Basics in Primary Knee Arthroplasty

Foreword
Preface
Contents
About the Editors
1: Anthropometry of the Native Knee
	1.1	 Introduction
	1.2	 Distal Femur
	1.3	 Patella
	1.4	 Proximal Tibia and Menisci
	1.5	 Ligamentous Structures
		1.5.1	 Anterior Cruciate Ligament (ACL)
		1.5.2	 Posterior Cruciate Ligament (PCL)
		1.5.3	 Medial Knee Structures
		1.5.4	 Lateral Knee Structures
	References
2: Kinematics of the Native Knee
	2.1	 Introduction
	2.2	 Physiology
	2.3	 The Lower Limb Kinetic Chain
		2.3.1	 Tibiofemoral Kinematics
			2.3.1.1	 Sagittal Plane
			2.3.1.2	 Transverse Plane
		2.3.2	 Patellofemoral Kinematics
			2.3.2.1	 Patella Tracking
			2.3.2.2	 Patellar Height
			2.3.2.3	 Tibial Tubercle–Trochlear Groove Distance
		2.3.3	 Stability
	2.4	 Kinematics during Different Activities
		2.4.1	 Walking
		2.4.2	 Stair Climbing and Descent
		2.4.3	 Sitting Down and Standing from Seated
		2.4.4	 Squatting, Lunging, and Kneeling
		2.4.5	 Vertical Drop Jump
		2.4.6	 Sports
	2.5	 Inter-Individual, Gender, Age, and Ethnic Variations
		2.5.1	 Sexual Variations
		2.5.2	 Age Variations
		2.5.3	 Ethnic Variations Differences
	References
3: Kinematics of the Knee After Partial and Total Knee Arthroplasty
	3.1	 Modalities for Studying Knee Kinematics After Arthroplasty
	3.2	 The Kinematics of Total Knee Replacements
		3.2.1	 Cruciate-Retaining TKA Designs
		3.2.2	 Posterior-Stabilized TKA Designs
		3.2.3	 Medial-Pivot Design
		3.2.4	 Lateral-Pivot Design
		3.2.5	 Bicruciate-Retaining TKA Designs
		3.2.6	 Fixed and Mobile-Bearing Designs in TKA
		3.2.7	 Highly Conforming Designs in TKA
	3.3	 The Kinematics of Unicondylar Knee Replacement
		3.3.1	 Introduction
		3.3.2	 The Kinematics of UKA
		3.3.3	 Mobile vs. Fixed-Bearing UKA
		3.3.4	 Medial vs. Lateral UKA
		3.3.5	 The Importance of the Anterior Cruciate Ligament in UKA
	References
4: Loading of the Knee Joint After Total Knee Arthroplasty
	4.1	 Introduction
	4.2	 Technical Capabilities: How to Measure Knee Loading in Vivo?
		4.2.1	 Tibial Tray Design
		4.2.2	 Coordinate System and Nomenclature
	4.3	 In Vivo Loading in Activities of Daily Living
		4.3.1	 The Observed Peak Loads
			4.3.1.1	 Resultant Forces F
			4.3.1.2	 Shear Forces
			4.3.1.3	 Flexion–Extension Moments
			4.3.1.4	 Abduction–Adduction Moments
			4.3.1.5	 External–Internal Rotation Moments
		4.3.2	 Load Patterns
			4.3.2.1	 Two/One-Legged Stance
			4.3.2.2	 Knee Bend, Standing Up, and Sitting Down
			4.3.2.3	 Level Walking
			4.3.2.4	 Ascending/Descending Stairs
		4.3.3	 Force Directions
	4.4	 The Third Player: The Patellofemoral Joint Contact during High Knee Flexion
	4.5	 Mediolateral Force Distribution: Shifts across Activities and Is Driven by Tibiofemoral Alignment
		4.5.1	 Determination of Medial Force and Medial Force Ratio
		4.5.2	 Determination of Static Leg Alignment
		4.5.3	 Variation of the Medial Force Ration (MR) and Medial Femorotibial Force (Fmed)
		4.5.4	 Influence of Leg Alignment on MR and Fmed during Static One-Legged Stance [9]
		4.5.5	 Influence of Leg Alignment on MR and Fmed during Dynamic Limb Loading
	References
5: The Optimal Indication for Unicompartmental Knee Arthroplasty
	5.1	 Introduction
	5.2	 Indication for UKA in Medial Femorotibial OA
	5.3	 Indication in Lateral Femorotibial OA
	5.4	 The Impact of Patellofemoral OA on the Indication for UKA
	5.5	 Contraindications
	References
6: The Optimal Indication for Patellofemoral Arthroplasty
	6.1	 Introduction
	6.2	 Epidemiological Data
	6.3	 Etiology of Patellofemoral OA
		6.3.1	 Primary Patellofemoral OA
		6.3.2	 OA Secondary to Presence of Predisposing Factors for Patellofemoral Instability
			6.3.2.1	 Dislocation
			6.3.2.2	 Extensor Mechanism Malalignment
			6.3.2.3	 Lack of Congruency between the Patella and the Trochlea
		6.3.3	 Posttraumatic Patellofemoral OA (9%)
		6.3.4	 Patellofemoral OA Secondary to Chondrocalcinosis or Other Rheumatic Diseases (9%)
	6.4	 Predisposing Factors for Patellofemoral Osteoarthritis
		6.4.1	 Trochlear Dysplasia
		6.4.2	 Dysplasia of the Patella
		6.4.3	 Other Factors
	6.5	 Therapeutic Consequences
		6.5.1	 Non-operative Treatment
		6.5.2	 Non-prosthetic Treatment
		6.5.3	 Patellofemoral Arthroplasty
			6.5.3.1	 Indication and Contraindications
			6.5.3.2	 Technical Considerations
				Patellofemoral Osteoarthritis without Dysplasia
				Patellofemoral Osteoarthritis with Dysplasia
	References
7: The Optimal Indication for Combined Patellofemoral and Unicondylar Knee Arthroplasty
