Total Knee Arthroplasty

Total Knee Arthroplasty

CHAPTER 80 Total Knee Arthroplasty Mark I. Ellen, MD David R. Forbush, MD Thomas E. Groomes, MD Synonyms Total knee replacement Total knee implant U...

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Total Knee Arthroplasty Mark I. Ellen, MD David R. Forbush, MD Thomas E. Groomes, MD

Synonyms Total knee replacement Total knee implant Unicompartmental knee arthroplasty Revision knee arthroplasty

ICD-10 Codes M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.5 Other unilateral secondary osteoarthritis of knee

Definition Arthroplasty involves the reconstruction of a diseased, damaged, or an ankylosed joint. This can be accomplished by modification of naturally occurring elements, by artificial replacement, or by a combination. Total knee arthroplasty (TKA) consists of resection of abnormal articular surfaces of the knee with resurfacing predominantly using metal and polyethylene components.1 There are three basic types of TKA: totally constrained, semi-constrained, and unconstrained. The amount of constraint built into an artificial joint reflects the amount of stability that the hardware provides. A constrained joint has the femoral portion physically attached to the tibial component and requires no ligamentous or soft tissue support. The semi-constrained TKA has two separate components that glide upon each other, but the physical characteristics of the tibial component prevent excessive femoral glide. The unconstrained device relies completely on the body’s ligaments and soft tissues to maintain the stability of the joint. The semi-constrained and unconstrained knee implants are most often used. In general, the unconstrained implants have been found to afford the most normal range of motion and gait.3

A subset within knee arthroplasty is referred to as unicompartmental knee arthroplasty (UKA). It differs from a traditional TKA in that the joint surfaces on only one side of the knee (usually the medial compartment) are replaced. UKA reportedly provides better pain relief than does high tibial osteotomy, and in skilled hands can achieve greater functional outcomes than TKA in younger patients as well as female patients.4 One limitation of UKA is that both the anterior and posterior cruciate ligaments are spared during the process and therefore must be intact and functioning in order to stabilize the knee. Notably, UKA is contraindicated for rheumatoid arthritis due to a tendency for bone and cartilaginous lesions to spread to involve the entire knee.3 Approximately 700,000 TKAs are performed annually in the United States. The most common age group for total knee replacements remains from 65 to 84 years. With the aging of the US population, the number of annually performed TKAs is projected to increase to more than 3 million by the year 2030.2 Absolute contraindications to knee replacement include purulent arthritis, tuberculosis, or other active infection.3 A non-functioning extensor mechanism, recurvatum deformity due to muscle weakness, poor circulation, or the presence of a well-functioning knee arthrodesis are also contraindications. Relative contraindications may include neuropathic joint, morbid obesity, a past history of osteomyelitis, and skin conditions such as psoriasis within the field of surgery.14,13 

Symptoms Preoperatively, refractory knee pain is the most common symptom among patients who undergo TKA. Stiffness, deformity, and instability are also commonly noted. During the perioperative period, acute surgical pain is most intense during the initial 2 weeks postoperatively. Disruption and inflammation of the periarticular soft tissues are manifested as soft tissue stiffness. This stiffness differs in severity with regard to limitation of range of motion from the preoperative stiffness of advanced arthrosis. Surgical disruption of muscle and joint can impair proprioception immediately postoperatively and may give a sense of knee instability. Balance and proprioception can be impaired for patients perioperatively, but seem to improve during convalescence.11 Occasionally postoperatively, patients may experience a noise or sensation such as popping or grinding, and there have been cases reported of postoperative debris (biologic or wear particles) that may explain this.12  443


