1. The document describes the basic surgical technique for total knee arthroplasty (TKA), including the medial parapatellar approach and steps for femoral and tibial bone cuts.
2. It discusses different alignment techniques in TKA including anatomical, mechanical, and kinematic alignment. Kinematic alignment aims to restore the natural three motion axes of the knee.
3. Key steps like distal femoral cuts, flexion and extension gap balancing, and tibial rotation and slope are explained. Ten commandments for optimal TKA outcomes are also listed.
Reconstruction of the anterior cruciate ligament (ACL) is a well-established surgical procedure. However, post-operative imaging in the early phase is not routinely performed. The rationale for performing such imaging is to provide a baseline examination for future controls, to provide immediate feedback to surgeons regarding tunnel placement, and to assess placement of fixation devices
This document summarizes the key points of a procedure for total wrist arthroplasty. It begins with indications and contraindications. It then describes the implant components and surgical steps involved in implantation. The procedure involves resection of the distal radius and proximal row of carpal bones, followed by insertion of radial and carpal prosthetic components with a polyethylene bearing surface. Postoperative rehabilitation aims to achieve pain relief and functional range of motion of the wrist. Complications can include loosening and instability of the prosthetic components.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Evolution of tunnel placement in ACL reconstructionDhananjaya Sabat
One of my talks at Delhi Arthroscopy Club....... this presentation provides a insight regarding the conceptual evolution in tunnel placement during ACL reconstruction.
This document discusses the concept and methodology of templating for total hip replacement surgery. It begins by defining templating as a radiographic planning process using templates to estimate implant positioning and identify difficult cases. It then describes the goals of templating as predicting implant size and position to restore hip biomechanics. The document outlines the steps of templating, including identifying anatomical landmarks and mechanical references on radiographs. It emphasizes the importance of restoring leg length, offset, and the center of rotation.
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233DelhiArthroscopy
ACL Reconstruction Surgery in Delhi by Dr. Shekhar Srivastav - Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients.
Check Out Details at http://www.delhiarthroscopy.com
This document discusses high tibial osteotomy (HTO), a procedure that corrects knee alignment to relieve pressure from arthritic areas. It was first described in 1961 and involves cutting and reshaping the tibia to transfer weight from an arthritic to a healthier area of cartilage. The document outlines indications, contraindications, techniques like closing wedge and opening wedge osteotomy, management of the fibula, fixation methods, advantages and disadvantages of different techniques, expected results, and potential complications. HTO is a well-established procedure for unicompartmental knee arthritis with typical satisfactory results in 80% of cases.
1. The document describes the basic surgical technique for total knee arthroplasty (TKA), including the medial parapatellar approach and steps for femoral and tibial bone cuts.
2. It discusses different alignment techniques in TKA including anatomical, mechanical, and kinematic alignment. Kinematic alignment aims to restore the natural three motion axes of the knee.
3. Key steps like distal femoral cuts, flexion and extension gap balancing, and tibial rotation and slope are explained. Ten commandments for optimal TKA outcomes are also listed.
Reconstruction of the anterior cruciate ligament (ACL) is a well-established surgical procedure. However, post-operative imaging in the early phase is not routinely performed. The rationale for performing such imaging is to provide a baseline examination for future controls, to provide immediate feedback to surgeons regarding tunnel placement, and to assess placement of fixation devices
This document summarizes the key points of a procedure for total wrist arthroplasty. It begins with indications and contraindications. It then describes the implant components and surgical steps involved in implantation. The procedure involves resection of the distal radius and proximal row of carpal bones, followed by insertion of radial and carpal prosthetic components with a polyethylene bearing surface. Postoperative rehabilitation aims to achieve pain relief and functional range of motion of the wrist. Complications can include loosening and instability of the prosthetic components.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Evolution of tunnel placement in ACL reconstructionDhananjaya Sabat
One of my talks at Delhi Arthroscopy Club....... this presentation provides a insight regarding the conceptual evolution in tunnel placement during ACL reconstruction.
This document discusses the concept and methodology of templating for total hip replacement surgery. It begins by defining templating as a radiographic planning process using templates to estimate implant positioning and identify difficult cases. It then describes the goals of templating as predicting implant size and position to restore hip biomechanics. The document outlines the steps of templating, including identifying anatomical landmarks and mechanical references on radiographs. It emphasizes the importance of restoring leg length, offset, and the center of rotation.
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233DelhiArthroscopy
ACL Reconstruction Surgery in Delhi by Dr. Shekhar Srivastav - Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients.
Check Out Details at http://www.delhiarthroscopy.com
This document discusses high tibial osteotomy (HTO), a procedure that corrects knee alignment to relieve pressure from arthritic areas. It was first described in 1961 and involves cutting and reshaping the tibia to transfer weight from an arthritic to a healthier area of cartilage. The document outlines indications, contraindications, techniques like closing wedge and opening wedge osteotomy, management of the fibula, fixation methods, advantages and disadvantages of different techniques, expected results, and potential complications. HTO is a well-established procedure for unicompartmental knee arthritis with typical satisfactory results in 80% of cases.
This document describes the surgical steps for ACL reconstruction using a hamstring autograft. The key steps include:
1. Arthroscopic examination and addressing other lesions.
2. Harvesting the gracilis and semitendinosus tendons from the thigh.
3. Preparing bone tunnels in the femur and tibia.
4. Passing the graft through the tunnels and fixing it in place with interference screws to reconstruct the ligament.
The document summarizes a study on high tibial osteotomy with concomitant meniscal scaffold implantation. It discusses how osteotomies can transfer loading from arthritic to healthy cartilage areas. It also notes that meniscectomies increase contact stresses in the knee joint. The study involved 10 patients receiving collagen scaffolds, 10 receiving polyurethane scaffolds, and 20 control patients receiving osteotomy alone. Results found the osteotomies achieved good union and correction maintenance, and patients receiving meniscal repair showed superior clinical improvement compared to debridement alone, with no difference between scaffold types.
This document discusses tibiotalocalcaneal (TTC) fusion with an intramedullary nail. It provides indications for TTC fusion including arthritis, deformities, and failed fusions. Studies have shown TTC fusion and isolated ankle fusion have similar outcomes in function and pain relief. However, ankle fusion is more likely to lead to subtalar joint arthritis over time. The document then reviews a case of a TTC fusion using an intramedullary nail, including pre-op imaging, surgical technique, and post-op recovery. Tips are provided such as ensuring proper nail entry point and using intraoperative imaging to confirm screw placement.
This document discusses the use of osteotomy procedures, specifically high tibial osteotomy (HTO), for treating osteoarthritis (OA) in younger patients with malalignment. It provides details on the purpose and techniques of HTO, including closed-wedge and open-wedge approaches. Ideal candidates for HTO are identified as those under age 60 with isolated medial compartment OA and varus malalignment of under 15 degrees. Complications of HTO procedures are outlined. Studies have found obesity, inadequate correction, and age over 50 to be negative prognostic factors, while joint line preservation is key to success.
This document provides information about an elective on knee surgery focusing on ACL failure and reconstruction. It discusses the anatomy of the ACL and its role in preventing internal tibial rotation. It also describes the anterolateral ligament (ALL) and its role in stabilizing internal rotation above 35 degrees of flexion. Finally, it discusses various surgical techniques for ACL reconstruction, including intra-articular, extra-articular, and combined intra- and extra-articular approaches, with the combined approach currently considered the best practice.
Journal club presentation on Shoulder Arthroplasty for Fractures of the Proximal part of the Humerus. Based on review article published in Journal of Bone & Joint Surgery (America)
Indications, Surgical techniques, outcomes are discussed in detail.
The Principe of high tibial osteotomy is to reduce the stresses of the internal compartment of the knee by valgizing the tibia.The
total knee arthroplasty on this tibia with a “malunion” presents technical difficulties related to the initial approach, the presence of osteosynthesis material, the presence of malunion and the change of bone density. The objectives of this study are to determine the clinical and radiographic results of patients undergoing Total Knee Arthroplasty (TKA) after High Tibial Osteotomy (HTO). This is a retrospective descriptive study including patients undergoing Total Knee Arthroplasty (TKA) after an High Tibial Osteotomy (HTO) at the Hospital of Mont de Marsan (France) from 2008 to 2017 with a minimum follow-up of 12 months. Thirty knees (27 patients) were recruited. The sex ratio was 1.72. The average age was 70.33 years (54years-88years). The average time between High Tibial Osteotomy (HTO) and Total Knee Arthroplasty (TKA) was 10.83 years (1 year-26 years). The medial opening was 63.33% and lateral closure for the rest. Clinical improvement was observed, with an average gain of 24.97 points for pain, 1 point for stability, 1 point for knee mobility and 5 points for walking distance. The clinical result was perfect in 13.33%, excellent in 42% and medium in 36.67% of cases. The alignment was obtained in 76.67% of cases (p = 0.0039). The posterior tibial slope, epiphyseal varus, patellar height were corrected in 80% of cases respectivly (p = 0.000011, p = 0.44, p = 0.15). Residual pain was observed in 26.66%, joint stiff ness in 16.66%, skin healing disorder in
16% and infection in 6.66% of cases. Total knee arthroplasty made it possible to recover the failure of an high tibial osteotomy.
