2. Introduction
Indications
Contraindications
Pre op preparation
◦ Consent
◦ investigations
◦ Templating
Intra op
◦ Anaesthesia
◦ Antibiotics
◦ Positioning
◦ Exposure
3. ◦ bone cut
◦ Soft tissue balancing
◦ Trial components
◦ Implantation of prosthesis
◦ Closure
Post op
◦ Antibiotics
◦ Analgesics
◦ Anti DVT
◦ Physio
Complications
Conclusion
4. It is a surgical procedure where the articular
surfaces of the knee are replaced with a
prosthesis
The primary aim of TKR is to relieve pain and
restoration of normal function of the knee
5. Severe knee pain not amenable to
conservative management
◦ Degenerative OA
◦ Post traumatic OA
◦ Rheumatoid arthritis
◦ Crystalline arthropathy
Severe deformity
6. Absolute
◦ Infections
◦ Non functioning extensor mechanism
Relative
◦ Super obesity
◦ Severe peripheral vascular disease
◦ Poor bone stock
◦ Neuropathic arthropathy
◦ Poor condition of knee skin
◦ Significant medical comorbidities
7. History
◦ Indications met/no contraindications
◦ Comorbidities
◦ Drug history
Examination
◦ Alignment
◦ Deformity/instability
◦ ROM
◦ Extensor mechanism
◦ Distal neurovascular status is intact
16. Incision
◦ Knee in 90 degree
flexion
◦ Size 22 blade on size
4 bard parker
◦ Longitudinal straight
◦ 6 cm above patella
◦ 1 cm medial to the
tibial tubercle
◦ Knee extension
17. Superficial dissection
◦ Medial fasciocutaneous
flap raised
Quadriceps tendon
Medial border of patella
Patella tendon
Pad of fat
◦ Arthrotomy
3-5mm cuff of tissue
Extend on either sides
18. Patella is dislocated laterally
Rotate 180 degrees
Knee is then flexed 90
degrees
Further releases
Retractors subperiosteally
ACL/menisci/osteophytes
removed
19. Medullary entry
◦ 1 cm anterior to the
insertion of PCL
using 9.5mm drill bit
◦ Just medial to the
tangent of Whiteside
line and intercondylar
line
20. Insertion of
intramedullary rod
and distal femoral
cutting jig
Cut set at
determined angle
of valgus
Secure cutting jig
with pins
25. 90 degrees to the
axis of the tibia
Distal tip lie just
medial to the center
of ankle
Rod in line with the
tibial crest
AP slope of 3
degrees (sagital
plane)
26. In varus knee
◦ Resect 10mm from
lateral compartment
◦ Resect 2mm from
medial compartment
In valgus knee
◦ Resection should
extend to the tip of
the fibula head
Resect
31. Order of cuts
◦ Anterior
◦ Posterior
◦ Anterior Chamfer cut
◦ Posterior Chamfer cut
◦ Box cut
32.
33.
34.
35.
36. Not needed in not deformed knee
Ensure adequate removal of osteophytes
Correction of
◦ Flexion contracture
◦ Varus deformity
◦ Valgus deformity
37. Ensure resection of PCL
Strip adherent capsule from posterior aspect
of the femur
Flexion contracture pre op?
◦ Release posterior capsule transversely
Additional distal femur resection
38. Initial medial
capsulotomy and
medial
subperiosteal
release may suffice
Extend medial
subperiosteal
release by
additional 2-3cm
39. Tight in flexion
only?
◦ Release anterior
superficial part of
MCL
40. Tight in flexion
only?
◦ Release posterior
oblique fibres of
superficial MCL
41. Tight in extension?
◦ Release
semimembranosus
and posteriormedial
capsule
42. Tight in both
flexion and
extension?
◦ Osteophytes
◦ Release superficial
element of MCL
43. Lateral knee tight in extension?
◦ Release iliotibial band
Lateral knee tight in flexion?
◦ Release popliteal tendon and then LCL
subperiosteally from femoral condyles
Lateral knee tight in both flexion and
extension
◦ Iliotibial band
◦ Popliteal tendon
◦ LCL
◦ Posterior capsule
45. Tibia
◦ Cement applied into the cut surface and tibial
component
◦ Tibial component positioned and impacted
◦ Excess cement removed
◦ Trial tibial insert placed
◦ Femur is lifted up
46. Femur
◦ Cement is placed onto the prosthesis
◦ Prosthesis is then positioned and impacted
◦ Excess cement removed
◦ Knee is extended and axial compression applied
◦ Cement allowed to set
47. Trial tibial insert
replaced with
definitive insert
Knee is extended
Final irrigation
Suction drain –
laterally
48. Knee in flexion
Deep layer using vicryl 1
◦ Quadricep tendon – continuous suture
◦ Medial capsule and patella tendon – continuous
◦ Parapatella retinaculum – interrupted
◦ Subcutaneous fat – interrupted
Skin
◦ non absorbable suture/staples
49. Analgesics
Antibiotics
Anti DVT
◦ Clexane
◦ Compression stockings
◦ Chest physio
Drain and catheter removal
Active ROM
FWB
Hb check 48hrs post op
50.
51. Intra op
◦ Patella tendon rupture
◦ Injury to the infrapatella branch of saphenous nerve
◦ Injury to MCL/LCL
◦ Injury to popliteal vessels and nerve
◦ Haemorrhage
52. Post op
◦ Infection
◦ DVT/PE
◦ Implant failure
◦ Periprosthetic fracture
53. A reliable and predictable surgery with
reported survival rate of 85% with 10 – 23
years
Good favorable gains for pain and
functionality following TKR
54. Aroju S. A Discuss approaches to the knee &
describe in detail the operation of TKA, National
Orthopaedic Hospital Dala-Kano, 5th January, 2018
S. Terry, James H.B., Frederick M.A, Campbell’s
core orthopaedic procedure, 12th edition, 2016.
p.50-61
Sam W. Wiesel, Operative techniques in orthopaedic
surgery 2011 P.918-933
Said Saghieh, Stuart L., Jamal J., operative
dictations in orthopaedics p.133-136
Anatomical alignment, good ROM, good stability, ligamentous balancing and good patella tracking
Planning bony cut, estimating coronal laxity, ruling out extra articular deformity
Process of anticipating the size and position of the implants prior to surgery
Cruciate retaining; more technically demanding, less cut, prosthesis last longer
Cruciate substituting; faster
Flexion/extension gaps
The femoral and tibial cuts should be made such
that the rectangular spaces created are the same in
both full extension and 90° of flexion
