Article: Total Knee Arthoplasty

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Technique for Total Knee Arthroplasty using Simultaneous Cementing of Components

David F. Bindelglass, M.D., Jondy L. Cohen, M.D., and
Lawrence D. Door, M.D.

The surgical technique for total knee arthroplasty (TKA) as performed by he senior author is reviewed. Certain steps in the procedure are discussed in detail to provide insight into how these steps can be carried out more precisely with reproducible results. The method of cementing all three components with one mixture of cement is particularly helpful and time saving, which makes cemented fixation more attractive. As in any surgery, attention to detail and organization produces superior results

Much has been written about the techniques of performing total knee arthroplasty (TKA).8-11 The purpose of this article is to detail our technique for cemented TKA, which can be used whether the posterior cruciate ligament (PCL) is retained or sacrificed. The technique will be illustrated with cruciate retention because the operation is more difficult when the PCL is retained. Emphasis will be placed on technical steps that simplify the operation and on dealing with common problems that may complicate the procedure. Exposure, soft tissue balancing, bone cuts, and the technique for cementing all three components from one mixture of cement will be examined. Attention to detail, as outlined below, is critical to achieving optimal results.

Exposure is accomplished through a midline incision.29 A tourniquet is used in almost all cases, the exception being in the limb with any vascular compromise or diabetes. The distal incision should pass just medial to the tibial tubercle rather than directly over it, avoiding a scar over the bony prominence and decreasing the chance of wound healing problems. Prior incisions should be incorporated and the skin incision for TKA modified to allow this. Specifically, parallel incisions isolating an island of skin must be avoided.10

The approach to the knee joint is made through a medial parapatellar incision. The medial subvastus approach described in this journal of Mullen can also be used and avoids any incision into the quadriceps mechanism. The patella is then everted. If this cannot be accomplished a number of options exist. The incision in the quadriceps tendon should be carried proximally to the most proximal extent of the tendinous portion. Distally, the medial third of the patella tendon can be elevated off the tubercle with a scalpel. The tendon is elevated in continuity with the anterior periosteum so that if an accidental avulsion does occur this soft tissue remains as a continuous sleeve that will scar back down. Sometimes a lateral release is necessary at this stage of the procedure in order to successfully evert the patella. Finally, in a very stiff knee (60° arc of motion or less) a patellar turndown approach may be needed.12 A modification of the Coonse Adams approach is used. A standard lateral release is performed and carried proximally along the lateral border of the quadriceps tendon. At the proximal end of the incision an oblique cut is made across the tendon, connecting the lateral release and medial parapatella incisions (Fig 1). This incision passes only through the tendinous portion, and the deeper muscle fibers often can be left intact. After the components are put in place the final repair is done. The tendon is reattached side to side medially so that proper tracking is achieved. Proper tension to minimize a postoperative lag is achieved with the knee flexed at 90° . The quadriceps mechanism must be absolutely taut and the patella held centered in the trochlear groove so that it cannot be moved at all with manual pressure.

Rehabilitation after quadriceps turndown is modified so that range of motion is restricted to 60° passively during the first 10 postoperative days. No active motion is allowed and an immobilizer is worn except when the patient is in continuous passive motion (CPM). After 10 days, unrestricted active and passive motion are allowed.

After the patella is prepared the medial soft tissues are released from the tibia. While a medial release is part of the soft tissue balancing in correcting a varus deformity, some release is necessary in all knees for exposure. Adequate tibial preparation requires anterior subluxation of the tibia, which cannot be accomplished without release of the medial capsule from the proximal tibia. The scalpel or electrocautery is used initially to elevate the capsule subperiosteally at the level of the tibial tubercle. This begins at the edge of the distal portion of the capsular incision and is wide enough to allow an elevator to peel periosteum as far medially and posteriorly as the medial edge of the triangular tibia (Fig. 2a). The elevator is replaced by a bent Hohmann retractor (Fig 2b). A scalpel is used to release the medial sleeve, which is now under tension. This is carried proximally through the coronoid ligaments between the tibia and the medial meniscus, and the transverse ligament is cut allowing the medial meniscus to fall away with the medial soft tissues. Dissection continues posteriorly with a scalpel while under direct vision and then may be continued further with an elevator, care being taken to remain in contact with the bone. In all knees the dissection is continued to the midcoronal plane and in varus knees to the midposterior line.