	7.1	 Introduction
	7.2	 Concepts of Combined Patellofemoral and Medial Unicondylar Knee Arthroplasty
	References
8: The Optimal Indication for Total Knee Arthroplasty
	8.1	 Introduction
	8.2	 Indication for Total Knee Arthroplasty (TKA)
	8.3	 Prediction for Outcome after TKA
	References
9: Partial Resurfacing Implants
	9.1	 Introduction
	9.2	 Knee Resurfacing Implant Types
		9.2.1	 HemiCAP® Implants
		9.2.2	 The Episealer® Implant
	9.3	 Indications for the Use of a Resurfacing Prosthesis
	9.4	 Surgical Techniques
		9.4.1	 HemiCAP®
		9.4.2	 Episealer®
	9.5	 Biological Response to Resurfacing Implants
	9.6	 Clinical Outcome
		9.6.1	 Case Series (Table 9.2)
		9.6.2	 Failure after Resurfacing Implant Treatment
	9.7	 Discussion
	References
10: Patients’ Evaluation Prior to Knee Arthroplasty
	10.1	 Introduction
	10.2	 Patients’ Evaluation
		10.2.1	 Specific History of the Knee
		10.2.2	 General Medical History
			10.2.2.1	 Diabetes Mellitus (DM)
			10.2.2.2	 Anaemia
			10.2.2.3	 Cardiovascular Diseases
			10.2.2.4	 Chronic Renal Disease (CRD)
			10.2.2.5	 Neurological Diseases
			10.2.2.6	 Rheumatoid Arthritis (RA)
			10.2.2.7	 Malnutrition
			10.2.2.8	 Obesity
			10.2.2.9	 Smoking
			10.2.2.10	 Alcohol Misuse
			10.2.2.11	 Depression
			10.2.2.12	 Urinary Tract Infection
		10.2.3	 Clinical Examination
			10.2.3.1	 Inspection
			10.2.3.2	 Feel
			10.2.3.3	 Move
			10.2.3.4	 Specific Testing
		10.2.4	 Radiological Examination
	References
11: Cardiovascular Comorbidity in Patients Scheduled for TKA
	11.1	 Introduction
	11.2	 Risk Indices
	11.3	 Cardiac Biomarkers
	11.4	 Noninvasive Testing of Cardiac Disease
		11.4.1	 Electrocardiography
		11.4.2	 Echocardiography
		11.4.3	 Noninvasive Testing of Ischemic Heart Disease
	11.5	 Perioperative Management in Patients on Antiplatelet Agents or Anticoagulation Therapy
		11.5.1	 Aspirin
		11.5.2	 Dual Antiplatelet Therapy (DAPT)
	11.6	 Perioperative Management in Patients on Anticoagulants
		11.6.1	 Chronic Heart Failure
		11.6.2	 Hypertension
		11.6.3	 Valve Disease
		11.6.4	 Aortic Stenosis
		11.6.5	 Secondary Mitral Regurgitation
		11.6.6	 Patients with Prosthetic Heart Valves
		11.6.7	 Prophylaxis of Infective Endocarditis
		11.6.8	 Arrhythmias
		11.6.9	 Perioperative Management of Patients with Pacemakers/Implantable Cardioverter Defibrillators
		11.6.10 Stroke
		11.6.11 Peripheral Artery Disease
	11.7	 Pulmonary Disease
	References
12: Patient Expectations in Total Knee Arthroplasty
	12.1	 What Do Patients Expect from TKA?
	12.2	 Measuring and Managing Expectations—Predicting Satisfaction
	References
13: Basic Principles of Partial Knee Arthroplasty
	13.1	 Introduction—Anthropology and Partial Knee Arthroplasty
	13.2	 Indication