PART 1 MSK Disorders

Table 80.1  Required Knee Range of Motion Activity of Daily Living


Walking in stance phase


Walking in swing phase


Stair climbing step over step


Standing up from a chair


Standing up from a toilet


Stooping to lift an object


Tying a shoelace


Physical Exam Physical examination of the patient begins with an overall inspection of the limbs. The skin over both legs should be assessed for signs of vascular disease or infection. The exam should progress to palpation of the knee to evaluate for effusion as well as joint line collateral ligament tenderness. The patient’s gait pattern should be documented with attention to the possible presence of knee thrust (abnormal medial or lateral movement of the knee), which may indicate ligamentous instability as well as valgus or varus deformity. Preoperative knee range of motion should be recorded to assess the extensor mechanism. Findings of either contracture or congenital hyper-ligamentous laxity should be noted, as these will need to be addressed at the time of operation. Due to the importance of preserving both medial and lateral collateral ligaments during a TKA surgery, preoperative assessment of the stability of these ligaments is a must. The lower back and hip should routinely be examined to rule out the possibility of referred symptoms to the knee.13 

Functional Limitations Advanced arthrosis can affect a person’s ability to perform functional tasks such as arising from a chair, walking, or utilizing stairs. Table 80.1 depicts the required knee range of motion for specific functional mobility tasks. In an otherwise healthy patient population, knee arthritis may impede participation in recreational or sporting activities, or even in more basic activities of daily living. These functional limitations play a role in selecting patients for whom TKA seems to be most beneficial. The profile of a patient with the highest chance of postoperative locomotor recovery is a male with relatively low body mass index, few comorbidities, relatively greater knee range of motion, preserved lower extremity strength and relatively better preoperative locomotion as measured by the 6-minute walk test.5,6 The converse is also true, as the profile of a patient at risk for poor postoperative locomotor recovery is a woman with a high body mass index, many comorbidities, high intensity of knee pain, restriction in flexion amplitude, deficits in knee strength, as well as poor preoperative locomotion.6 Multiple studies have further identified and corroborated factors associated with a suboptimal postoperative functional outcome.7,5 These factors include marked functional limitation, severe pain, low mental health score, and other comorbid conditions prior to TKA. These are associated

with worse outcomes at 1 year and 2 years postoperatively.7 A recurring finding among studies is that patients who had lower preoperative functional status related to knee arthritis functioned at a lower level postoperatively than did patients with a higher preoperative functional status.5 Several studies have focused on quadriceps strength as a significant contributing factor to postoperative functional recovery.8–10 They have found that functional measures declined early after TKA, but postoperative recovery was more rapid than anticipated and long-term outcomes were better in patients with higher baseline quadriceps strength. The high correlation between quadriceps strength and functional performance suggests that an emphasis on postoperative quadriceps strengthening is vital to enhance the potential benefits of TKA.8 Preoperative quadriceps strength training has not been proven to enhance long-term functional outcome after TKA.9,10 

Diagnostic Studies Plain radiographs of the knee remain the mainstay of diagnosis and preoperative planning. Three basic views are often used. These include standing anteroposterior view to assess the medial and lateral joint spaces while the joint is under load, the lateral view to assess all joint compartments including the patellofemoral joint and position of the patella, and finally, the merchant view taken tangential to the flexed knee to assess the patellofemoral joint space.15 A fourth view, the Notch or Rosenberg view, is integral in assessing the posterior aspect of the femoral condyles and earlier arthritic changes within the notch itself. Magnetic resonance imaging is more sensitive than plain radiography in assessing cartilage, meniscus, and ligament integrity, but may overestimate meniscal and ligament damage in the older population and underestimate the amount of degenerative damage of the articular surfaces.16,17 Consideration should also be given to radiographic evaluation of the cervical spine in patients with rheumatoid arthritis. These patients are at increased risk for atlantodental instability and therefore may be at increased risk for spinal cord impingement secondary to perioperative positioning, movement, and manipulation.18 Patients with rheumatoid arthritis are thought to be at 2.6-fold greater risk of infections than patients with osteoarthritis. Therefore, rheumatoid arthritis patients should be screened for potential sources of infections, including urinary tract infections, skin infections, and dental infections, before TKA.19 In all situations where knee infection is suspected, it must be fully assessed and remedied prior to considering TKA. Aspiration of the knee for aerobic and anaerobic cultures and sensitivities is the most reliable method for diagnosis of infection. Strict sterile technique must be used throughout the aspiration procedure.20