Updated HTO vs UniKnee for Postgraduate Orthopaedic Course in Newcastle March...Professor Deiary Kader
This document discusses osteotomy and unicompartmental knee replacement (UKR or "Uni Knee") for the treatment of varus malalignment and osteoarthritis in the knee. It provides details on the surgical techniques, outcomes, advantages, and contraindications of high tibial osteotomy (HTO) and UKR. Non-operative treatments for knee osteoarthritis like weight loss, exercise, and injections are also summarized.
Lateral closing isosceles triangular osteotomy for the treatmentsongao
Dr. Sandeep Tripathi presented a new technique for correcting cubitus varus, or gunstock deformity of the elbow, using a lateral closing wedge isosceles triangular osteotomy. The technique was performed on 25 patients aged 6-12 with cubitus varus secondary to malunion of a supracondylar fracture. A lateral incision was made, the osteotomy performed, and fixed with K-wires. Most patients had excellent results with a mean carrying angle of 11.7 degrees. Complications included minor infection and scarring, with one revision for displacement. The author concluded the technique is practical, effective, and reliable for correcting cubitus varus.
Dr. Satyendra Bhattacharyya's document discusses the history and procedure of shoulder arthroplasty. It begins with the first documented shoulder replacement in 1894, but focuses on developments starting in 1951 by Dr. Charles Neer, who created the first hemi-arthroplasty and total shoulder replacement. The document then discusses factors that influence arthroplasty outcomes, indications for the procedure for conditions like osteoarthritis and rheumatoid arthritis, and details each step of the surgical procedure. It concludes by describing postoperative rehabilitation protocols.
This document discusses hip arthroscopy, including hip anatomy, operative setup, portal placement, and complications. It describes the three major ligaments surrounding the hip joint and placement of the anterolateral, anterior, posterolateral, and accessory portals under fluoroscopy guidance. Operative setup involves patient positioning, equipment like arthroscopes and distractors, and preoperative imaging. Potential complications include labral/cartilage injuries, neurovascular injuries, osseous reshaping errors, anchor-related cartilage damage, fluid extravasation, hypothermia, infection, and DVT.
This document summarizes a presentation on medial opening wedge high tibial osteotomy. Key points include:
1) Preoperative planning is critical to determine the appropriate correction and wedge size.
2) Wedge geometry is complex, as the correction depends on both coronal and sagittal plane alignment.
3) Intraoperative assessment of alignment is challenging, and while the bovie cord provides a reasonable estimate, alternatives like radiolucent grids may improve accuracy by reducing parallax error.
Current Concepts in High Tibial osteotomy and Unicondylar knee replacementPaudel Sushil
This document discusses current concepts in unicondylar knee arthroplasty and high tibial osteotomy for the management of unicompartmental osteoarthritis of the knee. It provides an overview of the procedures, including types of osteotomies for high tibial osteotomy, indications and contraindications for each procedure, long-term results, and risks of converting between the two procedures. The document also reviews principles and considerations for each technique as well as selected implant designs for unicondylar knee arthroplasty.
Current trends in ACL surgery include a shift towards anatomical reconstruction techniques that more closely restore the native ACL footprint. While double bundle reconstruction aims to better restore knee rotation, high quality studies show no difference in outcomes compared to single bundle reconstruction. Autograft tissue like hamstring tendon is preferred over allograft for younger patients due to higher failure rates with allograft. Postoperative rehabilitation protocols emphasize early range of motion restoration and return to sport is recommended between 8 to 12 months following surgery accompanied by meeting specific strength and performance benchmarks.
Meniscal ramp lesions occur at the posterior meniscocapsular junction of the medial meniscus. They were historically difficult to diagnose due to limitations of standard anterior arthroscopic portals and MRI. Ramp lesions are increasingly recognized as an important injury, occurring in 9.3-24% of ACL deficient knees. A systematic exploration of the posteromedial compartment via a trans-notch approach is needed for diagnosis. Left untreated, ramp lesions may contribute to residual instability after ACL reconstruction. Arthroscopic repair techniques using suture hooks and all-inside sutures exist for treatment of ramp lesions when they are greater than 10mm in size or unstable.
This document discusses instability after total knee arthroplasty (TKA). It begins by outlining the goals and basic principles of TKA. It then describes the bone cuts made during TKA and emphasizes that resection of the proximal tibia influences both flexion and extension gaps. The document discusses various causes of instability after TKA including improper bone cuts, soft tissue imbalance, and component malpositioning. It provides details on managing different types of instability such as instability in extension, flexion, and mid-flexion. Prevention of instability through proper bone cuts and soft tissue balancing is emphasized.
Preoperative preparation of total knee arthroplastyIhab El-Desouky
This document discusses the pre-operative preparation for primary total knee arthroplasty. It covers topics such as analyzing the patient's complaints, examining the knee joint and other joints, obtaining radiographic images and using them for classification and templating, and optimizing the patient's medical conditions. The goal of the preparation process is to collect all relevant information about the patient and their knee to inform surgical planning and implant selection prior to the total knee replacement procedure.
The document discusses reverse total shoulder arthroplasty (rTSA), including:
- The procedure reverses the ball and socket of the shoulder joint.
- It was approved for use in the US in 2004.
- The new design moves the center of rotation medially and inferiorly, increasing deltoid tension and function as the primary shoulder elevator.
- Indications include severe rotator cuff deficiency or previous TSA failure. Contraindications include infection or inadequate bone stock. Potential complications range from minor issues like stiffness or hematoma to more serious problems like prosthesis loosening or nerve damage.
Updated PCL, PLC and Knee Dislocation for Postgraduate Orthopaedic Course in ...Professor Deiary Kader
The document discusses the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee. It provides details on the anatomy, mechanisms of injury, clinical assessment, treatment, and complications for injuries to these structures. For PCL injuries, the strongest ligament in the knee, treatment involves conservative management for isolated acute injuries or reconstruction for chronic symptomatic injuries. For PLC injuries, addressing all injured ligaments is important as isolated treatment can fail. Reconstruction of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament is recommended for chronic complete injuries.
Reverse shoulder arthroplasty involves replacing the humeral head and glenoid fossa with prosthetics to alter the center of rotation and increase deltoid tension and function. It is indicated for rotator cuff tear arthropathy, proximal humeral fractures in the elderly, failed shoulder replacements, and other conditions. The procedure involves an deltopectoral approach to expose the joint, removal of the humeral head and shaping of the glenoid, then implantation of the glenosphere and humeral cup components. Outcomes are best for osteoarthritis and worse for trauma or revision cases. Complications can include infection, nerve injury, implant loosening or breakage.
The I-Assist personalized guidance system gives perfectly aligned knee replacements which prolongs the life of the implant. You the patient don't have to worry about your knee wearing out in the rest of your life. Get it done with once and enjoy restored mobility for the rest of your life.
This document provides tips on how to effectively search for medical references using keywords. It discusses searching PubMed using keywords, fields, Boolean operators, and MeSH terms to retrieve the most relevant results. Cochrane reviews and Google can also be used as reference sources. The most important aspects of reference searching are using a structured approach, practicing search techniques, and constantly learning.
This document describes the surgical steps for ACL reconstruction using a hamstring autograft. The key steps include:
1. Arthroscopic examination and addressing other lesions.
2. Harvesting the gracilis and semitendinosus tendons from the thigh.
3. Preparing bone tunnels in the femur and tibia.
4. Passing the graft through the tunnels and fixing it in place with interference screws to reconstruct the ligament.
The document summarizes a study on high tibial osteotomy with concomitant meniscal scaffold implantation. It discusses how osteotomies can transfer loading from arthritic to healthy cartilage areas. It also notes that meniscectomies increase contact stresses in the knee joint. The study involved 10 patients receiving collagen scaffolds, 10 receiving polyurethane scaffolds, and 20 control patients receiving osteotomy alone. Results found the osteotomies achieved good union and correction maintenance, and patients receiving meniscal repair showed superior clinical improvement compared to debridement alone, with no difference between scaffold types.
This document discusses tibiotalocalcaneal (TTC) fusion with an intramedullary nail. It provides indications for TTC fusion including arthritis, deformities, and failed fusions. Studies have shown TTC fusion and isolated ankle fusion have similar outcomes in function and pain relief. However, ankle fusion is more likely to lead to subtalar joint arthritis over time. The document then reviews a case of a TTC fusion using an intramedullary nail, including pre-op imaging, surgical technique, and post-op recovery. Tips are provided such as ensuring proper nail entry point and using intraoperative imaging to confirm screw placement.
