial components with an offset stem if ondary to the osteotomy in which case medial
available in such situations. Rotational malunion build up with bone graft or augment may be nec-
of the proximal tibia may render the tibial tuber- essary. Rarely, severe extra-articular deformity in
a b c d
Fig. 8.12 Positioning the tibial tray in the presence of (dotted line) in the presence of a malunited fracture of the
tibial extra-articular deformity. (a) Lateral offset of the tibial midshaft with a broken nail in situ. (g) Postoperative
proximal tibial medullary axis (dashed line) with respect anteroposterior knee radiograph of the same patient (f)
to the tibial mechanical axis (solid line) and the tibial cut showing the all polyethylene tibial component in line with
(dotted line) in the presence of tibia vara. (b) Preoperative the tibial mechanical axis (solid line). (h) Preoperative
standing, full-length tibia radiograph showing lateral off- standing, full-length tibia radiograph showing lateral off-
set of the proximal tibial medullary axis (dashed line) set of the proximal tibial medullary axis (dashed line)
with respect to the tibial mechanical axis (solid line) and with respect to the tibial mechanical axis (solid line) and
the tibial cut (dotted line) in the presence of a malunited the tibial cut (dotted line) in the presence of a malunited
fracture of the distal ½ of the tibial shaft. (c) Postoperative fracture of the tibial midshaft. (i) Postoperative anteropos-
anteroposterior knee radiograph of the same patient (b) terior knee radiograph of the same patient (h) showing the
showing central position of the long tibial stem within the tibial component in line with the tibial mechanical axis
medullary canal. The tibial component was implanted (solid line). (j) Preoperative standing, full-length tibial
after lateralisation in line with the proximal tibial medul- radiograph showing significant extra-articular deformity
lary axis. (d) Postoperative lateral knee radiograph of the due to malunited fracture of the proximal 1/3 of the tibial
same patient (b) showing central position of the long tibial shaft. The proximal tibial medullary axis (dashed line) is
stem within the medullary canal even in the sagittal plane. angled away with respect to the tibial mechanical axis
(e) Postoperative standing, full-length tibial radiograph of (solid line) and the tibial cut (dotted line). (k) Postoperative
the same patient (b) showing the tibial component in line anteroposterior knee radiograph of the same patient (j)
with the tibial mechanical axis. (f) Preoperative standing, showing the all polyethylene tibial component with a
full-length tibial radiograph showing lateral offset of the short stem in line with the tibial mechanical axis. The
proximal tibial medullary axis (dashed line) with respect tibial component was implanted in line with the mechani-
to the tibial mechanical axis (solid line) and the tibial cut cal axis of the tibia (solid line)
e f g h
i j k

a b c d
e f g h i
Fig. 8.13 Treatment of tibial stress fractures during metal augment and stabilised with a tibial stem extender.
TKA. (a) Preoperative standing knee radiograph showing (e) Preoperative standing knee radiograph showing an
an intra-articular ununited tibial stress fracture (arrow). (b) extra-articular acute stress fracture (arrow) of the proximal
Postoperative standing knee radiograph of same patient (a) tibial shaft. (f) Postoperative standing knee radiograph of
showing the medial tibial bone defect caused by the stress the same patient (e) showing the fracture stabilised with a
fracture treated with autologous bone graft fixed with long tibial stem extender. (g) Standing knee radiograph of
Kirschner wires (arrow) and stabilised with a tibial stem the same patient (e) at 3 months postoperatively showing
extender. (c) Preoperative standing knee radiograph show- union at the fracture site. (h) Preoperative standing knee
ing an intra-articular ununited tibial stress fracture with radiograph showing an extra-articular ununited stress frac-
significant bone loss of the medial tibial plateau (arrow). ture of the proximal tibial shaft. (h) Standing knee radio-
(d) Postoperative standing knee radiograph of same patient graph of the same patient (f) at 6 months postoperatively
(c) showing the medial tibial bone defect treated with a showing union at the fracture site
the proximal tibia due to previous osteotomy has been overcorrected (valgus) or undercor-
may require a corrective osteotomy to achieve rected (varus) and to what extent has the tibial
optimum limb and component alignment and slope altered. Overcorrection by HTO will cause
also soft-tissue balance (Fig. 8.15e–f). stretching of the medial soft-tissue structures
Significant soft-tissue imbalance due to previ- along with the already stretched out lateral
ous HTO primarily depends on whether the knee soft-tissue structures (due to pre-HTO medial
a b c
Fig. 8.14 Previous skin incisions encountered during vertical, midline TKA incision (dotted line). A vertical inci-
TKA performed in post-high tibial osteotomy (HTO) knees. sion in this case could have jeopardised the vascularity of
(a) Clinical photograph of the knee taken 1 month postop- the flap distally. In this case, we extended the incision proxi-
eratively after TKA. A previous horizontal incision (arrow) mally and medially in line with the previous incision. (c)
does not interfere with healing of the subsequent vertical Preoperative knee radiograph of the same patient in (b)
incision used for TKA. (b) Clinical photograph of another shows a large plate and multiple screws used to fix the HTO.
patient taken 2 weeks postoperatively after TKA during Since the hardware had to be removed before start of TKA,
suture removal. A curved anterolateral incision (arrow) used a more extensive approach to include the previous curved
for a previous HTO poses a challenge for the subsequent anterolateral incision [as seen in (b)] was used
OA). Hence, overcorrected limbs will show sig- ambulation with walking frame usually com-
nificant laxity on both medial and lateral sides, menced within 6 h after surgery. In patients where
causing increase in the extension gap. Similarly, a lateral epicondylar or a sliding medial condylar
anterior sloping will cause the knee to go into osteotomy has been performed, the patient is
hyperextension, laxity of posterior soft-tissue allowed full weight-bearing ambulation with a
structures and a large extension gap. Both these long knee brace. Knee movement is not allowed
scenarios require the surgeon to minimise resec- for 2 weeks after which the patient is advised to
tion from not only the proximal tibia but also the remove the brace three to four times a day and
distal femur. Hence, a thicker tibial insert or very perform gentle, active knee flexion and extension.
rarely constrained implant may be required in Knee brace is discontinued at 4 weeks and patient
post-HTO knees during TKA. Furthermore, sig- allowed full activity. In patients where a correc-
nificant medial tibial bone loss and the resultant tive osteotomy is performed, knee movements
tibial cut will cause increase in both extension and partial weight-bearing ambulation in long-leg
and flexion gap. Hence, the femoral component knee brace are commenced the next day postop-
may have to be upsized in order to balance the eratively. If x-rays at 4–6 weeks show satisfactory
flexion gap with the extension gap. healing, patients are allowed full weight-bearing
In all patients treated with intra-articular cor- ambulation with a stick but are advised to wear
rection only, routine postoperative rehabilitation the brace. After 3 months, the brace and stick
is carried out with bedside knee range of motion, may be discontinued once x-rays show that the
and quadriceps strengthening exercises and osteotomy site has consolidated.
Fig. 8.15 TKA in knees with previous HTO. (a) line). Note that the tibial stem is lateral and closer to the
Preoperative standing, full-length tibial radiograph show- lateral cortex of the tibia as expected. (d) Postoperative
ing a lateral closing wedge HTO fixed with staples. Tibial lateral knee radiograph showing final position of the tibial
component if aligned with respect to the tibial mechanical tray and its stem in the sagittal plane. (e) Severe extra-
axis (solid thin line) will lateralise the tibial stem (short articular varus deformity (25° varus) of the proximal tibia
thick line), close to the lateral cortex of the tibia. Dotted with implant in situ. A corrective osteotomy is required
line in (a) is tentative position of the tibial tray. (b) here to restore limb alignment considering the severity
Preoperative lateral knee radiograph showing tentative and proximity of the extra-articular deformity to the knee
position of the tibial tray (dotted line) and its stem (solid joint, significant lateral soft-tissue laxity and the defi-
thick line) with respect to the proximal tibial intramedul- ciency of osteophytes. (f) Postoperative standing knee
lary axis. (c) Postoperative standing, full-length tibial radiograph of same patient (e) showing the final position
radiograph of same patient (a) showing the tibial compo- of the tibial component and stem following a corrective
nent aligned along the tibial mechanical axis (solid thin osteotomy (arrow)
References 121
Computer-Assisted Technique An osteotomy (lateral epicondylar, SMCO

or corrective osteotomy) may have to be per-
Navigation systems determine mechanical formed simultaneously with TKA in cases
axis of femur, tibia and the lower limb using with severe EADs as previously discussed.
specific points (centre of the hip, knee and Conventional measuring techniques to deter-
ankle) acquired during registration. Hence, mine the amount of correction required or the
navigation has the ability to determine the amount by which the medial condyle or lateral
mechanical axis and the position of compo- epicondyle needs to be shifted can be impre-
nents irrespective of the presence of any EAD cise and unreliable. Navigation helps to accu-
of femur or tibia or hardware in between. In rately measure the degree of deformity and the
contrast, conventional TKA requires the use of amount of gap imbalance and therefore helps
alignment devices (intramedullary for the the surgeon to accurate quantify the amount of
femur) to determine implant position and limb correction required in alignment and gap
mechanical alignment. The presence of a dis- imbalance. Therefore, navigation can be a
torted femoral canal and/or hardware will more accurate and quantitative method to per-
require the surgeon to use an extramedullary form osteotomies during TKA [9, 10, 18].
guide, remove the obstructing hardware or cor- However, the surgeon must be well versed
rect the deformity with a corrective osteotomy. with the navigation before attempting to per-
Navigation, therefore, is a better option com- form simultaneous computer-assisted osteoto-
pared to conventional techniques when TKA is mies during TKA.
performed in the presence of significant EAD
especially in the presence of hardware [1, 18].
8. Kim KI, Ramteke AA, Bae DK. Navigation-assisted

References minimal invasive total knee arthroplasty in patients
with extra-articular femoral deformity. J Arthroplasty.
1. Mullaji A, Shetty GM. Computer-assisted total knee 2009;25:658.e17–22.
arthroplasty for arthritis with extra-articular defor- 9. Mullaji AB, Shetty GM. Lateral epicondylar osteot-
mity. J Arthroplasty. 2009;24:1164–9. omy using computer navigation in total knee arthro-
2. Mullaji A, Shetty G. Total knee arthroplasty for arthritic plasty for rigid valgus deformities. J Arthroplasty.
knees with tibiofibular stress fractures classification and 2010;25:166–9.
treatment guidelines. J Arthroplasty. 2010;25:295–301. 10. Mullaji AB, Shetty GM. Surgical technique:
3. Wang JW, Wang CJ. Total knee arthroplasty for arthri- computer-assisted sliding medial condylar osteotomy
tis of the knee with extra-articular deformity. J Bone to achieve gap balance in varus knees during TKA.
Joint Surg Am. 2002;84:1769–74. Clin Orthop Relat Res. 2013;471:1484–91.
4. Fehring TK, Mason JB, Moskal J, Pollock DC, Mann 11. Mullaji AB, Marawar SV, Mittal V. A comparison of
J, Williams VJ. When computer-assisted knee replace- coronal plane axial femoral relationships in Asian
ment is the best alternative. Clin Orthop Relat Res. patients with varus osteoarthritic knees and healthy
2006;452:132–6. knees. J Arthroplasty. 2009;24:861–7.
5. Chou WY, Ko JY, Wang CJ, Wang FS, Wu RW, Wong 12. Bonnin M, Zayni R. Total knee arthroplasty after
T. Navigation-assisted total knee arthroplasty for a failed high tibial osteotomy. In: Bonnin M, Amendola
knee with malunion of the distal femur. J Arthroplasty. NA, Bellemans J, MacDonald SJ, Menetrey J,
2008;23:1239.e13–9. editors. The knee joint. Paris: Springer; 2012.
6. Klein GR, Austin MS, Smith EB, Hozack WJ. Total p. 923–32.
knee arthroplasty using computer-assisted navigation 13. Madan S, Ranjith RK, Fiddian NJ. Total knee replace-
in patients with deformities of the femur and tibia. ment following high tibial osteotomy. Bull Hosp Jt
J Arthroplasty. 2006;21:284–8. Dis. 2002–2003;61:5–10.
7. Bottros J, Klika AK, Lee HH, Polousky J, Barsoum 14. Mullaji AB, Shetty GM, Kanna R, Vadapalli RC. The
WK. The use of navigation in total knee arthroplasty for influence of preoperative deformity on valgus correc-
patients with extra-articular deformity. J Arthroplasty. tion angle: an analysis of 503 total knee arthroplasties.
2008;23:74–8. J Arthroplasty. 2013;28:20–7.
15. Mullaji A, Kanna R, Marawar S, Kohli A, Sharma A. 17. Mullaji AB, Shetty GM. Correction of varus defor-
Comparison of limb and component alignment using mity during TKA with reduction osteotomy. Clin
computer-assisted navigation versus image intensifier- Orthop Relat Res. 2014;472:126–32.
guided conventional total knee arthroplasty: a pro- 18. Mason JB, Fehring TK. Management of extra-
spective, randomized, single-surgeon study of 467 articular deformity in total knee arthroplasty with
knees. J Arthroplasty. 2007;22:953–9. navigation. In: Scott WN, editor. Insall & scott sur-
16. Mullaji AB, Padmanabhan V, Jindal G. Total knee gery of the knee. Philadelphia: Elsevier Churchill
arthroplasty for profound varus deformity: technique Livingstone; 2012. p. 1234.
and radiological results in 173 knees with varus of more
than 20 degrees. J Arthroplasty. 2005;20:550–61.
The Stiff Knee
9
Introduction aggressive postoperative rehabilitation is the key

