Knee Arthroplasty: New and Future Directions

Foreword
Foreword
Preface
Acknowledgements
Contents
Contributors
About the Editor
Part I: Primary Total Knee Arthroplasty
	1: Pre-operative Planning in Primary Total Knee Arthroplasty
		1.1	 Introduction
		1.2	 History and Physical Examination
		1.3	 Indications
		1.4	 Imaging
			1.4.1	 Anteroposterior View
			1.4.2	 Lateral View
			1.4.3	 Axial View
			1.4.4	 Long-Leg Standing Radiograph
			1.4.5	 Stress Tests
			1.4.6	 Laboratory Test
		1.5	 Templating
			1.5.1	 Femoral Templating in Coronal Plane
			1.5.2	 Tibial Templating in Coronal Plane
			1.5.3	 Templating in the Sagittal Plane
		1.6	 Planning in Complex Primary Knee Arthroplasty
			1.6.1	 Ligamentous Instability
			1.6.2	 Extra-articular Deformity
			1.6.3	 Bone Loss
		1.7	 Selecting the Right Implant Size
		1.8	 Summary
		References
	2: Surgical Exposures in Total Knee Arthroplasty
		2.1	 Introduction
		2.2	 Anteromedial Parapatellar Approach
		2.3	 Alternate Approaches
			2.3.1	 Subvastus Approach
			2.3.2	 Midvastus Approach
		2.4	 Anterolateral Approach
		2.5	 Quadriceps Snip
		2.6	 Summary
		References
	3: Implant Evolution and Design Rationale in Total Knee Arthroplasty
		3.1	 Introduction
		3.2	 History of TKA
			3.2.1	 Early Prosthetic Models
				3.2.1.1	 Interposition and Resurfacing Prostheses
			3.2.2	 Cruciate Excision, Retention, and Substitution
		3.3	 Cruciate Retaining (“PCL Retaining,” CR-TKA)
		3.4	 Highly Congruent Liner (Anterior Stabilized)
		3.5	 Bicruciate Retaining (BCR-TKA)
		3.6	 Mobile Bearing Versus Fixed Bearing Total Knee Arthroplasty
		3.7	 Non-cemented Versus Cemented Knee Prostheses
		3.8	 Constrained Condylar Knee Prosthesis
		3.9	 Polyethylene in TKA
		3.10	 Metals Used in TKA
		3.11	 Summary
		References
	4: Basics in Total Knee Arthroplasty: A Step-by-Step Approach to a Varus Knee
		4.1	 Introduction
		4.2	 Preoperative Planning
		4.3	 Surgical Considerations
			4.3.1	 Exposure
			4.3.2	 Proximal Tibial Preparation
			4.3.3	 Femoral Preparation
			4.3.4	 Femoral Sizing
			4.3.5	 Ligament Balancing
			4.3.6	 Tibial Preparation
			4.3.7	 Patella Resurfacing
		4.4	 Discussion
		4.5	 Summary
		References
	5: Total Knee Arthroplasty in Knees with Fixed Flexion Deformity
		5.1	 Introduction
		5.2	 Preoperative Patient Evaluation
		5.3	 Intraoperative Steps
			5.3.1	 Flexion Deformity Assessment After Anaesthesia
			5.3.2	 Surgical Technique
				5.3.2.1	 Grade I: Mild Deformity <15°
				5.3.2.2	 Grade II: Moderate Deformity >15° and <30°
				5.3.2.3	 Grade III: Severe Deformity >30°
		5.4	 Post-operative Rehabilitation
		5.5	 Complications of Residual Fixed Flexion Deformity
		5.6	 Summary
		References
	6: Total Knee Replacement in a Valgus Arthritic Knee
		6.1	 Introduction
		6.2	 Patho-Anatomy of a Valgus Arthritic
		6.3	 Classification
		6.4	 Principles of Correction
		6.5	 Preoperative Planning
		6.6	 Surgical Technique
			6.6.1	 Approaches
			6.6.2	 Bone Resection
			6.6.3	 Gap Assessment and Soft Tissue Balancing
		6.7	 Complications Following TKR in a VAK
		6.8	 Results
			6.8.1	 Results Based on the Surgical Approach Employed
			6.8.2	 Results Based on the Technique of Soft Tissue Balancing
		6.9	 Summary
		References
	7: Mobile Bearing Unicompartmental Knee Arthroplasty
		7.1	 Introduction
		7.2	 History of Unicompartmental Knee Arthroplasty
		7.3	 Indications for Medial Compartment Unicompartmental Arthroplasty
		7.4	 Surgical Procedure of Mobile Bearing Medial UKA (Oxford Phase 3 with Microplasty Instrumentation)
			7.4.1	 Position
			7.4.2	 Approach
			7.4.3	 Tibial Cut
			7.4.4	 Femoral Preparation
			7.4.5	 Cementation of Components
		7.5	 Post-operative X-Rays
		7.6	 Rehabilitation
		7.7	 Complications of Mobile Bearing Unicondylar Arthroplasty
		7.8	 Results of Mobile Bearing Unicondylar Knee Arthroplasty
		7.9	 Summary
		References
	8: Fixed Bearing Unicondylar Knee Arthroplasty
		8.1	 Introduction
		8.2	 Evolution of UKA
		8.3	 Indications
		8.4	 Preoperative Assessment and Planning
		8.5	 Surgical Approach
			8.5.1	 Incision and Exposure
			8.5.2	 Proximal Tibial Resection
			8.5.3	 Distal Femoral Resection
			8.5.4	 Tibia Preparation and Implantation
		8.6	 Discussion
		8.7	 Case Illustration
		8.8	 Summary
		References
	9: Radiological Assessment of Total Knee Arthroplasty
		9.1	 Introduction
		9.2	 Radiological Modalities
		9.3	 Conventional or Plain Radiography
