Review Article

Preoperative Planning in Primary

Total Knee Arthroplasty
Abstract
Michael Tanzer, MD, FRCSC
Asim M. Makhdom, MD, MSc

From the Division of Orthopaedic

Surgery, McGill University, Montreal,
Quebec, Canada (Dr. Tanzer and
Dr. Makhdom), and the Department of
Orthopaedic Surgery, King Abdulaziz
University, Jeddah, Saudi Arabia,
(Dr. Makhdom).
Dr. Tanzer or an immediate family
member serves as a paid consultant
to Pipeline Biotechnology and
Zimmer; has received research or
institutional support from Johnson &
Johnson and Zimmer; has received
nonincome support (such as
equipment or services), commercially
derived honoraria, or other non
research-related funding (such as
paid travel) from Zimmer; and serves
as a board member, owner, officer, or
committee member of The Hip
Society. Neither Dr. Makhdom nor any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2016;24:
220-230
http://dx.doi.org/10.5435/
JAAOS-D-14-00332
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.

220

Preoperative planning is of paramount importance in primary total

knee arthroplasty. A thorough preoperative analysis helps the
surgeon envision the operation, anticipate any potential issues,
and minimize the risk of premature implant failure. Obtaining a
thorough history is critical for appropriate patient selection. The
physical examination should evaluate the integrity of the soft tissues,
the neurovascular status, range of motion, limb deformity, and the
status of the collateral ligaments to help determine the soft-tissue
balancing and constraint strategy required. Standard radiographs,
with a known magnification, should be obtained for preoperative total
knee arthroplasty templating. Routine standing AP, lateral, and
skyline radiographs of the knee can help the surgeon plan the bone
cuts and tibial slope as well as the implant size and position at the time
of surgery. In certain circumstances, such as severe coronal
deformities, bone deficiencies, and/or extra-articular deformities,
additional measures are frequently necessary to successfully
reconstruct the knee. Constrained implants, metal augments, and
bone graft must be part of the surgeons armamentarium.

rimary total knee arthroplasty

(TKA) is an increasingly common
procedure; the number of procedures
performed in the last two decades has
increased 162%.1 It is projected that
the number of revisions in the United
States will increase by 600%
between 2005 and 2030.2 Although
excellent functional outcomes and
long-term survival rates have been
reported, infection, instability, wear,
osteolysis, mechanical loosening,
and periprosthetic fracture are
common causes of revision TKA.3
Many of these failure modes are
related directly to the surgical technique and, therefore, are under the
control of the surgeon.
Thorough preoperative planning
is critical in optimizing implant
position and soft-tissue balancing,
which will minimize the probability

of subsequent TKA failure and

improve the surgical outcome.4 In
addition, preoperative planning
helps the surgeon to visualize the
procedure and thereby appropriately counsel patients about potential surgical complications. Careful
planning allows the surgeon to
communicate with the surgical team
preoperatively to ensure the availability of the required instrumentation and implants.

History and Physical

Examination
Obtaining a thorough history is crucial for patient selection and for
the evaluation of potential postoperative complications. Factors that
should be considered include the
preoperative diagnosis, patient age

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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

and sex, characteristics of the knee

pain, level of activity, functional
limitations, involvement of other
joints, mechanical symptoms, and
previous treatment. The presence of
comorbid conditions, smoking status, alcohol consumption, medications, and mental status should be
assessed carefully to further guide
preoperative evaluation and medical
optimization. Active infection must
be treated and resolved before surgery to prevent a postoperative
infection. An assessment of the
patients overall venous thromboembolism risk, including any history
of previous deep vein thrombosis or
pulmonary embolism, is recommended to optimize perioperative
management. Evaluation of the
patients social history can guide
postoperative rehabilitation and
discharge planning.
Dementia, diabetes mellitus, a body
mass index .40, and renal and
cerebrovascular diseases have been
shown to be independent predictors
for in-hospital mortality and postoperative complications after primary TKA. Therefore, the benefits of
TKA should be weighed against such
risks.5 Patients with neuromuscular
conditions, such as Parkinson disease, are at high risk of instability
following TKA and may benefit from
specific implant options (eg, varus
valgus-constrained TKA, hinged
knee components).6
The patients gait should be assessed. In addition to observing the
overall knee alignment, the surgeon
should look for the presence of
thrust and/or hyperextension during
walking, which indicates ligamentous laxity. This indication may
prompt the surgeon to consider a
constrained knee design. An intoeing
or out-toeing gait may indicate preexisting
rotational
deformities.
Hindfoot inspection also should be
part of the examination because
hindfoot valgus is not uncommon,
and it tends to shift the mechanical

