Chapter 2 Total Knee Arthroplasty
Surgical Overview
• Surgical techniques in TKA have made significant advances in the past 3 decades to treat advanced degenerative arthritis of the knee.
• Technology has allowed surgeons to replace the entire anatomical knee joint or replace either the medial or lateral portions of the knee, known as a unicondylar knee replacement.
1 Minimally invasive surgery and high-flex knee prostheses are a few of the most recent technological advancements in joint replacement surgery.
2 Standard TKA designs allow for bicondylar surface replacement, with either a posterior cruciate retaining (PCR) design or posterior cruciate substituting (PCS) design.
3 Other prosthetic designs are either constrained or semi-constrained, which provide different levels of stability and varying degrees of freedom.
• Osteotomies of the proximal tibia, distal femur, anterior and posterior aspect of the femoral condyles, and retropatellar surface are performed.
• The anterior cruciate ligament (ACL) is resected to provide greater joint exposure during the procedure.
• The posterior cruciate ligament (PCL) may be resected if severe damage from degenerative osteophytes is found or if the surgeon prefers a PCS design.
• The medial and lateral collateral ligaments are retained; however, their anatomical positions may be surgically altered to achieve optimal varus or valgus alignment.
• If a knee flexion contracture is found, posterior condylar osteophytes may be removed, or the posterior capsule may be released.
• Once soft tissue balance is achieved, a trial reduction is performed, and stability and alignment of tibiofemoral and patellofemoral joints are checked in both flexion and extension.
• When optimal joint kinematics are achieved, the components are fixated with methylmethacrylate cement.
• The majority of patients who undergo TKA at HSS receive a combination spinal/epidural anesthesia, with a local femoral nerve block (FNB).
Rehabilitation Overview
• The postoperative TKA rehabilitation program at our institution is designed and individually based on functional ability, clinical research, objective measurements, and the clinical expertise of the physical therapist.
• The HSS TKA rehabilitation guideline incorporates three progressive phases of postoperative rehabilitation to maximize patient outcomes. These guidelines include a general timeline of expected goals, which patients may achieve at a faster or slower rate, depending on age, comorbidities, pain, or surgical complications.
1 Postoperative phase I of the inpatient TKA guideline was developed in part from functional outcome data that have been collected on more than 10,000 patients who have undergone TKA over the past 15 years at the HSS, using a valid and reliable Functional Milestones Form. This valuable information enabled us to benchmark functional status and design treatment interventions and goals in the early postoperative or inpatient phase.
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