KNEE SURGERYpostgraduatebooks.jaypeeapps.com/pdf/Orthopedics/... · Department of Physiotherapy...
Transcript of KNEE SURGERYpostgraduatebooks.jaypeeapps.com/pdf/Orthopedics/... · Department of Physiotherapy...
KNEE SURGERY
System requirement:• OperatingSystem—WindowsXPorabove• WebBrowser—InternetExplorer8orabove,GoogleChrome,MozillaFirefox• Essentialplugins—JavaandFlashPlayer – Facingproblemsinviewingcontent—itmaybeyoursystemdoesnothaveJavaenabled. – Ifvideosdonotshowup—itmaybethesystemrequiresFlashPlayerorneedtomanageFlashsetting.Tolearnmore
aboutFlashsettingclickonthelinkinthehelpsection. – YoucantestJavaandFlashbyusingthelinksfromthehelpsectionoftheCD/DVD.
Accompanying DVD-ROM is playable only in Computer and not in DVD player. CD/DVDhasautorunfunction—itmaytakefewsecondstoloadonyourcomputer.Ifitdoesnotworkforyou,thenfollowthestepsbelowtoaccessthecontentsmanually:• Clickonmycomputer• SelecttheCD/DVDdriveandclickopen/explore—thiswillshowlistoffilesintheCD/DVD• Findanddoubleclickfile—“launch.html”
Formoreinformationabouttroubleshootofautorunclickon:http://support.microsoft.com/kb/330135
Prelims.indd 1 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
Video 1: Cruciate Retaining Total Knee Arthroplasty (No voice over)
Video 2: Anatomically Anterior Cruciate Ligament Reconstruction (No voice over)
D V D C O N T E N T S
Prelims.indd 2 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
Ashok Rajgopal MS MCh FRCS
ChairmanMedanta Bone and Joint Institute
Medanta—The MedicityGurgaon, Haryana, India
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTDNew Delhi • London • Philadelphia • Panama
KNEE SURGERY
Forewords
Kim C BertinChitranjan S Ranawat
Prelims.indd 3 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
Overseas OfficesJ.P. Medical Ltd.83, Victoria Street, LondonSW1H 0HW (UK)Phone: +44-2031708910Fax: +02-03-0086180Email: [email protected]
Jaypee-Highlights Medical Publishers Inc.City of Knowledge, Bld. 237, ClaytonPanama City, PanamaPhone: +1 507-301-0496Fax: +1 507-301-0499Email: [email protected]
Jaypee Medical Inc.The Bourse111, South Independence Mall EastSuite 835, Philadelphia, PA 19106, USAPhone: +1 267-519-9789Email: [email protected]
Jaypee Brothers Medical Publishers (P) Ltd.17/1-B, Babar Road, Block-B, ShaymaliMohammadpur, Dhaka-1207BangladeshMobile: +08801912003485Email: [email protected]
Jaypee Brothers Medical Publishers (P) Ltd.Bhotahity, Kathmandu, NepalPhone: +977-9741283608Email: [email protected]
Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com
© 2014, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication and DVD-ROM may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
Inquiries for bulk sales may be solicited at: [email protected]
Knee Surgery
First Edition: 2014
ISBN : 978-93-5152-225-6
Printed at
Jaypee Brothers Medical Publishers (P) Ltd
HeadquartersJaypee Brothers Medical Publishers (P) Ltd.4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314Email: [email protected]
Prelims.indd 4 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
Dedicated to
The Joy of Walking
Prelims.indd 5 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
C O N T R I B U T O R S
Aaron G Rosenberg Professor of Surgery Rush Medical College 1611 W Harrison Chicago, Illinois, USA
Ajit J Deshmukh Orthopedic Surgery Fellow Insall Scott Kelly Institute North Shore LIJ/Lenox Hill Hospital New York, NY, USA
Alberto Combi Clinica Ortopedica e Traumatologica Università Degli Studi di Pavia Fondazione IRCCS Policlinico San Matteo Pavia Pavia, Italy
Alfred J Tria Jr Clinical Professor of Orthopedic Surgery Director of Fellowship Training Department of Orthopedic Surgery Robert Wood Johnson Medical School New Brunswick, New Jersey Chief, Department of Orthopedic Surgery St Peter's University Hospital New Brunswick, New Jersey, USA
Alok Mohan Domiciliary Physiotherapist Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Amit Jawa Consultant Radiologist Dr Gulati Imaging Institute New Delhi, India
Andrea Baldini IFCA Clinic Florence, Italy
Andrew A Freiberg Arthroplasty Service Chief and Vice Chairperson Department of Orthopedic Surgery Massachusetts General Hospital Associate Professor Harvard Medical School Massachusetts, USA
Anoop Jhurani Consultant Orthopedic Surgeon Joint Replacement Service Fortis Escorts Hospital Jaipur, Rajasthan, India
Arun Mullaji Director The Arthritis Clinic, Cornelian Kemp’s Corner, Mumbai Joint Replacement Surgeon Breach Candy Hospital Cumballa Hill Hospital and Hinduja Healthcare Mumbai, Maharashtra, India
Ashok Rajgopal Chairman Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Attique Vasdev Associate Director, Knee Division Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
A Zahar HELIOS ENDO-Klinik 22767 Hamburg, Germany
Azam Badar Khan Specialist Orthopedic Surgery PMC Dubai Health Authority (DHA) Dubai, UAE
Bijaya Kumar Shadangi Consultant Anesthesiologist Medanta Institute of Critical Care and Anesthesiology Medanta—The Medicity Gurgaon, Haryana, India
Brian Culp Orthopedic Surgery Resident, PGY III Department of Orthopedic Surgery Robert Wood Johnson Medical School New Brunswick New Jersey, USA
Carlos A Higuera Staff, Adult Reconstruction Cleveland Clinic Cleveland, Ohio, USA
Caterina Guarducci IFCA Clinic Florence, Italy
Charles H Brown Abu Dhabi Knee and Sports Medicine Center Abu Dhabi, UAE
Prelims.indd 7 04-03-2014 13:43:22
Jayp
ee B
rothe
rs
viii Knee Surgery
C J Thakkar Honorary Professor of Orthopedics Maharashtra University of Health Science Honorary Professor Department of Orthopedics Sion Hospital, Mumbai Consultant Joint Specialist Breach Candy and Lilavati Hospital Mumbai, Maharashtra, India
David V Rajan Orthopedic Speciality Center Coimbatore Tamil Nadu, India
Dinshaw Pardiwala DirectorArthroscopy and Joint Preservation ServiceHead Center for Sports Medicine Kokilaben Dhirubhai Ambani Hospital Mumbai, Maharashtra, India
D Kendoff HELIAS ENDO Klinik 22767 Hamburg, Germany
Douglas A Dennis Adjunct Professor Department of Biomedical Engineering University of Tennessee Adjunct Professor of Bioengineering University of Denver Assistant Clinical Professor Department of Orthopedics University of Colorado School of Medicine Colorado, USA
Francesco Benazzo Clinica Ortopedica e Traumatologica Università Degli Studi di Pavia Fondazione IRCCS Policlinico San Matteo Pavia Pavia, Italy
Francesco Traverso Istituto Clinico Humanitas Milan, Italy
Giles R Scuderi 210 East 64th Street 4th Floor New York, USA
Hemant Wakankar Specialist Joint Replacement Surgeon Deenanath Mangeshkar Hospital Pune, Maharashtra, India
Himanshu Gupta Consultant, Knee Division Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Jack W Shilling Aria Health Langhorne, Pennsylvania, USA
Jatinder Pal Singh Senior Consultant Department of Radiology Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Javad Parvizi Professor Department of Orthopedic Surgery Rothman Institute at Thomas Jefferson University Sheridan Building, 10th Floor 125 South 9th Street Philadelphia, Pennsylvania, USA
J Clement Joseph Senior Consultant Head Department of Arthroscopy and Sports Medicine Global Hospitals and Health City Chennai, Tamil Nadu, India
