Total Knee Arthroplasty
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The primary indication for total knee arthroplasty (TKA; also referred to as total knee replacement [TKR]) is relief of significant, disabling pain caused by severe arthritis. (See the image below.)
Anesthesia
TKA may be performed with the patient under regional or general anesthesia. Which of these is used depends partly on the medical condition of the patient, though cardiovascular outcomes, cognitive function, and mortality rates associated with regional and general anesthesia have not been proved to be significantly different.
Patients who have epidural anesthesia have been shown to develop fewer perioperative deep vein thromboses (DVTs). Whether this has an overall positive benefit for the patient is not known.
Equipment
Types of TKA prostheses include the following:
Patient evaluation
Preoperative medical evaluation of the patient includes the following:
Antibiotics and antithromboembolic devices
Antibiotics and antithrombotic prophylaxis are administered approximately 30 minutes before the incision is made. Mechanical antithromboembolic devices (eg, stockings, foot pumps) are used intraoperatively.
TKA is performed as follows:
The patient undergoes recovery and is usually observed for a 24-hour period in a high-dependency ward. Adequate hydration and analgesia are essential in this time of high physical stress. Analgesia is provided through continuation of the intraoperative epidural, patient-controlled intravenous analgesia, or oral analgesia. Cryotherapy is used to reduce postoperative swelling and pain.
At this early stage, the patient begins knee movement, sometimes using a continuous passive motion (CPM) machine and exercises. These are continued under the supervision of a physiotherapist until discharge. [1, 2]
Drains are usually removed within 24 hours, and the patient is encouraged to walk on the second postoperative day. Continual improvement is generally observed, and discharge occurs in 5-14 days. Thromboembolism prophylaxis is often continued at home for a period of time.
Total knee replacement (TKR) in some form has been practiced for more than 50 years, but in the earleist days of the procedure, the complexities of the knee joint were not fully understood. Because of this, TKR initially was not as successful as Sir John Charnley’s artificial hip. However, dramatic advancements in the knowledge of knee mechanics have led to design modifications that appear to be durable.
Significant advances have occurred in the type and quality of the metals, polyethylene, and, more recently, ceramics used in the prosthesis manufacturing process, leading to improved longevity. As with most techniques in modern medicine, more and more patients are receiving the benefits of total knee arthroplasty (TKA). [3, 4] Approximately 130,000 knee replacements are performed every year in the United States.
In the 1860s, Fergusson reported performing a resection arthroplasty of the knee for arthritis. Verneuil is thought to have performed the first interposition arthroplasty using joint capsule. Other tissues were subsequently tried, including skin, muscle, fascia, fat, and even pig bladder.
The first artificial implants were tried in the 1940s as molds fitted to the femoral condyles following similar designs in the hip. In the next decade, tibial replacement was also attempted, but both designs had problems with loosening and persistent pain.
Combined femoral and tibial articular surface replacements appeared in the 1950s as simple hinges. These implants failed to account for the complexities of knee motion and consequently had high failure rates from aseptic loosening. They were also associated with unacceptably high rates of postoperative infection.
In 1971, Gunston importantly recognized that the knee does not rotate on a single axis like a hinge; rather, the femoral condyles roll and glide on the tibia with multiple instant centers of rotation. His polycentric knee replacement had early success with its improved kinematics over hinged implants but was ultimately unsuccessful because of inadequate fixation of the prosthesis to bone.
The highly conforming and constrained Geomedic knee arthroplasty introduced in 1973 at the Mayo Clinic ignored Gunston’s work, and a kinematic conflict arose. Other designs followed, either following Gunston’s principle in attempting to reproduce normal knee kinematics or allowing a conforming articulation to govern knee motion.