to improve overall function after TKA in stiff
A stiff knee is defined as having a range of motion knees. In this chapter, the authors describe their
of less than 50° [1]. The most common cause of approach to treating stiff arthritic knees with
stiffness in an arthritic knee is osteoarthritis and TKA.
rheumatoid arthritis [2–6]. Less common causes
include previous trauma, surgery, infection,
ankylosing spondylitis, psoriatic arthritis and Pathoanatomy
haemophilic arthropathy [2–6].
Approaching a stiff knee for TKA is not only Stiffness in arthritic knees undergoing TKA is
difficult but is fraught with risks. This is one situ- mainly a consequence of severe soft-tissue adhe-
ation where a tibial tubercle osteotomy or a quad- sions within and around the joint. This is more
riceps snip may be required to achieve adequate pronounced in stiffness caused due to previous
exposure [7]. Furthermore, stiffness of soft tis- trauma, surgery or infection. In cases with osteo-
sues and the associated osteoporosis put these arthritis and rheumatoid arthritis, large multiple
knees at high risk for inadvertent intraoperative osteophytes and adaptive bone changes may
fractures or soft-tissue avulsions [3, 4]. Apart cause mechanical blocks to knee movement, fur-
from the difficulty in approaching the knee dur- ther aggravating the stiffness.
ing TKA, stiff knees usually have significant Adhesions tethering the quadriceps muscle in
changes in the intra- and periarticular soft tissues the suprapatellar area along with severe patello-
which make soft-tissue release and balancing femoral arthritis (Fig. 9.1) can be a major cause
more challenging. In addition to excessive fibrous of limited flexion. Contraction of the posterior
tissue within the joint, important soft-tissue capsule along with large osteophytes posteriorly
structures such as the quadriceps, cruciates and can block extension (Fig. 9.1). Fibrous tissue in
collateral ligaments and the joint capsule may be the lateral and medial gutters, posterior compart-
scarred and contracted. Hence, the integrity and ment and the suprapatellar pouch and around
competence of these important soft-tissue stabi- soft-tissue structures such as cruciates, collater-
lisers of the knee is unclear and often difficult to als, quadriceps and flexor tendons can severely
assess. restrict joint range of motion.
Although technically demanding, TKA in stiff A thorough examination of the knee under
knees has been reported to significantly improve anaesthesia will give clues about the actual type
knee range of motion and function [2–4, 8–10]. of deformity in the coronal plane (varus or valgus)
However, meticulous surgical technique and and the amount of medio-lateral laxity present
124 9 The Stiff Knee
Fig. 9.1 Preoperative lateral knee radiograph showing

severe patellofemoral arthritis which will restrict knee
flexion and large posterior femoral osteophyte (arrow)
which will restrict knee extension
(Fig. 9.2). It will also enable the surgeon to assess

the actual knee ROM which might be severely
restricted if examined without anaesthesia due to
pain and reactive (muscular) spasm. A proper
assessment of medio-lateral soft-tissue imbalance
can only be possible once the knee has been
exposed and the range of motion improves with
excision of fibrous tissue, cruciates and osteo-
Fig. 9.2 Examination of the knee under anaesthesia to
phytes. The key is to proceed with caution and
determine the type of coronal deformity and severity of
patience and release all the fibrous tissue and teth- knee stiffness. (a) Medial laxity with a valgus stress at the
ered soft-tissue structures and excise all the osteo- knee joint. (b) Lateral laxity with a varus stress at the knee
phytes. In most cases, this will correct the flexion joint. (c) Maximum knee flexion. (d) Maximum knee
extension
and extension deformity to a large extent, and the
surgeon will achieve adequate exposure of the
joint to proceed with the actual TKA procedure.

c
Patients with a stiff knee need to be counselled the knee in extension (Fig. 9.3). All the parapatel-
in detail about their expectations and the likely lar and anteromedial femoral osteophytes are
outcome. They must be told that they may not excised. A thorough synovectomy is performed.
achieve as much flexion as a person without long- The infrapatellar fat pad, medial patellofemoral
standing stiffness and must not compare their ligament, fibrous tissue in the suprapatellar pouch
progress with other patients undergoing routine (or any fibrous bands tethering the quadriceps
TKA! Also it must be emphasised to them that muscle) and medial gutter are excised, and the
they will need to undergo extensive physiother- tibial attachment of anteromedial capsule is
apy to maintain and augment the range obtained released using electrocautery. A block pin is
at surgery. inserted into the patellar tendon attachment on
the tibial tuberosity to prevent any inadvertent
avulsion while the knee is flexed.
Surgical Technique The aim should not be to achieve eversion but
to obtain sufficient lateral subluxation of the
Adequate exposure of the joint is initially patella. A preliminary release of the lateral reti-
restricted due to immobility of the extensor appa- naculum may be required to achieve sufficient
ratus. After a medial parapatellar arthrotomy, mobility of the patella. With the patella laterally
exposure is extended in the deeper planes with displaced and held in place using a Hohmann’s
a b
Fig. 9.3 Intraoperative photographs showing approaches rongeur and osteotome. (b) The patella is gently lifted
for the stiff knee in extension. (a) The parapatellar and using a towel clip to reach the lateral aspect for a retinacu-
anteromedial femoral osteophytes are removed using a lar release
retractor applied on the lateral side of the tibia,

the knee is then gently flexed as much as possi-
ble. Intercondylar notch osteophytes are now
removed using a narrow osteotome, and both cru-
ciates and the medial meniscus are excised.
Osteophytes on the lateral aspect of the femoral
condyle and the medial aspect of the tibial pla-
teau are now excised. A preliminary medial soft-
tissue release (deep medial collateral ligament,
posteromedial capsule and semimembranosus) is
now done using electrocautery to achieve ante-
rior dislocation of the tibia. The lateral meniscus
is excised after the tibia has been displaced for-
wards. Rarely, large posterior osteophytes may
act as a mechanical block and prevent anterior
displacement of the tibia (Fig. 9.4). In such cases,
they need to be detached using a thin, narrow
osteotome inserted in the joint gap. The remain-
der of these osteophytes are removed after the
tibial cut has been performed for better access.
All these steps will further improve knee flexion
and expose the tibial plateau for bone cut. A pos-
terior capsular release may be required for resid-
ual flexion deformity present despite excision of
osteophytes; this is done at its attachment to the Fig. 9.4 Preoperative lateral knee radiograph showing a
posterior femoral condyles. The TKA is then per- large posterior tibial osteophyte (arrow) which acts as a
formed in a routine manner in terms of deformity mechanical block and prevents anterior dislocation of the
tibia
correction and ligament/gap balance (Fig. 9.5).
a b
c e f
Fig. 9.5 Postsurgical stiff arthritic knee treated with a radiograph of the same patient. (e) Postoperative full-
cruciate-substituting (CS) design. (a) Preoperative clini- length hip-to-ankle radiograph of the same patient (c)
cal photograph showing maximum knee flexion. (b) showing complete restoration of limb mechanical axis
Preoperative clinical photograph showing maximum knee with a cruciate-substituting knee implant. Note that the
extension. (c) Preoperative anteroposterior standing knee tibial nail had to be removed before TKA to facilitate
radiograph of the same patient (a, b) showing an intra- implantation of the tibial component. (f) Postoperative lat-
medullary tibial nail in situ. (d) Preoperative lateral knee eral knee radiograph of the same patient (c)
The authors occasionally perform a quadri- Quadriceps strengthening exercises along with
ceps snip but never a V-Y plasty or turndown to electric stimulation and gravity-assisted active
achieve exposure. Very rarely, a tibial tubercle knee flexion and extension exercises and full
osteotomy (TTO) may have to be performed to weight-bearing walking with support are started
achieve adequate exposure. However, the authors after 48 h. Working closely with a physiothera-
use a more conservative modification of the con- pist and frequent monitoring of their progress are
ventional TTO technique which involves detach- essential to obtain optimal function in these diffi-
ing the patellar tendon from the tibial tubercle cult cases. Subsequently, stationary bicycling and
with a thin layer of bone using a sharp osteotome swimming are encouraged.
(refer to Chap. 11), leaving the extensor mecha-
nism intact distally and laterally. The osteot-
omised bone fragment detached with the tendon References
heals when the capsulotomy is repaired without
the need for fixation in this technique. 1. Aglietti P, Windsor RE, Buzzi R, Insall JN.
Arthroplasty for the stiff or ankylosed knee.
A quadricepsplasty is a useful technique to
achieve greater flexion in these stiff knees. This is 2. Rajgopal A, Ahuja N, Dolai B. Total knee arthro-
initiated by isolating 3–5 cm length of the deeper plasty in stiff and ankylosed knees. J Arthroplasty.
layer of the vastus intermedius tendon from the 2005;20:585–90.
3. Bhan S, Malhotra R, Kiran EK. Comparison of total
rest of the quadriceps tendon insertion into the
knee arthroplasty in stiff and ankylosed knees. Clin
upper pole of the patella. A length of 2 cm or so Orthop Relat Res. 2006;451:87–95.
of the intermedius tendon is excised. The knee is 4. Massin P, Lautridou C, Cappelli M, Petit A, Odri G,
gently manipulated to check the improvement in Ducellier F, Sabatier C, Hulet C, Canciani JP,
Letenneur J, Burdin P, Société d’Orthopédie de l’Ouest.
flexion. If more range is desired, pie crusting of
Total knee arthroplasty with limitations of flexion.
the rectus tendon is performed using an 11 num- Orthop Traumatol Surg Res. 2009;95(4 Suppl 1):
ber stab knife to make multiple transverse nicks S1–6.
in the tendon in a staggered fashion. The knee is 5. Su EP, Su SL, Della Valle AG. The stiff knee – expo-
sure and management. Tech Orthop. 2011;26:105–10.
then manipulated again so that there is lengthen-
6. Argenson JN, Vinel H, Aubaniac JM. Total knee
ing of the tendon and further flexion achieved. arthroplasty for the stiff knee. In: Bonnin M, Chambat
Postoperatively, aggressive physiotherapy P, editors. Osteoarthritis of the knee – surgical treat-
is recommended to maintain and improve on ment. Paris: Springer; 2008. p. 315–21.
7. Barrack R. Surgical exposure of the stiff knee. Acta
the range of motion gained after TKA. A 90/90
Orthop Scand. 2000;71:85–9.
anterior splint from the proximal thigh to the 8. Bae DK, Yoon KH, Kim HS, Song SJ. Total knee
ankle is applied in the operation theatre before arthroplasty in stiff knees after previous infection.
the patient is shifted. This is removed along with J Bone Joint Surg Br. 2005;87:333–6.
9. Fosco M, Filanti M, Amendola L, Savarino LM,
the drain the next day morning, and the patient
Tigani D. Total knee arthroplasty in stiff knee com-
is put on continuous passive motion (CPM) pared with flexible knees. Musculoskelet Surg.
machine for the next 48 h. A muscle relaxant is 2011;95:7–12.
given orally to the patient along with analgesic/ 10. Hsu CH, Lin PC, Chen WS, Wang JW. Total knee
arthroplasty in patients with stiff knees. J Arthroplasty.
anti-inflammatory medications to prevent muscle
2012;27:286–92.
spasms and pain while the patient is on CPM.
The Unstable Knee
10
Excessive soft-tissue laxity is frequently Severe arthritic knee deformities are associated
encountered in severely deformed arthritic with significant tibio-femoral bone erosions and
knees undergoing TKA [1]. It is usually uni- or adaptive changes in the periarticular ligaments
biplanar where the lateral side (in varus defor- and soft tissues. In varus deformities, bony ero-
mity) or medial side (in valgus deformity) sion of the medial tibia and femur, periarticular
shows excessive laxity with or without an asso- inflammation and osteophytes cause gradually
ciated posterior laxity (in hyperextension defor- relative shortening and stiffness of the medial
mity) [2]. However, rarely, an arthritic knee soft-tissue structures [2]. The patient subse-
undergoing TKA may also show multiplanar or quently walks with a varus moment at the knee
global laxity where there is significant medial, causing gradual adaptive elongation of the lateral
lateral and posterior ligamentous insufficiency soft-tissue structures [2]. Hence, severe varus
along with significant bone loss. Although deformities typically present with medial soft-
extremely rare in osteoarthritis or rheumatoid tissue contracture and excessive laxity on the lat-
arthritis, severe or global knee instability may eral side. Similarly, in valgus knees, the lateral
be secondary to a neuromuscular disorder (such soft-tissue structures show contracture and there
as post-poliomyelitis, spinal neuropathy) or due is laxity on the medial side. This scenario may be
to post-traumatic global ligamentous insuffi- compounded by additional laxity or contracture
ciency [2–7]. of posterior soft-tissue structures if there is an
Lack of competent and functional collateral associated hyperextension or flexion deformity.
ligaments makes it extremely difficult for the This complex situation results in medio-lateral as
surgeon to achieve optimum soft-tissue bal- well as flexion-extension gap asymmetry.
ance in an unstable knee using conventional Although most arthritic knees undergoing
cruciate-substituting implants. This gets even TKA can be dealt with using standard cuts, gradu-
more challenging when the knee has an associated soft-tissue release and a cruciate-substituting
ated hyperextension due to lax and stretched knee design, knees with significant laxity or insta-
out posterior soft-tissue structures. Hence, an bility need to be tackled differently.
unstable knee is one of the rare occasions Based on the authors’ experience, instability
where a constrained or hinged prosthesis may encountered in arthritic knees undergoing TKA
be required during primary TKA. This chapter can be classified into three types (Table 10.1):
outlines the management of instability during Type 1, severe coronal plane (medial or lateral)
primary TKA. laxity; Type 2, severe coronal (medial or lateral)
130 10 The Unstable Knee
Table 10.1 Classification of instability