Jean-Noel Argenson Professor and Chairman Department of Orthopedic Surgery The Institute for Locomotion Center for Arthritis Surgery Aix-Marseille University Sainte-Marguerite Hospital Marseille, France
Jess H Lonner Attending Orthopedic Surgeon Rothman Institute Associate Professor of Orthopedic Surgery Thomas Jefferson University Philadelphia, Pennsylvania, USA
Joel Kolmodin Orthopedic Surgery Resident Cleveland Clinic Cleveland, Ohio, USA
Joseph W Greene Norton Orthopedic Specialists- Brownsboro Norton Medical Plaza II (Orthopedic and Hand Center) 9880 Angies Way, Suite 250 Louisville, Kentucky, USA
Justin Duke Colorado Joint Replacement Colorado, USA
Kalpana Aggarwal Chief Department of Physiotherapy Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Karthikeyan Chinnakkannu Research Fellow Rothman Institute at Thomas Jefferson University Philadelphia, USA Assistant Professor in Orthopedics Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research Melmaruvathur, Tamil Nadu, India
Kelly G Vince Consultant Surgeon Department of Orthopedic Surgery Whangarei Medical Center Northland District Health Board Whangarei, New Zealand
K Santosh Sahanand Orthopedic Speciality Center Coimbatore, Tamil Nadu, India
Matteo Ghiara Clinica Ortopedica e Traumatologica Università Degli Studi di Pavia Fondazione IRCCS Policlinico San Matteo Pavia Pavia, Italy
Prelims.indd 8 04-03-2014 13:43:23
Jayp
ee B
rothe
rs
ixContributors
Matthew J Dietz Assistant Professor Department of Orthopedic Surgery West Virginia University West Virginia, USA
Matthieu Ollivier Department of Orthopedic Surgery The Institute for Locomotion Center for Arthritis Surgery Aix-Marseille University Sainte-Marguerite Hospital Marseille, France
Michael A Kelly Chairman Department of Orthopedic Surgery Hackensack University Medical Center New Jersey Fellowship Director Insall Scott Kelly Institute for Orthopedic Surgery and Sports Medicine New York, USA
Michel Malo Assistant Professor Department of Surgery University of Montreal Chief of Orthopedics Sacré-Coeur Hospital Montreal, Quebec, Canada
Mohamed Elfekky Senior Specialist Orthopedic Surgery Dubai Health Authority Dubai, UAE
Mojieb Manzary Consultant Orthopedic and Reconstructive Surgeon Dhahran Health Center Dhahran, Saudi Arabia
Nicholas A Antao Consultant Orthopedic Arthroscopic, Sports Medicine, Joint Reconstruction and Replacement Surgeon Head Department of Orthopedics Holy Family Hospital and Holy Spirit Hospital Mumbai, Maharashtra, India
Nirav N Antao Molecular and Cellular Biology University of Illinois Urbana-Champaign Medical Student Midwestern University Illinois, USA
Nishith Shah Fellow, Arthroscopy Association of North America (AANA) President, Indian Arthroscopy Society HeadArthroscopy, General Hospital, AhmedabadAash Arthroscopy Center Ahmedabad, Gujarat, India
Parveen Gulati Director and Chief Radiologist Dr Gulati Imaging Institute New Delhi, India
Pierpaolo Summa IFCA Clinic Florence, Italy
Pranjal Kodkani Fellowships in Arthroscopy Shoulder and Knee Surgery USA, Norway, Japan, Germany Consultant Arthroscopy Sports Injuries and Joint Preservation Surgery Bombay Hospital Sports Medicine, Shushruta Hospital Mumbai, Maharashtra, India
P Sripathi Rao Medcare Orthopedics Spine Hospital Dubai, UAE
Raju Easwaran Senior Consultant Shree Meenakshi Orthopedics and Sports Medicine Clinic, New Delhi Department of Orthopedics Max Super Specialty Hospital Saket and Shalimar Bagh New Delhi, India
Robert E Booth Aria Health Langhorne, Pennsylvania, USA
Rohan K Vakta Consultant Orthopedic Surgeon Ahmedabad, Gujarat, India
Sachin Tapaswi Director Department of Orthopedics Sports Injuries and Joint Replacement The Orthopedic Specialty Clinic and Oyster Pearl Hospital Pune, Maharashtra, India
Samih Tarabichi Director of Tarabichi Institute for Joint Surgeries Burjeel Hospital Dubai, UAE
Sandeep Vijayan Associate Professor Department of Orthopedics Kasturba Medical College and Hospital Manipal, Karnataka, India
Saumitra Goyal Senior Resident Kasturba Medical College and Hospital Manipal, Karnataka, India
Sebastien Parratte Department of Orthopedic Surgery The Institute for Locomotion Center for Arthritis Surgery Aix-Marseille University Sainte-Marguerite Hospital Marseille, France
Sharath K Rao Professor and Head Department of Orthopedics Kasturba Medical College and Hospital Manipal, Karnataka, India
Shivani Jain Senior Physiotherapist Medanta Bone and Joint Institute Medanta—The Medicity, Gurgaon, Haryana, India
Sinukumar Bhaskaran Consultant Orthopedics and Joint Replacement Surgery Columbia Asia Hospital Pune, Maharashtra, India
Prelims.indd 9 04-03-2014 13:43:23
Jayp
ee B
rothe
rs
x Knee Surgery
Stefano Marco Paolo Rossi Clinica Ortopedica e Traumatologica Università Degli Studi di Pavia Fondazione IRCCS Policlinico San Matteo Pavia Pavia, Italy
Sujit Kadrekar Clinical Associate Arthroscopy and Joint Preservation Service Kokilaben Dhirubhai Ambani Hospital Mumbai, Maharashtra, India
Suryanarayan P Senior Consultant Department of Orthopedic Surgery Apollo Hospitals Chennai, Tamil Nadu, India
Vipin Tyagi Consultant, Knee Division Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Vivek Dahiya Consultant, Knee Division Medanta Bone and Joint Institute Medanta—The Medicity Gurgaon, Haryana, India
Vivek Pandey Associate Professor Sports Injury Division Department of Orthopedics Kasturba Medical College and Hospital Manipal, Karnataka, India
Waseem Siddiqui Clinical Associate Arthroscopy and Joint Preservation Service Kokilaben Dhirubhai Ambani Hospital Mumbai, Maharashtra, India
William Baione Orthopedic Surgery Resident, PGY III Department of Orthopedic Surgery Robert Wood Johnson Medical School New Brunswick, New Jersey, USA
W Klauser HELIAS ENDO Klinik 22767 Hamburg, Germany
Xavier Flecher Professor Department of Orthopedic Surgery The Institute for Locomotion Center for Arthritis Surgery Aix-Marseille University Sainte-Marguerite Hospital Marseille, France
Yair D Kissin Attending Orthopedic Surgeon Department of Orthopedic Surgery Hackensack University Medical Center New Jersey Assistant Clinical Professor University of Medicine and Dentistry of New Jersey-Newark New Jersey, USA
Yatin Mehta Chairman Medanta Institute of Critical Care and Anesthesiology Medanta—The Medicity Gurgaon, Haryana, India
Prelims.indd 10 04-03-2014 13:43:23
Jayp
ee B
rothe
rs
F O R E W O R D
Treatment of disorders of the knee has become the most commonly performed group procedures for the practicing orthopedic surgeons. Presently, there are almost over one million knee replacements and more than two million knee arthroscopic procedures performed in the world every year. This book is a timeless resource for the practicing orthopedic surgeons to understand and master these two procedures.
This book of Knee Surgery comprehensively handles the state-of-the-art knee replace-ment. The readers will be exposed to every essential aspect of knee replacement surgery. Single compartment replacement, through total knee replacement, is thoughtfully addressed. In a unique way, the readers will understand the advantages and disadvantages of different techniques and current options in knee arthroplasty.