axis of the lower extremity after

TKA.7
The presence of surgical scars
should be noted during the skin
examination because it can inform
the decision of whether to use a
standard midline surgical incision.
When multiple previous incisions
are encountered, it has traditionally
been recommended that the most
lateral incision be used and that at
least 5 or 6 cm of skin bridging be
provided between incisions to avoid
postoperative skin complications.8
The presence of local signs of skin
infection or adherence to the
underlying bone also should be
noted. Such findings necessitate
further investigation and treatment
before surgery.
Examination of preoperative knee
range of motion (ROM) is essential.
Although postoperative stiffness is
multifactorial, preoperative ROM
remains the most important predictor
of postoperative motion.9 Identification of preoperative knee flexion
contractures can help the surgeon
plan an intraoperative strategy for
correction.
Preoperative assessment of the collateral and cruciate ligaments is
required to guide the strategy for softtissue balancing and the selection of
the implant. The integrity of the collateral ligaments is essential when
performing TKA with an unconstrained or semiconstrained implant.
Any fixed coronal deformity found
on physical examination should be
noted to allow for planning of intraoperative correction.
A thorough neurovascular examination also should be performed. The
surgeon should note any signs of poor
circulation, such as skin discoloration,
atrophic nails, absent hair, or asymmetric or absent distal pulses. If any
suspicion of peripheral arterial insufficiency is present, the ankle-brachial
index should be determined. If the
ankle-brachial index is ,0.9, a preoperative vascular surgery consulta-

tion is warranted.10 Because patients

with preexisting peripheral vascular
disease are at high risk of arterial
injuries and compromised blood flow
during TKA, the surgeon should
consider not using a tourniquet during the procedure or inflating it just at
the time of cementing.10
Finally, assessment of the ipsilateral
hip and ankle joint and the contralateral limb should be performed to
evaluate the involvement of these
joints and the effects they may have on
the patients postoperative mobility
and rehabilitation. Ipsilateral hip
arthritis can present as isolated knee
pain and must be ruled out. Patients
with a fixed flexion deformity on the
contralateral knee may benefit from a
shoe lift postoperatively. In cases of
severe bilateral deformities, bilateral
one-stage or two-stage TKAs should
be planned.

Imaging and Laboratory

Testing
Plain Radiography
Standard radiographic evaluation for
patients undergoing primary TKA
includes a weight-bearing AP view of
the knee, a lateral view of the knee,
and a patellofemoral joint view, such
as a skyline view. Although a fulllength hip-to-ankle AP weightbearing view is not performed
routinely at some institutions, many
authors feel that this view is useful for
preoperative planning, especially in
complex cases.11,12 The AP weightbearing hip-to-ankle radiograph
allows the surgeon to rule out extraarticular deformities, estimate the
amount of coronal laxity, and plan
the bone resection and the position
of the femoral and tibial components
with respect to the mechanical axis.
Radiographic Technique
The full-length hip-to-ankle AP
weight-bearing view typically is
taken with both knees in maximum

