Patients are rightfully trying to become more educated about their surgery and recovery. They often obtain (mis)information on the Internet or from friends. They need to be informed about their surgeon’s individual postoperative protocol, and they need to have their anxieties relieved when “things happen” during their recovery. For years, measures had been in place at our hospitals to try to address this. These measures included…

Many problems or mishaps can be encountered during routine and not-so-routine total knee arthroplasty (TKA). In this chapter, I address several of these and offer potential solutions. Choosing the Correct Incision Wound necrosis after TKA can be a minor inconvenience or a major disaster that can lead to secondary infection and potential loss of the knee replacement. Necrosis is most likely to occur in the setting…

Sepsis occurring after total knee arthroplasty (TKA) is a disastrous complication. I was fortunate in my career in that after more than 6000 primary TKAs, none of my patients had experienced an early deep infection. I have seen late “metastatic” infection to primary TKAs at a rate that was 0.6% at average 10-year follow-up. The observations and recommendations in this chapter have been gleaned from my…

Because arthritis of the knee has a significant incidence of bilaterality, both patients and surgeons often consider the possibility of bilateral simultaneous total knee arthroplasty (TKA). I am a strong advocate of this procedure in properly selected patients, and the incidence of performing bilateral knee replacements in my practice varied from 10% to 20% of my knee replacement patients. The Decision For me to have considered…

Femoral Deficiency Options available for reconstitution of deficient bone stock on the femoral side include bone grafting, cement alone, cement plus screw augmentation, augmented components, trabecular metal augments and custom components. Bone Grafting Bone grafting is appropriate for all contained defects. The graft can be in the form of morsels, solid blocks, or a combination of both. Early in my experience with patients with rheumatoid arthritis,…

Total knee arthroplasty (TKA) in patients with rheumatoid arthritis has unique features that are different from those encountered in patients with osteoarthritis. Through the years, I have taken care of a large number of patients with rheumatoid arthritis requiring TKA (both adult and juvenile patients). When I started practice in 1975 at the Robert Breck Brigham Hospital, 85% of patients undergoing TKA had rheumatoid arthritis. Since…

Conversion of osteotomy to total knee arthroplasty (TKA) can be extremely difficult for multiple reasons including the presence of prior incisions, difficult operative exposure, the presence of retained hardware, joint line angle distortion, malunion, nonunion, patella baja, offset tibial shafts, and relative deficiency of the lateral tibial plateau ( Fig. 8.1 ). Open full size image • Fig. 8.1 Failed tibial osteotomy with a nonunion, malalignment,…

A fixed flexion contracture can result from several disease processes, including osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis. Often a common pathway starts with pain and leads to decreased motion and posterior capsular scarring. The scarring promoted by the inflammatory component of rheumatoid arthritis also plays a role. In arthrosis resulting from osteoarthritis or trauma, osteophytes play a significant role. Osteophytes develop posteriorly and in the intercondylar…

Among the goals of total knee arthroplasty (TKA) are relief of pain and restoration of function. Adequate range of motion is necessary for return to certain activities. For example, to walk normally on level ground, a person needs 70 degrees of knee flexion. Ninety degrees is necessary to ascend most stairs (depending on the height of the rise), and 100 degrees is needed to descend stairs…

Patellofemoral complications once accounted for as much as 50% of complications after total knee arthroplasty (TKA). These statistics come from arthroplasties performed in the 1980s and early 1990s. With improvements in surgical technique and prosthetic design, the incidence has decreased, but it is still significant. Problems include pain after an unresurfaced patella, maltracking, fracture, prosthetic loosening, osteonecrosis, and prosthetic wear. One of the persistent controversies in…

The typical patient with a severe valgus deformity is an elderly woman ( Fig. 4.1 ). She usually is in her seventh or eighth decade and reports that she has had “knock-knees” her entire life. She also may give a history of patellofemoral problems through adolescence and young adulthood. These problems might be symptoms of chondromalacia or recurrent subluxation episodes. As the valgus deformity progresses, loss…

Severe varus deformity appears to have no predilection for male or female patients. Typically, patients report some varus alignment in their knees since childhood and may have a history of medial meniscectomy. The deformity gradually progresses, and the patient may present with significant disability any time after the age of 50 years. Lateral subluxation of the tibia on the femur is not uncommon. The source of…

I have tried to make the surgical technique of primary total knee arthroplasty (TKA) as generic as possible. Obviously, TKA systems will vary in terms of instrumentation and nuances of surgical technique. Some differences will also exist between posterior cruciate ligament (PCL) retention, sacrifice, and substitution. Some surgeons will prefer femur first preparation and others will prefer tibia first preparation. Some prefer the “measured resection” technique,…