a b
Type 1: Severe coronal plane (medial or lateral) laxity
Type 2: Severe coronal (medial or lateral) and sagittal
(posterior) plane laxity
Type 3: Global (medial, lateral and posterior) laxity
M L A P
Fig. 10.2 Type 2 instability. The lateral side (L) in varus

knees or the medial side (M) in valgus knees (a) and the
M L posterior aspect (P) of the knee (b) show excessive laxity
a b
A P
M
Fig. 10.1 Type 1 instability. The lateral side (L) in varus
knees or the medial side (M) in valgus knees shows exces-
sive laxity
and sagittal plane (posterior) laxity; and Type 3,

global (medial, lateral and posterior) laxity. In
Type 1 instability, the lateral (in varus deformity)
or medial (in valgus deformity) soft-tissue struc- Fig. 10.3 Type 3 instability. The lateral (L), medial (M)
tures may show significant laxity and pose a (a) and posterior (P) aspect (b) of the knee show excessive
challenge in equalising the medio-lateral gap laxity
balance (Fig. 10.1). In Type 2 instability, in addi-
tion to the lax lateral or medial soft-tissue struc- the knee (medial, lateral and posterior) shows
tures, the posterior structures may be attenuated significant laxity and the patient may present
due an associated hyperextension deformity with a subluxated or a dislocated knee joint
(Fig. 10.2). In Type 3 instability, three sides of (Fig. 10.3).
Pathoanatomy 131
a b
Fig. 10.4 Clinical photographs of a patient showing (b) Excessive laxity on the medial side on applying a val-
global or Type 3 instability. (a) Excessive laxity on gus stress at the knee. (c) Excessive laxity posteriorly
the lateral side on applying a varus stress at the knee. resulting in a hyperextension deformity at the knee
Global laxity as seen in Type 3 instability, knee instability, and the resultant muscular atro-
although rare, is usually associated with an phy especially of the knee extensors accentuates
underlying neuropathic component (Fig. 10.4). A posterior instability. Hence, such patients with
common cause for it is spinal degeneration and Type 3 instability who undergo TKA will require
the resulting neuropathy involving both lower prolonged postoperative physiotherapy to
limbs. Furthermore, many of these patients have improve muscle strength around the knee joint
not been walking due to severe arthritic pain and and treatment of the underlying neuropathy.
Surgical Technique by downsizing the tibia tray (compatible with the

femur size) at this point will help further reduce
In view of excessive laxity and bony erosion this medio-lateral discrepancy in the extension
commonly associated with unstable knees, the gap (Fig. 10.5). In view of the substantial soft-
tibial and the distal femoral cuts need to be con- tissue release done, the flexion gap may be much
servative (typically less than 8 mm). However, in larger than the extension gap which may require
Type 1 instability where the patient has an associ- upsizing of the femur to achieve flexion-exten-
ated fixed flexion deformity, the tibial cut needs sion balance. This may sometimes have to be
to be adequate (8–10 mm) since the extension combined with a constrained design to account
gap may be smaller when compared to the flexion for the large flexion gap (Fig. 10.6). Rarely, a
gap. Surgical technique may have to be modified medial condylar or lateral epicondylar osteotomy
based on the type of instability present. may be required if the medial or lateral gap is
tighter despite maximum soft-tissue release in
varus or valgus knees, respectively (Fig. 10.7).
Type 1 Instability
For varus knees, a graduated stepwise medial Type 2 Instability

soft-tissue release is performed in order to correct
the varus deformity. However, typically, although On account of the posterior laxity encountered in
the mechanical axis may get fully restored to Type 2 instability, soft-tissue release should be
180°, the lateral side will still show excessive lax- strictly avoided posteriorly, and the tibial and dis-
ity vis-à-vis the medial side. This can be con- tal femur bone cuts must be conservative.
firmed by applying a varus stress at the knee with Although the technique to achieve medio-lateral
the knee in full extension. A reduction osteotomy balance in extension is similar to Type 1, due to
a b c d
Fig. 10.5 Type 1 instability in a varus arthritic knee anteroposterior standing knee radiograph showing the
treated with a cruciate-substituting (CS) design. (a) same patient (a) treated with a simple CS design. Note
Preoperative anteroposterior standing knee radiograph that medial tibial bone defect has been treated with an
showing excessive opening of the lateral joint space autologous bone graft fixed with Kirschner wires
(arrow) implying excessive soft-tissue laxity on the (arrow) and supplemented with a long tibial stem. (d)
lateral side. (b) Preoperative lateral knee radiograph Postoperative lateral knee radiograph of the same
showing mild flexion deformity. (c) Postoperative patient (c)
a b c d
Fig. 10.6 Type 1 instability in a varus arthritic knee knee radiograph showing flexion deformity. (c)
treated with a constrained design. (a) Preoperative antero- Postoperative anteroposterior standing knee radiograph
posterior standing knee radiograph showing excessive showing the same patient (a) treated with a constrained
opening of the lateral joint space implying excessive soft- design. (d) Postoperative lateral knee radiograph of the
tissue laxity on the lateral side. (b) Preoperative lateral same patient (c)
a b c d
Fig. 10.7 Type 1 instability in a valgus arthritic knee standing knee radiograph showing the same patient (a)
treated with a lateral epicondylar osteotomy and constrained treated with a constrained design. Note that a lateral epicon-
design. (a) Preoperative anteroposterior standing knee dylar osteotomy along with subperiosteal excision of the
radiograph showing excessive opening of the medial joint fibular head (arrow) was required in order to equalise the
space (arrow) implying excessive soft-tissue laxity on the rigid lateral gap with the lax medial gap. The resultant large
medial side. (b) Preoperative lateral knee radiograph show- flexion gap necessitated the use of a constrained design. (d)
ing mild flexion deformity. (c) Postoperative anteroposterior Postoperative lateral knee radiograph of the same patient (c)
associated hyperextension, the extension gap is However, owing to substantial soft-tissue release
expected to be large [8]. Hence, the femoral to correct the varus/valgus deformity, the flexion
component may have to be downsized to match gap may also become significant in some knees.
the large extension gap to the smaller flexion gap. Hence, a constrained design is more likely to be
a b c
Fig. 10.8 Type 2 instability (post-poliomyelitis) in a on the right side. (b) Postoperative anteroposterior stand-
varus arthritic knee treated with proximalisation of the lat- ing knee radiograph showing the same patient (a) treated
eral epicondyle and a constrained design. (a) Preoperative with a constrained design. Owing to the enormous discrep-
anteroposterior standing knee radiograph showing exces- ancy between the lateral and medial side, the lateral col-
sive opening of the lateral joint space (arrow) and a large lateral ligament was shortened using a lateral epicondylar
joint divergence angle (dashed line). The patient had post- osteotomy where the lateral epicondyle was proximalised
poliomyelitis residual paralysis of the right lower limb and and fixed with cancellous crews. (c) Postoperative lateral
a combination of varus and hyperextension knee deformity knee radiograph of the same patient (b)
used here than in Type 1 instability. Rarely, the Type 3 Instability