Elevation of the soft tissue exposes osteophytes on the proximal tibia and distal femur. These are removed with an osteotome to release tension on the medial soft tissue, a procedure that is an integral portion of soft tissue balancing (Fig. 3). The remnant of the medial meniscus is now visible. One clamp is placed at its anterior edge and a second on the medial capsule to place it under tension. The meniscus is resected leaving a small cuff at its attachment to the medial collateral ligaments (MCL) so as to protect the latter structure.

The knee is now flexed with the patella everted. In the stiff knee a release of the superficial MCL will be necessary before flexing the knee. The MCL can be very tight in the stiff knee and flexion may lead to tearing of the ligament or avulsion of the medial epicondyle.12

The anterior cruciate ligament (ACL) is divided in mid substance with a knife, and the lateral meniscus is divided anteriorly where it becomes the transverse ligament, so that it will fall away laterally. As much fat pad as necessary is excised so that the surgeon’s view of the lateral plateau is not obstructed. The tibia can now be displaced forward by placing a straight Hohmann retractor in the midline posteriorly. The foot is externally rotated with one hand and the tibia pried forward using the retractor (Fig 4). Residual medial and lateral meniscal tissue is excised. A bent Hohmann retractor is used on the lateral side to hold the extensor mechanism and lateral capsule laterally. The Hohmann is placed in the lateral midline and should be in place whenever any work is done on the tibia. The lateral patellofemoral ligaments are incised to facilitate retraction of the patella. The synovium that overlies the anterior femoral cortex is incised so that the junction between the trochlea and the anterior cortex is clearly seen. Undercutting or notching the cortex can then be avoided.

Patellofemoral problems represent a large percentage of complications of TKA.13 Most surgeons leave the preparation of the patella as the last step in the operation and as a result may not treat it with the same detail to attention and precision as in the tibial and femoral preparation. Therefore, the patella cut is performed first. A patellar osteotomy guide is used to perform the cut. It is important to maintain the thickness of the patella during TKA for proper tracking. The initial thickness is measured with a caliper, and the level of cut determined so that the combined thickness of the patellar bone and prosthesis equals the initial thickness. Osteophytes are removed from the periphery to facilitate proper positioning of the jib and the starting point for the saw, and then the cut is made (Fig 5). Fixation holes are made using a guide and the trial patella is placed. It should cover the cut surface of the bone nearly completely. Excess bone is removed with a rongeur (Fig. 6).

Intramedullary cutting guides have become generally accepted for the distal femoral cuts. Placement of the opening hole can affect the component position. The femoral starting point should be just anterior to the attachment of the PCL and a few millimeters lateral to the midline. The canal should be drilled with a larger drill than the alignment rod and fat contents should be removed with suction. A fluted rod should be used. These precautions reduce the pressure increase caused by a rod in the medullary canal, which can lead to fat emboli.7 The surgeon should also have a short alignment rod and external guide for cases where the medullary canal is abnormal (ie, postfracture). Once the distal cutting guide is fixed in place, the angle of the cut can be checked using a block with a hole made at 6° to its axis; this first over the alignment rod confirming proper orientation for the cut (Fig 7). Anterior and posterior cuts are made using standard cutting blocks.

To promote better patellar tracking, the anterior and posterior femur are cut in slight external rotation. External rotation cuts also compensate for a 0° tibial cut rather than the anatomic 3° varus, maintaining a symmetric flexion gap.10 External rotation of the component can be checked three ways. First, the femur can be lifted up by the cutting block so the tibia is lifted off the table. The block position is now evaluated by observing the rotation of the block relative to the femoral shaft. (Fig. 8a). Second, most blocks with measuring guides have an anterior projection whose position relative to the anterior femoral cortex can be noted to determine rotation. Lateral rotation denotes external rotation (Fig. 8b). Third, when the posterior cuts are made, assuming minimal deformity of the posterior condyles, the medial posterior condyle fragment should be thicker than the lateral (Fig. 8C).