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221

Preoperative Planning in Primary Total Knee Arthroplasty

Figure 1

A through C, Full-length hip-to-ankle AP weight-bearing radiographs in a patient

with a varus knee deformity. A, The mechanical axis is represented by a line
drawn from the center of the femoral head to the center of the talus. A neutral
mechanical alignment should bisect the center of the knee (asterisk). B, The
tibiofemoral angle is determined by measuring the angle between the anatomic
axis of the femur (ie, a line bisecting the intramedullary canal of the femur) and
the anatomic axis of the tibia (ie, a line bisecting the intramedullary canal of the
tibia). The neutral tibiofemoral angle is 76 1 of valgus. C, The hip-knee-ankle
angle is determined by measuring the angle between the mechanical axis of the
femur (ie, a line from the center of femoral head to the center of the knee joint)
and the mechanical axis of the tibia (ie, a line from the center of the knee to
center of the talus). The neutral hip-knee-ankle angle is 0.

extension and with the patients

knees placed 18 inches apart. The
rotational position of the lower
extremity may influence the reliability of the measurements; therefore, it is important to have the
patellae facing forward. The AP
weight-bearing view of the knee
typically is obtained with the x-ray
beam focused at the knee joint and
the patella, facing directly anteriorly. The true lateral view can be
verified if no overlap is present
between the medial and lateral
femoral condyles. Finally, the tangential axial view of the patellofemoral joint is performed with the
knee in 30 of flexion.
The surgeon must know the
magnification of the radiographs to
perform adequate conventional or

222

digital radiographic templating.

Adding a calibrated reference
marker, such as a ball or coin at the
level of the joint line, can increase
the accuracy of the sizing of the
tibial and femoral components
during templating. Using this technique, preoperative planning accurately predicts the component size
within one size larger or smaller
100% of the time for the tibia and
90% of the time for the femur.4
Knowing the expected implant size
is beneficial for ensuring the
availability of the implant, particularly if extreme sizes will be used.
Radiographic Landmarks and
Templating
Before templating, the radiographs
should be reviewed to confirm the

diagnosis and ensure appropriate

patient positioning to avoid inaccurate planning. The first step in
radiographic templating is to draw a
line on the full-length hip-to-ankle
view that shows the overall mechanical alignment of the lower extremity
(Figure 1, A). Varus or valgus malalignment and any extra-articular
deformities should be noted. The tibiofemoral angle then is drawn to
estimate the magnitude of a coronal
deformity (Figure 1, B). Some
authors use the hip-knee-ankle angle
instead of the tibiofemoral angle to
estimate the degree of the coronal
deformity (Figure 1, C).
When an intramedullary distal
femoral cutting jig is required, the
femoral resection angle, which is the
difference between the mechanical
axis and the anatomic axis of the
femur, can be used (Figure 2). This
angle most commonly measures
between 5 and 7 of valgus. In one
report, however, Mullaji et al13
showed that this angle can vary from
3 to 11 of valgus. The authors
suggested using an individualized
femoral resection angle rather than a
fixed resection angle, such as those
measuring 5, 6, or 7.
The tibial bone cut is perpendicular to the mechanical axis of the
tibia. The amount of resection
required usually is based on the
combined thickness of the tibial
component and the thinnest
available polyethylene component
thickness for the implant system
being used, typically 10 mm. This
amount of bone resection should be
performed on the unaffected side of
the tibial plateau or, if both sides are
affected, from the level of the prearthritic tibial plateau (Figure 3).
The AP weight-bearing view of the
knee is scrutinized to detect medial
and/or lateral osteophytes and bone
defects. The lateral knee view typically
is used to detect posterior osteophytes
and to measure the tibial slope and the
patellar height (Figure 4). The skyline

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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

Figure 2

Full-length hip-to-ankle AP weightbearing radiograph demonstrating

the femoral resection angle, which is
the difference between the
mechanical axis (line A) and the
anatomic axis (line B) of the femur. In
this case, the distal femur should be
resected in 5 of valgus, when using
an intramedullary distal femoral
cutting jig, to achieve a perpendicular
cut to the mechanical axis of the
femur (line A).