Treatment Initial During the first 48 to 72 hours, patients can receive controlled analgesia therapy administered via intravenous or epidural route. Patients often receive oral opioids. Controlled-release and short-acting opioids may be used, depending on the

CHAPTER 80  Total Knee Arthroplasty

clinician’s and patient’s preferences, and can be given on a fixed schedule as a rescue medication, or both. Opioids should be titrated to achieve balance of analgesia while minimizing side effects.16,34–36 Several studies have found that nonsteroidal anti-inflammatory drugs (NSAIDs) may adversely affect bone healing via their effect on prostaglandins.37 Care for the incision postoperatively involves dry, sterile gauze dressings to be re-applied as long as drainage is present. Bleeding can continue at incision site and through the surgical drain, which blood can be collected and used for reinfusion, thus decreasing the need for donor blood.38 Bleeding tends to be greater for cementless than for cemented prostheses. Staples and sutures can safely be removed 10 to 14 days after surgery.39,40 Knee immobilizers may be used postoperatively to maintain knee extension and to avoid flexion contracture. Range of motion exercises supervised by a physical therapist should be initiated as soon as possible. Properly fitting, thigh-high elastic compression stockings and local cryotherapy can be used to manage swelling.41–44 If the patient was receiving oral anticoagulation therapy preoperatively, bridging therapy with a low-molecular-weight heparin compound may be considered.45 Even for those not previously anticoagulated, prophylactic anticoagulation significantly reduces the incidence of symptomatic venous thromboembolism (VTE) during hospitalization.46 In selecting a prophylactic agent, consideration should be given to patient-specific factors, such as bleeding risk, kidney function, and other comorbidities.46 Intermittent pneumatic compression has also been used for prophylaxis. It works by increasing venous blood flow in the deep veins of the legs and by reducing plasminogen activator inhibitor.47 This mechanical prophylaxis has not been found to be as effective as warfarin and by corollary is not as effective as the other pharmacologic prophylaxis. It can still be considered when pharmacologic options are contraindicated or in conjunction with pharmacologic prophylaxis in patients at high risk for VTE.46 Perioperative antibiotic use has been addressed in the literature and evidence supporting the preoperative and intraoperative administration of antibiotics has been well established.48 The International Consensus Meeting on Periprosthetic Joint Infection held in 2013 recommended pre-intraoperative antibiotic prophylaxis starting no less than 1 hour prior to knee arthroplasty.49 Despite the consensus for pre- and intraoperative antibiotics, the efficacy of postoperative prophylactic antibiotic administration has not been established and is typically limited to no more than 24 hours postoperatively.48 Vancomycin is often used for this purpose, but other antibiotics may also be used.50 

Rehabilitation The focus of postoperative rehabilitation in the TKA patient should include joint range of motion, quadriceps strengthening, and training in gait and activities of daily living. Specific protocols may vary depending upon surgeon preference, incision type, type of implant, and patient bone stock, but in general, the rehabilitation program can be conceptualized as occurring in stages or phases.


Phase One In the immediate postoperative period, the inhibited quadriceps and hamstrings may not adequately stabilize the knee. A knee immobilizer may be of help for transfers and walking. The patient may often require a two-handed assistive device (e.g., walker or axillary crutches) for initial gait training to help with balance and proprioception. Adaptive equipment for bathing and dressing (e.g., tub or shower seat, grab bars, dressing sticks, sock aid) is generally very helpful as well due to limitations in early range of motion. Some patients may not have sufficient range of motion during the first week postoperatively to negotiate stairs. The motor reactions typically normalize by the third week; therefore, patients may return to driving activities if they can perform car transfers independently and can tolerate sitting for prolonged periods (see Table 80.2).51 During early rehabilitation, knee stiffness tends to be a complication of TKAs.52 Continuous passive motion (CPM) devices have been used to combat this, but there is uncertainty whether the cost and inconvenience lead to any significant clinical benefits. A Cochran review published in 2015 found no benefit from the use of CPM over conventional physiotherapy for the following outcomes: Active knee flexion at 6 weeks, function at 6 months, and quality of life at 6 months. There was one outcome which showed possible benefit from CPM and that was number of patients requiring manipulation at 6 weeks, but the evidence grade for this was very low.53 There is no substantial evidence that CPM influences the degree of swelling, risk of VTE, incidence of wound infection, or incision site complications following TKA.54 Given the lack of demonstrated efficacy, it is suggested that clinicians consider discontinuing the routine use of CPM following uncomplicated primary TKA.53 