			9.3.1	 How to Obtain the Ideal AP and Lateral X-Rays After TKA
				9.3.1.1	 Proper Patient-Positioning for AP View of the Knee Joint
				9.3.1.2	 Patient Positioning for Lateral View of the Knee Joint
				9.3.1.3	 How Should Ideal Post-operative X-Rays Look?
			9.3.2	 What to Look for in Post-operative Radiographs?
			9.3.3	 Long-Knee Films Versus Short-Knee Radiographs for Assessment of Alignment After TKA
			9.3.4	 Evaluation of the Patella After TKA
			9.3.5	 Assessment of the Joint Line
			9.3.6	 Assessment of Component Sizing
		9.4	 Fluoroscopy
		9.5	 Computed Tomography (CT) Scanning
			9.5.1	 Role of Computed Tomography in the Painful Total Knee Arthroplasty
			9.5.2	 Metal Artifact Reduction in Computed Tomography
			9.5.3	 Assessment of Radiolucencies After TKA
		9.6	 Magnetic Resonance Imaging (MRI) After Total Knee Arthroplasty
			9.6.1	 Recent Developments in Magnetic Resonance Imaging
			9.6.2	 Merits and Demerits of Magnetic Resonance Imaging
		9.7	 Radiostereographic Analysis (RSA)
		9.8	 Nuclear Medicine and Bone-Scintigraphy Scans
			9.8.1	 Three-Phase Bone Scintigraphy
			9.8.2	 Phases of Bone Scans
			9.8.3	 Recent Advances in Scintigraphy Scanning
		9.9	 Role of Ultrasound in the Post-operative Evaluation of TKA
		9.10	 Summary
		References
Part II: Total Knee Arthroplasty in Complex Primary Situations
	10: Total Knee Arthroplasty in Stiff/Ankylosed Knees
		10.1	 Introduction
			10.1.1 Aetiology
			10.1.2 Patho-Anatomy
		10.2	 Definition of a Stiff Knee
			10.2.1 Ankylosed Knee
			10.2.2 Muscle Function After TKA Conversion in Bony Ankylosis
			10.2.3 Bone Quality
			10.2.4 Patello-Femoral Ankylosis
		10.3	 Pre-operative Evaluation
		10.4	 Surgical Planning
		10.5	 Surgical Approach
			10.5.1 Extensile Exposures
				10.5.1.1	 Quadricep Snip (Insall 1993 for Stiff Knee)
				10.5.1.2	 V-Y Quadricep Turndown (Coonse and Adam for Stiff Knee 1943)
				10.5.1.3	 Tibial Tubercle Osteotomy (TTO): (First by Dolin Modified by Whiteside 1983)
				10.5.1.4	 Femoral Peel
		10.6	 Steps for Bony Ankylosis Conversion to TKA
			10.6.1 Patellar Ankylosis Clearance
			10.6.2 Lateral Mobilisation of Patella and Quadricep
			10.6.3 Tibio-Femoral Osteotomy
		10.7	 Selection of Implants
		10.8	 Case Discussion
			10.8.1 Case 1: Bilateral Ankylosed Knee in Case of Rheumatoid Arthritis
			10.8.2 Case 2: Bilateral Knee Bony Ankylosis 90 Post RA
			10.8.3 Case 3: OA Bilateral Knee Subluxation, Osteophytes, Loose Bodies and Stiffness
			10.8.4 Case 4: OA with Osteophytes with Mechanical Block
			10.8.5 Case 5: Post RA Stiff Knee with Fracture While Attempted Manipulation
			10.8.6 Case 6: Stiff Knee with Stress Fracture in Post Patellectomy
			10.8.7 Case 7: Stiff Knee with Non-union Fracture Tibia
			10.8.8 Case 8: Stiff Knee with Extension Stem Tip Cut Out Due to Loss of Medial Pillar
		10.9	 Post-operative Management
		10.10	 Management of Residual Flexion Deformity in Ankylosed Knee
		10.11	 Discussion
			10.11.1 Comparative Results Stiff and Ankylosed Knee
			10.11.2 Complications
		10.12	 Summary
		References
	11: Total Knee Arthroplasty in Extra-Articular Deformity
		11.1	 Introduction
		11.2	 Causes of EAD [4, 5]
		11.3	 Radiographic Evaluation [4, 5, 8, 9]
		11.4	 Preoperative Planning
		11.5	 Surgical Options
		11.6	 Implant Choice for Osteotomy Fixation
		11.7	 Implant Choices for TKA
		11.8	 Role of Computer Navigation in TKA Associated with EAD
		References
	12: Post-High Tibial Osteotomy Total Knee Arthroplasty
		12.1	 Introduction
		12.2	 Pathoanatomy
		12.3	 Preoperative Evaluation
		12.4	 Procedure
			12.4.1	 Exposure
			12.4.2	 Proximal Tibial Cut
			12.4.3	 Ligament Balancing
			12.4.4	 Proximal Tibial Preparation
			12.4.5	 Patellar Preparation
			12.4.6	 Closure
			12.4.7	 Postoperative Rehabilitation
		12.5	 Discussion
		12.6	 Summary
		References
	13: Total Knee Arthroplasty in Osteoarthrosis Complicated with Stress Fractures
		13.1	 Introduction
		13.2	 Pathophysiology
		13.3	 Presentation
		13.4	 Risk Factors
		13.5	 Differential Diagnosis
		13.6	 Preoperative Planning
		13.7	 Treatment Options
			13.7.1	 Nonoperative Treatment
			13.7.2	 Operative Treatment
		13.8	 Surgical Technique
			13.8.1	 Intra-articular Fracture
			13.8.2	 Extra-articular Fracture
		13.9	 TKA as a Treatment of Stress Fracture in OA: A Review of Current Literature
