Pembimbing : dr. Pamudji Utomo Sp.

OT (K)
Oleh : Anggita Tri Yurisworo

Knee arthroplasty
Glucks
ivory total knee
1940 GUEPAR (Hinge Arthroplasty)
History
hinge arthroplasty
(1891)

1940 Campbell (Femoral resurfacing)

1958 McIntosh (Tibial resurfacing)

Normal Alignment
Long standing X-ray
with normal
alignment.
The mechanical axis is
87 to the joint line,
which is horizontal in
the stance position

Relationship of Alignment to
Kinematic Function of the Knee

Implant Component
Metal alloys, ceramic
material, or strong
plastic parts
The lower end of the

femur
The top surface of the
tibia
The back surface of the
patella

Concepts in Prosthetic
Design
Femoral rollback
the posterior

translation of the
femur with
progressive
flexion
improves range of

knee flexion
controlled by the ACL
and PCL

Constraint
varus-valgus and flexion-extension stability
ligamentous laxity or severe bone loss

standard cruciate-retaining or posteriorstabilized implants not provide stability

Modularity
balance soft tissues and/or restore bone loss
customize implant intraoperatively
Options : metal tibial baseplate with modular

polyethylene insert; metal augmentation for

bone loss; modular femoral and tibial stems

Implant Designs
Cruciate-Retaining
(CR) Design
depends on an
intact PCL to provide
stability in flexion
Indications :
arthritis with

minimal bone loss,

minimal soft tissue
laxity, and an intact
PCL

Advantages :
avoids tibial impingement/dislocation
normal knee kinematics
less distal femur needs to be cut
improved proprioception with preservation

of native PCL

Disadvantages :
tight PCL accelerated polyethylene wear
loose or ruptured PCL flexion instability

and subluxation

Posterior Stabilized (PS) Design

Constrained

prosthesis sacrifice of PCL

femoral component contains a cam engages the
tibial polyethylene during flexion

Indications :
previous patellectomy
inflammatory arthritis
deficient or absent PCL

Advantages
easier to balance a

knee with absent PCL

>> range of motion
easier surgical
exposure

Disadvantages
tibial post

polyethylene wear
additional bone is cut
from distal femur to
balance extension
gap

Constrained Nonhinged Design

without axle connecting
tibial and femoral
components

Indications :
LCL adn MCL deficiency
flexion gap laxity
moderate bone loss

Advantages :
stability soft tissue or bony

deficiency

Disadvantages :
more femoral bone resection
aseptic loosening

Constrained Hinged Design

linked femoral and tibial
components

Advantages :
Stability soft tissue

or bony deficiency

Disadvantages :
aseptic loosening

Indications :
global ligamentous

deficiency
hyperextension
instability
resection for tumor
massive bone loss

Mobile Bearing Design

minimally constrained
prosthesis. the
polyethylene can rotate on
the tibial baseplate
PCL is removed

Advantages :
reduces polyethylene wear

Disadvantages :
bearing spin-out

Unicompartmental Knee
Replacement
Knee arthrititis only
one compartment of the
knee is involved
medial compartment is
most common
Advantages
faster rehabilitation and
quicker recovery
less blood loss, less
morbidity, less expensive
preservation of normal
kinematics
smaller incision

Indications
alternative

to total knee arthroplasty or osteotomy for

unicompartmental disease
reserved for older (>60), lower-demand, and thin (<82 kg)
patients

Contraindications
inflammatory

arthritis
ACL deficiency
fixed varus deformity > 10 degrees
fixed valgus deformity >5 degrees
restricted motion
previous meniscectomy in other compartment
tricompartmental arthritis (diffuse or global pain)
younger high activity patients and heavy laborers
overweight patients (> 82 kg)
grade IV patellofemoral chondrosis (anterior knee pain)

Complications

Stress fractures
Involve tibia
high activity and patient weight
pain free interval followed by spontaneous pain

with activity
blood on joint aspiration

Tibial component collapse

poor mechanical properties of bone

Defining Knee Motion

(Kinematics)

Femoral roll-back
during flexion to
90
The femur starts in
the anterior position
at full extension
then moves
posteriorly as the
knee flexes

Implant Materials

Metal parts : titanium or cobaltchromium based alloys

plastic parts : ultra high molecular weight
polyethylene
Material Criteria :
Biocompatible
Retain strength and shape for a long time
able to duplicate the knee structures

Implant Fixation
Cemented fixation
Implants are most commonly held in place
with a fast-curing bone cement
(polymethylmethacrylate)
Cementless fixation
"press-fit" onto bone. relies on new bone
growing into the surface of the implant
Hybrid fixation
the femoral component is inserted without
cement, and the tibial and patellar
components are inserted with cement

Terima Kasih

Revision of TKR

The rate of revision of primary TKA

remains relatively low.
In a population-based study by Coyte et
al., a similar revision rate estimated
between 4.3% and 8% was seen at 7
years postoperatively in 18,530
patients.

patellofemoral
maltracking
abnormal joint line
problems
component
loosening
osteolytic wear
ligament instability
periprosthetic
fracture

Reconstruction Principles

anatomical position
Bone defects treated appropriately
Restored Knee stability prosthetic
constraint and soft-tissue balancing
Appropriate limb alignment
Rigid fixation prolonged implant
survival

Revision Components

some or all of the parts of the

original implant are removed and
replaced with new components
longer stems which fit into the
femur and tibia. Metal augments
which substitute for missing bone
a cam in the center of the knee
a posterior stabilized component.
the cam is larger to give the knee
more stability

TKR revision

Prosthesis Selection
Unconstrained Posterior Cruciate
Retaining
indicated PCL is intact

Unconstrained Posterior Cruciate

Substituting
indicated PCL deficiency

Constrained Nonhinged
large central post substitutes for MCL/LCL

function
indicated varus/valgus instability

Constrained Hinged with rotating

platform
tibial component internal/external rotation

within a yoke
indicated global ligament deficiency