Phase Two During the second stage of TKA rehabilitation (weeks 1 to 4), the patient may progress to low-resistance dynamic exercise for the involved lower extremity. This can be carried out with a stationary bicycle set at low resistance. Some patients may prefer aquatic-based exercise regimens during this period. At this stage, patients are usually independent in ambulating with a two-handed or single-handed device if they are fully weight bearing on level surfaces up to 500 feet. Supervision is advised in negotiating stairs. Electrical stimulation of the quadriceps can be considered for patients who have inhibited recruitment.57 Soft tissue mobilization can be introduced to facilitate patellar glide. During this stage, the patient should advance to independence in all basic activities of daily living. In the past 20 years, there has been a progressive push toward earlier outpatient rehab with patient-directed home exercise programs. In this regard, there are no reproducible and enforceable guidelines that may be uniformly applied.77-79 

Phase Three During the third stage of TKA rehabilitation (weeks 4 to 8), the patient’s range of motion should reach 0 to 115 degrees. Patients may then advance their dynamic resistance exercise regimens and more freely pursue both open and closed


PART 1 MSK Disorders

Table 80.2  Clinical Pathway for First-phase Rehabilitation Postoperative Day




Deep breathing

Sits to chair transfer


Activities of Daily Living

Incentive spirometer Quadriceps and gluteal sets

Education on continuous passive motion machine

Straight-leg raise Hip abduction Ankle pumps 1

Deep breathing

Bed mobility

Lower extremity static resistance exercises

Bed to chair transfers with knee immobilizer

Assess adaptive equipment: reachers, long-handled sponges, and shoehorns

Ankle pumps and circles Continuous passive motion 2

Continue previously described exercises

Continue bed mobility and transfers

Assisted ambulation in room, partial weight bearing or weight bearing as tolerated with knee immobilizer

Short arc quads Straight-leg raise with knee immobilizer

Raised toilet seat

Grooming and dressing well while seated Begin toilet transfers

Upper extremity strengthening 3

Continue previously described exercises

Decreased assistance in basic transfers

Sitting full arc motion flexion and extension in conjunction with supine passive flexion and extension

Independent ambulation with walker or crutches in room, partial weight bearing or weight bearing as tolerated with knee immobilizer

Independent toileting and grooming

Trial of ambulation in corridor, possibly practice negotiating 2–4 stairs

Education on joint protection and energy conservation techniques

Depending on community resources and home safety and support availability, the patient may be ready for hospital discharge and post-acute care rehabilitation at this time. 4

Continue previously described exercises with increased intensity

Independent in basic transfers

Gait training to improve pattern and endurance

Continue previously described activities of daily living

Discontinue knee immobilizer (if quadriceps strength is greater than 3/5) Initiate active assistive range of motion exercises and quadriceps and hamstrings self-stretch 5–6

Continue previously described exercises

Independent ambulation with assistive device

Transition from passive to active assistive range of motion exercises

Begin stairs with railing, cane as needed

Independent dressing with tapered use of adaptive equipment

CHAPTER 80  Total Knee Arthroplasty


kinetic chain and dynamic balance exercises. Patients may advance to a single-handed device or no assistive device for ambulation and at different speeds on different terrain. We also can expect independence with stair climbing. 