This book also addresses most common arthroscopic interventions. The chapters begin with anatomy and examination and proceed through more difficult and complex topics of posterior cruciate ligament (PCL) and posterolateral corner reconstruction. Each chapter is well-written and the illustrations help clearly convey the authors’ intended message.
The assembled contributors are established experts in their respective fields and have written authoritative chapters sharing their expertise. The chapters are well-designed to build on each other and construct a solid foundation of knowledge for treating a wide variety of knee problems. The experienced surgeon and the novice alike will appreciate the book as each seeks to better his skill. The clinical utility of the book is made evident by the inclusive discussion on anesthesia, postoperative pain management and rehabilitation of the knee.
As a student of knee surgery for over three decades, I would compliment the contributors and strongly recommend the book to the residents and surgeons for increasing their understandings of knee pathology and treatment.
Kim C Bertin MD Orthopedic Surgeon
Utah Bone and Joint Center 5323, Woodrow Street
Suite-202 Salt Lake City
Utah, USA
Prelims.indd 11 04-03-2014 13:43:23
Jayp
ee B
rothe
rs
F O R E W O R D
Ashok Rajgopal has invited various authors who are experts in the field of knee surgery. Many of these authors have extensive publication expertise in their respective specialties.
Knee Surgery covers topics on total knee surgery and sports medicine which are of current interest, some of which deal with controversial issues. These include management of major and minor cartilage defects, meniscal transplant, tibial osteotomy and isolated patellar femoral replacement.
Looking towards the future, the book offers many insightful points of view on custom-jig, robotic surgery, pain control, patient satisfaction, early diagnosis of infection and noncemented fixation.
It is with great pleasure and honor that I write the foreword for this multi-authored book on surgery of the knee, which I strongly recommend for postgraduates, practicing orthopedic surgeons and individuals interested in research.
Chitranjan S Ranawat MD Orthopedic Surgeon 535, East 70th Street
6th Floor Hospital for Special Surgery
New York, USA
Prelims.indd 13 04-03-2014 13:43:23
Jayp
ee B
rothe
rs
The field of orthopedics, especially that of the knee, has evolved over the years. Our understanding of the kinematics and biomechanics of the knee has evolved by leaps and bounds in recent years. Better understanding of the knee biomechanics is leading to design changes at a very fast pace. While certain concepts, which were thought to be flawed earlier, are the gold standards today, others are open to debate. To retain or sacrifice the posterior cruciate ligament, fixed or mobile-bearing surfaces, cemented or uncemented are all issues which have still not seen a conclusive end. Computer navigation, patient-specific instrumentation and robotics are all emerging concepts. Wear pattern analysis and newer technology have led to the introduction of highly crosslinked polyethylene and ceramics that were previously unknown.
Anatomic reconstruction of the anterior cruciate ligament (ACL) has, today, replaced the transtibial ACL reconstruction. Open ligament reconstructions are a thing of the past era.
Encouraged by my peers and friends, I undertook to put together in Knee Surgery. As I embarked on this endeavor, the enormity of this gratifying and enriching challenge dawned upon me.
The book focuses on total knee replacement and arthroscopy of the knee. It represents present-day concepts, on various aspects of knee surgery, sports medicine and biomechanics. It also represents current issues such as recent advances and evolving technology. The book is intended to be a reference guide for orthopedic surgeons with abundant pictorial contents and an atlas on MRI images and arthroscopic appearances of normal and pathological situations.
Contributors, renowned in the similar field, have unhesitatingly made the time and effort to write the chapters. Each of them is an expert in his respective field, with extensive personal contributions in peer-reviewed journals, enhancing the art and science of knee surgery. Each chapter in the book goes beyond the present available literature, incorporating new thoughts and ideas based on the knowledge and experience of years by the contributors to provide a clear thought process to the reader. I would like to express my gratitude for their contribution.
I would also like to acknowledge the tremendous help from my own group and friends for their constant encouragement during the innumerable hours spent in putting the book together. A special word of thanks to Drs Attique Vasdev, Vivek Dahiya and Puneet Puri for burning the midnight oil with me. I would also like to acknowledge my patients without whom my journey of knee surgery, over the years, would not have been possible. Finally, a grateful appreciation to my family, who put up with my long hours devoted to the compilation of the book.
Ashok Rajgopal
P R E F A C E
Prelims.indd 15 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
An acknowledgment to the people who impacted my career:zz John Charleyzz John Insallzz Grahm Hayeszz Arjun Dev Sehgalzz Madan G Abbot
A C K N O W L E D G M E N T S
Prelims.indd 17 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
C O N T E N T S
SECTION 1: KNEE ARTHROPLASTY
1. History of Total Knee Arthroplasty 3Michael A Kelly, Yair D Kissin
Total knee arthroplasty development 3
Evolution 4
Mobile-bearing 6
Modularity 6
Hinged prostheses 8
Total knee arthroplasty systems 8
Cementless fixation 9
Patellar resurfacing 9
2. Biomechanics of Normal and Replaced Knee 13Sharath K Rao, Sandeep Vijayan
Mechanical Axis 13
Patellofemoral joint 13
Tibiofemoral articulation 14
Knee in normal gait 16
Biomechanics of an arthritic knee 18
Role of posterior cruciate ligament in knee replacement 20
Patellofemoral joint 21
Bone loss 21
Mobile-bearing knees 21
Knee biomechanics in high flexion 23
Gender differences in knees 23
Rehabilitation biomechanics 23
3. Surgical Approaches to Total Knee Arthroplasty 26Sharath K Rao, Sandeep Vijayan
Anatomy 26
Medial parapatellar approach 28
Midvastus approach 30
Subvastus approach 31
Lateral approach 32
Trivector approach 34
Quadriceps (rectus) snip 35
Quadriceps turndown 35
Tibial tubercle osteotomy 36
4. Role of MRI in Evaluation of the Knee 39Parveen Gulati, Amit Jawa
Technique 39
Menisci 40
Cruciate ligaments 44
Medial collateral ligament 48
Femoral trochlear groove 50
Transient lateral patellar dislocation 50
Evaluation of articular cartilage 50
Cysts, bursae, and ganglion 53
Infections 54
Tubercular knee 54
Prelims.indd 19 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xx Knee Surgery
5. Current Principles of High Tibial Osteotomy, and its Role in Management of Unicompartmental Degenerative Joint Disease 62Suryanarayan P
Malalignment and osteoarthritis 63
Varus deformity and osteoarthritis 63
Patient selection 65
Open wedge osteotomy 67
Lateral closing wedge osteotomy 70
6. Choice of Knee Implant 76CJ Thakkar, Anoop Jhurani
History and long-term results of knee prosthesis 76
Fixed compared with mobile-bearings for knee replacement 78
biomechanics of a mobile-bearing knee 78
All polyethylene versus metal-backed tibial components in total knee arthroplasty 79
Monoblock tibia with compression-molded polyethylene: a case for reduced wear 80
High flexion knees 80
Oxinium femoral component 81
Gender-specific knee 81
Body mass index (BMI), age, and types of arthritis 82