This document discusses the use of osteotomy procedures, specifically high tibial osteotomy (HTO), for treating osteoarthritis (OA) in younger patients with malalignment. It provides details on the purpose and techniques of HTO, including closed-wedge and open-wedge approaches. Ideal candidates for HTO are identified as those under age 60 with isolated medial compartment OA and varus malalignment of under 15 degrees. Complications of HTO procedures are outlined. Studies have found obesity, inadequate correction, and age over 50 to be negative prognostic factors, while joint line preservation is key to success.
This document provides information about an elective on knee surgery focusing on ACL failure and reconstruction. It discusses the anatomy of the ACL and its role in preventing internal tibial rotation. It also describes the anterolateral ligament (ALL) and its role in stabilizing internal rotation above 35 degrees of flexion. Finally, it discusses various surgical techniques for ACL reconstruction, including intra-articular, extra-articular, and combined intra- and extra-articular approaches, with the combined approach currently considered the best practice.
Journal club presentation on Shoulder Arthroplasty for Fractures of the Proximal part of the Humerus. Based on review article published in Journal of Bone & Joint Surgery (America)
Indications, Surgical techniques, outcomes are discussed in detail.
The Principe of high tibial osteotomy is to reduce the stresses of the internal compartment of the knee by valgizing the tibia.The
total knee arthroplasty on this tibia with a “malunion” presents technical difficulties related to the initial approach, the presence of osteosynthesis material, the presence of malunion and the change of bone density. The objectives of this study are to determine the clinical and radiographic results of patients undergoing Total Knee Arthroplasty (TKA) after High Tibial Osteotomy (HTO). This is a retrospective descriptive study including patients undergoing Total Knee Arthroplasty (TKA) after an High Tibial Osteotomy (HTO) at the Hospital of Mont de Marsan (France) from 2008 to 2017 with a minimum follow-up of 12 months. Thirty knees (27 patients) were recruited. The sex ratio was 1.72. The average age was 70.33 years (54years-88years). The average time between High Tibial Osteotomy (HTO) and Total Knee Arthroplasty (TKA) was 10.83 years (1 year-26 years). The medial opening was 63.33% and lateral closure for the rest. Clinical improvement was observed, with an average gain of 24.97 points for pain, 1 point for stability, 1 point for knee mobility and 5 points for walking distance. The clinical result was perfect in 13.33%, excellent in 42% and medium in 36.67% of cases. The alignment was obtained in 76.67% of cases (p = 0.0039). The posterior tibial slope, epiphyseal varus, patellar height were corrected in 80% of cases respectivly (p = 0.000011, p = 0.44, p = 0.15). Residual pain was observed in 26.66%, joint stiff ness in 16.66%, skin healing disorder in
16% and infection in 6.66% of cases. Total knee arthroplasty made it possible to recover the failure of an high tibial osteotomy.
Updated HTO vs UniKnee for Postgraduate Orthopaedic Course in Newcastle March...Professor Deiary Kader
This document discusses osteotomy and unicompartmental knee replacement (UKR or "Uni Knee") for the treatment of varus malalignment and osteoarthritis in the knee. It provides details on the surgical techniques, outcomes, advantages, and contraindications of high tibial osteotomy (HTO) and UKR. Non-operative treatments for knee osteoarthritis like weight loss, exercise, and injections are also summarized.
Lateral closing isosceles triangular osteotomy for the treatmentsongao
Dr. Sandeep Tripathi presented a new technique for correcting cubitus varus, or gunstock deformity of the elbow, using a lateral closing wedge isosceles triangular osteotomy. The technique was performed on 25 patients aged 6-12 with cubitus varus secondary to malunion of a supracondylar fracture. A lateral incision was made, the osteotomy performed, and fixed with K-wires. Most patients had excellent results with a mean carrying angle of 11.7 degrees. Complications included minor infection and scarring, with one revision for displacement. The author concluded the technique is practical, effective, and reliable for correcting cubitus varus.
Dr. Satyendra Bhattacharyya's document discusses the history and procedure of shoulder arthroplasty. It begins with the first documented shoulder replacement in 1894, but focuses on developments starting in 1951 by Dr. Charles Neer, who created the first hemi-arthroplasty and total shoulder replacement. The document then discusses factors that influence arthroplasty outcomes, indications for the procedure for conditions like osteoarthritis and rheumatoid arthritis, and details each step of the surgical procedure. It concludes by describing postoperative rehabilitation protocols.
This document discusses hip arthroscopy, including hip anatomy, operative setup, portal placement, and complications. It describes the three major ligaments surrounding the hip joint and placement of the anterolateral, anterior, posterolateral, and accessory portals under fluoroscopy guidance. Operative setup involves patient positioning, equipment like arthroscopes and distractors, and preoperative imaging. Potential complications include labral/cartilage injuries, neurovascular injuries, osseous reshaping errors, anchor-related cartilage damage, fluid extravasation, hypothermia, infection, and DVT.
This document summarizes a presentation on medial opening wedge high tibial osteotomy. Key points include:
1) Preoperative planning is critical to determine the appropriate correction and wedge size.
2) Wedge geometry is complex, as the correction depends on both coronal and sagittal plane alignment.
3) Intraoperative assessment of alignment is challenging, and while the bovie cord provides a reasonable estimate, alternatives like radiolucent grids may improve accuracy by reducing parallax error.
Current Concepts in High Tibial osteotomy and Unicondylar knee replacementPaudel Sushil
This document discusses current concepts in unicondylar knee arthroplasty and high tibial osteotomy for the management of unicompartmental osteoarthritis of the knee. It provides an overview of the procedures, including types of osteotomies for high tibial osteotomy, indications and contraindications for each procedure, long-term results, and risks of converting between the two procedures. The document also reviews principles and considerations for each technique as well as selected implant designs for unicondylar knee arthroplasty.
Current trends in ACL surgery include a shift towards anatomical reconstruction techniques that more closely restore the native ACL footprint. While double bundle reconstruction aims to better restore knee rotation, high quality studies show no difference in outcomes compared to single bundle reconstruction. Autograft tissue like hamstring tendon is preferred over allograft for younger patients due to higher failure rates with allograft. Postoperative rehabilitation protocols emphasize early range of motion restoration and return to sport is recommended between 8 to 12 months following surgery accompanied by meeting specific strength and performance benchmarks.
Meniscal ramp lesions occur at the posterior meniscocapsular junction of the medial meniscus. They were historically difficult to diagnose due to limitations of standard anterior arthroscopic portals and MRI. Ramp lesions are increasingly recognized as an important injury, occurring in 9.3-24% of ACL deficient knees. A systematic exploration of the posteromedial compartment via a trans-notch approach is needed for diagnosis. Left untreated, ramp lesions may contribute to residual instability after ACL reconstruction. Arthroscopic repair techniques using suture hooks and all-inside sutures exist for treatment of ramp lesions when they are greater than 10mm in size or unstable.
This document discusses instability after total knee arthroplasty (TKA). It begins by outlining the goals and basic principles of TKA. It then describes the bone cuts made during TKA and emphasizes that resection of the proximal tibia influences both flexion and extension gaps. The document discusses various causes of instability after TKA including improper bone cuts, soft tissue imbalance, and component malpositioning. It provides details on managing different types of instability such as instability in extension, flexion, and mid-flexion. Prevention of instability through proper bone cuts and soft tissue balancing is emphasized.
Preoperative preparation of total knee arthroplastyIhab El-Desouky
This document discusses the pre-operative preparation for primary total knee arthroplasty. It covers topics such as analyzing the patient's complaints, examining the knee joint and other joints, obtaining radiographic images and using them for classification and templating, and optimizing the patient's medical conditions. The goal of the preparation process is to collect all relevant information about the patient and their knee to inform surgical planning and implant selection prior to the total knee replacement procedure.
The document discusses reverse total shoulder arthroplasty (rTSA), including:
- The procedure reverses the ball and socket of the shoulder joint.
- It was approved for use in the US in 2004.
- The new design moves the center of rotation medially and inferiorly, increasing deltoid tension and function as the primary shoulder elevator.
- Indications include severe rotator cuff deficiency or previous TSA failure. Contraindications include infection or inadequate bone stock. Potential complications range from minor issues like stiffness or hematoma to more serious problems like prosthesis loosening or nerve damage.
Updated PCL, PLC and Knee Dislocation for Postgraduate Orthopaedic Course in ...Professor Deiary Kader
The document discusses the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee. It provides details on the anatomy, mechanisms of injury, clinical assessment, treatment, and complications for injuries to these structures. For PCL injuries, the strongest ligament in the knee, treatment involves conservative management for isolated acute injuries or reconstruction for chronic symptomatic injuries. For PLC injuries, addressing all injured ligaments is important as isolated treatment can fail. Reconstruction of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament is recommended for chronic complete injuries.