view of the patella is used to measure patellar shift and patellar tilt
and to evaluate the extent of erosion of the patellofemoral joint
(Figure 5). Chia et al14 showed that
a preoperative lateral patellar shift
.3 mm was an independent risk
factor for patellar maltracking
during TKA.
Lastly, the femoral and tibial component sizing is performed (Figure 6).
The templating is dictated most
commonly by the anterior-posterior
dimensions of the femur and tibia.
Various digital and acetate templating techniques have been investigated and shown to be effective and
reliable, and they reduce surgical

Figure 3

Full-length hip-to-ankle AP weightbearing radiograph demonstrating a

planned tibial resection for primary
TKA. The tibial cut should be made
perpendicular to the tibial
mechanical axis. In this patient, the
tibial resection of the unaffected side
will be 10 mm.

time and cost.4,15 In this step, the

surgeon must carefully assess the
implant location and anticipate any
potential intraoperative adjustments,
such as the resection of an osteophyte, to accurately estimate the
implant location.

Advanced Imaging
CT or MRI is rarely indicated during planning for primary TKA.
When the use of an extreme implant
size is planned, CT can be invaluable in determining the size and
whether a custom implant is
required. A preoperative CT or
MRI of the knee is obtained when
patient-specific
instrumentation
and/or custom implants will be
used.16

Figure 4

Lateral radiograph of the knee

illustrating the posterior slope angle,
which can be determined by drawing
a line (A) over the anterior cortex of
the tibia and then a perpendicular
line (B) extending to it. Finally, a line
(C) is drawn to connect the articular
surface of the knee and line A. The
posterior slope angle is measured
between lines B and C. Note the
posterior femoral osteophytes
(arrow).

Laboratory Tests
Routine preoperative laboratory testing, including a complete blood count
and electrolyte levels, must be performed. Additional laboratory tests
should be guided by the patients
medical condition. Although having
tight glycemic control with the goal of
obtaining a hemoglobin (Hb) A1c
(HbA1c) test result of #7% is desirable, Giori et al17 recently proposed
that achieving a HbA1c level of #8%
is acceptable to avoid substantial
delays in performing the TKA. A low
Hb level is an independent predictor
for the need for a perioperative blood
transfusion. The risk of transfusion is
increased 3.7-fold for each 1 g/dL
decrease in the Hb level below the
threshold of 13 g/dL preoperatively.18
Various options are available to treat

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223

Preoperative Planning in Primary Total Knee Arthroplasty

Figure 5

Figure 6

Skyline radiographs of the patella showing patellar tilt (A) and patellar shift (B).
A, Patellar tilt is the angle between the horizontal axis of the patella (line A) and
the anterior intercondylar line (line B). The angle is positive when the patella is
tilted laterally. B, The patellar shift is the lateral displacement (asterisk) of the
median ridge of the patella from the intercondylar sulcus of the femur (arrow),
which is positive when the patella is lateral to the sulcus. The distance (doubleended arrow) between the two vertical lines indicates the amount of patellar shift.

a low preoperative Hb level, including

iron supplementation, recombinant
human erythropoietin administration, and tranexamic acid (ie, a antifibrinolytic agent) administered
intraoperatively.

Surgical Principles of
Primary Total Knee
Arthroplasty
An understanding of implant designs
used in primary TKA, as well as the
technical principals of the procedure,
is crucial to help the surgeon successfully reconstruct the knee (Table 1).
Technical principles of TKA include
restoration of neutral mechanical
alignment, preservation of the joint
line, restoration of coronal and sagittal balance, maintenance of patellar
tracking, and restoration of the posterior tibial slope.