		13.2.1	 Medial Femorotibial Osteoarthritis
		13.2.2	 Lateral Femorotibial Osteoarthritis
	13.3	 Key Points of Examination
	13.4	 Surgical Planning
	13.5	 Technical Tips and Tricks
		13.5.1	 Medial UKA
		13.5.2	 Lateral UKA
		13.5.3	 Closure
		13.5.4	 Postoperative Regimen
	13.6	 Compartmental Arthroplasty
	13.7	 Postoperative Care
	References
14: Principles of Total Knee Arthroplasty
	14.1	 Introduction
	14.2	 Patient Selection
	14.3	 Choice of Implant
	14.4	 Polyethylene
	14.5	 Informed Consent and Preoperative Patient Education
	14.6	 Preoperative Physiotherapy
	14.7	 Day of Surgery Preoperative Review
	14.8	 The Operating Theatre Environment
	14.9	 Anaesthesia
	14.10	 Theatre Setup and Draping
	14.11	 Arthrotomy and Exposure
	14.12	 Tibial Alignment and Resection
	14.13	 Distal Femoral Preparation
	14.14	 Overview of Final Femoral Preparation
	14.15	 Soft Tissue Balancing
	14.16	 Final Implantation
	14.17	 Haemostasis
	14.18	 Prior to Closure
	14.19	 Dressings
	14.20	 Immediate Medical Supervision
	14.21	 Enhanced Recovery
	14.22	 After Care
	14.23	 Postoperative Physiotherapy
	14.24	 Minimising Risk of Complications
	References
15: UKA Component Design: What Do We Need to Know?
	15.1	 Introduction
	15.2	 Biomechanical Considerations
	15.3	 Fixed-Bearing Design
	15.4	 Mobile-Bearing Design
	15.5	 Cemented Versus Uncemented
	15.6	 All Polyethylene Versus Metal Backed
	15.7	 Customized Unicompartmental Knee Arthroplasty
16: TKA Component Design: What Do Engineers Need to Know?
	16.1	 Introduction
	16.2	 Implant Design
		16.2.1	 Single Versus Multiple Femoral Radius Design
		16.2.2	 Fixed Versus Mobile Bearing Design
		16.2.3	 Cruciate-Retaining, Posterior-Stabilized, and Bicruciate-Retaining Design
		16.2.4	 Orientation of the Trochlea Groove
		16.2.5	 Symmetrical or Asymmetrical Tibial Trays
	16.3	 Implant Development—From the Idea to Clinical Application
		16.3.1	 Morphology Data
		16.3.2	 Materials
		16.3.3	 Collaboration
	16.4	 Development Method
	16.5	 Risk Management
	16.6	 Instrumentation—What Are the Most Important Aspects?
	16.7	 New Medical Device Regulation in Europe
	References
17: Patellofemoral Arthroplasty: Onlay Versus Inlay Prostheses
	17.1	 Introduction
	17.2	 Indication
	17.3	 Contraindication
	17.4	 Inlay Prosthesis—Implant Design and Surgical Technique
	17.5	 Onlay Prosthesis—Implant Design and Surgical Technique
	17.6	 Postsurgical Rehabilitation
	17.7	 Clinical Outcome
	References
18: Surgical 2D Planning of Total Knee Arthroplasty
	18.1	 Introduction
	18.2	 Radiographies
	18.3	 Digital Planning
		18.3.1	 Automatic Planning
		18.3.2	 Manual Planning
	18.4	 Accuracy of Planning
	References
19: 3D Planning of Total Knee Arthroplasty: Why and How?