			13.9.1	 Author’s Recommendation: Single-Stage TKA with a Long Stem
		13.10	 Complications
		13.11	 Summary
		References
	14: Management of Bone Defects in Primary Total Knee Arthroplasty
		14.1	 Introduction
		14.2	 Classification
		14.3	 Management of Bone Defects
		14.4	 Pre-Operative Planning
		14.5	 Surgical Considerations
		14.6	 Complications
		14.7	 Tips and Pearls
		14.8	 Current Concept
		14.9	 Discussion
		14.10	 Summary
		References
	15: Total Knee Replacement in Obese Patients
		15.1	 Introduction
			15.1.1	 Survival of TKA
			15.1.2	 Basic Science
		15.2	 Obesity and Total Knee Arthroplasty
		15.3	 Considerations in TKA in Obese Patient
		15.4	 Summary
		References
	16: TKA in Post-Trauma and Failed Fixations
		16.1	 Introduction
		16.2	 Challenges in Post-Trauma Situation
		16.3	 Preoperative Planning
			16.3.1	 Radiological Evaluation
			16.3.2	 Blood Investigations
			16.3.3	 Role of Preoperative Knee Aspiration
		16.4	 Surgical Considerations
			16.4.1	 Incision and Exposure
			16.4.2	 Hardware Removal and Timing of Surgery
			16.4.3	 Joint Reconstruction and Bone Loss Management
			16.4.4	 Implant Selection
		16.5	 TKA After Intramedullary Nailing
		16.6	 Computer-Assisted Surgery (CAS)
		16.7	 Primary Arthroplasty for Acute Fractures Around the Knee
		16.8	 Complications: How to Avoid and Tackle Them?
			16.8.1	 Infection
			16.8.2	 Skin Problems
			16.8.3	 Postoperative Knee Stiffness
			16.8.4	 Instability
			16.8.5	 Extensor Mechanism Disruption
			16.8.6	 Malalignment
		16.9	 Clinical Outcomes and Survivorship
		16.10	 Summary
		References
	17: Sliding Condylar Osteotomy for Managing Severe Deformities in Total Knee Arthroplasty
		17.1	 Introduction
			17.1.1	 The Varus Knee Deformity
			17.1.2	 The Valgus Knee Deformity
		17.2	 Pre-Operative Planning
			17.2.1	 History-Taking
			17.2.2	 Physical Examination
			17.2.3	 Radiological Evaluation
			17.2.4	 Indications for SCO
			17.2.5	 Contraindications for SCO
			17.2.6	 Pre-Operative Implant Planning
		17.3	 Surgical Technique of Various Types of SCO
			17.3.1	 Medial Condylar Downsliding Osteotomy (MCDO) for Severe Varus Deformity
			17.3.2	 Lateral Condylar Downsliding Osteotomy (LCDO) for Severe Valgus Deformity
			17.3.3	 Lateral Condylar Upsliding Osteotomy (LCUO) for Severe Varus Deformity
			17.3.4	 Medial Condylar Upsliding Osteotomy (MCUO) for Severe Valgus Deformity
		17.4	 Discussion
			17.4.1	 Complications, and How to Avoid and Manage them
		17.5	 Current Concepts and Recent Advances
		17.6	 Clinical Cases
			17.6.1	 Case 1
			17.6.2	 Case 2
			17.6.3	 Case 3
		17.7	 Summary
		References
	18: Total Knee Arthroplasty in Genu Recurvatum
		18.1	 Introduction
		18.2	 Etiology
		18.3	 Management
		18.4	 Basic Surgical Pearls
		18.5	 Discussion
		18.6	 Summary
		References
	19: Total Knee Arthroplasty in Persons with Haemophilia
		19.1	 Introduction
		19.2	 Indications of TKA in Haemophilia
		19.3	 Administration of Factor
			19.3.1	 First Option
			19.3.2	 Second Option
			19.3.3	 Inhibitors of Factor
		19.4	 Preoperative Care
		19.5	 Intraoperative Considerations
			19.5.1	 The Femur
			19.5.2	 The Tibia
			19.5.3	 The Patella
		19.6	 Post-operative Care
		19.7	 Discussion
		19.8	 Complications
		19.9	 Summary
		References
	20: Total Knee Arthroplasty in Patient with History of Previous Knee Sepsis
		20.1	 Introduction
		20.2	 Preoperative Planning
		20.3	 Scenario 1: Single-Stage TKA
		20.4	 Scenario 2: Two-Stage TKA
		20.5	 Discussion
		20.6	 Summary
		References
Part III: Managing Complications Post Total Knee Arthroplasty
	21: Periprosthetic Fractures Following TKR
		21.1	 Introduction
		21.2	 Risk Factors for Periprosthetic Fractures Around TKR
		21.3	 Classification
		21.4	 Evaluation and Planning
		21.5	 Supracondylar Periprosthetic Fracture Femur
			21.5.1	 Non-operative Treatment
			21.5.2	 Operative Treatment
				21.5.2.1	 Plate Fixation
				21.5.2.2	 Intramedullary Nails
				21.5.2.3	 Revision Total Knee Replacement
		21.6	 Tibial Periprosthetic Fractures
			21.6.1	 Treatment
		21.7	 Periprosthetic Fractures of the Patella
			21.7.1	 Risk Factors
				21.7.1.1	 Vascular Compromise
				21.7.1.2	 Patellar Thickness
				21.7.1.3	 Implant Design
				21.7.1.4	 Limb Alignment
			21.7.2	 Classification of Patellar Periprosthetic Fractures
			21.7.3	 Treatment
		21.8	 Summary
		References
