Section 3 Knee Replacement

*Knee Surgery - Reconstruction and Replacement*

Knee Surgery, Sports Traumatology, Arthroscopy. 2015;**23**(11):3151-3156

et al. Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later. Arthroscopy.

[50] Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR, et al. Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2018;**26**(12):3652-3659

[51] Ferretti A. Extra-articular

Joints. 2014;**2**(1):41-47

reconstruction in the anterior cruciate ligament deficient knee: A commentary.

[52] Ramaniraka NA, Saunier P, Siegrist O, Pioletti DP. Biomechanical evaluation of intra-articular and extra-articular procedures in anterior cruciate ligament

analysis. Clinical Biomechanics (Bristol,

reconstruction: A finite element

[53] Rezende FC, de Moraes VY, Martimbianco AL, Luzo MV, da Silveira Franciozi CE, Belloti JC. Does combined intra- and extraarticular ACL reconstruction improve function and stability? A meta-analysis. Clinical Orthopaedics and Related Research.

Avon). 2007;**22**(3):336-343

2015;**473**(8):2609-2618

2016;**32**(10):2039-2047

AM. Percutaneous reconstruction of the anterolateral ligament of the knee with a polyester tape. Arthroscopy Techniques.

[43] Chahla J, Menge TJ, Mitchell JJ, Dean CS, LaPrade RF. Anterolateral ligament reconstruction technique: An anatomic-based approach. Arthroscopy Techniques. 2016;**5**(3):e453-e457

[44] Helito CP, Demange MK, Bonadio MB, Tirico LE, Gobbi RG, Pecora JR, et al. Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. The American Journal of Sports Medicine. 2014;**42**(10):2356-2362

[45] Saithna A, Thaunat M, Delaloye JR, Ouanezar H, Fayard JM, Sonnery-Cottet B. Combined ACL and anterolateral ligament reconstruction. JBJS Essential Surgical Techniques. 2018;**8**(1):e2

[46] Lutz C, Sonnery-Cottet B, Imbert P, Barbosa NC, Tuteja S, Jaeger

stabilization of the knee with the iliotibial band. Arthroscopy Techniques.

[47] Sonnery-Cottet B, Barbosa NC, Tuteja S, Daggett M, Kajetanek C, Thaunat M. Minimally invasive

injury. Arthroscopy Techniques.

Techniques. 2019;**8**(1):e23-ee9

[49] Ferretti A, Monaco E, Ponzo A, Basiglini L, Iorio R, Caperna L,

[48] Delaloye JR, Murar J, Vieira TD, Saithna A, Barth J, Ouanezar H, et al. Combined anterior cruciate ligament repair and anterolateral ligament reconstruction. Arthroscopy

anterolateral ligament reconstruction in the setting of anterior cruciate ligament

2016;**5**(2):e251-e256

2016;**5**(1):e211-e215

JH. Combined anterior and anterolateral

[42] Wagih AM, Elguindy

2016;**5**(4):e691-e6e7

**40**

**43**

**Chapter 4**

*Gabriel Stan*

**Abstract**

preserved.

**1. Introduction**

and stair-climbing.

Medial Epicondyle Osteotomy for

Varus malalignment is the most common deformity leading to total knee arthroplasty (TKA) for knee arthritis. For correcting this deformity, a stepwise approach is used by surgeons during TKA. When a severe varus malalignment is present, there are some concerns regarding balancing procedure, meaning that aggressive release of medial structures could lead to instability and need for a more constrained implant. In this chapter, the results of an unconventional method for balancing severe varus malalignment are shown. This method is medial epicondyle osteotomy (MEO). For this reason, a total of 135 knees with severe varus deformity were studied. In 65 cases, the MEO technique was used for balancing during TKA. The other 70 cases were balanced using additional resection of medial tibial plateau. Clinical and radiological outcomes were measured before and after surgery for both groups. Also the results were compared to a control group consisting of 50 patients with TKA for varus deformity less than 15 degrees. The amount of resected tibial bone was noted for study groups. Range of motion, the Knee Society Score (KSS), frontal laxity, and correction of femoro-tibial angle were studied. Frontal laxity decreased from 12.81° ± 3.9° to 0.37° ± 1.2° (P < 0.001). The results showed no statistically significant differences between groups regarding the KSS, range of motion, femoro-tibial angle, and frontal laxity. The amount of resected tibial bone and the mean thickness of the polyethylene insert were statistically significantly smaller in the MEO group. MEO technique could be useful when treating severe varus arthritis knee during TKA by avoiding aggressive medial release and malalignment. Also the bone stock is

Balancing Severe Varus Knee

**Keywords:** medial epicondyle osteotomy , knee varus deformity, total knee arthroplasty, prosthetic outcomes, survivorship

Total knee arthroplasty is a common surgical procedure for the end stage of knee arthritis, providing long-term pain relief and patient satisfaction. Although many studies have measured the success of knee arthroplasty in terms of survival, another important aspect of TKA is its functional outcome; that is, postoperatively, patients should be free of pain and able to perform daily activities such as standing, walking,

The varus knee is the most common deformity that requires total knee arthroplasty. Malalignment affects articular hyaline cartilage, menisci, subchondral bone, and ligaments, and contributes to progression of osteoarthritis (OA). When varus

#### **Chapter 4**

## Medial Epicondyle Osteotomy for Balancing Severe Varus Knee

*Gabriel Stan*

#### **Abstract**

Varus malalignment is the most common deformity leading to total knee arthroplasty (TKA) for knee arthritis. For correcting this deformity, a stepwise approach is used by surgeons during TKA. When a severe varus malalignment is present, there are some concerns regarding balancing procedure, meaning that aggressive release of medial structures could lead to instability and need for a more constrained implant. In this chapter, the results of an unconventional method for balancing severe varus malalignment are shown. This method is medial epicondyle osteotomy (MEO). For this reason, a total of 135 knees with severe varus deformity were studied. In 65 cases, the MEO technique was used for balancing during TKA. The other 70 cases were balanced using additional resection of medial tibial plateau. Clinical and radiological outcomes were measured before and after surgery for both groups. Also the results were compared to a control group consisting of 50 patients with TKA for varus deformity less than 15 degrees. The amount of resected tibial bone was noted for study groups. Range of motion, the Knee Society Score (KSS), frontal laxity, and correction of femoro-tibial angle were studied. Frontal laxity decreased from 12.81° ± 3.9° to 0.37° ± 1.2° (P < 0.001). The results showed no statistically significant differences between groups regarding the KSS, range of motion, femoro-tibial angle, and frontal laxity. The amount of resected tibial bone and the mean thickness of the polyethylene insert were statistically significantly smaller in the MEO group. MEO technique could be useful when treating severe varus arthritis knee during TKA by avoiding aggressive medial release and malalignment. Also the bone stock is preserved.

**Keywords:** medial epicondyle osteotomy , knee varus deformity, total knee arthroplasty, prosthetic outcomes, survivorship

#### **1. Introduction**

Total knee arthroplasty is a common surgical procedure for the end stage of knee arthritis, providing long-term pain relief and patient satisfaction. Although many studies have measured the success of knee arthroplasty in terms of survival, another important aspect of TKA is its functional outcome; that is, postoperatively, patients should be free of pain and able to perform daily activities such as standing, walking, and stair-climbing.

The varus knee is the most common deformity that requires total knee arthroplasty. Malalignment affects articular hyaline cartilage, menisci, subchondral bone, and ligaments, and contributes to progression of osteoarthritis (OA). When varus

alignment is present, the forces passing the knee are unequally distributed between condyles with an increased load passing through medial condyle due to an increase of the adduction moment during gait [1].

Anatomical changes are present in varus knee as a result of deforming forces. According to Puthumanapully, some reference axes and surface features are significantly different to normal knees [2]. For the femur, he found less femoral anteversion in varus knees. In the tibia, the tubercle (and tibial tubercle axis) was externally rotated and there was a medial tilt of the tibial plateau in the coronal plane. The coronal slope was found to be significantly more (P = 0.001) in varus knees (3.5°) when compared to normal knees (0°), indicating that the slope contributes to the varus deformity. Normal femoral version has been reported to be varied between 10° and 20° [3]. Retroversion or decreasing femoral anteversion is associated with external rotation of the knee and varus deformity contributing to the development of OA in adults [4]. Authors like Bretin and Papaioannou showed that loads shift from center to medial compartment when external femoral malrotation is present [5, 6].

OA also affects the anatomy of superficial medial collateral ligament (MCL), which is the main structure providing medial stability. These changes are secondary to fibrosis of the posteromedial complex, to impingement of marginal osteophytes, and to extrusion of the medial meniscus. According to Haidar, there is no shortening of the MCL in knee OA. There are deforming structures such as the oblique ligament with adhesion and thickening of posteromedial corner structures. Those changes are supposed to cause a posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion act as a soft phyte tensioning and deform the ligament and the posterior capsule [7].

Ignorance, fear of surgery, access to alternative and traditional medicine, and the high costs of treatment are among main reasons that contribute to late presentation for treatment. Factors like age of the patients, level of activity or disease progression have been discussed when deciding to choose methods of treatment in knee osteoarthritis (OA). Financial aid is a leading factor in decision-making of treating OA. Conservative treatment in knee osteoarthritis is also expensive because it fails to correct the malalignment and abnormal joint loading. The disease will progress and the TKA will be the optimal solution for treatment. Severe preoperative deformities have long been a challenge for surgeons performing total knee arthroplasty.

Limb alignment and proper soft tissue balance are the main factors that influence long-term results of TKA in terms of survivorship. What kind of alignment should be obtained, anatomical, mechanical, or kinematic, is still a matter of debate, but everyone agrees that a balanced prosthetic knee will provide better results. Most of the authors state that the mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia [8].

Technical flows are challenging for surgeons no matter the surgical strategy. A part of this issue is represented by the instruments' errors. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal respect the anatomic axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Alignment is critical to load transfer, both at the articular surface and at the implant-host interface, and hence essential for the success of total knee replacement (TKA). Most of the early failures

**45**

(Zimmer Nexgen).

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

of TKAs are related to technical flaws. Valgus or varus malpositioning of the tibial component of a total knee implant may cause increased propensity for loosening or implant wear and they may eventually lead to revision surgery [9]. Experimental and clinical data indicate that, in order to achieve optimal mid-term and long-term results of a TKR, good alignment in the frontal plane of the lower limb is mandatory. Releasing the superficial MCL can sometimes lead to a major instability of the knee and other surgical methods should be assessed for balancing the prosthetic knee in cases of severe varus deformity when aggressive MCL release is expected. A severe varus deformity (more than 15 degrees) is a challenge in terms of the type and extent of release required. More constrained types of implants may be needed

A balanced knee must be the goal of every TKA because this will increase the chances for a better survivorship [10–13]. When malalignment is present, some parts of the soft tissue around the knee are contracted and must be released, thus

When severe varus deformity is present, medial structures become fibrous. Among the methods used to correct severe varus deformity, the most common are subperiosteal release of the superficial medial collateral ligament and joint line release of the medial collateral ligament. Some other methods like medial epicondyle osteotomy (MEO) and tibial reduction osteotomy are less used due to concerns

For this study, we used the medial epicondyle osteotomy technique because we believe that this method will allow early recovery, bone stock preservation, and a good overall alignment of the limb as we will show later in this chapter. Some authors also used the MEO technique in the past, but their method involves subsequently reattaching the medial epicondyle with screws, sutures, or anchors in an optimal position for balancing the prosthetic knee, which will not allow early rehabilitation after surgery. We did not reattach this fragment and early rehabilitation program was started. The goal of our study was to underline the results of TKA after using MEO as a balancing method for severe varus deformity. The results were compared with those of TKA after using additional resection of the tibial medial plateau to correct this deformity and to those of TKA for varus deformity less than

Between April 2006 and April 2017, we performed 135 TKAs on patients with

patients with TKA for preoperative varus less than 15°. In 65 cases (40 female and 25 men), the MEO technique was used, and in 70 cases (45 female and 25 men), additional resection of the tibial medial plateau. The mean age at the time of the TKA in MEO group was 68.6; mean height, 1.72 m; and mean weight, 76 kg. In the resection group, the mean age was 65.4 years; mean height, 1.77 m; and mean weight, 76.9 kg. In the control group, there were 30 female and 20 male patients; mean age was 62.5;

Patients with preoperative valgus and secondary OA to trauma or inflammatory diseases were not included in the study. All surgeries were performed by the same main surgeon, using the medial-parapatellar and subvastus approaches. The same type of cemented postero-stabilized knee prosthesis was implanted in all cases

No full weight bearing X Ray films were available for this study, so the distal femoral cut was performed at 5° of valgus relative to the anatomical axis of the

severe preoperative varus (of more than 15°). The control group included 50

15 degrees when standard measures were used for balancing.

mean height was 1.71 m; and mean weight was 76 kg.

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

if the MCL cannot be trusted.

regarding survivorship [16].

**2. Materials and methods**

leading to correction of the deformity [14, 15].

#### *Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Knee Surgery - Reconstruction and Replacement*

of the adduction moment during gait [1].

alignment is present, the forces passing the knee are unequally distributed between condyles with an increased load passing through medial condyle due to an increase

Anatomical changes are present in varus knee as a result of deforming forces. According to Puthumanapully, some reference axes and surface features are significantly different to normal knees [2]. For the femur, he found less femoral anteversion in varus knees. In the tibia, the tubercle (and tibial tubercle axis) was externally rotated and there was a medial tilt of the tibial plateau in the coronal plane. The coronal slope was found to be significantly more (P = 0.001) in varus knees (3.5°) when compared to normal knees (0°), indicating that the slope contributes to the varus deformity. Normal femoral version has been reported to be varied between 10° and 20° [3]. Retroversion or decreasing femoral anteversion is associated with external rotation of the knee and varus deformity contributing to the development of OA in adults [4]. Authors like Bretin and Papaioannou showed that loads shift from center

to medial compartment when external femoral malrotation is present [5, 6]. OA also affects the anatomy of superficial medial collateral ligament (MCL), which is the main structure providing medial stability. These changes are secondary to fibrosis of the posteromedial complex, to impingement of marginal osteophytes, and to extrusion of the medial meniscus. According to Haidar, there is no shortening of the MCL in knee OA. There are deforming structures such as the oblique ligament with adhesion and thickening of posteromedial corner structures. Those changes are supposed to cause a posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion act as

a soft phyte tensioning and deform the ligament and the posterior capsule [7].

Ignorance, fear of surgery, access to alternative and traditional medicine, and the high costs of treatment are among main reasons that contribute to late presentation for treatment. Factors like age of the patients, level of activity or disease progression have been discussed when deciding to choose methods of treatment in knee osteoarthritis (OA). Financial aid is a leading factor in decision-making of treating OA. Conservative treatment in knee osteoarthritis is also expensive because it fails to correct the malalignment and abnormal joint loading. The disease will progress and the TKA will be the optimal solution for treatment. Severe preoperative deformities have long been a challenge for surgeons performing total knee

Limb alignment and proper soft tissue balance are the main factors that influence long-term results of TKA in terms of survivorship. What kind of alignment should be obtained, anatomical, mechanical, or kinematic, is still a matter of debate, but everyone agrees that a balanced prosthetic knee will provide better results. Most of the authors state that the mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpen-

Technical flows are challenging for surgeons no matter the surgical strategy. A part of this issue is represented by the instruments' errors. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal respect the anatomic axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Alignment is critical to load transfer, both at the articular surface and at the implant-host interface, and hence essential for the success of total knee replacement (TKA). Most of the early failures

**44**

arthroplasty.

dicular to the mechanical axis of the tibia [8].

of TKAs are related to technical flaws. Valgus or varus malpositioning of the tibial component of a total knee implant may cause increased propensity for loosening or implant wear and they may eventually lead to revision surgery [9]. Experimental and clinical data indicate that, in order to achieve optimal mid-term and long-term results of a TKR, good alignment in the frontal plane of the lower limb is mandatory.

Releasing the superficial MCL can sometimes lead to a major instability of the knee and other surgical methods should be assessed for balancing the prosthetic knee in cases of severe varus deformity when aggressive MCL release is expected. A severe varus deformity (more than 15 degrees) is a challenge in terms of the type and extent of release required. More constrained types of implants may be needed if the MCL cannot be trusted.

A balanced knee must be the goal of every TKA because this will increase the chances for a better survivorship [10–13]. When malalignment is present, some parts of the soft tissue around the knee are contracted and must be released, thus leading to correction of the deformity [14, 15].

When severe varus deformity is present, medial structures become fibrous. Among the methods used to correct severe varus deformity, the most common are subperiosteal release of the superficial medial collateral ligament and joint line release of the medial collateral ligament. Some other methods like medial epicondyle osteotomy (MEO) and tibial reduction osteotomy are less used due to concerns regarding survivorship [16].

For this study, we used the medial epicondyle osteotomy technique because we believe that this method will allow early recovery, bone stock preservation, and a good overall alignment of the limb as we will show later in this chapter. Some authors also used the MEO technique in the past, but their method involves subsequently reattaching the medial epicondyle with screws, sutures, or anchors in an optimal position for balancing the prosthetic knee, which will not allow early rehabilitation after surgery. We did not reattach this fragment and early rehabilitation program was started. The goal of our study was to underline the results of TKA after using MEO as a balancing method for severe varus deformity. The results were compared with those of TKA after using additional resection of the tibial medial plateau to correct this deformity and to those of TKA for varus deformity less than 15 degrees when standard measures were used for balancing.

#### **2. Materials and methods**

Between April 2006 and April 2017, we performed 135 TKAs on patients with severe preoperative varus (of more than 15°). The control group included 50 patients with TKA for preoperative varus less than 15°. In 65 cases (40 female and 25 men), the MEO technique was used, and in 70 cases (45 female and 25 men), additional resection of the tibial medial plateau. The mean age at the time of the TKA in MEO group was 68.6; mean height, 1.72 m; and mean weight, 76 kg. In the resection group, the mean age was 65.4 years; mean height, 1.77 m; and mean weight, 76.9 kg. In the control group, there were 30 female and 20 male patients; mean age was 62.5; mean height was 1.71 m; and mean weight was 76 kg.

Patients with preoperative valgus and secondary OA to trauma or inflammatory diseases were not included in the study. All surgeries were performed by the same main surgeon, using the medial-parapatellar and subvastus approaches. The same type of cemented postero-stabilized knee prosthesis was implanted in all cases (Zimmer Nexgen).

No full weight bearing X Ray films were available for this study, so the distal femoral cut was performed at 5° of valgus relative to the anatomical axis of the

femur, using an intramedullary rod. The tibial cut was perpendicular to the tibial mechanical axis, also using an intramedullary guide. A 3° femoral external rotation was set in almost every case. Rotation of the femoral component was decided using Whiteside's line, transepicondylar axis, and posterior condylar reference. A combined anterior and posterior referencing was used for sizing of femur.

All patients underwent stepwise sequential medial soft tissue release consisting of deep MCL, posteromedial release, superficial MCL, and pes anserinus. All the osteophytes were removed. Bony defects were managed with the cement or structural bone grafts and screws. No stem extenders were used. For the control group, no further measures were necessary to balance the prosthetic knee.

For both study groups, these steps were insufficient for balancing the knee and therefore further action was necessary.

In the first group, the surgeon performed a medial epicondyle osteotomy, containing the insertion of the MCL, starting with a saw-blade and finishing with an osteotome (**Figure 1**). Then, a valgus stress was applied lowering the epicondyle to its new position. The inferior margin of the epicondyle was cut with a rongeur for not interfering with the articular part of the implant during movements. No fixation method was used for the epicondyle. The flexion and extension gaps were assessed for balance.

In the second group, as the medial compartment was still tight in extension and flexion, the surgeon performed a secondary asymmetrical tibial coronal recut using the specific instrument and removed an extra 2 mm of bone from the medial tibial plateau (**Figure 2**). Thus proceeding, the extension and flexion gaps were equal and the knee was balanced.

For all cases, the patella was resurfaced and no tourniquet was used. Rehabilitation started immediately after surgery, with alternative positioning of the knee in flexion-extension. On day 1 after surgery, all patients started active motion of the operated knee with flexion-extension exercises. Full weight bearing was allowed form day 1, using no brace for protection. No passive motion device was needed. Postoperative follow-up was scheduled 6 weeks, 3 months, 6 months, and 1 year after the surgery, and once per year afterward. The mean follow-up for the study was 7 years (± 3).

**47**

P = 0.005.

cance throughout testing.

motion, femoro-tibial angle, and frontal laxity. The results are summarized in **Table 1**.

**3. Results**

**Figure 2.**

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

The main inclusion criterion for the study group was preoperative varus deformity greater than 15°. The outcomes were measured: Knee Society score (KSS), the range of the motion (ROM), clinical frontal laxity of the knee, femoro-tibial angle, the mean thickness of the polyethylene insert, the amount of resected tibial medial plateau bone, and the union state of the osteotomy site. The amount of resected tibial medial plateau bone was defined as the difference between preoperative and postoperative distance from a perpendicular to the axis of tibia through the peroneal head and a perpendicular to the same axis through the lowermost point of the tibial medial plateau in anteroposterior Rx incidence. The choice of surgical technique was random and we did not use any criteria for performing one or other in this study, but we selected the patients who had a preoperative varus deformity greater than 15°. Statistical tests were performed using SPSS software. Paired Samples Test was used to compare the results. The 0.05 level was used to denote statistical signifi-

*Additional medial tibial resection (note the varus malposition of tibial component).*

There were no statistically significant differences regarding personal characteristics (age, sex, height, and weight) between the two groups and the control group. No differences were noted regarding postoperative outcomes of KSS, range of

We observed a significant statistical difference regarding positioning of tibial component between groups. The mean angle between tibial component and tibial mechanical axis was 1° ± 3.5°of varus for the MEO group, and 4° ± 2.5° of varus for the resection group (P < 0.001). In the control group, the angle was 0.7° ± 2.3°. The mean thickness of the polyethylene insert was 12.5 ± 1.24 mm in the MEO

group and 13.61 ± 1.59 mm in the second group, with statistically significant

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

**Figure 1.** *Medial epicondyle osteotomy with TKA.*

*Knee Surgery - Reconstruction and Replacement*

therefore further action was necessary.

the knee was balanced.

study was 7 years (± 3).

femur, using an intramedullary rod. The tibial cut was perpendicular to the tibial mechanical axis, also using an intramedullary guide. A 3° femoral external rotation was set in almost every case. Rotation of the femoral component was decided using Whiteside's line, transepicondylar axis, and posterior condylar reference. A com-

All patients underwent stepwise sequential medial soft tissue release consisting of deep MCL, posteromedial release, superficial MCL, and pes anserinus. All the osteophytes were removed. Bony defects were managed with the cement or structural bone grafts and screws. No stem extenders were used. For the control group,

For both study groups, these steps were insufficient for balancing the knee and

In the first group, the surgeon performed a medial epicondyle osteotomy, containing the insertion of the MCL, starting with a saw-blade and finishing with an osteotome (**Figure 1**). Then, a valgus stress was applied lowering the epicondyle to its new position. The inferior margin of the epicondyle was cut with a rongeur for not interfering with the articular part of the implant during movements. No fixation method was used for the epicondyle. The flexion and extension gaps were assessed for balance. In the second group, as the medial compartment was still tight in extension and flexion, the surgeon performed a secondary asymmetrical tibial coronal recut using the specific instrument and removed an extra 2 mm of bone from the medial tibial plateau (**Figure 2**). Thus proceeding, the extension and flexion gaps were equal and

For all cases, the patella was resurfaced and no tourniquet was used.

Rehabilitation started immediately after surgery, with alternative positioning of the knee in flexion-extension. On day 1 after surgery, all patients started active motion of the operated knee with flexion-extension exercises. Full weight bearing was allowed form day 1, using no brace for protection. No passive motion device was needed. Postoperative follow-up was scheduled 6 weeks, 3 months, 6 months, and 1 year after the surgery, and once per year afterward. The mean follow-up for the

bined anterior and posterior referencing was used for sizing of femur.

no further measures were necessary to balance the prosthetic knee.

**46**

**Figure 1.**

*Medial epicondyle osteotomy with TKA.*

**Figure 2.** *Additional medial tibial resection (note the varus malposition of tibial component).*

The main inclusion criterion for the study group was preoperative varus deformity greater than 15°. The outcomes were measured: Knee Society score (KSS), the range of the motion (ROM), clinical frontal laxity of the knee, femoro-tibial angle, the mean thickness of the polyethylene insert, the amount of resected tibial medial plateau bone, and the union state of the osteotomy site. The amount of resected tibial medial plateau bone was defined as the difference between preoperative and postoperative distance from a perpendicular to the axis of tibia through the peroneal head and a perpendicular to the same axis through the lowermost point of the tibial medial plateau in anteroposterior Rx incidence. The choice of surgical technique was random and we did not use any criteria for performing one or other in this study, but we selected the patients who had a preoperative varus deformity greater than 15°.

Statistical tests were performed using SPSS software. Paired Samples Test was used to compare the results. The 0.05 level was used to denote statistical significance throughout testing.

#### **3. Results**

There were no statistically significant differences regarding personal characteristics (age, sex, height, and weight) between the two groups and the control group. No differences were noted regarding postoperative outcomes of KSS, range of motion, femoro-tibial angle, and frontal laxity.

The results are summarized in **Table 1**.

We observed a significant statistical difference regarding positioning of tibial component between groups. The mean angle between tibial component and tibial mechanical axis was 1° ± 3.5°of varus for the MEO group, and 4° ± 2.5° of varus for the resection group (P < 0.001). In the control group, the angle was 0.7° ± 2.3°.

The mean thickness of the polyethylene insert was 12.5 ± 1.24 mm in the MEO group and 13.61 ± 1.59 mm in the second group, with statistically significant P = 0.005.


#### **Table 1.**

*Results after TKA for the study groups.*

**Figure 3.** *Medial epicondyle osteotomy Rx (3 months and 5 years follow up).*

#### **Figure 4.**

*The amount of tibial medial plateau resected bone- MEO.*

For all knees with medial epicondyle osteotomy, a fibrous union occurred at the site of osteotomy (**Figure 3**). In this group, the amount of resected tibial medial plateau bone (**Figures 4** and **5**) was statistically significantly smaller than in the other group (1.33 ± 0.46 mm in the MEO group and 3.73 ± 2.5 mm in the other group; P < 0,001).

**49**

follow-up.

**Figure 5.**

**4. Discussion**

this problem.

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

that bone and soft tissue are affected by the disease.

Residual frontal laxity was present in four cases, two in the MEO group and two in the second one. No revision surgery was necessary for any of the cases at the last

*The amount of tibial medial plateau resected bone (an additional resection of tibial medial plateau case).*

The varus knee is the most common deformity that requires total knee arthroplasty. Severe varus deformity grossly affects normal anatomy of the knee, meaning

For better survivorship of a knee implant, it is mandatory to achieve a proper alignment and a perfect balance of total knee prosthesis. It is a great challenge for surgeons to balance a severe varus knee due to changes in the anatomy of medial compartment. Fibrosis of the posteromedial complex, marginal osteophytes, extrusion of the medial meniscus, adhesion and thickening of the oblique ligament with all the posterior medial complex, and posterior bowing to the superficial MCL are problems that must be corrected during surgery. MCL release is very important in balancing the fixed varus deformity. The surgeon must progressively release the medial soft tissue until it reaches the length of lateral structures. The endpoint of the release is when the knee is stable and the alignment is optimal. In severe varus deformity, the separation of the periosteal layer from the tibia is distal to the MCL attachment. For this reason, some authors raised concerns about the integrity of the MCL after aggressive release. Releasing the superficial MCL can sometimes lead to a major instability of the knee, requiring a more constrained implant [7]. Our method of medial epicondyle osteotomy for severe varus deformity could prevent

There are few literature reports that describe MEO as a method of balancing the prosthetic knee. Engh has described his results after medial epicondyle osteotomy during TKA. He performed this procedure on 80 patients [16]. The clinical results showed the KSS improvement from 42 to 93 points after surgery and the range of motion increase from 101 to 111 degrees. He has found no instability in his patients group during the follow-up period. Regarding frontal laxity, the mean varus-valgus stability measured 14.2 points (Knee Society scale, 0–15 points). Improvement of function and patient satisfaction was found in 95% of the cases. In every case of his study, the osteotomized epicondyle was fixed during surgery at the optimal position for balance. Despite this, bone union occurred only in 54% of the knees and

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

#### **Figure 5.**

*Knee Surgery - Reconstruction and Replacement*

**Group KSS ROM F-T angle Frontal laxity** MEO Preop. 18.15 ± 15.6 72.3° ± 23.5° 25.3° ± 5.51° varus 12.43° ± 3.5°

Resection Preop. 21.44 ± 13.6 86.8° ± 15.5° 24.7° ± 5.1° varus 12.81° ± 3.9°

Control Preop. 25.15 ± 12.1 76.4° ± 24.3° 15.6° ± 7.41° varus 8.81° ± 2.8°

Postop. 94.1 ± 5.6 112.3° ± 10.8° 4.0° ± 1.18° valgus 0.32° ± 1.3°

Postop. 91.7 ± 7.6 115.4° ± 8.4° 4.1° ± 0.97° valgus 0.37° ± 1.2°

Postop. 96.3 ± 5.6 118.3° ± 9.7° 2.0° ± 1.2° valgus 1.34° ± 1.2°

*Medial epicondyle osteotomy Rx (3 months and 5 years follow up).*

*The amount of tibial medial plateau resected bone- MEO.*

For all knees with medial epicondyle osteotomy, a fibrous union occurred at the site of osteotomy (**Figure 3**). In this group, the amount of resected tibial medial plateau bone (**Figures 4** and **5**) was statistically significantly smaller than in the other group (1.33 ± 0.46 mm in the MEO group and 3.73 ± 2.5 mm in the other group; P < 0,001).

**48**

**Figure 4.**

**Figure 3.**

**Table 1.**

*Results after TKA for the study groups.*

*The amount of tibial medial plateau resected bone (an additional resection of tibial medial plateau case).*

Residual frontal laxity was present in four cases, two in the MEO group and two in the second one. No revision surgery was necessary for any of the cases at the last follow-up.

#### **4. Discussion**

The varus knee is the most common deformity that requires total knee arthroplasty. Severe varus deformity grossly affects normal anatomy of the knee, meaning that bone and soft tissue are affected by the disease.

For better survivorship of a knee implant, it is mandatory to achieve a proper alignment and a perfect balance of total knee prosthesis. It is a great challenge for surgeons to balance a severe varus knee due to changes in the anatomy of medial compartment. Fibrosis of the posteromedial complex, marginal osteophytes, extrusion of the medial meniscus, adhesion and thickening of the oblique ligament with all the posterior medial complex, and posterior bowing to the superficial MCL are problems that must be corrected during surgery. MCL release is very important in balancing the fixed varus deformity. The surgeon must progressively release the medial soft tissue until it reaches the length of lateral structures. The endpoint of the release is when the knee is stable and the alignment is optimal. In severe varus deformity, the separation of the periosteal layer from the tibia is distal to the MCL attachment. For this reason, some authors raised concerns about the integrity of the MCL after aggressive release. Releasing the superficial MCL can sometimes lead to a major instability of the knee, requiring a more constrained implant [7]. Our method of medial epicondyle osteotomy for severe varus deformity could prevent this problem.

There are few literature reports that describe MEO as a method of balancing the prosthetic knee. Engh has described his results after medial epicondyle osteotomy during TKA. He performed this procedure on 80 patients [16]. The clinical results showed the KSS improvement from 42 to 93 points after surgery and the range of motion increase from 101 to 111 degrees. He has found no instability in his patients group during the follow-up period. Regarding frontal laxity, the mean varus-valgus stability measured 14.2 points (Knee Society scale, 0–15 points). Improvement of function and patient satisfaction was found in 95% of the cases. In every case of his study, the osteotomized epicondyle was fixed during surgery at the optimal position for balance. Despite this, bone union occurred only in 54% of the knees and

fibrous union occurred in 46%. No symptoms like tenderness, restricted motion, or other were associated with fibrous union. Other authors like Sim and Kwak reported their results after using medial epicondylar osteotomy for treating varus deformity in 32 cases [17]. Clinical and radiological outcomes, including the Knee Society score (KSS), the function score (FS), the range of the motion (ROM), the union state of the osteotomy site, were measured. They found an improvement of KSS after surgery from 46.5 ± 7.6 to 89.1 ± 5.9 points (P < 0.001). The FS increased from 39.5 ± 9.2 to 84.2 ± 8.5 points (P < 0.001). Also the range of motion was better after the surgery (101.5° ± 28.2° to 116.0° ± 10.8°; P = 0.006). A significant number of patients presented fibrous union on the osteotomy site despite the fixation of the condyle during procedure (10 patients). Bone union occurred only in 22 knees. There was no significant difference regarding clinical outcomes between the bone union group and the fibrous union group (P = 0.175). The femoro-tibial angle was corrected from an 8.2° ± 5.0°-varus to a 5.6° ± 1.5°-valgus (P < 0.001). Despite the fact that in both studies the epicondyle was fixed with sutures or screws, a major part of the patients presented fibrous union of the epicondyle. The authors concluded that there was no significant difference between the bone union group and the fibrous union group. We do not consider that any reattachment of the epicondyle is necessary, and in consequence, we did not perform fixation in any of the cases. Also no splinting after the surgery was used and the rehab program was started immediately, avoiding knee stiffness and accelerating recovery.

Nobody could tell for sure the ideal positioning of the knee prosthetic components. The disagreement among surgeons is amplified by the significant number of unsatisfied patients with TKA.

Most of the authors state that mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia. If mechanical alignment is achieved, it means that mechanical axis of the leg passes through the center of the knee and the loads are equally distributed between medial and lateral compartments. The native knee interline is inclined about 3 degrees in varus, meaning that the mechanical alignment will change it to 0 degrees, changing the normal anatomy of the knee. The proximal tibial joint line is therefore converted from 87 degrees (3 degrees of varus) to 90 degrees and the distal femoral line from 87 degrees (3 degrees of valgus) to 90 degrees.