Chamfer cuts are completed and a trial femur malleted into place. With the trial in place, osteophytes in the intercondylar notch can be resected so that the inner walls of the notch vault become continuous with the edge of the prosthesis (Fig. 9a). A small rongeur should pass freely through the notch on either side of the PCL (Fig. 9b).

The authors prefer the use of an intramedullary (IM) tibial cutting guide as recommended by Laskin11 and Whitesides.16 This produces the most consistent results for tibial bone cuts and avoids varus. Recent criticism of the accuracy of intramedullary guides is based on the inability to fully seat the rod, especially in valgus knees.14 However, using a ¼" rod resolves this problem.

The entry point for the IM rod is the insertion of the ACL on the tibia. Precautions are again used to avoid increasing intramedullary pressure. A guide is used that makes certain the mediolateral cut of the tibial surface will be exactly perpendicular to the long axis of the tibia. We prefer this cut of the medial tibia, rather than the anatomic 3° varus cut, so that an extensive varus tibial cut is avoided. A posterior slope of 7° to 8° is built into the cutting jib. Initially recommended by the Townley,15 a posterior slope significantly improves postoperative flexion.

The rotation of the cutting guide relative to the tibia can affect the orientation of the tibial cut. The jig should be centered over the tibial tubercle between the medial third and lateral two thirds of the tubercle (Fig. 10). If an extramedullary guide is used it should be closer to the medial malleolus than the center of the ankle. The level of the tibial cut is important because tibial bone weakens rapidly as one goes distally from the joint surface. 1 Tibial fixation is compromised by a low tibial cut. Maximum thickness of the tibial cut should be no more than 5 to 8 mm. Specifically, defects in the tibial surface should not be the guide for determining the depth of the tibial cut (Fig. 11).6

Most soft tissue balancing is performed prior to the bone cuts. Releases are done routinely as part of the exposure, with the extent depending on the measured preoperative deformity. The previous section on exposure describes the standard medial release. In addition, in a varus knee with the tibia subluxed forward, more posterior osteophyte is removed and the cautery can be used to release 1 cm of tissue from the top of the tibia between the posteromedial corner and the posterior midline (Fig.12). This is all the release necessary in 98% of varus knees.5

For a valgus knee an analogous release is done laterally as part of the exposure. Once the knee is flexed a bent Hohmann retractor is placed anterolaterally on the proximal tibia to hold the patella laterally. The cautery is used to elevate 1 cm of capsule from the lateral proximal tibia, around to the posterior midline (Fig. 13). Osteophytes are removed from the tibia and femur. In most valgus knees this is an adequate release.

For inspection of the posterior knee joint a lamina spreader is used to jack open the joint. Posterior osteophytes are palpated and then removed with a curved osteotome until flush with a posterior diaphyseal cortex (Fig 14.) The elevator may also be used to elevate the posterior capsule from the posterior diaphysis. In the knee with a preoperative flexion contracture this will release a fixed contracture of no more than 15° .

After any posterior release is completed the trial components are placed. The knee is then tested for varus/valgus stability at 90° , 30° and full extension. The varus knee may still have medial tightness necessitating further medial release. The superficial MCL is released subperiosteally with an osteotome, creating a continuous sleeve of medial soft tissue (Fig 15). This sleeve maintains continuity of the medial side. No repair is therefore necessary. A detailed discussion of techniques for dealing with varus deformity has been previously published.5

When valgus knees remain tight on the lateral side, medial laxity will remain. There are three lateral structures to be released. The first is the popliteus, which is released sharply from its femoral attachment. If this release is insufficient, the iliotibial (IT) band is step-cut at the level of the joint line and stretched (Fig 16). An alternative method is to Z-cut the IT band and lengthen the tendon.8 Lastly, in rare cases the lateral collateral ligament is sharply released from the femur. These releases generally require a thicker tibial polyethylene component.