	22: Management of Extensor Mechanism Disruption in Total Knee Arthroplasty (Primary and Revision)
		22.1	 Introduction
		22.2	 Anatomy
		22.3	 Clinical Features
		22.4	 Classification
		22.5	 Quadriceps Tendon Ruptures
			22.5.1	 Surgical Technique of Using a Marlex Mesh for Extensor Mechanism Reconstruction [27, 28]
			22.5.2	 Patellar Tendon Ruptures
			22.5.3	 Surgical Technique of Patellar Tendon Reconstruction Using a Quadriceps Tendon-Bone Graft Augmented with ST [15]
			22.5.4	 Surgical Technique of Extensor Mechanism Reconstruction Using an Allograft
		22.6	 Summary
		References
	23: Painful Total Knee Arthroplasty: An Algorithmic Approach
		23.1	 Introduction
		23.2	 History
		23.3	 Evaluation of Psychological and Mental Health
		23.4	 Physical Examination
		23.5	 Imaging
		23.6	 Laboratory Tests
		23.7	 Intra-Articular Causes of Pain Following TKA
			23.7.1	 Aseptic Loosening
			23.7.2	 Instability
			23.7.3	 Patellofemoral Dysfunction
		23.8	 Implant Malposition
		23.9	 Popliteal Tendon Dysfunction
		23.10	 Hypersensitivity to Metal or Cement
		23.11	 Complex Regional Pain Syndrome (CRPS)
		23.12	 Extra-Articular Cause of Pain
		23.13	 Summary
		References
	24: Management of the Stiff Total Knee Replacement
		24.1	 Introduction
		24.2	 Risk Factors and Aetiology
			24.2.1	 Preoperative
			24.2.2	 Intraoperative
			24.2.3	 Post-Operative
		24.3	 Evaluating the Stiff Painful TKR
		24.4	 Management of a Stiff Knee Replacement
			24.4.1	 Conservative Treatment
			24.4.2	 Physical Therapy
			24.4.3	 Manipulation Under Anaesthesia (MUA)
			24.4.4	 Arthroscopic Arthrolysis
			24.4.5	 Open Surgery
			24.4.6	 Revision Knee Arthroplasty
		24.5	 Summary
		References
	25: Knee Prosthetic Instability
		25.1	 Introduction
		25.2	 Risk Factors and Prevention
		25.3	 Diagnosing Instability
			25.3.1	 Physical Examination
			25.3.2	 Radiological Examination
		25.4	 Classification of Types of Instability
			25.4.1	 Flexion Instability
			25.4.2	 Mid-flexion Instability (MFI)
				25.4.2.1	 Causes of Mid-flexion Instability
				25.4.2.2	 Elevated Joint Line
				25.4.2.3	 Multiradius Design
				25.4.2.4	 Medial Collateral Ligament (Mcl) Laxity
			25.4.3	 Extension Instability
				25.4.3.1	 Acute Instability in Extension
				25.4.3.2	 Symmetric Extension Instability
				25.4.3.3	 Asymmetrical Extension Instability
			25.4.4	 Global Instability
			25.4.5	 Genu Recurvatum
		25.5	 Types of Constraint in Knee Implants
			25.5.1	 Cruciate Retaining (CR)
			25.5.2	 Ultracongruent Inserts
			25.5.3	 Cruciate Substituting
			25.5.4	 Non-linked Hinged
			25.5.5	 Linked Hinged Implants
		25.6	 Summary
		References
	26: Periprosthetic Joint Infection: Diagnosis and Principles of Management
		26.1	 Introduction
		26.2	 Classification
			26.2.1	 Stage 1 (Acute Postoperative Infections)
			26.2.2	 Stage 2 (Delayed Deep Infections)
			26.2.3	 Type 3 Infection (Late Hematogenous Infections)
		26.3	 Diagnosis of PJI
		26.4	 Principles of Management of PJI
			26.4.1	 Medical Therapy (Antibiotic Suppression)
			26.4.2	 Debridement with Implant Retention
			26.4.3	 Single-Stage Revision
			26.4.4	 Two-Stage Revision
			26.4.5	 Knee Arthrodesis
		26.5	 Summary
		References
	27: DAIR: Concepts and Results (Debridement, Antibiotics, Irrigation, and Implant Retention)
		27.1	 Introduction
		27.2	 When to Proceed with DAIR
		27.3	 Technical Aspects
		27.4	 Use of Antibiotics
		27.5	 Results of DAIR
		27.6	 Failure of Treatment
		27.7	 Future Perspective
		27.8	 Summary
		References
	28: Single-Stage Revision TKA for Periprosthetic Joint Infection: The New Gold Standard
		28.1	 Introduction
		28.2	 Pathogenesis and Diagnosis of PJIs
			28.2.1	 Diagnosis
		28.3	 Classification
		28.4	 Indications of Single-Stage Revision TKA
		28.5	 Relative Contraindications of Single-Stage Revision TKA
		28.6	 Surgical Technique
		28.7	 Advantages of Single-Stage Revision
		28.8	 Summary
		References
	29: Revision for Infected Total Knee Replacement
		29.1	 Introduction
		29.2	 Burden of the Problem and the Role of Joint Registries
		29.3	 Classification
		29.4	 Diagnosis
		29.5	 Principles
		29.6	 One-Stage Vs. Two-Stage Revision
			29.6.1	 One-Stage Revision
			29.6.2	 Two-Stage Revision
		29.7	 Authors’ Preferred Technique for First Stage of a Two-Stage Revision
		29.8	 Results
		29.9	 Summary
		References
Part IV: Technology in Total Knee Arthroplasty
	30: The Science Behind Computer-Assisted Surgery of the Knee
