Technical considerations for successful primary TKR To improve ROM

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Technical considerations for successful primary
TKRTo improve ROM

• Lee Beom Koo
• Gachon university
• Gil hospital.

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Advantage of high flexion

• although the degree of postoperative knee flexion
  did not affect patient satisfaction, it did
  influence fulfillment of expectations, functional
  ability, and knee perception.

Brandon N. Devers, Michael A. Conditt, Miranda L.
Jamieson, Matthew D. Driscoll, Philip C. Noble,
Brian S. Parsley Does Greater Knee Flexion
Increase Patient Function and Satisfaction After
Total Knee Arthroplasty? JA feb 2011 Pages
178-186
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Factor for high flexion

• Pre-operative factor
• Intraoperative factor
• Post-operative factor
• Design

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Factor for high flexion

• Pre-operative factor
• Intraoperative factor
• Post-operative factor
• Design

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Intraoperative factor
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Posterior translation
Need functional PCL or PCL substitution
mechanism for good flexion
Dennis CORR 464, Nov 2007,53 Philippe Massin J
arthroplasty 2006 sept
7
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Adequate PCL balancing

• Tight posterior cruciate ligament result in
  tightness in flexion decreased flexion

TKA with Tight PCL
Laskin R Total knee replacement with posterior
cruciate ligament retention in patients with a
fixed varus deformity. Clin Orthop 33129, 1996
Lombardi AV, Mallory TH, Fada RA, et al An
algorithm for the posterior cruciate ligament in
total knee arthroplasty. Clin Orthop 39275, 2003
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PS gt CR

• Consistent posterior translation
• Increased flexion gap
• Kurosaka Jarthroplasty 2002
• Dennis CORR 464 2007

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Posterior condylar offset
For every 2mm decrease in condylar offset, the
maximum flexion was reduced by a mean of 12.2
Bellman JBJS (Br) 2002-84-B50-3
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Larger flexion gap

• PCL-substituting prosthesis
• can provide a more predictable flexion
• gap and a larger flexion angle

Dennis DA, Komistek RD, Stiehl JB, et al Range
of motion after total knee arthroplasty the
effect of implant design and weight-bearing
conditions. J Arthroplasty 13748, 1998
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Sagittal Laxity ROM

• Laxities of less than 5 mm, irrespective of
  implant design, were associated with an impaired
  range of passive motion and an increased
  likelihood of incurring a flexion deformity in
  excess of 4 degrees.
• It was concluded that anteroposterior laxity in
  excess of 5 mm in prosthetic knees is desirable
  for unimpaired joint function, although an upper
  limit of acceptable anteroposterior laxity could
  not be identified.

Warren PJ, Olanlokun TK, Walker PS, et al.
Laxity and function in knee replacements. Clin
Orthop 1994 305200
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Sagittal Laxity ROM in CR
lt5 5-10 gt10 P value
flexion 98.73 112.27 117.66 0.000
extension 2.47 75 -2.93 0.005
Function score gt80 40 52 43 0.080
Oxford score 18.5 17.1 18.1 0.045

• Moderate laxity (5-10mm) is likely associated
  with
• Significant better functional outcome
• Minimal hyperextension

Hee-Nee Pang singapore AAOS 2012
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Sagittal Laxity ROM

• . Dejour et al compared PCR and posterior
  stabilised (PSknees at 3 to 4 years postoperative
  using clinical examination and radiological
  laxity on weightbearing radiographs,
• more than 10mm of anterior translation had a
  worse outcome,
• as shown by Knee Society Function Scores

Dejour D, Deschamps G, Garotta L, et al. Laxity
in posterior cruciate sparing and posterior
stabilized total knee prostheses. Clin Orthop
1999364182
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Sagittal laxity ROM
. Knees with more than 10 mm of AP laxity at 75
had significantly less flexion and lower Knee
Society Scores than knees with 5 to 10 mm of AP
laxity.in PCL retaining TKA

• David P. Gwynne Jones
• JA aug'06 Pages 719-723

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Instability ROM
Y. Matsuda, Y. Ishii, H. Noguchi, and R. IshiiJ
Bone Joint Surg Br, Jun 2005 87-B 804 - 808.
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Trapezoidal flexion gap

• the range of flexion was decreased and the
  incidence of medial tibial pain and zone I
  radiolucencies in trapezoidal flexion space

Laskin The Journal of Arthroplasty Vol. 10 No. 5
1995
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Internal rotated femoral component
The femoral component rotation was more
internally rotated in symptomatic patients (5.5)
than in controls (1.0) (P .04). Varus laxity
in flexion was higher in symptomatic patients
(11.0) than in controls (7.0)