Reverse shoulder arthroplasty involves replacing the humeral head and glenoid fossa with prosthetics to alter the center of rotation and increase deltoid tension and function. It is indicated for rotator cuff tear arthropathy, proximal humeral fractures in the elderly, failed shoulder replacements, and other conditions. The procedure involves an deltopectoral approach to expose the joint, removal of the humeral head and shaping of the glenoid, then implantation of the glenosphere and humeral cup components. Outcomes are best for osteoarthritis and worse for trauma or revision cases. Complications can include infection, nerve injury, implant loosening or breakage.
The I-Assist personalized guidance system gives perfectly aligned knee replacements which prolongs the life of the implant. You the patient don't have to worry about your knee wearing out in the rest of your life. Get it done with once and enjoy restored mobility for the rest of your life.
This document provides tips on how to effectively search for medical references using keywords. It discusses searching PubMed using keywords, fields, Boolean operators, and MeSH terms to retrieve the most relevant results. Cochrane reviews and Google can also be used as reference sources. The most important aspects of reference searching are using a structured approach, practicing search techniques, and constantly learning.
Este documento describe la técnica quirúrgica de resurfacing de cadera. Ofrece una filosofía conservadora al reemplazar solo la superficie dañada en lugar de resecar la cabeza y el cuello femoral. Proporciona las características, ventajas y desventajas de esta técnica, así como la experiencia de varios autores. Finalmente, resume la experiencia del autor con 76 casos de resurfacing de cadera.
Hip implants are used to replace damaged or diseased hip joints. The document discusses the history and development of hip implants from the 1950s onwards. It describes the key figures like Sir John Charnley who pioneered total hip arthroplasty. The anatomy of the hip joint and biomechanics considerations for implant design are outlined. Different types of femoral and acetabular components including cemented, cementless, and alternative bearing surfaces are explained. Indications, contraindications and risks of hip replacement surgery are also summarized.
Robotic-assisted total knee arthroplasty provides enhanced accuracy in femoral rotation and tibiofemoral alignment compared to conventional surgery. However, conventional surgery is quicker and less expensive than robotic-assisted surgery. While robotic-assisted surgery achieves better short-term alignment results, both procedures show no significant differences in functional outcomes after two years.
The document provides an overview of recent advances in various types of joint arthroplasty procedures, including the hip, knee, shoulder, and elbow. It discusses new implant designs, materials, surgical techniques such as minimally invasive procedures, computer navigation, and in some cases robotics. The goal of many new procedures and devices is to better restore normal joint biomechanics, reduce invasiveness and recovery times, and increase implant longevity and patient function.
This document describes a technique for arthroscopically grafting cysts in the greater tuberosity during rotator cuff repair. The technique involves debriding the cyst, drilling a socket, and implanting a resorbable scaffold to fill the defect. The authors present a case of using this technique to successfully repair a rotator cuff tear and fill a associated greater tuberosity cyst. They believe this technique offers a minimally invasive option for addressing cysts during rotator cuff repair.
High tibial osteotomies are a surgical procedure used to treat unicompartmental osteoarthritis of the knee caused by malalignment. There are several types of high tibial osteotomies including medial opening wedge, lateral closing wedge, medial opening hemicallotasis, and dome osteotomies. Complications can include recurrence of deformity, irritation or failure of implants, nerve palsy, nonunion, infection, or stiffness. Outcomes of high tibial osteotomies are generally good, though some patients may eventually require total knee arthroplasty. High tibial osteotomies can be combined with cartilage restoration procedures, though long-term outcomes of graft survival are mixed.
Computer Navigated Medial Opening Wedge High Tibial Osteotomy- Review of Lite...CrimsonPublishersOPROJ
Computer Navigated Medial Opening Wedge High Tibial Osteotomy- Review of Literature by Kunal Dhurve* in Crimson Publishers: Orthopedic Research and Reviews Journal
Total hip replacement surgery has become very successful over the past 50 years with over 90% implant survival rates at 15-20 years. Younger and more active patients are now candidates due to improved implant fixation and new bearing surfaces that reduce wear. The most common surgical approaches are direct lateral and posterolateral. Cementless fixation is now more common, especially for acetabular components, to reduce loosening rates. Ongoing areas of focus include further improving implant longevity and developing options for younger patients.
Retrograde Intramedullary Nail with Femoral Head Allograft for Large Deficit ...skisnfeet
The document summarizes a study that evaluated the outcomes of using a retrograde intramedullary nail with femoral head allograft for large defect tibiotalocalcaneal arthrodesis. Eleven patients were included who had this procedure for conditions such as Charcot neuroarthropathy, avascular necrosis, or revision fusion. While complications occurred in six patients, eight patients were considered successes based on clinical and radiographic criteria, such as stability and union. The technique provides a powerful one-stage method to address large bony deficits but also carries risk, as only partial unions were observed in some cases. Overall, it was deemed a useful technique for this difficult patient population.
Patella in total knee arthroplasty to resurface or not is the questionBipulBorthakur
This document discusses different perspectives and techniques regarding patellar resurfacing during primary total knee arthroplasty. It notes that while resurfacing was routinely performed in North America, Asian surgeons often do not due to patient characteristics. Three main approaches are described: always resurfacing, never resurfacing, and selective resurfacing based on factors like cartilage quality and arthritis. Complications of both resurfacing and non-resurfacing are presented. Multiple studies are reviewed that compare outcomes between the two techniques, with many finding reduced reoperation rates but similar pain levels with resurfacing. The conclusion is that the best approach remains controversial, though resurfacing is often recommended for inflammatory arthritis or severe patellar deformity.
This technical note describes an arthroscopic technique for addressing both a rotator cuff tear and a cyst within the greater tuberosity. The authors debrided the cyst cavity to create a socket, then implanted a resorbable scaffold to provide structure and promote bone ingrowth. This allowed the standard rotator cuff repair to then be performed. MRI at 6 months showed healing of both the cyst and rotator cuff tear. The technique provides a readily available option for surgeons facing this clinical challenge.
Surgery is the best method for treatment of cancer. Dr. Martin Malawer uses the finest surgical methods to treat the sarcoma cancer in patients. He had got specialization in the field of limb sparing surgery.
This technical note describes an arthroscopic technique for addressing both a rotator cuff tear and a cyst within the greater tuberosity. The authors present a 1-step procedure using porous, resorbable scaffolds to fill the cyst defect at the time of rotator cuff repair. The cyst is thoroughly debrided and a matching implant is placed flush with the bone. Standard rotator cuff repair is then performed. In a 57-year-old patient, MRI at 6 months showed healing of both the cyst and rotator cuff. The technique provides an option for surgeons facing this clinical challenge with minimal additional time or morbidity.
ANESTHETIC MANAGEMENT OF TOTAL HIP REPLACEMENT SURGERYDebashish Mondal
This document discusses hip replacement arthroplasty (HRA). It provides information on the types of HRA, indications for surgery, preoperative evaluation and anesthesia considerations. The key points are:
- HRA involves replacing damaged hip joint surfaces with prosthetics to relieve pain and restore function. It can be total or half (hemi) replacement.
- Candidates typically have severe osteoarthritis or other conditions causing irreversible hip damage and unremitting pain.
- Patients require thorough medical evaluation due to common comorbidities in the elderly population undergoing HRA.
- Regional anesthesia like spinal is preferred over general anesthesia for HRA due to benefits like reduced blood loss and better postoperative pain control.
Effect of a_knee_ankle_foot_orthosis_on_knee.10huda alfatafta
The KAFO significantly reduced knee varus angle and the first peak of the external knee adduction moment during walking compared to no orthosis. It also reduced the knee adduction angular impulse during stair ascent compared to no orthosis. No significant differences were found between the custom and off-the-shelf knee valgus braces for any measures. The KAFO showed greater improvements in knee alignment and loading than the knee valgus braces for this individual with varus knee alignment.
This document summarizes a study of 110 patients who underwent distal femur resection and endoprosthetic reconstruction between 1980-1998. The majority had malignant bone tumors. Reconstruction was performed with modular, custom-made, or expandable prostheses. At minimum 2-year follow up, function was good or excellent in 85% of patients. Complications included deep infection in 5%, aseptic loosening in 5%, and prosthetic failure in 5%. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction provided good function and local tumor control in most patients.
Biocartilage to Treat Osteochondral Defects of the Talus: Case Report and Tec...Jennifer Gerres, DPM
The document describes a case study and technique using BioCartilage to treat a large osteochondral defect of the talus. The key points are:
1) A 24-year old male presented with ankle pain and imaging revealed a 1.2cm x 1.6cm osteochondral defect of the talus.
2) The defect was excised and microdrilled. BioCartilage, a micronized hyaline cartilage allograft, mixed with blood or PRP was used to fill the defect.