The total condylar prosthesis was designed by Insall at the Hospital for Special Surgery in 1973. This prosthesis concentrated on mechanics and did not try to reproduce normal knee motion. In 1993, Ranawat et al reported a rate of survivorship of 94% at 15 years of follow-up, which is the most impressive reported to date. [5]
The component was subsequently altered to artificially introduce normal kinematics so as to improve the component’s range of motion (ROM). At the same time, a prosthesis with more natural kinematics was developed at the Hospital for Special Surgery, relying on the retained cruciate ligaments to provide knee motion.
The argument over whether knee ligaments should be preserved or sacrificed continues to this day. Long-term follow-up studies do not show any significant differences, though gait appears to be less abnormal if ligaments are preserved, especially when walking up and down stairs. One theoretical way of incorporating normal kinematics and maximal conformity is to use mobile tibial bearings. Midterm follow-up studies of these prostheses have shown encouraging results.
Cemented TKR procedures have been the criterion standard for TKA, but uncemented designs with bioactive surfaces (eg, hydroxyapatite) have shown promising midterm results (see the image below). [6]
For patient education information, see the Foot, Ankle, Knee, and Hip Center, Bone Health Center, and Arthritis Center, as well as Knee Joint Replacement and Knee Pain.
The primary indication for TKA is to relieve pain caused by severe arthritis. The pain should be significant and disabling. Night pain is particularly distressing. If dysfunction of the knee is causing significant reduction in the patient’s quality of life, this should be taken into account.
Correction of significant deformity is an important indication but is rarely used as the primary indication for surgery. Roentgenographic findings must correlate with a clear clinical impression of knee arthritis. Patients who do not have significant loss of joint space tend to be less satisfied with their clinical result after TKA. All conservative treatment measures should be exhausted before surgery is considered.
Knee replacement has a finite expected survival that is adversely affected by activity level. [5, 7, 8] Generally, it is indicated in older patients with more modest activities. It is also clearly indicated in younger patients who have limited function because of systemic arthritis with multiple joint involvement. Young patients requesting knee replacement, especially those with posttraumatic arthritis, are not excluded by age but must be significantly disabled and must understand the inherent longevity of joint replacement.
Rarely, severe patellofemoral arthritis (see the image below) may justify arthroplasty on the grounds that the expected outcome of arthroplasty is superior to that of patellectomy. Isolated patellofemoral replacement still is undergoing clinical investigation.
Deformity can sometimes become the principal indication for knee replacement in patients with moderate arthritis when flexion contracture or varus or valgus laxity is significant. In such cases, a more constrained prosthesis is often required, leading to greater technical difficulty in surgery and greater uncertainty regarding long-term survival.
Absolute contraindications for TKA include the following:
Relative contraindications include medical conditions that preclude safe anesthesia and the demands of surgery and rehabilitation. Other relative contraindications include the following:
Movement of the knee joint can be classified as having six degrees of freedom, comprising three translations and three rotations, as follows:
Movements of the knee joint are determined by the shape of the articulating surfaces of the tibia and femur and the orientation of the four major ligaments of the knee joint. The anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL; see the image below), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL) serve as a four-bar linkage system.
Knee flexion/extension involves a combination of rolling and sliding called femoral rollback, which is an ingenious way of allowing increased ranges of flexion. Because of asymmetry between the lateral and medial femoral condyles, the lateral condyle rolls a greater distance than the medial condyle during 20º of knee flexion. This causes coupled external rotation of the tibia, which has been described as the screw-home mechanism of the knee that locks the knee into extension.
Medial and lateral collateral ligaments
The primary function of the MCL is to restrain valgus rotation of the knee joint, with its secondary function being control of external rotation. The LCL restrains varus rotation and resists internal rotation.
Anterior cruciate ligament
The primary function of the ACL is to resist anterior displacement of the tibia on the femur when the knee is flexed and control the screw-home mechanism of the tibia in terminal extension of the knee. A secondary function of the ACL is to resist varus or valgus rotation of the tibia, especially in the absence of the collateral ligaments. The ACL also resists internal rotation of the tibia.