Jose Romero, Thomas Stähelin, Chistoph Binkert,
Christian Pfirrmann, Jurg Hodler and Oliver
Kessler Pages 235-240 J A Feb'07
The Clinical Consequences of Flexion Gap
Asymmetry in Total Knee Arthroplasty
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Lateral Laxity in Flexion Increases the
Postoperative Flexion Angle in Cruciate-Retaining
Total Knee Arthroplasty
Tatsuya Kobayashi The Journal of Arthroplasty
Vol. 27 No. 2 2012
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J Bone Joint Surg Am. 200587(Suppl 2)5258.
Geert Van Damme,
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Joint line

• ? 10 mm. 32 flexed gt 120
• gt 10 mm. 7 flexed gt 120

Maloney Jarthroplasty June2002 P 71)
Shoji et al. Orthopaedics 1990
???
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Posterior spur resection
Laskin The Journal of Arthroplasty Suppl. 1 June
2004
Dennis CORR 464 2007
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Efficacy of tibia slope
Philippe Massin J arthroplasty 2006 sept.
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Increasing tibia slope

• high load in anterior portion of polyethylene
• (Walker CORR262,2271991)
• Knee unstable in flexion
• Hungerford AAOS ICL 96

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The Effect of Posterior Tibial Slope on Range of
Motion After posterior cruciatesacrificing
designTotal Knee Arthroplasty (scorpio)

• but increasing posterior slope did not result in
  a significant increase in ROM or Hospital for
  Special Surgery functional score

J Arthroplasty sept2006Pages 809-813 Devanshu
Kansara and David C. Marke
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Avoid ? patellar thickness

• ? 20 - 26 flexed gt 100
• lt 20 - 97 flexed gt 100
• Shoji et al. Orthopaedics 90
• good flexion - ? 0.8 mm
• poor flexion - ? 2.6 mm
• Ryu et al. Bull Hosp Joint Dis 93

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Flexed femoral component
Slightly flexed positining of femoral component
posteriorly tilted positioning of tibia can
create slightly better range of flexion
Kurosaka JA 2002
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Wound closure in flexion

• Wound closed in 90 - 110 of flexion
• At 6 months - 2 more flexion
• compared with pre-operative range vs. 4 less
  flexion with extension
• closure
• Emerson Jr et al. Clin Orthop 1996
• No difference in the early post-op. or the 2- to
  3-month follow-up parameters
• Masri et al. Clin Orthop 1996

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No tourniquet?

• Without tourniquet significantly better
• knee flexion at 1 week
• Wakanker et al. JBJS-B 1999

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MIS
Lee Myung chul SNUH
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Post-op factor

• Aggressive rehabilitation adequate pain control
  is necessary to optimize post-op flexion
• Sultan CORR 416 2003.

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Design aspect for high flexion
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Nexgen LPS-Flex

• Thick posterior condyle
• PE deep anterior patella cut

Most E, JBJS(Am), 2004
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Scorpio

• single-axis knee
• a relaxed posterior slope of the tibial
  polyethyle
• .
• a reduced femoral rise, improved collateral
  ligament function in deep flexion

Klein J arthroplasty 2004 Dec.
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Design for high flexion

• Small femoral radius? large flexion gap
• (Kurasaka JA 2002 June)

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internal rotation of the tibia in deep flexion
(mobile bearing)

• Another important factor for achieving deep knee
  flexion is the need for large internal rotation
  of the tibia,

Maximizing Flexion After TKA Kurosaka et al. J
arthroplasty June 2002
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RPF
internal rotation of the tibia
relaxed posterior slope of the tibial polyethyle
Small femoral radius
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ROM between high flex knee and standard knee

• high-flexion design and those that had the
  standard design were found to have a similar
  range of motion under both non-weightbearing
• and weight-bearing conditions. Moreover, no
  significant difference was found in terms of the
  other functional outcomes examined.

Jong Keun Seon,, Eun Kyoo Song, MD, PhD J. Bone
Joint Surg. Am., Mar 2009 91 (3) 672-679
Young-Hoo Kim,, Jun-Shik Kim, MD J. Bone Joint
Surg. Am., Aug 2009 91 (8) 1874-1881
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High-flexion total knee arthroplasty in stiff
knees( pre-op max flex lt100)

• In the LPS-flex group, about half of the knees (n
  18,44) could achieve a maximum flexion of 140
  postoperatively,
• but in the LPS group only five knees (13)
  achieved a maximum flexion of 140.

Bum-Sik Lee, Seong-il Bin Knee Surg Sports
Traumatol Arthrosc (2011) 19936942
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SummaryTKA? ?? ??? ?? ????

• ligament balancing? ??? ? ? ??????
• ??? joint line,patella thickness? ?? ??? ???
  ???? post spur resection? ????
• MIS, pain control, repair in flexion,?
• ??? ??? ? ?? ? ??
• High flexion design? ??? ??????? ??? ?? ? ?? ? ? ?

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Thank you for your attention