Ligament laxity and condition of ligaments 82
Bone quality and bone defects 82
Preoperative range of movement and deformity 82
Training and surgical skills 83
7. The Role of Unicompartmental Knee Arthroplasty in the Arthritic Knee 87Matthieu Ollivier, Sebastien Parratte, Xavier Flecher, Jean-Noel Argenson
Patient selection and indications 88
Radiological evaluation 88
Age and weight 88
Surgical techniques 89
Tibial finishing and trials 90
Results of modern unicompartment Knee arthroplasty 91
8. Patellofemoral Arthroplasty 100Jess H Lonner, Joel Kolmodin, Carlos A Higuera
Epidemiology 100
Indications 101
Design considerations 102
Surgical considerations 105
Results 106
9. Cruciate Retaining Total Knee Arthroplasty: Technique and Results 110Ashok Rajgopal, Attique Vasdev, Vivek Dahiya, Vipin Tyagi
History 111
Posterior cruciate ligament 111
Personal experience 119
10. Posterior Cruciate Substituting Total Knee Arthroplasty 122Giles R Scuderi, Ajit J Deshmukh, Joseph W Greene
Historical perspective and design features 122
11. Mobile-bearing Total Knee Arthroplasty 130Samih Tarabichi, Mohamed Elfekky, Azam Badar Khan
Indications and design rationale 131
Biomechanical and clinical review of a mobile-bearing total knee arthroplasty 131
Multidirectional platform 133
Rotating platform 134
Meniscal bearing devices 134
Combination of rotating platform and meniscal bearing 134
Our experience with mobile-bearing total knee replacement 135
12. Patellar Resurfacing in Total Knee Arthroplasty 144Alfred J Tria Jr, William Baione, Brian Culp
Historical perspective 144
Component designs 145
Complications 151
Outcomes 153
Prelims.indd 20 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xxiContents
13. Patient-specific Instrumentation in Total Knee Arthroplasty 159Francesco Benazzo, Stefano Marco Paolo Rossi, Matteo Ghiara, Alberto Combi
Patient-specific instrumentation 159
Surgical technique 160
Literature evidence 160
Our experience 161
Considerations 164
14. Technique of Navigated Total Knee Arthroplasty 165Arun Mullaji
Surgical approach and exposure 166
Balancing in extension and distal femoral resection 169
Balancing in flexion, femoral sizing, and rotation 171
Tibial sizing and rotation 171
Patella 171
Cementing 172
Closure 172
15. Cementless Total Knee Arthroplasty 176Aaron G Rosenberg
Basic science of cementless fixation 176
Assessing ingrowth: retrieval studies 181
16. Minimally Invasive Approach to Total Knee Arthroplasty 190Alfred J Tria Jr, William Baione, Brian Culp
Evolution of approaches 190
History 191
Patient selection 191
Preoperative planning 192
Transitioning to the MIS technique 192
Component considerations 195
Complications 195
Outcomes 196
17. Defect Management in Total Knee Arthroplasty and Role of Trabecular Metal in TKA 199Hemant Wakankar, Sinukumar Bhaskaran
Bone defects in complex primary total knee arthroplasty 199
Bone defects in revision total knee arthroplasty 200
AORI bone defect classification 200
Guidelines for classifying
defects using radiographs 200
Principles of bony reconstruction 201
Options for management of bone defects in complex primary total knee arthroplasty 201
Tantalum: trabecular metal 203
18. Instability Following Total Knee Arthroplasty 206Andrew A Freiberg, Matthew J Dietz
Risk factors for postoperative instability 206
Categorization of total knee instability 208
Extension instability 208
Global instability 212
Ligament advancement and tightening procedures 214
19. Osteolysis in Total Knee Arthroplasty 219Douglas A Dennis, Justin Duke
Pathogenesis 221
Factors affecting polyethylene wear 221
Osteolysis diagnosis 225
Osteolysis treatment 226
20. Extensor Mechanism Reconstruction for Ruptures or Deficiencies after Total Knee Arthroplasty 232Andrea Baldini, Francesco Traverso, Caterina Guarducci, Pierpaolo Summa
Preoperative planning 232
Graft choice criteria 233
Surgical technique 234
Rehabilitation protocol 240
Results 242
21. Complications Following Total Knee Arthroplasty 248Jack W Shilling, Robert E Booth
Periprosthetic fractures 248
Infection and wound healing concerns 250
Deep venous thrombosis and pulmonary embolism 251
Nerve and vascular injury 252
Prelims.indd 21 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xxii Knee Surgery
Stiff total knee 253
Instability 254
22. Principles of Revision Total Knee Arthroplasty 257Kelly G Vince, Michel Malo
Thoughts experimental keys to revision TKA surgical technique 257
A revision arthroplasty is not a primary knee replacement 263
23. Current Practices in Diagnosing Periprosthetic Infection in Knee 279Karthikeyan Chinnakkannu, Javad Parvizi
History and physical examination 279
X-ray 280
Serology 280
Knee joint aspiration 281
Synovial CRP 282
Biopsy 282
Culture 282
Algorithm for diagnosis of PJI 284
Other imaging modalities 284
Molecular markers 288
Nonrecommended tests 289
24. Infected Total Knee Arthroplasty and its Management 295W Klauser, D Kendoff, A Zahar
Classification 296
Diagnostics 296
Joint aspiration 297
Irrigation and debridement 297
Two-stage exchange 298
The spacer 299
Antibiotic therapy 300
Reimplantation 301
One-stage exchange 301
25. Salvage after Failed Total Knee Arthroplasty 311Mojieb Manzary
Knee arthrodesis 311
Above knee amputation 316
Resection arthroplasty 317
26. Revisions Following Aseptic Failures 319Ashok Rajgopal, Attique Vasdev, Vivek Dahiya, Himanshu Gupta
Preoperative assessment 320
Surgical technique 321
Explantation 322
Trials 323
Reimplantation 326
Complications 326
27. Total Knee Arthroplasty in the Stiff Knee 328Ashok Rajgopal, Attique Vasdev, Vivek Dahiya, Vipin Tyagi
Preoperative evaluation 330
Surgical technique 330
Postoperative management 332
Complications 332
28. Hinged Knee Prosthesis 335Ashok Rajgopal, Attique Vasdev, Himanshu Gupta, Vipin Tyagi
Personal experience 338
Why we chose to use the NexGen RHK? 339
29. Anesthesia and Pain Management of Total Knee Arthroplasty 344Yatin Mehta, Bijaya Kumar Shadangi
Predictors influencing the outcome of knee arthroplasty 344
Assessment and optimization of comorbidities 345
Multidimensional model of perioperative risk stratification 345
Prelims.indd 22 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xxiiiContents
Preoperative medications 346
Anesthetic management 346
Central neuroaxial blockade 347
Regional anesthesia and anticoagulation 348
Intraoperative complication 349
Postoperative pain management 349
Multimodal approach to pain management 350
Patient controlled epidural analgesia (PCEA) 350
Transdermal PCA 351
Step-down analgesia 351
30. Rehabilitation in Total Knee Arthroplasty and Ligament Injuries 354Kalpana Aggarwal, Shivani Jain, Alok Mohan
The structure and components of knee joint 354
Injuries of knee joint 355
Types of exercise 355
SECTION 2: ARTHROSCOPY AND SPORTS INJURIES OF THE KNEE
31. Knee Anatomy 369Vivek Pandey, Saumitra Goyal, P Sripathi Rao
Bony architecture 369
Hyaline cartilage 373
Cruciate ligaments 373
Meniscus 378
Medial aspect of the knee 380
Lateral side of the knee 383
Anterior aspect of the knee 385
Fascial structures 386
Posterior aspect of the knee and popliteal fossa 386
Capsule 388
Blood supply to the knee and anastomosis around knee 388
Nerves around the knee joint 389
32. History of Arthroscopy 395P Sripathi Rao
Professor Kenji Takagi (1888–1963) 396
Eugene Bircher (1882–1956) 396
Michael Burman (1883–1943) 396
Masaki Watanabe (1911–1994) 396
Arthroscopic surgery and the concept of triangulation 397
Arthroscopy in the United States 397
Arthroscopy in Europe 397
33. Portals in Knee Arthroscopy 399Nicholas A Antao, Nirav N Antao
Portals 400
Universal (inferolateral) portal 400
Incision 401
Inferomedial portal (anteromedial portal/working portal/instrument portal) 401