For these considerations, some authors proposed the so-called "anatomic alignment" when the tibial component was placed at 3 degrees of varus and the femoral component at 3 degrees of valgus, and overall alignment to be neutral [18]. There is an important variability in natural alignment among population. A significant part of neutral alignment is not normal, leading to distalization of the joint line on the lateral compartment, which can cause anterior knee pain. The concept of restoring constitutional alignment rather than mechanical has gained more interest recently. For the supplementary tibial resection group in our study, we have created the situation of placing the tibial component in varus. In case of a medio-lateral tibial plateau length of 8 cm, an additional resection of 2 mm from medial side lead to a maximum 3 degrees of varus positioning of tibial implant. Attention should be paid in cases where this additional cut adds to a previous unknown error of first cuts due to the instrument's or surgeon's mistake, and this could lead to a supplemental varus, and potential danger in terms of survivorship.

Other authors showed that a femoral component placed in 7° valgus, with tibial plateau placed at 90° to the long axis of the tibia, provides equal force distribution between the medial and lateral plateaus and consecutively best chances for

**51**

thetic knee.

**5. Conclusion**

any of the cases.

better for revision surgery.

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

survivorship [19]. According to Howell, kinematically aligning the knee means coaligning the transverse axis of the femoral component with the primary transverse axis in the femur about which the tibia flexes and extends and placing the tibial component so that the longitudinal axis of the tibia is perpendicular to the transverse axis in the femur, about which the tibia flexes and extends [20]. This means that the femoral cut is plus 1°–2° in valgus and tibial cut, plus 1°–2° in varus compared with the mechanically aligned total knee arthroplasty [21]. The authors who propose this approach state that restoring mechanical alignment is unnatural in patients with constitutional varus and valgus alignment and could cause higher strain in collateral ligaments [22]. They say that by restoring the native alignment, patients will have better clinical and functional outcome scores as compared with patients in whom the limb alignment is corrected to neutral [23]. The present general consensus is that overall mechanical femoro-tibial alignment should be 0 ± 3 degrees, thus providing the best survivorship chances for the knee implant [24]. No matter of the technique used for TKA, the next important problem for surgeons are technical flows. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal to be in line with anatomical axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Regarding tibial component alignment, we observed a significant difference between groups. For the MEO group, the alignment was neutral (1°± 3.5°) and in the resection group, the alignment was mainly in varus (4° ± 2.5°). In 90% of MEO group cases, the tibial component is placed in line with mechanical axis. Only 5% of the knees from the second group present 90° tibial component placement. The vast majority of them are outliers due to additional asymmetric tibial varus cut. The MEO is a method that increases chances for a mechanical alignment of the pros-

Based on our results, we suggest that the outcomes of TKA with MEO are similar to those with additional resection of the tibial medial plateau and to those from the control group. No revision surgery was needed at the last follow-up in

Some advantages of medial epicondyle osteotomy have resulted from this study. First of all, it avoids excessive weakening of the medial collateral ligament in cases of severe contracture of medial structures by lowering the epicondyle instead of aggressive releasing of the ligament. This will prevent also the need for a more constrained implant. The exposure during surgery is much easier and avoids complications like extensor mechanism disruption. It is a technique that provides optimal conditions for obtaining neutral overall alignment of the limb, minimizing the risk of malpositioning the tibial component, which is higher in cases of additional tibial resection. The tibial bone loss is less than that in additional resection group which is

This study highlights early and mid-term results of TKA with medial epicondyle osteotomy. Further analyses are necessary to assess the long-term results of this technique, especially in terms of survivorship. So far, there are no differences between groups regarding patient satisfaction, range of motion, or survivorship.

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Knee Surgery - Reconstruction and Replacement*

unsatisfied patients with TKA.

valgus) to 90 degrees.

varus, and potential danger in terms of survivorship.

fibrous union occurred in 46%. No symptoms like tenderness, restricted motion, or other were associated with fibrous union. Other authors like Sim and Kwak reported their results after using medial epicondylar osteotomy for treating varus deformity in 32 cases [17]. Clinical and radiological outcomes, including the Knee Society score (KSS), the function score (FS), the range of the motion (ROM), the union state of the osteotomy site, were measured. They found an improvement of KSS after surgery from 46.5 ± 7.6 to 89.1 ± 5.9 points (P < 0.001). The FS increased from 39.5 ± 9.2 to 84.2 ± 8.5 points (P < 0.001). Also the range of motion was better after the surgery (101.5° ± 28.2° to 116.0° ± 10.8°; P = 0.006). A significant number of patients presented fibrous union on the osteotomy site despite the fixation of the condyle during procedure (10 patients). Bone union occurred only in 22 knees. There was no significant difference regarding clinical outcomes between the bone union group and the fibrous union group (P = 0.175). The femoro-tibial angle was corrected from an 8.2° ± 5.0°-varus to a 5.6° ± 1.5°-valgus (P < 0.001). Despite the fact that in both studies the epicondyle was fixed with sutures or screws, a major part of the patients presented fibrous union of the epicondyle. The authors concluded that there was no significant difference between the bone union group and the fibrous union group. We do not consider that any reattachment of the epicondyle is necessary, and in consequence, we did not perform fixation in any of the cases. Also no splinting after the surgery was used and the rehab program was

started immediately, avoiding knee stiffness and accelerating recovery.

Nobody could tell for sure the ideal positioning of the knee prosthetic components. The disagreement among surgeons is amplified by the significant number of

Most of the authors state that mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia. If mechanical alignment is achieved, it means that mechanical axis of the leg passes through the center of the knee and the loads are equally distributed between medial and lateral compartments. The native knee interline is inclined about 3 degrees in varus, meaning that the mechanical alignment will change it to 0 degrees, changing the normal anatomy of the knee. The proximal tibial joint line is therefore converted from 87 degrees (3 degrees of varus) to 90 degrees and the distal femoral line from 87 degrees (3 degrees of

For these considerations, some authors proposed the so-called "anatomic alignment" when the tibial component was placed at 3 degrees of varus and the femoral component at 3 degrees of valgus, and overall alignment to be neutral [18]. There is an important variability in natural alignment among population. A significant part of neutral alignment is not normal, leading to distalization of the joint line on the lateral compartment, which can cause anterior knee pain. The concept of restoring constitutional alignment rather than mechanical has gained more interest recently. For the supplementary tibial resection group in our study, we have created the situation of placing the tibial component in varus. In case of a medio-lateral tibial plateau length of 8 cm, an additional resection of 2 mm from medial side lead to a maximum 3 degrees of varus positioning of tibial implant. Attention should be paid in cases where this additional cut adds to a previous unknown error of first cuts due to the instrument's or surgeon's mistake, and this could lead to a supplemental

Other authors showed that a femoral component placed in 7° valgus, with tibial

plateau placed at 90° to the long axis of the tibia, provides equal force distribution between the medial and lateral plateaus and consecutively best chances for

**50**

survivorship [19]. According to Howell, kinematically aligning the knee means coaligning the transverse axis of the femoral component with the primary transverse axis in the femur about which the tibia flexes and extends and placing the tibial component so that the longitudinal axis of the tibia is perpendicular to the transverse axis in the femur, about which the tibia flexes and extends [20]. This means that the femoral cut is plus 1°–2° in valgus and tibial cut, plus 1°–2° in varus compared with the mechanically aligned total knee arthroplasty [21]. The authors who propose this approach state that restoring mechanical alignment is unnatural in patients with constitutional varus and valgus alignment and could cause higher strain in collateral ligaments [22]. They say that by restoring the native alignment, patients will have better clinical and functional outcome scores as compared with patients in whom the limb alignment is corrected to neutral [23]. The present general consensus is that overall mechanical femoro-tibial alignment should be 0 ± 3 degrees, thus providing the best survivorship chances for the knee implant [24]. No matter of the technique used for TKA, the next important problem for surgeons are technical flows. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal to be in line with anatomical axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Regarding tibial component alignment, we observed a significant difference between groups. For the MEO group, the alignment was neutral (1°± 3.5°) and in the resection group, the alignment was mainly in varus (4° ± 2.5°). In 90% of MEO group cases, the tibial component is placed in line with mechanical axis. Only 5% of the knees from the second group present 90° tibial component placement. The vast majority of them are outliers due to additional asymmetric tibial varus cut. The MEO is a method that increases chances for a mechanical alignment of the prosthetic knee.

#### **5. Conclusion**

Based on our results, we suggest that the outcomes of TKA with MEO are similar to those with additional resection of the tibial medial plateau and to those from the control group. No revision surgery was needed at the last follow-up in any of the cases.

Some advantages of medial epicondyle osteotomy have resulted from this study. First of all, it avoids excessive weakening of the medial collateral ligament in cases of severe contracture of medial structures by lowering the epicondyle instead of aggressive releasing of the ligament. This will prevent also the need for a more constrained implant. The exposure during surgery is much easier and avoids complications like extensor mechanism disruption. It is a technique that provides optimal conditions for obtaining neutral overall alignment of the limb, minimizing the risk of malpositioning the tibial component, which is higher in cases of additional tibial resection. The tibial bone loss is less than that in additional resection group which is better for revision surgery.

This study highlights early and mid-term results of TKA with medial epicondyle osteotomy. Further analyses are necessary to assess the long-term results of this technique, especially in terms of survivorship. So far, there are no differences between groups regarding patient satisfaction, range of motion, or survivorship.

*Knee Surgery - Reconstruction and Replacement*

#### **Author details**

Gabriel Stan Carol Davila Faculty of Medicine, Elias University Hospital, Bucharest, Romania

\*Address all correspondence to: gabisus2000@yahoo.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**53**

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

Clinical Orthopaedics and Related

[9] Werner F, Ayers D, Maletsky L. The effect of valgus/varus malalignment on load distribution in total knee replacements. Journal of Biomechanics.

[10] W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthopaedica.

Research. 1985;**192**:13

2005;**38**:349-355

2010;**81**(2):161-164

2006;**30**(5):403-408

[11] Papachristou G, Plessas S, Sourlas J. Deterioration of longterm

osteotomy in patients under 60 years of age. International Orthopaedics.

postoperative collateral ligament laxity in total knee arthroplasty. Clinical Orthopaedics. 1998;**236**:44

[13] Hunt MA, Birmingham TB, Bryant D, et al. Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis. Osteoarthritis and Cartilage. 2008;**16**:591-599

[14] Mundermann A, Dyrby CO, Hurwitz DE. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: Reduced walking speed. Arthritis and Rheumatism.

[15] Birmingham TB, Hunt MA, Jones IC. Test–retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis and Rheumatism.

[16] Engh GA. Medial epicondylar osteotomy: A technique used with

2004;**50**:1172-1178

2007;**57**:1012-1017

results following high tibial

[12] Edwards E. The eVect of

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

[1] Amis AA. Biomechanics of high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**:197-205. DOI: 10.1007/

[2] Puthumanapully PK, Harris SJ, Leong A, Cobb JP, Amis AA, Jeffers J. A morphometric study of normal and varus knees. Knee Surgery, Sports Traumatology, Arthroscopy.

2014;**22**(12):2891-2899. DOI: 10.1007/

[4] Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: A cause of pain and osteoarthritis. Journal of Pediatric Orthopedics.

10.1097/01241398-199107000-00001

[5] Bretin P, O'Loughlin PF, Suero EM, Kendoff D, Ostermeier S, Hüfner T, et al. Influence of femoral malrotation on knee joint alignment and intraarticular contract pressures. Archives of Orthopaedic and Trauma Surgery. 2011;**131**:1115-1120. DOI: 10.1007/

[6] Papaioannou T, Digas G, Bikos C, Karamoulas V, Magnissalis E. Femoral neck version affects medial femorotibial loading. ISRN Orthopedics. 2013;**2013**:

[7] Haidar F, Tarabichi S, Osman A,

of varus knee on MRIcan lead to a better algorithm to balance the knee. Orthopaedic Proceedings.

[8] Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty.

Understanding the pathological changes

1-6. DOI: 10.1155/2013/328246

Elkabbani M, Mohamed T.

2019;**101-B**(SUPP\_4):85

[3] Cibulka MT. Determination and significance of femoral neck anteversion. Physical Therapy.

**References**

s00167-012-2122-3

s00167-014-3337-2

2004;**84**:550-558

1991;**11**:419-431. DOI:

s00402-010-1210-4

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

#### **References**

*Knee Surgery - Reconstruction and Replacement*

**52**

**Author details**

Carol Davila Faculty of Medicine, Elias University Hospital, Bucharest, Romania

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: gabisus2000@yahoo.com

provided the original work is properly cited.

Gabriel Stan

[1] Amis AA. Biomechanics of high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**:197-205. DOI: 10.1007/ s00167-012-2122-3

[2] Puthumanapully PK, Harris SJ, Leong A, Cobb JP, Amis AA, Jeffers J. A morphometric study of normal and varus knees. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;**22**(12):2891-2899. DOI: 10.1007/ s00167-014-3337-2

[3] Cibulka MT. Determination and significance of femoral neck anteversion. Physical Therapy. 2004;**84**:550-558

[4] Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: A cause of pain and osteoarthritis. Journal of Pediatric Orthopedics. 1991;**11**:419-431. DOI: 10.1097/01241398-199107000-00001

[5] Bretin P, O'Loughlin PF, Suero EM, Kendoff D, Ostermeier S, Hüfner T, et al. Influence of femoral malrotation on knee joint alignment and intraarticular contract pressures. Archives of Orthopaedic and Trauma Surgery. 2011;**131**:1115-1120. DOI: 10.1007/ s00402-010-1210-4

[6] Papaioannou T, Digas G, Bikos C, Karamoulas V, Magnissalis E. Femoral neck version affects medial femorotibial loading. ISRN Orthopedics. 2013;**2013**: 1-6. DOI: 10.1155/2013/328246

[7] Haidar F, Tarabichi S, Osman A, Elkabbani M, Mohamed T. Understanding the pathological changes of varus knee on MRIcan lead to a better algorithm to balance the knee. Orthopaedic Proceedings. 2019;**101-B**(SUPP\_4):85

[8] Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clinical Orthopaedics and Related Research. 1985;**192**:13

[9] Werner F, Ayers D, Maletsky L. The effect of valgus/varus malalignment on load distribution in total knee replacements. Journal of Biomechanics. 2005;**38**:349-355

[10] W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthopaedica. 2010;**81**(2):161-164

[11] Papachristou G, Plessas S, Sourlas J. Deterioration of longterm results following high tibial osteotomy in patients under 60 years of age. International Orthopaedics. 2006;**30**(5):403-408

[12] Edwards E. The eVect of postoperative collateral ligament laxity in total knee arthroplasty. Clinical Orthopaedics. 1998;**236**:44

[13] Hunt MA, Birmingham TB, Bryant D, et al. Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis. Osteoarthritis and Cartilage. 2008;**16**:591-599

[14] Mundermann A, Dyrby CO, Hurwitz DE. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: Reduced walking speed. Arthritis and Rheumatism. 2004;**50**:1172-1178

[15] Birmingham TB, Hunt MA, Jones IC. Test–retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis and Rheumatism. 2007;**57**:1012-1017

[16] Engh GA. Medial epicondylar osteotomy: A technique used with primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity. Instructional Course Lectures. 1999;**48**:153-156

[17] Sim JA, Kwak JH. Short-term follow-up results of medial epicondylar osteotomy for the varus knee in TKA. Journal of Korean Knee Society. 2009;**21**:194-204

[18] Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clinical Orthopaedics and Related Research. 1985;**192**:23

[19] Hsu RW, Himeno S, Coventry MB. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clinical Orthopaedics. 1990;**255**:215-227

[20] Howell SM, Roth JD, Hull ML. Kinematic alignment in total knee arthroplasty. Definition, history, principle, surgical technique, and results of an alignment option for TKA. Art. 2014;**1**:44-53

[21] Scott W. Kinematic alignment in total knee arthroplasty. In: Insall & Scott Surgery of the Knee. 5th ed. Vol. 121. Churchill Livingstone; 2012. pp. 1255-1268

[22] Gu Y, Roth JD, Howell SM, Hull ML. How frequently do four methods for mechanically aligning a total knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white patients? Journal of Bone and Joint Surgery. 2014;**96**(12):e101

[23] Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**(10):2325-2330

[24] HD1 C, Math KR, Scuderi GR. Polyethylene post failure in posterior stabilized total knee arthroplasty. The Journal of Arthroplasty. 2004;**19**(5):652-657

**55**

**Chapter 5**

Arthroplasty

*and Orkun Gül*

knee replacement surgery.

Some of these are listed below:

• Medical error.

• Nurse error.

• Trauma.

• Error in surgical technique.

• Patient non-compliance.

• Associated comorbid diseases.

**1. Introduction**

**Abstract**

Complications after Total Knee

*Muhammet Salih AYAS, Muhammet Kalkışım, Ahmet Köse* 

Nowadays, the incidence of knee arthritis increases with the prolongation of human life and the increase in world population. As a result, total knee arthroplasty application rates increased and surgeons gained more experience. There have also been technical advances and total knee arthroplasty operations have been performed using better implants. However, despite these developments, the number and variety of complications are increasing. In addition to performing total knee arthroplasty correctly, it is now becoming more important to recognize complications that may or may develop. Variety of complications after total knee replacement; from minor skin problems to life-threatening complications. In this review article, we aimed to investigate early and late complications during and after total

Total knee arthroplasty is an effective treatment option which has been applied with increasing rates in recent years with its highly satisfactory results. Recently increased total knee arthroplasty (TKA) procedures increase the number of complications too. In addition to proper patient selection, an accurate surgical technique, early diagnosis, and proper management of complications are required. Complications of TKA have a wide range. Complications vary from small skin problems to mortality. The development of complications may be due to many factors.

**Keywords:** knee, total knee arthroplasty, survival, complications

### **Chapter 5**

*Knee Surgery - Reconstruction and Replacement*

[24] HD1 C, Math KR, Scuderi GR. Polyethylene post failure in posterior stabilized total knee arthroplasty. The Journal of Arthroplasty.

2004;**19**(5):652-657

primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity.

Instructional Course Lectures.

[17] Sim JA, Kwak JH. Short-term follow-up results of medial epicondylar

osteotomy for the varus knee in TKA. Journal of Korean Knee Society.

[18] Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clinical Orthopaedics and Related Research.

[19] Hsu RW, Himeno S, Coventry MB. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clinical Orthopaedics.

[20] Howell SM, Roth JD, Hull ML. Kinematic alignment in total knee arthroplasty. Definition, history, principle, surgical technique, and results of an alignment option for

[21] Scott W. Kinematic alignment in total knee arthroplasty. In: Insall & Scott Surgery of the Knee. 5th ed. Vol. 121. Churchill Livingstone; 2012.

[22] Gu Y, Roth JD, Howell SM, Hull ML. How frequently do four methods for mechanically aligning a total knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white patients? Journal of Bone and Joint

Surgery. 2014;**96**(12):e101

2013;**21**(10):2325-2330

[23] Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surgery, Sports Traumatology, Arthroscopy.

1999;**48**:153-156

2009;**21**:194-204

1985;**192**:23

1990;**255**:215-227

TKA. Art. 2014;**1**:44-53

pp. 1255-1268

**54**

## Complications after Total Knee Arthroplasty

*Muhammet Salih AYAS, Muhammet Kalkışım, Ahmet Köse and Orkun Gül*

#### **Abstract**

Nowadays, the incidence of knee arthritis increases with the prolongation of human life and the increase in world population. As a result, total knee arthroplasty application rates increased and surgeons gained more experience. There have also been technical advances and total knee arthroplasty operations have been performed using better implants. However, despite these developments, the number and variety of complications are increasing. In addition to performing total knee arthroplasty correctly, it is now becoming more important to recognize complications that may or may develop. Variety of complications after total knee replacement; from minor skin problems to life-threatening complications. In this review article, we aimed to investigate early and late complications during and after total knee replacement surgery.

**Keywords:** knee, total knee arthroplasty, survival, complications

#### **1. Introduction**

Total knee arthroplasty is an effective treatment option which has been applied with increasing rates in recent years with its highly satisfactory results. Recently increased total knee arthroplasty (TKA) procedures increase the number of complications too. In addition to proper patient selection, an accurate surgical technique, early diagnosis, and proper management of complications are required. Complications of TKA have a wide range. Complications vary from small skin problems to mortality. The development of complications may be due to many factors. Some of these are listed below:


Reviewing all the risk factors before surgery and being prepared for the complications that may occur may be lifesaving in TKA, which is currently applied frequently. It is important to recognize, identify, and classify the complications in a timely manner in the correct and effective management of complications. The ambiguity about the complications of TKA in the literature helped identify and classify the complications in a study conducted in 2013 by the knee community [1]. According to this study, 22 complications were described. These are [1]:


When the complications are examined, it is seen that some of them are simple and easy to overcome with a short-term solution, while some of them can be serious and can go to revision arthroplasty. The number of complications such as implant

**57**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

Extensor mechanism injury Patellar tendon injury Quadriceps tendon injury Patella fractures

tions (**Table 1).**

**Table 1.**

**2.1 Vascular injuries**

**2. Intraoperative complications**

fracture and polyethylene surface wear has been reduced due to the techniques and innovations in implant materials and designs. In a study, it was shown that the most common cause of revisions in the first 5 years postop was infection, and the reasons for revision in the next 5 years were polyethylene loosening [2]. Complications will be classified as intraoperative, early postoperative, and late postoperative complica-

Medial collateral ligament injury Patellofemoral joint problems

Deep skin problems Periprosthetic joint infection Deep vein thrombosis Periprosthetic fractures Pulmonary embolism Aseptic loosening

Osteolysis

**Intraoperative Early postoperative Late postoperative**

Vascular injuries Bleeding Instability Neurological complications Superficial skin problems Joint stiffness

Although arterial injury during knee replacement is rare, it may have serious results from limb loss to mortality. Arterial injuries can be seen as thromboembolism, direct vascular laceration, pseudoaneurysm, and arteriovenous fistula [3]. The

Vascular injuries may develop due to the thermal effect of cement polymerization, joint manipulations, dislocations, and excessive manipulation [5]. Considering the issue as specific to the total knee arthroplasty, care should be taken against vascular injury during posterior cruciate ligament and posterior capsular release during femoral condylar cutting. Atypical localization of vascular structures due to changes in adhesions and normal anatomy in revision cases increases the risk of vascular injury twice as compared to primary cases [6]. Nowadays, increasing procedures of TKA bring about the possibility of vascular injuries although they are rare. Therefore, it is necessary to take precautions against vascular injuries that may develop, to identify risky patients and to make an early diagnosis. For this, a good anamnesis and physical examination are essential. It is important to examine the presence of hypertension, diabetes, smoking, and vascular claudication. Coldness of the extremities to be operated during physical examination, skin atrophy and thinning, prominent vascular structures, ulcerative wound, and distal arterial pulse weakness are the findings that need attention. In addition to these findings, the presence of vascular calcifications in radiological scanning, a history of bypass, and an ankle-brachial index below 0.9 are other findings that should be considered. No tourniquet should be used in patients with the abovementioned conditions [7]. Embolism and arterial insufficiency may develop due to tourniquet effect in patients with vascular disease and atheroma plaque in the superficial artery [8]. It has been shown that during the manipulation of the superficial femoral artery fixed during tourniquet effect, intimal damage may occur [9]. Improper placement of retractors can also cause damage by direct mechanical trauma [10]. Particularly during insertion of the posterior retractor, a 1 cm area

incidence is reported to be 0.03–0.2% in the literature [4].

*Intraoperative, early postoperative, and late postoperative complications.*


**Table 1.**

*Knee Surgery - Reconstruction and Replacement*

• Bleeding

• Wound problems

• Thromboembolism

• Neural deficit

• Vascular issues

• Instability

• Fracture

• Osteolysis

• Malalignment

• Medial collateral ligament injury

• Stiffness-toughness-contracture

• Deep wound infection

• Extensor mechanism injury

• Patellofemoral dislocation

• Tibiofemoral dislocation

• Bearing surface wear

• Implant loosening

• Implant breakage

• Re-hospitalization and mortality [1]

When the complications are examined, it is seen that some of them are simple and easy to overcome with a short-term solution, while some of them can be serious and can go to revision arthroplasty. The number of complications such as implant

• Reoperation

• Revision

Reviewing all the risk factors before surgery and being prepared for the complications that may occur may be lifesaving in TKA, which is currently applied frequently. It is important to recognize, identify, and classify the complications in a timely manner in the correct and effective management of complications. The ambiguity about the complications of TKA in the literature helped identify and classify the complications in a study conducted in 2013 by the knee community [1].

According to this study, 22 complications were described. These are [1]:

**56**

*Intraoperative, early postoperative, and late postoperative complications.*

fracture and polyethylene surface wear has been reduced due to the techniques and innovations in implant materials and designs. In a study, it was shown that the most common cause of revisions in the first 5 years postop was infection, and the reasons for revision in the next 5 years were polyethylene loosening [2]. Complications will be classified as intraoperative, early postoperative, and late postoperative complications (**Table 1).**

#### **2. Intraoperative complications**

#### **2.1 Vascular injuries**

Although arterial injury during knee replacement is rare, it may have serious results from limb loss to mortality. Arterial injuries can be seen as thromboembolism, direct vascular laceration, pseudoaneurysm, and arteriovenous fistula [3]. The incidence is reported to be 0.03–0.2% in the literature [4].

Vascular injuries may develop due to the thermal effect of cement polymerization, joint manipulations, dislocations, and excessive manipulation [5]. Considering the issue as specific to the total knee arthroplasty, care should be taken against vascular injury during posterior cruciate ligament and posterior capsular release during femoral condylar cutting. Atypical localization of vascular structures due to changes in adhesions and normal anatomy in revision cases increases the risk of vascular injury twice as compared to primary cases [6]. Nowadays, increasing procedures of TKA bring about the possibility of vascular injuries although they are rare. Therefore, it is necessary to take precautions against vascular injuries that may develop, to identify risky patients and to make an early diagnosis. For this, a good anamnesis and physical examination are essential. It is important to examine the presence of hypertension, diabetes, smoking, and vascular claudication. Coldness of the extremities to be operated during physical examination, skin atrophy and thinning, prominent vascular structures, ulcerative wound, and distal arterial pulse weakness are the findings that need attention. In addition to these findings, the presence of vascular calcifications in radiological scanning, a history of bypass, and an ankle-brachial index below 0.9 are other findings that should be considered. No tourniquet should be used in patients with the abovementioned conditions [7]. Embolism and arterial insufficiency may develop due to tourniquet effect in patients with vascular disease and atheroma plaque in the superficial artery [8]. It has been shown that during the manipulation of the superficial femoral artery fixed during tourniquet effect, intimal damage may occur [9]. Improper placement of retractors can also cause damage by direct mechanical trauma [10]. Particularly during insertion of the posterior retractor, a 1 cm area

in the lateral portion of the midline was identified as a risky area [11]. In a cadaver study, neurovascular structures on the tibial side were mapped on a clock diagram. Accordingly, the popliteal vein at 12 o'clock, the popliteal artery at 1 o'clock, and the anterior tibial artery at 2 o'clock for the left knee were shown as in place [12]. Cautious use of the saw between 11 and 3 o'clock defined in the tibial cutting is important in protecting vascular structures [12].

If vascular injury is suspected the tourniquet should be deflated, and bleeding control should be performed before the incision is closed. The possibility of arterial injury should be taken into consideration in the presence of excessive and pulsatile bleeding and in the absence of peripheral pulses. Although recent studies suggest bleeding control after routine tourniquet deflation prior to incision, its benefit is controversial [13]. The surgeon should perform a postoperative peripheral pulse examination routinely, suspect acute ischemia in the presence of cold and delayed distal capillary filling, and request cardiovascular consultation [14]. Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic fasciotomy is performed after revascularization [14].

Pseudoaneurysm may present with pulsatile swelling in the popliteal fossa due to direct damage to the popliteal artery during surgery. Doppler ultrasonography is useful in the diagnosis. In the treatment, excision of the lesion and repair with vascular graft is applied after embolization [15]. Arteriovenous fistula is less common. It usually occurs due to injury to the medial and lateral geniculate arteries and its branches. It may present with pulsatile swelling in the popliteal region that gives "trill." Hemarthrosis or pseudoaneurysm may develop. Ultrasound and angiography are used for diagnosis [16]. The detected lesions should be evaluated together with cardiovascular surgery, and treatment should be planned. Embolization, lesion excision, and graft repair are treatment options [15].

#### **2.2 Neurologic complications**

Nerve injuries are rare during TKA. Peroneal nerve injury is the most common of these [17]. Sacral plexopathy and sciatica neuropathy are also seen, although rarely [18]. Risk factors for neurological injury are [19]:


It has been shown that the risk of nerve injury is increased in patients with rheumatoid arthritis [20]. However, none of these risk factors is directly related to nerve injury [18]. Nerve injury is associated not only with the surgical procedure but also with the anesthesiologist-induced regional anesthesia [21]. Hypertension, diabetes, nerve compression history, presence of tethered cord, and rheumatoid arthritis in the patients increase the risk of neural complications secondary to regional anesthesia [22]. The duration of tourniquet use was associated with nerve injuries. According to this, in the tourniquet applications exceeding 2 hours, the risk of peroneal and tibial nerve injuries including 89% peroneal nerve was determined as 7%. All of these have been shown to get recovery. In procedures exceeding 2 hours, the 10–30-minute break and deflation of the tourniquet reduces the complication rate [19]. Although there is a minimal effect on the functional results of the patients effect on the functional results of the patients during the follow-up, paresthesia and numbness are seen in the distal and lateral site of incision due to the injury of the infrapatellar branch of

**59**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

**2.3 Extensor mechanism injuries**

are not satisfactory.

• Patella baja

be used [28–30].

*2.3.2 Quadriceps tendon rupture*

• Previous surgery

*2.3.1 Patellar tendon rupture*

tendon mobility decreases. These are [26]:

• Severe limitation of movement in the knee

repeated contact of the polyethylene insert [27].

palpable defect at the infrapatellar side are detected.

the saphenous nerve. It is seen in the literature at a rate of 25–76%, and most of these recover spontaneously [23]. Nerve injuries are difficult to detect intraoperatively. In the presence of postoperative nerve injury, physical therapy should be planned immediately. EMG examination is recommended after 3 months [20]. If no improve-

The extensor mechanism in the knee joint consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and tuberositas tibia. Extensor mechanism integrity may be impaired during surgery [20]. Although extensor mechanism injuries occur more frequently postoperatively, they may also occur intraoperative. The incidence is reported to be between 1 and 12% [24]. The treatment of extensor mechanism injuries is quite difficult and the results

Rupture usually occurs at the site of insertion to the tuberositas tibia. The risk of development is less than 1% [25]. Less frequently, intratendinous and infrapatellar tendon rupture may also occur [25]. The risk of injury increases when patellar

The risk of tendon injury especially on stiffness knees due to forced manipulations and during the tibial bone cutting increases during surgery. The most common injury mechanism after surgery is falling onto the knee while knee is flexed [27]. Patellar tendon injury without trauma is seen by weakening the tendon after

In patients with patellar tendon rupture, pain, swelling, loss of extension, and a

Age, functional status, tendon rupture localization, and soft tissue status are the determinants of the treatment. Splitting and bracing are considered in patients who do not have functional expectations and are unsuitable for surgery [28]. Treatment of acute patellar tendon rupture intraoperative is primary repair [26]. Several techniques have been described using staple and suture anchors for this purpose [28]. Reconstruction techniques are used in patients with poor soft tissue quality. For this purpose, biological materials (hamstring tendon autograft, achilles, peroneal tendon autograft, and extensor mechanism allograft) and synthetic materials can

It is very rare. It is especially seen as a rupture from the intersion side to the patella. Excessive patella cutting, previous quadriceps snip, or V-Y tipping are risk

Good results have been reported with plaster cast in partial tears [31]. Extensor loss greater than 20° is considered a complete tear and should be treated surgically.

factors [28]. The clinical finding is similar to patellar tendon rupture.

ment is observed, nerve exploration may be planned in the future.

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

protecting vascular structures [12].

fasciotomy is performed after revascularization [14].

excision, and graft repair are treatment options [15].

rarely [18]. Risk factors for neurological injury are [19]:

• Presence of an intra-articular hematoma

**2.2 Neurologic complications**

• Flexion deformity

• Advanced valgus deformity

in the lateral portion of the midline was identified as a risky area [11]. In a cadaver study, neurovascular structures on the tibial side were mapped on a clock diagram. Accordingly, the popliteal vein at 12 o'clock, the popliteal artery at 1 o'clock, and the anterior tibial artery at 2 o'clock for the left knee were shown as in place [12]. Cautious use of the saw between 11 and 3 o'clock defined in the tibial cutting is important in

If vascular injury is suspected the tourniquet should be deflated, and bleeding control should be performed before the incision is closed. The possibility of arterial injury should be taken into consideration in the presence of excessive and pulsatile bleeding and in the absence of peripheral pulses. Although recent studies suggest bleeding control after routine tourniquet deflation prior to incision, its benefit is controversial [13]. The surgeon should perform a postoperative peripheral pulse examination routinely, suspect acute ischemia in the presence of cold and delayed distal capillary filling, and request cardiovascular consultation [14]. Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic

Pseudoaneurysm may present with pulsatile swelling in the popliteal fossa due to direct damage to the popliteal artery during surgery. Doppler ultrasonography is useful in the diagnosis. In the treatment, excision of the lesion and repair with vascular graft is applied after embolization [15]. Arteriovenous fistula is less common. It usually occurs due to injury to the medial and lateral geniculate arteries and its branches. It may present with pulsatile swelling in the popliteal region that gives "trill." Hemarthrosis or pseudoaneurysm may develop. Ultrasound and angiography are used for diagnosis [16]. The detected lesions should be evaluated together with cardiovascular surgery, and treatment should be planned. Embolization, lesion

Nerve injuries are rare during TKA. Peroneal nerve injury is the most common of these [17]. Sacral plexopathy and sciatica neuropathy are also seen, although

It has been shown that the risk of nerve injury is increased in patients with rheumatoid arthritis [20]. However, none of these risk factors is directly related to nerve injury [18]. Nerve injury is associated not only with the surgical procedure but also with the anesthesiologist-induced regional anesthesia [21]. Hypertension, diabetes, nerve compression history, presence of tethered cord, and rheumatoid arthritis in the patients increase the risk of neural complications secondary to regional anesthesia [22]. The duration of tourniquet use was associated with nerve injuries. According to this, in the tourniquet applications exceeding 2 hours, the risk of peroneal and tibial nerve injuries including 89% peroneal nerve was determined as 7%. All of these have been shown to get recovery. In procedures exceeding 2 hours, the 10–30-minute break and deflation of the tourniquet reduces the complication rate [19]. Although there is a minimal effect on the functional results of the patients effect on the functional results of the patients during the follow-up, paresthesia and numbness are seen in the distal and lateral site of incision due to the injury of the infrapatellar branch of

**58**

the saphenous nerve. It is seen in the literature at a rate of 25–76%, and most of these recover spontaneously [23]. Nerve injuries are difficult to detect intraoperatively. In the presence of postoperative nerve injury, physical therapy should be planned immediately. EMG examination is recommended after 3 months [20]. If no improvement is observed, nerve exploration may be planned in the future.