		30.1	 Introduction
		30.2	 Classification
			30.2.1	 Computer-Assisted Technology
			30.2.2	 Systems
			30.2.3	 Modalities
		30.3	 Principles on Tracking Technology
			30.3.1	 Simplified Overview [22]
			30.3.2	 Detailed Principles
				30.3.2.1	 The Optical Active Technology
		30.4	 Computer-Assisted Image-Based Systems and Technology
			30.4.1	 Pre-operative Phase
				30.4.1.1	 Image Protocol Acquisition
				30.4.1.2	 Surface Reconstruction
				30.4.1.3	 Planning and Simulation
			30.4.2	 Intra-operative Procedure
				30.4.2.1	 Planning [47, 48]
				30.4.2.2	 Set-up
				30.4.2.3	 Registration [20]
					Registration Processes
				30.4.2.4	 Execution: Surgical Execution [1, 20, 40, 41]
		30.5	 Intra-operative Fluoroscopic Image Technology
		30.6	 Image-Free Technology [56, 57]
			30.6.1	 General Remarks
			30.6.2	 Understanding the Concept of CT-Free TKR
			30.6.3	 Detailed Principles: Collecting Landmarks of the Lower Limb
				30.6.3.1	 Hip Centre
				30.6.3.2	 Knee Centre
				30.6.3.3	 Ankle Centre
				30.6.3.4	 Coronal, Sagittal and Transversal Plane of the Femur
				30.6.3.5	 Anterior Referencing and Notching
				30.6.3.6	 Anterior and Femur Implant Size
				30.6.3.7	 Femoral Rotation References
				30.6.3.8	 Landmark References for Bone Cut Height
				30.6.3.9	 Coronal, Sagittal and Transversal Plane of the Tibia
			30.6.4	 Execution
		30.7	 Summary
		References
	31: Computer-Assisted Total Knee Arthroplasty: Stepwise Approach
		31.1	 Introduction
		31.2	 Rationale of Using CAOS in TKR
		31.3	 Operative Technique
			31.3.1	 System Setup
			31.3.2	 Registration of Biomechanical Axis
			31.3.3	 Distal Femoral Anatomy Registration
			31.3.4	 Proximal Tibial Anatomy Registration
			31.3.5	 Femoral Cuts
			31.3.6	 Tibial Cut
			31.3.7	 Component Implantation
		31.4	 Summary
		References
	32: Navigation-assisted Unicondylar Knee Replacement
		32.1	 Introduction
		32.2	 Surgical Technique
			32.2.1	 Medial UKA
				32.2.1.1	 Patient Setup
				32.2.1.2	 Hardware Setup
					Camera
					Fluoroscopy System
					Trackers
					Accelerometer-based Portable Navigation
				32.2.1.3	 Surgical Approach
				32.2.1.4	 Registration
				32.2.1.5	 Planning
				32.2.1.6	 Execution
			32.2.2	 Lateral Unicompartmental Knee Replacement
		32.3	 Results
		32.4	 Discussion
		32.5	 Summary
		References
	33: Patient-specific Instrumentation in Total Knee Arthroplasty
		33.1	 Introduction
		33.2	 Evolution of Patient-specific Instrumentation
		33.3	 Patient-specific Instrumentation in TKA
		33.4	 Planning PSI in TKA
			33.4.1	 Medical Image Acquisition
				33.4.1.1	 Image Spatial Resolution and Slice Thickness
				33.4.1.2	 Image Data Sharing/Transmission
			33.4.2	 Image Data Processing and 3D Modeling
				33.4.2.1	 Software
					Open Source Software
					Off the Shelf Software
				33.4.2.2	 Image Segmentation
			33.4.3	 Virtual Surgical Planning
				33.4.3.1	 Offline Planning Platforms
				33.4.3.2	 Online Planning Platform
		33.5	 Manufacturing of PSI
			33.5.1	 Materials
			33.5.2	 3D Printers
				33.5.2.1	 SLS Machines
				33.5.2.2	 SLA Machines
				33.5.2.3	 Fused Deposition Modeling (FDM Machines)
				33.5.2.4	 3D-printed PSI Guides
			33.5.3	 Sterilization of PSI Guides
		33.6	 Surgical Considerations
			33.6.1	 Learning Curve
			33.6.2	 Cost-effectiveness of PSI
			33.6.3	 Blood Loss
			33.6.4	 Operative Time
			33.6.5	 Complications
		33.7	 Discussion
		33.8	 PSI Versus CAS
		33.9	 Future
		33.10	 Summary
		References
	34: Overview of Robotics in Total Knee Arthroplasty
		34.1	 Introduction
		34.2	 The Role of Functional Alignment
		34.3	 The Process of Robotic-assisted TKA
			34.3.1	 Pre-operative Planning
			34.3.2	 Intra-operative Registration
			34.3.3	 Bone Resections
			34.3.4	 Knee Balancing and Fine Adjustment
			34.3.5	 Implantation
		34.4	 Learning Curve
		34.5	 Current Evidence Base
			34.5.1	 Alignment
			34.5.2	 Soft Tissue Trauma
			34.5.3	 Functional Outcomes
		34.6	 Cost-effectiveness and Other Challenges
		34.7	 Future Direction
		34.8	 Summary
		References
	35: Total Knee Arthroplasty Using Robotics (MAKO)
		35.1	 Introduction
		35.2	 Pre-operative Planning
			35.2.1 CT Landmarks
			35.2.2 Resection Landmarks
			35.2.3 Implant Positioning (Pre-operative)
		35.3	 Surgical Technique
			35.3.1 Patient Positioning
			35.3.2 MAKO System Setup
			35.3.3 Surgical Exposure