Posterior cruciate ligament
The main function of the PCL is to allow femoral rollback in flexion and resist posterior translation of the tibia relative to the femur. The PCL also controls external rotation of the tibia with increasing knee flexion. Retention of the PCL in TKR has been shown biomechanically to provide normal kinematic rollback of the femur on the tibia. This also is important for improving the lever arm of the quadriceps mechanism with flexion of the knee.
Patellofemoral joint
Movement of the patellofemoral joint can be characterized as gliding and sliding. During flexion of the knee, the patella moves distally on the femur. This movement is governed by the attachments of the patellofemoral joint to the quadriceps tendon, the ligamentum patellae, and the anterior aspects of the femoral condyles. The muscles and ligaments of the patellofemoral joint are responsible for producing extension of the knee.
The patella acts as a pulley in transmitting the force developed by the quadriceps muscles to the femur and the patellar ligament. It also increases the mechanical advantage of the quadriceps muscle relative to the instant center of rotation of the knee.
Mechanical axis
The mechanical axis of the lower limb is an imaginary line through which the weight of the body passes. It runs from the center of the hip to the center of the ankle through the middle of the knee. This axis is altered in the presence of deformity and must be reconstituted at surgery, which allows normalization of gait and protects the prosthesis from eccentric loading and early failure.
See Knee Joint Anatomy for more information.
A number of operative procedures should be considered in patients with degenerative disease of the knee. Arthroscopic debridement is sometimes indicated in mild degenerative joint disease with mechanical symptoms and recurrent persistent effusions. Proximal tibial valgus osteotomy should be reserved for patients with medial tibiofemoral compartment disease, stable collateral ligaments, and a correctable varus deformity of the knee joint (see the image below).
Similarly, a distal femoral varus osteotomy can be considered for patients with lateral tibiofemoral compartment disease, stable collateral ligaments, and a valgus deformity of the knee joint (see the image below).
These procedures restore the mechanical axis of the lower limb and offload the diseased compartment. Proximal tibial valgus osteotomy and distal femoral varus osteotomy are generally reserved for young high-demand patients because of concerns about the durability of TKA in this patient group.
A prospective, randomized, controlled trial in England compared unicompartmental knee replacement with TKA over 8, 10, 12, and 15 years of follow-up. At 5 years, the number of failures were equal in the two groups. At 15-year follow-up, the survivorship rate was 89.8% for unicompartmental knee replacement and 78.7% for TKA. Four of the unicompartmental knees failed, and six of the TKA knees failed. Newman et al determined from their findings that the results of their study justify increased use of unicompartmental replacement. [9]
Arthrodesis or fusion of the knee is rarely performed but should be considered in patients with chronic sepsis, younger patients with tricompartmental disease (eg, following trauma) who require stability and durability, and patients with deficient extensor mechanisms. TKA is performed in patients with symptomatic advanced degenerative changes in one or more compartments of the knee joint.
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Simon H Palmer, MD, MBBS, MSc Consultant Surgeon, Department of Orthopaedics and Trauma, Worthing and Southlands NHS Trust, UK
Disclosure: Nothing to disclose.
Mervyn J Cross, MBBS, FRACS, MD Director of the Australian Institute of Musculoskeletal Research, Department of Orthopedic Surgery, North Sydney Orthopedic/Sports Medicine Center, Crows Nest, Australia
Mervyn J Cross, MBBS, FRACS, MD is a member of the following medical societies: American Orthopaedic Society for Sports Medicine, Australasian College of Sports Physicians, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Hughston Society, Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Professor of Orthopedic Surgery, Baylor College of Medicine as Co-Director, Combined Baylor College of Medicine-The San Antonio Orthopaedic Group, Texas Sports Medicine Fellowship; Medical Director, Burkhart Research Institute for Orthopaedics (BRIO) of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; The Foundry, Cotera; ABMT; Conmed; <br/>Received research grant from: Histogenics; Cotera; Arthrex.
Total Knee Arthroplasty
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