	19.1	 Introduction
	19.2	 How to Plan a TKA in 3D
		19.2.1	 Data Acquisition
		19.2.2	 Frame of References
		19.2.3	 Tutorial
			19.2.3.1	 Step 1: Femoral Frame of Reference
			19.2.3.2	 Step 2: Femoral Condyles
			19.2.3.3	 Step 3: Tibial Frame of Reference
			19.2.3.4	 Step 4: Tibial Condyles
	19.3	 What to Do with the Information Obtained in 3D Planning?
		19.3.1	 Coronal Lower Limb Alignment
		19.3.2	 Joint Line Angulation
		19.3.3	 Femoral Rotation
	19.4	 How 3D Planning Influences Knee Surgery? – The Knee Phenotype Concept
	References
20: Optimal Setup of the Operating Room
	20.1	 Introduction
	20.2	 Operating Room Requirements
	20.3	 Setup of the Operating Room during Knee Arthroplasty
	References
21: Pain Management in Total Knee Arthroplasty
	21.1	 Introduction
	21.2	 Preoperative Management
		21.2.1	 Preoperative Physiotherapy
		21.2.2	 Anesthesia
			21.2.2.1	 Preemptive Analgesia
			21.2.2.2	 General Versus Spinal Anesthesia
			21.2.2.3	 Peripheral Nerve Blocks
			21.2.2.4	 Peripheral Nerve Blocks Versus Intrathecal Morphine
		21.2.3	 Tourniquet Time
	21.3	 Postoperative Management
		21.3.1	 Oral Analgesics
		21.3.2	 Joint Infiltration Analgesia
		21.3.3	 Cryotherapy
		21.3.4	 Continuous Passive Motion
		21.3.5	 Neuromuscular Electrical Stimulation (NMES)
		21.3.6	 Transcutaneous Electrical Nerve Stimulation (TENS)
	References
22: Optimal Positioning of the Patient
	22.1	 Introduction
	22.2	 Positioning of the Patient on the Operating Table
	22.3	 Positioning of the Surgeon in the OR
	References
23: Pros and Cons of Using a Tourniquet
	23.1	 Introduction
		23.1.1	 Historical Perspectives [6–8]
	23.2	 Characteristics of Tourniquets in TKA
	23.3	 Cuff Pressure and Duration
		23.3.1	 Cementation
	23.4	 Possible Complications Related to the Use of a Tourniquet
		23.4.1	 Ischaemia Reperfusion Injury
		23.4.2	 Muscle Damage
		23.4.3	 Nerve Injuries
		23.4.4	 DVT and PE
	23.5	 Practical Recommendations
	References
24: Pro and Cons of Tranexamic Acid (TXA) in Total Knee Arthroplasty
	24.1	 Background
	24.2	 Basic Pharmacokinetics
	24.3	 Modes of Administration
		24.3.1	 Intravenous Administration
			24.3.1.1	 Bolus Regimens
			24.3.1.2	 Continuous Regimens
		24.3.2	 Topical Administration
			24.3.2.1	 Intra-Articular Administration Regimens
			24.3.2.2	 Topical Wash Regimens
		24.3.3	 Oral Administration
		24.3.4	 Combined Administration
	24.4	 Efficacy
	24.5	 Risk of Thromboembolic Disease
	References
25: Standard Approaches to the Knee
	25.1	 Introduction
	25.2	 Skin Incision
	25.3	 Arthrotomy
		25.3.1	 Midline Capsular Incision
		25.3.2	 Medial Parapatellar or Anteromedial Arthrotomy
		25.3.3	 Lateral Parapatellar Arthrotomy
	25.4	 Exposure of the Joint
	25.5	 Tissue-Sparing Arthrotomies
		25.5.1	 Subvastus Approach
		25.5.2	 Midvastus Approach
	References
26: Is There an Optimal TKA Component Position?
	26.1	 Introduction
	26.2	 What Is the Evidence?
		26.2.1	 Optimal Coronal TKA Alignment
			26.2.1.1	 Coronal Alignment of Femoral Component
			26.2.1.2	 Coronal Alignment of Tibial Component
		26.2.2	 Optimal Sagittal TKA Alignment
			26.2.2.1	 Sagittal Alignment of Femoral Component
			26.2.2.2	 Sagittal Alignment of Tibial Component
		26.2.3	 Optimal Rotational TKA Alignment
			26.2.3.1	 Rotational Alignment of Femoral Component
			26.2.3.2	 Rotational Alignment of Tibial Component
	References
27: Neutral Mechanical Alignment: The Gold Standard
	27.1	 Introduction
	27.2	 The Current Evidence for Restoration of Mechanical Alignment (Table 27.1)
	27.3	 Mechanical Alignment
	References
28: The Anatomical Alignment Concept for Total Knee Arthroplasty
	28.1	 Basics for a Better Understanding
	28.2	 Coronal Alignment
	28.3	 Sagittal Alignment
	28.4	 Rotational Alignment
	28.5	 Clinical Outcome Anatomical Alignment Versus Mechanical Alignment
	References
29: Kinematic Alignment in Total Knee Arthroplasty
	29.1	 Introduction
	29.2	 Kinematic Alignment
		29.2.1	 Biomechanical Rational for Kinematic Alignment
		29.2.2	 Concept of Kinematic Alignment
	29.3	 Surgical Technique
		29.3.1	 Tibia First Vs. Femur First Technique for KA TKA
		29.3.2	 Manual Surgical Technique: Femur First
		29.3.3	 Computer-Assisted Surgical Techniques.
	29.4	 Clinical Evidence Base
	29.5	 Indications and Limitations
		29.5.1	 Constitutional vs. Pathological Alignment and Biomechanical Aspects
	29.6	 Preoperative Planning and Analysis
	29.7	 Prosthetic Design Features for KA TKA
	References
30: Measured Resection Technique: How Does it Work?