#### **2.3 Extensor mechanism injuries**

The extensor mechanism in the knee joint consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and tuberositas tibia. Extensor mechanism integrity may be impaired during surgery [20]. Although extensor mechanism injuries occur more frequently postoperatively, they may also occur intraoperative. The incidence is reported to be between 1 and 12% [24]. The treatment of extensor mechanism injuries is quite difficult and the results are not satisfactory.

#### *2.3.1 Patellar tendon rupture*

Rupture usually occurs at the site of insertion to the tuberositas tibia. The risk of development is less than 1% [25]. Less frequently, intratendinous and infrapatellar tendon rupture may also occur [25]. The risk of injury increases when patellar tendon mobility decreases. These are [26]:


The risk of tendon injury especially on stiffness knees due to forced manipulations and during the tibial bone cutting increases during surgery. The most common injury mechanism after surgery is falling onto the knee while knee is flexed [27]. Patellar tendon injury without trauma is seen by weakening the tendon after repeated contact of the polyethylene insert [27].

In patients with patellar tendon rupture, pain, swelling, loss of extension, and a palpable defect at the infrapatellar side are detected.

Age, functional status, tendon rupture localization, and soft tissue status are the determinants of the treatment. Splitting and bracing are considered in patients who do not have functional expectations and are unsuitable for surgery [28]. Treatment of acute patellar tendon rupture intraoperative is primary repair [26]. Several techniques have been described using staple and suture anchors for this purpose [28]. Reconstruction techniques are used in patients with poor soft tissue quality. For this purpose, biological materials (hamstring tendon autograft, achilles, peroneal tendon autograft, and extensor mechanism allograft) and synthetic materials can be used [28–30].

#### *2.3.2 Quadriceps tendon rupture*

It is very rare. It is especially seen as a rupture from the intersion side to the patella. Excessive patella cutting, previous quadriceps snip, or V-Y tipping are risk factors [28]. The clinical finding is similar to patellar tendon rupture.

Good results have been reported with plaster cast in partial tears [31]. Extensor loss greater than 20° is considered a complete tear and should be treated surgically. It has unsatisfactory results due to high complication rates and tendency to rerupture depending on tendon quality and soft tissue condition.

#### *2.3.3 Patella fractures*

Patellar fractures are the most common injury among the extensor mechanism injuries [24, 32]. In general, the risk increases with excessive bone cutting while preparing for patellar component. Patellar fracture may occur by direct trauma to the anterior knee or as an avulsion due to the pull of the quadriceps muscle [32].

For diagnosis, pain, swelling, and extensor insufficiency are detected in front of the knee. Lateral knee radiography and tomography in case of clinical suspicion are helpful imaging methods for the diagnosis.

A classification has been developed to assess implant stability and extensor mechanism continuity for periprosthetic patella fractures [33]. Type 1, a stable implant and continuous extensor mechanism; Type 2, a stable implant but a discontinuous extensor mechanism; and Type 3, which indicates instable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor. Treatment is also determined according to this classification. Conservative treatment methods are preferred for type 1 cases, while surgical treatments are preferred for types 2 and 3 [33]. In recent studies, it is reported that 40–50% of complications occur and more than half strength loss of extensor mechanism is observed [34].

#### **2.4 Medial collateral ligament injury**

During total knee replacement, medial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. The incidence of iatrogenic MCL injury is 2.2–2.7% [35]. In the case of surgical injuries, direct repair, constrained prosthesis use, and even revision at the same session are among the options [36]. Unrecognized MCL injuries during surgery cause early instability. This leads to early implant wear and consequently the need for early revision. Therefore, it is important to diagnose and repair the injury during surgery [37]. Sudden instability in the valgus stress test during knee stabilization indicates MCL injury. Injury may occur from femoral insertion, within the tendon or tibial insertion [38]. Primary repair technique varies according to injury level. Fixation with screw is recommended if MCL injury occurs from its femoral insertion site. Otherwise, if it is through tendon, repairing with insoluble suture technique is recommended. Finally, if MCL injury occurs from its tibial insertion site, both insoluble suture anchor technique and fixation with staple technic are recommended [39, 40]. Factors that increase the risk of medial collateral ligament injury during surgery are as follows [39]:


Patient-related risk factors include obesity and severe deformities [41, 42]. A certain algorithm has not yet been established for the treatment of iatrogenic MCL injuries that occur intraoperative. Many treatment methods with

**61**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

**3. Early postoperative complications**

• Use of femoral intramedullary plugs [48]

• Cryotherapy and Jones bandage [50]

• Use of fibrin tissue adhesive [50, 51]

• Application of tranexamic acid [55]

• Hypotensive anesthesia [49]

• Clamping the drain [52–54]

due to transfusion are reduced.

**3.1 Bleeding**

are as follows:

disadvantages and advantages have been used [39, 43, 44]. The traditional method is using constrained prosthesis. However, in this method, it was shown that the stress load on the implant increased and direct repair and treatment with nonconstrained prosthesis were recommended instead. In addition, augmentation or increase in polyethylene thickness has been proposed [45]. In one study, it was shown that the risk of instability was 57% in the use of non-constrained prostheses independent of the repair technique after MCL injury [37]. In a 2016 study, four treatment modalities were compared after MCL injury. These are the use of nonconstrained prosthesis only, the use of non-constrained prosthesis with primary repair, the use of non-constrained prosthesis only, and the use of constrained prosthesis with primary repair. In 23 patients, the most appropriate treatment method according to the knee community scoring was found to be the use of constrained prosthesis only [46]. However, due to the small number of patients, larger series of

studies are needed to determine which treatment is most appropriate.

Bleeding is seen in varying rates between 0 and 39% after TKA [47]. This naturally increases the need for blood transfusion. Intraoperatively, care should be taken about bleeding and good bleeding control is established. Thus, the amount of bleeding is reduced to a minimum. As a result, the risks of immunological reaction

Bleeding tolerance is low in patients with comorbid disease and in patients with insufficient cardiac capacity, and the risk of complications increases even in small amounts of bleeding. Preoperative blood preparation before surgery and limitation of the use of anticoagulants are among the measures that can be taken. Precautions during and after TKA surgery can reduce the amount of bleeding. These methods

Fibrinolysis is activated by surgical trauma and tourniquet use [56]. Increased fibrinolytic activity causes increased bleeding during TKA. Tranexamic acid shows an anti-fibrinolytic effect by inhibiting the conversion of plasmin to plasminogen [57]. Tranexamic acid can be administered in four different ways: intravenous, oral, intramuscular, and intra-articular [55]. Transition to maximum plasma levels is 30 minutes for intramuscular use, 5–15 minutes for intravenous use, and 2 hours after oral use [58]. Patients with total knee arthroplasty may be treated with a fast-acting intravenous route. Many studies have shown that administration of tranexamic acid after tourniquet deflation and postoperative dose repeat reduces the amount of

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

disadvantages and advantages have been used [39, 43, 44]. The traditional method is using constrained prosthesis. However, in this method, it was shown that the stress load on the implant increased and direct repair and treatment with nonconstrained prosthesis were recommended instead. In addition, augmentation or increase in polyethylene thickness has been proposed [45]. In one study, it was shown that the risk of instability was 57% in the use of non-constrained prostheses independent of the repair technique after MCL injury [37]. In a 2016 study, four treatment modalities were compared after MCL injury. These are the use of nonconstrained prosthesis only, the use of non-constrained prosthesis with primary repair, the use of non-constrained prosthesis only, and the use of constrained prosthesis with primary repair. In 23 patients, the most appropriate treatment method according to the knee community scoring was found to be the use of constrained prosthesis only [46]. However, due to the small number of patients, larger series of studies are needed to determine which treatment is most appropriate.

### **3. Early postoperative complications**

#### **3.1 Bleeding**

*Knee Surgery - Reconstruction and Replacement*

helpful imaging methods for the diagnosis.

mechanism is observed [34].

**2.4 Medial collateral ligament injury**

• Using a larger saw blade than femoral condyle

• Delayed excision of medial side osteophytes

• Patients with flexion contractures [39]

• Performing challenging manipulations of varus-valgus

Patient-related risk factors include obesity and severe deformities [41, 42]. A certain algorithm has not yet been established for the treatment of iatrogenic MCL injuries that occur intraoperative. Many treatment methods with

*2.3.3 Patella fractures*

It has unsatisfactory results due to high complication rates and tendency to re-

Patellar fractures are the most common injury among the extensor mechanism injuries [24, 32]. In general, the risk increases with excessive bone cutting while preparing for patellar component. Patellar fracture may occur by direct trauma to the anterior knee or as an avulsion due to the pull of the quadriceps muscle [32]. For diagnosis, pain, swelling, and extensor insufficiency are detected in front of the knee. Lateral knee radiography and tomography in case of clinical suspicion are

A classification has been developed to assess implant stability and extensor mechanism continuity for periprosthetic patella fractures [33]. Type 1, a stable implant and continuous extensor mechanism; Type 2, a stable implant but a discontinuous extensor mechanism; and Type 3, which indicates instable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor. Treatment is also determined according to this classification. Conservative treatment methods are preferred for type 1 cases, while surgical treatments are preferred for types 2 and 3 [33]. In recent studies, it is reported that 40–50% of complications occur and more than half strength loss of extensor

During total knee replacement, medial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. The incidence of iatrogenic MCL injury is 2.2–2.7% [35]. In the case of surgical injuries, direct repair, constrained prosthesis use, and even revision at the same session are among the options [36]. Unrecognized MCL injuries during surgery cause early instability. This leads to early implant wear and consequently the need for early revision. Therefore, it is important to diagnose and repair the injury during surgery [37]. Sudden instability in the valgus stress test during knee stabilization indicates MCL injury. Injury may occur from femoral insertion, within the tendon or tibial insertion [38]. Primary repair technique varies according to injury level. Fixation with screw is recommended if MCL injury occurs from its femoral insertion site. Otherwise, if it is through tendon, repairing with insoluble suture technique is recommended. Finally, if MCL injury occurs from its tibial insertion site, both insoluble suture anchor technique and fixation with staple technic are recommended [39, 40]. Factors that increase the risk of medial collateral ligament injury during surgery are

rupture depending on tendon quality and soft tissue condition.

**60**

as follows [39]:

Bleeding is seen in varying rates between 0 and 39% after TKA [47]. This naturally increases the need for blood transfusion. Intraoperatively, care should be taken about bleeding and good bleeding control is established. Thus, the amount of bleeding is reduced to a minimum. As a result, the risks of immunological reaction due to transfusion are reduced.

Bleeding tolerance is low in patients with comorbid disease and in patients with insufficient cardiac capacity, and the risk of complications increases even in small amounts of bleeding. Preoperative blood preparation before surgery and limitation of the use of anticoagulants are among the measures that can be taken. Precautions during and after TKA surgery can reduce the amount of bleeding. These methods are as follows:


Fibrinolysis is activated by surgical trauma and tourniquet use [56]. Increased fibrinolytic activity causes increased bleeding during TKA. Tranexamic acid shows an anti-fibrinolytic effect by inhibiting the conversion of plasmin to plasminogen [57]. Tranexamic acid can be administered in four different ways: intravenous, oral, intramuscular, and intra-articular [55]. Transition to maximum plasma levels is 30 minutes for intramuscular use, 5–15 minutes for intravenous use, and 2 hours after oral use [58]. Patients with total knee arthroplasty may be treated with a fast-acting intravenous route. Many studies have shown that administration of tranexamic acid after tourniquet deflation and postoperative dose repeat reduces the amount of

bleeding and the need for transfusion [59–61]. However, many different protocols for the use of tranexamic acid have been implemented. Preoperative single dose and repeated dose every 8 hours for 3 days have been described in the literature and shown to be effective [62]. In a study conducted in 2011, tranexamic acid was administered at a dose of 10 mg/kg 10 minutes before the tourniquet was opened, and the same dose was repeated 3 hours postoperatively. Five hundred mg tranexamic acid was administered orally 3 times a day for 5 days. At the end of this study, it was shown that the amount of hemorrhage and the rate of transfusion decreased effectively [55].

#### **3.2 Skin healing problems: superficial and deep infections**

The incidence of wound problems after TKA is 1–25% [63]. The skin problems may be delayed wound healing, skin necrosis, traumatic or atraumatic separation of the lips of the wound, prolonged serous discharge at the wound site, formation of superficial or deep hematoma, allergic reaction to patch, suture material or dressing materials, bullae formation, fat necrosis, bleeding, keloid formation, and superficial or deep infection [64].

Etiologic reasons that may develop the problem before TKA should be determined in advance, and appropriate measures should be taken [65]. Presence of systemic diseases such as diabetes, hypertension, rheumatoid arthritis, and vascular insufficiency, which may adversely affect wound healing before TKA, should be questioned. Since the soft tissues around the knee are thinner than the other parts of the body, even the smallest problem that may occur at the wound site can cause serious complications. Incision planning should be made carefully in the case of a history of operation from the same place and scarring beforehand, and if necessary, plastic surgery assistance should be taken.

#### *3.2.1 Skin healing problems*

Factors adversely affecting wound healing are obesity, hypertension, diabetes, smoking, chronic drug use, steroid use, previous radiotherapy, scarring, inflammatory disease, malnutrition, albumin levels below 3.5 g/dl, and hemoglobin levels below 10 g/dl. Transferrin and lymphocyte levels may also contribute to wound healing problems [66]. Therefore, a detailed anamnesis and physical examination and laboratory examination before surgery give an idea about possible skin problems. Accordingly, measures are taken, replacement therapies are given, and surgery may be postponed until the current pathology is corrected, if necessary. Adjustment of fasting blood sugar levels below 200 g/dl and keeping HbA1C below 6.5 in patients with diabetes will reduce the risk of possible wound problems [67].

Patients with a body mass index above 30 kg/m<sup>2</sup> are 6 times more likely to have infection and wound problems [66]. In obese patients, dietician support should be given before surgery; unnecessary exclusion should be avoided during surgery, and soft tissue surgery should be applied carefully.

A study of smoking patients showed that there were 2 times more wound problems [65]. Because of the vasoconstrictor effect of nicotine in the cigarette, it is recommended to quit smoking 60 days before surgery due to decreased blood supply at the wound site.

Incision planning should be performed in the presence of scar after previous surgery. In the presence of a single longitudinal incision without problems, the same incision should be used. If the old incision cannot be used, a distance of at least 7–8 cm should be left. If there is more than one old incision scar in the anterior part of the knee, the most lateral scar is used considering that the anterior knee feeding is from the medial perforating artery. In addition, the lateral soft tissue flap should not be dissected too

**63**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

debridement [70].

*3.2.2 Superficial and deep infections*

be planned through detailed examination.

much [65]. Unnecessary retractors and additional soft tissue damage should be avoided during surgery. The wound lips should be exactly opposite to each other. Overstretched

Especially in patients with risk factors, it should be performed without tourniquet

Despite all current precautions, surgical site infections remain the most serious and feared complications of TKA. After TKA, patients should be followed up with daily dressings, and wound discharge should be evaluated carefully. Prolonged wound discharge is defined as a discharge that lasts more than 48 hours regardless of the amount of drainage [64]. Wet wounds greater than 2×2 cm are considered abnormal after 72 hours and are associated with fat necrosis, hematoma, necrosis, or poor closure of the fascia. They are reported as 1–10% after primary knee replacement [65]. In the early stage of treatment, usually dressing and immobilization for 3–5 days is recommended [71]. Continuous discharge for 72 hours is dangerous. If it exceeds 5 days, debridement should be applied in operating room

conditions as it will increase the risk of superficial or deep infection [64]. Superficial infection: It is defined as infection of the soft tissue above the skin—subcutaneous and deep fascia that has not passed under the deep fascia, not opened into the joint cavity. It occurs most frequently in the first 30 days after surgery. The incidence of superficial infection after TKA has been reported as 10% [72]. It may occur through direct contamination or blood. Improper preparation of direct contamination sterilization environment, inadequate surgical field preparation, presence of sloppy surgical team, non-sterile dressing materials, and application may occur as a result of the presence of infected patients in the same environment [73]. The risk of direct contamination can be minimized by precautions. Hematogen contamination can occur if there is any other focus of infection in the body. Therefore, in the presence of a possible infection focus with detailed anamnesis and examination before the operation, the current focus treatment can

Infection after TKA can be evaluated as patient-related risk factors, surgical

• *Patient-related risk factors* include advanced age, previous knee surgery, previous knee infection, steroid use, presence of inflammatory disease, obesity, diabetes, smoking, intravenous drug use, hematologic diseases, oncologic

intervention-related factors, and postoperative factors [66, 68, 74–77].

closing should be avoided. This should be checked with capillary filling time.

or at low pressures [65]. Difficult rehabilitation in the early postoperative period should be postponed if possible until it is ensured that there are no wound problems. Hematoma formation increases the risk of infection [65]. Therefore, measures should be taken to prevent the formation of hematoma. These include no dead space during wound closure, good bleeding control, use of a Jones bandage, and avoidance of overdose of the prophylactic anticoagulants used [65, 68]. Once the hematoma has developed, a needle aspiration can be performed. However, if the hematoma is organized and the drainage cannot be achieved, discharge and debridement can be achieved by arthrotomy under operating room conditions. The presence of necrosis in the wound leads to catastrophic consequences. Respect to soft tissue is the most important step to prevent necrosis development. The depth of necrosis is important. Superficial necrosis can be treated by local intervention. If larger, debridement and full-thickness skin grafts or fasciocutaneous flaps are required [69]. If necrosis includes full-thickness soft tissue, closure with fascial skin or muscular skin graft should be performed after urgent aggressive

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

cial or deep infection [64].

*3.2.1 Skin healing problems*

supply at the wound site.

plastic surgery assistance should be taken.

Patients with a body mass index above 30 kg/m<sup>2</sup>

soft tissue surgery should be applied carefully.

bleeding and the need for transfusion [59–61]. However, many different protocols for the use of tranexamic acid have been implemented. Preoperative single dose and repeated dose every 8 hours for 3 days have been described in the literature and shown to be effective [62]. In a study conducted in 2011, tranexamic acid was administered at a dose of 10 mg/kg 10 minutes before the tourniquet was opened, and the same dose was repeated 3 hours postoperatively. Five hundred mg tranexamic acid was administered orally 3 times a day for 5 days. At the end of this study, it was shown that the amount of hemorrhage and the rate of transfusion decreased effectively [55].

The incidence of wound problems after TKA is 1–25% [63]. The skin problems may be delayed wound healing, skin necrosis, traumatic or atraumatic separation of the lips of the wound, prolonged serous discharge at the wound site, formation of superficial or deep hematoma, allergic reaction to patch, suture material or dressing materials, bullae formation, fat necrosis, bleeding, keloid formation, and superfi-

Etiologic reasons that may develop the problem before TKA should be determined in advance, and appropriate measures should be taken [65]. Presence of systemic diseases such as diabetes, hypertension, rheumatoid arthritis, and vascular insufficiency, which may adversely affect wound healing before TKA, should be questioned. Since the soft tissues around the knee are thinner than the other parts of the body, even the smallest problem that may occur at the wound site can cause serious complications. Incision planning should be made carefully in the case of a history of operation from the same place and scarring beforehand, and if necessary,

Factors adversely affecting wound healing are obesity, hypertension, diabetes, smoking, chronic drug use, steroid use, previous radiotherapy, scarring, inflammatory disease, malnutrition, albumin levels below 3.5 g/dl, and hemoglobin levels below 10 g/dl. Transferrin and lymphocyte levels may also contribute to wound healing problems [66]. Therefore, a detailed anamnesis and physical examination and laboratory examination before surgery give an idea about possible skin problems. Accordingly, measures are taken, replacement therapies are given, and surgery may be postponed until the current pathology is corrected, if necessary. Adjustment of fasting blood sugar levels below 200 g/dl and keeping HbA1C below 6.5 in patients with diabetes will reduce the risk of possible wound problems [67].

infection and wound problems [66]. In obese patients, dietician support should be given before surgery; unnecessary exclusion should be avoided during surgery, and

A study of smoking patients showed that there were 2 times more wound problems [65]. Because of the vasoconstrictor effect of nicotine in the cigarette, it is recommended to quit smoking 60 days before surgery due to decreased blood

In the presence of a single longitudinal incision without problems, the same incision should be used. If the old incision cannot be used, a distance of at least 7–8 cm should be left. If there is more than one old incision scar in the anterior part of the knee, the most lateral scar is used considering that the anterior knee feeding is from the medial perforating artery. In addition, the lateral soft tissue flap should not be dissected too

Incision planning should be performed in the presence of scar after previous surgery.

are 6 times more likely to have

**3.2 Skin healing problems: superficial and deep infections**

**62**

much [65]. Unnecessary retractors and additional soft tissue damage should be avoided during surgery. The wound lips should be exactly opposite to each other. Overstretched closing should be avoided. This should be checked with capillary filling time.

Especially in patients with risk factors, it should be performed without tourniquet or at low pressures [65]. Difficult rehabilitation in the early postoperative period should be postponed if possible until it is ensured that there are no wound problems.

Hematoma formation increases the risk of infection [65]. Therefore, measures should be taken to prevent the formation of hematoma. These include no dead space during wound closure, good bleeding control, use of a Jones bandage, and avoidance of overdose of the prophylactic anticoagulants used [65, 68]. Once the hematoma has developed, a needle aspiration can be performed. However, if the hematoma is organized and the drainage cannot be achieved, discharge and debridement can be achieved by arthrotomy under operating room conditions.

The presence of necrosis in the wound leads to catastrophic consequences. Respect to soft tissue is the most important step to prevent necrosis development. The depth of necrosis is important. Superficial necrosis can be treated by local intervention. If larger, debridement and full-thickness skin grafts or fasciocutaneous flaps are required [69]. If necrosis includes full-thickness soft tissue, closure with fascial skin or muscular skin graft should be performed after urgent aggressive debridement [70].

#### *3.2.2 Superficial and deep infections*

Despite all current precautions, surgical site infections remain the most serious and feared complications of TKA. After TKA, patients should be followed up with daily dressings, and wound discharge should be evaluated carefully. Prolonged wound discharge is defined as a discharge that lasts more than 48 hours regardless of the amount of drainage [64]. Wet wounds greater than 2×2 cm are considered abnormal after 72 hours and are associated with fat necrosis, hematoma, necrosis, or poor closure of the fascia. They are reported as 1–10% after primary knee replacement [65]. In the early stage of treatment, usually dressing and immobilization for 3–5 days is recommended [71]. Continuous discharge for 72 hours is dangerous. If it exceeds 5 days, debridement should be applied in operating room conditions as it will increase the risk of superficial or deep infection [64].

Superficial infection: It is defined as infection of the soft tissue above the skin—subcutaneous and deep fascia that has not passed under the deep fascia, not opened into the joint cavity. It occurs most frequently in the first 30 days after surgery. The incidence of superficial infection after TKA has been reported as 10% [72]. It may occur through direct contamination or blood. Improper preparation of direct contamination sterilization environment, inadequate surgical field preparation, presence of sloppy surgical team, non-sterile dressing materials, and application may occur as a result of the presence of infected patients in the same environment [73]. The risk of direct contamination can be minimized by precautions. Hematogen contamination can occur if there is any other focus of infection in the body. Therefore, in the presence of a possible infection focus with detailed anamnesis and examination before the operation, the current focus treatment can be planned through detailed examination.

Infection after TKA can be evaluated as patient-related risk factors, surgical intervention-related factors, and postoperative factors [66, 68, 74–77].

• *Patient-related risk factors* include advanced age, previous knee surgery, previous knee infection, steroid use, presence of inflammatory disease, obesity, diabetes, smoking, intravenous drug use, hematologic diseases, oncologic

diseases, above ASA score 2, immunosuppressive use, regional skin problems, old incision scars, previous radiotherapy procedures, malnutrition, vascular insufficiency, albumin level below 3.5 g/dl, transferrin level below 200 mg/dl, hemoglobin level below 10 g/dl [78, 79].


Superficial wound infection is considered with the presence of at least one of the following: discharge from the wound incision, culture of the wound from aseptic conditions, suspicion of infection in clinical evaluation, disproportionate pain, increased temperature, erythema, and localized swelling [79].

In superficial wound infection, unlike deep infection, there is no progressive change in erythrocyte sedimentation rate, C-reactive protein level, and peripheral leukocyte count; the increase is below 25% [82]. In addition, leukocytes in synovial fluid are detected less than 2000/ml, and polymorphonuclear leukocytes are detected under 50%. Alpha defensin and leukocyte esterase tests are negative [71].

When superficial wound infection is detected, the development of deep infection can be prevented by early intervention. Otherwise, it may develop into periprosthetic infection and cause catastrophic results. In the presence of superficial infection, local wound care due to the underlying cause and debridement should be performed if appropriate anti-therapy is required [80]. In the selection of antibiotics, consultation with infectious diseases should be requested. Antibiotherapy is continued after reproduction. If deep infection is excluded in surgical debridement, the joint should not be opened, and the implant should not be touched [83]. Hyperbaric oxygen therapy has a positive effect on appropriate patient selection [84].

#### **3.3 Deep vein thrombosis and pulmonary embolism**

Deep vein thrombosis is the general name of thrombosis in the venous circulatory system. It occurs most commonly in the deep veins of the lower extremity [85]. From asymptomatic deep vein thrombosis to pulmonary embolism, which can be fatal, it can be confused with clinical manifestations of varying degrees [85]. It is one of the important complications that increase morbidity and mortality after TKA [86]. Even with mechanical or pharmacological methods, the incidence of asymptomatic DVT is 5.1%, and the incidence of symptomatic DVT is 0.4% [87]. The mortality rate due to pulmonary embolism after TKA is 0.08% [88].

It is important to understand the Virchow triad in the pathogenesis of DVT development. There is a slowdown in blood flow (stasis), endothelial damage, and hypercoagulability [89]. The admixture of fat and bone marrow particles into the venous system after engraving of the femoral canal during TKA explains the hypercoagulability branch of the Virchow triad. Hyperflexion of the leg during surgery and anterior manipulation of the tibia with retractors explain endothelial damage. In addition, this manipulation causes obstruction of the popliteal veins and prolonged immobilization of the leg, leading to venous pooling and stasis [89].

**65**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

• VTE risk increases after age of 40 and doubles every 10 years after that age [90]. Age increases the risk of VTE regardless of other risk factors.

• Genetic factors are also an important parameter that increases the risk of

DVT. Factor V Leiden mutation that causes thrombophilia, as well as protein C, protein S, and antithrombin III deficiency are among the factors that increase

• Although tourniquet use has been reported to cause venous stasis, it has been shown that it does not significantly increase the risk of DVT because of its

• The type of anesthesia also affects the risk of developing DVT. General anesthesia has been shown to increase the risk of DVT compared to neuraxial anesthesia (spinal or epidural). Neuroaxial blockade causes vasodilatation in the lower extremities and reduces venous pooling; therefore it explains the mechanism of action [93].

• Other risk factors that increase the risk of DVT are immobilization, smoking, oral contraceptive and hormone use, history of VTE, obesity, malignancy, and

A painful, swollen, and reddened leg after TKA should suggest the possibility of DVT. Incomplete DVTs usually do not show signs. Incomplete DVTs are seen especially after arthroplasty. Clinical findings are seen in 1% of all DVT cases. Physical examination findings include redness, swelling, and Homan's sign test and Pratt test positivity. Clinical Wells risk score was established for the diagnosis of deep vein thrombosis [94]. Clinical Wells Scoring criteria are malignancy, paralysis (paresthesia or splinting lower extremity), immobilization for more than 3 days, localized tenderness in the deep venous system, swelling of the lower extremity, 3-cm-diameter differentiation from the other leg, pretibial gode positive edema, history of deep vein thrombosis, and collateral superficial veins. The presence of each risk factor was evaluated as 1 point, and clinical scoring of 3 and above was found to

Clinical data are not sufficient for the diagnosis of DVT. Therefore, further examination with clinical risk scoring, D-dimer level, Doppler ultrasonography, contrast-enhanced venography, CT, and MRI should be performed. Venography is the best method for the diagnosis of DVT in the lower extremities. The accuracy rate was 97% in the lower extremity veins and 70% in the iliac veins [95]. Venography is not preferred as first-line imaging because it has a 3% risk of DVT and is an invasive method, and also it requires contrast matter that can be toxic to the kidneys. Doppler USG is the most commonly used first-line imaging method because of its cheapness, reproducibility, and patient comfort in the suspicion of DVT. Proximal DVT sensitivity was 96%, distal DVT sensitivity was 44%, and DVT specificity was 93% [96]. Pulmonary embolism should be suspected in the case of sudden shortness of breath, tachypnea, tachycardia, and chest pain after TKA. However, since there are many other diseases with these findings, risk factor assessment and effective differential diagnosis should be made. Wells pulmonary embolism clinical probability scoring was established [97]. Pulmonary angiography is the gold standard for the

*3.3.1 Risk factors*

the risk of DVT.

fibrinolytic effect [91, 92].

difficult knee manipulations.

diagnosis of pulmonary embolism [85].

be a high risk for the development of deep vein thrombosis.

*3.3.2 Diagnosis*

#### *3.3.1 Risk factors*

*Knee Surgery - Reconstruction and Replacement*

sterility rules [80].

negative [71].

hemoglobin level below 10 g/dl [78, 79].

diseases, above ASA score 2, immunosuppressive use, regional skin problems, old incision scars, previous radiotherapy procedures, malnutrition, vascular insufficiency, albumin level below 3.5 g/dl, transferrin level below 200 mg/dl,

• *Surgical intervention related risk factors* include prolonged surgical time of more than 2 hours, absence of laminar flow in the operating room, transfusion, use of hinged knee prosthesis, failure of surgical team to comply with asepsis, and

• *Operative period related risk factors* include prolonged hospital stay pre- and postoperative, lack of appropriate antibiotic prophylaxis, hematoma forma-

Superficial wound infection is considered with the presence of at least one of the following: discharge from the wound incision, culture of the wound from aseptic conditions, suspicion of infection in clinical evaluation, disproportionate pain,

In superficial wound infection, unlike deep infection, there is no progressive change in erythrocyte sedimentation rate, C-reactive protein level, and peripheral leukocyte count; the increase is below 25% [82]. In addition, leukocytes in synovial fluid are detected less than 2000/ml, and polymorphonuclear leukocytes are detected under 50%. Alpha defensin and leukocyte esterase tests are

When superficial wound infection is detected, the development of deep infection can be prevented by early intervention. Otherwise, it may develop into periprosthetic infection and cause catastrophic results. In the presence of superficial infection, local wound care due to the underlying cause and debridement should be performed if appropriate anti-therapy is required [80]. In the selection of antibiotics, consultation with infectious diseases should be requested. Antibiotherapy is continued after reproduction. If deep infection is excluded in surgical debridement, the joint should not be opened, and the implant should not be touched [83]. Hyperbaric oxygen

Deep vein thrombosis is the general name of thrombosis in the venous circulatory system. It occurs most commonly in the deep veins of the lower extremity [85]. From asymptomatic deep vein thrombosis to pulmonary embolism, which can be fatal, it can be confused with clinical manifestations of varying degrees [85]. It is one of the important complications that increase morbidity and mortality after TKA [86]. Even with mechanical or pharmacological methods, the incidence of asymptomatic DVT is 5.1%, and the incidence of symptomatic DVT is 0.4% [87].

It is important to understand the Virchow triad in the pathogenesis of DVT development. There is a slowdown in blood flow (stasis), endothelial damage, and hypercoagulability [89]. The admixture of fat and bone marrow particles into the venous system after engraving of the femoral canal during TKA explains the hypercoagulability branch of the Virchow triad. Hyperflexion of the leg during surgery and anterior manipulation of the tibia with retractors explain endothelial damage. In addition, this manipulation causes obstruction of the popliteal veins and prolonged immobilization of the leg, leading to venous pool-

tion, and prolonged wound drainage for more than 5 days [81].

increased temperature, erythema, and localized swelling [79].

therapy has a positive effect on appropriate patient selection [84].

The mortality rate due to pulmonary embolism after TKA is 0.08% [88].

**3.3 Deep vein thrombosis and pulmonary embolism**

**64**

ing and stasis [89].


#### *3.3.2 Diagnosis*

A painful, swollen, and reddened leg after TKA should suggest the possibility of DVT. Incomplete DVTs usually do not show signs. Incomplete DVTs are seen especially after arthroplasty. Clinical findings are seen in 1% of all DVT cases. Physical examination findings include redness, swelling, and Homan's sign test and Pratt test positivity. Clinical Wells risk score was established for the diagnosis of deep vein thrombosis [94]. Clinical Wells Scoring criteria are malignancy, paralysis (paresthesia or splinting lower extremity), immobilization for more than 3 days, localized tenderness in the deep venous system, swelling of the lower extremity, 3-cm-diameter differentiation from the other leg, pretibial gode positive edema, history of deep vein thrombosis, and collateral superficial veins. The presence of each risk factor was evaluated as 1 point, and clinical scoring of 3 and above was found to be a high risk for the development of deep vein thrombosis.