lateral collateral ligament (LCL) may show enor-
mous elongation (such as in post-poliomyelitis Incompetent collateral ligaments along with an
limbs) in varus knees where a lateral epicondylar attenuated posterior capsule pose a complex
osteotomy with proximalisation of the LCL challenge to the surgeon in terms of ligament bal-
attachment (to effectively shorten the LCL) is ance during TKA. Such knees also show signifi-
warranted (Fig. 10.8). This procedure is espe- cant joint subluxation and bone loss (Fig. 10.10).
cially preferred in young patients where a hinge Although optimal ligament balance may be elu-
knee design is best avoided. Significant bone loss sive in such cases, the surgeon must follow the
which is frequently encountered in such cases basic principles of conservative tibial and distal
needs to be addressed using autologous bone femoral bone cuts and minimal soft-tissue release
grafts supplemented with a long tibial stem in these cases. Owing to large extension and flex-
(Fig. 10.9). ion gaps, a simple CS or constrained prosthesis
a b c d e
Fig. 10.9 Type 2 instability in a varus arthritic knee treated hip-to-ankle radiograph showing complete restoration of
with a constrained design. (a) Preoperative standing, full- limb alignment (dotted line) after TKA with constrained
length hip-to-ankle radiograph showing profound varus prosthesis. (d) Postoperative anteroposterior standing knee
deformity of approximately 40° on the left side. (b) radiograph of the same patient (c) showing TKA done with a
Preoperative anteroposterior standing knee radiograph of the constrained design and the medial tibial bone loss treated
same patient (a) showing joint subluxation and significant with autologous bone graft fixed with screw. (e) Postoperative
medial tibial bone loss. (c) Postoperative standing, full-length lateral knee radiograph of the same patient (d)
a b c d
Fig. 10.10 Type 3 instability treated with a hinge knee. (a) severe posterior tibial bone loss and a large slope (arrow).
Preoperative anteroposterior standing knee radiograph sig- (c) Postoperative anteroposterior standing knee radiograph
nificant joint subluxation and significant medial tibial bone showing the same patient (a) treated with a hinge knee. (d)
loss. (b) Preoperative lateral knee radiograph showing Postoperative lateral knee radiograph of the same patient (c)
(such as TC3 or VVC) may not be sufficient to the additional stresses on the implant/cement/
provide stability, and most of these knees may bone interface [3]. A rotating hinge is preferable
require a hinged prosthesis which requires more to reduce the forces on the fixation, and tibial and
solid fixation in the femur and tibia to withstand femoral sleeves and/or stems are essential [3].
a b c d
Fig. 10.11 Type 3 instability treated with a hinge knee tibial spine. (c) Postoperative anteroposterior standing
(same patient from Fig. 10.4). This patient had severe sen- knee radiograph showing the same patient (a) treated with
sorimotor neuropathy of both lower limbs due to lumbar a hinge knee. Note that a femoral stem could not be used
spine degeneration. (a) Preoperative anteroposterior in this patient owing to a narrow and bowed distal femoral
standing knee radiograph. (b) Preoperative lateral knee canal. (d) Postoperative lateral knee radiograph of the
radiograph showing complete dislocation of the knee joint same patient (c). Note the excessive anteroposterior cur-
with the anterior cortex of the distal femur resting on the vature of the distal femur
However, the surgeon must be cautious and vigi- which the patient is advised to remove the brace
lant while preparing the tibia and femur for three to four times a day and perform gentle,
sleeves and stems. The distal femur is typically active knee flexion and extension. Knee brace is
osteoporotic in the elderly and may be narrow discontinued at 4 weeks and patient allowed full
which puts it at high risk for fracture while activity. A long knee brace is also advised while
impacting with trial sleeves. The surgeon may walking in patients with preoperative Type 2
have to perform prophylactic wire cerclage instability with long-standing hyperextension
before preparing the distal femur for sleeves to deformity for 1 month to prevent recurrence of
prevent this complication. Furthermore, the distal recurvatum; they are also advised to use a pillow
femoral and tibial canal may be too narrow or under the knee while sleeping for 2–4 weeks. In
bowed in the coronal or sagittal plane to accom- Type 3 instability, although most patients show
modate a long intramedullary stem. The surgeon satisfactory early functional recovery, the authors
needs to take care while reaming the canal to pre- advice the use of a long knee brace and walker
vent any inadvertent cortical penetration, and during ambulation till the patient regains suffi-
very rarely the prosthesis may have to be cient muscle strength (knee and hip muscles) and
implanted without the stem (and only sleeve) if risk of fall is minimised (Fig. 10.12).
the canal is too narrow or bowed on the femoral In patients where the contralateral knee is
side (Fig. 10.11). unaffected or less severely deformed, we warn
Postoperative rehabilitation is routine for the patients before surgery that there may be
TKAs performed for Type 1 or Type 2 instability. some leg-length discrepancy between the two
However, in cases where an epicondylar/condy- legs which may require a shoe lift on the unoper-
lar osteotomy has been performed, the patient is ated side. This is unlikely however when both
allowed full weight-bearing ambulation with a knees are affected to a nearly equal extent in
long knee brace on the first postoperative day. terms of angular deformity and ligament
Knee movement is not allowed for 2 weeks after elongation.
a c
Fig. 10.12 Clinical photographs showing functional knee flexion. (b) Active knee extension in the sitting posi-
recovery (at 72 h postoperatively) in a patient with Type 3 tion. (c) Full weight-bearing ambulation with a walker.
instability where a hinge knee was used (same patient Note that a long knee brace has been applied on the oper-
from Figs. 10.4 and 10.11). (a) Gravity-assisted active ated side while walking
References 4. Tigani D, Fosco M, Amendola L, Boriani L. Total

knee arthroplasty in patients with poliomyelitis. Knee.
2009;16:501–6.
1. Mullaji AB, Shetty GM, Lingaraju AP, Bhayde S.
5. Jordan L, Kligman M, Sculco TP. Total knee arthro-
Which factors increase risk of malalignment of the
plasty in patients with poliomyelitis. J Arthroplasty.
hip-knee-ankle axis in TKA? Clin Orthop Relat Res.
2007;22:543–8.
2013;471:134–41.
6. Hernández-Vaquero D, Sandoval-García MA. Hinged
2. Vail TP, Lang JE, Van Sikes C. Surgical techniques
total knee arthroplasty in the presence of ligamentous
and instrumentation in total knee arthroplasty. In:
deficiency. Clin Orthop Relat Res. 2010;468:1248–53.
Scott WN, editor. Insall & Scott surgery of the knee.
7. Springer BD, Hanssen AD, Sim FH, Lewallen DG. The
Philadelphia: Elsevier/Churchill Livingstone; 2012.
kinematic rotating hinge prosthesis for complex knee
p. 1075–86.
arthroplasty. Clin Orthop Relat Res. 2001;392:283–91.
3. Morgan H, Battista V, Leopold SS. Constraint in pri-
8. Mullaji A, Lingaraju AP, Shetty GM. Computer-
mary total knee arthroplasty. J Am Acad Orthop Surg.
assisted total knee replacement in patients with arthri-
2005;13:515–24.
tis and a recurvatum deformity. J Bone Joint Surg Br.
2012;94:642–7.
Osteotomies in Total
Knee Arthroplasty 11
Introduction a medial closing wedge corrective osteotomy is

required, the intact fibula at the apex may not
Bone cuts and soft-tissue releases are the princi- allow complete closure at the osteotomy site, and
pal steps in TKA. However, some knees undergo- therefore a segmental fibular osteotomy will have
ing TKA may require an additional procedure in to be performed [6]. Sometimes in a stiff knee,
the form of an osteotomy. An osteotomy in pri- excessive soft-tissue contractures and severe
mary TKA is usually indicated in rigid or severe arthritis of the patellofemoral joint may result in
deformities to facilitate soft-tissue balance and poor exposure through the routine arthrotomy
deformity correction, to concomitantly correct an approach. A tibial tubercular osteotomy in such
extra-articular deformity or rarely to facilitate cases will facilitate adequate exposure of the
exposure of the joint. Frequently, in varus arthritic joint for TKA. Hence, the main indications of an
knees undergoing TKA, the medial and postero- osteotomy in primary TKA are (a) correction of
medial side of the tibial plateau shows adaptive limb malalignment in knee arthritis due to an
changes resulting in the formation of a prominent associated extra-articular deformity, (b) soft-
bony flare in this area (Fig. 11.1a). This causes tissue balance in severe and/or rigid knee defor-
local tenting of the medial soft-tissue structures mities and (c) surgical exposure in a stiff or
and contributes to knee deformity and medio- ankylosed knee joint. Each osteotomy as dis-
lateral soft-tissue imbalance (Fig. 11.1b). A cussed above has a specific role to play during
reduction osteotomy involves excision of this TKA (Fig. 11.2). This chapter aims to outline the
medial bony flare to decompress the medial soft- indications and technique of various osteotomies
tissue structures [1, 2]. Rarely, despite extensive used in primary TKA.
soft-tissue release and a reduction osteotomy, a
knee deformity may be too rigid and/or the
medio-lateral soft-tissue imbalance too severe to Types of Osteotomies
correct. In such cases a sliding medial condylar and Technique
osteotomy (SMCO) in a varus knee [3] or a lat-
eral epicondylar osteotomy (LEO) in a valgus Reduction Osteotomy of the Tibia
knee [4] may be required to achieve optimum
limb alignment and soft-tissue balance. Principle: A reduction osteotomy involves exci-
In cases with severe extra-articular deformi- sion of the posteromedial bony flare on the tibial
ties, a corrective osteotomy may be required plateau to decompress medial soft-tissue struc-
simultaneously with the TKA in order to facili- tures in a varus arthritic knee undergoing TKA
tate restoration of limb alignment [5–7]. However, (Fig. 11.1). This osteotomy works similar to the
in severe tibial extra-articular deformities where excision of osteophytes where they cause tenting
140 11 Osteotomies in Total Knee Arthroplasty
a b
Fig. 11.1 Medial and posteromedial bony changes of the standing radiograph showing the bony flare (triangle)
tibial plateau in varus arthritic knees. (a) Intraoperative which causes tenting of the medial soft-tissue structures
photograph showing posteromedial bony flare (dotted in varus arthritic knee
line) of the tibial plateau (arrows). (b) Preoperative knee
Fig. 11.2 Step-by-step technique of reduction osteotomy ing a valgus stress at the knee. Based on the “2-mm exci-
performed to achieve deformity correction and/or medio- sion for 1° degree correction” principle, a reduction
lateral soft-tissue balance in varus arthritic knees undergo- osteotomy of 5 mm is required in this case to achieve full
ing TKA. (a, b) Step 1 – Intraoperative recording of varus correction (or neutral alignment). (e, f) Step 4 – Using the
deformity of 17.5° (a) and maximum correctibility up to tibial tray of appropriate size as reference, the required
6.5° varus (b) on applying a valgus stress at the knee. (c) amount of osteotomy is marked on the tibial cut surface
Step 2 – Posteromedial soft-tissue release (deep medial (distance AB) along the margin of the tibial tray as seen in
collateral ligament, posteromedial capsule and semimem- the axial (e) and frontal (f) views. (g, h) Step 5 – Reduction
branosus) to achieve deformity correction and medio-lat- osteotomy performed along the marked line using an
eral soft-tissue balance. (d) Step 3 – Intraoperative osteotome as seen intraoperatively (g) and on a schematic
recording of final correction achieved after posteromedial diagram (h)
release shows a residual varus deformity of 2.5° on apply-
Types of Osteotomies and Technique 141
a c
b
d
e f
LATERAL MEDIAL
A B
ANTERIOR
g h
and a bowstring effect on the adjoining medial especially in arthritic knees with <15° preopera-
soft-tissue structure (Fig. 11.1). Reduction oste- tive varus deformity, the surgeon should be care-
otomy allows correction of deformity and medio- ful not to perform it in limbs where the varus
lateral soft-tissue balance without having to deformity is <5° or where the deformity is fully
resort to excessive soft-tissue release and acts as correctible as it may lead to excessive slackening
a soft-tissue sparing step. of soft tissue medially and overcorrection [1].
Indications: These include residual varus Furthermore, the surgeon needs to take care that
deformity of >2° (when measured using com- only the medial bony flare is excised (as previ-
puter navigation) or medio-lateral soft-tissue ously measured in relation to the residual varus
imbalance (excessive medial tightness or exces- deformity and keeping the tibial tray as the refer-
sive lateral laxity) despite sufficient medial soft- ence) and the osteotomy should not be too medial
tissue release (deep MCL, posteromedial capsule and excessive as this may detach the superficial
and semimembranosus) in a varus arthritic knee MCL which is attached 6–7 cm distal to the joint
undergoing TKA. line (Fig. 11.3). In case the patient has a signifi-
Technique: Reduction osteotomy can achieve cant medial bone loss which has been built up
deformity correction in a predictable manner with cement or bone graft, the fixation should be
using the “2-mm excision for 1° degree correc- supplemented with a long tibial stem (Fig. 11.4).
tion” formula especially in knees with <15° pre- Postoperative Care: Postoperative physiother-
operative varus deformity [1]. However, this apy is similar to that of a routinely performed
formula may not be as predictable in knees with TKA and no postoperative bracing is required.
>15° preoperative varus deformity due to associ-
ated severe medial soft-tissue contracture or lat-
eral soft-tissue laxity and/or an associated Sliding Medial Condylar
extra-articular deformity [1]. A step-by-step tech- Osteotomy (SMCO)
nique for this osteotomy is illustrated in Fig. 11.2.
Precautions: Since reduction osteotomy can Principle: A sliding medial condylar osteotomy
achieve deformity correction in a predictable involves detachment of a bony segment medially
manner (1° correction for every 2 mm of excision) from the medial femoral condyle with the medial
collateral ligament (MCL) attached to it. This