Phase Four (Final) In the final stage (weeks 8 to 12), patients may return to their preoperative exercise regimens and recreation activities and kneeling. Most patients who participated in sports before surgery are able to return to low-impact athletic activities and exercise regimens. Patients are able to return to sedentary, light, and medium work categories. Patients who are on sick leave for more than 6 months preoperatively are less likely to return to work. There is evidence that the degree of physical activity does not contribute to premature revision TKA.61 However, younger patients may be at risk for earlier revision TKA, depending on their degree of physical activity.62 Contact sports are advised against, and caution should be exercised with high-impact aerobic activities.63–67


Midline Subvastus Anterolateral

Procedures Some patients with unsatisfactory gains in knee range of motion may be candidates for manipulation. The role of manipulation for the patient with a TKA contracture remains controversial. Outcome studies are divided as to whether functional outcomes and quality of life are enhanced as a result of manipulation. This procedure is typically carried out in an operating room with the use of general or epidural anesthesia. The goal is to overcome arthrofibrotic lesions after quadriceps resistance is eliminated. Manipulation is most commonly performed during the second or third postoperative week if the range of motion of the involved knee is less than 75 degrees.55,56 

Technology Recent developments in the area of arthroplasty have led to the concept of minimally invasive surgery (MIS) techniques for knee arthroplasty. In MIS, the approach can be a variation on those described in the section on Surgery; “minimally invasive” refers to limited violation of anatomic structures21 rather than a smaller incision. While the procedure is not done for cosmesis, it often involves a smaller skin incision and accompanying smaller arthrotomy, including inferior and superior patellar capsular releases.24 There is also decreased or absent patellar eversion, which can reduce extensor disruption and lower the risk of permanent dysfunction of the quadriceps muscle. The intraoperative loss of blood is relatively limited in MIS, leading to fewer transfusions and complications in that regard.25–27 

Surgery There are multiple surgical approaches that can be utilized for TKA (Fig. 80.1). The medial parapatellar arthrotomy, also known as the anteromedial approach, has been the most used approach for exposure of the knee joint.21 Two other surgical approaches that are fairly common for TKA are the midvastus approach and the subvastus approach.22 These are some of the technical considerations of the various approaches. The medial parapatellar approach compromises the quadriceps tendon in its medial third, which gives

FIG. 80.1  Surgical approaches for total knee arthroplasty. (Pictures taken from Insall & Scott Surgery of the Knee, 5th ed.)

rise to more postoperative patellofemoral complications. The midvastus approach splits the vastus medialis,21 but does not compromise the extensor mechanism of the knee joint. The subvastus approach also preserves the integrity of the extensor mechanism, but does not expose the knee as well as the other two approaches do.23 Once the arthrotomy is accomplished, bone is removed from the tibia and femur to provide room for the prosthesis. Cutting guides help the surgeon accomplish this in a precise manner to later achieve good prosthetic fit and alignment. The proper size prosthesis is then placed.21 These guides can be seen below (Fig. 80.2). Fixation of the prosthesis can be achieved with cement, may be cementless, or may be a hybrid of the two.1 Cementless prostheses were developed in the 1980s out of concern that cement would fail over time. The first generation of cementless prostheses was developed with porous, indented, or serrated surfaces to promote ingrowth of host bone (Fig. 80.3).28–30 The first generation of these prostheses failed at a higher rate than their cemented counterparts,31,32 and they have since been revised. With newer versions of cementless prostheses, there remains evidence of increased aseptic loosening within 5 years as compared to their cemented counterparts.33 Long-term studies are under way to better assess outcomes. 

Potential Disease Complications The overall rate of infection for initial TKA is around 1%.75 Patients with diabetes mellitus, advanced rheumatoid arthritis, revision TKA, or constrained prostheses are known to have higher infection rates. Infection may occur at any time


PART 1 MSK Disorders




FIG. 80.2  (A) Distal femoral cutting guide. (B) Femoral sizing guide. (C) Femoral cutting block. (Pictures taken from Insall & Scott Surgery of the Knee, 5th ed.)