Once the medial and lateral soft tissue balance is completed, alignment and stability are again evaluated. The tightness of the PCL is assessed. With the knee flexed at 90° , the distal femoral condyles should be within 1 cm of the anterior lip of the tibial component (Fig 17). If the femoral component rests on the posterior half of the tibial tray the PCL needs to be recessed. This is done with electrocautery, partially dissecting the attachment off the femur (Fig 18). Usually 2 to 3 mm is sufficient, so that the tibia falls back easily under the femur. Lastly, patellar tracking is assessed. The patella is reduced and the knee is ranged. The foot is held in neutral rotation, and as the knee is flexed and extended the patella tilt and displacement are assessed. If the patella tilts laterally or tracks laterally, a lateral release is needed. This is performed from the inside out. The patella is grabbed between the thumb and index finger and pulled forward to put the retinaculum under tension. An incision is made through only the retinaculum at the level of the patella and approximately 1 t 2 cm lateral to the patella. Once the retinaculum is incised the surgeon is able to get a finger between the retinaculum and the subcutaneous tissue (fig 19). This finger protects from ‘button-holing’ the skin. The release is then carried straight down the tibia over the finger. Tracking is again checked. If the patella still tracks laterally the lateral release is extended proximally into the muscle fibers of the vastus lateralis, and if this is still insufficient then the modified turndown described above is performed.

A number of techniques exist for dealing with bone defects. We have previously discussed the use of bone grafts.4 Richard Scott initiated the use of wedges, which has become more common.3 In general, if 50% of the condyle is involved then some form of augmentation is necessary.

One of the reasons given for cementless fixation is a reduction in operating room time. The increased time required for cementing results from separately cementing the femur and tibia. Ewald initially advocated simultaneously cementing all components and discusses the technique in this issue. We too use a technique where all three components are cemented with one mixture of cement.

Bone is lavaged with a water pik and packed with a sponge while two packages of Simplex cement (Howmedica, Rutherford, NJ) are mixed. At 2 minutes, cement is spread onto the patella surface with a spatula. When the component has multiple fixation pegs the holes may be difficult to find. Methylene blue can be placed in the holes prior to cementing to outline them after the cement is manually pressurized into the bone. (Fig 20). The patella is seated and held with the surgeon’s thumb and index finger. A curette is used to remove excess cement from the periphery. The assistant then maintains manual pressure.

    The tibia is subluxed anteriorly with a straight Hohmann retractor posteriorly. One or two bent Hohmann retractors are placed laterally to retract the extensor mechanism (fig 21). AT 3 to 4 minutes cement is spread onto the tibial surface, manually pressurized into the plateaus using both thumbs, and pushed into the central peg hole (Fig 22). Care is taken not to push cement posteriorly into the back of the joint. The tibial base plate with cement packed onto the stem is seated, maintaining proper rotation, excess cement is removed from the periphery with a scalpel (Fig 23) and the real polyethylene tibial insert is then placed on the base plate. Retractors are removed, the tibia is reduced under the femur, and the femoral trial is malleted into place. The leg is then extended fully to compress the tibial cement column. This ensures proper seating of the tibia. The knee is then flexed, the trial femur removed, the tibia retracted anteriorly, and cement is again trimmed from around the tibia. To cement the femoral component the remaining cement is taken manually (at6 to 7 minutes) and applied to the cancellous bone of the trochlea and condyles, except the posterior condyles (Fig 24). Cement is manually pressurized into peg holes in the bony surfaces, again with both thumbs and again avoiding extrusion posteriorly. Cement is placed on the posterior condyles of the prosthesis, but only enough to be flush with the lateral edges. The component is then malleted into position. Methylene blue can again be helpful in locating the peg holes. Excess cement is removed from the medial and lateral borders with a scalpel and from the intercondylar notch. The knee is then extended to make sure full extension is achieved with proper alignment (Fig 25). T he knee is flexed and further excess cement is removed. A tonsil clamp is passed posteriorly around both condyles to make sure that there is no excess cement posteriorly (Fig 26). The leg is held in extension to compress the cement during final polymerization.

Closure is routine over two hemovac drains. Postoperatively patients are placed in CPM on the first or second day. They ambulate on the first postoperative day in the knee immobilizer which remains until the patient can do a straight leg raise. They are discharged when they can ambulate independently with crutches and achieve at least 70° motion, usually after 6 or 7 days.


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