allows distal displacement and fixation of the
femoral attachment of the MCL (while preserv-
ing its attachment to bone) to increase the medial
gap vis-à-vis the lateral gap in varus arthritic
knees during TKA. Subperiosteal stripping of
tibial attachment of MCL or its detachment from
the femoral side with a wafer of bone is an impre-
cise technique and carries the risk of overrelease
and medio-lateral instability [8], whereas SMCO
is precise and quantitative and allows reposition-
ing the MCL more accurately.
Indications: These include rigid, recalcitrant
varus deformities not amenable to full correction
of limb alignment and/or medio-lateral imbal-
ance despite extensive medial soft-tissue release
(except superficial MCL and pes anserinus) and a
reduction osteotomy during TKA.
Technique: A step-by-step technique for this
osteotomy is illustrated in Fig. 11.5.
Precautions: This osteotomy is best avoided in
knees where the distal femur is small in size and
Fig. 11.3 Intraoperative photograph showing relation of
the reduction osteotomy (arrows) to the medial soft-tissue
where performing a SMCO carries the risk of
sleeve (MST). Note that the attachment of the superficial intraoperative fracture of the medial femoral con-
MCL (asterisk) is distal to the distal border of the reduc- dyle. The condylar bone block with the attached
tion osteotomy (arrows)
a b
Fig. 11.4 Pre- and postopera-

tive standing knee radiograph
of a case with varus arthritis in
which reduction osteotomy
has been performed as part of
TKA. (a) Preoperative
radiograph showing prominent
medial tibial bony flare with
medial tibial bone loss. (b)
Postoperative radiograph of
the same patient showing final
alignment after TKA with a
reduction osteotomy. The
medial bone loss has been
built up using bone autograft
fixed with Kirschner wires and
supplemented with a long
tibial stem
a b
c
d
Fig. 11.5 Step-by-step technique of sliding medial con- by which the medial condylar block needs to be shifted
dylar osteotomy (SMCO) performed to achieve deformity distally. This distance can be determined using either
correction and/or medio-lateral soft-tissue balance in navigation or a measuring scale. (i, j) Step 7 – Plane of the
varus arthritic knees undergoing TKA. (a, b) Step 1 – osteotomy cut is marked on the medial femoral condyle.
Intraoperative recording of varus deformity of 17.5° (a) The cut starts 5 mm lateral to the medial edge of the bony
and maximum correctibility up to 6.5° varus (b) on apply- medial condyle (red line) and continues obliquely in the
ing a valgus stress at the knee. (c) Step 2 – Posteromedial superomedial direction to exit distal to the adductor tuber-
soft-tissue release (deep medial collateral ligament, pos- cle (asterisk). The osteotomy is performed using a recip-
teromedial capsule and semimembranosus) to achieve rocating saw. (j, k) Step 8 – The amount by which the
deformity correction and medio-lateral soft-tissue bal- medial condylar block needs to be shifted distally is
ance. (d) Step 3 – Intraoperative recording shows a resid- marked on the block using a measuring scale and electro-
ual varus deformity of 3.5° on applying valgus stress at cautery. (l) Step 9 – The condylar block is now controlled
the knee despite posteromedial soft-tissue release. A using sutures (Vicryl no. 1) passed through its soft-tissue
reduction osteotomy will have to be performed to correct attachment. Dotted line signifies amount of bone marked
this residual deformity. (e) Step 4 – Reduction osteotomy on the condylar block which will be excised. (m) Step 10
done to correct the residual varus deformity based on the – The amount of bone previously marked on the condylar
“2-mm excision for 1° degree correction” principle. (f, g) block is now excised using a bone cutter. (n) Step 11 –
Step 5 – Intraoperative recording shows complete correc- The condylar block is now gently shifted distally and
tion of deformity after reduction osteotomy (f): however, repositioned in place using the attached sutures. The
on maximum varus stress to the knee the same knee shows medio-lateral balance and alignment are then checked
excessive lateral soft-tissue laxity (arrow) vis-à-vis the with trial implants in full extension and the knee in 90°
medial side (g). A SMCO is now required to achieve flexion with the condylar block in its new position. (o)
medio-lateral soft-tissue balance. (h) Step 6 – The differ- Step 12 – After cementing of the final implant, the condy-
ence between the medial and lateral gap in knee extension lar block is fixed in position using two to three cancellous
(distance CD–AB) is measured to determine the amount screws with the knee in 45° flexion
h i j
∗
C A
D B

k l
n o
MCL must be handled with care once it has been The condylar block must be controlled with the
osteotomised from the femoral condyle, with attached sutures at all times (especially during
sutures passed through its soft-tissue attachment. knee flexion or extension) as otherwise it may
fracture if directly handled using instruments or if passed through its soft-tissue attachment. The
it gets entrapped during knee movement. The con- block should be fixed with the knee in 45° flexion
dylar block should be fixed with the knee in 45° similar to SMCO, and underdrilling with a 2 mm
flexion to gain sufficient access to insert the drill bit is advisable in osteoporotic patients.
screws and to avoid excessive traction of the block Postoperative Care: Similar to SMCO, the
and distraction at the osteotomy fixation site. patient where a LEO has been performed is
Although the condylar block is fixed with two to allowed full weight-bearing ambulation with a
three 4-mm cancellous screws, underdrilling with long knee brace on the first postoperative day.
a 2-mm drill bit is advisable in osteoporotic Knee movement is not allowed for 2 weeks after
patients to achieve better purchase of screws. which the patient is advised to remove the brace
Postoperative Care: In cases where a SMCO three to four times a day and perform gentle,
has been performed, the patient is allowed full active knee flexion and extension. Knee brace is
weight-bearing ambulation with a long knee discontinued at 4 weeks and patient allowed full
brace on the first postoperative day. Knee move- activity. An anteroposterior standing and lateral
ment is not allowed for 2 weeks after which the knee radiograph is performed at 6 weeks to con-
patient is advised to remove the brace three to firm union at the osteotomy site.
four times a day and perform gentle, active knee
flexion and extension. Knee brace is discontinued
at 4 weeks and patient allowed full activity. An Corrective Osteotomy
anteroposterior standing and lateral knee radio-
graph is performed at 6 weeks to confirm union at Principle: Corrective osteotomy is performed
the osteotomy site. (usually a closing wedge) at the apex of an
extra-articular deformity (EAD) which com-
pounds an already severe intra-articular defor-
Lateral Epicondylar Osteotomy (LEO) mity in arthritic knees undergoing TKA. This
allows for restoration of the limb mechanical axis
Principle: A lateral epicondylar osteotomy to neutral alignment which may not be possible
involves detachment of the lateral epicondyle with intra-articular bony resections and releases
with the lateral collateral ligament (LCL) and alone during TKA.
popliteus tendon attached to it. This allows distal Indications: Corrective osteotomy may be
displacement and fixation of the LCL and indicated when bone resections of the distal
popliteus tendon (while preserving its attachment femur or proximal tibia compromise the collat-
to bone) to increase the lateral gap vis-à-vis the eral attachments or create a large asymmetric
medial gap in valgus arthritic knees during TKA. soft-tissue gap that may be difficult to balance.
Indications: These include rigid, recalcitrant Furthermore, corrective osteotomy for EADs is
valgus deformities not amenable to full correc- indicated if the EAD is 20° or more in the femur
tion of limb alignment and/or medio-lateral bal- and 30° or more in the tibia in the coronal plane
ance despite extensive lateral soft-tissue release and is close to the knee joint in order to restore
(including iliotibial band, posterolateral capsule limb mechanical axis [5, 7, 9].
and popliteofibular ligament) during TKA. Technique: In the femur, an intramedullary
Technique: A step-by-step technique for this femoral guide rod is unsuitable due to distorted
osteotomy is illustrated in Fig. 11.6. medullary canal and/or old hardware and in cases
Precautions: Similar to SMCO, this osteot- where a corrective osteotomy has been performed
omy is best avoided in knees where the distal and fixed with an intramedullary nail and/or plate
femur is small in size to prevent intraoperative and screws and TKA is to be performed subse-
fracture of the lateral femoral condyle. The epi- quently. Hence, computer navigation for TKA is
condylar bone block with the attached LCL and ideal for such situations as it bypasses any distor-
popliteus tendon must be handled using sutures tion of the femoral canal or hardware. Achieving
a b
C
A
B D
Fig. 11.6 Step-by-step technique of lateral epicondylar cut starts 2 mm medial to the lateral edge of the bony lat-
osteotomy (LEO) performed to achieve deformity correc- eral condyle and continues obliquely in the superolateral
tion and/or medio-lateral soft-tissue balance in valgus direction. The osteotomy is performed using a reciprocat-
arthritic knees undergoing TKA. (a) Step 1 – Intraoperative ing saw. (d) Step 4 – The amount by which the lateral epi-
recording of valgus deformity of 8° on applying a varus condylar block needs to be shifted distally is marked on the
stress at the knee and a medio-lateral gap mismatch of block using a measuring scale and electrocautery. The
6 mm (lateral gap tighter than the medial) despite lateral block is then controlled using sutures (Vicryl no. 1) passed
soft-tissue release (posterolateral capsule, iliotibial band, through its soft-tissue attachment, and the amount of bone
and popliteofibular ligament). A LEO needs to be per- previously marked on the condylar block is now excised
formed here to achieve deformity correction and medio- using a bone cutter. (e) Step 5 – The epicondylar block is
lateral soft-tissue balance. (b) Step 2 – The difference now gently shifted distally and repositioned in place using
between the medial and lateral gap in knee extension (dis- the attached sutures. The medio-lateral balance and align-
tance CD–AB) is measured to determine the amount by ment are then checked with trial implants in full extension
which the lateral epicondylar block needs to be shifted and the knee in 90° flexion with the epicondylar block in
distally. This distance can be determined using either navi- its new position. (f) Step 6 – After cementing of the final
gation or a measuring scale. (c) Step 3 – Plane of the oste- implant, the condylar block is fixed in position using two
otomy cut is marked on the lateral femoral condyle. The to three cancellous screws with the knee in 45° flexion