3) BioCartilage offers advantages over other techniques like autografts in eliminating donor site morbidity and over ACI in being a single-stage procedure without wait time.
This document discusses posterior cruciate ligament (PCL) tears. It begins with an overview of PCL anatomy and mechanisms of injury. It then covers clinical evaluation including physical examination tests like the posterior drawer test. Investigations like MRI are discussed. Finally, the document outlines management approaches for PCL tears, including non-operative treatment for mild injuries and surgical reconstruction or repair for more severe injuries. Surgical techniques like single versus double bundle reconstruction using autografts or allografts are compared. Post-operative rehabilitation protocols are also summarized.
1. The author describes a modified posterior approach to the hip joint that involves a posterior trochanteric osteotomy. This approach aims to minimize dislocation rates seen with traditional posterior approaches by preserving the short external rotators and imparting greater stability.
2. An initial study of 44 patients who underwent hemiarthroplasty using this approach found no dislocations. Subsequent studies by other surgeons of total hip arthroplasties using this approach also reported low dislocation rates.
3. Potential advantages of this modified approach include less bleeding, avoidance of sciatic nerve injury, and an intact abductor mechanism while maintaining the exposure benefits of a posterior approach. Disadvantages can include issues with trochanteric
This document provides an overview of anterior cruciate ligament (ACL) injuries, including the functions of the ACL, typical mechanisms of injury, symptoms, signs, diagnostic imaging, natural history if untreated, and treatment options. It discusses the goals of ACL reconstruction surgery, including proper graft selection, placement, tensioning, and fixation. Post-operative rehabilitation is also summarized, with the goal of regaining motion and strength while protecting the graft.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Similar to British Columbia Medical Journal - November 2010: Knee Arthroplasty (20)
Four cancer survivors accompanied a riderless bike to represent those unable to participate in the Ride to Conquer Cancer due to actively fighting or having succumbed to cancer. The author was moved by stories shared during the ride, including a father who lost his son to cancer, a mother supporting her son with brain cancer, and a man riding in memory of his father who died of cancer. The stories highlighted the suffering caused by cancer and its impact on families and friends. Despite outward cynicism, the author was moved to tears and committed to fighting cancer through fundraising for research.
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
This document summarizes kidney, pancreas, and pancreatic islet transplantation. It discusses how kidney transplantation has become the treatment of choice for many with kidney failure due to improved outcomes. However, there remains a shortage of donor organs. The document outlines efforts in BC to increase living donors and use of expanded criteria deceased donors. Individualized immunosuppression also improves outcomes while reducing side effects. Pancreas transplantation requires strict criteria due to limited donors and aims to restore normoglycemia without insulin.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
British Columbia Medical Journal - November 2010: Knee Arthroplasty
1. www.bcmj.org VOL. 52 NO. 9, NOVEMBER 2010 BC MEDICAL JOURNAL 447
ABSTRACT: While osteoarthritis re-
mains the most common indication
for total knee replacement, the num-
ber of primary total knee arthroplas-
ties performed annually has increas-
ed exponentially over the last 55
years. Outcomes have improved
with the use of careful preoperative
assessment, a range of component
options, and operative technique
guided by clear surgical goals.
Informed consent of any patient con-
templating total knee arthroplasty
must be obtained by discussing the
risks and benefits and explaining that
between 80% and 85% of patients
are satisfied after the procedure.
M
ajor joint arthroplasty is
undoubtedly one of the
surgical success stories
of modern times. The
number of primary knee arthroplas-
ties performed annually increased
exponentially over the last half of the
20th century and increased between
16% and 44% during the first 5 years
of the 21st century.1,2 The history of
total knee arthroplasty began back
in 1860, when the German surgeon
Themistocles Gluck implanted the
first primitive hinge joints made of
ivory. Development really took off
following the introduction of the
Walldius hinge joint in 1951: initially
manufactured from acrylic and later,
in 1958, from cobalt and chrome.3
Unfortunately, this hinge joint suffer-
ed from early failure.
Intheearly1960s,JohnCharnley’s
cementedmetal-on-polyethylenetotal
hip arthroplasty inspired the develop-
ment of the modern total knee replace-
ment.4 Gunston, from the same centre
as Charnley, went on to design an
unhinged knee that replaced both the
medial and lateral sides of the joint
with separate condylar components.
Improvedbiomechanicsresultedfrom
the preserved intact cruciate and col-
lateral ligaments, which maintained
the stability of unlinked femoral and
tibial components, and a design that
allowedthecentreofrotationtochange
with flexion of the knee.5 The metal-
on-polyethylene condylar design—
completely replacing the femoral and
tibial articulating surfaces—was pur-
sued throughout the early 1970s at
centres across the world.6-11 The result
was an implant relying on component
geometry and soft tissue balance to
provide stability, with a large articu-
lating surface area to spread load and
minimize polyethylene wear. Incre-
mental improvements in component
materials, geometry, and fixation
continued throughout the 1970s and
1980s. More accurate sizing, the
option of patellafemoral replacement,
better instrumentation, and compo-
nents that allowed an increased range
of motion and a lower wear rate have
since been developed.
Unicompartmental knee arthro-
plasty developed in parallel with total
kneereplacementfromtheearlyefforts
Total knee arthroplasty:
Techniques and results
Providing a patient with a pain-free, stable knee joint that will last a
long time can be achieved by focusing on five surgical goals.
Daniel H. Williams, MSc, FRCS (Tr & Orth), Donald S. Garbuz, MD, MPH, FRCSC, B.A.
Masri, MD, FRCSC
Dr Williams is a fellow in the Division of
Lower Limb Reconstruction and Oncology
in the Department of Orthopaedics at
the University of British Columbia. Dr Gar-
buz is an associate professor and head of
the Division of Lower Limb Reconstruction
and Oncology in the Department of Ortho-
paedics at UBC. Dr Masri is a professor and
head of the Department of Orthopaedics at
UBC.
2. BC MEDICAL JOURNAL VOL. 52 NO. 9, NOVEMBER 2010 www.bcmj.org448
of McKeever and Elliott in 1952.12
However, because the unicompartmen-
tal procedure replaces only the dis-
eased part of the joint with more nat-
uralkinematicsorjointmovement,13,14
the indications for its use are more
limited.
Indications and
preoperative assessment
Osteoarthritis, whether primary, post-
traumatic, or secondary to avascular
necrosis, osteochondritis, or sepsis, is
by far the most common indication for
total knee replacement. Inflammatory
arthritides make up the bulk of the
remaining indications. Diagnosis of
the underlying condition allows appli-
cation of appropriate nonoperative
treatment, while the functional impact
of disease upon the everyday life of
the patient determines the appropriate
timing of surgery. Mechanical symp-
toms—locking or giving way—may
be amenable to arthroscopic assess-
ment and treatment. The severity of
symptoms are assessed by noting
reduced walking distance, analgesic
use, and sleep disturbance. Ability to
climb stairs or inclines, use of walk-
ing aids or other orthotics, and exac-
erbating or relieving factors all build a
more detailed picture of disability.
Knee examination should include
assessment of gait, surgical scars, loc-
alized tenderness, active and passive
range of motion, limb alignment, co-
ronal and sagittal plane ligament sta-
bility, and neurovascular status of the
limb. Other pathology contributing to
symptoms should be excluded by
examination of the back, hip, foot, and
ankle of the same limb.
Up-to-date and serial (if available)
radiographs of the knee should in-
clude an anteroposterior view as well
as true lateral and skyline patello-
femoral views of the involved knee
together with full long leg views if
there is significant deformity, previ-
ous fracture, or previous osteotomy of
the femur or tibia. An anteroposterior
pelvis and lateral radiograph of the
ipsilateralhipshouldbesoughtifthere
are symptoms of groin pain or signs of
stiffness or pain on rotation of the hip.
Magnetic resonance imaging can be
used to assess for meniscal or liga-
mentous injury in appropriate cases,
but is generally not required for the
routine assessment of the painful
arthritic knee. Radiographs should
always be performed before MRI is
ordered; in many cases, the plain rad-
iographic findings will make MRI
unnecessary.
The option of total knee arthro-
plasty is typically discussed with pa-
tients at the point in their lives when
knee pain from arthritis is significant-
ly interfering with activities of daily
living. Informed consent requires a
full discussion of the risks and bene-
fits of surgery to ensure that patient
expectations are realistic. Generally,
between 80% and 85% of patients are
satisfied with their knee arthroplasty.