Clinical data are not sufficient for the diagnosis of DVT. Therefore, further examination with clinical risk scoring, D-dimer level, Doppler ultrasonography, contrast-enhanced venography, CT, and MRI should be performed. Venography is the best method for the diagnosis of DVT in the lower extremities. The accuracy rate was 97% in the lower extremity veins and 70% in the iliac veins [95]. Venography is not preferred as first-line imaging because it has a 3% risk of DVT and is an invasive method, and also it requires contrast matter that can be toxic to the kidneys. Doppler USG is the most commonly used first-line imaging method because of its cheapness, reproducibility, and patient comfort in the suspicion of DVT. Proximal DVT sensitivity was 96%, distal DVT sensitivity was 44%, and DVT specificity was 93% [96].

Pulmonary embolism should be suspected in the case of sudden shortness of breath, tachypnea, tachycardia, and chest pain after TKA. However, since there are many other diseases with these findings, risk factor assessment and effective differential diagnosis should be made. Wells pulmonary embolism clinical probability scoring was established [97]. Pulmonary angiography is the gold standard for the diagnosis of pulmonary embolism [85].

#### *3.3.3 Prophylaxis*

Primary treatment of DVT and related pulmonary embolism is very difficult and cost-effective. Therefore, it is more plausible to establish protocols that prevent the development of DVT and to give ideal prophylaxis. Many pharmacological and mechanical prophylaxis methods are available. The aim is to prevent the development of DVT and not to increase bleeding. Therefore the drug or method of choice should be patient-specific:

	- *K vitamin antagonist warfarin*: It prevents the formation of fibrin by inactivating 2, 7, 9, and 10 of the clotting factors. It also inhibits the activation of fibrinolysis-causing protein C and S. Since this effect occurs earlier, it creates a temporary clotting condition. Patients with warfarin should therefore be heparinized until the effect on coagulation factors begins. The anticoagulant effects of warfarin are reversible and monitored by the international normalization rate (INR) measurement. Interaction with other drugs, narrow confidence interval, and dual effect have recently reduced the usage of post-TKA [99, 100].
	- *Heparin*: It acts by inactivating circulating antithrombin III. Antithrombin III also inactivates circulating factors 2, 9, 10, 11, and 12. The use of standard heparin has recently been restricted due to the low risk of bleeding due to low-molecular-weight heparin.
	- *Acetylsalicylic acid*: It acts as an anticoagulant by blocking thromboxane A2, which is necessary for platelet aggression. Recent studies have shown that VTE can be used prophylactically [101].
	- Other oral anticoagulants that may be used: *rivaroxaban (direct factor Xa inhibitor), apixaban (direct factor Xa inhibitor), and dabigatran (direct thrombin inhibitor*).

#### **4. Late postoperative complications**

#### **4.1 Instability**

The development of instability after TKA is the third most common cause of revision (17%) after aseptic loosening and infection [102]. Patients present with signs of pain and swelling with movement and weight loss. There may also be pain, emptiness, or abnormal friction and rattling noise in some range of motion.

**67**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

global instability [103].

*4.1.1 Risk factors*

On the knee during walking, varus or valgus orientation and recurvatum can be seen. Anterior knee pain during sitting up is typical in flexion instabilities. The heaviest table is knee dislocation. The treatment of instability is revision surgery. However, the rate of recurrent instability after revision was 18–60% [103]. This high rate is usually due to the lack of correct identification of the cause of instability. A clinical classification of knee instability was established. Components of this classification are flexion-extension gap mismatch, component alignment problem, isolated ligament failure, extensor mechanism failure, component loosening, and

The success of total knee replacement depends on the correct alignment of the lower limb mechanical axis. It is recommended that the postoperative lower limb mechanical axis should be in neutral alignment. The tibial cut surface in the coronal plane should be made perpendicular to the mechanical axis of the tibia. Similarly the femoral cut in the coronal plane should be made perpendicular to the mechanical axis of the femur. It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. Balancing the gaps is important to ensure stability and for full range of motion. Flexion gap controlled by posterior femoral condylar cut and tibial cut. Extansion gap controlled by distal femoral condylar cut and the tibial cut. If there is a symmetric gap problem, tibial bone cut is adjusted first; otherwise if there is asymmetric gap problem, adjust femoral bone cut first. For example, if the knee is tight both in extension and flexion, it is called symmetrical gap problem, and its solution is to cut more proximal tibia. The asymmetric gap is one of the most common causes of instability. In some patients, the underlying

cause increases the risk of instability. These reasons can be listed as follows:

• Internal side ligament or posterior cruciate ligament failure.

It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. If the cavity is larger than the prosthesis, the term symmetrical discrepancy is used. The reason for this instability is that the distal femoral incision or the tibial incision is more than necessary [85].

If the tibial incision is excessive, both extension and flexion will be loose. If this condition is noticed intraoperatively, it is thought that the problem is solved with a thicker insert, but in fact, both the patellofemoral joint problems can arise as the joint line will go down more inferiorly and the early relaxation and fixation problems can arise because the tibial component will sit on the narrower surface.

If the distal femoral incision is excessive, there will be looseness in the extension range. The use of a thick insert during surgery will improve the looseness of the

• Knee with advanced deformity.

• Obesity and rheumatoid arthritis.

• Regional muscle weakness.

• Neuromuscular disease.

• Charcot arthropathy

*4.1.2 Treatment*

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

On the knee during walking, varus or valgus orientation and recurvatum can be seen. Anterior knee pain during sitting up is typical in flexion instabilities. The heaviest table is knee dislocation. The treatment of instability is revision surgery. However, the rate of recurrent instability after revision was 18–60% [103]. This high rate is usually due to the lack of correct identification of the cause of instability.

A clinical classification of knee instability was established. Components of this classification are flexion-extension gap mismatch, component alignment problem, isolated ligament failure, extensor mechanism failure, component loosening, and global instability [103].

#### *4.1.1 Risk factors*

*Knee Surgery - Reconstruction and Replacement*

mechanical prophylaxis [98].

low-molecular-weight heparin.

*thrombin inhibitor*).

**4. Late postoperative complications**

VTE can be used prophylactically [101].

Primary treatment of DVT and related pulmonary embolism is very difficult and cost-effective. Therefore, it is more plausible to establish protocols that prevent the development of DVT and to give ideal prophylaxis. Many pharmacological and mechanical prophylaxis methods are available. The aim is to prevent the development of DVT and not to increase bleeding. Therefore the drug or method of choice

• *Mechanical prophylaxis*: The aim is to reduce venous stasis by compressing the lower extremity and to increase fibrinolysis. The risk of hemorrhage is very low, and, if applied correctly, there are almost no complications. Patient compliance is important in mechanical prophylaxis and is the only negative aspect of the method. Mechanical prophylaxis methods include early mobilization, in-bed exercise, use of antithromboembolic socks, and pneumatic compression devices. It has ben shown that intermittent pneumatic compression devices provide as effective prophylaxis as chemical prophylactic agents, and the American College of Chest Physicians (ACCP) recommends the use of

• *Chemical prophylaxis*: Many agents are used. They all have their own advantages and disadvantages. Risk factors are determined by patient-based evalua-

and dual effect have recently reduced the usage of post-TKA [99, 100].

○ *Heparin*: It acts by inactivating circulating antithrombin III. Antithrombin III also inactivates circulating factors 2, 9, 10, 11, and 12. The use of standard heparin has recently been restricted due to the low risk of bleeding due to

○ *Acetylsalicylic acid*: It acts as an anticoagulant by blocking thromboxane A2, which is necessary for platelet aggression. Recent studies have shown that

○ Other oral anticoagulants that may be used: *rivaroxaban (direct factor Xa inhibitor), apixaban (direct factor Xa inhibitor), and dabigatran (direct* 

The development of instability after TKA is the third most common cause of revision (17%) after aseptic loosening and infection [102]. Patients present with signs of pain and swelling with movement and weight loss. There may also be pain, emptiness, or abnormal friction and rattling noise in some range of motion.

○ *K vitamin antagonist warfarin*: It prevents the formation of fibrin by inactivating 2, 7, 9, and 10 of the clotting factors. It also inhibits the activation of fibrinolysis-causing protein C and S. Since this effect occurs earlier, it creates a temporary clotting condition. Patients with warfarin should therefore be heparinized until the effect on coagulation factors begins. The anticoagulant effects of warfarin are reversible and monitored by the international normalization rate (INR) measurement. Interaction with other drugs, narrow confidence interval,

tion and the most appropriate agent should be preferred:

*3.3.3 Prophylaxis*

should be patient-specific:

**66**

**4.1 Instability**

The success of total knee replacement depends on the correct alignment of the lower limb mechanical axis. It is recommended that the postoperative lower limb mechanical axis should be in neutral alignment. The tibial cut surface in the coronal plane should be made perpendicular to the mechanical axis of the tibia. Similarly the femoral cut in the coronal plane should be made perpendicular to the mechanical axis of the femur. It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. Balancing the gaps is important to ensure stability and for full range of motion. Flexion gap controlled by posterior femoral condylar cut and tibial cut. Extansion gap controlled by distal femoral condylar cut and the tibial cut. If there is a symmetric gap problem, tibial bone cut is adjusted first; otherwise if there is asymmetric gap problem, adjust femoral bone cut first. For example, if the knee is tight both in extension and flexion, it is called symmetrical gap problem, and its solution is to cut more proximal tibia. The asymmetric gap is one of the most common causes of instability. In some patients, the underlying cause increases the risk of instability. These reasons can be listed as follows:


#### *4.1.2 Treatment*

It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. If the cavity is larger than the prosthesis, the term symmetrical discrepancy is used. The reason for this instability is that the distal femoral incision or the tibial incision is more than necessary [85].

If the tibial incision is excessive, both extension and flexion will be loose. If this condition is noticed intraoperatively, it is thought that the problem is solved with a thicker insert, but in fact, both the patellofemoral joint problems can arise as the joint line will go down more inferiorly and the early relaxation and fixation problems can arise because the tibial component will sit on the narrower surface.

If the distal femoral incision is excessive, there will be looseness in the extension range. The use of a thick insert during surgery will improve the looseness of the

extension, but there will be tightness in flexion [104]. In addition, as the joint line will increase, both the effective distance of collateral ligament will decrease, and patellofemoral joint problems will occur. Therefore, if the distal femoral incision is excessive, the use of distal femoral augment should be preferred instead of the use of a thick insert [105].

Asymmetric mismatches occur when the joint space is trapezoidal rather than rectangular. It occurs mostly during surgery after excessive loosening of the soft tissue and is most commonly seen in extension. In this case, the transition to the restrictive prosthesis should be considered [106].

#### **4.2 Joint stiffness**

One of the reasons that greatly affect patient satisfaction after TKA operations is the amount of joint range of motion. To achieve good results, a flexion range of at least 90° is required. Sixty-five degrees of flexion is required during walking; 106° of flexion is required when sitting on a chair and tying shoes. Postoperative limited and painful joint movements significantly reduce patient comfort. A flexion range of less than 90° for 6 weeks after TKA surgery is defined as a rigid knee [107].

#### *4.2.1 Risk factors and causes*

Hip osteoarthritis, heterotropic ossification, and reflex symptomatic dystrophy can be considered as independent factors. Inadequate posterior femoral incision and inadequate medial collateral ligament releasing of the knee with severe varus deformity may be among the causes for a rigid knee due to surgical technique [108, 109]. In one study, it was observed that joint stiffness occurred more frequently than unilateral knee arthroplasty in patients who underwent bilateral total knee arthroplasty in the same session, and manipulation was required under anesthesia [110].

Excessive tight extension and flexion gap, tight PCL, malrotation of components, and inadequate tibial slop angle may lead to joint stiffness [108].

One of the most important indicators of joint stiffness is the extremely limited range of motion in the knee before surgery [109]. The range of motion obtained within the surgery should be considered in the determination of joint stiffness. A sudden loss of motion should suggest a mechanical problem, loosening, and infection.

Arthrofibrosis is the most treatment-resistant cause of joint stiffness. It develops due to excessive increase of fibrous tissue in the joint [108].

#### *4.2.2 Treatment*

The strongest determinant of postoperative flexion movements is the degree of preoperative flexion. Other than that, age, preoperative diagnosis, and severity of deformity are other factors [111].

The efficacy of conservative treatment is limited in joint stiffness after TKA. Aggressive range of motion improvement of 3.1° was observed with aggressive physical therapy for almost 1 year [112]. It has been shown that the use of continuous passive motion device (CPM) in the early postoperative period reduces bleeding and is beneficial in preventing joint stiffness by reducing the formation of fibrosis [113].

Although there is no consensus in the literature, manipulation under anesthesia should be performed in cases where knee flexion is below 90° between 2 weeks and 3 months. Revision rates are lower in patients with early manipulation [114]. Manipulation is performed under general anesthesia using a muscle relaxant until the knee and hip reach at least 90°. After this procedure, an average gain of 30–47° was reported [115].

**69**

*4.3.1 Diagnosis*

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

**4.3 Periprosthetic joint infections**

and prolonged skin problems.

longer one [120].

prevent infection [121].

If the joint movement limitation continues despite these methods, surgical procedures are performed. These are arthroscopic release, open release and limited

Deep infection after TKA is the most common cause of revision. Systemic complications such as septicemia and cardiopulmonary insufficiency may also occur in patients with periprosthetic infection [117]. As a result, it increased mortality rates. Nowadays, the incidence of deep infection after TKA varies between 0.4 and 2% [74]. Factors that pave the way for infection in the postoperative period include the presence of rheumatoid arthritis, diabetes, hemophilia, malignancy, HIV, obesity, smoking, intravenous drug addiction, knee septic arthritis and osteomyelitis, prolonged surgical time, malnutrition, steroid use,

Antibiotic prophylaxis is the most effective method to prevent infection [118]. Prophylaxis should be administered 30–60 minutes. Before skin incision [119]. It has been shown that short postoperative antibiotherapy is more beneficial than the

Fewer people entering the operating room, using drapes to prevent superficial

Risk groups of patients should be identified before the operation, and a separate planning should be made for each patient according to comorbid diseases. Antibiotic cement has been shown to reduce the infection rate in patients at risk [122]. However, it has been reported that the use of antibiotic cement in the patient

The most common organisms produced after infected knee arthroplasties are *Staphylococcus aureus*, coagulase negative *Staphylococcus*, and *Streptococcus* bacteria [124]. However, many microorganisms can also be active. Variations have occurred in microorganisms due to the unnecessary antibiotics used recently, and this has led to the development of resistance. Of these microorganisms, the most common isolates are methicillin-resistant *Staphylococcus aureus* (MRSA) and many antibiotics [125]. Fungal infections are not common, but the most common causative agents in

Bacteria that cause prosthetic infection form a biofilm layer on the implant. This biofilm layer increases the virulence of the agent. In addition, it forms resistance to treatment because of its limitation on antibiotic permeability. The best antibiotic to cross the biofilm layer is rifampicin [127]. There are studies suggesting the addition of rifampicin to antibiotic treatment specific for the reproductive bacteria [127, 128].

Detailed anamnesis and detailed physical examination should be performed in the diagnosis of periprosthetic infection. In addition, the presence of a progressive radiolucent area around the prosthesis with direct radiographs, osteopenia, or osteolysis extending to the subchondral bone and the formation of new bone in the periosteal area can be evaluated in favor of infection [129]. The pain caused by rest is unique. However, increasing severity of pain and prolonged drainage at the wound site can also be evaluated in favor of infection. Arthrocentesis is then performed. In the case of active isolation, the necessary treatment is started. Empirical antibiotic therapy should be avoided. Wait until the agent is isolated.

contamination, providing laminar air flow, effective sterilization of surgical instruments, and keeping the surgical time 150 minutes below are also necessary to

group with no risk may cause premature loosening [123].

these isolated are *Candida* species [126].

revision knee arthroplasty, and total revision knee arthroplasty [116].

*Knee Surgery - Reconstruction and Replacement*

restrictive prosthesis should be considered [106].

of a thick insert [105].

**4.2 Joint stiffness**

*4.2.1 Risk factors and causes*

*4.2.2 Treatment*

deformity are other factors [111].

extension, but there will be tightness in flexion [104]. In addition, as the joint line will increase, both the effective distance of collateral ligament will decrease, and patellofemoral joint problems will occur. Therefore, if the distal femoral incision is excessive, the use of distal femoral augment should be preferred instead of the use

Asymmetric mismatches occur when the joint space is trapezoidal rather than rectangular. It occurs mostly during surgery after excessive loosening of the soft tissue and is most commonly seen in extension. In this case, the transition to the

One of the reasons that greatly affect patient satisfaction after TKA operations is the amount of joint range of motion. To achieve good results, a flexion range of at least 90° is required. Sixty-five degrees of flexion is required during walking; 106° of flexion is required when sitting on a chair and tying shoes. Postoperative limited and painful joint movements significantly reduce patient comfort. A flexion range of less than 90° for 6 weeks after TKA surgery is defined as a rigid knee [107].

Hip osteoarthritis, heterotropic ossification, and reflex symptomatic dystrophy can be considered as independent factors. Inadequate posterior femoral incision and inadequate medial collateral ligament releasing of the knee with severe varus deformity may be among the causes for a rigid knee due to surgical technique [108, 109]. In one study, it was observed that joint stiffness occurred more frequently than unilateral knee arthroplasty in patients who underwent bilateral total knee arthroplasty

Excessive tight extension and flexion gap, tight PCL, malrotation of compo-

One of the most important indicators of joint stiffness is the extremely limited range of motion in the knee before surgery [109]. The range of motion obtained within the surgery should be considered in the determination of joint stiffness. A sudden loss of motion should suggest a mechanical problem, loosening, and infection. Arthrofibrosis is the most treatment-resistant cause of joint stiffness. It develops

The strongest determinant of postoperative flexion movements is the degree of preoperative flexion. Other than that, age, preoperative diagnosis, and severity of

The efficacy of conservative treatment is limited in joint stiffness after TKA. Aggressive range of motion improvement of 3.1° was observed with aggressive physical therapy for almost 1 year [112]. It has been shown that the use of continuous passive motion device (CPM) in the early postoperative period reduces bleeding and is beneficial in preventing joint stiffness by reducing the formation of fibrosis [113]. Although there is no consensus in the literature, manipulation under anesthesia should be performed in cases where knee flexion is below 90° between 2 weeks and 3 months. Revision rates are lower in patients with early manipulation [114]. Manipulation is performed under general anesthesia using a muscle relaxant until the knee and hip reach at least 90°. After this procedure, an average gain of 30–47°

in the same session, and manipulation was required under anesthesia [110].

nents, and inadequate tibial slop angle may lead to joint stiffness [108].

due to excessive increase of fibrous tissue in the joint [108].

**68**

was reported [115].

If the joint movement limitation continues despite these methods, surgical procedures are performed. These are arthroscopic release, open release and limited revision knee arthroplasty, and total revision knee arthroplasty [116].

#### **4.3 Periprosthetic joint infections**

Deep infection after TKA is the most common cause of revision. Systemic complications such as septicemia and cardiopulmonary insufficiency may also occur in patients with periprosthetic infection [117]. As a result, it increased mortality rates. Nowadays, the incidence of deep infection after TKA varies between 0.4 and 2% [74]. Factors that pave the way for infection in the postoperative period include the presence of rheumatoid arthritis, diabetes, hemophilia, malignancy, HIV, obesity, smoking, intravenous drug addiction, knee septic arthritis and osteomyelitis, prolonged surgical time, malnutrition, steroid use, and prolonged skin problems.

Antibiotic prophylaxis is the most effective method to prevent infection [118]. Prophylaxis should be administered 30–60 minutes. Before skin incision [119]. It has been shown that short postoperative antibiotherapy is more beneficial than the longer one [120].

Fewer people entering the operating room, using drapes to prevent superficial contamination, providing laminar air flow, effective sterilization of surgical instruments, and keeping the surgical time 150 minutes below are also necessary to prevent infection [121].

Risk groups of patients should be identified before the operation, and a separate planning should be made for each patient according to comorbid diseases. Antibiotic cement has been shown to reduce the infection rate in patients at risk [122]. However, it has been reported that the use of antibiotic cement in the patient group with no risk may cause premature loosening [123].

The most common organisms produced after infected knee arthroplasties are *Staphylococcus aureus*, coagulase negative *Staphylococcus*, and *Streptococcus* bacteria [124]. However, many microorganisms can also be active. Variations have occurred in microorganisms due to the unnecessary antibiotics used recently, and this has led to the development of resistance. Of these microorganisms, the most common isolates are methicillin-resistant *Staphylococcus aureus* (MRSA) and many antibiotics [125]. Fungal infections are not common, but the most common causative agents in these isolated are *Candida* species [126].

Bacteria that cause prosthetic infection form a biofilm layer on the implant. This biofilm layer increases the virulence of the agent. In addition, it forms resistance to treatment because of its limitation on antibiotic permeability. The best antibiotic to cross the biofilm layer is rifampicin [127]. There are studies suggesting the addition of rifampicin to antibiotic treatment specific for the reproductive bacteria [127, 128].

#### *4.3.1 Diagnosis*

Detailed anamnesis and detailed physical examination should be performed in the diagnosis of periprosthetic infection. In addition, the presence of a progressive radiolucent area around the prosthesis with direct radiographs, osteopenia, or osteolysis extending to the subchondral bone and the formation of new bone in the periosteal area can be evaluated in favor of infection [129]. The pain caused by rest is unique. However, increasing severity of pain and prolonged drainage at the wound site can also be evaluated in favor of infection. Arthrocentesis is then performed. In the case of active isolation, the necessary treatment is started. Empirical antibiotic therapy should be avoided. Wait until the agent is isolated.

#### *Knee Surgery - Reconstruction and Replacement*

Because empirical antibiotherapy will suppress a possible infection and may cause deep infection due to delayed diagnosis of prosthesis infection that may be saved by debridement and may require removal of the prosthesis [130].

CRP and sedimentation values should be evaluated in diagnosis. However, it should be remembered that CRP returns to its previous level after 14–21 days postoperatively [131]. Alpha defensin, lactoferrin, ELA-2, BPI, procalcitonin, and synovial CRP values are other parameters that can be used in diagnosis [132].

Current consensus has been reached in the diagnosis of periprosthetic infection [133]. Accordingly:

	- Generation of the same agent in two positive cultures.
	- Presence of sinus mouth associated with prosthesis. In the presence of one of them, the diagnosis is established [133].
	- Calculated weights of high serum CRP (>1 mg/dL), D-dimer (>860 ng/mL), and erythrocyte sedimentation rate (>30 mm/h) are also 2, 2, and 1 points, respectively.
	- High synovial fluid white cell count (>3000 cells/μL), alpha defensin (signal cutoff ratio > 1), leukocyte esterase (++), polymorphonuclear percentage (>80%), and synovial CRP (>6.9 mg/L) were arranged as 3, 3, 3, 2, and 1 points, respectively.

Patients with a total score equal to or greater than 6 were considered infected.

#### *4.3.2 Treatment*

The goal of infection treatment in total knee arthroplasty is eradication of the infection, pain relief, and maintenance of limb function. Treatment options are antibiotic pressure, debridement, single- or double-stage revision, arthrodesis, resection arthroplasty, and amputation. Revision surgery also has single-stage or double-stage revision options [134–136].

#### **4.4 Periprosthetic fractures**

Periprosthetic fractures around the knee are fractures that occur during or after surgery within 15 cm of the knee joint or within 5 cm of the intramedullary part of the prosthesis, if any [137]. The incidence of these fractures after TKA is 0.3–2.5% for femur and 0.4 01% for tibia [138, 139].

The main risk factor related to the patient is the age of the patient. This risk is due to an increased risk of falling due to the patient's age and osteoporosis associated with age [140]. Corticosteroid use, diseases that may increase the risk of falling with rheumatoid arthritis (epilepsy, Parkinson's, cerebellar ataxia, myasthenia gravis) can be counted as other patient-related risk factors [141].

Intraoperative diaphyseal femoral fractures may occur due to incorrect placement of the intramedullary guide and osteopenia [142]. Unsuitable bone incisions, aggressive impaction of the ligamentous posterior stabilized femoral component, and eccentric placement of trial components are also risk factors for femoral

**71**

**Figure 1.**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

fracture displacement and component fixation.

5 mm or angulation of more than 5°.

• Type 3 indicates loose fractures [145].

least twice the diameter of the femoral canal [146].

*4.4.1.1 Femoral fractures during surgery*

*4.4.1.2 Postoperative femoral fractures*

leg plaster, or hinged orthosis is followed.

*4.4.1 Treatment*

fracture. It has been shown to increase the frequency of periprosthetic fractures due to increased resistance in flexion and rotation movements in anterior femoral notching [143]. The possibility of periprosthetic fracture is increased in revision TKA cases [144]. Periprosthetic fractures are more common due to the rotational

forces of restrictive prosthesis using shear forces in the prosthesis [141]. Due to the stronger structure of the tibia, fracture development is rare. For femoral periprosthetic fractures, there is a classification that questions

• Type 1 describes fractures with non-displaced and stable components.

• Type 2 refers to component stable fractures with displacement of more than

The femur fractures vertically more than the metaphyseal region. A stable periosteum prevents displacement. It is followed conservatively without any additional intervention. For fractures penetrating the femoral cortex, whether or not a bone graft is used, the penetration level should be treated with a stem prosthesis that is at

When non-displaced fractures and stable prosthesis occur after TKA, conservative treatment may be preferred. Four to six weeks of non-weight procedure, long

Displaced and unreducible supracondylar fractures are almost always treated

surgically in the presence of adequate bone stock (**Figure 1**) [147].

*Supracondylar periprosthetic femur fracture treated with open reduction and internal fixation.*

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

fracture. It has been shown to increase the frequency of periprosthetic fractures due to increased resistance in flexion and rotation movements in anterior femoral notching [143]. The possibility of periprosthetic fracture is increased in revision TKA cases [144]. Periprosthetic fractures are more common due to the rotational forces of restrictive prosthesis using shear forces in the prosthesis [141].

Due to the stronger structure of the tibia, fracture development is rare.

For femoral periprosthetic fractures, there is a classification that questions fracture displacement and component fixation.


#### *4.4.1 Treatment*

*Knee Surgery - Reconstruction and Replacement*

[133]. Accordingly:

• Major criteria

• Minor criteria

respectively.

*4.3.2 Treatment*

points, respectively.

double-stage revision options [134–136].

for femur and 0.4 01% for tibia [138, 139].

**4.4 Periprosthetic fractures**

Because empirical antibiotherapy will suppress a possible infection and may cause deep infection due to delayed diagnosis of prosthesis infection that may be saved by

CRP and sedimentation values should be evaluated in diagnosis. However, it should be remembered that CRP returns to its previous level after 14–21 days postoperatively [131]. Alpha defensin, lactoferrin, ELA-2, BPI, procalcitonin, and synovial CRP values are other parameters that can be used in diagnosis [132].

Current consensus has been reached in the diagnosis of periprosthetic infection

○ Presence of sinus mouth associated with prosthesis. In the presence of one of

○ Calculated weights of high serum CRP (>1 mg/dL), D-dimer (>860 ng/mL), and erythrocyte sedimentation rate (>30 mm/h) are also 2, 2, and 1 points,

○ High synovial fluid white cell count (>3000 cells/μL), alpha defensin (signal cutoff ratio > 1), leukocyte esterase (++), polymorphonuclear percentage (>80%), and synovial CRP (>6.9 mg/L) were arranged as 3, 3, 3, 2, and 1

Patients with a total score equal to or greater than 6 were considered infected.

The goal of infection treatment in total knee arthroplasty is eradication of the infection, pain relief, and maintenance of limb function. Treatment options are antibiotic pressure, debridement, single- or double-stage revision, arthrodesis, resection arthroplasty, and amputation. Revision surgery also has single-stage or

Periprosthetic fractures around the knee are fractures that occur during or after surgery within 15 cm of the knee joint or within 5 cm of the intramedullary part of the prosthesis, if any [137]. The incidence of these fractures after TKA is 0.3–2.5%

The main risk factor related to the patient is the age of the patient. This risk is due to an increased risk of falling due to the patient's age and osteoporosis associated with age [140]. Corticosteroid use, diseases that may increase the risk of falling with rheumatoid arthritis (epilepsy, Parkinson's, cerebellar ataxia, myasthenia

Intraoperative diaphyseal femoral fractures may occur due to incorrect placement of the intramedullary guide and osteopenia [142]. Unsuitable bone incisions, aggressive impaction of the ligamentous posterior stabilized femoral component, and eccentric placement of trial components are also risk factors for femoral

gravis) can be counted as other patient-related risk factors [141].

debridement and may require removal of the prosthesis [130].

○ Generation of the same agent in two positive cultures.

them, the diagnosis is established [133].

**70**

#### *4.4.1.1 Femoral fractures during surgery*

The femur fractures vertically more than the metaphyseal region. A stable periosteum prevents displacement. It is followed conservatively without any additional intervention. For fractures penetrating the femoral cortex, whether or not a bone graft is used, the penetration level should be treated with a stem prosthesis that is at least twice the diameter of the femoral canal [146].

#### *4.4.1.2 Postoperative femoral fractures*

When non-displaced fractures and stable prosthesis occur after TKA, conservative treatment may be preferred. Four to six weeks of non-weight procedure, long leg plaster, or hinged orthosis is followed.

Displaced and unreducible supracondylar fractures are almost always treated surgically in the presence of adequate bone stock (**Figure 1**) [147].

Locked compression plates are preferred for knee periprosthetic fractures [144]. Prosthetic revision should be performed in fractures that cause prosthesis loosening and malposition. In these cases, stented prosthesis of sufficient length should be placed to obtain a stable fixation of the intact bone [138]. Knee replacement revision after periprosthetic fractures is often associated with the loss of range of motion (ROM) [148].

#### *4.4.1.3 Tibia fractures*

The majority of tibial periprosthetic fractures during surgery involve the plateau region and are generally non-displaced [146, 149]. If prosthetic loosening is present, revision surgery using a stem component long enough to cross the fracture line is required [150].

Postoperative tibial fractures can be examined in four groups. In type 1 fracture, revision is recommended because tibial component will be in varus alignment. The medial defect should be closed with bone graft or metal support [150]. Type 2 fractures are treated with nonsurgical treatment if the component is stable and there is minimal displacement [149]. Displaced type 2 fractures are treated with internal fixation. If the component is unstable, it must be revised using a long tibial stem to cross the fracture line [149]. Internal fixation should be performed for type 3 and 4 fractures [145].

#### **4.5 Aseptic loosening**

The deterioration of the relationship between prosthesis and bone is defined as loosening. The loosening may be between the prosthetic cement and the cement bone. Loosening is inevitable in long-term prostheses. It is useful to distinguish the concepts of osteolysis and loosening. Without prosthesis osteolysis, loosening of the cement may occur. The mechanisms that cause loosening are micromotion, component collapse, and periprosthetic osteolysis [151].

Overuse and osteopenia are the causes of patient-related loosening. Implant design may also be the cause of loosening. According to this, loosening is more likely in cementless prosthesis and constrained prosthesis. One of the most important causes of aseptic loosening is malalignment. It has been shown that a 4 mm medial collapse of the tibial component and varus deformity of more than 2° increases the likelihood of loosening [152]. In the early period, a radiolucent line is seen between the component and bone on radiography, and a collapse occurs as the loosening progresses. Loosening is more common around the tibial component [152]. In the presence of loosening around the whole component, septic loosening should be considered, and differential diagnosis should be performed.

In the case of loosening, the treatment is decided according to symptoms and progress. If pain is associated with instability and there are X-ray findings, early revision surgery is recommended for bone stock preservation.

#### **4.6 Osteolysis**

Osteolysis usually occurs due to inflammatory reactions caused by worn polyethylene particles or in the presence of infection. Metal particles can also cause osteolysis. Titanium causes more osteolysis than cobalt and chromium. Giant cells that develop against abrasive particles act by forming a membrane [153]. Particle size is important for this mechanism. The particle sizes range from 1 to 100 micrometers under the electron microscope. Large parts do not cause osteolysis [153]. There is no osteolysis if the parts are not spread to the cancellous bone, so osteolysis is not seen when

**73**

problems.

joint problems [164, 165].

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

bone graft. The second is revision [159].

patellofemoral joint problems. These are [163]:

**4.7 Patellofemoral joint problems**

the cancellous bone is properly covered with cement [154]. On the other hand, the incidence of osteolysis increases when pres-fit prosthesis is applied; screw fixation without cement is used or cement breaks [155]. Osteolysis is closely related to prosthetic design. Osteolysis usually occurs after 2 years of TKA. Occurrence is rare before 2 years [156]. Osteolysis is mostly seen in the tibia [157]. Diagnosis includes pain, joint effusion, and synovitis due to joint instability. Focal bone destruction may be seen on radiolucent line and X-ray. It can be seen that there is no continuity of trabeculae and bone cortex in cancellous bone. Therefore, control X-rays are very important in patient follow-up and must be compared with old radiographs in controls. CT and MRI can be

If the lesion is small in treatment and the prosthesis is stable, observation is sufficient. Bisphosphonate and calcium supplementation can be initiated [159]. If the prosthesis is instable, two options can be applied. The first one is debridement, polyethylene replacement, and curettage, followed by impaction of the defect with

Patellofemoral joint problems after TKA generally cause anterior knee pain. Patients' ability to tolerate this pain rarely causes patellofemoral joint problems to be revised [160]. It should be kept in mind that not only patellar component-related procedures but also procedures involving the tibiofemoral joint may cause this problem. Even in revision surgery due to a problem of patellofemoral origin, it is often caused by a component in the tibia and femur [161]. In a study, patella and malrotation were among the eight most common causes of failed TKA [162].