Potential Treatment Complications

FIG. 80.3  A type of cementless knee prosthesis. (Pictures taken from Insall & Scott Surgery of the Knee, 5th ed.)

from days to months after surgery. This is usually manifested as an increase in pain, swelling, and fever. The diagnosis is confirmed by joint fluid analysis, as described earlier. The most successful technique for treatment of the infected total knee replacement is a two-stage reimplantation of the TKA components. A 2- to 6-week course of antibiotic treatment between the period of component removal and reimplantation is typical.76 The symptoms are commonly the same as those seen with aseptic loosening. A progressive radiolucency between the prosthesis and its adjacent bone almost always is considered an infection until proven otherwise. A negative aspirate from the knee, normal sedimentation rate and C-reactive protein level, and normal contrast-enhanced imaging study does not rule out infection of the prosthetic device. Even in the presence of normal test results, infection of the prosthetic device may be discovered intraoperatively and necessitate the removal of the prosthetic device. 

The need for surgical revision has been described as a clinically meaningful endpoint for TKA complications. The rate of revisions has steadily declined, according to the Swedish Knee Arthroplasty Registry, with rates dropping from around 20% in the 1970s and 80s to under 5% for primary surgeries performed between 2006 and 2009.68 Loosening of the implant has been the most common reason for total arthroplasty failure and possible revision.69 Factors associated with loosening include infection, implant constraint, failure to achieve neutral mechanical alignment, instability, and cement technique. The prodromal features of impending loosening and failure of the components are an increase in pain and swelling with or without angular deformity of the knee.70 The radiographic features include a widening radiolucent zone between the implant and the adjacent bone. Loosening may occur at the component-cement interface or bone-cement interface. Implant loosening can be attributed to both mechanical and biologic factors. The mechanical factors include limb alignment, ligamentous balance, and preservation of a contracted posterior cruciate ligament. Implant loosening can occur early or late. Early implant loosening usually occurs within the first 2 years and represents a mechanical failure of the interlock of the implant and bone. Late loosening of total knee implants is often secondary to the host’s biologic response to the implant’s debris, which weakens the mechanical bond of implant to bone. One such response is known as metallosis, during which metallic debris is found within the periprosthetic soft tissues thought to be from abrasion of the metallic components. This metallic debris may induce a release of cytokines from the host’s inflammatory cells. This release may accelerate osteolysis and loosening of the prosthesis.71 The inflammatory cells may also infiltrate the synovium, resulting in synovitis, which may be manifested acutely as a painful effusion.72 In addition, the metallic debris may have a direct toxic effect on human marrow stroma-derived mesenchymal stem cells. If the osteolysis becomes severe, revision surgery may be more difficult. Both biological and mechanical factors contribute to aseptic loosening in the early and late stages.73

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Other potential complications of TKA include periprosthetic fractures, patellofemoral complications, infection, DVT/PE, infection, and paresthesias. Periprosthetic fractures may occur in the patella, around the femoral component, or around the tibial component, with the latter being the most rare.74 Osteoporosis and rheumatoid arthritis also increase the risk for periprosthetic fractures. Patellofemoral complications are a potential reason for reoperation after TKA. Examples include patellar instability, patellar component loosening or failure, patellar fracture, patella clunk syndrome, and rupture of the exterior mechanism. Patella clunk syndrome results from formation of fibrous tissue on the quadriceps tendon. The patient may feel a “clunk” as the knee is actively extended from 60 to 30 degrees. The development of DVT with the subsequent risk for fatal PE is another complication of TKA. Without prophylaxis, the incidence of DVT after TKA ranges from 40% to 88%, the incidence of asymptomatic PE ranges from 10% to 20%, and the incidence of symptomatic PE ranges from 0.5% to 3%, with mortality up to 2%. With prophylaxis, the incidence of symptomatic DVT and PE drops to less than 1% and 0.3%, respectively.77 The most common neurologic complication is common peroneal nerve palsy (CPNP). Clinical presentation includes paresthesias and ankle dorsiflexion weakness. Incidence is less than 1%. One study found CPNP to be more associated with younger patients and patients with higher BMI. Recovery is variable, with one study reporting up to 75% full recovery.78 Care should be taken in the postoperative positioning of limb to avoid external rotation of the limb and pressure on peroneal nerve from bed rail, bedding, or medical equipment.79


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PART 1 MSK Disorders

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