The most significant complication is
deep infection, which complicates
between 1% and 2% of operations and
mayrequirefurtherandrepeatedmajor
joint surgery. Arterial injury compli-
cates between 0.03% and 0.17% of
cases15 and peroneal nerve injury has
been reported in between 0.3% and
2.0% of patients.16 The 20-day post-
operative mortality rate of 0.2% is
increased above the age-matched pop-
ulation and is the same as that meas-
ured for total hip arthroplasty. The
mortality rate normalizes with the
age-matched population after the 70th
postoperative day.17 Mortality at 1
year following knee arthroplasty is
1.6%, which is half the mortality rate
oftheage-matchedpopulation,demon-
strating that total knee arthroplasty
patients are a highly select group.18
Operative technique
Preoperative radiographic templating
for knee arthroplasty, while not as cru-
cial as for hip arthroplasty, does indi-
cate the size and shape of the tibial
bone to be removed and the compo-
nent type and size that is likely to be
required. It is particularly important
in cases requiring the extremes of
implant size to ensure that all likely
sizes are available, in cases of severe
deformity, and in cases where there is
severe bone loss.
Components
Most orthopaedic supply companies
manufacture a range of implant de-
signs, from cruciate ligament retain-
ing ( ) and posterior stabilized
( ) implants that usually pro-
vide sufficient stability in the primary
setting, through to megaprotheses for
replacing tumor or bone.
The level of built-in constraint, or
stability,requiredbyakneeprostheses
depends upon whether the posterior
cruciate and collateral ligaments are
intact. If the posterior cruciate liga-
ment is compromised, as it is in most
rheumatoid knees, or there is fixed
Figure 2
Figure 1
Total knee arthroplasty: Techniques and results
Radiographs should
always be performed
before MRI is ordered;
in many cases, the
plain radiographic
findings will make
MRI unnecessary.
3. www.bcmj.org VOL. 52 NO. 9, NOVEMBER 2010 BC MEDICAL JOURNAL 449
Total knee arthroplasty: Techniques and results
coronal plane or significant flexion
deformity, then the PCL is replaced
by a cam and post, the design of which
controls sagittal plane kinematics.
A larger post can provide additional
side-to-side/coronal plane stability
( ). If the medial collateral lig-
ament is compromised, a hinged pros-
thesis is chosen to further improve
coronal plane stability ( ). In-
evitably this puts greater strain upon
the hinge itself and produces increas-
ed shear stresses at the implant inter-
face with the bone. A rotating hinge
allows movement in the axial plane
between the polyethylene and tibial
surface, decreasing these stresses but
producing a secondary surface for the
generation of wear debris. Modular
femoral and tibial stems are added to
the resurfacing implants in this scen-
ario to increase the area of fixation,
spreading load and decreasing stress-
es at the implant bone interface.
Femoral or tibial stems of varying
lengths may also be added if there are
significant uncontained bone defects.
Generally, a contained bony defect
with an intact cortical rim or an uncon-
tained defect of less than 5 mm can be
filled with cement upon implantation.
Contained defects greater than 5 mm
with an intact cortical rim can be treat-
ed with morcelized impaction bone
allografting. Uncontained defects re-
quire shaping to accommodate the
metal wedges that are added to the
implant. Larger defects are not com-
monly encountered in the primary set-
ting, but when present may require
bulk bone allograft. The addition of a
femoral or tibial stem provides addi-
tional stability and protects supple-
mented defects, minimizing the risk
of long-term implant subsidence.
Surgical goals
The clinical aims of knee arthroplasty
are to provide the patient with a pain-
free, stable joint that will last a long
Figure 4
Figure 3
Figure 1. Cruciate ligament retaining
implant.
Figure 2. Posterior stabilized implant. The
presence of a post (arrow) distinguishes this
design from the cruciate ligament retaining
design in Figure 1, which has no such post.
Figure 3. Posterior stabilized implant
with larger post (arrow) for improving
coronal plane stability.
Figure 4. Hinged implant for improving
coronal plane stability. The hinge is linked
into the femoral component as indicated by
the arrow.
4. BC MEDICAL JOURNAL VOL. 52 NO. 9, NOVEMBER 2010 www.bcmj.org450
time.Toachievethis,thesurgicalteam
focuses on five surgical goals:
• Mechanical alignment of the limb.
The proximal tibia and the distal
femur are cut so that the mechanical
axis of the limb—from the centre of
the hip to the centre of the ankle
joint—passes through the centre of
the knee arthroplasty. This ensures
that forces are transmitted equally
through each side of the new joint,
optimizing the lifetime of the joint.19
Aligning the limb correctly also pro-
vides the correct starting platform
for achieving subsequent surgical
goals.
• Joint line preservation. The depth of
bone removed from the tibia and the
femur should be equal to the height
of the respective components that
are implanted. By taking out what is
to be put back in, the position of the
original joint line is preserved. This
optimizes the function of the liga-
ments and muscles acting upon the
knee.
• Soft tissue balance in the coronal
plane. Balancing the knee to varus
and valgus stress maintains equal
load transmission through each side
of the knee. Following many years
of disease, deformity in the coronal
plane can become fixed by contrac-
ture of soft tissues. Osteoarthritis
most commonly leads to a varus
deformity and tight medial soft tis-
sues, which are released in the fol-
lowing order to attain satisfactory
balance:
1. Medial osteophyte removal.
2. Proximal subperiosteal stripping
of the deep medial collateral lig-
ament.
3. Posteromedial capsular release.
4. PCLsacrifice requiring the use of
a posterior stabilized component.
5. Distal tibial periosteal stripping
of the MCL (avoiding complete
release and subsequent valgus
instability).
Rheumatoid arthritis or lateral
femoral condyle hypoplasia can lead
to a valgus deformity that requires the
following releases to attain satisfac-
tory balance:
1. Lateral osteophyte removal.
2. Subperiosteal dissection of the lat-
eral joint capsule.
3. Lateral patellofemoral ligament
release.
4. “Pie crusting” of the iliotibial band
if tight in extension.
5. Popliteus release if tight in flexion.
6. PCL sacrifice requiring the use of a
posterior stabilized component.
7. Lateral collateral ligament release
from its femoral insertion (avoid-
ing complete release and subse-
quent varus instability).
• Balance of the flexion and extension
gaps in the sagittal plane. This re-
sults in the knee maintaining stabil-
ity throughout its full range of mo-
tion.Flexioninstabilityoccurswhen
the gap between the tibia and the
femur is wider in flexion than in
extension and must be corrected to
ensure the patient is asymptomatic.
Recurvatum or extension beyond
0 degrees may result from a “loose”
extension gap. A “tight” flexion or
extension gap may restrict the full
range of flexion or extension. Loss
of full range of motion at either
extreme can be disabling. Loss of
full flexion can make stair and hill
climbing difficult. Loss of full ex-
tension makes complete lockout of
the knee impossible and requires
prolonged quadriceps muscle en-
gagement—which is tiring for the
patient—when standing in one spot.
A tibiofemoral gap consistent
throughout a full range of motion
can be achieved by using an appro-
priately sized tibial insert combined
with a femoral component implant-
ed in the correct position.
• Q angle correction. This is the angle
between the quadriceps and the
patella tendon and is a function of
the positioning of the tibial, femoral,
and, if used, patella component. In
particular the femoral component
requires appropriate positioning in
all three planes to allow the patella
to track correctly.
Each of these goals may not nec-
essarily be addressed in strict order
during surgery. Indeed, some of the
steps involved during the procedure
may address more than one goal at the
same time. For instance, sizing and
positioning the femur ensures balance
of the flexion and extension gaps as
well as creating a Q angle that affords
correct patella tracking. What is vital
is that every goal be considered in
order to produce a pain-free, stable
joint that will last a long time.
The operation
Following complete preoperative
assessment and planning to ensure
correct implant availability, a typical
total knee arthroplasty would proceed
as follows:
• Intravenous antibiotics are given
well before inflation of a proximal
thigh tourniquet to 300 mm Hg.
• The skin is prepped and draped to
allow an adequate midline longitu-
dinal incision to access the knee
joint, usually via a medial parapatel-
lar approach.
• Part of the anterior fat pad, remnants
of the medial and lateral menisci,
the anterior cruciate ligament and
the PCL (if a posterior stabilized
implant is to be used) are excised.
Osteophytes are excised and the
proximal medial soft tissues are
released to allow visualization of the
edge of the medial tibial plateau and
forward subluxation of the tibia in
full flexion and external rotation.
Further preliminary soft tissue re-
leases are performed at this stage as
appropriate.
• The tibia is cut at 90 degrees to its
Total knee arthroplasty: Techniques and results
5. www.bcmj.org VOL. 52 NO. 9, NOVEMBER 2010 BC MEDICAL JOURNAL 451
mechanical axis using an extra-
medullary or intramedullary jig.
Tibial bone is removed from the
normal side of the joint to the same
depth—usually 10 mm—as the
height of the tibial component to be
implanted, with the aim of preserv-
ing the position of the original joint
line.