Advanced valgus alignment, previous high tibial osteotomy, or tuberositas tibia

• *Component placement*: If the femoral component is placed medially, anteriorly, or flexed, or if there is internal rotation and if the component is excessive in size, patellofemoral problems may occur finally. Likewise, the medialization

• *Surgical approach type*: Midvastus and subvastus interventions that protect the

• *Lateral release*: The need for lateral retinacular release increases PF joint

• *Patella resection amount*: When patellar component is used, resection of the patella with anterior–posterior reduction of 12 mm increases the risk of PF

Patellar surface replacement is controversial today. However, in a recent study, it was found that anterior knee pain was less common in patients who underwent patellar surface change than those who did not. In the same study, the causes of PF joint revision were more common in patients without patella surface changes [166]. The results in patients with patellar articular surface alteration due to persistent anterior knee pain after TKA are not as successful as those with surface replacement during primary TKA [167]. In the treatment of anterior knee pain after TKA, mechanical causes should be investigated after the exclusion of an underlying infection.

osteotomy increases the rate of patellofemoral joint problems in TKA [160]. There are many points to be considered in the surgical technique to prevent

and internal rotation of the tibial component increases the risk.

extensor mechanism more can reduce PF joint problems.

used for osteolysis that cannot be detected on direct radiography [158].

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

motion (ROM) [148].

*4.4.1.3 Tibia fractures*

is required [150].

**4.5 Aseptic loosening**

nent collapse, and periprosthetic osteolysis [151].

Locked compression plates are preferred for knee periprosthetic fractures [144]. Prosthetic revision should be performed in fractures that cause prosthesis loosening and malposition. In these cases, stented prosthesis of sufficient length should be placed to obtain a stable fixation of the intact bone [138]. Knee replacement revision after periprosthetic fractures is often associated with the loss of range of

The majority of tibial periprosthetic fractures during surgery involve the plateau region and are generally non-displaced [146, 149]. If prosthetic loosening is present, revision surgery using a stem component long enough to cross the fracture line

Postoperative tibial fractures can be examined in four groups. In type 1 fracture, revision is recommended because tibial component will be in varus alignment. The medial defect should be closed with bone graft or metal support [150]. Type 2 fractures are treated with nonsurgical treatment if the component is stable and there is minimal displacement [149]. Displaced type 2 fractures are treated with internal fixation. If the component is unstable, it must be revised using a long tibial stem to cross the fracture line [149]. Internal fixation should be performed for type 3 and 4 fractures [145].

The deterioration of the relationship between prosthesis and bone is defined as loosening. The loosening may be between the prosthetic cement and the cement bone. Loosening is inevitable in long-term prostheses. It is useful to distinguish the concepts of osteolysis and loosening. Without prosthesis osteolysis, loosening of the cement may occur. The mechanisms that cause loosening are micromotion, compo-

Overuse and osteopenia are the causes of patient-related loosening. Implant design may also be the cause of loosening. According to this, loosening is more likely in cementless prosthesis and constrained prosthesis. One of the most important causes of aseptic loosening is malalignment. It has been shown that a 4 mm medial collapse of the tibial component and varus deformity of more than 2° increases the likelihood of loosening [152]. In the early period, a radiolucent line is seen between the component and bone on radiography, and a collapse occurs as the loosening progresses. Loosening is more common around the tibial component [152]. In the presence of loosening around the whole component, septic loosening

In the case of loosening, the treatment is decided according to symptoms and progress. If pain is associated with instability and there are X-ray findings, early

Osteolysis usually occurs due to inflammatory reactions caused by worn polyethylene particles or in the presence of infection. Metal particles can also cause osteolysis. Titanium causes more osteolysis than cobalt and chromium. Giant cells that develop against abrasive particles act by forming a membrane [153]. Particle size is important for this mechanism. The particle sizes range from 1 to 100 micrometers under the electron microscope. Large parts do not cause osteolysis [153]. There is no osteolysis if the parts are not spread to the cancellous bone, so osteolysis is not seen when

should be considered, and differential diagnosis should be performed.

revision surgery is recommended for bone stock preservation.

**72**

**4.6 Osteolysis**

the cancellous bone is properly covered with cement [154]. On the other hand, the incidence of osteolysis increases when pres-fit prosthesis is applied; screw fixation without cement is used or cement breaks [155]. Osteolysis is closely related to prosthetic design. Osteolysis usually occurs after 2 years of TKA. Occurrence is rare before 2 years [156]. Osteolysis is mostly seen in the tibia [157]. Diagnosis includes pain, joint effusion, and synovitis due to joint instability. Focal bone destruction may be seen on radiolucent line and X-ray. It can be seen that there is no continuity of trabeculae and bone cortex in cancellous bone. Therefore, control X-rays are very important in patient follow-up and must be compared with old radiographs in controls. CT and MRI can be used for osteolysis that cannot be detected on direct radiography [158].

If the lesion is small in treatment and the prosthesis is stable, observation is sufficient. Bisphosphonate and calcium supplementation can be initiated [159]. If the prosthesis is instable, two options can be applied. The first one is debridement, polyethylene replacement, and curettage, followed by impaction of the defect with bone graft. The second is revision [159].

#### **4.7 Patellofemoral joint problems**

Patellofemoral joint problems after TKA generally cause anterior knee pain. Patients' ability to tolerate this pain rarely causes patellofemoral joint problems to be revised [160]. It should be kept in mind that not only patellar component-related procedures but also procedures involving the tibiofemoral joint may cause this problem. Even in revision surgery due to a problem of patellofemoral origin, it is often caused by a component in the tibia and femur [161]. In a study, patella and malrotation were among the eight most common causes of failed TKA [162].

Advanced valgus alignment, previous high tibial osteotomy, or tuberositas tibia osteotomy increases the rate of patellofemoral joint problems in TKA [160].

There are many points to be considered in the surgical technique to prevent patellofemoral joint problems. These are [163]:


Patellar surface replacement is controversial today. However, in a recent study, it was found that anterior knee pain was less common in patients who underwent patellar surface change than those who did not. In the same study, the causes of PF joint revision were more common in patients without patella surface changes [166].

The results in patients with patellar articular surface alteration due to persistent anterior knee pain after TKA are not as successful as those with surface replacement during primary TKA [167]. In the treatment of anterior knee pain after TKA, mechanical causes should be investigated after the exclusion of an underlying infection.

*Knee Surgery - Reconstruction and Replacement*

#### **Author details**

Muhammet Salih AYAS1 , Muhammet Kalkışım2 \*, Ahmet Köse1 and Orkun Gül<sup>2</sup>

1 Orthopedics and Traumatology, University of Health Sciences, Erzurum Regional Training and Research Hospital, Turkey

2 Department of Orthopedics and Traumatology, Karadeniz Technical University, Turkey

\*Address all correspondence to: muhammetkalkisim@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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three cases. Journal of Arthroplasty.

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[10] Saleh KJ, Hoeffel DP, Kassim RA, Burstein G. Complications after revision total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 2003;**85-A**(Suppl 1):S71-S74. DOI: 10.2106/00004623-200300001-00013

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Clark TWI. Embolization of traumatic

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pseudoaneurysms after total knee arthroplasty. The Journal of Arthroplasty. 2004;**19**:123-128

[11] Ninomiya JT, Dean JC,

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Turkey

**Author details**

Muhammet Salih AYAS1

Training and Research Hospital, Turkey

provided the original work is properly cited.

, Muhammet Kalkışım2

\*Address all correspondence to: muhammetkalkisim@gmail.com

1 Orthopedics and Traumatology, University of Health Sciences, Erzurum Regional

2 Department of Orthopedics and Traumatology, Karadeniz Technical University,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*, Ahmet Köse1

and Orkun Gül<sup>2</sup>

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Surgeons. 2003;**11**:238-247

tendon rupture after total knee

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arthroplasty. Clinical Orthopaedics and Related Research. 1989;**246**:233-238

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10.1016/j.arth.2007.07.012

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[113] O'Driscoll SW, Giori NJ. Continuous passive motion (CPM): Theory and principles of clinical application. Journal of Rehabilitation Research and Development. 2000;**37**(2):179-188

[114] Scranton PE. Management of knee pain and stiffness after total knee arthroplasty. The Journal of Arthroplasty. 2001;**16**:428-435. DOI: 10.1054/arth.2001.22250

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[129] Morrey BF, Westholm F, Schoifet S, Rand JA, Bryan RS. Long-term results of various treatment options for infected total knee arthroplasty. Clinical Orthopaedics and Related Research. 1989:120-128

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[148] Mortazavi SMJ, Kurd MF, Bender B, Post Z, Parvizi J,

after total knee arthroplasty. The Journal of Arthroplasty. 2010;**25**:775- 780. DOI: 10.1016/j.arth.2009.05.024

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[150] Rand JA, Coventry MB. Stress fractures after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 1980;**62**:226-233

[152] Lee B-S, Cho H-I, Bin S-I, Kim J-M, Jo B-K. Femoral component varus malposition is associated with tibial aseptic loosening after TKA. Clinical Orthopaedics and Related Research. 2018;**476**:400-407. DOI: 10.1007/ s11999.0000000000000012

[151] Işık C, Emre F, Ertaş SE. Aseptik gevşeme. TOTBİD Dergisi. 2019;**18**:163-169. DOI: 10.14292/totbid.

[153] Tírico LEP, Pasqualin T, Pécora JO, Gobbi RG, Pécora JR, Demange MK. Estudo da estabilidade dos componentes na artroplastia total do joelho sem cimento. Acta Ortopédica Brasileira. 2012;**20**(4):230-234. DOI: 10.1590/s1413-78522012000400008

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[140] Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic

epidemiology, risk factors, diagnosis, management and outcome. Acta Biomedica. 2017. DOI: 10.23750/abm.

Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clinical Orthopaedics and Related Research. 1987;**222**:212-222

Waterman RA, Eberle RW. Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty. The Journal of

[143] Gujarathi N, Putti AB, Abboud RJ, MacLean JGB, Espley AJ, Kellett CF. Risk of periprosthetic fracture after anterior femoral notching: A 9-year follow-up of 200 total knee arthroplasties. Acta Orthopaedica. 2009;**80**(5):553-556. DOI:

knee fractures. A review of

[141] Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL,

[142] Lombardi AV, Mallory TH,

Arthroplasty. 1995;**10**:643-650

10.3109/17453670903350099

Schmidt AH. Periprosthetic knee fractures. Journal of Orthopaedic Trauma. 2008;**22**:663-671. DOI: 10.1097/BOT.0b013e31816ed989

[145] Rorabeck CH, Taylor JW. Periprosthetic fractures of the femur complicating total knee arthroplasty. The Orthopedic Clinics of North America. 1999;**30**:265-277

[144] Parvizi J, Jain N,

v88i2 -S.6522

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

Bone and Joint Surgery. American Volume. 2009;**91**:38-47. DOI: 10.2106/JBJS.G.01686

for infected total knee arthroplasty: A report of two cases. Journal of Arthroplasty. 1990;**5**(3):277-279. DOI: 10.1016/S0883-5403(08)80083-6

[131] White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee replacement. Journal of Bone and Joint Surgery. British Volume

(London). 1998;**80**:909-911

[132] Tahta M, Simsek ME, Isik C, Akkaya M, Gursoy S, Bozkurt M. Does inflammatory joint diseases affect the accuracy of infection biomarkers in patients with periprosthetic joint infections? A prospective comparative reliability study. Journal of Orthopaedic

Science. 2019;**24**:286-289. DOI: 10.1016/j.jos.2018.08.022

[133] Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, et al. The 2018 definition of Periprosthetic hip and knee infection: An evidencebased and validated criteria. The Journal of Arthroplasty. 2018;**33**:1309-1314.e2. DOI: 10.1016/j.arth.2018.02.078

[134] Shaikh AA, Ha CW, Park YG, Park YB. Two-stage approach to primary TKA in infected arthritic knees using intraoperatively molded articulating cement spacers. Clinical Orthopaedics and Related Research. 2014. DOI: 10.1007/s11999-014-3545-6

[135] Juul R, Fabrin J, Poulsen K, Schroder HM. Use of a new knee prosthesis as an articulating spacer in two-stage revision of infected total knee arthroplasty. The Knee Surgery and Related Research. 2016. DOI: 10.5792/

[136] Ha C-W. Treatment of infected total knee arthroplasty. The Knee Surgery and Related Research. 2017.

ksrr.2016.28.3.239

DOI: 10.5792/ksrr.17.301

Lectures. 2001;**50**:379-389

[137] Dennis DA. Periprosthetic fractures following total knee arthroplasty. Instructional Course

[123] Hanssen AD. Prophylactic use of antibiotic bone cement: An emerging standard--in opposition. Journal of

Arthroplasty. 2004;**19**:73-77

Arthroplasty. 1996;**11**:931-938

[125] Kilgus DJ, Howe DJ,

[124] Wasielewski RC, Barden RM, Rosenberg AG. Results of different surgical procedures on total knee arthroplasty infections. The Journal of

Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clinical Orthopaedics and Related

Research. 2002;**404**:116-124. DOI: 10.1097/00003086-200211000-00021

[126] Phelan DM, Osmon DR, Keating MR, Hanssen AD. Delayed reimplantation arthroplasty for candidal prosthetic joint infection: A report of 4 cases and review of the literature. Clinical Infectious Diseases. 2002;**34**:930-938. DOI: 10.1086/339212

[127] Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: A randomized controlled trial. Foreign-body infection (FBI) study group. JAMA.

1998;**279**(19):1537-1541

[128] Arizono T, Oga M, Sugioka Y. Increased resistance of bacteria after adherence to polymethyl methacrylate. An in vitro study. Acta Orthopaedica Scandinavica. 1992;**63**:661-664

[129] Morrey BF, Westholm F, Schoifet S, Rand JA, Bryan RS. Long-term results of various treatment options for

infected total knee arthroplasty. Clinical Orthopaedics and Related Research.

[130] Schoifet SD, Morrey BF. Persistent infection after successful arthrodesis

**84**

1989:120-128

[138] Ricci WM. Periprosthetic femur fractures. Journal of Orthopaedic Trauma. 2015. DOI: 10.1097/ BOT.0000000000000282

[139] Haller JM, Kubiak EN, Spiguel A, Gardner MJ, Horwitz DS. Intramedullary nailing of tibial shaft fractures distal to total knee arthroplasty. Journal of Orthopaedic Trauma. 2014. DOI: 10.1097/BOT.0000000000000096

[140] Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome. Acta Biomedica. 2017. DOI: 10.23750/abm. v88i2 -S.6522

[141] Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL, Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clinical Orthopaedics and Related Research. 1987;**222**:212-222

[142] Lombardi AV, Mallory TH, Waterman RA, Eberle RW. Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty. The Journal of Arthroplasty. 1995;**10**:643-650

[143] Gujarathi N, Putti AB, Abboud RJ, MacLean JGB, Espley AJ, Kellett CF. Risk of periprosthetic fracture after anterior femoral notching: A 9-year follow-up of 200 total knee arthroplasties. Acta Orthopaedica. 2009;**80**(5):553-556. DOI: 10.3109/17453670903350099

[144] Parvizi J, Jain N, Schmidt AH. Periprosthetic knee fractures. Journal of Orthopaedic Trauma. 2008;**22**:663-671. DOI: 10.1097/BOT.0b013e31816ed989

[145] Rorabeck CH, Taylor JW. Periprosthetic fractures of the femur complicating total knee arthroplasty. The Orthopedic Clinics of North America. 1999;**30**:265-277

[146] Engh GA, Ammeen DJ. Periprosthetic fractures adjacent to total knee implants: Treatment and clinical results. Instructional Course Lectures. 1998;**47**:437-448

[147] Merkel KD, Johnson EW. Supracondylar fracture of the femur after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 1986;**68**:29-43

[148] Mortazavi SMJ, Kurd MF, Bender B, Post Z, Parvizi J, Purtill JJ. Distal femoral arthroplasty for the treatment of periprosthetic fractures after total knee arthroplasty. The Journal of Arthroplasty. 2010;**25**:775- 780. DOI: 10.1016/j.arth.2009.05.024

[149] Felix NA, Stuart MJ, Hanssen AD. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clinical Orthopaedics and Related Research. 1997;**345**:113-124

[150] Rand JA, Coventry MB. Stress fractures after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 1980;**62**:226-233

[151] Işık C, Emre F, Ertaş SE. Aseptik gevşeme. TOTBİD Dergisi. 2019;**18**:163-169. DOI: 10.14292/totbid. dergisi.2019.19

[152] Lee B-S, Cho H-I, Bin S-I, Kim J-M, Jo B-K. Femoral component varus malposition is associated with tibial aseptic loosening after TKA. Clinical Orthopaedics and Related Research. 2018;**476**:400-407. DOI: 10.1007/ s11999.0000000000000012

[153] Tírico LEP, Pasqualin T, Pécora JO, Gobbi RG, Pécora JR, Demange MK. Estudo da estabilidade dos componentes na artroplastia total do joelho sem cimento. Acta Ortopédica Brasileira. 2012;**20**(4):230-234. DOI: 10.1590/s1413-78522012000400008

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**87**

**Chapter 6**

**Abstract**

total knee arthroplasty

**1. Introduction**

**2. Prevalence**

Arthroplasty

*Alisina Shahi and Ali Oliashirazi*

Stiffness after Primary Total Knee

Total knee arthroplasty remains the definitive treatment for end-stage osteoarthritis of the knee. Despite being a very successful intervention in terms of relieving pain and returning a patient's function, it is not without complications. Post-operative stiffness after total knee arthroplasty is one of those complications that can be puzzling for physicians and debilitating for patients. While the etiology of stiffness is multifactorial, the treatment options are essentially limited to manipulation under anesthesia, removal of adhesions and revision total knee arthroplasty. With patient outcomes directly related to relief of pain and post-operative range of motion, it is paramount that surgeons do all that is necessary to minimize risk of post-operative stiffness.

**Keywords:** total knee arthroplasty, stiffness, manipulation under anesthesia, revision

Total knee arthroplasty (TKA) remains the mainstay of treatment in terms of pain relief, restoring mobility, and quality of life improvement for patients with end-stage osteoarthritis of the knee. Pain relief and postoperative range of motion (ROM) have consistently been the two variables of most importance to patients [1–3]. Stiffness after TKA can be debilitating due to pain and functional limitations in daily activities such as going up or down the stairs and sitting or arising from a chair. This chapter discusses

the prevalence, etiology, and management of stiffness after primary TKA.

The reported incidence of stiffness after TKA varies greatly in literature with rates ranging from 1.3 to 12% [4, 5]. This wide range of incidence results largely due to lack of a consistent widely accepted definition of stiffness after TKA. Laubenthal et al. reported in their quantitative analysis of knee range of motion during activities of daily living (ADL) that patients required a mean of 83 degrees of knee flexion to climb stairs, 93 degrees to sit in a chair without using their hands and 106 degrees for tying their shoes while seated [6]. In fact, many authors use a cut-off of around 95 degrees of flexion to define stiffness as that allows patients to do most of their ADLs [7]. What is less clear is perhaps, at what time point in the postoperative period must a patient obtain 95° [7–9]. Based on the international consensus definition for stiffness

*Vishavpreet Singh, Galen Berdis, Akshay Goel,* 

#### **Chapter 6**

*Knee Surgery - Reconstruction and Replacement*

and Joint Journal 2014;96-B:105-111. doi:10.1302/0301-620X.96B11.34531

Patellofemoral problems following total knee arthroplasty. Orthopaedic Review.

[164] Young SW, Saffi M, Spangehl MJ, Clarke HD. Unexplained pain following total knee arthroplasty: Is rotational malalignment the problem? The Knee. 2018. DOI: 10.1016/j.knee.2018.01.011

[163] Doolittle KH, Turner RH.

[165] Czurda T, Fennema P, Baumgartner M, Ritschl P. The association between component malalignment and post-operative pain following navigation-assisted total knee arthroplasty: Results of a cohort/nested case-control study. The Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/

s00167-009-0990-y

1=U&auinitm=G

[167] Petersen W, Rembitzki IV, Brüggemann GP, Ellermann A, Best R, Koppenburg AG, et al. Anterior knee pain after total knee arthroplasty: A narrative review. International Orthopaedics. 2014;**38**(2):319-328. DOI:

10.1007/s00264-013-2081-4

[166] Longo UG, Ciuffreda M,

Mannering N, D'Andrea V, Cimmino M, Denaro V, et al. Patellar resurfacing in total knee arthroplasty: Systematic review and meta-analysis. Journal of Arthroplasty. 2017. DOI:10.1016/j. arth.2017.08.041 LK. Available from: http://sfxit.ugent.be/ugent?sid=EMBA SE&issn=15328406&id=doi:10.1016% 2Fj.arth.2017.08.041&atitle=Patellar+ Resurfacing+in+Total+Knee+Arthropl asty%3A+Systematic+Review+and+M eta-Analysis&stitle=J.+Arthroplasty& title=Journal+of+Arthroplasty&volum e=&issue=&spage=&epage=&aulast= Longo&aufirst=Umile+G.&auinit=U.G .&aufull=Longo+U.G.&coden=JOARE &isbn=&pages=-&date=2017&auinit-

1988

[156] Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, et al. The epidemiology of revision total knee arthroplasty in the United States. Clinical Orthopaedics and Related Research. 2010;**468**:45-51. DOI:

[157] Peters PC, Engh GA, Dwyer KA, Vinh TN. Osteolysis after total knee arthroplasty without cement. The Journal of Bone and Joint Surgery. American Volume. 1992;**74**:864-876

arthroplasty: A quick review. The Journal of Knee Surgery. 2015;**28**:139- 144. DOI: 10.1055/s-0034-1398375

[155] Naudie DDR, Ammeen DJ, Engh GA, Rorabeck CH. Wear and osteolysis around total knee arthroplasty. The Journal of the American Academy of Orthopaedic

Surgeons. 2007;**15**:53-64

10.1007/s11999-009-0945-0

[158] Robinson EJ, Mulliken BD, Bourne RB, Rorabeck CH,

[159] Callaghan JJ, O'Rourke MR, Liu SS. The role of implant constraint in revision total knee arthroplasty: Not too little, not too much. Journal of

Research. 1995;**321**:98-105

Arthroplasty. 2005;**20**:41-43

[161] Bozic KJ, Kamath AF,

1988;**17**:696-702

[160] Doolittle KH, Turner RH.

Patellofemoral problems following total knee arthroplasty. Orthopaedic Review.

Ong K, Lau E, Kurtz S, Chan V, et al. Comparative epidemiology of revision arthroplasty: Failed THA poses greater clinical and economic burdens than failed TKA. Clinical Orthopaedics and Related Research. 2015;**473**:2131-2138. DOI: 10.1007/s11999-014-4078-8

[162] Vince KG. The problem total knee replacement: Systematic, comprehensive and efficient evaluation. The The Bone

Alvarez C. Catastrophic osteolysis in total knee replacement. A report of 17 cases. Clinical Orthopaedics and Related

**86**

## Stiffness after Primary Total Knee Arthroplasty

*Vishavpreet Singh, Galen Berdis, Akshay Goel, Alisina Shahi and Ali Oliashirazi*

#### **Abstract**

Total knee arthroplasty remains the definitive treatment for end-stage osteoarthritis of the knee. Despite being a very successful intervention in terms of relieving pain and returning a patient's function, it is not without complications. Post-operative stiffness after total knee arthroplasty is one of those complications that can be puzzling for physicians and debilitating for patients. While the etiology of stiffness is multifactorial, the treatment options are essentially limited to manipulation under anesthesia, removal of adhesions and revision total knee arthroplasty. With patient outcomes directly related to relief of pain and post-operative range of motion, it is paramount that surgeons do all that is necessary to minimize risk of post-operative stiffness.

**Keywords:** total knee arthroplasty, stiffness, manipulation under anesthesia, revision total knee arthroplasty

#### **1. Introduction**

Total knee arthroplasty (TKA) remains the mainstay of treatment in terms of pain relief, restoring mobility, and quality of life improvement for patients with end-stage osteoarthritis of the knee. Pain relief and postoperative range of motion (ROM) have consistently been the two variables of most importance to patients [1–3]. Stiffness after TKA can be debilitating due to pain and functional limitations in daily activities such as going up or down the stairs and sitting or arising from a chair. This chapter discusses the prevalence, etiology, and management of stiffness after primary TKA.

#### **2. Prevalence**

The reported incidence of stiffness after TKA varies greatly in literature with rates ranging from 1.3 to 12% [4, 5]. This wide range of incidence results largely due to lack of a consistent widely accepted definition of stiffness after TKA. Laubenthal et al. reported in their quantitative analysis of knee range of motion during activities of daily living (ADL) that patients required a mean of 83 degrees of knee flexion to climb stairs, 93 degrees to sit in a chair without using their hands and 106 degrees for tying their shoes while seated [6]. In fact, many authors use a cut-off of around 95 degrees of flexion to define stiffness as that allows patients to do most of their ADLs [7]. What is less clear is perhaps, at what time point in the postoperative period must a patient obtain 95° [7–9]. Based on the international consensus definition for stiffness

according to restriction in ROM, the severity may be graded according to loss of movement based on the deviation from full flexion or extension as mild, moderate, and severe extension restriction (5–10, 11–20, >20) or flexion range (90–100, 70–89, <70) [10]. However, no consensus statement was made on time frame.

#### **3. Etiology**

The etiology of stiffness is multifactorial and the associated risk factors can be evaluated by dividing them into three categories: preoperative, intraoperative, and postoperative.

#### **3.1 Preoperative risk factors**

There are several preoperative risk factors that may contribute to stiffness after TKA and can be further subcategorized into modifiable versus nonmodifiable.

#### *3.1.1 Modifiable*

The major modifiable risk factor is preoperative ROM. Preoperative ROM has consistently been shown to be one of the best predictors of postoperative ROM. Patients with decreased preoperative ROM often have decreased postoperative ROM as well as lower functional scores compared to those without decreased preoperative ROM [11, 12]. With respect to flexion, studies have shown that patients with poor preoperative flexion (<90 degrees) tend to gain flexion postoperatively and those with good preoperative flexion (>105 degrees) experience a net loss in flexion, yet retain a greater ROM overall [13, 14].

#### *3.1.2 Nonmodifiable*

Certain patients, that senior author calls "scar-formers", may be at increased risk of stiffness due to their genetic makeup. Several studies have implicated the role of genetics in the formation of arthrofibrosis [15, 16]. It is unclear how to identify these Scar-formers as literature is lacking on whether or not patients with previous keloids or hypertrophic scars go onto to develop stiffness after TKA. At the very least, these findings may serve as a reminder to the treating physician to pay particular attention to these patients as they progress through their postoperative rehabilitation.

While a history of previous surgery and/or trauma has certainly been shown to adversely influence outcomes after TKA, whether or not previous surgery predicts postoperative ROM or stiffness is less clear [17]. In a study by Scranton et al., 85% of the patients with a stiff knee after TKA had previous surgery or diabetes mellitus [9]. Another study evaluating the results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis, reported average arc of motion to be 8 degrees less in TKA patients with prior history of failed proximal tibial osteotomy than those without it. Despite the small difference in arc of motion, the final average arc of motion was 95 degrees in the osteotomy group and there were no differences in rate of people undergoing manipulation for stiffness when compared to those without the osteotomy [18]. Similarly, Harvey et al. showed previous proximal tibial osteotomy had no effect on ultimate ROM [13]. Patients that underwent TKA after a failed unicompartmental knee arthroplasty have demonstrated mean postoperative arcs of motion between 104 and 115 degrees [19]. When comparing patients undergoing TKA for primary osteoarthritis versus post-traumatic osteoarthritis, literature demonstrates that overall there is significant improvement in

**89**

*Stiffness after Primary Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89565*

**3.2 Intraoperative risk factors**

contribute to stiffness in both flexion and extension.

postoperative ROM when compared to preoperative ROM in both cohorts [20, 21]. However, the improvements were significantly inferior in the post-traumatic cohort [20]. Ultimately, we suspect that the specific type of prior surgery and/or trauma may play a significant role in determining its effect on postoperative ROM.

Lastly, obesity itself has not been shown to be a significant risk factor for postoperative stiffness, but patients with large thigh diameters may have reduced range of motion with flexion due to a mechanical block from abutment of soft tissues [22].

Total knee arthroplasty should be thought of as a patient-specific procedure. Each patient's anatomy and deformity presents a unique challenge and no two consecutive knee arthroplasties are the same and therefore, attention to small details is crucial for a successful result. Most of the intraoperative variables that contribute to postoperative stiffness are related to the surgical technique. Improper gap balancing, incorrect component sizing or positioning, excessively elevating or lowering the joint line, incomplete resection of osteophytes, and closure techniques can all

Improper gap balancing can lead to a joint that is "overstuffed" in flexion and/or extension, resulting in a stiff joint. Gap balancing can be easily understood by applying McPherson rules: if the tightness is symmetric in both flexion and extension, problem lies in the proximal tibia resection and if the tightness is asymmetric (i.e. tight in flexion but not in extension and vice versa), problem lies in the femoral resection. Excessive tightness in extension is caused by inadequate distal femur resection, tight posterior capsule, and inadequate resection of osteophytes. If tightness is present in both flexion and extension, it is generally due to a polyethylene insert that is too thick or insufficient proximal tibial resection. Excessive tightness in flexion is often caused by inadequate posterior femoral cut, decreased tibial slope, an oversized femoral component, and a femoral component that is shift posteriorly or malrotated. If using a cruciate retaining implant, a tight posterior cruciate ligament can also limit flexion. Furthermore, intimate knowledge of the instrumentation used during TKA is crucial as when an anterior referencing guide is used, the selection of a larger femoral component leads to tightness in flexion if sizing guide measurement is in between sizes. While gap balancing in the sagittal plane is important, the patellofemoral joint (PFJ) deserves equal attention as overstuffing the PFJ can lead to tightness of the extensor mechanism and stiffness after TKA. PFJ is usually overstuffed due to two reasons: (i) inadequate resection of the patella or (ii) anterior placement of the femoral component. Generally speaking, the amount of patellar bone resected should equal the width of the patellar component while also keeping in mind the thickness of the cartilage that may not be present at the time of TKA. In a study by Alcerro et al., patients in whom the patellar thickness after TKA was restored as close to the native thickness demonstrated the greatest improvements in quality of life, physical measures and Western Ontario and McMaster Universities Arthritis Index stiffness scores [23]. Additionally, their study also showed that patients who reported more stiffness and lower knee active flexion had greater than native patella thickness after surgery [23]. Studies by Daluga et al. and Shoji et al. further show that an increase of 12% in anterior–posterior diameter of the knee and increase of 20% in patellar thickness, respectively, leads to marked increase in postoperative stiffness [8, 22]. In a similar fashion, joint line elevation can lead to issues with PFJ kinematics and cause stiffness after TKA. Elevated joint line, whether due to inadequate resection of tibia, excessive resection of distal femur, or thick polyethylene inserts, leads to patella baja. Patella baja has been associated with decreased postoperative ROM and patient reported outcome measures [24, 25]. The importance of maintaining correct patellar

*Knee Surgery - Reconstruction and Replacement*

**3. Etiology**

postoperative.

*3.1.1 Modifiable*

*3.1.2 Nonmodifiable*

**3.1 Preoperative risk factors**

according to restriction in ROM, the severity may be graded according to loss of movement based on the deviation from full flexion or extension as mild, moderate, and severe extension restriction (5–10, 11–20, >20) or flexion range (90–100, 70–89, <70)

The etiology of stiffness is multifactorial and the associated risk factors can be evaluated by dividing them into three categories: preoperative, intraoperative, and

There are several preoperative risk factors that may contribute to stiffness after

TKA and can be further subcategorized into modifiable versus nonmodifiable.

The major modifiable risk factor is preoperative ROM. Preoperative ROM has consistently been shown to be one of the best predictors of postoperative ROM. Patients with decreased preoperative ROM often have decreased postoperative ROM as well as lower functional scores compared to those without decreased preoperative ROM [11, 12]. With respect to flexion, studies have shown that patients with poor preoperative flexion (<90 degrees) tend to gain flexion postoperatively and those with good preoperative flexion (>105 degrees) experience a net

Certain patients, that senior author calls "scar-formers", may be at increased risk of stiffness due to their genetic makeup. Several studies have implicated the role of genetics in the formation of arthrofibrosis [15, 16]. It is unclear how to identify these Scar-formers as literature is lacking on whether or not patients with previous keloids or hypertrophic scars go onto to develop stiffness after TKA. At the very least, these findings may serve as a reminder to the treating physician to pay particular attention to

While a history of previous surgery and/or trauma has certainly been shown to adversely influence outcomes after TKA, whether or not previous surgery predicts postoperative ROM or stiffness is less clear [17]. In a study by Scranton et al., 85% of the patients with a stiff knee after TKA had previous surgery or diabetes mellitus [9]. Another study evaluating the results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis, reported average arc of motion to be 8 degrees less in TKA patients with prior history of failed proximal tibial osteotomy than those without it. Despite the small difference in arc of motion, the final average arc of motion was 95 degrees in the osteotomy group and there were no differences in rate of people undergoing manipulation for stiffness when compared to those without the osteotomy [18]. Similarly, Harvey et al. showed previous proximal tibial osteotomy had no effect on ultimate ROM [13]. Patients that underwent TKA after a failed unicompartmental knee arthroplasty have demonstrated mean postoperative arcs of motion between 104 and 115 degrees [19]. When comparing patients undergoing TKA for primary osteoarthritis versus post-traumatic osteoarthritis, literature demonstrates that overall there is significant improvement in

these patients as they progress through their postoperative rehabilitation.

[10]. However, no consensus statement was made on time frame.

loss in flexion, yet retain a greater ROM overall [13, 14].

**88**

postoperative ROM when compared to preoperative ROM in both cohorts [20, 21]. However, the improvements were significantly inferior in the post-traumatic cohort [20]. Ultimately, we suspect that the specific type of prior surgery and/or trauma may play a significant role in determining its effect on postoperative ROM.

Lastly, obesity itself has not been shown to be a significant risk factor for postoperative stiffness, but patients with large thigh diameters may have reduced range of motion with flexion due to a mechanical block from abutment of soft tissues [22].

#### **3.2 Intraoperative risk factors**

Total knee arthroplasty should be thought of as a patient-specific procedure. Each patient's anatomy and deformity presents a unique challenge and no two consecutive knee arthroplasties are the same and therefore, attention to small details is crucial for a successful result. Most of the intraoperative variables that contribute to postoperative stiffness are related to the surgical technique. Improper gap balancing, incorrect component sizing or positioning, excessively elevating or lowering the joint line, incomplete resection of osteophytes, and closure techniques can all contribute to stiffness in both flexion and extension.