	30.1	 Basics for a Better Understanding
	30.2	 Bone Cuts
	30.3	 Measured Resection Technique
		30.3.1	 Anatomical Landmarks
			30.3.1.1	 Transepicondylar Axis (TEA)
			30.3.1.2	 Posterior Condylar Axis
			30.3.1.3	 Anterior-Posterior Axis
			30.3.1.4	 Akagi Line
			30.3.1.5	 Anterior Tibial Border
		30.3.2	 Bone Cuts
			30.3.2.1	 Tibial Cut
			30.3.2.2	 Femoral Cuts
				Distal Femoral Cut
					4-in-1 Femoral Cuts (Anterior, Posterior, Oblique)
		30.3.3	 Pros and Cons of the Measured Resection Technique
	References
31: Ligament Balancing Technique: How Does It Work
	31.1	 Introduction
	31.2	 Surgical Technique
		31.2.1	 Extension Gap First Technique
		31.2.2	 Flexion Gap First
	31.3	 Discussion
	References
32: Posterior Femoral Referencing in Total Knee Arthroplasty
	32.1	 Introduction
	32.2	 Morphometry of the Distal Femur
	32.3	 Relation of the Posterior Condylar Line to Other Landmarks for Femoral Component Placement
	32.4	 Femoral Component Placement Referenced to the Posterior Condyles
	References
33: Anterior Femoral Referencing in Total Knee Arthroplasty
	33.1	 Introduction
	33.2	 Principles of Anterior Femoral Referencing in TKA
	33.3	 Surgical Technique of Anterior Femoral Referencing in TKA
	33.4	 Impact of External Femoral Rotation
	33.5	 Typical Clinical Scenarios
	33.6	 Influence of AR on Outcome in TKA
	References
34: Tibial Component Rotation in Total Knee Arthroplasty
	34.1	 Implications of Component Rotation on Tibiofemoral Kinematics
		34.1.1	 Internal Rotation of the Tibial Component
		34.1.2	 External Rotation of the Tibial Component
	34.2	 Bony Landmarks of the Proximal Tibia
		34.2.1	 Tibial Tuberosity (Fig. 34.1)
		34.2.2	 Posterior Tibial Condylar Axis (Fig. 34.2)
		34.2.3	 Transtibial Axis (Fig. 34.3)
		34.2.4	 Anterior Surface of the Tibia (Fig. 34.4)
		34.2.5	 Patellar Tendon to PCL Axis (Akagi’s Line) (Fig. 34.5)
		34.2.6	 Other Extra-Articular References
	34.3	 Surgical Techniques Used to Determine Rotational Alignment
		34.3.1	 Single Point/Single Axis
		34.3.2	 Range of Motion/Self-Adjustment Method
		34.3.3	 Navigation
		34.3.4	 Symmetric Versus Asymmetric Tibial Baseplates (Fig. 34.6a, b)
		34.3.5	 Rotating Platform TKA
	References
35: Patient-Specific Instrumentation in TKA
	35.1	 Introduction
	35.2	 Preoperative Considerations
	35.3	 Perioperative Considerations
	35.4	 Postoperative Considerations
	35.5	 Clinical Outcome
	35.6	 Discussion
	References
36: Patient-Specific Partial and Total Knee Arthroplasty: An Update
	36.1	 Introduction
	36.2	 Patient-Specific UKA
		36.2.1	 Surgical Technique of Patient-Specific Medial UKA
		36.2.2	 Surgical Technique of Patient-Specific Lateral UKA
	36.3	 Bicompartmental Patient-Specific Knee Arthroplasty (BKA)
		36.3.1	 Surgical Technique of Bicompartmental Arthroplasty
	36.4	 Patient-Specific TKA
		36.4.1	 Surgical Technique
	36.5	 Discussion
	References
37: Navigation in Total Knee Arthroplasty
	37.1	 Introduction
	37.2	 What Is Computer-Assisted Surgery (CAS)?
	37.3	 Basic Concepts of Navigation
	37.4	 Why Navigation (CAS) in TKA?
	37.5	 Why Navigation Is Useful for Young Surgeons?
	37.6	 (CAS) Navigation in TKA: Surgical Technique
	37.7	 The Future of CAS
	References
38: Optimal Sizing of the Femoral, Tibial, and Patellofemoral Components in TKA
	38.1	 Introduction
	38.2	 Is Oversizing Frequent in TKA?
	38.3	 Does Oversizing Influences Outcomes in TKA?
	38.4	 Why Oversizing Is So Frequent in TKA?
		38.4.1	 Manufacturing Limitations
		38.4.2	 Anatomic Variability
		38.4.3	 Influence of Implants Orientation on Sizing
	38.5	 Why Oversizing Is Painful in TKA?
	References
39: Optimal Implant Fixation in Knee Arthroplasty: Cemented Versus Cementless Knee Arthroplasty
	39.1	 Introduction
	39.2	 Cemented Fixation
		39.2.1	 Surface Preparation
		39.2.2	 Cementing Technique
		39.2.3	 Cement Type