Restoration of Neutral
Mechanical Alignment
Neutral mechanical alignment is achieved when the mechanical axis of the
lower extremity passes through the
center of the knee joint or when the
anatomic axis of the lower extremities

224

is 7 6 1 of valgus.11 Restoration of
neutral knee alignment with TKA
distributes the weight-bearing loads
equally across the medial and lateral
compartment of the knee joint,
thereby minimizing the risk of
implant wear and aseptic loosening.
Achievement of a neutral anatomic
alignment between 2.4 and 7.2 of
valgus has been shown to substantially improve implant survival
following primary TKA.20 To achieve
mechanical alignment, the femoral
and tibial cuts are made perpendicular
to the mechanical axis, and soft-tissue
releases correct any coronal deformity. Bellemans et al21 questioned this
concept and reported that a portion of
the normal population does not have
a neutral mechanical alignment at
skeletal maturity, but rather has $3
of varus. The authors termed this
observation constitutional varus.
The clinical disadvantages of restoring patients with constitutional varus
to neutral alignment at the time
of TKA are unknown. In the last
decade, the concept of achieving a
kinematically aligned knee has
emerged and involves resection of the
bone to restore the prearthritic state
and anatomic angle while soft-tissue

Digitally templated lateral radiograph

of a right total knee arthroplasty
created with templating software. A
standard 20-mm calibration marker
was used to increase accuracy.

releases are performed to balance the

knee.22

Preservation of the Joint Line

The preservation or restoration of the
anatomic position of the joint line is
an important factor for a successful
primary TKA. This measure can be
achieved if bone cuts are so accurate
that the amount of bone eroded preoperatively and the amount of bone
resected at the time of TKA identically match the thickness of the
prosthesis. Proximal elevation of the
joint line leads to pseudopatella baja,
which is associated with high contact
forces at the patellofemoral joint and
dysfunction of the extensor mechanism. Shifting the joint line distally
can lead to patellar subluxation and
retropatellar pain.23

Restoration of Coronal and

Sagittal Balance
Postoperative knee instability is a
major cause of premature failure
following primary TKA.24 This

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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

Table 1
Types of Knee Implant Designs in Total Knee Arthroplasty19
Implant Design (Example)

Advantages

Disadvantages

Unconstrained knee (cruciate-retaining Increased quadriceps muscle strength, Risk of postoperative PCL rupture,
potential loss of femoral rollback with
design; PCL is preserved)
lower shear forces at tibial componentsome current designs
host bone interface, preserved bone
stock on the femoral side, improved
stair climbing
Risk of cam-post impingement or
Semiconstrained knee (posterior
Potential ease of ligament balancing,
dislocation, increased constraints in
stabilized design; PCL is substituted)
no need to correct a contracted PCL,
varus or valgus direction compared
suitable after patellectomy and for
with cruciate-retaining knee design,
PCL-deficient knees, great versatility
risk of tibial post polyethylene wear
for different types of substantial knee
from cam-post mechanism, risk of
deformities
patellar clunk syndrome
Constrained knee (varusvalgusCoronal stability in severe coronal bone Decreased femoral bone stock,
constrained design, also known as
deformities
potentially higher rate of aseptic
condylar constrained knee)
loosing from increased constraint in
younger and active patients, risk of
tibial post polyethylene wear and/or
fracture from cam-post mechanism
Potentially high rate of aseptic loosing
Highly constrained knee (rotating hinge Highly constrained implants typically
from increased constraint, substantial
design)
reserved for complex instability cases,
reduction of bone stock
when gaps are greater than the largest
available polyethylene liner and/or for
substantial bone loss
PCL = posterior cruciate ligament

outcome can be prevented with adequate preoperative assessment and

careful intraoperative soft-tissue
releases performed to achieve intraoperative stability throughout
the ROM. Patients with coronal
knee deformities typically have tight
soft-tissue structures, such as ligaments, on the concave side of the
deformity and stretched out softtissue structures on the convex side.
A stepwise approach must be considered for soft-tissue releases when
managing coronal deformities. It is
recommended
that
osteophyte
removal and all bone cuts should be
performed first. A prosthetic trial or
spacer blocks are then inserted to
evaluate the medial and lateral gaps
during flexion and extension. If the
medial or lateral gaps are not balanced, then sequential soft-tissue
releases should be performed. The
soft-tissue releases should be performed with caution; overly zealous
releases on the contracted side of the