Improper gap balancing can lead to a joint that is "overstuffed" in flexion and/or extension, resulting in a stiff joint. Gap balancing can be easily understood by applying McPherson rules: if the tightness is symmetric in both flexion and extension, problem lies in the proximal tibia resection and if the tightness is asymmetric (i.e. tight in flexion but not in extension and vice versa), problem lies in the femoral resection. Excessive tightness in extension is caused by inadequate distal femur resection, tight posterior capsule, and inadequate resection of osteophytes. If tightness is present in both flexion and extension, it is generally due to a polyethylene insert that is too thick or insufficient proximal tibial resection. Excessive tightness in flexion is often caused by inadequate posterior femoral cut, decreased tibial slope, an oversized femoral component, and a femoral component that is shift posteriorly or malrotated. If using a cruciate retaining implant, a tight posterior cruciate ligament can also limit flexion. Furthermore, intimate knowledge of the instrumentation used during TKA is crucial as when an anterior referencing guide is used, the selection of a larger femoral component leads to tightness in flexion if sizing guide measurement is in between sizes.

While gap balancing in the sagittal plane is important, the patellofemoral joint (PFJ) deserves equal attention as overstuffing the PFJ can lead to tightness of the extensor mechanism and stiffness after TKA. PFJ is usually overstuffed due to two reasons: (i) inadequate resection of the patella or (ii) anterior placement of the femoral component. Generally speaking, the amount of patellar bone resected should equal the width of the patellar component while also keeping in mind the thickness of the cartilage that may not be present at the time of TKA. In a study by Alcerro et al., patients in whom the patellar thickness after TKA was restored as close to the native thickness demonstrated the greatest improvements in quality of life, physical measures and Western Ontario and McMaster Universities Arthritis Index stiffness scores [23].

Additionally, their study also showed that patients who reported more stiffness and lower knee active flexion had greater than native patella thickness after surgery [23]. Studies by Daluga et al. and Shoji et al. further show that an increase of 12% in anterior–posterior diameter of the knee and increase of 20% in patellar thickness, respectively, leads to marked increase in postoperative stiffness [8, 22]. In a similar fashion, joint line elevation can lead to issues with PFJ kinematics and cause stiffness after TKA. Elevated joint line, whether due to inadequate resection of tibia, excessive resection of distal femur, or thick polyethylene inserts, leads to patella baja. Patella baja has been associated with decreased postoperative ROM and patient reported outcome measures [24, 25]. The importance of maintaining correct patellar height is further demonstrated by Vives-Barquiel et al. by showing improvements in flexion and clinical scores after osteotomy of the tibial tuberosity to move it proximally in knees with postoperative patella baja [26]. Of course, there is potential for catastrophic complication with this procedure, including nonunion and escape.

Lastly, several studies have demonstrated that knee position (i.e. flexion, semi-flexed, versus extended) during surgical wound closure may influence postoperative ROM. In a literature review by Faour et al., authors concluded that wound closure in flexion was associated with significant improvement in ROM recovery at earlier follow-ups after TKA and faster physical recovery compared with wound closure in extension. However, no difference was noticed in long-term ROM recovery when comparing closure with knee in flexion versus extension [27]. On the contrary, studies by Motififard et al. and Masri et al. demonstrated no differences in postoperative ROM with knees closed in flexion versus extension [28, 29].

#### **3.3 Postoperative risk factors**

Postoperative risk factors that can contribute to stiffness include lack of patient participation/compliance with therapy, uncontrolled pain, complex regional pain syndrome (CRPS), heterotrophic ossification (HO), infection, patellar complications, and arthrofibrosis. Postoperative physical therapy is an integral component of recovery after TKA, as patients often have issues with gait, balance, strength, and ROM. It requires significant commitment on the part of the both the physician and the patient to come up with an individualized plan meet postoperative rehabilitation goals. Poorly motivated patients are less likely to mobilize after surgery, comply with postoperative ROM and more likely to have a prolonged hospital stay. It is pertinent to identify these patients early (often even before surgery) and intervene early.

Uncontrolled pain or CRPS can also prohibit patients from exerting their maximum effort at therapy and must be correctly identified early and correct interventions including a possible referral to pain management be instituted. The incidence of postoperative infection after TKA is around 2% and should be considered in any patient with postoperative stiffness. If suspicion for infection is high appropriate labs including ESR, CRP and possible aspiration must be obtained to rule out an infection. Patellar complications such as unresurfaced patella, avascular necrosis of patella, patellar fracture, or mal-tracking can also cause also cause pain and stiffness. Lastly, while the incidence of radiographic HO after TKA may be as high as 26%, it is rare to find HO significant enough to limit ROM.

#### **4. Management**

The most important aspect of management for a stiff TKA is identifying the underlying etiology.

There are several treatment options available for stiffness after TKA including observation with more aggressive physical therapy, manipulation under anesthesia (MUA), surgical debridement, and revision total knee arthroplasty (rTKA). All of these strategies are only successful if done for the right indications. For example, a patient with stiff knee due to component misalignment or underlying infection is not likely to respond to a MUA.

#### **4.1 Manipulation under anesthesia (MUA)**

MUA should be considered when stiffness persists despite an aggressive program to gain motion.

**91**

12 weeks after TKA (p = 0.36) [35].

**4.2 Surgical treatment**

*Stiffness after Primary Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89565*

Since MUA is not a benign procedure given the risk of fracture, extensor mechanism disruption, and hemarthrosis, correct patient selection is crucial. Anterior femoral notching is considered an absolute contraindication to MUA due to increased risk of femoral fractures. When it comes to MUA, one is faced with two questions: (i) which patients to manipulate? And (ii) what is the best time for manipulation? The answer to the first question lies in how one defines post-operative stiffness. Some physicians may stick to a strict number (i.e. flexion <90 by 6 weeks) and offer to manipulate everyone who fails to meet those criteria. However, the issue with a strict-number definition of TKA is that a patient who may not be considered to have stiffness (based on the aforementioned criteria, for example) might in fact be the one who needs the MUA as his/her activity requirements may consist of kneeling and hence greater need for flexion, as is often the case in Middle Eastern cultures. Therefore, the decision to proceed with a TKA should be centered on a joint conversation between the patient and the physician. We have patients in our practice who are very content with a ROM of 0–85 degrees, as they are able to do all the

activities that they desire to do and therefore, do not need a MUA.

With respect to the timing for MUA, there is no consensus in the literature. Studies demonstrate both increased and no additional benefit with early MUA. In their review of patients undergoing MUA for stiffness, Issa et al. report that patients who underwent early MUA (<12 weeks postoperatively) had significantly higher mean gain in flexion (36.5 versus 17), higher final range of motion (119 versus 95 degrees) and higher function scores (88 versus 83) than those who had late (>12 weeks postoperatively) MUA [30]. Furthermore, when they sub-stratified outcomes based incremental time to MUA demonstrated that there was significant drop in range of motion gained after MUA as more time elapsed postoperatively. While some range of motion was gained with MUA at all periods postoperatively, authors reported that best results were obtained when MUA was done within 12 weeks postoperatively and significantly worse at 26 weeks (36.5 versus 12 degrees). Other authors who found higher gains in flexion with early MUA reported similar results [7, 22, 31–33]. Yercan et al. reported a study of 46 patients that underwent MUA for stiffness after TKA had mean flexion arc improvement from 67+/−11 to 114+/−16 degrees. Furthermore, patients that underwent a MUA within the first 3 weeks after TKA had significantly higher final range of motion compared with those who underwent after 3 months (121+/−11 versus 112+/−16). Similarly, Namba et al. reported that although both early and late MUA result in significant gains in flexion arc, early manipulation resulted in approximately twice the mean flexion gains [31]. In contrast to the above studies, there are several studies that have shown no difference in outcomes when stratified based on timing of MUA. Yeoh et al. report on 48 patients that underwent MUA for stiffness and they noticed that at 1 year there was no difference in gain in ROM between knees that were manipulated within 12 weeks postoperatively versus after 12 weeks [34]. Similarly, Keating et al. report their results of 113 MUAs in 90 patients followed for a mean of 4.6 years and noticed that mean knee flexion improved from 70 to 105 degrees, however, no significant difference was found for patients that underwent MUA before or after

Surgical treatment of stiffness in the forms of arthroscopic or open lysis of adhesions with or without MUA after TKA should be considered as the last resort after a patient has failed both physical therapy and MUA (or is outside the time window where MUA alone might not be beneficial). While arthroscopic debridement of adhesions with MUA has shown promising results in patients

#### *Stiffness after Primary Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89565*

*Knee Surgery - Reconstruction and Replacement*

**3.3 Postoperative risk factors**

height is further demonstrated by Vives-Barquiel et al. by showing improvements in flexion and clinical scores after osteotomy of the tibial tuberosity to move it proximally in knees with postoperative patella baja [26]. Of course, there is potential for catastrophic complication with this procedure, including nonunion and escape. Lastly, several studies have demonstrated that knee position (i.e. flexion, semi-flexed, versus extended) during surgical wound closure may influence postoperative ROM. In a literature review by Faour et al., authors concluded that wound closure in flexion was associated with significant improvement in ROM recovery at earlier follow-ups after TKA and faster physical recovery compared with wound closure in extension. However, no difference was noticed in long-term ROM recovery when comparing closure with knee in flexion versus extension [27]. On the contrary, studies by Motififard et al. and Masri et al. demonstrated no differences in

postoperative ROM with knees closed in flexion versus extension [28, 29].

Postoperative risk factors that can contribute to stiffness include lack of patient participation/compliance with therapy, uncontrolled pain, complex regional pain syndrome (CRPS), heterotrophic ossification (HO), infection, patellar complications, and arthrofibrosis. Postoperative physical therapy is an integral component of recovery after TKA, as patients often have issues with gait, balance, strength, and ROM. It requires significant commitment on the part of the both the physician and the patient to come up with an individualized plan meet postoperative rehabilitation goals. Poorly motivated patients are less likely to mobilize after surgery, comply with postoperative ROM and more likely to have a prolonged hospital stay. It is pertinent to identify these patients early (often even before surgery) and intervene early.

Uncontrolled pain or CRPS can also prohibit patients from exerting their maximum effort at therapy and must be correctly identified early and correct interventions including a possible referral to pain management be instituted. The incidence of postoperative infection after TKA is around 2% and should be considered in any patient with postoperative stiffness. If suspicion for infection is high appropriate labs including ESR, CRP and possible aspiration must be obtained to rule out an infection. Patellar complications such as unresurfaced patella, avascular necrosis of patella, patellar fracture, or mal-tracking can also cause also cause pain and stiffness. Lastly, while the incidence of radiographic HO after TKA may be as high as

The most important aspect of management for a stiff TKA is identifying the

There are several treatment options available for stiffness after TKA including observation with more aggressive physical therapy, manipulation under anesthesia (MUA), surgical debridement, and revision total knee arthroplasty (rTKA). All of these strategies are only successful if done for the right indications. For example, a patient with stiff knee due to component misalignment or underlying infection is

MUA should be considered when stiffness persists despite an aggressive program

26%, it is rare to find HO significant enough to limit ROM.

**90**

to gain motion.

**4. Management**

underlying etiology.

not likely to respond to a MUA.

**4.1 Manipulation under anesthesia (MUA)**

Since MUA is not a benign procedure given the risk of fracture, extensor mechanism disruption, and hemarthrosis, correct patient selection is crucial. Anterior femoral notching is considered an absolute contraindication to MUA due to increased risk of femoral fractures. When it comes to MUA, one is faced with two questions: (i) which patients to manipulate? And (ii) what is the best time for manipulation? The answer to the first question lies in how one defines post-operative stiffness. Some physicians may stick to a strict number (i.e. flexion <90 by 6 weeks) and offer to manipulate everyone who fails to meet those criteria. However, the issue with a strict-number definition of TKA is that a patient who may not be considered to have stiffness (based on the aforementioned criteria, for example) might in fact be the one who needs the MUA as his/her activity requirements may consist of kneeling and hence greater need for flexion, as is often the case in Middle Eastern cultures. Therefore, the decision to proceed with a TKA should be centered on a joint conversation between the patient and the physician. We have patients in our practice who are very content with a ROM of 0–85 degrees, as they are able to do all the activities that they desire to do and therefore, do not need a MUA.

With respect to the timing for MUA, there is no consensus in the literature. Studies demonstrate both increased and no additional benefit with early MUA. In their review of patients undergoing MUA for stiffness, Issa et al. report that patients who underwent early MUA (<12 weeks postoperatively) had significantly higher mean gain in flexion (36.5 versus 17), higher final range of motion (119 versus 95 degrees) and higher function scores (88 versus 83) than those who had late (>12 weeks postoperatively) MUA [30]. Furthermore, when they sub-stratified outcomes based incremental time to MUA demonstrated that there was significant drop in range of motion gained after MUA as more time elapsed postoperatively. While some range of motion was gained with MUA at all periods postoperatively, authors reported that best results were obtained when MUA was done within 12 weeks postoperatively and significantly worse at 26 weeks (36.5 versus 12 degrees). Other authors who found higher gains in flexion with early MUA reported similar results [7, 22, 31–33]. Yercan et al. reported a study of 46 patients that underwent MUA for stiffness after TKA had mean flexion arc improvement from 67+/−11 to 114+/−16 degrees. Furthermore, patients that underwent a MUA within the first 3 weeks after TKA had significantly higher final range of motion compared with those who underwent after 3 months (121+/−11 versus 112+/−16). Similarly, Namba et al. reported that although both early and late MUA result in significant gains in flexion arc, early manipulation resulted in approximately twice the mean flexion gains [31].

In contrast to the above studies, there are several studies that have shown no difference in outcomes when stratified based on timing of MUA. Yeoh et al. report on 48 patients that underwent MUA for stiffness and they noticed that at 1 year there was no difference in gain in ROM between knees that were manipulated within 12 weeks postoperatively versus after 12 weeks [34]. Similarly, Keating et al. report their results of 113 MUAs in 90 patients followed for a mean of 4.6 years and noticed that mean knee flexion improved from 70 to 105 degrees, however, no significant difference was found for patients that underwent MUA before or after 12 weeks after TKA (p = 0.36) [35].

#### **4.2 Surgical treatment**

Surgical treatment of stiffness in the forms of arthroscopic or open lysis of adhesions with or without MUA after TKA should be considered as the last resort after a patient has failed both physical therapy and MUA (or is outside the time window where MUA alone might not be beneficial). While arthroscopic debridement of adhesions with MUA has shown promising results in patients

with stiffness from procedures other than TKA, this is not always the case for patients who have it done after TKA [36–39]. Campbell reports an increase of only 11 degrees in flexion and 55 degrees in extension for 8 patients in 1 year after arthroscopy. Similarly, Bocell et al. report that only 2 out of 7 patients maintained pain-free improvements in ROM after arthroscopic debridement and MUA after TKA. On the contrary, other authors have reported marked improvements in ROM after arthroscopic lysis. Tjoumakaris et al. report in their study that after arthroscopic lysis with gentle manipulation for stiffness after TKA, mean flexion improved from 79 to 103 degrees and mean extension deficit from 16 to 4 degrees at average of 31 months, leading authors to conclude that arthroscopic lysis of adhesions is a reliable procedure [40]. However, they also noticed that patients achieved approximately half of the improvement that was obtained at the time of surgery. Volchenko et al. report on a matched cohort study of 35 patients treated with MUA and 35 patients treated with arthroscopic lysis of adhesions plus MUA. Arthroscopic lysis with MUA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (p = 0.032), a 50.0% increase 12+ weeks after TKA (p = 0.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0–60 degrees (p = 0.001). MUA alone yielded a 49.2% increase 4 to 12 weeks after index TKA (p = 0.161), a 27.0% increase 12+ weeks after TKA (p = 0.161) and a 68.8% increase in patients with pre-manipulation ROM of 0 to 60 degrees [41]. Authors concluded arthroscopic lysis of adhesions plus MUA led to greater increases in ROM (p = 0.026) and final knee flexion (p = 0.028) compare with those treated with MUA alone. After arthroscopic lysis of adhesions and manipulation, Diduch et al., Scranton, and Bae et al. also report similar results with mean flexion improvement of 26 degrees, mean gain in ROM of 31 degrees, and mean improvement in arc of motion of 42 degrees, respectively [9, 42, 43]. There is evidence in literature that for patients with a PCL-retaining implant and limitations in ROM (especially flexion), there may be a benefit from arthroscopic release of PCL. Williams et al. report a mean flexion increase of 30 degrees and mean extension improvement from 4 to 1.5 degrees at 20 month follow up 10 knees after arthroscopic release of PCL.

Lastly, revision TKA should be reserved for patients when a clear diagnosis for the cause of stiffness (i.e. malpositioning of components, infection, loosening, etc.) can be made and corrected during surgery as these patients have more predictable results compared to revisions done in patients without a clear-cut diagnosis [44–47]. Hartman et al. report on 35 patients that underwent rTKA for stiffness and at mean of 54.5 months, the mean arc of motion improved by 44.5 degrees. However, 49% (17/35) of the patients required a further intervention for stiffness or sustained a complication. Authors concluded that while rTKA can be performed with reasonable expectation of improvement in ROM, the complication risk is significant [48]. Ries et al. reported better results with rTKA in 6 knees with mean increase in arc of motion of 50 degrees at minimum of 2 year follow up for patients with stiffness secondary to arthrofibrosis only [49]. Generally, results of rTKA specifically for stiffness are less predictable and may be influenced by surgical technique and patient's response to surgical trauma.

#### **5. Conclusion**

TKA is an excellent option for patients with end-stage knee osteoarthritis in terms of pain relief. Postoperative stiffness continues to be a challenge for both the physicians and the patients. Due to the multifactorial etiology of stiffness, the interventions to address it are limited to MUA, lysis of adhesions, and revision TKA. The results with each intervention are variable, especially with surgical options.

**93**

**Author details**

Vishavpreet Singh1

and Ali Oliashirazi1

Camden, NJ, USA

, Galen Berdis1

\*Address all correspondence to: alisinair@gmail.com

provided the original work is properly cited.

, Akshay Goel1

1 Oliashirazi Institute at Marshall University, Huntington, West Virginia, USA

2 Cooper Bone and Joint Institute at Cooper Medical School of Rowan University,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Alisina Shahi2

\*

*Stiffness after Primary Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89565* *Stiffness after Primary Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89565*

*Knee Surgery - Reconstruction and Replacement*

with stiffness from procedures other than TKA, this is not always the case for patients who have it done after TKA [36–39]. Campbell reports an increase of only 11 degrees in flexion and 55 degrees in extension for 8 patients in 1 year after arthroscopy. Similarly, Bocell et al. report that only 2 out of 7 patients maintained pain-free improvements in ROM after arthroscopic debridement and MUA after TKA. On the contrary, other authors have reported marked improvements in ROM after arthroscopic lysis. Tjoumakaris et al. report in their study that after arthroscopic lysis with gentle manipulation for stiffness after TKA, mean flexion improved from 79 to 103 degrees and mean extension deficit from 16 to 4 degrees at average of 31 months, leading authors to conclude that arthroscopic lysis of adhesions is a reliable procedure [40]. However, they also noticed that patients achieved approximately half of the improvement that was obtained at the time of surgery. Volchenko et al. report on a matched cohort study of 35 patients treated with MUA and 35 patients treated with arthroscopic lysis of adhesions plus MUA. Arthroscopic lysis with MUA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (p = 0.032), a 50.0% increase 12+ weeks after TKA (p = 0.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0–60 degrees (p = 0.001). MUA alone yielded a 49.2% increase 4 to 12 weeks after index TKA (p = 0.161), a 27.0% increase 12+ weeks after TKA (p = 0.161) and a 68.8% increase in patients with pre-manipulation ROM of 0 to 60 degrees [41]. Authors concluded arthroscopic lysis of adhesions plus MUA led to greater increases in ROM (p = 0.026) and final knee flexion (p = 0.028) compare with those treated with MUA alone. After arthroscopic lysis of adhesions and manipulation, Diduch et al., Scranton, and Bae et al. also report similar results with mean flexion improvement of 26 degrees, mean gain in ROM of 31 degrees, and mean improvement in arc of motion of 42 degrees, respectively [9, 42, 43]. There is evidence in literature that for patients with a PCL-retaining implant and limitations in ROM (especially flexion), there may be a benefit from arthroscopic release of PCL. Williams et al. report a mean flexion increase of 30 degrees and mean extension improvement from 4 to 1.5

degrees at 20 month follow up 10 knees after arthroscopic release of PCL.

technique and patient's response to surgical trauma.

Lastly, revision TKA should be reserved for patients when a clear diagnosis for the cause of stiffness (i.e. malpositioning of components, infection, loosening, etc.) can be made and corrected during surgery as these patients have more predictable results compared to revisions done in patients without a clear-cut diagnosis [44–47]. Hartman et al. report on 35 patients that underwent rTKA for stiffness and at mean of 54.5 months, the mean arc of motion improved by 44.5 degrees. However, 49% (17/35) of the patients required a further intervention for stiffness or sustained a complication. Authors concluded that while rTKA can be performed with reasonable expectation of improvement in ROM, the complication risk is significant [48]. Ries et al. reported better results with rTKA in 6 knees with mean increase in arc of motion of 50 degrees at minimum of 2 year follow up for patients with stiffness secondary to arthrofibrosis only [49]. Generally, results of rTKA specifically for stiffness are less predictable and may be influenced by surgical

TKA is an excellent option for patients with end-stage knee osteoarthritis in terms of pain relief. Postoperative stiffness continues to be a challenge for both the physicians and the patients. Due to the multifactorial etiology of stiffness, the interventions to address it are limited to MUA, lysis of adhesions, and revision TKA. The results with each intervention are variable, especially with surgical options.

**92**

**5. Conclusion**

#### **Author details**

Vishavpreet Singh1 , Galen Berdis1 , Akshay Goel1 , Alisina Shahi2 \* and Ali Oliashirazi1

1 Oliashirazi Institute at Marshall University, Huntington, West Virginia, USA

2 Cooper Bone and Joint Institute at Cooper Medical School of Rowan University, Camden, NJ, USA

\*Address all correspondence to: alisinair@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[24] Behrend H, Graulich T, Gerlach R, Spross C, Ladurner A. Blackburne-Peel ratio predicts patients' outcomes after total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2019;**27**(5):1562-1569. DOI: 10.1007/ s00167-018-5016-1

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*Knee Surgery - Reconstruction and Replacement*

[1] Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient

affecting postoperative flexion in total knee arthroplasty. Orthopedics.

[9] Scranton PE. Management of knee pain and stiffness after total knee arthroplasty. The Journal of Arthroplasty. 2001;**16**(4):428-435. DOI:

1990;**13**(6):643-649

10.1054/arth.2001.22250

2006;**44**(16):1101-1105

[10] Kalson NS, Borthwick LA,

Mann DA, et al. International consensus on the definition and classification of fibrosis of the knee joint. The Bone & Joint Journal. 2016;**98-B**(11):1479-1488. DOI: 10.1302/0301-620X.98B10.37957

[11] Shi M, Lü H, Guan Z. Influence of preoperative range of motion on the early clinical outcome of total knee arthroplasty. Zhonghua Wai Ke Za Zhi.

[12] Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME. Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis. The Journal of Bone and Joint Surgery. American Volume. 2003;**85**(7):1278-1285. DOI: 10.2106/00004623-200307000-00014

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arthroplasty? Clinical Orthopaedics and Related Research. 1992;**275**:204-210

Spector TD, MacGregor AJ. Genetic associations between frozen shoulder and tennis elbow: A female twin

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1993;**75**(6):950-955

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[2] Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patient satisfaction after TKA. Clinical Orthopaedics and Related Research. 2013;**471**(1):127-133. DOI: 10.1007/

[3] Williams DP, O'Brien S, Doran E, et al. Early postoperative predictors of satisfaction following total knee arthroplasty. The Knee. 2013;**20**(6):442- 446. DOI: 10.1016/j.knee.2013.05.011

[4] Bong MR, Di Cesare PE. Stiffness

[5] Parvizi J, Tarity TD, Steinbeck MJ, et al. Management of stiffness following total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 2006;**88**(Suppl 4):175-181.

after total knee arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons.

DOI: 10.2106/JBJS.F.00608

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43. DOI: 10.1093/ptj/52.1.34

after total knee arthroplasty:

10.1016/j.knee.2005.10.001

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[7] Yercan HS, Sugun TS, Bussiere C, Ait Si Selmi T, Davies A, Neyret P. Stiffness

Prevalence, management and outcomes. The Knee. 2006;**13**(2):111-117. DOI:

[8] Shoji H, Solomonow M, Yoshino S, D'Ambrosia R, Dabezies E. Factors

2004;**12**(3):164-171

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total knee arthroplasty. Clinical Orthopaedics and Related Research.

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[41] Volchenko E, Schwarzman G, Robinson M, Chmell SJ, Gonzalez MH. Arthroscopic Lysis of adhesions with manipulation under anesthesia versus manipulation alone in the treatment of arthrofibrosis after TKA: A matched cohort study.

Orthopedics. 2019;**42**(3):163-167. DOI: 10.3928/01477447-20190424-08

[42] Diduch DR, Scuderi GR, Scott WN, Insall JN, Kelly MA. The efficacy of arthroscopy following total knee replacement. Arthroscopy.

[43] Bae DK, Lee HK, Cho JH. Arthroscopy of symptomatic total knee replacements. Arthroscopy.

[44] Babis GC, Trousdale RT,

of isolated tibial insert exchange and arthrolysis for the management

Pagnano MW, Morrey BF. Poor outcomes

1997;**13**(2):166-171

1995;**11**(6):664-671

1987;**3**(1):31-35

1991;**271**:125-134

Related Research. 1996;**331**:81-86. DOI: 10.1097/00003086-199610000-00011

[31] Namba RS, Inacio M. Early and late manipulation improve flexion after total knee arthroplasty. The Journal of Arthroplasty. 2007;**22**(6 Suppl 2):58-61.

DOI: 10.1016/j.arth.2007.02.010

10.1007/s11999-010-1230-y

1999;**81**(1):27-29

[32] Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: A systematic review. Clinical Orthopaedics and Related Research. 2010;**468**(4):1096-1106. DOI:

[33] Esler CN, Lock K, Harper WM, Gregg PJ. Manipulation of total knee replacements. Is the flexion gained retained? Journal of Bone and Joint Surgery. British Volume (London).

[34] Yeoh D, Nicolaou N, Goddard R, et al. Manipulation under anaesthesia post total knee replacement: Long term follow up. The Knee. 2012;**19**(4):329- 331. DOI: 10.1016/j.knee.2011.05.009

[35] Keating EM, Ritter MA, Harty LD, et al. Manipulation after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 2007;**89**(2):282-286. DOI: 10.2106/

[36] Sprague NF. Motion-limiting arthrofibrosis of the knee: The role of

trial. Clinical Orthopaedics and

[30] Issa K, Banerjee S, Kester MA, Khanuja HS, Delanois RE, Mont MA. The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 2014;**96**(16):1349- 1357. DOI: 10.2106/JBJS.M.00899

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of stiffness following total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 2001;**83**(10):1534-1536. DOI: 10.2106/00004623-200110000-00012

[45] Ritter MA, Stringer EA. Predictive range of motion after total knee replacement. Clinical Orthopaedics and Related Research. 1979;**143**:115-119

[46] Haidukewych GJ, Jacofsky DJ, Pagnano MW, Trousdale RT. Functional results after revision of well-fixed components for stiffness after primary total knee arthroplasty. The Journal of Arthroplasty. 2005;**20**(2):133-138

[47] Nicholls DW, Dorr LD. Revision surgery for stiff total knee arthroplasty. The Journal of Arthroplasty. 1990;**5**(Suppl):S73-S77

[48] Hartman CW, Ting NT, Moric M, Berger RA, Rosenberg AG, Della Valle CJ. Revision total knee arthroplasty for stiffness. The Journal of Arthroplasty. 2010;**25**(6 Suppl):62-66. DOI: 10.1016/j.arth.2010.04.013

[49] Ries MD, Badalamente M. Arthrofibrosis after total knee arthroplasty. Clinical Orthopaedics and Related Research. 2000;**380**:177-183. DOI: 10.1097/00003086-200011000-00024

**99**

surgical correction.

**Chapter 7**

**Abstract**

arthroplasty.

flexion contracture

**1. Introduction**

Arthroplasty

Management of Flexion

Contracture in Total Knee

*Kavin Khatri, Deepak Bansal and Karan Rajpal*

Fixed flexion deformity at knee is common in osteoarthritic knee and is a combination of bony deformity, capsular and ligamentous deformity. It affects knee biomechanics in terms of increased forces at the patellofemoral and tibiofemoral joint. This in turn makes carrying out of routine daily activities like walking or use of staircase very difficult. Therefore, it is essential to correct this deformity at the time of operative intervention. Major interventions like posterior capsular release and removal of osteophytes and adequate bony resection helps in correcting the deformity. Post operatively, use of extension night splints and adequate physiotherapy can help in correcting the residual deformity left over at the time of knee

**Keywords:** total knee arthroplasty, fixed flexion deformity, range of motion,

Flexion deformity at knee in osteoarthritis or rheumatoid arthritis is due to synovial inflammation leading to fluid in joint subsequently resulting in assuming of position maximum accommodation i.e. flexion. Posterior femoral and tibal osteophytes tent upon the capsule resulting in further flexion at the knee and sometimes mechanical block to extension. Other factors like hamstring shortening and ligament contracture also contribute to flexion at the knee. There is increase in energy expenditure while walking or standing along with decreased endurance and inability to stand for long period of time [1–2]. Fixed flexion at single knee increases abnormal forces on other knee resulting in abnormal gait. There is limb length discrepancy and short stride length. There is associated increase in extension and adduction. In severe flexion deformities, there is alteration of kinematics of spine. There are increased chances of lumbar spondylosis and accelerated degeneration of contralateral knee in cases of long standing flexion deformity at knee. Isolated flexion deformity is very rare and generally associated with either varus or valgus deformity at knee [3]. Some authors have reported incidence of flexion deformity up to 60° in cases of osteoarthritis knee [4]. To achieve complete range of movement at knee, full surgical correction should be achieved during

#### **Chapter 7**

## Management of Flexion Contracture in Total Knee Arthroplasty

*Kavin Khatri, Deepak Bansal and Karan Rajpal*

#### **Abstract**

Fixed flexion deformity at knee is common in osteoarthritic knee and is a combination of bony deformity, capsular and ligamentous deformity. It affects knee biomechanics in terms of increased forces at the patellofemoral and tibiofemoral joint. This in turn makes carrying out of routine daily activities like walking or use of staircase very difficult. Therefore, it is essential to correct this deformity at the time of operative intervention. Major interventions like posterior capsular release and removal of osteophytes and adequate bony resection helps in correcting the deformity. Post operatively, use of extension night splints and adequate physiotherapy can help in correcting the residual deformity left over at the time of knee arthroplasty.

**Keywords:** total knee arthroplasty, fixed flexion deformity, range of motion, flexion contracture

#### **1. Introduction**

Flexion deformity at knee in osteoarthritis or rheumatoid arthritis is due to synovial inflammation leading to fluid in joint subsequently resulting in assuming of position maximum accommodation i.e. flexion. Posterior femoral and tibal osteophytes tent upon the capsule resulting in further flexion at the knee and sometimes mechanical block to extension. Other factors like hamstring shortening and ligament contracture also contribute to flexion at the knee. There is increase in energy expenditure while walking or standing along with decreased endurance and inability to stand for long period of time [1–2]. Fixed flexion at single knee increases abnormal forces on other knee resulting in abnormal gait. There is limb length discrepancy and short stride length. There is associated increase in extension and adduction. In severe flexion deformities, there is alteration of kinematics of spine. There are increased chances of lumbar spondylosis and accelerated degeneration of contralateral knee in cases of long standing flexion deformity at knee. Isolated flexion deformity is very rare and generally associated with either varus or valgus deformity at knee [3]. Some authors have reported incidence of flexion deformity up to 60° in cases of osteoarthritis knee [4]. To achieve complete range of movement at knee, full surgical correction should be achieved during surgical correction.

#### **2. Prevalence and risk factors**

Ritter et al. [5] had described that residual flexion contracture by more than 10 degree can result in poor functional outcome in patients who undergo knee replacement. The risk factors for persistence of deformity were male gender, higher age and preoperative flexion contracture of more than five or more degrees [6]. Among these the single most important factor predictive of residual flexion contracture was preoperative flexion deformity at knee. Body mass index has no role in persistence of flexion deformity after surgical correction [7]. Surgical technique factor like overstuffing of extension gap and flexion of femoral component also determines the post-operative flexion deformity. The femoral component placed in flexion can result in limitation of arc of motion due to constraints in articulation.

#### **3. Pathoanatomy**

Long standing cases of arthritis have intercondylar osteophytes, which acts as mechanical block to extension [4]. The posterior osteophytes in addition impinge upon posterior capsule further increasing flexion contracture. Subsequently, it leads to contraction of soft tissues over the posterior aspect of knee adding to the deformity.

There is erosion of the posterior aspect of the tibia and reduction in the strength of quadriceps resulting in extension lag even after correction of deformity. Lombardi et al. [8] had classified flexion deformity into three grades depending upon the severity of deformity. Grade I is mild contracture with deformity limited to less than 15°. Grade II is moderate contracture with deformity between 15° and 30°. Grade III is severe contracture with deformity greater than 30°.

#### **4. Preoperative preparation**

A patient with knee flexion contracture undergoing knee replacement should be evaluated for coronal plane deformities, grade of flexion deformity, extensor lag and preoperative range of motion is recorded. The assessment of these variables helps a surgeon to decide regarding the clinical expectations, surgical technique, associated risks and complications. The next important step is to grade the flexion contracture. The standard radiographs should be evaluated to determine the disturbances in the bony anatomy especially posterior condylar deficiencies, coronal deformities and prominent osteophytes. The posterior condylar deficiency affects the rotation of femoral component when posterior referencing system or measured resection technique is used. Sometimes large bony defects would require augments in the form of allografts or modular inserts.