			35.3.4 Tracker Array Placement
			35.3.5 Bone Registration
			35.3.6 Intra-operative Planning
			35.3.7 Positioning the Robot
			35.3.8 Bone Preparation
			35.3.9 Trial Reduction and Joint Assessment
				35.3.9.1	 Soft Tissue Balancing with Trial Implants
				35.3.9.2	 Soft Tissue Balancing with Tensioner
			35.3.10 Final Component Preparation and Implantation
		35.4	 Discussion
			35.4.1 Accuracy of Implant Positioning
			35.4.2 Soft Tissue and Bone Preservation
			35.4.3 Functional Outcome
			35.4.4 Complications and Implant Survivorship
			35.4.5 Learning Curve
		35.5	 Drawbacks
			35.5.1 Pin Tracts-related Complications
			35.5.2 Radiation Exposure
			35.5.3 Operative Time
			35.5.4 Cost
		35.6	 Case Examples Demonstrating the Accurate Execution of Different Alignment Options
		35.7	 The Future
		35.8	 Summary
		References
	36: Robotic-Assisted Unicondylar Knee Arthroplasty
		36.1	 Introduction
		36.2	 Patient Selection
		36.3	 Planning
			36.3.1	 Preoperative
			36.3.2	 Intraoperative
		36.4	 Surgical Approach
			36.4.1	 Design Approach
			36.4.2	 Surgical Technique
		36.5	 Discussion
			36.5.1	 Implant Positioning
			36.5.2	 Recovery and Hospitalization
			36.5.3	 Pain Outcomes
			36.5.4	 Functional Outcomes
			36.5.5	 Survivorship
			36.5.6	 Cost-Effectiveness
		36.6	 Summary
		References
	37: Fast-Track Total Knee Arthroplasty
		37.1	 Introduction
		37.2	 Components of Fast-Track Protocol
			37.2.1	 Preoperative Phase
				37.2.1.1	 Optimization of Comorbidities
				37.2.1.2	 Patient Education
				37.2.1.3	 Preoperative Fasting and Nutrition
			37.2.2	 Intraoperative Phase
				37.2.2.1	 Anesthesia Approach
				37.2.2.2	 Surgical Procedure
			37.2.3	 Postoperative Phase
				37.2.3.1	 Multimodal Analgesia
				37.2.3.2	 Prophylaxis Against Thromboembolism
				37.2.3.3	 Early Mobilization and Rehabilitation
		37.3	 Protocol at Our Institute
			37.3.1	 Patient Selection
			37.3.2	 Preoperative Considerations
			37.3.3	 Surgical Considerations
			37.3.4	 Postoperative Rehabilitation
			37.3.5	 Precautions
		37.4	 Discussion
		37.5	 Summary
		References
Part V: Revision Total Knee Arthroplasty
	38: Mechanisms of Failure in Total Knee Arthroplasty: Diagnosis and Evaluation
		38.1	 Introduction
		38.2	 Mechanisms of Failure in Total Knee Arthroplasty
			38.2.1	 Infection
			38.2.2	 Aseptic Loosening
			38.2.3	 Instability
			38.2.4	 Arthrofibrosis
			38.2.5	 Polyethylene Wear
			38.2.6	 Malalignment
			38.2.7	 Periprosthetic Fractures
		38.3	 Diagnosis and Evaluation (Table 38.2)
		38.4	 Investigations
			38.4.1	 Plain Radiographs
			38.4.2	 CT Scan
			38.4.3	 MRI Scan
			38.4.4	 Bone Scan
			38.4.5	 SPECT Scan
		38.5	 Summary
		References
	39: Exposure Options in Revision Total Knee Arthroplasty
		39.1	 Introduction
		39.2	 Surgical Exposure
		39.3	 Vascular Supply of Anterior Part of Knee [19–22]
		39.4	 Exposures for Easy Revision
			39.4.1	 Medial Parapatellar Approach
			39.4.2	 Lateral Parapatellar
			39.4.3	 Tissue Sparing Arthrotomy
		39.5	 Deep Dissection
		39.6	 Exposures for Difficult Revisions
			39.6.1	 Quadriceps Snip
			39.6.2	 Tibial Tubercle Osteotomy (TTO)
			39.6.3	 Banana Peel
			39.6.4	 V-Y Turndown
		39.7	 Alternative Techniques
			39.7.1	 Medial Epicondylar Osteotomy
			39.7.2	 Femoral Peel
			39.7.3	 Extensor Mechanism Tenolysis
		39.8	 Historical Approaches
			39.8.1	 Coonse and Adams
			39.8.2	 Insall’s Patellar Turndown
		39.9	 Complications and Management
		39.10	 Summary
		References
	40: Prosthesis Extraction in Revision Total Knee Arthroplasty
		40.1	 Introduction
		40.2	 Preoperative Planning
		40.3	 Principles of Implant Removal
		40.4	 Special Considerations
			40.4.1	 Stem Fractures
			40.4.2	 Difficult Cement Removal
		40.5	 Summary
		References
	41: Prosthesis Selection and Rationale for Use in Revision Total Knee Arthroplasty
		41.1	 Introduction
		41.2	 Discussion
			41.2.1	 Instability
				41.2.1.1	 Posterior-Stabilized Design Prosthesis
				41.2.1.2	 Varus-Valgus Constraint Prosthesis
				41.2.1.3	 Rotating Hinged Knee Prosthesis
			41.2.2	 Bone Defect
				41.2.2.1	 Metaphyseal Sleeve and Cone
				41.2.2.2	 Megaprosthesis
		41.3	 Summary
		References
	42: Management of Bone Defects in Revision Total Knee Arthroplasty: Concept of Sleeves
		42.1	 Introduction
		42.2	 Preoperative Evaluation and Planning
		42.3	 Surgical Technique
		42.4	 Discussion
		42.5	 Summary