joint can lead to instability, and

subsequent conversion to a constrained knee design might be
required.
The aim of sagittal balance is to
achieve equal flexion and extension
gaps. Intraoperatively, these gaps
can be achieved by soft-tissue
releases, adjusting the tibial or
femoral resections, or changing
component size. It is important to
correct a fixed flexion contracture
because it can adversely influence
functional outcomes after TKA.
Although existing evidence shows
that, in TKAs with a cruciateretaining implant, residual flexion
contracture may improve with time
after surgery, it is imperative that all
the necessary releases and osteophyte resections be addressed intraoperatively.25 This also has been
shown to be required in patients
with flexion contractures at the
time of TKA performed with a
posterior-stabilized (PS) implant.26

Maintenance of Patellar
Tracking
Patellofemoral complications are
responsible for approximately 8% of
primary TKA failures.14 Alteration
in knee kinematics, such as an
increased Q angle (normal Q angle =
15) and an imbalance of peripatellar soft-tissue structures, can
produce a laterally directed muscle
vector that can lead to patellofemoral instability.14,27 Several factors
influence the Q angle, including
component malposition and limb
malalignment. For example, internal
rotation and medialization of the
femoral or tibial components, as well
as a femoral component positioned
in .7 of valgus, can increase the Q
angle during TKA.27 When patellar
resurfacing is planned, improper
patellar preparation, such as underresection or an asymmetric patellar
cut with a thick lateral facet,
and lateralization of the patellar

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225

Preoperative Planning in Primary Total Knee Arthroplasty

226

Figure 7

Journal of the American Academy of Orthopaedic Surgeons

Algorithm demonstrating the key elements required for the clinical approach, choice of implant design, and techniques used during primary total knee arthroplasty. For
radiographic templating, the hip-knee-ankle (HKA) angle or the tibiofemoral angle and the femoral resection angle should be measured on the full-length HKA weightbearing AP radiograph to plan for the tibial and femoral resection. The weight-bearing AP radiograph is scrutinized to detect bone defects and medial or lateral
osteophytes and to estimate the size of the bone resections. The tibial slope and patellar height should be measured on the patellofemoral view. CR = cruciateretaining, MCL = medial collateral ligament, PS = posterior stabilized, RH = rotating hinge, TKA = total knee arthroplasty, VVC = varusvalgus constrained.

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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

component also can increase the Q

angle. Additionally, a patellar boneprosthesis construct that is thicker
than the native patella results in an
increase in the lateral tilt and contributes to patellar maltracking.28

Figure 8

Restoration of Posterior
Tibial Slope
The normal posterior slope angle
(PSA) is highly variable, with a reported range of 5 to 15.29 Although
restoring the PSA should be considered when cutting the proximal tibia
to optimize ROM, some authors
recommend reducing the PSA in
TKAs with PS knee implants to prevent cam-post impingement.9,19,29,30

Complex Primary Total

Knee Arthroplasty
In complex cases, a specific implant
design or surgical technique might be
preferred over another. Several conditions, including severe coronal
deformities and instability, extraarticular deformities, severe bone
deficiency, and previous patellectomy, warrant careful preoperative
consideration and selection of the
optimal implant design and surgical
technique. The surgeon must be
aware of the various options available to manage such conditions during TKA to increase the likelihood of
optimal outcomes (Figure 7).