#### **5. Preoperative measures to treat flexion deformity**

In patients suffering from inflammatory arthritis, there is minimal or no osteophyte formation associated with fixed flexion deformity hence preoperative manipulation is sometimes helpful in selected cases. In cases with bilateral hip and knee deformity, the preoperative manipulation is carried out after hip replacement with the aid of serial casting over the knee in maximal stretch [9]. The cast should be adequately padded to avoid pressure sores over the anterior

**101**

**Figure 1.**

*Posterior osteophytes are removed with the help of osteotome.*

*Management of Flexion Contracture in Total Knee Arthroplasty*

casting becomes relatively pain free and fruitful.

aspect of knee. Epidural anesthesia can be very helpful in these cases as serial

After all preoperative preparations, tourniquet is applied over the limb to operated and activated just before incision. The operative leg is examined again under anesthesia to ascertain the degree of deformities. Limb is draped and prepared with betadine or chlorhexidine solution as per the hospital infection control protocols. A midline skin incision is given extending approximately 5 cm proximal to suprapatellar pouch to a point just medial to tibial tubercle. Medial parapatellar osteotomy is performed with eversion of patella exposing both lateral and medial femoral condyle. Next step is to correction of coronal deformities with removal of osteophytes and soft tissue contractures. All efforts should be concentrated to correct the flexion deformity intraoperatively while maintaining soft tissue and adequate stability. The classical approach described by Insall [10] is to resect the posterior femoral condyle and releasing the soft tissues in order to achieve a rectangular flexion gap. Another technique of balancing is to measure the resected pieces of bones from femoral and

The primary focus in case of fixed flexion deformity is over the posterior femoral recess. The posterior capsule should be released as far as possible. The posterior capsule release makes the extension gap equivalent to flexion gap. It also avoids excessive resection of distal femur which can lead to elevation of joint line and mid

Tibial and femoral cuts are carried out in usual manner as in primary uncomplicated arthroplasty. The flexion contracture is due to posterior recess and posterior osteophytes indenting upon the capsule. After the bony cuts, the osteophytes can easily be visualized and removed with the help of ¾ inch osteotome (**Figure 1**). A intramedullary rod may be used to elevate the distal femur or lamina spreaders can be used for better visualization of posterior capsule. There is clear dividing line between the osteophytes and femoral condyle. The loose osteophytes can be removed with the help of curette. The posterior obliterated posterior recess can be then be created with osteotome. The osteophytes from posterior aspect of tibia are visible clearly at this stage and can be removed with the help of curette and osteotome. The osteophytes attached to the posterior capsule is pulled forward and removed with the help of electrocautery. In case extension gap is less than flexion

tibial condyle and replacing the same with components of same size.

flexion instability there by altering the patellofemoral kinematics.

**7. Grade 1 flexion contracture**

*DOI: http://dx.doi.org/10.5772/intechopen.90417*

**6. Surgical technique**

aspect of knee. Epidural anesthesia can be very helpful in these cases as serial casting becomes relatively pain free and fruitful.

### **6. Surgical technique**

*Knee Surgery - Reconstruction and Replacement*

Ritter et al. [5] had described that residual flexion contracture by more than 10 degree can result in poor functional outcome in patients who undergo knee replacement. The risk factors for persistence of deformity were male gender, higher age and preoperative flexion contracture of more than five or more degrees [6]. Among these the single most important factor predictive of residual flexion contracture was preoperative flexion deformity at knee. Body mass index has no role in persistence of flexion deformity after surgical correction [7]. Surgical technique factor like overstuffing of extension gap and flexion of femoral component also determines the post-operative flexion deformity. The femoral component placed in flexion can result in limitation of arc of motion due to constraints in

Long standing cases of arthritis have intercondylar osteophytes, which acts as mechanical block to extension [4]. The posterior osteophytes in addition impinge upon posterior capsule further increasing flexion contracture. Subsequently, it leads to contraction of soft tissues over the posterior aspect of knee adding to the

There is erosion of the posterior aspect of the tibia and reduction in the strength

A patient with knee flexion contracture undergoing knee replacement should be evaluated for coronal plane deformities, grade of flexion deformity, extensor lag and preoperative range of motion is recorded. The assessment of these variables helps a surgeon to decide regarding the clinical expectations, surgical technique, associated risks and complications. The next important step is to grade the flexion contracture. The standard radiographs should be evaluated to determine the disturbances in the bony anatomy especially posterior condylar deficiencies, coronal deformities and prominent osteophytes. The posterior condylar deficiency affects the rotation of femoral component when posterior referencing system or measured resection technique is used. Sometimes large bony defects would require augments

In patients suffering from inflammatory arthritis, there is minimal or no osteophyte formation associated with fixed flexion deformity hence preoperative manipulation is sometimes helpful in selected cases. In cases with bilateral hip and knee deformity, the preoperative manipulation is carried out after hip replacement with the aid of serial casting over the knee in maximal stretch [9]. The cast should be adequately padded to avoid pressure sores over the anterior

of quadriceps resulting in extension lag even after correction of deformity. Lombardi et al. [8] had classified flexion deformity into three grades depending upon the severity of deformity. Grade I is mild contracture with deformity limited to less than 15°. Grade II is moderate contracture with deformity between 15° and

30°. Grade III is severe contracture with deformity greater than 30°.

**2. Prevalence and risk factors**

articulation.

deformity.

**3. Pathoanatomy**

**4. Preoperative preparation**

in the form of allografts or modular inserts.

**5. Preoperative measures to treat flexion deformity**

**100**

After all preoperative preparations, tourniquet is applied over the limb to operated and activated just before incision. The operative leg is examined again under anesthesia to ascertain the degree of deformities. Limb is draped and prepared with betadine or chlorhexidine solution as per the hospital infection control protocols. A midline skin incision is given extending approximately 5 cm proximal to suprapatellar pouch to a point just medial to tibial tubercle. Medial parapatellar osteotomy is performed with eversion of patella exposing both lateral and medial femoral condyle. Next step is to correction of coronal deformities with removal of osteophytes and soft tissue contractures. All efforts should be concentrated to correct the flexion deformity intraoperatively while maintaining soft tissue and adequate stability. The classical approach described by Insall [10] is to resect the posterior femoral condyle and releasing the soft tissues in order to achieve a rectangular flexion gap. Another technique of balancing is to measure the resected pieces of bones from femoral and tibial condyle and replacing the same with components of same size.

The primary focus in case of fixed flexion deformity is over the posterior femoral recess. The posterior capsule should be released as far as possible. The posterior capsule release makes the extension gap equivalent to flexion gap. It also avoids excessive resection of distal femur which can lead to elevation of joint line and mid flexion instability there by altering the patellofemoral kinematics.

#### **7. Grade 1 flexion contracture**

Tibial and femoral cuts are carried out in usual manner as in primary uncomplicated arthroplasty. The flexion contracture is due to posterior recess and posterior osteophytes indenting upon the capsule. After the bony cuts, the osteophytes can easily be visualized and removed with the help of ¾ inch osteotome (**Figure 1**). A intramedullary rod may be used to elevate the distal femur or lamina spreaders can be used for better visualization of posterior capsule. There is clear dividing line between the osteophytes and femoral condyle. The loose osteophytes can be removed with the help of curette. The posterior obliterated posterior recess can be then be created with osteotome. The osteophytes from posterior aspect of tibia are visible clearly at this stage and can be removed with the help of curette and osteotome. The osteophytes attached to the posterior capsule is pulled forward and removed with the help of electrocautery. In case extension gap is less than flexion

**Figure 1.** *Posterior osteophytes are removed with the help of osteotome.*

gap further release of posterior recess is carried out. However, if extension gap is more than flexion gap, the posterior slope of tibia is evaluated. The slope can be increased up to 8° in order to balance the knee. Tight flexion gap can result in poor roll back of femoral component and lift off of tibia tray.

In majority of the cases, the flexion contracture is corrected with these simple maneuvers. The type of knee prosthesis i.e. cruciate retaining or cruciate sacrificing depends upon the choice of surgeon in mild flexion contracture. Laskin [11] described a test to assess the correction of flexion deformity intraoperatively. The operated limb is lifted from the table and foot is dorsiflexed at ankle subsequently axial pressure is applied along the long axis of the limb. The sudden flexion at knee suggests residual flexion deformity. If there is no bending at knee due to axial pressure then it suggests achievement of adequate correction at the knee joint.

#### **8. Grade II flexion contracture**

In addition to release of posterior recess and removal of osteophytes as described in management of grade I flexion, the posterior cruciate ligament is released from the femoral end first and subsequently from the tibial end as per the requirement. Medial and lateral perforations of posterior cruciate ligament can also result in fractional lengthening. With this technique, the cruciate retaining components can be used. In other cases where posterior cruciate ligament is significantly weakened, one should opt for posterior stabilized components.

At the end of all the above releases, if extension gap is smaller than flexion gap, the distal femur is resected by 2 mm. However, if surgeon decides to go ahead with cruciate retaining knee components then distal femur should be resected by more than 4 mm as it can lead to posterior cruciate ligament dysfunction due to elevation of joint line.

#### **9. Grade III flexion contracture**

In case of flexion contracture is more than 30°, sequential release is carried out as described in management of grade I and II flexion contracture. The posterior cruciate ligament should be released from its proximal and distal attachment to balance flexion and extension gap at this stage. The choice of implant should preferably be posterior stabilized rather than cruciate retaining. It is important to release posterior capsule and gastrocnemius heads from the posterior aspect of distal femur. In majority of the cases the balanced flexion and extension gap is achieved, however, if there is valgus-varus instability due to laxity of medial or lateral collateral ligament then constrained prosthesis should preferably be used. The lax extensor mechanism can be countered by distal and lateral advancement of vastus medialis and medial capsular structures.

Sequential correction of fixed flexion deformity in total knee replacement (**Figure 2**).


**103**

**Figure 2.**

*posterior stabilized constrained). Reproduced from [12].*

*Treating algorithms for grade I, II and III deformity (EG, extension gap; FC, flexion contracture; FG, flexion gap; PCL, posterior cruciate ligament; PCR, posterior cruciate retaining; PS, posterior stabilized; PSC,* 

*Management of Flexion Contracture in Total Knee Arthroplasty*

*DOI: http://dx.doi.org/10.5772/intechopen.90417*

*Management of Flexion Contracture in Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.90417*

*Knee Surgery - Reconstruction and Replacement*

**8. Grade II flexion contracture**

**9. Grade III flexion contracture**

medialis and medial capsular structures.

of joint line.

roll back of femoral component and lift off of tibia tray.

one should opt for posterior stabilized components.

gap further release of posterior recess is carried out. However, if extension gap is more than flexion gap, the posterior slope of tibia is evaluated. The slope can be increased up to 8° in order to balance the knee. Tight flexion gap can result in poor

In majority of the cases, the flexion contracture is corrected with these simple maneuvers. The type of knee prosthesis i.e. cruciate retaining or cruciate sacrificing depends upon the choice of surgeon in mild flexion contracture. Laskin [11] described a test to assess the correction of flexion deformity intraoperatively. The operated limb is lifted from the table and foot is dorsiflexed at ankle subsequently axial pressure is applied along the long axis of the limb. The sudden flexion at knee suggests residual flexion deformity. If there is no bending at knee due to axial pres-

In addition to release of posterior recess and removal of osteophytes as described in management of grade I flexion, the posterior cruciate ligament is released from the femoral end first and subsequently from the tibial end as per the requirement. Medial and lateral perforations of posterior cruciate ligament can also result in fractional lengthening. With this technique, the cruciate retaining components can be used. In other cases where posterior cruciate ligament is significantly weakened,

At the end of all the above releases, if extension gap is smaller than flexion gap, the distal femur is resected by 2 mm. However, if surgeon decides to go ahead with cruciate retaining knee components then distal femur should be resected by more than 4 mm as it can lead to posterior cruciate ligament dysfunction due to elevation

In case of flexion contracture is more than 30°, sequential release is carried out as described in management of grade I and II flexion contracture. The posterior cruciate ligament should be released from its proximal and distal attachment to balance flexion and extension gap at this stage. The choice of implant should preferably be posterior stabilized rather than cruciate retaining. It is important to release posterior capsule and gastrocnemius heads from the posterior aspect of distal femur. In majority of the cases the balanced flexion and extension gap is achieved, however, if there is valgus-varus instability due to laxity of medial or lateral collateral ligament then constrained prosthesis should preferably be used. The lax extensor mechanism can be countered by distal and lateral advancement of vastus

Sequential correction of fixed flexion deformity in total knee replacement

1.Correct coronal deformity with mediolateral balancing and removal of all visible osteophytes. Perform all bony tibial and femoral cuts in the usual manner. In majority of mild flexion contractures, the deformity shall be corrected.

2.The posterior recess should be established with help of osteotome and periosteal elevator. If required the medial and lateral head of gastrocnemius should

sure then it suggests achievement of adequate correction at the knee joint.

**102**

(**Figure 2**).

**Figure 2.**

*Treating algorithms for grade I, II and III deformity (EG, extension gap; FC, flexion contracture; FG, flexion gap; PCL, posterior cruciate ligament; PCR, posterior cruciate retaining; PS, posterior stabilized; PSC, posterior stabilized constrained). Reproduced from [12].*

also be raised from the posterior and distal end of femur. Sometimes transverse capsulotomy is carried out starting medially and moving laterally. The collaterals are carefully separated from the capsule by longitudinal incisions.


#### **10. Postoperative management**

The patients are encouraged to do quadriceps exercises at regular intervals. In cases of mild residual flexion deformity, patients are advised to wear night splints. Stretching exercises play a vital role in the rehabilitation of these cases. It is advised to avoid pillow below the knee and sitting on recliner chairs for a long time as there is tendency towards flexion. The patients should be closely followed in the postoperative period to look for recurrence of deformity. Sometimes patient require manipulation under anesthesia to achieve range of motion similar to that attained in immediate post-operative period. Excessive force should be avoided during manipulation as it might lead to fracture of distal femur.

#### **11. Complications**

1.Recurrence of flexion contracture and loss of movement

As stated earlier, the aim should be full correction of flexion deformity intraoperatively. However, at the end of 1 year few cases experience recurrence of deformity.

2.Flexion extension imbalance

Flexion extension instability in case of flexion extension mismatch might require restraint with rotating hinge prostheses.

3.Peroneal nerve injury

Peroneal nerve injury sometimes occurs in cases of fixed flexion with valgus deformity at knee. There could be associated lengthening of the lower limb.

**105**

**Author details**

Bathinda, Punjab, India

Faridkot, Punjab, India

\*, Deepak Bansal<sup>2</sup>

2 AIMC Bassi Hospital, Ludhiana, Punjab, India

provided the original work is properly cited.

and Karan Rajpal3

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Department of Orthopedics, All India Institute of Medical Sciences,

3 Department of Orthopedics, GGS Medical College and Hospital,

\*Address all correspondence to: kavinkhatri84@gmail.com

Kavin Khatri1

*Management of Flexion Contracture in Total Knee Arthroplasty*

The complexity of surgical procedure increases with increasing flexion deformity of knee. The less complex deformities correct with usual bony resections and removal of osteophytes. Special attention should be paid to creation of posterior capsule. The bony resection especially distal femur should be reserved in cases where soft tissue release achieves inadequate flexion-extension gap match. Postoperatively, the patients should be followed up closely to prevent recurrence of deformity. The patients need monitoring of neurovascular status to miss on an

*DOI: http://dx.doi.org/10.5772/intechopen.90417*

**12. Summary**

untoward complication.

#### **12. Summary**

*Knee Surgery - Reconstruction and Replacement*

casting prior to total knee arthroplasty.

manipulation as it might lead to fracture of distal femur.

1.Recurrence of flexion contracture and loss of movement

**10. Postoperative management**

2.Flexion extension imbalance

3.Peroneal nerve injury

require restraint with rotating hinge prostheses.

prosthesis.

**11. Complications**

deformity.

also be raised from the posterior and distal end of femur. Sometimes transverse capsulotomy is carried out starting medially and moving laterally. The collaterals are carefully separated from the capsule by longitudinal incisions.

3.In cases of severe flexion deformity, distal femoral resection of up to 4 mm in increments of 2 mm is carried out and gap mismatch is checked. It is advisable to resect minimal bone from the distal femur in order to prevent problem of patellofemoral kinematics, patella baja and elevation of joint line. Sometimes it results in mediolateral instability necessitating the need for constrained

4.Medial and lateral hamstrings are tenotomised in order to achieve full correction in rare cases. Biceps femoris should be clearly identified and separated under vision in order to avoid injury to common peroneal nerve. In cases with flexion deformity of more than 60 degrees, it is advisable to undergo serial

The patients are encouraged to do quadriceps exercises at regular intervals. In cases of mild residual flexion deformity, patients are advised to wear night splints. Stretching exercises play a vital role in the rehabilitation of these cases. It is advised to avoid pillow below the knee and sitting on recliner chairs for a long time as there is tendency towards flexion. The patients should be closely followed in the postoperative period to look for recurrence of deformity. Sometimes patient require manipulation under anesthesia to achieve range of motion similar to that attained in immediate post-operative period. Excessive force should be avoided during

As stated earlier, the aim should be full correction of flexion deformity intraoperatively. However, at the end of 1 year few cases experience recurrence of

Flexion extension instability in case of flexion extension mismatch might

Peroneal nerve injury sometimes occurs in cases of fixed flexion with valgus

deformity at knee. There could be associated lengthening of the lower limb.

**104**

The complexity of surgical procedure increases with increasing flexion deformity of knee. The less complex deformities correct with usual bony resections and removal of osteophytes. Special attention should be paid to creation of posterior capsule. The bony resection especially distal femur should be reserved in cases where soft tissue release achieves inadequate flexion-extension gap match. Postoperatively, the patients should be followed up closely to prevent recurrence of deformity. The patients need monitoring of neurovascular status to miss on an untoward complication.

### **Author details**

Kavin Khatri1 \*, Deepak Bansal<sup>2</sup> and Karan Rajpal3

1 Department of Orthopedics, All India Institute of Medical Sciences, Bathinda, Punjab, India

2 AIMC Bassi Hospital, Ludhiana, Punjab, India

3 Department of Orthopedics, GGS Medical College and Hospital, Faridkot, Punjab, India

\*Address all correspondence to: kavinkhatri84@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. Knee fl exion contracture will lead to mechanical overload in both limbs: A simulation study using gait analysis. The Knee. 2008;**15**:467-472

[2] Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. A gait analysis of simulated knee fl exion contracture to elucidate kneespine syndrome. Gait & Posture. 2008;**28**:687-692

[3] Su EP. Fixed flexion deformity and total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume (London). 2012;**94**(11 Suppl A):112-115

[4] León HO, Blanco CE, Guthrie TB, Martínez OJ. Intercondylar notch stenosis in degenerative arthritis of the knee. Arthroscopy. 2005;**21**:294-302

[5] Ritter MA, Lutgring JD, Davis KE, et al. The role of flexion contracture on outcomes in primary total knee arthroplasty. The Journal of Arthroplasty. 2007;**22**:1092-1096

[6] Silva A, Tan S, Tay A, Pang HN, Lo NN, Yeo SJ. Risk factors for a postoperative neutrally aligned total knee arthroplasty in the sagittal plane developing fixed flexion deformity at 2 years follow up study. nternational Journal of Research in Orthopaedics. 2019;**5**:211-215

[7] Cheng K, Ridley D, Bird J, McLeod G. Patients with fixed flexion deformity after total knee arthroplasty do just as well as those without: Tenyear prospective data. International Orthopaedics. 2010;**34**(5):663-667. DOI: 10.1007/s00264-009-0801-6

[8] Lombardi AJ, Mallory T, Adams J. A stepwise algorithmic approach to fl exion contractures in total knee arthroplasty. The Journal of the

American Academy of Orthopaedic Surgeons. 1997;**1**:1-8

[9] Tateishi H. Contracture of the knee joint. The Journal of Joint Surgery. 1985;**4**:361-365

[10] Insall JN, editor. Surgery of the Knee. New York, NY: Churchill Livingstone; 2000. pp. 1558-1562

[11] Laskin RW, Beksac B. Assess and achieve maximal extension. In: Bellemans J, Ries MD, Victor J, editors. Total Knee Arthroplasty: A Guide to Get Better Performance. Berlin: Springer; 2005. pp. 194-197

[12] Lombard AV Jr, Berend KR. Soft tissue balancing of the knee—Flexion contractures. Techniques in Knee Surgery. 2005;**4**(3):193-206

**107**

**Chapter 8**

**Abstract**

Overview

*Melvin J. George*

tive complications.

**1. Introduction**

Valgus Deformity Correction

in Total Knee Replacement: An

Valgus deformity in total knee replacement is a much lesser encountered problem than varus deformity. The deformity can be caused by either bony or ligamentous pathology or both. Bone defects like lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodeling along with soft tissue pathologies like tight lateral collateral ligament (LCL), posterolateral capsule (PLC), popliteus tendon (POP), hamstring tendons, the lateral head of the gastrocnemius (LHG) and iliotibial band (ITB) can add to the magnitude of valgus deformity. Various sequences have been described to achieve balancing while doing a total knee replacement. Proper preoperative planning, clinical examination, necessary implant backup and good operative skill are mandatory to manage bone deformities or soft tissue pathology or both in valgus deformity. Obtaining an accurate axis restoration, component orientation and joint stability in a valgus knee with combined bony and ligamentous pathology may be a difficult task. The long-term results in valgus knees are relatively inferior to those with varus deformity. This chapter structure wise describes the pathology, classification of valgus deformity, radiographic planning, surgical approaches, method of valgus deformity correction, implant selection, associated deformities, precautions and intraopera-

**Keywords:** valgus, total knee replacement, deformity, balancing, hypoplasia

Mechanical axis and anatomical axis are the two alignment parameters in the lower extremity. Mechanical axis is the axis or the line of weight bearing through the bone. In the case of straight bone like the tibia, both mechanical and anatomical axes are the same. Mechanical axis of the femur is different from that of anatomical axis. The former is at 5–7° valgus to the anatomical axis (**Figure 1**). Mechanical tibiofemoral angle (1.3 ± 2° varus) or anatomical tibiofemoral angle (6 ± 2° valgus) can be used to denote normal knee joint alignment. Normal mechanical axis of the knee is defined as a line that passes from the centre of the hip to the centre of the ankle. Normal alignment is defined when this line passes through the centre of the knee. A line that falls towards the lateral side of the knee indicates that the lower extremity is in valgus. Varus alignment is more common in males than in females. Valgus deformity is usually defined when the anatomical tibiofemoral angle is equal to or greater than 10°. Since the weight-bearing axis of the lower limb follows

#### **Chapter 8**

## Valgus Deformity Correction in Total Knee Replacement: An Overview

*Melvin J. George*

#### **Abstract**

Valgus deformity in total knee replacement is a much lesser encountered problem than varus deformity. The deformity can be caused by either bony or ligamentous pathology or both. Bone defects like lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodeling along with soft tissue pathologies like tight lateral collateral ligament (LCL), posterolateral capsule (PLC), popliteus tendon (POP), hamstring tendons, the lateral head of the gastrocnemius (LHG) and iliotibial band (ITB) can add to the magnitude of valgus deformity. Various sequences have been described to achieve balancing while doing a total knee replacement. Proper preoperative planning, clinical examination, necessary implant backup and good operative skill are mandatory to manage bone deformities or soft tissue pathology or both in valgus deformity. Obtaining an accurate axis restoration, component orientation and joint stability in a valgus knee with combined bony and ligamentous pathology may be a difficult task. The long-term results in valgus knees are relatively inferior to those with varus deformity. This chapter structure wise describes the pathology, classification of valgus deformity, radiographic planning, surgical approaches, method of valgus deformity correction, implant selection, associated deformities, precautions and intraoperative complications.

**Keywords:** valgus, total knee replacement, deformity, balancing, hypoplasia

#### **1. Introduction**

Mechanical axis and anatomical axis are the two alignment parameters in the lower extremity. Mechanical axis is the axis or the line of weight bearing through the bone. In the case of straight bone like the tibia, both mechanical and anatomical axes are the same. Mechanical axis of the femur is different from that of anatomical axis. The former is at 5–7° valgus to the anatomical axis (**Figure 1**). Mechanical tibiofemoral angle (1.3 ± 2° varus) or anatomical tibiofemoral angle (6 ± 2° valgus) can be used to denote normal knee joint alignment. Normal mechanical axis of the knee is defined as a line that passes from the centre of the hip to the centre of the ankle. Normal alignment is defined when this line passes through the centre of the knee. A line that falls towards the lateral side of the knee indicates that the lower extremity is in valgus. Varus alignment is more common in males than in females. Valgus deformity is usually defined when the anatomical tibiofemoral angle is equal to or greater than 10°. Since the weight-bearing axis of the lower limb follows

**106**

2019;**5**:211-215

*Knee Surgery - Reconstruction and Replacement*

[1] Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. Knee fl exion contracture will lead to mechanical overload in both limbs: A simulation study using gait analysis. The Knee.

American Academy of Orthopaedic

[9] Tateishi H. Contracture of the knee joint. The Journal of Joint Surgery.

[10] Insall JN, editor. Surgery of the Knee. New York, NY: Churchill Livingstone; 2000. pp. 1558-1562

[11] Laskin RW, Beksac B. Assess and achieve maximal extension. In: Bellemans J, Ries MD, Victor J, editors. Total Knee Arthroplasty: A Guide to Get Better Performance. Berlin: Springer;

[12] Lombard AV Jr, Berend KR. Soft tissue balancing of the knee—Flexion contractures. Techniques in Knee Surgery. 2005;**4**(3):193-206

Surgeons. 1997;**1**:1-8

1985;**4**:361-365

2005. pp. 194-197

[2] Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. A gait analysis of simulated knee fl exion contracture to elucidate kneespine syndrome. Gait & Posture.

[3] Su EP. Fixed flexion deformity and total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume (London). 2012;**94**(11 Suppl A):112-115

[4] León HO, Blanco CE, Guthrie TB, Martínez OJ. Intercondylar notch stenosis in degenerative arthritis of the knee. Arthroscopy. 2005;**21**:294-302

[5] Ritter MA, Lutgring JD, Davis KE, et al. The role of flexion contracture on outcomes in primary total knee arthroplasty. The Journal of Arthroplasty. 2007;**22**:1092-1096

[6] Silva A, Tan S, Tay A, Pang HN, Lo NN, Yeo SJ. Risk factors for a postoperative neutrally aligned total knee arthroplasty in the sagittal plane developing fixed flexion deformity at 2 years follow up study. nternational Journal of Research in Orthopaedics.

[7] Cheng K, Ridley D, Bird J,

10.1007/s00264-009-0801-6

McLeod G. Patients with fixed flexion deformity after total knee arthroplasty do just as well as those without: Tenyear prospective data. International Orthopaedics. 2010;**34**(5):663-667. DOI:

[8] Lombardi AJ, Mallory T, Adams J. A stepwise algorithmic approach to fl exion contractures in total knee arthroplasty. The Journal of the

2008;**15**:467-472

**References**

2008;**28**:687-692

**Figure 1.** *The method of measuring valgus angle at the knee.*

the mechanical axis, a valgus alignment will increase the load in the lateral compartment of the knee. According to Paley and Tetsworth [1], the knee joint is not perpendicular to the mechanical axis of the lower limb but internally rotated at 3°.

In this chapter, let us discuss about the etiology, clinical examination, radiological examination, pre-op planning for total knee replacement, intraoperative steps and precautions to take and complications.

#### **2. Valgus deformity in total knee replacement**

#### **2.1 Aetiology**

Varus or valgus malalignment has a tremendous influence on the loading of the articular surfaces of the knee. This malalignment results in an increased rate of progression of osteoarthrosis in the knee is proven in animal models. The causative factors for valgus deformity of the knee are described as many.

It can be congenital or secondary to osteoarthrosis, rheumatic diseases and posttraumatic arthritis and due to an over-correction consequent to a valgus osteotomy. Valgus deformity in adults is most commonly seen in patients with inflammatory arthritis, tibial malunion, physeal arrest or tibial plateau fracture [2–6]. Persistence of genu valgum from childhood may exist secondary to metabolic disorders, such as rickets and renal osteodystrophy [7]. But in those patients who undergo total knee replacement, osteoarthrosis remains the most common cause.

The pathologic structures which cause the valgus deformity are mainly bony and soft tissue related. Bone factors consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodeling. Soft tissue factors include tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of

**109**

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

the gastrocnemius and iliotibial band. Rarely, the long head of the biceps femoris is also affected. Lax medial structures (mainly MCL) can add on to the deformity. In addition, these deformities can cause tibial external rotation and to a certain extent patellar lateral subluxation [8]. All these factors in varying severity coexisting around a knee make valgus correction a challenging task during

Ranawat et al. [9] have described three grades of valgus deformity.

cally not functional, and hence it calls for a constrained implant [9, 10].

Type I—Correctible valgus and an intact MCL. Type II—Fixed valgus deformity with an intact MCL.

Type VI—Valgus secondary to extra-articular deformity.

Type V—Severe valgus with a lax MCL.

Type F1—Valgus in extension only

• F1a—Intra-articular deformity, loose LCL

• F1b—Extra-articular deformity, normal LCL

lateral collateral ligament, lateral femoral condyle hypoplasia

Type T1—Intra-articular deformity, lateral tibial plateau deficiency Type 2—Extra-articular deformity, tibial metaphyseal or shaft

Grade I is where the deformity is less than 10° and it is not a fixed deformity. In Grade I the medial collateral ligament is intact; hence the deformity is passively

Grade II is featured by a range of deformity from 10 to 20°, whereas the MCL is

Grade III patients have deformity more than 20°. The medial stabilizers are typi-

Since Ranawat's classification did not take into consideration the extra-articular

Another recently introduced classification system based on the bone affected

Type F2—Valgus in both flexion and extension: Intra-articular deformity, tight

From the history, the most important part is the functional disability the patient

is facing and the severity of the pain. Pain, limitation of daily living activities, increasing angular deformity and worsening instability are the usual complaints. The treatment is based on the severity of the symptoms. The co-existence of other pathologies affecting joints like rheumatoid arthritis (RA) and gout has to be evalu-

and multiplanar deformities, Mullaji and Shetty [11] modified it into six types:

Type III—Valgus and hyperextension deformity with an intact MCL. Type IV—Valgus and fixed flexion deformity (FFD) with an intact MCL.

and the soft tissue status is by the International Society for Technology in Arthroplasty. The JST Classification [12] of valgus knees is as follows:

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

total knee replacement.

stretched out but still functional.

*2.2.1 Femoral deformity*

*2.2.2 Tibial deformity*

**2.3 Clinical examination**

ated and treated simultaneously.

**2.2 Classifications**

correctable.

the gastrocnemius and iliotibial band. Rarely, the long head of the biceps femoris is also affected. Lax medial structures (mainly MCL) can add on to the deformity. In addition, these deformities can cause tibial external rotation and to a certain extent patellar lateral subluxation [8]. All these factors in varying severity coexisting around a knee make valgus correction a challenging task during total knee replacement.

#### **2.2 Classifications**

*Knee Surgery - Reconstruction and Replacement*

and precautions to take and complications.

*The method of measuring valgus angle at the knee.*

**2. Valgus deformity in total knee replacement**

factors for valgus deformity of the knee are described as many.

replacement, osteoarthrosis remains the most common cause.

the mechanical axis, a valgus alignment will increase the load in the lateral compartment of the knee. According to Paley and Tetsworth [1], the knee joint is not perpendicular to the mechanical axis of the lower limb but internally rotated at 3°. In this chapter, let us discuss about the etiology, clinical examination, radiological examination, pre-op planning for total knee replacement, intraoperative steps

Varus or valgus malalignment has a tremendous influence on the loading of the articular surfaces of the knee. This malalignment results in an increased rate of progression of osteoarthrosis in the knee is proven in animal models. The causative

It can be congenital or secondary to osteoarthrosis, rheumatic diseases and posttraumatic arthritis and due to an over-correction consequent to a valgus osteotomy. Valgus deformity in adults is most commonly seen in patients with inflammatory arthritis, tibial malunion, physeal arrest or tibial plateau fracture [2–6]. Persistence of genu valgum from childhood may exist secondary to metabolic disorders, such as rickets and renal osteodystrophy [7]. But in those patients who undergo total knee

The pathologic structures which cause the valgus deformity are mainly bony and soft tissue related. Bone factors consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodeling. Soft tissue factors include tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of

**108**

**2.1 Aetiology**

**Figure 1.**

Ranawat et al. [9] have described three grades of valgus deformity.

Grade I is where the deformity is less than 10° and it is not a fixed deformity. In Grade I the medial collateral ligament is intact; hence the deformity is passively correctable.

Grade II is featured by a range of deformity from 10 to 20°, whereas the MCL is stretched out but still functional.

Grade III patients have deformity more than 20°. The medial stabilizers are typically not functional, and hence it calls for a constrained implant [9, 10].

Since Ranawat's classification did not take into consideration the extra-articular and multiplanar deformities, Mullaji and Shetty [11] modified it into six types:

Type I—Correctible valgus and an intact MCL.

Type II—Fixed valgus deformity with an intact MCL.

Type III—Valgus and hyperextension deformity with an intact MCL.

Type IV—Valgus and fixed flexion deformity (FFD) with an intact MCL.

Type V—Severe valgus with a lax MCL.

Type VI—Valgus secondary to extra-articular deformity.

Another recently introduced classification system based on the bone affected and the soft tissue status is by the International Society for Technology in Arthroplasty. The JST Classification [12] of valgus knees is as follows:

#### *2.2.1 Femoral deformity*

Type F1—Valgus in extension only


Type F2—Valgus in both flexion and extension: Intra-articular deformity, tight lateral collateral ligament, lateral femoral condyle hypoplasia

#### *2.2.2 Tibial deformity*

Type T1—Intra-articular deformity, lateral tibial plateau deficiency Type 2—Extra-articular deformity, tibial metaphyseal or shaft

#### **2.3 Clinical examination**

From the history, the most important part is the functional disability the patient is facing and the severity of the pain. Pain, limitation of daily living activities, increasing angular deformity and worsening instability are the usual complaints. The treatment is based on the severity of the symptoms. The co-existence of other pathologies affecting joints like rheumatoid arthritis (RA) and gout has to be evaluated and treated simultaneously.