Accessory anterior Inferior medial portal 402
Superolateral portal 402
Superomedial portal 402
Midpatellar lateral/medial portal 402
Central portal 402
Posterior portals (posteromedial) 403
Prerequisites before doing this portal 403
Surface marking 403
Posterolateral portal 404
Postero accessory Secondary portals 404
Trans-septal portal 405
Management of arthroscopy portals 405
Complications of arthroscopy 405
Latrogenic articular cartilage damage 405
Hemarthrosis 405
Thromboembolism 405
Complex regional pain syndrome (CRPS) 406
Compartment syndrome 406
Prelims.indd 23 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xxiv Knee Surgery
34. Clinical Examination and Diagnostic Arthroscopy of the Knee Joint 408P Sripathi Rao, Vivek Pandey
Anterior instability 408
Posterior instability 409
Varus instability 410
Valgus instability 411
Rotatory instabilities 412
Diagnostic arthroscopy of the knee 413
Portals 414
35. The Menisci: Menisectomy and Meniscal Repair 421Vivek Dahiya, Attique Vasdev, Himanshu Gupta, Ashok Rajgopal
36. Meniscal Allograft Transplantation 427Dinshaw Pardiwala, Sujit Kadrekar, Waseem Siddiqui
Biomechanics 427
Indications 428
Allograft selection and biology 428
Lateral meniscus Allograft transplant 430
Medial meniscus Allograft transplant 432
Concomitant procedures 433
Complications 433
Postoperative rehabilitation 433
Results and outcomes 433
37. Cartilage Defects: Mosaicplasty/Microfracture/ Autologous Chondrocyte 440David V Rajan, K Santosh Sahanand
Basic science 440
Evaluation 441
Principles of treatment 442
Treatment options 442
Chondroplasty 443
Microfracture 443
Mosaicplasty 445
Autologous chondrocyte implantation 447
Future trends 449
38. Classification of Knee Ligament Injuries (Including Dislocations) 451Raju Easwaran
Basics 451
Evolution of knee instability classification 451
Directional/position classification system 452
Energy of injury classification system 453
Anatomical classification 454
39. Anterior Cruciate Ligament Reconstruction 456Ashok Rajgopal, Attique Vasdev, Vivek Dahiya, Himanshu Gupta
Preoperative evaluation 457
Surgery 457
Graft selection 458
Surgical technique 459
40. Double-bundle ACL Reconstruction: Principles and Surgical Technique 469J Clement Joseph
Surgical technique 470
Rehabilitation 474
Discussion 475
41. Posterior Cruciate Ligament Reconstruction 476Vivek Pandey, Charles H Brown, Sachin Tapaswi
Anatomy 476
Operative treatment 482
Single-bundle tibial tunnel technique PCL reconstruction using quadrupled hamstring graft 485
Double-bundle PCL reconstruction using quadriceps tendon-bone graft 491
42. Posterolateral Complex Knee Injuries 502Pranjal Kodkani
Normal anatomy and functional biomechanics 503
Injuries to the postero-lateral complex 505
Treatment options 510
Technique of PLC reconstruction 513
Prelims.indd 24 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
xxvContents
43. Revision Options in Failed ACL and PCL Reconstruction 516Nishith Shah, Rohan K Vakta
Failed ACL reconstruction 516
Important steps to be considered in revision ACL reconstruction 526
Revision posterior cruciate ligament (PCL) Reconstruction 527
PCL reconstruction: surgical technique 530
44. Dislocation of the Knee 536Ashok Rajgopal, Vivek Dahiya, Vipin Tyagi
Incidence 536
Mechanism of injury 536
Classification 536
Vascular injury 537
Neurologic injury 538
Evaluation 538
Principles of management of a knee dislocation 538
Rehabilitation 539
45. Illustration of Knee MRI 541Jatinder Pal Singh
Imaging protocol and MRI anatomy 541
Cruciate ligament pathologies 547
Meniscal pathologies 551
Collateral ligament pathologies 557
Anterior structures of the knee 558
Impingement syndromes 561
Synovial pathologies 563
Cartilage pathologies 565
Marrow pathologies 567
Cysts and bursae 572
46. Atlas: Arthroscopy 575
Ashok Rajgopal, Attique Vasdev, Vivek Dahiya,
Vipin Tyagi, Himanshu Gupta
Index 603
Prelims.indd 25 04-03-2014 13:43:24
Jayp
ee B
rothe
rs
Chapter
EPIDEMIOLOGY
Patellofemoral arthritis is proving to be a much more
common entity than was thought in the past. A 2002
study by Davies et al. evaluated knee radiographs of
206 knees in 174 consecutive patients, looking specifically
for patellofemoral arthritis on weight bearing AP and
skyline views.2 The prevalence was striking 32.7% of
men and 36.1% of women older than 60 years displayed
the patellofemoral joint space narrowing to less than
3 mm. Obviously, a large percentage of these patients had
patellofemoral joint arthritis in the setting of medial and
lateral tibiofemoral compartment osteoarthritis. However,
arthritis was actually isolated to the patellofemoral
compartment in 13.6% of men and 15.4% women over
60 years of age. Moreover, it was found in 9.2% of patients
over the age of 40.
Patellofemoral arthritis has been found to be much
more prevalent in women than in men. In agreement
with the above study, another notable analysis compared
273 patients with knee pain to 240 control subjects.3
Radiographic evidence of arthritis was found in 53% of
those with pain and 17% of those who were asymptomatic.
INTRODUCTION
Rates of total joint arthroplasty have risen remarkably
over the past 40 years, and these rates are only projected
to increase further as the population ages and the burden
of arthritis increases. According to a recent study, the
demand for total hip and total knee arthroplasty (TKA) in
America is expected to grow by 174 and 673% respectively,
by the year 2030.1 Concordant with the overall progression
of arthritis, an increasing number of young patients to
develop isolated patellofemoral arthritis is expected. While
this type of arthritis can often be treated nonoperatively,
it will become progressively more imperative that
conservative operative options are available as an
alternative to TKA for this small cohort of patients. Herein
lies the role of patellofemoral arthroplasty (PFA), which
is becoming a mainstream management option as the
implant design improves and surgical technique is refined.
This chapter will cover the prevalence and epidemiology
surrounding isolated patellofemoral arthritis, the typical
evaluation of a patient with this condition, the history and
evolution of PFA implants, and past and present clinical
results.
Patellofemoral Arthroplasty
8
Jess H Lonner, Joel Kolmodin, Carlos A Higuera
8.indd 100 03-03-2014 17:39:22
Jayp
ee B
rothe
rs
101Chapter 8 Patellofemoral Arthroplasty
Isolated, symptomatic patellofemoral arthritis was found
to be four times more common in women (8% versus 2%
of the patients surveyed), while women were twice as
likely (24% versus 11%) to have radiographic evidence of
isolated anterior compartment arthritis. Though the cause
has not yet been fully elucidated, it is thought that these
differences in prevalence are due to slight dysplasia and
malalignment that is seen more commonly in the female
population.4
Evaluation
Patients with isolated patellofemoral arthritis often
complain of anterior knee pain during activity. This
pain is frequently exacerbated by active extension of the
flexed knee—during activities such as stair climbing,
squatting, or rising from a seated position. Patients
may even report anterior knee pain when seated with
the knee flexed for an extended period of time. Often,
these symptoms are reproducible on examination by
having the patient perform a simple squat. Physical
exam may reveal tenderness to the palpation around
the patellofemoral joint (particularly with patellar
compression and inhibition testing), an abnormal
Q-angle, a positive J-sign, and appreciable quadriceps
weakness and/or atrophy. Patellofemoral crepitus will
be noted with active quadriceps contraction and knee
motion.