d e
stable fixation of the osteotomy performed in the otomy. A step-by-step technique for corrective
distal third of the femur is challenging due to the osteotomy in the femur is illustrated in Fig. 11.7.
distal flaring of the endosteal canal. The authors In the tibia, after adequate soft-tissue release and
have used femoral stems, sleeves with stems and the distal femoral cut, the tibial cut is performed at
retrograde intramedullary locked nails supple- an angle equal to the residual deformity remaining
mented by a derotation plate to stabilise the oste- after soft-tissue release to achieve rectangular
a b c d
Fig. 11.7 Step-by-step technique of corrective osteotomy lateral closing wedge osteotomy is performed to correct the
for femoral EAD during TKA. (a) Step 1 – The severity of EAD through a separate lateral incision. (c) Step 3 – The
femoral EAD is measured on preoperative standing knee osteotomy is fixed using an intramedullary interlocking fem-
radiograph. (b) Step 2 – The angle of wedge for the corrective oral nail. (d) Step 4 – The TKA is then performed in the
osteotomy is determined on preoperative radiograph, and a routine manner in the same sitting
flexion and extension gaps. The alignment is then site without the need for additional fixation [5].
fully restored by performing a closing wedge cor- However, the surgeon should be careful while pre-
rective osteotomy (equal to the residual deformity paring the tibial medullary canal (to accommodate
present) at the apex of the tibial deformity. A long the long stem of the tibial component) to avoid
cementless stem for the tibial component ensures inadvertent cortical penetration with the reamer tip
stability at the osteotomy site. The stem (which or the tibial stem extender tip. Intraoperatively, the
allows for compressive forces to act at the osteot- position of the trial tibial stem within the medul-
omy site) along with adjuvant bone grafting (can- lary canal should be verified with an image inten-
cellous bone obtained from TKA bone cuts) hastens sifier before final implantation.
union at the osteotomy site. A step-by-step tech- Postoperative Care: Knee movements and
nique for corrective osteotomy in the tibia is illus- partial weight-bearing ambulation in long-leg
trated in Fig. 11.8. knee brace is commenced 48 h postoperatively.
Precautions: The authors perform corrective Patients are allowed full weight-bearing ambula-
osteotomy simultaneously with TKA. Proper tion with a knee brace and stick if knee radio-
planning on preoperative radiographs is important graphs show satisfactory healing at 4–6 weeks.
to decide the apex and amount of osteotomy After 3 months, the brace and stick are discontin-
required to correct the extra-articular deformity ued once x-rays show that the osteotomy site had
(see Chap. 8 for details). In cases with femoral consolidated.
extra-articular deformity, fixation at the osteotomy
site is dictated by the anatomy of the femur and
site of osteotomy; it should be rigid so that postop- Tibial Tubercle Osteotomy (TTO)
erative rehabilitation is not delayed or restricted
after TKA. On the tibial side, a tibial component Principle: The conventional medial parapatellar
with a long stem helps in stabilising the osteotomy arthrotomy approach, although adequate in most
a b c d
Fig. 11.8 Step-by-step technique of corrective osteotomy incision. (c) Step 3 – The osteotomy is gently closed using
for tibial EAD during TKA. (a) Step 1 – The severity of a valgus force, and limb alignment is checked for correc-
tibial EAD is measured on preoperative standing knee tion. The tibial canal is then reamed using progressive large
radiograph. After performing the distal femoral cut, the reamers until endosteal “chatter” is felt. (d) Step 4 – The
tibial cut is performed at an angle equal to the tibial defor- osteotomy site is now stabilised with a trial tibial tray with
mity (dotted line) ignoring the tibial EAD. Solid line indi- a long stem, the extension and flexion gaps are balanced,
cates medullary axis of the tibia. (b) Step 2 – The angle of the femoral preparation is completed and the final align-
wedge for the corrective osteotomy is determined on preop- ment and balance are checked. During final implantation,
erative radiograph, and a lateral closing wedge osteotomy is only the tibial baseplate and metaphyseal part of stem are
performed to correct the EAD through a separate lateral cemented, taking care no cement enters the osteotomy site
knees, may not be sufficient to achieve good associated with a higher rate of complications
exposure in stiff or ankylosed knees especially such as skin necrosis, proximal migration of the
when associated with severe deformities. A tibial osteotomised tubercle, delayed or nonunion, per-
tubercle osteotomy (TTO) facilitates retraction of sistent extensor lag and patellar fracture [12–14].
the quadriceps mechanism and allows adequate Young et al. [13] in a review of TTO done for
exposure in stiff, ankylosed knees undergoing primary and revision TKAs reported that there is
TKA. The typical TTO involves detaching the an increased risk of patellar fracture when TTO is
patellar tendon with a block of the tibial tubercle combined with a lateral retinacular release which
and fixation of the block with either cortical may compromise the blood supply to the patella.
screws or wires. The V-Y quadricepsplasty Rarely, TTO may be combined with the lateral
technique is an alternative to improving exposure parapatellar arthrotomy in severe, fixed valgus
in such difficult knees during TKA. However, deformity with associated patellar maltracking or
this technique is associated with greater extensor patella baja [15] or may be used routinely for all
lag and carries the risk of avascular necrosis of primary TKAs in combination with an anterolat-
patella [10, 11]. eral approach [16, 17]. The rationale given for
Indications: Although frequently used in revi- routine use of such an approach is that it provides
sion TKAs [11], the use of TTO in primary TKAs better exposure, preservation of patellar blood
has not been universally accepted with doubts supply, intact sensation over the saphenous nerve
about its safety and reliability. Piedade et al. [12] distribution and preserving the extensor mecha-
in a comparison of 126 primary TKAs with TTO nism [16, 17].
and 1,348 primary TKAs without TTO reported Technique: A more conservative modification
no significant difference in terms of postopera- of the TTO technique involves detaching the
tive pain and function and revision rates between patellar tendon from the tibial tubercle with a thin
the two groups. However, this technique may be layer of bone using a sharp osteotome, leaving the
a b
Fig. 11.9 Tibial tubercle osteotomy (TTO) during TKA. showing frontal view after detachment of the tibial tuber-
(a) The patellar tendon is detached with a thin layer of cle. Note that the distal soft-tissue attachments of the
tubercular bone using a sharp osteotome. (b) tibial tubercle have been preserved. (d) Postoperative lat-
Intraoperative photograph showing lateral view after eral knee radiograph of the same patient taken 2 days
detachment of the tibial tubercle showing continuity of after surgery showing the repositioned tibial tubercle
the extensor mechanism. (c) Intraoperative photograph without any fixation
extensor mechanism intact distally and laterally. TTO and may have the risk of failure at its distal
The authors use this technique in cases of stiff attachment if care is not taken intraoperatively.
arthritic knees which undergo TKA as also when The layer of bone detached with the tendon facili-
performing a lateral approach for a severe valgus tates healing without the need for fixation.
deformity (Fig. 11.9). This technique has the Postoperative Care: Postoperatively, the
advantage of being less traumatic, less painful and patient is allowed full weight-bearing ambulation
not requiring fixation. However, this approach in a long knee brace with static quadriceps exer-
may provide less access compared to the typical cises (although straight leg rising is discouraged)
References 153
a b
Fig. 11.10 Fibular head resection during TKA. (a) the nerve. (b) Postoperative standing knee radiograph of
Preoperative standing knee radiograph of a patient show- the same patient (a) showing a fibular head resection
ing severe valgus deformity with an associated flexion (arrow) done to facilitate full correction of valgus defor-
deformity. Acute correction during TKA may put this mity and also to prevent excessive traction on the nerve
patient at risk for peroneal nerve palsy due to stretching of during correction with TKA
on the day after surgery. Gentle, active knee TKA. To minimise this risk, the authors subperi-
flexion-extension is started 4 weeks after surgery osteally resect the fibular head by osteotomising
with application of knee brace intermittently and it at the neck of the fibula (Fig. 11.10). The
knee flexion restricted up to 90° till the end of attachments of the biceps tendon and LCL are
8 weeks postoperatively. The brace is then discon- preserved as the dissection is subperiosteal – sim-
tinued and the patient encouraged to gradually ilar to the manner in which medial tibial osteo-
increase flexion beyond 90° over the next 4 weeks. phytes are resected subperiosteally without
damage to the MCL. Also in these cases, the knee
Segmental Fibular Osteotomy is kept flexed 10°–15° over a pillow till the anaes-
This may be indicated in cases of severe varus thesia wears out and the patient is able to dorsi-
tibial extra-articular deformity where performing flex the foot and toes subsequently. The patient is
a closed wedge tibial osteotomy at the apex of the encouraged to perform static quadriceps exer-
deformity may not afford full correction. cises to correct and maintain correction of the
Resecting 2 cm of fibula (subperiosteally) flexion contracture.
through a separate lateral approach is useful. A
safe level at which to resect the fibula is four fin-
gerbreadths above the lateral malleolus. References
Fibular Head Resection 1. Mullaji AB, Shetty GM. Correction of varus defor-
mity during TKA with reduction osteotomy. Clin
In severe valgus deformities with long-standing
Orthop Relat Res. 2014;472(1):126–32.
flexion contracture, there is a risk of peroneal 2. Dixon MC, Parsch D, Brown RR, Scott RD. The
nerve palsy from correcting the deformity at correction of severe varus deformity in total knee
arthroplasty by tibial component downsizing and resec- 11. Della Valle CJ, Berger RA, Rosenberg AG. Surgical
tion of uncapped proximal medial bone. J Arthroplasty. exposures in revision total knee arthroplasty. Clin
2004;19:19–22. Orthop Relat Res. 2006;446:59–68.
3. Mullaji AB, Shetty GM. Surgical technique: 12. Piedade SR, Pinaroli A, Servien E, Neyret P. Tibial
computer-assisted sliding medial condylar osteotomy tubercle osteotomy in primary total knee arthroplasty:
to achieve gap balance in varus knees during TKA. a safe procedure or not? Knee. 2008;15:439–46.
Clin Orthop Relat Res. 2013;471:1484–91. 13. Young CF, Bourne RB, Rorabeck CH. Tibial tubercle
4. Mullaji AB, Shetty GM. Lateral epicondylar osteot- osteotomy in total knee arthroplasty surgery.
omy using computer navigation in total knee J Arthroplasty. 2008;23:371–5.
arthroplasty for rigid valgus deformities. J Arthroplasty. 14. Zonnenberg CB, Lisowski LA, van den Bekerom MP,
2010;25:166–9. Nolte PA. Tuberositas osteotomy for total knee arthro-
5. Mullaji A, Shetty GM. Computer-assisted total knee plasty: a review of the literature. J Knee Surg.
arthroplasty for arthritis with extra-articular defor- 2010;23:121–9.
mity. J Arthroplasty. 2009;24:1164–9. 15. Apostolopoulos AP, Nikolopoulos DD, Polyzois I,
6. Mullaji AB, Padmanabhan V, Jindal G. Total knee Nakos A, Liarokapis S, Stefanakis G, Michos IV.
arthroplasty for profound varus deformity: technique Total knee arthroplasty in severe valgus deformity:
and radiological results in 173 knees with varus of more interest of combining a lateral approach with a tibial
than 20 degrees. J Arthroplasty. 2005;20:550–61. tubercle osteotomy. Orthop Traumatol Surg Res.
7. Mason JB, Fehring TK. Management of extra- 2010;96:777–84.
articular deformity in total knee arthroplasty with 16. Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh
navigation. In: Scott WN, editor. Insall & Scott sur- RA, Arnold MP, Friederich NF. Anterolateral
gery of the knee. Philadelphia: Elsevier Churchill approach with tibial tubercle osteotomy versus stan-
Livingstone; 2012. p. 1234. dard medial approach for primary total knee arthro-
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with medial epicondylar osteotomy to correct varus 2010;11:167.
deformity. Clin Orthop Relat Res. 1999;367:141–8. 17. Hay GC, Kampshoff J, Kuster MS. Lateral subvastus
9. Wang JW, Wang CJ. Total knee arthroplasty for arthri- approach with osteotomy of the tibial tubercle for
tis of the knee with extra-articular deformity. J Bone total knee replacement: a two-year prospective, ran-
Joint Surg Am. 2002;84:1769–74. domised, blinded controlled trial. J Bone Joint Surg
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2012;27:286–92.
Postoperative Pain Management
and Rehabilitation 12
Introduction Pain After TKA
Patients undergo TKA to gain relief from arthritic Postoperative pain is a complex phenomenon and
pain, to regain function and to improve their quality the aetiology of acute postoperative pain in TKA
of life. However, the patient needs to deal with sig- is still unclear. However, both systemic and local
nificant pain during the early postoperative period factors are known to play a role in it [9]. Patient-
after TKA. Postoperative outcome and satisfaction specific factors such as age, gender, aetiology of
after TKA depend to a large extent on optimal pain arthritis, prior experience, expectations and the psy-
control [1–3]. Suboptimal pain management after chological make-up all have been reported to play
TKA has severe consequences. It may not only a part in how postoperative pain is perceived and
lead to physical and emotional distress and dissat- experienced after TKA [10, 11]. Intraoperatively,
isfaction in the patient and relatives but often leads local factors such as the amount and depth of soft-
to longer hospital stay, delay in functional recovery tissue dissection or release, optimum limb align-
and non-compliance of patients with rehabilitation ment, component alignment and rotation and the
programme. Delay in mobilisation due to excessive soft-tissue balance achieved may have an associa-
pain may also put the patient at increased risk for tion with recovery from acute postoperative pain
systemic complications such as deep vein throm- and the risk of chronic persistent pain after TKA
bosis, pneumonia and thromboembolism [4, 5] or [9, 12–14]. Postoperatively, it has been reported
local complications such as residual knee defor- that control of the local rather than systemic
mity (usually fixed flexion deformity), limited knee inflammatory response may be more important for
ROM (typically flexion beyond 100°) and chronic early postoperative functional recovery [15].
pain at the surgical site [6–8]. Therefore, the impor- In view of various systemic and local factors
tance of optimal pain control after TKA cannot be involved in acute postoperative pain, a multi-
emphasised enough given the consequences. modal approach to pain control has now become
Postoperative physical rehabilitation after standard practice in patients undergoing TKA
TKA is equally important to help the patient [16, 17]. The principle of this multimodal
achieve full functional recovery as soon as approach is to deploy various techniques and
possible. Rehabilitation and pain control go pharmacological agents which will act synergis-
hand in hand, and optimal pain control is neces- tically at different levels to achieve optimal pain
sary to initiate early mobilisation and ambula- control after TKA. The authors use a similar mul-
tion and achieve functional recovery. This timodal pain control protocol involving preopera-
chapter aims to discuss the postoperative pain tive patient education, pre-emptive analgesia,
control and rehabilitation protocol being fol- optimal anaesthesia and surgical technique and
lowed by the authors. postoperative analgesia in order to minimise pain
156 12 Postoperative Pain Management and Rehabilitation
and facilitate early functional recovery of the Intraoperative Local Infiltration