**Figure 2.** *The valgus deformity corrected with a varus stress test.*

First and foremost observation while examining an end-stage degenerative knee disease is the pattern of gait. This is the best way to assess the dynamic instabilities. Due importance should be given if there is a medial thrust and recurvatum/fixed flexion deformity, the amount of deformity and its correctability. **Figure 2** shows the valgus deformity correctability in a varus stress test. The overall alignment should be assessed both in standing and supine positions. The range of motion (ROM) should be measured and recorded. The stability of the knee, anteroposterior laxity, range of motion, coronal and sagittal deformity, mediolateral instability, status of the extensor mechanism and patellofemoral articulation are important in the knee examination.

Lastly, pain due to other causes like neurovascular and lumbosacral pathologies is also to be ruled out. In fixed valgus deformity, the lateral structures are tight, and the medial ligaments are lax. So, when a standard lateral soft tissue release is done, the resulting laxity will be much more than the preoperative, and it usually requires the usage of constrained prosthesis.

#### **2.4 Radiological assessment**

A proper radiological evaluation for a valgus knee undergoing TKR includes weight-bearing anteroposterior, lateral, long leg standing, Rosenberg and Merchant views. Lateral views help you size the components and look for any posterior osteophytes. In case of correctable deformities, varus and valgus stress views are mandatory. The critical points to look for in these cases are the amount of bone stock, lateral distal femoral hypoplasia, posterior femoral condyle erosion, metaphyseal remodeling of proximal tibia and distal femur and the status of patella-femoral joint. Patella can be subluxed in case of severe valgus deformities. The depth of resection needs to be planned preoperatively. **Figure 3** shows a valgus knee with lateral tibial

**111**

motor symptoms.

**Figure 3.**

**2.5 Templating**

templating systems are available.

*A valgus knee with lateral tibial plateau defect.*

taken [13] (**Figure 4**).

the system you use is a must to reconstruct the slope.

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

plateau defect. If suspecting bony erosion, a CT scan can help you assess the dimensions of the defect more accurately in order to help you plan the augments early and back it up. Also the hypoplastic lateral femoral condyle, the eroded posterior femoral condyle and the remodeled femoral or tibial metaphysis which can lead to malalignment of the femoral component can be evaluated preoperatively in a CT scan. Apart from evaluating the knee, plain X-rays of the lumbosacral spine would be worthwhile as a part of ruling out any spine pathology. NCV and EMG may be advised to patients who complain of associated paraesthesia and other sensory or

With the X-rays available, preliminary templating should be done to have a rough idea on the level of resection, valgus angle to keep and sizing of the components. Twenty percent magnification is what most of the templates are made for. Most of the implant companies provide hard copies of TKR templates, or digital

For the tibia, a line is drawn along tibial anatomical axis, and then a perpendicular one is drawn at the level of the lateral tibial plateau. This will provide the depth of resection to be taken. Try to avoid overhanging. Tibial slope needs to be assessed in lateral view. Some tibial jig/inserts have inbuilt slope. So, thorough knowledge of

For measuring the valgus cut angle, the femoral anatomical axis is drawn, and then a second line is drawn from the centre of the intercondylar notch to the centre of the femoral head. The angle formed gives the desired amount of valgus cut to be

The sizing of the components is then conducted with the templates provided by the implant company. The femur is sized in lateral view and tibia in AP view. Try to

avoid notching in the femur and overhanging in the tibia (**Figure 5**).

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

*Valgus Deformity Correction in Total Knee Replacement: An Overview DOI: http://dx.doi.org/10.5772/intechopen.89739*

**Figure 3.** *A valgus knee with lateral tibial plateau defect.*

plateau defect. If suspecting bony erosion, a CT scan can help you assess the dimensions of the defect more accurately in order to help you plan the augments early and back it up. Also the hypoplastic lateral femoral condyle, the eroded posterior femoral condyle and the remodeled femoral or tibial metaphysis which can lead to malalignment of the femoral component can be evaluated preoperatively in a CT scan.

Apart from evaluating the knee, plain X-rays of the lumbosacral spine would be worthwhile as a part of ruling out any spine pathology. NCV and EMG may be advised to patients who complain of associated paraesthesia and other sensory or motor symptoms.

#### **2.5 Templating**

*Knee Surgery - Reconstruction and Replacement*

requires the usage of constrained prosthesis.

*The valgus deformity corrected with a varus stress test.*

**2.4 Radiological assessment**

First and foremost observation while examining an end-stage degenerative knee disease is the pattern of gait. This is the best way to assess the dynamic instabilities. Due importance should be given if there is a medial thrust and recurvatum/fixed flexion deformity, the amount of deformity and its correctability. **Figure 2** shows the valgus deformity correctability in a varus stress test. The overall alignment should be assessed both in standing and supine positions. The range of motion (ROM) should be measured and recorded. The stability of the knee, anteroposterior laxity, range of motion, coronal and sagittal deformity, mediolateral instability, status of the extensor mechanism and patellofemoral articulation are important in the knee examination. Lastly, pain due to other causes like neurovascular and lumbosacral pathologies is also to be ruled out. In fixed valgus deformity, the lateral structures are tight, and the medial ligaments are lax. So, when a standard lateral soft tissue release is done, the resulting laxity will be much more than the preoperative, and it usually

A proper radiological evaluation for a valgus knee undergoing TKR includes weight-bearing anteroposterior, lateral, long leg standing, Rosenberg and Merchant views. Lateral views help you size the components and look for any posterior osteophytes. In case of correctable deformities, varus and valgus stress views are mandatory. The critical points to look for in these cases are the amount of bone stock, lateral distal femoral hypoplasia, posterior femoral condyle erosion, metaphyseal remodeling of proximal tibia and distal femur and the status of patella-femoral joint. Patella can be subluxed in case of severe valgus deformities. The depth of resection needs to be planned preoperatively. **Figure 3** shows a valgus knee with lateral tibial

**110**

**Figure 2.**

With the X-rays available, preliminary templating should be done to have a rough idea on the level of resection, valgus angle to keep and sizing of the components. Twenty percent magnification is what most of the templates are made for. Most of the implant companies provide hard copies of TKR templates, or digital templating systems are available.

For the tibia, a line is drawn along tibial anatomical axis, and then a perpendicular one is drawn at the level of the lateral tibial plateau. This will provide the depth of resection to be taken. Try to avoid overhanging. Tibial slope needs to be assessed in lateral view. Some tibial jig/inserts have inbuilt slope. So, thorough knowledge of the system you use is a must to reconstruct the slope.

For measuring the valgus cut angle, the femoral anatomical axis is drawn, and then a second line is drawn from the centre of the intercondylar notch to the centre of the femoral head. The angle formed gives the desired amount of valgus cut to be taken [13] (**Figure 4**).

The sizing of the components is then conducted with the templates provided by the implant company. The femur is sized in lateral view and tibia in AP view. Try to avoid notching in the femur and overhanging in the tibia (**Figure 5**).

**Figure 4.** *Templating the bone cuts.*

**Figure 5.** *The digital templates for sizing the components.*

#### **2.6 Component selection**

Component selection should be made based on the clinical evaluation and the radiological examination. Adequate armamentarium should be ready in the operation theatre (OT) including constrained knee/hinge knee based on the severity of the deformity and its correctability. The final decision is made after bone cuts and soft tissue balancing. If proper soft tissue balance is restored, one can get away with

**113**

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

normal components. In a Grade-III valgus deformity, medial soft tissues are not functional, and hence, a higher constrained prosthesis is mandatory to achieve a

One of the main controversies is regarding the choice and design of the implant to be used in valgus deformities. There are proponents of both the cruciate retaining (CR) and posterior stabilized (PS) designs in existing literature, and they have their valid reasons too. I tend to lean towards PS designs in valgus deformities. PCL is a secondary stabilizer and it is often found contracted intraoperatively [14]. This can limit the deformity correction and almost always end up in resecting PCL too. PS designs are found more stable because of the post-cam mechanism. Also, PS designs allow better lateralization of the components which in turn improve patella tracking. PS prosthesis provides some degree of posterior stabilization as well as protection against posteromedial and posterolateral translation. But the mediolateral

Extreme valgus knees will have a deficient lateral femoral condyle. Such knees will require the use of component augmentation if the femoral component is being cemented. The lateral femoral condyle may or may not have distal femoral bone

The dictum in such complex cases is "plan your work, work out your plan". The plan starts right from the clinical examination. We need to assess whether the valgus deformity is fixed or correctable and the presence of a coexisting deformity—mostly hyperextension. Lateral release should be minimal in case of a fixed deformity because that can make the knee unstable necessitating a constrained

The knee can be approached both anteromedial and anterolateral. Too much of debate exists on the choice of approach in extreme valgus knees and is often chosen based on the surgeon's preference. The advantages of anterolateral approach as explained by Keblish [8] are better visualization of the tight lateral tissues; lateral release happened with the arthrotomy. Also, if a lateral retinaculum release is necessary, the patellar vascularization will not be compromised. Functional and radiological outcomes in TKA approached either ways have been studied by Sekiya et al. [15]. They found no significant differences in ROM but better postoperative flexion in the anterolateral group. The author is of the opinion that if the residual surgical valgus is more than 15°, it is easier to correct with an anterolateral approach.

Femur—It is useful to reduce valgus degrees of resection from 5 to 7° to 3° in order to accommodate the distal femoral metaphyseal remodeling. Lateral condyle distal femoral resection can be minimal (1–2 mm) or absent in severe valgus deformity. Femoral resection should be no more than 10 mm in the medial condyle (usually 7–8 mm). Special attention is to be given to lateral condylar hypoplasia that can determine the rotation of the components if a posterior reference is used. In cases of severe trochlear dysplasia, the Whiteside line can be extremely difficult to identify: in these cases the epicondylar axis or parallel to the tibial cut technique

should be used to assess a correct femoral rotation.

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

laxity is not supported by the PS designs.

**2.7 Intraoperative considerations**

resected like in the chamfer and posterior cuts, as well.

stable knee [9].

prosthesis.

*2.7.1 Approach*

*2.7.2 Bone cuts*

*Valgus Deformity Correction in Total Knee Replacement: An Overview DOI: http://dx.doi.org/10.5772/intechopen.89739*

normal components. In a Grade-III valgus deformity, medial soft tissues are not functional, and hence, a higher constrained prosthesis is mandatory to achieve a stable knee [9].

One of the main controversies is regarding the choice and design of the implant to be used in valgus deformities. There are proponents of both the cruciate retaining (CR) and posterior stabilized (PS) designs in existing literature, and they have their valid reasons too. I tend to lean towards PS designs in valgus deformities. PCL is a secondary stabilizer and it is often found contracted intraoperatively [14]. This can limit the deformity correction and almost always end up in resecting PCL too. PS designs are found more stable because of the post-cam mechanism. Also, PS designs allow better lateralization of the components which in turn improve patella tracking. PS prosthesis provides some degree of posterior stabilization as well as protection against posteromedial and posterolateral translation. But the mediolateral laxity is not supported by the PS designs.

Extreme valgus knees will have a deficient lateral femoral condyle. Such knees will require the use of component augmentation if the femoral component is being cemented. The lateral femoral condyle may or may not have distal femoral bone resected like in the chamfer and posterior cuts, as well.

#### **2.7 Intraoperative considerations**

The dictum in such complex cases is "plan your work, work out your plan". The plan starts right from the clinical examination. We need to assess whether the valgus deformity is fixed or correctable and the presence of a coexisting deformity—mostly hyperextension. Lateral release should be minimal in case of a fixed deformity because that can make the knee unstable necessitating a constrained prosthesis.

#### *2.7.1 Approach*

*Knee Surgery - Reconstruction and Replacement*

**112**

**Figure 5.**

**Figure 4.**

*Templating the bone cuts.*

**2.6 Component selection**

*The digital templates for sizing the components.*

Component selection should be made based on the clinical evaluation and the radiological examination. Adequate armamentarium should be ready in the operation theatre (OT) including constrained knee/hinge knee based on the severity of the deformity and its correctability. The final decision is made after bone cuts and soft tissue balancing. If proper soft tissue balance is restored, one can get away with

The knee can be approached both anteromedial and anterolateral. Too much of debate exists on the choice of approach in extreme valgus knees and is often chosen based on the surgeon's preference. The advantages of anterolateral approach as explained by Keblish [8] are better visualization of the tight lateral tissues; lateral release happened with the arthrotomy. Also, if a lateral retinaculum release is necessary, the patellar vascularization will not be compromised. Functional and radiological outcomes in TKA approached either ways have been studied by Sekiya et al. [15]. They found no significant differences in ROM but better postoperative flexion in the anterolateral group. The author is of the opinion that if the residual surgical valgus is more than 15°, it is easier to correct with an anterolateral approach.

#### *2.7.2 Bone cuts*

Femur—It is useful to reduce valgus degrees of resection from 5 to 7° to 3° in order to accommodate the distal femoral metaphyseal remodeling. Lateral condyle distal femoral resection can be minimal (1–2 mm) or absent in severe valgus deformity. Femoral resection should be no more than 10 mm in the medial condyle (usually 7–8 mm). Special attention is to be given to lateral condylar hypoplasia that can determine the rotation of the components if a posterior reference is used. In cases of severe trochlear dysplasia, the Whiteside line can be extremely difficult to identify: in these cases the epicondylar axis or parallel to the tibial cut technique should be used to assess a correct femoral rotation.

Tibia—The tibial cut has to be perpendicular to the tibial long axis. The depth of resection should be limited to 6–8 mm in the medial compartment. In cases of severe bony deformity of the tibial plateau, almost no bone is resected on the lateral side to avoid medial over-resection or malaligned cuts.

#### *2.7.3 Soft tissue release*

The lateral structures are contracted in valgus knees, and the most important ones to be considered in deformity correction are iliotibial band, posterolateral corner, posterior cruciate ligament, lateral collateral Ligament, popliteus tendon and lateral head of gastrocnemius.

Again controversy exists regarding the sequence and extent of lateral release. Krackow et al. [10] suggest ITB-LCL-popliteus-PLC sequence, whereas Ranawat [9] on the other hand advocates PCL-ITB-LCL technique. Krackow and Mihalko [16] published a cadaveric study in which they studied the amount of correction achieved with each release step of two different sequences, comparing it in flexion and extension. They concluded that LCL release caused largest correction and popliteus, and ITB should be considered to grade the release.

Regarding the technique of release, most of the surgeons do a subperiosteal release from the tibia. In severe valgus deformities, performing a lateral parapatellar approach automatically releases ITB from Gerdy's tubercle and helps in deformity correction to an extent. Ranawat's pie-crusting technique is also done widely. With the knee in extension and lamina spreaders to open up the extension gap, the tight lateral structures are palpated and released by multiple stab incisions with a No. 15 blade (**Figure 6**).

Lateral epicondylar osteotomy as described by Brilhault et al. [17] can be useful in severe valgus deformities. A sliding osteotomy along with the femoral insertion of LCL and popliteus insertions is made, and the bone block is mobilized distally and fixed with screws.

In case of severe valgus deformity, if MCL is attenuated, division and imbrications can be done to tighten the medial structures. Other options are distalizing the PLC insertion from the tibia and fixation with trans-osseous sutures. In all those cases requiring such measures, a constrained condylar prosthesis is the norm.

**115**

preferred.

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

*Option 2*—Soft tissue release + constrained prosthesis.

supply to the osteotomy site causing non-union.

osteotomy may be required for a T2 knee.

Based on JST Classification of valgus knees, an intraoperative algorithm is given

Deformity is due to tight ITB and posterior-lateral capsule instead of LCL and popliteus tendon. Releasing ITB and posterior-lateral capsule can correct the deformity. Additionally, a bony graft or a metal block may be used to augment the

Deformity is at the level of supra-condylar region. Three options are used based

F1b valgus knee is due to supra-condylar deformity; a supra-condylar osteotomy (SCO) can aid in balancing. SCO + TKA can be done in a single stage, but be careful about the cortical break while inserting the IM rod. Also femoral stem extension may be needed in such cases; hence there can be a serious compromise in the blood

Both the distal and posterior parts of LFC are deficient; LCL is contracted. The release of lateral soft tissues, including LCL and popliteus, may become essential.

This is rare and mostly seen in rheumatoids or post-traumatic cases. The recon-

struction of the plateau can be done with augments in T1 knee, and corrective

Approach—Medial parapatellar approach. Careful not to release medial structures much, minimizing medial dissection to fully expose the tibia. If under anesthesia valgus correction is more than 15°; lateral parapatellar approach is

Implant—PS only. It is important to keep the condylar knee constrained and rotate the hinge knee as back up based on the severity and pathology of valgus.

Femur first—Reduce the valgus degree of resection to 3°; the entry point for IM rod in a valgus knee is usually more medial than in a standard knee. Ascertain the point with preoperative radiographs. With regard to anteroposterior cuts, watch out for hypoplasia of the lateral femoral condyle, and check the posterior condylar reference cutting block position with both Whiteside line and transepicondylar axis. Also, with the cutting blocks fixed, further check the balancing in flexion

*Option 1*—Lateral condyle distal sliding osteotomy is done to convert an F1b deformity into an F1a deformity. The procedure brings the deformity level into the

*Option 3*—One-stage or two-stage supra-condylar osteotomy + TKA.

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

hypoplastic lateral distal femoral condyle.

below [12].

*2.7.3.1 Type F1a*

*2.7.3.2 Type F1b*

*2.7.3.3 Type F2*

*2.7.3.4 Type T deformity*

**2.8 My preferred technique**

before performing the cuts.

on the severity of deformity.

collateral ligament level.

**Figure 6.** *Ranawat's pie-crusting technique for extensive lateral release.*

*Valgus Deformity Correction in Total Knee Replacement: An Overview DOI: http://dx.doi.org/10.5772/intechopen.89739*

Based on JST Classification of valgus knees, an intraoperative algorithm is given below [12].

#### *2.7.3.1 Type F1a*

*Knee Surgery - Reconstruction and Replacement*

*2.7.3 Soft tissue release*

(**Figure 6**).

and fixed with screws.

and lateral head of gastrocnemius.

ITB should be considered to grade the release.

side to avoid medial over-resection or malaligned cuts.

Tibia—The tibial cut has to be perpendicular to the tibial long axis. The depth of resection should be limited to 6–8 mm in the medial compartment. In cases of severe bony deformity of the tibial plateau, almost no bone is resected on the lateral

The lateral structures are contracted in valgus knees, and the most important ones to be considered in deformity correction are iliotibial band, posterolateral corner, posterior cruciate ligament, lateral collateral Ligament, popliteus tendon

Again controversy exists regarding the sequence and extent of lateral release. Krackow et al. [10] suggest ITB-LCL-popliteus-PLC sequence, whereas Ranawat [9] on the other hand advocates PCL-ITB-LCL technique. Krackow and Mihalko [16] published a cadaveric study in which they studied the amount of correction achieved with each release step of two different sequences, comparing it in flexion and extension. They concluded that LCL release caused largest correction and popliteus, and

Regarding the technique of release, most of the surgeons do a subperiosteal release from the tibia. In severe valgus deformities, performing a lateral parapatellar approach automatically releases ITB from Gerdy's tubercle and helps in deformity correction to an extent. Ranawat's pie-crusting technique is also done widely. With the knee in extension and lamina spreaders to open up the extension gap, the tight lateral structures are palpated and released by multiple stab incisions with a No. 15 blade

Lateral epicondylar osteotomy as described by Brilhault et al. [17] can be useful in severe valgus deformities. A sliding osteotomy along with the femoral insertion of LCL and popliteus insertions is made, and the bone block is mobilized distally

In case of severe valgus deformity, if MCL is attenuated, division and imbrications can be done to tighten the medial structures. Other options are distalizing the PLC insertion from the tibia and fixation with trans-osseous sutures. In all those cases requiring such measures, a constrained condylar prosthesis is the norm.

**114**

**Figure 6.**

*Ranawat's pie-crusting technique for extensive lateral release.*

Deformity is due to tight ITB and posterior-lateral capsule instead of LCL and popliteus tendon. Releasing ITB and posterior-lateral capsule can correct the deformity. Additionally, a bony graft or a metal block may be used to augment the hypoplastic lateral distal femoral condyle.

#### *2.7.3.2 Type F1b*

Deformity is at the level of supra-condylar region. Three options are used based on the severity of deformity.

*Option 1*—Lateral condyle distal sliding osteotomy is done to convert an F1b deformity into an F1a deformity. The procedure brings the deformity level into the collateral ligament level.

*Option 2*—Soft tissue release + constrained prosthesis.

*Option 3*—One-stage or two-stage supra-condylar osteotomy + TKA.

F1b valgus knee is due to supra-condylar deformity; a supra-condylar osteotomy (SCO) can aid in balancing. SCO + TKA can be done in a single stage, but be careful about the cortical break while inserting the IM rod. Also femoral stem extension may be needed in such cases; hence there can be a serious compromise in the blood supply to the osteotomy site causing non-union.

#### *2.7.3.3 Type F2*

Both the distal and posterior parts of LFC are deficient; LCL is contracted. The release of lateral soft tissues, including LCL and popliteus, may become essential.

#### *2.7.3.4 Type T deformity*

This is rare and mostly seen in rheumatoids or post-traumatic cases. The reconstruction of the plateau can be done with augments in T1 knee, and corrective osteotomy may be required for a T2 knee.

#### **2.8 My preferred technique**

Approach—Medial parapatellar approach. Careful not to release medial structures much, minimizing medial dissection to fully expose the tibia. If under anesthesia valgus correction is more than 15°; lateral parapatellar approach is preferred.

Implant—PS only. It is important to keep the condylar knee constrained and rotate the hinge knee as back up based on the severity and pathology of valgus.

Femur first—Reduce the valgus degree of resection to 3°; the entry point for IM rod in a valgus knee is usually more medial than in a standard knee. Ascertain the point with preoperative radiographs. With regard to anteroposterior cuts, watch out for hypoplasia of the lateral femoral condyle, and check the posterior condylar reference cutting block position with both Whiteside line and transepicondylar axis. Also, with the cutting blocks fixed, further check the balancing in flexion before performing the cuts.

Perform the tibial cut, perpendicular to the anatomical axis, allowing 3–5° posterior slope using an extramedullary rod. Try to remove the least possible bone amount, especially from the lateral side.

Extension gap is assessed using lamina spreaders and limited lateral release—pie crusting or ITB release is done to make it rectangular. Popliteus has to be preserved as it is a stabilizer in flexion. Varus-valgus stability is assessed in extension. Once the knee is balanced in extension, the flexion gap can be evaluated and assessed. When the knee is balanced, femoral chamfer cuts are made, and the trial components can be tested.

With trial femur, tibia and insert, it is important to assess patella tracking. If needed, a lateral retinacular release can be done inside out at this stage.

#### **2.9 Complications**

Complications which can happen in correcting a valgus deformity in TKR include tibiofemoral instability, residual valgus deformity (most common ones), restricted ROM, wound dehiscence, patella fracture, patella maltracking and peroneal nerve palsy. Correction of a severe valgus deformity can induce peroneal nerve injury due to traction or ischemia.

So, it is of utmost importance to specifically mention these complications to the patient and bystanders and get a well-informed consent prior to surgery.

#### **2.10 Clinical outcomes**

Revision rates following TKA for valgus knees at 10–15-year follow-up have been reported at between 0 and 17% [18]. Failure rate is more when the preoperative deformity is more or the residual valgus is more. The long-term results of TKA in valgus knees are reported to be not up to that of varus knees.

#### **3. Conclusion**

Valgus deformity correction in total knee replacement is not everyone's cup of coffee. Associated bone defects and ligamentous contractures add to the difficulty. Sequential release of the lateral tight structures, correcting the deformity and balancing the knee, is a tricky job. A thorough planning, surgical skill, adequate implant back up and an active physiotherapy team are mandatory to achieve the desired functional results in a valgus knee TKR.

**117**

**Author details**

Melvin J. George

Sree Narayana Institute of Medical Sciences, Kochi, Kerala, India

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: johnirimpenz@yahoo.co.in

provided the original work is properly cited.

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

#### **Conflict of interest**

There is no conflict of interest to declare.

*Valgus Deformity Correction in Total Knee Replacement: An Overview DOI: http://dx.doi.org/10.5772/intechopen.89739*

*Knee Surgery - Reconstruction and Replacement*

amount, especially from the lateral side.

nerve injury due to traction or ischemia.

nents can be tested.

**2.9 Complications**

**2.10 Clinical outcomes**

**3. Conclusion**

**Conflict of interest**

Perform the tibial cut, perpendicular to the anatomical axis, allowing 3–5° posterior slope using an extramedullary rod. Try to remove the least possible bone

Extension gap is assessed using lamina spreaders and limited lateral release—pie crusting or ITB release is done to make it rectangular. Popliteus has to be preserved as it is a stabilizer in flexion. Varus-valgus stability is assessed in extension. Once the knee is balanced in extension, the flexion gap can be evaluated and assessed. When the knee is balanced, femoral chamfer cuts are made, and the trial compo-

With trial femur, tibia and insert, it is important to assess patella tracking. If

Complications which can happen in correcting a valgus deformity in TKR include tibiofemoral instability, residual valgus deformity (most common ones), restricted ROM, wound dehiscence, patella fracture, patella maltracking and peroneal nerve palsy. Correction of a severe valgus deformity can induce peroneal

So, it is of utmost importance to specifically mention these complications to the

Revision rates following TKA for valgus knees at 10–15-year follow-up have been

Valgus deformity correction in total knee replacement is not everyone's cup of coffee. Associated bone defects and ligamentous contractures add to the difficulty. Sequential release of the lateral tight structures, correcting the deformity and balancing the knee, is a tricky job. A thorough planning, surgical skill, adequate implant back up and an active physiotherapy team are mandatory to achieve the

reported at between 0 and 17% [18]. Failure rate is more when the preoperative deformity is more or the residual valgus is more. The long-term results of TKA in

needed, a lateral retinacular release can be done inside out at this stage.

patient and bystanders and get a well-informed consent prior to surgery.

valgus knees are reported to be not up to that of varus knees.

desired functional results in a valgus knee TKR.

There is no conflict of interest to declare.

**116**

#### **Author details**

Melvin J. George Sree Narayana Institute of Medical Sciences, Kochi, Kerala, India

\*Address all correspondence to: johnirimpenz@yahoo.co.in

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clinical Orthopaedics and Related Research. 1992 Jul;**280**:48-64

[2] Favorito PJ, Mihalko WM, Krackow KA. Total knee arthroplasty in the valgus knee. The Journal of the American Academy of Orthopaedic Surgeons. 2002;**10**(1):16-24

[3] Rossi R, Rosso F, Cottino U, Dettoni F, Bonasia DE, Bruzzone M. Total knee arthroplasty in the valgus knee. International Orthopaedics. 2014;**38**:273-283

[4] Apostolopoulos AP, Nikolopoulos DD, Polyzois I, Nakos A, Liarokapis S, Stefanakis G, et al. Total knee arthroplasty in severe valgus deformity: Interest of combining a lateral approach with a tibial tubercle osteotomy. Orthopaedics & Traumatology, Surgery & Research. 2010;**96**:777-784

[5] Nikolopoulos DD, Polyzois I, Apostolopoulos AP, Rossas C, Moutsios-Rentzos A, Michos IV. Total knee arthroplasty in severe valgus knee deformity: Comparison of a standard medial parapatellar approach combined with tibial tubercle osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2011;**19**:1834-1842

[6] Karachalios T, Sarangi PP, Newman JH. Severe varus and valgus deformities treated by total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume (London). 1994;**76**:938-942

[7] White GR, Mencio GA. Genu Valgum in children: Diagnostic and therapeutic alternatives. The Journal of the American Academy of Orthopaedic Surgeons. 1995;**3**:275-283

[8] Keblish PA. The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation. Clinical Orthopaedics and Related Research. 1991;**271**:52-62

[9] Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. The Journal of Bone and Joint Surgery. American Volume. 2005;**87**(Suppl 1):271-284

[10] Krackow KA, Jones MM, Teeny SM, Hungerford DS. Primary total knee arthroplasty in patients with fixed valgus deformity. Clinical Orthopaedics and Related Research. 1991;**273**:9-18

[11] Mullaji AB, Shetty GM. Deformity Correction in Total Knee Arthroplasty. New York: Springer Science and Business Media; 2014. pp. 59-71

[12] Zhou Y. JST classification and treatment algorithm of a valgus knee. Orthopaedic Proceedings;**92-B** (Suppl 1). International Society for Technology in Arthroplasty. 2018

[13] Nogueira JBS, do Carmo Araújo LH, Bezerra MJC. Planning Total Knee Arthroplasties. Croatia, Rijeka: Intech Open Publishers; 2018

[14] Krackow KA. The Technique of Total Knee Arthroplasty. Mosby, St. Louis; 1990

[15] Sekiya H, Takatoku K, Takada H, Sugimoto N, Hoshino Y. Lateral approach is advantageous in total knee arthroplasty for valgus deformed knee. European Journal of Orthopaedic Surgery and Traumatology. 2014 Jan;**24**(1):111-115

[16] Krackow KA, Mihalko WM. Flexion-extension joint gap changes after lateral structure release for

**119**

*Valgus Deformity Correction in Total Knee Replacement: An Overview*

*DOI: http://dx.doi.org/10.5772/intechopen.89739*

[17] Brilhault J, Lautman S, Favard L, Burdin P. Lateral femoral sliding osteotomy lateral release in total knee arthroplasty for a fixed valgus deformity. Journal of Bone and Joint Surgery. British Volume (London).

[18] Elkus M, Ranawat CS, Rasquinha VJ, et al. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. Journal of Bone and Joint Surgery 2004;**86-A**:2671-2676

valgus deformity correction in total knee arthroplasty: A cadaveric study. The Journal of Arthroplasty.

1999;**14**(8):994-1004

2002;**84**(8):1131-1137

*Valgus Deformity Correction in Total Knee Replacement: An Overview DOI: http://dx.doi.org/10.5772/intechopen.89739*

valgus deformity correction in total knee arthroplasty: A cadaveric study. The Journal of Arthroplasty. 1999;**14**(8):994-1004

[17] Brilhault J, Lautman S, Favard L, Burdin P. Lateral femoral sliding osteotomy lateral release in total knee arthroplasty for a fixed valgus deformity. Journal of Bone and Joint Surgery. British Volume (London). 2002;**84**(8):1131-1137

[18] Elkus M, Ranawat CS, Rasquinha VJ, et al. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. Journal of Bone and Joint Surgery 2004;**86-A**:2671-2676

**118**

*Knee Surgery - Reconstruction and Replacement*

[1] Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clinical Orthopaedics and Related Research. 1992 Jul;**280**:48-64 [8] Keblish PA. The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation. Clinical Orthopaedics and Related Research.

[9] Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. The Journal of Bone and Joint Surgery. American Volume. 2005;**87**(Suppl 1):271-284

[10] Krackow KA, Jones MM, Teeny SM, Hungerford DS. Primary total knee arthroplasty in patients with fixed valgus deformity. Clinical Orthopaedics and Related Research. 1991;**273**:9-18

[11] Mullaji AB, Shetty GM. Deformity Correction in Total Knee Arthroplasty. New York: Springer Science and Business Media; 2014. pp. 59-71

[12] Zhou Y. JST classification and treatment algorithm of a valgus knee. Orthopaedic Proceedings;**92-B** (Suppl 1). International Society for Technology in Arthroplasty. 2018

[13] Nogueira JBS, do Carmo Araújo LH, Bezerra MJC. Planning Total Knee Arthroplasties. Croatia, Rijeka: Intech

[14] Krackow KA. The Technique of Total Knee Arthroplasty. Mosby, St.

[15] Sekiya H, Takatoku K, Takada H, Sugimoto N, Hoshino Y. Lateral approach

arthroplasty for valgus deformed knee. European Journal of Orthopaedic Surgery and Traumatology. 2014

is advantageous in total knee

[16] Krackow KA, Mihalko WM. Flexion-extension joint gap changes after lateral structure release for

Open Publishers; 2018

Louis; 1990

Jan;**24**(1):111-115

1991;**271**:52-62

[2] Favorito PJ, Mihalko WM,

Surgeons. 2002;**10**(1):16-24

2014;**38**:273-283

**References**

2010;**96**:777-784

[4] Apostolopoulos AP,

Krackow KA. Total knee arthroplasty in the valgus knee. The Journal of the American Academy of Orthopaedic

[3] Rossi R, Rosso F, Cottino U, Dettoni F, Bonasia DE, Bruzzone M. Total knee arthroplasty in the valgus knee. International Orthopaedics.

Nikolopoulos DD, Polyzois I, Nakos A, Liarokapis S, Stefanakis G, et al. Total knee arthroplasty in severe valgus deformity: Interest of combining a lateral approach with a tibial tubercle osteotomy. Orthopaedics & Traumatology, Surgery & Research.

[5] Nikolopoulos DD, Polyzois I, Apostolopoulos AP, Rossas C,

with tibial tubercle osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2011;**19**:1834-1842

[6] Karachalios T, Sarangi PP,

[7] White GR, Mencio GA. Genu Valgum in children: Diagnostic and therapeutic alternatives. The Journal of the American Academy of Orthopaedic

Surgeons. 1995;**3**:275-283

1994;**76**:938-942

Newman JH. Severe varus and valgus deformities treated by total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume (London).

Moutsios-Rentzos A, Michos IV. Total knee arthroplasty in severe valgus knee deformity: Comparison of a standard medial parapatellar approach combined

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*Knee Surgery—Reconstruction and Replacement* is an intriguing book. From basic to advanced concepts, it collects relevant and reliable information obtained globally from validated collaborating researchers.

Published in London, UK © 2020 IntechOpen © M. Haneefa Nizamudeen / iStock

Knee Surgery - Reconstruction and Replacement

Knee Surgery

Reconstruction and Replacement

*Edited by João Bosco Sales Nogueira, José Alberto Dias Leite, Leonardo Heráclio Do Carmo Araújo* 

*and Marcelo Cortez Bezerra*