Radiographic evaluation of the patient with anterior
knee pain should include four views—AP, midflexion PA,
lateral and merchant (Figures 8.1A to D). The former are
important to rule out tibiofemoral arthritis. In patients with
isolated patellofemoral arthritis, marked narrowing of the
patellofemoral joint is often seen, along with osteophyte
formation. Abnormal patellar tilt or asymmetric patellar
degeneration on the Merchant view may provide evidence
for patellar maltracking. It cannot be stressed enough that
any patient being considered for PFA must have limited
evidence of medial or lateral compartment arthritis on
the AP or midflexion PA views. For surgical candidates
in whom PFA is being considered, preoperative MRI is
often recommended, primarily in an effort to evaluate
the medial and lateral tibiofemoral compartments for
signs of arthritis—including such subtleties as edema of
the subchondral bone or even overt chondral damage.
Also helpful is the evaluation of any pictures from past
arthroscopic surgery, as this gives a first-hand view of the
status of the tibiofemoral articular cartilage.
Nonoperative management is the initial treatment
of choice for most patients with isolated patellofemoral
arthritis. Options include anti-inflammatory medications,
injections (such as steroids and viscosupplementation),
physical therapy, weight reduction and certain types
of bracing. Each of these may have variable success,
with more limited benefit in the advanced stages of
patellofemoral arthritis. In surgical candidates with
substantial quadriceps weakness and atrophy, physical
therapy should be stressed preoperatively to overcome
potential postoperative functional limitations.
When nonoperative measures fail to provide
adequate relief, surgery is a viable option. Noteworthy
nonarthroplasty options include simple arthroscopic
debridement, microfracture, patellectomy, unloading
procedures, or cartilage restoration procedures. These
interventions often have limited success, in the range
of 60–70% efficacy.5 Thus, arthroplasty alternatives may
provide the most reliable outcomes, including pain relief
and functional improvement. While TKA is effective in
treating patellofemoral arthritis, some may prefer PFA for
this entity, as it preserves the healthy tissue and optimizes
natural kinematics.6,7
INDICATIONS
Patellofemoral arthroplasty should be limited to those
with isolated primary or secondary (due to dysplasia
or trauma) patellofemoral arthritis. Contraindications
for PFA are numerous and include tibiofemoral
arthritis, inflammatory arthritis, chondrocalcinosis,
and uncorrectable patellofemoral malalignment or
maltracking (as evidenced by an abnormally large Q-angle
and a positive J-sign). The latter problems can usually be
addressed at the time of PFA with soft tissue realignment
or tibial tubercle realignment. Relative contraindications
include cruciate ligament deficiency, obesity, limited
motion, and diffuse pain.8
8.indd 101 03-03-2014 17:39:22
Jayp
ee B
rothe
rs
102 Section 1 Knee Arthroplasty
A B
C D
Figures 8.1A to D Standing anteroposterior, midflexion posteroanterior, lateral, and sunrise radiographs show arthritis localized to the patellofemoral compartment
DESIGN CONSIDERATIONS
Inlay-style Designs
A thorough discussion of PFA design is imperative to
understand the progression from the generally unreliable
first-generation implants to the more reliable second-
and third-generation implants that are used today.
Initial attempts at PFA were of an inlay-style, where the
trochlear component was inset into the anatomic position
of the patient’s native trochlea. Some inlay-style designs
still exist today, with less optimal results reported in
national registries.9 The prostheses were designed to be
positioned flush with the surrounding trochlear articular
cartilage—an effort to preserve the patient’s native anatomy
(Figures 8.2A to D). The error in this design was the failure
to recognize that the patient’s native anatomy is at times
pathologic or dysplastic, and an attempt to recreate it
forces the trochlear component to be internally rotated
and can lead to prosthesis failure or more commonly
patellar maltracking. Of particular importance is this
tendency of the inlay designs to be placed in an overly
internally rotated position, as the position is determined
by the native trochlear rotation.10 Internal rotation of
the trochlear implant has three main effects: increasing
the Q-angle, medialization of the trochlear groove, and
placing abnormal tension on the lateral retinaculum.
8.indd 102 03-03-2014 17:39:23
Jayp
ee B
rothe
rs
103Chapter 8 Patellofemoral Arthroplasty
Figures 8.2A to D Postoperative AP, lateral and sunrise radiographs and computed tomography scan after PFA with an inlay-style trochlear component shows that it is internally rotated, causing lateral patellar subluxation and catching
A B
C D
This may predispose the prosthesis to excessively high
rates of mechanical symptoms such as catching, patellar
maltracking, and frank patellar subluxation.5 The trochlear inclination angles (TIAs) have recently
been found to be of utmost importance in PFA. A complete
understanding of the TIAs is imperative to be able to
correctly perform a PFA and to understand the rationale
for the transition from inlay-style implants to onlay-style
trochlear implants. The TIA, defined as the angle formed
by the line perpendicular to the AP axis (i.e. Whiteside’s
line) and a line connecting the peaks of the trochlear
surfaces of the medial and lateral femoral condyles, is
a measurement that can be made on any MRI. A recent
study by Kamath et al. used MRI to evaluate the TIA of
329 knees—both normal and dysplastic.10 They found that
the TIA is normally internally rotated significantly: 11.4°
for normal knees and 9.4° for dysplastic knees. Thus, when
this natural trochlear internal rotation is not accounted for
in the prosthesis design and surgical technique, patellar
instability can occur.
Other design flaws are also commonly seen in the
inlay-style prosthesis. As the prostheses are designed
to sit flush with the surrounding trochlear cartilage, it
was often unable to accommodate situations of severe
trochlear dysplasia. This leads to a malpositioned, proud
component that can cause catching. Additionally, several
8.indd 103 03-03-2014 17:39:23
Jayp
ee B
rothe
rs
104 Section 1 Knee Arthroplasty
early prostheses had abnormally large radii of curvature.
As one might expect, this would lead to the necessity for
the implant to be positioned in a flexed position to avoid
impingement on the ACL or tibia. In a component that
is designed to sit flush with the trochlear cartilage, any
implant flexion would cause the proximal aspect of the
prosthesis to sit proud. In this way, the patella may have
the propensity to catch or sublux in the initial phases of
flexion.11,12
Finally, many inlay-style trochlear implants have
inherent features that do not accommodate the patella
effectively, such as a narrow body, a deep trochlear sulcus
and limited extension. These features have contributed
to the patellar catching or subluxation in the initial 30°
of flexion that is common with inlay-style trochlear
designs.5
Onlay-style Designs
In contrast, the onlay-style trochlear prostheses are
designed to replace the entire anterior trochlear joint
surface, and they are positioned perpendicular to
the AP axis of the femur (Figures 8.3A to D). Unlike
inlay-style designs, the onlay-style prostheses have
almost eliminated the incidence of patellar instability.
Additionally, due to the fact that this style of implant
need not be influenced by the patient’s native anatomy
(which is often pathologic to begin with); the implant is
Figures 8.3A to D Intraoperative clinical photograph and postoperative AP, lateral, and sunrise radiographs after PFA with an onlay-style trochlear component positioned perpendicular to the AP axis of the femur, with good patellar tracking
A B
C D
8.indd 104 03-03-2014 17:39:23
Jayp
ee B
rothe
rs
105Chapter 8 Patellofemoral Arthroplasty
much more versatile and accommodating of all trochlear
morphologies.5
A variety of features have optimized outcomes.
Notably, the rotation of the trochlear component is based
on specific anatomic landmarks that are determined intra-
operatively—the component is placed perpendicular to
Whiteside’s line (the anteroposterior axis of the knee)
and parallel to the transepicondylar axis. By avoiding the
tendency to be internally rotated, the trochlear component
can better accommodate patellar tracking. Moreover, the
onlay-style trochlear implants tend to be wider and less
constraining than the inlay designs, accommodating
variations in patellar tracking throughout the arc of
motion. The onlay-style components are also made with
more accommodating radii of curvature, permitting the
prosthesis to sit flush with the anterior femoral cortex
proximally and the intercondylar notch distally, and they
tend to extend more proximally than inlay designs. These
features enhance patellar tracking through the entire
range of motion and account for the better outcomes with
onlay compared to inlay designs.
The main differences between inlay and onlay
generation designs are summarized in Table 8.1.
