2. TECHNIQUES IN PRIMARY
TOTAL KNEE
ARTHROPLASTY:
Balancing !
Douglas E. Padgett, M.D.
Adult Reconstruction and Joint Replacement
Hospital for Special Surgery
New York, New York

3. DDIISSCCLLOOSSUURREESS
None Related to the topic of this
presentation
Consultant: Mako, Stryker
AAHKS: Board Member

4. Success in TKR
Basic tenets of Dr.
John Insall:
– TKR should be
thought of as a soft
tissue operation
– Failure to address the
soft tissue envelope
will result in:
Pain
Stiffness
Laxity

5. “Thinking is the hardest work
there is, which is the probable
reason so few engage in it “
Henry Ford
American entrepreneurr

6. FAILURE IN TKR
Often can be traced back
to original patho-anatomy
Varus knee
– Preop: Tight medial side
– Trial Components: knee
noted to be tight medially
– Additional tibia resected
– Result: knee “books open”
medially

7. Failure in TKR:
The Valgus Knee
Complex patho-anatomy
Rotation often difficult to
discern
Effect of deficiency of
posterolateral condyle
upon landmarks
Insufficient lateral side
release: results is
unstable arthroplasty

8. The Happy TKR

9. THE VARUS KNEE

10. BALANCING THE VARUS KNEE:
May be straight forward
Items for
consideration:
– Fixed versus flexible
– Tightness:
Flexion
Extension or both !
– Osteophytes
– Bone Loss
– Subluxation and or
effect upon rotation

11. The Varus Knee:
At times, a surgical challenge

12. APPROACH TO THE
VARUS KNEE
Standard medial
parapatella approach
Sharp dissection onto
the proximo-medial
tibia
Dissection interval
above the pes but
below the joint line
Subperiosteal
elevation

13. The Varus Knee
Remove all
osteophytes
STOP !!!
– Assess ligamentous /
soft tissue tightness
before proceeding

14. RELEASE OF THE FIXED
VARUS KNEE
TIGHTNESS IN
EXTENSION
– Posterior ½ of the
superficial MCL is
primary factor
– Anteromedial capsule
can also contribute

15. RELEASE OF THE FIXED
VARUS KNEE
Tightness in Flexion
– Anterior ½ of the
superficial MCL
– Semi-membraneossus
and posteromedial
capsule are tight

16. FIXED VARUS KNEE:
FLEXION
Check gap symmetry
(medial and lateral
sides)
– Release anterior
portion of superficial
MCL
Flexion space should
not be excessively
tight (I prefer some
ability to translate
forward)

17. FIXED VARUS KNEE:
EXTENSION
Sequential
subperiosteal
elevation of posterior
portion of superficial
MCL
Ensure symmetry
medial and lateral
sides
Knee must come to
full extension !

18. ROLE OF BONE RESECTION
EFFECT UPON BALANCING
While majority of
balancing is soft
tissue in nature:
– tibial resection in
coronal plane (varus-valgus)
will effect soft
tissues
– Femoral rotation
clearly affects soft
tissue tension
especially in flexion

19. BALANCING THE
VALGUS KNEE

20. THE VALGUS KNEE
Fixed vs correctable
Associated bone loss
Tightness:
– Flexion ?
– Extension ?
– Both ?
Status of MCL

21. STEP #1: EXPOSURE /
RESECTION
Medial parapatella
Minimal medial side
release
Tibial resection:
– Minimal cut
perpendicular to shaft
Femoral resection:
– I favor 2-3 degrees off
of femoral line

22. FLEXION SPACE RELEASES
Laminar spreader is
the best device
Pie-crusting of the
posterolateral capsule
and arcuate complex
Leave the popliteus
intact if possible.
– Can result in flexion
instability in varus

23. EXTENSION SPACE RELEASE
Tight structures:
– ITB
– Posterolateral capsule
Pie-crusting
technique with SLOW
gradual releases work
best in my hands.

24. FINAL PRODUCT:
Ligament balance: M=L
Gap Balance: Flexion=Extension

25. THE VALGUS KNEE
Adhering to the
concept of sequential
releases, majority of
knees can be
corrected with the use
of additional
constraint from the
articulation.

26. THE FLEXION CONTRACTED
KNEE

27. THE FLEXION CONTRACTED
KNEE
Considerations:
– Definition: 15 degrees
or greater loss of
extension
– ? Length of
contracture
– Status of skin, prior
incisions
– Neurologic exam

28. THE FLEXION CONTRACTED
KNEE
Deformity
Bone loss
Patella height

29. THE CONTRACTED KNEE:
Surgical Technique
May require extensile approach if knee is stiff
Start with standard resection
Remove all osteophytes

30. THE CONTRACTED KNEE:
Soft Tissue Work
PCL recession if
using CR knee
Posterior capsular
release
Posterior capsular
stripping up to level of
gastroc

31. THE FLEXION CONTRACTED
KNEE: Bone Resection
Optional distal
femoral cut
Effectively decrease
the extension space
? How much can you
take ?
– DO NOT
COMPROMISE
COLLATERALS !!
If unstable: constraint

32. THE CONTRACTED KNEE:
POSTOP CARE
Emphasis on
extension
No pillows under
knee
Pain control
Dynamic splinting but
watch the skin !!
Role for manipulation
is not clear!

33. TOTAL KNEE
ARTHROPLASTY
RECURVATUM

34. RECURVATUM
Seen predominantly
in neuromuscular
diseases:
– Polio
– Neuropathic joints
– Spinal cord patients
Can occasionally be
seen in rheumatic
conditions

35. RECURVATUM:
Options
Hyperextension up to
20 degrees:
– Attempt to “overstuff”
the extension space
– Must balance the
temptation to leave the
knee with a flexion
contracture:
If recurvatum is due to
quad weakness, flexion
contracture will lead to
knee giving out !

36. RECURVATUM
Use of distal femoral
augmentation
– Will tighten the
extension space while
not affecting the
flexion space
Limits of distal
femoral augments:
– 10-15 mm
– Usually require use of
femoral stems

37. RECURVATUM
Posterior stabilized
implants are preferred
Less constraining
implants may lead to
instability

38. RECURVATUM
Reliance upon
standard implants will
lead to excessive
anterior polyethylene
impingement
Wear and or
loosening is clearly a
consequence

39. RECURVATUM:
The larger deformities
In instances where
there is more than 20
degrees of
recurvatum: consider
a more constrained
implant with an
extension stop
DO NOT RELY
UPON STANDARD
CONDYLAR
DESIGNS !!

40. Primary TKR:
Summary
Understanding of pathoanatomy crucial
Correction of deforming forces is vital to
successful outcome
Know the limits of your prosthetic implant

41. THANK YOU FOR YOUR
ATTENTION !