		39.2.4	 Surface Versus Full Cementation
		39.2.5	 Implant Surface and Design Properties
		39.2.6	 Antibiotic-Loaded Cement
	39.3	 Cementless Fixation
		39.3.1	 Initial Stability and Osteointegration
		39.3.2	 Bearing Type
		39.3.3	 Patient Age
		39.3.4	 Obesity
		39.3.5	 Cementless Patellar Implants
		39.3.6	 Inflammatory Arthritis
		39.3.7	 Hybrid Fixation
		39.3.8	 Surface Coating
			39.3.8.1	 Hydroxyapatite
			39.3.8.2	 Porous Tantalum
			39.3.8.3	 Other Surface Coatings
		39.3.9	 Clinical Outcomes and Survivorship of Cementless TKA
	39.4	 Cemented Unicondylar Knee Arthroplasty
	39.5	 Cementless Unicondylar Knee Arthroplasty
	References
40: Wound Closure in Total Knee Arthroplasty
	40.1	 Introduction
	40.2	 Risk Factors for Wound Complications
	40.3	 Optimal Wound Closure
	40.4	 Technical Tips and Tricks
		40.4.1	 Closure of the Capsule
		40.4.2	 Closure of Subcutaneous Layer
		40.4.3	 Skin Closure and Wound Dressing
	References
41: Pros and Cons of Drains for Wound Drainage in Total Knee Arthroplasty
	41.1	 Introduction
	41.2	 Wound Healing, Hematoma
	41.3	 Post-operative Function and Duration of Hospital Stay
	41.4	 Blood Loss and Transfusion Rate
		41.4.1	 Effect of Drain Clamping
		41.4.2	 Use of Tranexamic Acid (TXA)
		41.4.3	 Thromboembolic Events
		41.4.4	 Periprosthetic Joint Infection (PJI)
	References
42: Pain Management After Total Knee Arthroplasty
	42.1	 Introduction
	42.2	 Preoperative Patient Education
	42.3	 Oral or Parenteral Systemic Analgesia
		42.3.1	 Postoperative Conventional NSAIDs (Nonsteroidal Anti-inflammatory Drugs, ­COX-2-Selective Inhibitors and Paracetamol)
		42.3.2	 Opioids
		42.3.3	 Intravenous Patient-Controlled Analgesia (PCA)
	42.4	 Continuous Epidural Analgesia (CEA)
	42.5	 Peripheral Nerve Blocks (PNB)
	42.6	 Periarticular/Intra-articular Infiltration Analgesia and Continuous Intra-articular Analgesia
	42.7	 Comparison of LIA and PNB and Combining Techniques
	42.8	 Corticosteroids
	42.9	 Gabapentinoids
	References
43: How to Handle Complications in Unicompartmental Knee Arthroplasty
	43.1	 Introduction
	43.2	 Medial Unicondylar Knee Arthroplasty
	43.3	 Lateral Unicondylar Knee Arthroplasty
	43.4	 Patellofemoral Arthroplasty
	References
44: How to Handle Complications During TKA?
	44.1	 Introduction
	44.2	 Intraoperative Complications
		44.2.1	 Surgical Approach
		44.2.2	 Exposure of the Knee Joint
	44.3	 Femoral and Tibial Preparation
		44.3.1	 Vascular Injuries
		44.3.2	 Nerve Injuries
		44.3.3	 Ligament Injuries During Preparation of Femur and Tibia
		44.3.4	 Periprosthetic Fractures
	44.4	 Insertion of Implants and Wound Closure
		44.4.1	 Cementing with Use of a Tourniquet
		44.4.2	 The Final Steps
	References
45: Deformity Correction in Total Knee Arthroplasty
	45.1	 Introduction
	45.2	 Surgical Planning
	45.3	 Varus Deformity
		45.3.1	 Surgical Technique for Varus Deformity
		45.3.2	 Knee Deformity of Less Than 10°
		45.3.3	 Knee Deformity Between 10° and 20°
		45.3.4	 Knee Deformity of over 20°
	45.4	 Valgus Deformity
		45.4.1	 Surgical Technique for Valgus Knees
	45.5	 Flexion Deformity
	45.6	 Hyperextension Deformity
		45.6.1	 Pathoanatomy
		45.6.2	 Surgical Technique
		45.6.3	 Computer-Assisted and Robotic-Assisted Technique
	References
46: Total Knee Arthroplasty for Fracture Treatment
	46.1	 Introduction
	46.2	 AO-Classification
	46.3	 Indication for Total Knee Arthroplasty
	46.4	 Distal Femoral Fracture
	46.5	 Proximal Tibial Fracture
	46.6	 Outcome
	References
47: Thromboembolic Prophylaxis After Partial or Total Knee Arthroplasty
	47.1	 Introduction
	47.2	 Mechanical VTE Prophylaxis
	47.3	 Pharmacologic VTE Prophylaxis
		47.3.1	 Warfarin
		47.3.2	 Low-Molecular-Weight Heparin
		47.3.3	 Aspirin
		47.3.4	 Rivaroxaban
		47.3.5	 Dabigatran
		47.3.6	 Apixaban
	References
48: How to Avoid Typical Complications After Total Knee Arthroplasty?