• The femoral intrameduallary canal
is entered and the appropriate jig
is used to cut the distal femur in
between 5 and 7 degrees of valgus
relative to the anatomical axis. This
ensures the bone is cut at 90 degrees
to the mechanical axis of the femur,
thus satisfying the first surgical
goal of knee arthroplasty. Femoral
boneisremovedtothesamedepth—
again, usually 10 mm—as the height
of the femoral component to be im-
planted, with the aim of preserving
the position of the original joint line.
• The extension gap is checked to
ensurea10-mmspacercanbeinsert-
ed. If it cannot, the tibia or femur, as
appropriate, are recut by an appro-
priate amount—usually 2 to 4 mm.
Overall alignment of the bony cuts
is checked to ensure the limb is
straight and the soft tissues balance
to varus and valgus stress. Further
adjustments of the bony cuts and
further soft tissue releases proceed
if required.
• The femoral size is measured (in
the anteroposterior and mediolateral
plane) and correct position of
the femoral cutting block in the
sagittal (anteroposterior transla-
tion), the coronal (mediolateral
translation), and axial plane (rota-
tion) is ensured.
• The posterior femoral condylar cut
is made to enable trialing of the 10-
mm spacer block at 90 degrees of
flexion to confirm that the flexion
gap matches the extension gap be-
tween the tibia and the femur.
• The remaining femoral bony cuts
are made to match the inside of the
femoral component, and a drill hole
is made in each condyle to accom-
modate the two femoral pegs.The
trial components are inserted with
the appropriate tibial spacer. The
patella is prepared if it requires
replacement, and is rechecked prior
to final implantation. The optimum
position of the tibial component is
marked and preparation of the tibial
keel is completed.
• The cancellous bone surface is clean-
ed and the real components cement-
ed with antibiotic-loaded cement.
Compressionisappliedwiththeknee
in extension through a trial insert.
Once the cement has hardened any
loose cement is removed and the
appropriate real polyethylene insert
is implanted.
• The tourniquet is released to con-
firm hemostasis. A single drain is
used and the retinacular-tendinous
layer is closed with interrupted sut-
ures.The subdermal tissues and skin
are closed and dressings applied.
Postoperative care
Two further intravenous doses of anti-
biotics are given to cover the first 24
hours. Low molecular weight heparin
or a similar suitable anticoagulant is
prescribed—according to patient risk
assessment—usually up until the 10th
day postoperatively to ensure optimal
thromboprophylaxis. The patient is
mobilized, fully weight bearing in the
majority of cases, as soon as the gross
effectsoftheanesthetichavewornoff.
Patients are encouraged to maximize
knee extension and flexion at every
stage of their recovery to ensure opti-
mal outcome. Exercises are commen-
ced to ensure full recovery of quadri-
ceps tone and strength and analgesia
is provided to ensure the best possible
results from physiotherapy. Discharge
from hospital is allowed when the
wound is dry and the patient is safe
ascending and descending stairs.
Sutures or skin clips are removed at
10 to 14 days. A walking aid may be
required for several weeks following
surgery. The literature supports driv-
ing from 8 weeks, so long as the pa-
tient is clear of opiod analgesia and
can perform an emergency stop.20 Fol-
low-up appointments are scheduled at
6 to 8 weeks, 1 year, 5 years, and every
subsequent fifth year thereafter. Earli-
er follow-up should be requested if
there is any sign of infection or other
significant concern. Over 85% of total
knee arthroplasty patients will recover
knee function following a general
rehabilitation protocol. The remain-
ing 15% of patients will have difficul-
Total knee arthroplasty: Techniques and results
The patient is mobilized, fully weight
bearing in the majority of cases, as
soon as the gross effects of the
anesthetic have worn off.
6. BC MEDICAL JOURNAL VOL. 52 NO. 9, NOVEMBER 2010 www.bcmj.org452
ty obtaining proper knee function sec-
ondarytosignificantpain,limitedpre-
operative motion, or the development
of arthrofibrosis. This subset of
patients will require a more specific
prolonged rehabilitation program that
may involve ongoing oral analgesia,
continued physical therapy, additional
diagnostic studies, and occasionally
manipulation. Controlling pain is the
mainstay of any such treatment plan.21
Results
The survivorship rate is the percent-
age of total knee arthroplasties that
have not been revised in any given
series of patients. It is generally the
most often quoted outcome in the joint
arthroplasty literature. Survivorship
is arguably the most useful outcome
when distinguishing between differ-
ent prosthetic designs and also helps
answer the patient question, “How
long will the knee last?”
The pioneers of total knee arthro-
plasty saw early failures that quickly
led to the use of more durable materi-
als, better fixation, and improved de-
sign.5-11 Published longer-term results
have shown markedly differing sur-
vivorship rates between more subtle
differences in arthroplasty design. In
a recent study looking at 3234 knee
arthroplasties performed between
survivorship rates of 100% at 10 years
are seen with the Miller-Galante II
knee, which was redesigned to solve
the high rate of patellofemoral compli-
cations seen with the Miller-Galante I
(which still had an 84.1% survivorship
rate at 10 years).28 Studies comparing
the results of different design options
manufactured by the same company
are now also available: the 10-year
Genesis knee results for the (posteri-
or) cruciate retaining knee reveal 97%
survival compared with the Genesis
posterior stabilized knee, which has
96%survival—aninsignificantdiffer-
ence.29 The results of unicompartmen-
tal knee arthroplasty have been as
good as total knee arthroplasty in pub-
lished individual series, with sur-
vivorship rates of 98% at 10 years.30,31
It is arguably the recent registry
data for newer generation knee im-
plants that apply most readily to the
average patient considering total knee
arthroplasty. The 8-year survivorship
rate for the eight most common knee
joints in current use in Norway is
between 89% and 95%1 and the 7-year
rate in Australia is 95.7%.2 Of note,
purely in terms of survival, these reg-
istries have found inferior results for
even the best-performing unicompart-
mental knee arthroplasties when these
are compared with total knee arthro-
plasty. The cumulative survival at 7
years for unicompartmental knees in
Australia is only 88.1% compared
with95.7%fortotalknees.1,2 Thismay
relate to issues of patient selection or
reflect the increased technical expert-
ise required for this procedure. Con-
version of unicompartmental knee
arthroplasty to total knee replacement
isrelativelystraightforward,soappro-
priate patients seeking a partial knee
replacement should not be discour-
aged by the slightly lower long-term
survivorship seen in registry data.
Several knee scores have been
developed to assess outcome follow-
Total knee arthroplasty: Techniques and results
1969 and 1995, 89% of the condylar
designs had survived 10 years and
between 78% and 89% had survived
15years.22 Survivorshiprates,however,
varied considerably among different
implant designs. The corresponding
rates for some, now discontinued,
designs in this same study were
between 43% and 63% at 10 years
and between 28% and 59% at 15
years.22 Further studies have confirm-
ed clinical survival of the total condy-
lar knee design of 94% at 15 years23
and between 77% and 91% at 21 to 23
years.24,25 For this reason the total
condylar design has endured. Perhaps
the best long-term published results
are for the Anatomic Graduated Con-
dylar (AGC) knee arthroplasty, the
success of which is attributed to a
straightforward design that utilizes
carefullymanufacturedmaterials.The
AGC knee has a published survivor-
ship rate of 98.9% in 4583 knees at 15
years26 and a rate of 97.8% in 7760
knees at 20 years—quite impressive
survivorship. The number of knees
that reach long-term follow-up in such
series are, however, often small; only
36 of the 7760 knees in this study
made it to the 20-year point.27
Medium-term follow-up is becom-
ing available on updated versions of
the total condylar design. Improved
Improved survivorship rates of 100% at
10 years are seen with the Miller-Galante II
knee, which was redesigned to solve the
high rate of patellofemoral complications
seen with the Miller-Galante I.
7. www.bcmj.org VOL. 52 NO. 9, NOVEMBER 2010 BC MEDICAL JOURNAL 453
ingtotalkneearthroplasty.Thesetools
produce numbers that correspond to
excellent, good, fair, or poor outcome.
For example 92% of knees were as-
sessed as good or excellent in one
study, with 1.6% fair and 6.5% poor.23
Between 96% and 98% of knees were
assessed as good or excellent in anoth-
er study.29 However, more recently it
has been shown that the views of sur-
geons and their patients regarding the
outcome of surgical interventions do
not always correlate well—especially
with respect to function and pain.
Patient questionnaires are thought to
better assess patient outcome, and in a
recent study 81.8% of 8095 patients
were satisfied, 11.2% (906 of 8095)
were unsure, and 7.0% (566 of 8095)
were not satisfied with their new knee
joint.32
With regard to younger patients
under the age of 55 years, a survivor-
ship rate of 96% of 93 knees was
observed at 10 years,33 and of 90% of
108 knees at 18 years;34 94% of pa-
tients in the latter study had good or
excellent function and all but two
patients had improvement in their
activity score postoperatively. Fur-
thermore, 24% regularly participated
in activities such as tennis, skiing,
bicycling, or strenuous farm or con-
struction work.34 This suggests that
the traditional practice of withholding
knee replacement until patients are
over 65 or over is not warranted, and
replacement should proceed when
clinically appropriate.