		References
	43: Managing Bone Defects in Revision TKR: Concept and Use of Tantalum Cones
		43.1	 Introduction
		43.2	 Porous Tantalum
		43.3	 Surgical Technique
		43.4	 Removal of Cones
		43.5	 Discussion
		43.6	 Pictorial Case Studies (Figs. 43.9, 43.10, 43.11, 43.12, 43.13, and 43.14)
		43.7	 Case Examples
		References
	44: Gap Balancing in Revision Total Knee Arthroplasty
		44.1	 Introduction
		44.2	 Steps in the Management of Gaps in Revision TKA
			44.2.1	 Intraoperative Assessment of Gaps and Ligament Stability
			44.2.2	 Medial–Lateral Soft Tissue Balancing
			44.2.3	 Creating a Stable Tibial Platform
			44.2.4	 Flexion Gap
			44.2.5	 Extension Gap and Restoration of Joint Line
		44.3	 Assessment Done Once the Trials Are in Place to Confirm the Stability of the Knee
		44.4	 Approach to a Situation Where Gaps Cannot Be Balanced
		44.5	 Summary
		References
	45: Joint Line Restoration in Revision Total Knee Arthroplasty
		45.1	 Introduction
		45.2	 Landmarks for Defining Joint Line
		45.3	 Preoperative Planning
			45.3.1	 Assess Ligament Integrity
			45.3.2	 Assess Preoperative Patellar Height (Radiograph of Contralateral Knee)
		45.4	 Surgical Technique
			45.4.1	 Exposure
			45.4.2	 Implant Removal
			45.4.3	 Establish the Tibial Platform
			45.4.4	 Reconstruct the Femur
			45.4.5	 Insert Polyethylene Spacer
			45.4.6	 Soft Tissue Balancing
		45.5	 How Much of Joint Line Elevation Can Be Accepted?
		45.6	 Discussion
		45.7	 Summary
		References
	46: Rotating Hinge Knee in Primary and Revision Knee Arthroplasty
		46.1	 Introduction
		46.2	 Implant Design
			46.2.1	 Evolution of Hinge Knee Devices
				46.2.1.1	 First Generation Implants
				46.2.1.2	 Second Generation Implants
				46.2.1.3	 Third-Generation RHK
			46.2.2	 Peculiarities of Modern RHK Implants
				46.2.2.1	 NexGen RHK (Zimmer)
				46.2.2.2	 S-ROM RHK (Depuy)
			46.2.3	 Bone Loss
			46.2.4	 Augments Commonly Used Along with RHK
		46.3	 Surgical Technique
			46.3.1	 Surgical Technique Principals of NexGen RHK (Fig. 46.12)
			46.3.2	 Reconstruction of Bone Defect with T.M. Cones in TKA Revision
		46.4	 Indications
			46.4.1	 RHK for Primary Cases
			46.4.2	 RHK for Revision Situations
			46.4.3	 Special RHK: Distal Femur Replacing (DFR)
		46.5	 Complications
		46.6	 Discussion
			46.6.1	 RHK in Primary TKA
				46.6.1.1	 Non-Tumour Conditions
				46.6.1.2	 Primary RHK in Tumour Conditions
			46.6.2	 RHK in Revision Scenario
		46.7	 Summary
		References
	47: Revision of Failed Unicondylar Knee Arthroplasty to a Total Knee Arthroplasty
		47.1	 Introduction
		47.2	 Surgical Aspects: Conversion of Failed UKA to TKA
		47.3	 Preoperative Planning and Surgical Consideration
			47.3.1	 Step 1: Exposure
			47.3.2	 Step 2: Removal of Femoral Component
			47.3.3	 Step 3: Femur Preparation
			47.3.4	 Step 4: Tibial Implant Removal
			47.3.5	 Step 5: Tibial Resection and Preparation
			47.3.6	 Step 6: Management of Residual Bone Defect
			47.3.7	 Step 7: Soft Tissue Balancing and Final Implantation
		47.4	 Tips and Pearls
		47.5	 Discussion
		47.6	 Summary
		References
	48: Re-revision of a Previously Revised Total Knee Arthroplasty
		48.1	 Introduction
		48.2	 Indications
		48.3	 Preoperative Assessment
			48.3.1	 Patient History
			48.3.2	 Physical Exam
			48.3.3	 Laboratory Studies
			48.3.4	 Imaging
				48.3.4.1	 AP Knee Radiograph
				48.3.4.2	 Lateral Knee Radiograph
				48.3.4.3	 Sunrise or Merchant View
				48.3.4.4	 Advanced Imaging
				48.3.4.5	 General Considerations
		48.4	 Intraoperative Surgical Considerations
			48.4.1	 Skin Incision
			48.4.2	 Exposure
			48.4.3	 Implant Removal
				48.4.3.1	 Indications for Removal
				48.4.3.2	 Tools and Instrumentation
				48.4.3.3	 Order of Implant Removal
				48.4.3.4	 Removing the Femoral and Tibial Components
				48.4.3.5	 Removing Metaphyseal Components
				48.4.3.6	 Cement Removal
			48.4.4	 Reimplantation
				48.4.4.1	 Building a Stable Platform
				48.4.4.2	 Determining Femoral Rotation
				48.4.4.3	 Determining Size of Femoral Component and Balancing Knee in Flexion
				48.4.4.4	 Determining the Joint Line and Balancing the Knee in Extension
				48.4.4.5	 Determining Level of Constraint
				48.4.4.6	 Managing Bone Loss
				48.4.4.7	 The Patella
		48.5	 Postoperative Management
		48.6	 Salvage Options
		48.7	 Summary
		References
	49: Bulk Allografts in Revision Total Knee Arthroplasty