Severe Coronal Deformities

and Ligamentous Instability
Management of a coronal deformity
requires a planned, stepwise approach
to achieve a balanced knee intraoperatively. This approach includes
removing the osteophytes, sequential
soft-tissue balancing, and if necessary,
adjusting the bone cuts. In the setting
of severe varus deformity, however,
the surgeon may not be able to achieve
the desired intraoperative stability
in rare instances and must anticipate

A, Preoperative AP weight-bearing radiograph of the knee demonstrating a

severe valgus deformity. B, Postoperative AP radiograph of the knee after the
implantation of a varusvalgus-constrained knee design.

the conversion to a constrained knee

implant.31
Similarly, in knees with severe
valgus alignment, intraoperative
attempts should be made to balance
the knee in flexion and extension
before considering the use of a constrained implant. Several stepwise
lateral releases and ligament balancing strategies can be used when a
cruciate-retaining or PS implant is
selected.32 However, when the
medial collateral ligament (MCL) is
extremely attenuated and extensive
lateral releases have been performed,
balancing the coronal plane may fail
to correct the deformity and balance
the knee. In addition, extensive lateral releases may result in flexion
instability and/or a postoperative
peroneal nerve palsy. This problem
can be avoided by converting intraoperatively to a varusvalgus-constrained knee implant (Figure 8).
Some authors prefer to use a PS knee

implant with MCL advancement,

repair, or reconstruction.32,33 However, these procedures have been
criticized for their potentially
adverse influence on the ligaments
isometricity.34 In a study on the use
of lateral epicondylar osteotomy in
TKA for rigid valgus deformities,
Mullaji and Shetty35 reported no
complications. In elderly and lowdemand patients with severe valgus
and MCL deficiency, the surgeon
may consider performing a TKA
with a constrained knee implant.32,36
Although some surgeons have expressed concern that TKAs with
constrained implants will transfer
stresses to the implant-bone interface, which can result in premature
loosening, studies have shown that
the survivorship of these implants is
.96% at long-term follow-up.37
Nevertheless,
surgeons
should
attempt to reconstruct the knee using
nonconstrained knee implants and

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Preoperative Planning in Primary Total Knee Arthroplasty

Figure 9

Figure 10

Full-length hip-to-ankle AP weightbearing radiograph demonstrating

the lower extremities of a 57-yearold woman known to have rickets
who underwent bilateral femoral
and tibial corrective osteotomies
during childhood. The hip-kneeankle angle (not drawn) on the
left lower extremity is 33, with
substantial (30) extra-articular
deformity of the left femur. In the
left femur, the apex of the
deformity (arrow) is determined
by drawing two bisecting lines
through the anatomic axis. In this
patient, the deformity is relatively
close to the joint. When templating
the distal femoral valgus cut
(line A), it became clear that the
insertion site of the lateral
collateral ligament would have to
be sacrificed. Therefore, a
corrective osteotomy at the apex of
the deformity was considered in
this patient.

be prepared preoperatively to ensure

that constrained devices are readily
available when the intraoperative
assessment indicates that they are
necessary.

Extra-articular Deformity
Previous osteotomies, metabolic
bone disease, malunion of fractures,

228

AP radiograph of the knee

demonstrating a medial tibial plateau
bone defect (double arrows)
measuring 6 mm.

and bone tumors can lead to bowing

or angulation of the femur or tibia.
In the setting of extra-articular
deformities in the coronal plane,
the goal of TKA is to achieve a
neutral mechanical alignment to
optimize long-term results.20 However, the standard preoperative
templating, bone incisions, and
conventional instruments, such as
an intramedullary guide, may be
ineffective because of the bone
deformity. Rotational and sagittal
deformities also can add to the
complexity of these cases.
Preoperatively, the surgeon can
anticipate the impact of the deformity
based on its distance from the knee
joint. The closer the deformity is to
the joint, the greater its impact on
knee alignment. For example, if the
apex of a femoral or tibial deformity
is located at a distance from the joint
that corresponds to 25% of the
length of the bone, the effect of the
deformity will be twice that of a