SURGICAL CONSIDERATIONS
Any standard TKA incision (medial parapatellar,
subvastus, etc.) can be used to perform PFA. Since the goal
of this procedure is to maintain healthy portions of the
knee joint, extreme care should be taken to avoid injury to
the articular cartilage, the menisci, and the ligamentous
structures during the arthrotomy. After the joint is
accessed, a thorough inspection should commence. At
this point, any unanticipated joint derangement that
was not identified preoperatively may signal the need to
perform additional procedures such as the cartilage graft
or TKA.
Though surgical techniques vary between systems,
most protocols for onlay designs are centered on defining
the anteroposterior axis of the knee joint (Whiteside’s line).
This is the landmark around which trochlear component
rotation is set. Care is taken to position the trochlear
component within the confines of the trochlear groove—
not encroaching on weight-bearing condylar surfaces of
the femur. The trochlear component is designed to sit
flush with the surrounding articular cartilage; it should
not be allowed to sit proud, and any cement used to secure
the prosthesis must not be allowed to extrude from the
cartilage-component interface. The patellar preparation is
similar to that employed in TKA.
Trialling of the components allows for in vivo assessment of patellar tracking. Any abnormal patellar tilt
or maltracking must be addressed intraoperatively, first by
ensuring appropriate implant positioning, then with soft
tissue procedures—most commonly a lateral retinacular
release. Other more aggressive procedures (such as tibial
tubercle transfer) may be necessary as well, but ideally
the decision for a simultaneous procedure would be
determined preoperatively and is based on a high Q-angle.
Postoperative management includes standard use
of antibiotic prophylaxis and DVT chemoprophylaxis.
Generally, full weight-bearing is allowed immediately
after the procedure, with active and passive range of
motion encouraged. Physical therapy is continued until
reasonable quadriceps strength and range of motion
return.
TABLE 8.1 Differences between inlay and onlay generation
Trochlear position Trochlear rotation Trochlear width Trochlear proximal extension Trochlear radius of curvature
Inlay-style Inset within the native trochlea
Identical to that of the native trochlea (Tendency is internal rotation)
Narrow Identical to that of the native trochlea
Causes offset
Onlay-style Perpendicular to the AP axis (Whiteside’s line)
Determined by the surgeon; perpendicular to AP axis
Wide Extending more proximal than the native trochlea
Articulation
8.indd 105 03-03-2014 17:39:23
Jayp
ee B
rothe
rs
106 Section 1 Knee Arthroplasty
RESULTS
Primary Patellofemoral Arthroplasty
Proper patient selection and proper surgical technique
are important factors in determining the success of PFA.
However, evaluation of the outcomes of PFA have shown a
disparity in the short-term failures that occur as a result of
maltracking and patellar instability, depending on which
prosthesis is used—inlay- or onlay-style designs.5 To this
point there are no known studies which have directly
compared the inlay- and onlay-style trochlear designs. A
large majority of the evidence, however, shows improved
outcomes with onlay-style designs, particularly as it
relates to patellar maltracking, functional success rates
and durability.
The results of studies involving the use of inlay- and
onlay-style trochlear prosthesis designs are outlined in
Tables 8.2 and 8.3.
It has become apparent that high reoperation
and revision rates with inlay-style trochlear designs
are attributed to component malposition, soft tissue
imbalance and poor patient selection. In many series
evaluating the inlay-style designs, failure most likely
occurred due to improper trochlear component positioning
that resulted in the prosthesis sitting proud in relation
to surrounding articular surfaces (due to morphologic
mismatches between the trochlear implant and surface
TABLE 8.2
Author (year) Implant type Procedures performed
Average patient age (years)
Average follow-up (years)
Good/excellent results – (rating system) (%)
Revision rate (%)
Blazina (1979) Richards types I & II 57 39 2 — 35
Arciero (1988) Richards type II (14);CFS-Knight (11)
25 62 5.3 85 (H&K) 28
Cartier (1990) Richards types II & III 72 65 4 85 (MSS) 7
Argenson (1995) Autocentric 66 57 5.5 84 (HSS) 15
Krajca (1996) Richards types I & II 16 64 5.8 88 (H&K) 6
De Winter (2001) Richards type II 26 59 11 76 (KSS) 19
Kooijman (2003) Richards type II 45 50 17 86 (KSS) 22
Cartier (2005) Richards types II & III 79 60 10 77 (KSS) 25
Argenson (2005) Autocentric 66 57 16 — 42
van Jonbergen (2010)
Richards type II 185 52 13.3 — 25
Abbreviations: H&K – Hungerford and Kenna Knee Score, MSS – Mansat Scoring System, HSS – Hospital for Special Surgery Knee Score, KSS – Knee Society Score
TABLE 8.3
Author (year) Implant type Procedures performed
Average patient age (years)
Average follow-up (years)
Good/excellent results – (rating system) %
Revision rate (%)
Ackroyd (2007) Avon 109 68 5.2 80 (BPS) 3.6
Starks (2009) Avon 37 66 2 86 (KSS) 0
Leadbetter (2009) Avon 79 58 3 84 (KSS) 6.3
Gao (2010) Avon 11 54 2 100 (KSS) 0
Odumenya (2010) Avon 50 66 5.3 — 4
Mont (2012) Avon 43 29 7 — 12
Abbreviations: BPS – Bristol Pain Score, KSS – Knee Society Score
8.indd 106 03-03-2014 17:39:24
Jayp
ee B
rothe
rs
107Chapter 8 Patellofemoral Arthroplasty
anatomy) and internally rotated due to the native trochlear
inclination. Again, while poorly defined in studies to
this point, these trochlear component design features
likely lead to disproportionately low rates of satisfactory
outcomes in the inlay-style designs.13-26 These findings
have been corroborated by the information published
from the Australian National Joint Registry, showing a
five-year revision rate that is over 20% for the inlay-style
prostheses but less than 10% for the onlay-style designs.9
To this point, the incidence of patellar maltracking has
ranged from 17 to 36% in studies evaluating the results of
inlay-style implants.5,16,20,25,27 In contrast, series that have
reviewed the outcomes of onlay-style trochlear designs
have found much lower incidence of patellar maltracking,
often less than 1%.16,28-31 As a direct result of these finding,
several of the inlay-style PFA systems are not being used
presently. Nevertheless, as long as patella tracking is
acceptable after PFA—even when inlay-style designs are
used—acceptable outcomes can be achieved. In these
circumstances the primary mode of failure is progressive
tibiofemoral arthritis.
Many of the recent series regarding PFA have directly
compared TKA to PFA for the treatment of isolated
patellofemoral arthritis. A small study was published in
the Chinese Medical Journal in 2010. Matched according
to age, gender, bilaterality and body mass index, Gao
et al. compared 11 patients who received Avon PFA
implants with 23 patients who received TKA.32 Outcomes
were similar for both groups, but the PFA group had
shorter operation times, decreased blood loss, and better
post-operative range of motion. Additionally, Dahm et
al. recently published results comparing PFA to TKA in
patients with isolated patellofemoral arthritis.6 At a mean
follow-up of 29 months, significantly better results were
seen in the PFA group regarding UCLA scores, blood
loss, and hospital stay, while Knee Society Clinical Rating
System scores were identical.
Revision
With the high rates of failure seen in the first-generation
inlay-style PFAs, the need for revision can be a commonly
encountered problem for the arthroplasty surgeon.
Two options exist in this situation: revision to a second-
generation onlay-style prosthesis or conversion to a TKA.
In the short- to mid-term, both modalities have proven to
be viable options.
Hendrix et al. published a series of 14 knees that
were revised from first-generation (Lubinus) implants to
second-generation (Avon) implants between 1996 and
2002.33 Revision occurred in the setting of component
malposition, patellar subluxation, or mechanical patellar
problems. At a mean follow-up of 60 months, average
Bristol knee scores improved from 58 preoperatively to
79 postoperatively. No radiographic evidence of loosening,
malposition, or wear was seen in any revision patient.