It was traditionally thought that
obese patients do not fare as well as
normal-weight patients following
joint replacement. Postoperative out-
come scores for obese patients, how-
ever, were found to be comparable to
scores for patients who were not obese
in one recent study. Furthermore,
given the lower preoperative scores
measured in the obese group, the over-
all improvement was actually greater
than in the normal-weight group.
Additionally, survivorship rates in
obese patients were not significantly
lower than in patients who were not
obese at 10 years follow-up.35 There
was, however, a greater proportion of
lucent lines seen on the radiographs
around the implants of the obese
patients23,35 and in the morbidly obese
the complication rates are higher and
the implant survivorship rate is lower.
The final objective measure of
outcome perhaps most relevant to the
individual patient is range of flexion.
This has gradually improved from a
mean of 99 degrees23 to between 114
and 117 degrees with newer genera-
tion designs.29 Postoperative range of
motion largely depends on the preop-
erative range of motion. Generally,
what the patient has before the opera-
tion is what the patient can expect to
achieve after surgery and rehabilita-
tion.36 Patients seeking knee replace-
ment should be counseled that their
postoperative knee will not be “nor-
mal,” but it will feel and function
much better than their preoperative
arthritic knee.
Conclusions
Osteoarthritis remains the most com-
mon indication for total knee arthro-
plasty. Fortunately, technical devel-
opments over the last half century
have resulted in 10-year survivorship
rates of 90% and higher, and between
80% and 85% of patients have been
satisfied with their total knee replace-
ment. Further incremental improve-
ments in knee arthroplasty engineer-
ing, implant design, and material
science will continue to improve bear-
ing surface tribology, implant fixa-
tion, and implant longevity. These
advances will all help meet the main
surgical goals of total knee arthro-
plasty: to correct limb alignment, pre-
serve joint line position, balance the
soft tissues in the coronal plane, bal-
ance the flexion/extension gap in the
sagittal plan, and create a Q angle that
facilitates satisfactory patella track-
ing. Preoperative assessment and
planning will also help meet these
goals by ensuring patient expectations
are realistic and informed consent has
been obtained after a full discussion
of the risks and benefits of surgery.
Competing interests
None declared.
References
1. The Norwegian Arthroplasty Register.
Report 2006. www.haukeland.no/nrl/
eng (accessed 15 August 2009).
2. The Australian National Joint Replace-
Total knee arthroplasty: Techniques and results
Survivorship rates in obese patients
were not significantly lower than in
patients who were not obese at
10 years follow-up.
8. BC MEDICAL JOURNAL VOL. 52 NO. 9, NOVEMBER 2010 www.bcmj.org454
mentRegistry.Annualreport2008.www
.dmac.adelaide.edu.au/aoanjrr (acces-
sed 15 August 2009).
3. Walldius B. Arthroplasty of the knee joint
using an acrylic prosthesis. Acta Orthop
Scand 1953;23:121-131.
4. CharnleyJ.Arthroplastyofthehip.Anew
operation. Lancet 1961;1(7187):1129-
1132.
5. Gunston FH. Polycentric knee arthro-
plasty. Prosthetic simulation of normal
knee movement. J Bone Joint Surg Br
1971;53:272-277.
6. Ranawat CS. History of total knee
replacement. J South Orthop Assoc
2002;11:218-226.
7. Coventry MB, Finerman GA, Riley LH, et
al. A new geometric knee for total knee
arthroplasty. Clin Orthop Relat Res 1972;
83:157-162.
8. Freeman MA, Swanson SA, Todd RC.
Total replacement of the knee using the
Freeman-Swanson knee prosthesis. Clin
Orthop Relat Res 1973;(94):153-170.
9. Insall JF, Ranawat CS, Scott WN, et al.
Total condylar knee replacment: Prelimi-
nary report. Clin Orthop Relat Res
1976;149-154.
10. Ranawat CS, Shine JJ. Duo-condylar
total knee arthroplasty. Clin Orthop Relat
Res 1973;(94):185-195.
11. Townley C, Hill L. Total knee replace-
ment. Am J Nurs 1974;74:1612-1617.
12. McKeever DC. The classic: Tibial plateau
prosthesis 1960. Clin Orthop Relat Res
2005;440:4-8.
13. Goodfellow J, O’Connor J. The mechan-
ics of the knee and prosthesis design. J
Bone Joint Surg Br 1978;60-B:358-369.
14.Marmor L. The modular knee. Clin
Orthop Relat Res 1973;(94)242-248.
15. Smith DF, McGraw RW, Taylor DC, et al.
Arterial complications and total knee
arthroplasty. J Am Acad Orthop Surg
2001;9:253-257.
16. Lonner JH, Lotke PA. Aseptic complica-
tions after total knee arthroplasty. J Am
Acad Orthop Surg 1999;7:311-324.
17. Lie SA, Engesaeter LB, Havelin LI, et al.
Early postoperative mortality after
67,548 total hip replacements: Causes of
death and thromboprophylaxis in 68 hos-
pitals in Norway from 1987 to 1999. Acta
Orthop Scand 2002;73:392-399.
18. National Joint Registry [for England and
Wales 2007]. www.njrcentre.org.uk (ac-
cessed 13 September 2010).
19. Fang DM, Ritter MA, Davis KE. Coronal
alignment in total knee arthroplasty: Just
how important is it? J Arthroplasty 2009;
24:39-43.
20. Spalding TJ, Kiss J, Kyberd P, et al. Driv-
er reaction times after total knee replace-
ment. J Bone Joint Surg Br 1994;76:754-
756.
21. RanawatCS,RanawatAS,MehtaA.Total
knee arthroplasty rehabilitation protocol:
What makes the difference? J Arthro-
plasty 2003;18:27-30.
22. PradhanNR,GambhirAF,PorterML.Sur-
vivorship analysis of 3234 primary knee
arthroplasties implanted over a 26-year
period: A study of eight different implant
designs. Knee 2006;13:7-11.
23. Ranawat CS, Flynn WF Jr, Saddler S, et
al. Long-term results of the total condy-
lar knee arthroplasty. A 15-year survivor-
ship study. Clin Orthop Relat Res 1993;
(286)94-102.
24. Rodriguez JA, Bhende HF, Ranawat CS.
Total condylar knee replacement: A 20-
year followup study. Clin Orthop Relat
Res 2001;(388)10-17.
25. Pavone VM, Boettner FM, Fickert SM, et
al. Total condylar knee arthroplasty: A
long-term followup. Clin Orthop Relat
Res 2001;(388):18-25.
26. Ritter MA, Berend ME, Meding JB, et al.
Long-term followup of anatomic gradu-
ated components posterior cruciate-
retaining total knee replacement. Clin
Orthop Relat Res 2001;(388):51-57.
27. Ritter MA. The Anatomical Graduated
Component total knee replacement: A
long-term evaluation with 20-year sur-
vival analysis. J Bone Joint Surg Br
2009;91:745-749.
28. Berger RA, Rosenberg AG, Barden RM,
et al. Long-term followup of the Miller-
Galante total knee replacement. Clin
Total knee arthroplasty: Techniques and results
Orthop Relat Res 2001;(388):58-67.
29. Laskin RS. The Genesis total knee pros-
thesis: A 10-year followup study. Clin
Orthop Relat Res 2001;(388):95-102.
30. Berger RA, Meneghini RM, Jacobs JJ, et
al. Results of unicompartmental knee
arthroplasty at a minimum of ten years of
follow-up. J Bone Joint Surg Am
2005;87:999-1006.
31. Murray DW, Goodfellow JW, O’Connor
JJ. The Oxford medial unicompartmen-
tal arthroplasty: A ten-year survival study.
J Bone Joint Surg Br 1998;80:983-989.
32. Baker PN, van der Meulen JH, Lewsey
JF, et al. The role of pain and function in
determining patient satisfaction after
total knee replacement. Data from the
National Joint Registry for England and
Wales. J Bone Joint Surg Br 2007;
89:893-900.
33. Ranawat CS, Padgett DF, Ohashi Y. Total
knee arthroplasty for patients younger
than 55 years. Clin Orthop Relat Res
1989;(248)27-33.
34. Diduch DR, Insall JN, Scott WN, et al.
Total knee replacement in young, active
patients. Long-term follow-up and func-
tional outcome. J Bone Joint Surg Am
1997;79:575-582.
35. Griffin FM, Scuderi GR, Insall JN, et al.
Total knee arthroplasty in patients who
were obese with 10 years followup. Clin
Orthop Relat Res 1998;(356)28-33.
36. Gatha NM, Clarke HD, Fuchs RF, et al.
Factors affecting postoperative range of
motion after total knee arthroplasty. J
Knee Surg 2004;17:196-202.