deformity located at a distance corresponding to 50% of the length of

the bone.38 The magnitude of the
deformity plays an equally important role in its management. The
greater the deformity, the greater the
impact on knee alignment.
Preoperative templating allows the
surgeon to anticipate whether an intraoperative intra-articular compensatory correction is achievable or if
an extra-articular corrective osteotomy is required (Figure 9). In general,
an intra-articular compensatory
correction can be achieved if the
deformity is far from the joint and
limited to ,20 in the coronal plane
on the femoral side and ,30 on the
tibial side.39 This technique might
require extensive soft-tissue releases
secondary to the asymmetric oblique
cuts. Therefore, the surgeon should
be prepared to reconstruct and/or
advance the affected collateral ligament or convert to a constrained
knee design. In contrast, if the
deformity is severe and close to the
joint or if preoperative templating
indicates that the intra-articular
bone resection will include the
attachment sites of the MCL and/or
lateral collateral ligament, an extraarticular corrective osteotomy (performed in a staged fashion or at the
time of primary TKA) is recommended.40 Although this technique
is appealing and preserves ligamentous stability, it is associated with
high rates of nonunion, infection,
and arthrofibrosis.
Recent advances in computerassisted navigation for TKA have
expanded the indications for its use
in patients with severe extraarticular deformities. Although
computer-assisted surgery (CAS) has
not been found to be superior to
conventional techniques in routine
TKA, Catani et al41 suggested that
CAS has a definite advantage in
patients with severe extra-articular
deformities. The use of CAS can
sometimes obviate the need for a

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Michael Tanzer, MD, FRCSC, and Asim M. Makhdom, MD, MSc

corrective osteotomy or implant

removal, thereby reducing the risk
of complications.

Bone Defects
Bone defects on the tibial side commonly result from previous trauma,
bone erosion from conditions such as
inflammatory arthritis, and severe
coronal deformities. Varus deformity
typically is associated with medial
tibial bone defects, whereas valgus
deformity is associated with centrallateral defects. Preoperatively, the
surgeon should determine the extent
of the bone defect because management typically is based on its size
(Figure 10). Dorr et al42 determined
that any tibial bone defect that
involves ,50% of the tibial plateau
or is ,5 mm in depth can be filled
with cement. For larger defects,
management options include metal
augments and autogenous bone
grafts, with or without fixation. In
one report, Berend et al43 used
cement and screw fixation to manage
large tibial bone defects and achieved
low failure rates at 20-year follow-up.
Lee and Choi44 and Pagnano et al45
investigated the clinical outcome of
using metal rectangular block augments at a minimum 5-year followup. The authors reported good to
excellent results with no radiographic
or clinical failures. In these studies,
nonprogressive radiolucent lines were
noted at the metal-cement interface;
the significance of these findings on
the long-term survivorship of the
implant remains to be determined.
Although biomechanical studies have
shown that the tensile stress loads are
reduced and that better stability and
rigidity are achieved with metal block
augments than with metal wedge
augments,46 we are not aware of any
clinical studies that demonstrate the
superiority of one type of augment
over another.
The use of autogenous bone graft
to manage large tibial bone defects

is another option, but variable success rates have been reported in the
literature.47,48 Overall, metal augmentation is an attractive option
for managing large bone defects. It
provides immediate support and
satisfactory load distribution with
promising midterm results.44,45
Long-term data are required to
confirm the durability of these
implants, however. Autogenous
bone grafting may be best for
young patients, in whom restoration of the bone stock may be
necessary for future surgeries.

Previous Postpatellectomy
Patients who have undergone a previous patellectomy lose their extension strength by 20% to 70%.49 In
addition, in patients undergoing
TKA, the loss of the patella decreases
the stability of the knee and overloads the posterior cruciate ligament.
The literature has shown that these
patients achieve the best results when
they undergo TKA with a PS knee
implant.32 Nevertheless, even when
a PS device is used, patients with a
previous patellectomy have less
favorable outcomes than those with
a patella.50

Summary
Preoperative planning is crucial in
primary TKA. The application of
conventional surgical principles during this procedure allows the surgeon
to obtain reproducible results. A
thorough preoperative history, physical examination, and radiographic
templating can result in a precise plan
that helps the surgeon successfully
reconstruct the knee and anticipate
potential complications.

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Evidence-based Medicine: Levels of
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References 6, 8, 10, 16, 27, 31, 32,
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