	48.1	 Introduction
	48.2	 Arthrofibrosis
	48.3	 Nerve Injuries
	48.4	 Vascular Injuries
	References
49: Infection Prophylaxis in TKA
	49.1	 Preoperative Risk Factors
		49.1.1	 Diabetes Mellitus
		49.1.2	 Nutritional Deficiencies
		49.1.3	 Obesity
		49.1.4	 Smoking
		49.1.5	 Inflammatory Arthritis
		49.1.6	 MSSA and MRSA Colonization
	49.2	 Intraoperative Prevention of Infection
		49.2.1	 Skin Preparation and Draping
		49.2.2	 Surgical Gloves and Gowns
		49.2.3	 Antimicrobials
		49.2.4	 Operating Room Traffic
		49.2.5	 Wound Irrigation
		49.2.6	 Wound Closure and Dressings
		49.2.7	 Longer Surgical Time
	49.3	 Postoperative Risk Factors
		49.3.1	 Indwelling Catheters
		49.3.2	 Closed Suction Drains
		49.3.3	 Blood Transfusions
		49.3.4	 Dental Procedures
	References
50: Rehabilitation After Total Knee Arthroplasty
	50.1	 Introduction
		50.1.1	 Patients’ Individual Goals After TKA
		50.1.2	 Treatment Evaluation
	50.2	 Preoperative Treatments and Exercises
	50.3	 Postoperative Treatment and Exercises
		50.3.1	 Multimodal Rehabilitation Programs
		50.3.2	 Active Physical Therapy Programs
		50.3.3	 Continuous Passive Motion
		50.3.4	 Cryotherapy
		50.3.5	 Ergometer Cycling
		50.3.6	 Manual Lymphatic Drainage
		50.3.7	 Neuromuscular Electrical Stimulation
	50.4	 Additional Measures
	50.5	 Rehabilitation Programs
		50.5.1	 Standard Rehabilitation Program
		50.5.2	 Fast-Track Program
	References
51: How to Assess Outcome After Partial or Total Knee Arthroplasty—Measuring Results that Really Matter!
	51.1	 Health Outcome Measurement
	51.2	 Outcomes of Interest
	51.3	 Current Strategies for Standardization
		51.3.1	 Core Outcome Set (COS)
		51.3.2	 ICHOM Standard Set
		51.3.3	 What Outcomes Should Be Considered?
		51.3.4	 Traditional Outcomes
		51.3.5	 Clinician-Based Outcomes
	51.4	 Range of Motion (ROM)
	51.5	 Joint Stability
	51.6	 Imaging
	51.7	 Patient-Reported Outcomes
		51.7.1	 Generic PROMs
		51.7.2	 Short Form 36 Health Survey (SF-36)
		51.7.3	 Short Form 12 Health Survey (SF-12)
		51.7.4	 European Quality of Life (EuroQoL EQ-5D)
		51.7.5	 Disease-Specific PROM
		51.7.6	 Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC)
		51.7.7	 Oxford Knee Score (OKS)
		51.7.8	 Knee Injury and Osteoarthritis Outcome Score (KOOS)
		51.7.9	 Knee Society Clinical Rating System (KSS)
		51.7.10 University of California at Los Angeles (UCLA) Activity Rating Scale
	51.8	 Single-Item Satisfaction Outcome Measure
	51.9	 Expectations and Their Fulfillment
	51.10	 New Developments
	51.11	 Performance-Based Outcomes
		51.11.1 The 30-s Chair-Stand Test (30s CST)
		51.11.2 The 40-m Fast-Paced Walk Test (40m FPWT)
		51.11.3 Stair-Climbing Test (x-step SCT)
		51.11.4 The Six-Minute Walk Test (6MWT)
		51.11.5 The Timed Up-and-Go Test (TUG)
	51.12	 Activity Measurement
	51.13	 Measurement Properties and Practical Issues
		51.13.1 Consensus-Based Measurement Properties
		51.13.2 Practical Issues
	51.14	 Interpretation of Outcomes
	References
52: Function After Unicondylar Knee Arthroplasty—What Could You Expect?
	52.1	 Introduction
	52.2	 Range of Motion
	52.3	 Return to Sports
	52.4	 Patient-Reported Outcome
	52.5	 Gait Analysis
	52.6	 Limitations
	52.7	 Author’s Investigations
	References
53: Outcome After Total Knee Arthroplasty—What Can Be Expected?