patient after TKA.
What to infiltrate?
The periarticular infiltration “cocktail”
Multimodal Pain Management contains the following constituents diluted to
Protocol a total volume of 50 ml with 0.9 % normal
saline:
Preoperative Patient Education Bupivacaine 0.25 % (2.5 mg/kg)
Fentanyl 200 mcg (50 mcg/ml)
This involves educating the patient about the sur- Cefuroxime 750 mg
gical procedure and postoperative recovery course Triamcinolone 40 mg
after TKA. The patient is appraised about what to Ketorolac 30 mg
expect in terms of pain, complications and the Clonidine (1 mcg/kg)
time to reach a pain-free, fully functional joint The corticosteroid is excluded in patients with
after TKA. Patients are also encouraged to con- diabetes, rheumatoid arthritis, previous knee sur-
tact and discuss with patients who have already gery and any immunodeficiency disease.
undergone TKA and have now fully recovered. Where to infiltrate?
Edges of the arthrotomy, medial collateral
ligament, lateral retinaculum and posteromedial
Pre-emptive Analgesia soft-tissue sleeve
When to infiltrate?
After admission (previous night at 10 p.m.) – Tab After the components have been implanted
etoricoxib 60 mg and tab gabapentin 300 mg and while the cement is setting
Morning of surgery (at 6 a.m.) – Tab etoricoxib
60 mg and tab gabapentin 100 mg
Postoperative Analgesia
First 48 h
Anaesthesia
Tab paracetamol 650 mg 8 hourly + tab ibu-
profen 400 mg 12 hourly + diclofenac supposi-
Spinal anaesthesia (unilateral TKA) or combined
tory 12.5 mg, one at night + tab etoricoxib 60 mg,
spinal + epidural (for bilateral TKA)
one in the morning + tab gabapentin 300 mg, one
at night
Local ice fomentation every 6–8 h
Surgical Technique
After 48 h till suture removal (2 weeks)
Tab paracetamol 650 mg 8 hourly + diclofenac
Skin incision only as much as required (usually
suppository 12.5 mg, one at night + tab etoricoxib
extending from the upper pole of the patella to
60 mg, one in the morning + tab gabapentin
the tibial tuberosity)
300 mg, one at night
Minimise soft-tissue release by excision of
Tab ibuprofen 400 mg 12 h or as and when
osteophytes before any soft-tissue release,
needed
graduated stepwise soft-tissue release and reduc-
Local ice fomentation every 6–8 h
tion osteotomy before any substantial release in
After suture removal till 1 month
case of varus deformity
Full correction of knee deformity in both cor- Tab paracetamol 650 mg 8 hourly + tab
onal and sagittal planes, optimum component meloxicam 15 mg, one in the morning + tab
alignment and soft-tissue balance etoricoxib 60 mg, one at night + tab gabapentin
Complete homeostasis and airtight closure to 300 mg, one at night
minimise chances of a postoperative haematoma Tab ibuprofen 400 mg as and when needed
and facilitate proper wound healing Local ice fomentation every 6–8 h
Multimodal Pain Management Protocol 157
Rehabilitation Protocol day). The patients are made familiar with these
five exercises preoperatively using an illustrated
All our patients are instructed and trained in five instruction booklet which the patient can refer to
basic, simple exercises (Fig. 12.1) which need to from time to time postoperatively, and a resident/
be performed regularly throughout the day fellow/therapist demonstrates these exercises on
(10– 20 repetitions each, in 3–4 sessions per day 1 postoperatively. Subsequently, till the time
a b
c d
Fig. 12.1 The five basic exercises used in rehabilitation (d) Gravity-assisted active knee stretching. (e) Seated
after TKA. (a) Static quadriceps contraction. (b) Seated knee extension and flexion
straight leg raising. (c) Short arm knee extension.
of discharge, the patient is assessed everyday by 2. Improve knee range of motion

the surgeon for progress in knee motion and 3. Correct any residual flexion deformity or
functional ability. A physiotherapist is asked to extensor lag if present
intervene only in special cases with excessive 4. Improve gait
quadriceps weakness, slow improvement in knee 5. Be able to perform activities of daily living
flexion or gait abnormality. independently
Goals of Rehabilitation Postoperative Rehabilitation
1. Prevent wasting of the muscles and improve First 24 h

tone and strength of the muscles without On returning to room after surgery – in bed,
increasing pain ankle and toe movements, log rolling of both
Rehabilitation Protocol 159
lower limbs, static quadriceps contractions and Band resistance exercises and knee extension
turning on sides, 10 repetitions every hour using weight cuffs in cases with extensor lag.
Next day morning – static quadriceps contrac- Knee flexion is increased by graduated active
tion, short arm knee extension, seated knee knee flexion and recumbent cycling (Fig. 12.4).
extension and flexion, straight leg raising and Residual flexion deformity is corrected by
gravity-assisted active knee stretching (10 repeti- gravity-assisted active knee stretching and use of
tions every 6 h). Standing and short walk with a push-knee splint. Gait is improved with parallel
walker. Sitting on a chair bar walking, gait training and coordinated quad-
24–48 h riceps and hamstring training (Fig. 12.5).
Static quadriceps contraction, short arm knee
extension, seated knee extension and flexion,
straight leg raising and gravity-assisted active Special Cases
knee stretching (10 repetitions every 6 h).
Walk with walker or stick (Fig. 12.2). Sitting Bracing – Braces are usually avoided after TKA.
on a chair and commode chair Exceptionally, a long knee brace may be used in
48–72 h (discharge) patients with long-standing quadriceps weakness
Static quadriceps contraction, short arm knee to avoid sudden buckling of the knee and falls till
extension, seated knee extension and flexion, the quadriceps have regained strength. A long
straight leg raising and gravity-assisted active knee brace may also be indicated in cases with
knee stretching (10 repetitions every 6 h). long-standing hyperextension deformity of the
Walk with stick. Sitting on a commode knee and in cases where additional procedures
Stair climbing (Fig. 12.3), parallel bar walk- such as a corrective osteotomy, lateral epicondy-
ing and hip abductor strengthening in case of gait lar or medial condylar osteotomy has been
abnormality (waddling gait) performed. A push-knee splint may be indicated
Faradic stimulation two to three times a day in in cases with any residual flexion deformity to
case of significant quadriceps weakness and achieve gradual full correction postoperatively.
extensor lag Flexion Deformity – Although the authors
What should be achieved at the time of discharge? achieve full correction of flexion deformity in
Knee flexion of at least 100° in the sitting most cases intraoperatively, some patients with
position long-standing, severe preoperative flexion
Extensor lag or residual flexion deformity of deformity are at higher risk for recurrence. In
less than 10° such cases a push-knee splint is applied to be
Getting out of bed and getting up from a chair used while walking and for 40 min every 3–4 h at
without assistance rest. The splint is then gradually weaned off over
Walking with or without a stick 3–4 weeks.
Ability to use commode Hyperextension Deformity – Some patients
Stair climbing with a stick with long-standing, severe preoperative
72 h (discharge) to 2 weeks (suture removal) hyperextension deformity are at higher risk for
Static quadriceps contraction, short arm knee recurrence. Such patients are encouraged to keep
extension, seated knee extension and flexion, a pillow under their knee at rest for 2 weeks
straight leg raising and gravity-assisted active after surgery, and gravity-assisted quadriceps
knee stretching (10 repetitions every 6 h). tightening is avoided. A long knee splint is
Walk with stick. Sitting on a commode applied to be used while walking which is then
After 2 weeks gradually weaned off over 2–3 weeks.
Patients are clinically assessed at the end of Lateral Epicondylar or Medial Condylar
2 weeks postoperatively (during suture removal) Osteotomy – In cases where a lateral epicondy-
for muscle strength (quadriceps/hamstrings), lar or medial condylar osteotomy has been
residual deformity (flexion or extension lag), performed, the patient is allowed full weight-
knee flexion and gait, and specific exercises are bearing ambulation with a long knee brace on
prescribed. Quadriceps is strengthened by Thera- the first postoperative day. Knee movement is
a b
Fig. 12.2 Walking after TKA, 24–48 h postoperatively. (a) All patients can walk with a walker within 24 h of TKA.
(b) Most patients are able to walk with a stick by 48 postoperatively
not allowed for 2 weeks after which the patient flexion and extension. Knee brace is discontin-
is advised to remove the brace three to four ued at 4 weeks and patient allowed full
times a day and perform gentle, active knee activity.
Rehabilitation Protocol 161
a b
Fig. 12.3 Stair climbing after TKA, 48–72 h postoperatively. (a) All patients can climb steps by 72 h of TKA with the
help of a walking stick. (b) Most patients can climb steps by 72 h of TKA without the help of a walking aid
Fig. 12.4 Recumbent cycling to improve knee flexion