Lonner et al. demonstrated in a recent study that
revision to TKA can be a very successful option in patients
with failed PFAs.11 In their study, 12 failed patellofemoral
replacements were revised to total knee arthroplasties.
Indications for revision were progressive tibiofemoral
arthritis (six knees), mechanical symptoms due to
maltracking (three knees), or a combination thereof (three
knees). Short-term follow-up demonstrated marked
increase in the knee society functional and clinical scores,
with no signs of persistent maltracking, wear, or loosening.
SUMMARY
Patellofemoral arthroplasty is emerging as a reliable
method of treating isolated patellofemoral arthritis.
Though early designs yielded inconsistent results,
the development of improved implant designs, more
standardized surgical instrumentation and techniques,
and refinement of indications has improved all facets of
PFA implementation. It should be noted, however, that
though short-term follow-up studies regarding second-
generation implants have been very encouraging, long-
term studies are needed to verify that the prostheses
remain a reliable and satisfactory mode of treatment. We
anticipate that as our understanding of the patellofemoral
joint and its pathology grows, instrumentation will
only improve, which should lead to steadily improving
outcomes. If this proves to be correct, PFA will become
an increasingly mainstream alternative to total joint
arthroplasty to address this complex clinical problem.
8.indd 107 03-03-2014 17:39:24
Jayp
ee B
rothe
rs
108 Section 1 Knee Arthroplasty
REFERENCES
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections
of primary and revision hip and knee arthroplasty in
the United States from 2005 to 2030. J Bone Joint Surg.
2007;89(4):780-5.
2. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow MM.
The radiologic prevalence of patellofemoral osteoarthritis.
Clin Orthop Relat Res. 2002;402:206-12.
3. McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic
patterns of osteoarthritis of the knee joint in the community:
the importance of the patellofemoral joint. Ann Rheum Dis.
1992;51(7):844-9.
4. Grelsamer RP, Dejour D, Gould J. The pathophysiology
of patellofemoral arthritis. Orthop Clin North Am.
2008;39(3):269-74.
5. Lonner JH. Patellofemoral arthroplasty: pros, cons,
and design considerations. Clin Orthop Relat Res.
2004;428:158-65.
6. Dahm DL, et al. Patellofemoral arthroplasty versus total
knee arthroplasty in patients with isolated patellofemoral
arthritis. Am J Orthop. 2010;39(10):487-91.
7. Lonner JH. Patellofemoral arthroplasty. J Am Acad Orthop
Surg. 2007;15(8):495-506.
8. Lonner JH. Patellofemoral arthroplasty. In: Lotke PA,
Lonner JH (Eds), Master Techniques in Orthopaedic
Surgery: Knee Arthroplasty, 2nd edn. Philadelphia, PA:
Lippincott Williams and Wilkins; 2003. pp. 261-73.
9. Australian Orthopaedic Association National Joint
Replacement Registry. Available at: http://dmac.adelaide.
edu.au/aoanjrr/publications.jsp
10. Kamath AF, Slattery TR, Levack AE, et al. Trochlear
inclination angles in normal and dysplastic knees.
J Arthroplasty.2013;28(2):214-9.
11. Lonner JH, Jasko JG, Booth RE Jr. Revision of a failed
patellofemoral arthroplasty to a total knee arthroplasty.
J Bone Joint Surg. 2006;88(11):2337-42.
12. Lonner JH, Bloomfield MR. The clinical outcome of
patellofemoral arthroplasty. Orthop Clin North Am.
2013;44(3):271-80.
13. Arciero RA, Toomey HE. Patellofemoral arthroplasty.
A three- to nine-year follow-up study. Clin Orthop Relat
Res. 1988;236:60-71.
14. Argenson JN, Guillaume JM, Aubaniac JM. Is there a place
for patellofemoral arthroplasty? Clin Orthop Relat Res.
1995;321:162-7.
15. Argenson JN, Flecher X, Parratte S, Aubaniac JM.
Patellofemoral arthroplasty: an update. Clin Orthop Relat
Res. 2005;440:50-3.
16. Blazina ME, Fox JM, Del Pizzo W, Broukhim B, Ivey FM.
Patellofemoral replacement. Clin Orthop Relat Res.
1979(144):98-102.
17. Cartier P, Sanouiller JL, Grelsamer R. Patellofemoral
arthroplasty. 2–12-year follow-up study. J Arthrop.
1990;5(1):49-55.
18. Cartier P, Sanouiller JL, Khefacha A. Long-term results with
the first patellofemoral prosthesis. Clin Orthop Relat Res.
2005;436:47-54.
19. Charalambous CP, Abiddin Z, Mills SP, et al. The low
contact stress patellofemoral replacement: high early
failure rate. J Bone Joint Surg. 2011;93(4):484-9.
20. de Winter WE, Feith R, van Loon CJ. The Richards type
II patellofemoral arthroplasty: 26 cases followed for
1–20 years. Acta Orthop Scand. 2001;72(5):487-90.
21. Kooijman HJ, Driessen AP, van Horn JR. Long-term
results of patellofemoral arthroplasty. A report of 56
arthroplasties with 17 years of follow-up. J Bone Joint Surg.
2003;85(6):836-40.
22. Krajca-Radcliffe JB, Coker TP. Patellofemoral arthroplasty.
A 2- to 18-year follow-up study. Clin Orthop Relat Res.
1996;330:143-51.
23. Merchant AC. Early results with a total patellofemoral
joint replacement arthroplasty prosthesis. J Arthrop.
2004;19(7):829-36.
24. Sisto DJ, Sarin VK. Custom patellofemoral arthroplasty of
the knee. J Bone Joint Surg Am. 2006;88:1475-80.
25. Tauro B, Ackroyd CE, Newman JH, Shah NA. The Lubinus
patellofemoral arthroplasty. A five- to ten-year prospective
study. J Bone Joint Surg Br. 2001;83(5):696-701.
26. van Jonbergen HP, Werkman DM, Barnaart LF, van Kampen
A. Long-term outcomes of patellofemoral arthroplasty.
J Arthrop. 2010;25(7):1066-71.
27. Odumenya M, Costa ML, Parsons N, et al. The Avon
patellofemoral joint replacement: five-year results
from an independent centre. J Bone Joint Surg. 2010;92(1):
56-60.
8.indd 108 03-03-2014 17:39:24
Jayp
ee B
rothe
rs
109Chapter 8 Patellofemoral Arthroplasty
28. Ackroyd CE, Newman JH, Evans R, Eldridge JD, Joslin
CC. The Avon patellofemoral arthroplasty: five-year
survivorship and functional results. J Bone Joint Surg Br.
2007;89(3):310-5.
29. Leadbetter WB, Kolisek FR, Levitt RL, et al. Patellofemoral
arthroplasty: a multi-centre study with minimum 2-year
follow-up. Int Orthop. 2009;33(6):1597-601.
30. Mont MA, Johnson AJ, Naziri Q, Kolisek FR, Leadbetter
WB. Patellofemoral arthroplasty: 7-year mean follow-up. J
Arthrop. 2012;27(3):358-61.
31. Starks I, Roberts S, White SH. The Avon patellofemoral
joint replacement: independent assessment of
early functional outcomes. J Bone Joint Surg. 2009;91(12):
1579-82.
32. Gao X, Xu ZJ, He RX, Yan SG, Wu LD. A preliminary report
of patellofemoral arthroplasty in isolated patellofemoral
arthritis. Chin Med J. 2010;123(21):3020-3.
33. Hendrix MR, Ackroyd CE, Lonner JH. Revision
patellofemoral arthroplasty: three- to seven-year follow-up.
J Arthrop. 2008;23(7):977-83.
8.indd 109 03-03-2014 17:39:24
Jayp
ee B
rothe
rs