		49.1	 Introduction
		49.2	 Indication
		49.3	 Types of Bulk Allografts
			49.3.1	 Femoral Head Allograft
			49.3.2	 Distal Femoral Allograft
				49.3.2.1	 Preparation of Allograft
				49.3.2.2	 Preparation of Host Bed
			49.3.3	 Proximal Tibial Allograft
		49.4	 Summary
		References
	50: Condylar Replacement Prosthesis as a Salvage in Knee Arthroplasty
		50.1	 Introduction
		50.2	 Evolution and Implant Designs
		50.3	 Indications
			50.3.1	 Revision Total Knee Arthroplasty
			50.3.2	 Primary Total Knee Arthroplasty
		50.4	 Decision-Making
		50.5	 Preoperative Planning
			50.5.1	 History and Clinical Assessment
			50.5.2	 Radiological Assessment
		50.6	 Surgical Technique
			50.6.1	 Surgical Approach
			50.6.2	 Soft Tissue Dissection and Exposure
			50.6.3	 Removal of Distal Femoral Segment and Well-Fixed Implant in Revision Scenarios
			50.6.4	 Intraoperative Assessment of Bone Defect
			50.6.5	 Sequence of Reconstruction
			50.6.6	 Definitive Implant Fixation
		50.7	 Case Examples
		50.8	 Discussion
		50.9	 Summary
		References
Part VI: Advances in Perioperative Management in Total Knee Arthroplasty
	51: Managing Soft Tissue Deficiencies in Total Knee Arthroplasty
		51.1	 Introduction
		51.2	 Risk Factors
		51.3	 Classification
		51.4	 Preventive Strategies for Soft Tissue Management and Wound Complication
			51.4.1	 Optimization of Systemic Factors
			51.4.2	 Optimization of Local Factors
		51.5	 Options to Improve the Soft Tissue Envelope
			51.5.1	 Tissue Expanders
			51.5.2	 Prophylactic Flaps: Pedicled or Free
		51.6	 Intra-operative Management
		51.7	 Management of Established Soft Tissue Compromise and Infection
		51.8	 Reconstruction of Skin and Soft Tissue Defects
			51.8.1	 Secondary Suturing and Secondary Healing
			51.8.2	 Skin Grafting
			51.8.3	 Flap Coverage
				51.8.3.1	 Local Flaps
				51.8.3.2	 Free Flaps
		51.9	 Summary
		References
	52: Multimodal Pain Management in Total Knee Arthroplasty
		52.1	 Introduction
		52.2	 Multimodal Analgesia
			52.2.1	 Preoperative (Preemptive)
			52.2.2	 Intraoperative
				52.2.2.1	 General Anesthesia
				52.2.2.2	 Neuraxial Anesthesia
				52.2.2.3	 Peripheral Nerve Blocks
					Femoral Nerve Block
					Adductor Nerve Block
					IPACK (Infiltration Between Popliteal Artery and Capsule of Knee Joint)
					Local Infiltration Analgesia (LIA)
					Sciatic Block
				52.2.2.4	 Drug Adjuvants
			52.2.3	 Postoperative Period
		52.3	 Summary
		References
	53: Deep Vein Thrombosis: Prophylaxis and Management
		53.1	 Introduction
		53.2	 Pathogenesis
		53.3	 Epidemiology
		53.4	 Prophylaxis Following Total Knee Arthroplasty
		53.5	 Mechanical Methods
			53.5.1	 Pneumatic Compression Boots
			53.5.2	 Venous Plantar Compression
		53.6	 Pharmacological Methods (Fig. 53.1)
			53.6.1	 Low-Molecular-Weight Heparin
			53.6.2	 Warfarin
			53.6.3	 Aspirin
			53.6.4	 Fondaparinux
			53.6.5	 Newer Agents
				53.6.5.1	 Rivaroxaban
				53.6.5.2	 Apaxiban
				53.6.5.3	 Dabigatran
		53.7	 Influence of Anesthesia on the Rate of Thrombosis
		53.8	 Duration of Thromboprophylaxis
		53.9	 Screening Considerations
		53.10	 High-Risk Patients
		53.11	 Recommendations
		53.12	 Management
		53.13	 Summary
		References
	54: Optimal Rehabilitation After Total Knee Arthroplasty
		54.1	 Introduction
		54.2	 Rapid Rehabilitation
		54.3	 Pain Management
		54.4	 Continued Rehabilitation
			54.4.1	 Getting in and out of Bed
			54.4.2	 Standing up and Sitting down
			54.4.3	 Walking
			54.4.4	 Stairs
			54.4.5	 Occupational Therapy
			54.4.6	 Information for When Patient Goes Home
		54.5	 Homecare
			54.5.1	 Exercises
			54.5.2	 Walking
			54.5.3	 Gait
			54.5.4	 Kneeling
			54.5.5	 Sports/Hobbies
			54.5.6	 Physiotherapy
			54.5.7	 Driving
			54.5.8	 Flying
		54.6	 Do’s and Don’ts After TKA [18]
		54.7	 Discussion
		54.8	 Summary
		References
	55: Evolving Trends in Total Knee Arthroplasty
		55.1	 Introduction
		55.2	 Evolution of Total Knee Arthroplasty
		55.3	 Cruciate Retention versus Substitution
		55.4	 Advances in Materials
		55.5	 Advances in Design and Geometry
			55.5.1	 The Bicruciate Design Total Knee Replacement
			55.5.2	 Porous Coating in Cementless Knees
			55.5.3	 3D-Printing in Orthopaedics
			55.5.4	 Manufacturing of Cementless Implants using Newer Technologies
			55.5.5	 Patient-Specific Instrumentation
		55.6	 Rehabilitation and Recovery
		55.7	 Summary
		References