and flexibility after suture removal
a b
Fig. 12.5 Knee flexors strengthening with Thera-Band and flexors along with hip extensors and abductors need
resistance exercises in both sitting (a) and standing strengthening
(b) positions. To improve gait after TKA, knee extensors
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Index
A contracture classification, 77
Anaesthesia osteophytes in, 75, 76
severity of knee stiffness, 124 soft tissue structures, contracture of, 75, 76
valgus deformity, 61, 62 surgical technique
varus deformity, 46 computer assisted technique, 81
Aslam, N., 13 contracted tendons, fractional lengthening, 79
effect of posterior osteophytes, extension gap, 77,
79
B flexion-extension gap balancing, 78, 80
Bonnin, M.P., 97 hamstring tendons shortening, 79
intraoperative computer screen snapshots, 77, 78
E osteophytes removal, 77
Electromyography and nerve conduction studies posterior soft-tissue release, 77, 79
(EMG-NCV), 14 quadriceps weakness, 80
Engel, G.M., 95 splints and physiotherapy, 80
Extra-articular deformity (EAD)
causes of, 101, 102
computer assisted technique, 121 G
femoral Griffin, F.M., 75
canal, excessive distortion, 101, 103
coronal bowing, femoral shaft, 105, 111
femoral bowing, 105, 110 H
hip-to-ankle radiographs, 105 Healy, W.L., 69
intramedullary guide rod, 109 Hip-knee-ankle (HKA) axis, 60
shaft, excessive coronal bowing, 101, 104 Hyperextension deformity
sliding medial condylar osteotomy, 110, 115 incidence of, 85
high tibial osteotomy (HTO), 105, 107, 108 pathoanatomy
old implant removal, 112 minimal bone resection, 86
postoperative rehabilitation, 119 posterior soft-tissue laxity and attenuation, 85, 86
skin incision, 111 tibial slope in, 86
tibial cut thickness, 112 surgical technique
tibial tray positioning, 114 AP cutting block, 87
tibial computer assisted technique, 90–91
corrective osteotomy, 105, 113 intraoperative computer screen snapshots of, 87,
intra-articular ununited tibial stress fracture, 88
111, 118 outcome of, 87, 90
site of incision, 105, 107 postoperative management, 87
stress fractures classification, 105–107 tibial and distal femoral bone resection, 87
tibial tray placement, 110–112 varus knees release, 87
F I
Fibular head resection, 153 Instability
Flexion deformity type 1 (coronal medial or lateral laxity)
vs. coronal plane deformity, 75 with constrained design, 132, 133
pathoanatomy with cruciate-substituting (CS) design, 132
DOI 10.1007/978-1-4939-0566-9, © Springer Science+Business Media New York 2014
166 Index
Instability (cont.) principle, 139, 142

with lateral epicondylar osteotomy, 132, 133 technique, 141, 142
pathoanatomy, 130 tibial tubercle osteotomy, 150–153
postoperative rehabilitation, 136
type 2 (sagittal posterior plane laxity)
lateral collateral ligament (LCL) P
proximalisation, 134 Patellofemoral arthritis, 123, 124
pathoanatomy, 130 Peek, A.C., 13
postoperative rehabilitation, 136 Piedade, S.R., 151
tibial stem supplementation, 134, 135 Postoperative pain management
type 3 (global laxity) multimodal pain management protocol
with hinge knee, 134–136 anaesthesia, 156
pathoanatomy, 130 intra-operative local infiltration, 156
postoperative rehabilitation, 136, 137 postoperative analgesia, 156
pre-emptive analgesia, 156
pre-operative patient education, 156
K surgical technique, 156
Krackow, K.A., 95 rehabilitation (see Rehabilitation)
systemic inflammatory response, 155
Preoperative planning
L component size, 13
Lateral collateral ligament (LCL), 147 computer navigation system, 17–18
Lateral epicondylar osteotomy (LEO), 68 CT scan, 13
indications, 147 EMG-NCV, 14
postoperative care, 147 gap-balancing technique, 13
precautions, 147 hip-to-ankle radiograph
principle, 147 distal femoral resection, 5–7
technique, 147–149 extra-articular deformities/implant in situ, 8–10
Lombardi, A.J., 77 frontal/coronal alignment, 5, 6
preoperative joint divergence angle (JDA), 7
implant selection
M augments/wedges, 15
Magnetic resonance imaging (MRI), 13, 14, 97, 106 constraint, 15
Matsuda, S., 97 design, 14–15
Matsui, Y., 97 long stem extenders, 15
Mullaji, A.B., 8 knee anteroposterior (AP) radiograph
bone defect, 11
osteophytes, 11
N putative tibial tray, 10–11
Nagamine, R., 95 tibial and femoral resections, 10
knee lateral radiograph
joint line and patella height, 11, 13
O osteophytes, 12
Osteotomy tibial slope, 11
corrective osteotomy magnetic resonance imaging, 13–14
indications, 147 patient, 3
postoperative care, 150 physical examination, 4–5
precautions, 150
principle, 147
technique, 147, 149, 150 Q
fibular head resection, 153 Quadricepsplasty, 128
lateral epicondylar osteotomy (LEO), 147–149
segmental fibular osteotomy, 153
sliding medial condylar osteotomy (SMCO), R
142–147 Ranawat, A.S., 61
tibial reduction Rehabilitation
indications, 142 basic exercises, 157
postoperative care, 147 bracing, 159
precautions, 142 flexion deformity, 159
Index 167
goals of, 158–159 limb and gaps alignment, 38

hyperextension deformity, 159 navigating cutting blocks, 37, 38
knee flexors strengthening, 159, 162 surfaces registration, 36–37
lateral epicondylar, 159 extra-articular deformity (see Extra-articular
recumbent cycling, 159, 162 deformity)
stair climbing, 159, 161 flexion deformity (see Flexion deformity)
standing and short walk with walker, 159 gap balancing
type 1 or type 2 instability, 136 extension and distal femoral resection, 25, 33–34
Rotational deformity flexion, femoral sizing and rotation, 28–29, 34
femur hyperextension deformity (see Hyperextension
medio-lateral gap assessment, 97 deformity)
preoperative ct scan, 97, 98 instability (see Instability)
severity of varus deformity, 97 ligament balancing
varus vs. normal deformity, 97 equalising flexion gap, 26–28, 29
pathoanatomy equalising medial and lateral gap, 26–28
distal femoral bony landmarks, 96 soft-tissue release, 24–26
tibial torsion, 95–96 osteotomy (see Osteotomy)
tibial tuberosity, 97 patella, 35
tibial deformity, 98, 99 postoperative pain management (see Postoperative
pain management)
preoperative planning (see Preoperative planning)
S rotational deformity (see Rotational deformity)
Segmental fibular osteotomy, 153 stiff knee (see Stiff knee)
Sliding medial condylar osteotomy (SMCO), 69 surgery and exposure
indications, 143 anterior osteophytes, 30, 31
postoperative care, 147 anterior surface, 30
precautions, 143, 146, 147 cruciates, 30
principle, 142–143 knee dislocation, 30
technique, 143–146 menisci, 30
Staheli, L.T., 95 patella, 29
Stiff knee posterior osteophytes, 30, 31
definition, 123 tibial resection
patellofemoral arthritis, 123, 124 coronal plane, 30, 32
surgical technique mechanical axis, 32
cruciate-substituting (CS) design, 126, 127 medullary axis, 32
physiotherapy, 129 variations, 33
posterior tibial osteophyte, mechanical block, 126 tibial sizing and rotation, 34
quadricepsplasty, 128 valgus deformity (see Valgus deformity)
sufficient lateral subluxation, patella, 125 varus deformity (see Varus deformity)
synovectomy, 125
Sun, T., 97
Synovectomy, 125 V
Valgus correction angle (VCA), 5–7, 33, 65, 67
Valgus deformity
T algorithmic approach, 62, 66
Tibial torsion, 95–96 classical medial parapatellar approach, 62
Tibial tubercle osteotomy (TTO) computer-assisted technique, 70
indications, 151 electrocautery, 65
postoperative care, 152–153 fat pad flap, 64
principle, 150–151 IT band, 64
technique, 151–152 lateral and posterolateral aspects, 60, 64
Tibial tuberosity, 97 multiple stab incisions, 65
Total knee arthroplasty (TKA) patellar tracking, 66
cementing, 35 pathoanatomy
closure, 35 anteroposterior axis, 59–60
computer navigation system asymmetric wear/hypoplasia, 59, 60
bone cut verification, 37, 38 classification, 61
fixation arrays, 36 hindfoot valgus (flatfeet), 60, 61
gap balancing, 37–38 HKA axis, 60
168 Index
Valgus deformity (cont.) knee deformity>20°

patellar maltracking, 60 limb alignment and soft-tissue balance, 47, 53
posterior femoral condyles, 59 medial femoral bone defects, 54, 56
soft-tissue structures, 59, 60 medial tibial bone defects, 54–56
transepicondylar axis, 60 medio-lateral gap balance, 54
type 1 valgus deformity, 61 2-mm K-wires/cancellous screw, 54–56
type 2, 3 and 4 valgus deformity, 61–63 posteromedial tibia and medial femoral
type 5 valgus deformity, 61, 62, 64 condyle, 53
type 6 valgus deformity, 61, 65 tensioning device, 53
variants, 61 tibial stem extender, 54–56
popliteofibular ligament, 65, 68 valgus correction angle, 54
subperiosteal excision, 64, 67 osteophytes removed, 51
transepicondylar axis, 66 pathoanatomy
type 5 and 6 valgus deformity “at risk” knee, 49, 51
lateral approach, 67 clinical features, 46, 48
LEO, 68 extra-articular deformity, 47, 50
radiograph and VCA, 68 limb alignment and soft-tissue balance, 46, 47
SMCO, 69 medial soft-tissue structures, 45–46
VCA, 65, 68 preoperative radiographic features, 47, 49
Varus deformity stability and function, 45
computer-assisted technique, 57
deformity correction, 52
knee deformity <10°, 52, 53 Y
knee deformity 10°–20°, 52 Young, C.F., 151

Deformity Correction of Total Knee Arthroplasty

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Deformity

ISBN 978-1-4939-0565-2 ISBN 978-1-4939-0566-9 (eBook)

Library of Congress Control Number: 2014939034

© Springer Science+Business Media New York 2014

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

To Priyanka. Thank you for everything

Boston, MA, USA Richard D. Scott, MD

With rapid advancement in technology and materials in total knee arthro-

Mumbai, India Arun B. Mullaji

Arun B. Mullaji, FRCS Ed,

Gautam M. Shetty, MS Orth

Part I Preoperative Planning and Basic Technique of Total Knee

Tibial Sizing and Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

8 Extra-Articular Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Rehabilitation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Introduction are coming up for total knee arthroplasty (TKA)

A.B. Mullaji, G.M. Shetty, Deformity Correction in Total Knee Arthroplasty, 3

Physical Examination severe flexion deformity indicates the need for a

after surgery in order to improve the stance and Weight-Bearing Full-Length

may have to be combined with long tibial stem

Fig. 1.6 Implant in situ. (a)

used as an approximate guide. However,

Computed Tomography (CT) Scan

Preoperative Templating for

Computer Navigation (c) Instruments:

Fig. 1.13 Navigation

tibial cut each drawn perpendicular to their

The Arthritis Clinic

MIND Expectations, Mental/

SKIN & NAIL Lesions, Bleeding HIP Range, Abductors

THE ARTHRITS CLINIC

Valgus Correction Angle

Joint Divergeence Angle

Femoral/Tibial Bowing, Tibia Vara,

Extremes of implant size

Implant in-situ, prior Osteotomy

Condition of hip joints

References patients with varus osteoarthritic knees and healthy

With rapid advancement in technology and • Only posterior cruciate-substituting (CS)

A.B. Mullaji, G.M. Shetty, Deformity Correction in Total Knee Arthroplasty, 23

Ligament Balancing: The How to Assess Soft-Tissue Tension?

in a hyperextending knee it should be strictly alignment and medio-lateral balance

1.WHITESIDE’S LINE 4. ANTERIOR SURFACE

5.FLEXION GAP USING SPACER

3.POSTERIOR CUT LEVEL BASED ON SOFT TISSUE TENSION

to the laterally displaced patella helps to

Balancing in Flexion, Femoral

Patella cases where the tourniquet has not been used

Technique of Computer-Assisted TKR

The basic surgical technique followed by the

Fig. 2.11 Verification

Fig. 2.12 Optimised

Appendix Surgical Technique Workflow Chart for TKA

Clinical and Radiographic assessment

Exposure and preliminary release

Assessment of correctibility and gap imbalance

Assessment of extension gap balance and alignment

Distal femoral cut

Assessment of flexion gap balance