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KNEE SURGERY

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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

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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

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Overseas OfficesJ.P. Medical Ltd.83, Victoria Street, LondonSW1H 0HW (UK)Phone: +44-2031708910Fax: +02-03-0086180Email: [email protected]

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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]

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Dedicated to

The Joy of Walking

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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


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

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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


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


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

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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

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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


40. Double-bundle ACL Reconstruction: Principles and Surgical Technique 469J Clement Joseph


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

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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

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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

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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

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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.

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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

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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

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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

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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

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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.

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