	53.1	 Introduction
	53.2	 How to Define a ‘Successful’ TKA?
	53.3	 Relation Between Functional Abilities and Expectations After Knee Replacement?
	53.4	 Are ‘Young’ Patients a Specific Group When Managing Expectations?
	53.5	 Defining the Reasons for Dissatisfaction
	53.6	 Indication Criteria for Surgery?
	53.7	 How to Increase Patient Expectations and Improve Outcome?
	References
54: Function After Small Knee Implants
	54.1	 Introduction
	54.2	 Unicompartmental Knee Arthroplasty
	54.3	 Patellofemoral Arthroplasty
	54.4	 Bicompartmental Knee Arthroplasty
	54.5	 What is the Functional Outcome?
	54.6	 Functional Outcome After UKA
		54.6.1	 Influence of Type of Implant on Functional Outcome
		54.6.2	 Influence of Component Alignment on Functional Outcome
		54.6.3	 Influence of Patient Factors on Functional Outcome
			54.6.3.1 Patient Characteristics in the Preoperative Period
			54.6.3.2 Patient Characteristics in the Postoperative Period
	54.7	 Influence of Type of Rehabilitation on Functional Outcome
	54.8	 Lateral UKA
	54.9	 Functional Outcome After Patellofemoral Arthroplasty
	54.10	 Functional Outcome After Bicompartmental Knee Arthroplasty
	References
55: Sports After Partial or Total Knee Arthroplasty
	55.1	 Introduction
	55.2	 Sports After Partial Knee Arthroplasty
	55.3	 Sports After Total Knee Arthroplasty
	55.4	 Comparison Partial Versus Total Knee Arthroplasty
	55.5	 Concerns of Sports Activity in Patients Following UKA/ TKA
	55.6	 Recommendations
	References
56: The Immune Response to Metal in Total Knee Arthroplasty
	56.1	 Introduction
	56.2	 Prevalence of Type I Hypersensitivity to Metals
	56.3	 Mechanism of Metal Sensitivity
		56.3.1	 The Immunological Basis of Allergy
		56.3.2	 The Immunology of Type IV Hypersensitivity
	56.4	 Diagnostics
		56.4.1	 Patch Test
		56.4.2	 Tests for Metal Hypersensitivity
			56.4.2.1	 Lymphocyte Transformation Test
			56.4.2.2	 Modified Lymphocyte Stimulation Test (mLST)
			56.4.2.3	 Leucocyte Migration Inhibition Test
			56.4.2.4	 Other Investigations
	56.5	 Clinical Presentation
	56.6	 Alternative Implants
	References
57: Does Digital Support Influence Outcome After Total Knee Arthroplasty?
	57.1	 Introduction
	57.2	 Learning and Teaching CAS-TKA
	57.3	 Pros and Cons of CAS-TKA
		57.3.1	 Blood Loss and Blood Transfusion Requirements
		57.3.2	 Embolism
		57.3.3	 Fractures Around the Pin Sites
		57.3.4	 Costs and Operative Time
		57.3.5	 Effect on Alignment and Component Placement
			57.3.5.1	 Accuracy and Outliers
			57.3.5.2	 Coronal Alignment
			57.3.5.3	 Sagittal Alignment
			57.3.5.4	 Rotational Alignment
		57.3.6	 Joint Line Level, Mediolateral and Sagittal Stability
	57.4	 Clinical Outcomes
		57.4.1	 Long-Term Results
	57.5	 Robotics in TKA
	References
58: Registries—How Important Are They?
	58.1	 Introduction
	58.2	 History
	58.3	 Geological Aspects
	58.4	 International Associations
		58.4.1	 Nordic Arthroplasty Register Association (NARA)
		58.4.2	 Network of Orthopaedic Registries of Europe (NORE)
		58.4.3	 International Society of Registries (ISAR)
	58.5	 Quality Characteristics of Registries
	58.6	 Data Capturing
	58.7	 Classification of Data
	58.8	 Report of Data
	58.9	 How Should An Optimal Registry Be Performed?
	58.10	 Discussion
	References
59: Most Common Scores for Patients’ Evaluation
	59.1	 Introduction
	59.2	 Outcome Measures
		59.2.1	 Performance-Based Scores
		59.2.2	 Disease-Specific Scores
			59.2.2.1 PROM
				Oxford Knee Score (OKS)
				Knee Injury and Osteoarthritis Outcome Score (KOOS)
				Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
				Hospital for Special Surgery (HSS)
			59.2.2.2 Hybrid Scores
				Knee Society Clinical Rating System (KSS)
			59.2.2.3 Generic Scores
				Visual Analogue Scale (Pain)
				EuroQol 5 Dimension Health Outcome Survey (EQ-5D)
				Short Form 36 Health Survey (SF-36)
				Short Form 12 Health Survey (SF-12)
				Veterans RAND 12-Item Health Survey (VR-12)
	59.3	 How to Use Scores in Clinical Practice?
	59.4	 Discussion
	References