NATIVE KNEE KINEMATICS

The Knee is more complex than a simple hinge joint. Motion occurs not only in flexion-extension, but
also involves rotation, pivot, and gliding movements. The best way to understand our knee motion is
to first understand that it is controlled by three things: 1) the articular geometry; 2) the ligamentous
balance; and 3) muscular tension. We will look at these individually to appreciate the complexity of
knee kinematics.

1. THE ARTICULAR GEOMETRY.

Let’s first look at the femoral side of the joint.

The medial femoral condyle (MFC) and lateral femoral condyle (LFC) are different sizes and have a
different radius of curvature. The MFC is larger and more circular – meaning a uniform radius of
curvature. In contrast, the LFC is smaller and the two condyles, distal condyle and posterior
condyle, have very different radii of curvature to promote LFC motion during knee flexion.

The differences in femoral anatomy create unique motion patterns for the MFC and LFC and this drives
complex kinematics. For example, the MFC radius of curvature is relatively uniform and so the MFC
remains mostly stationary during knee flexion, while the LFC travels posteriorly on the tibia (posterior
rollback) due to the change in radius of curvature.
The difference in posterior rollback between the LFC and MFC (LFC rolls back while the MFC remains
relatively in place) drives the distal femur to externally rotate. The majority of this external rotation
occurs in the first 15° of knee flexion. This contributes to patellar tracking because at 15° of knee
flexion the patella engages the trochlear groove and this is the stress point where the patella needs
to be centrally located to prevent lateral dislocation or subluxation. Patellar mal tracking can occur if
the femur doesn’t rotate or if there is insufficient medial structures (specifically the medial
patellofemoral ligament) acting as a harness to guide the patella, or a hypoplastic trochlear groove
can also lead to patellar subluxation by failing to provide a bumper to guide tracking. So, as the femur
flexes, it externally rotates about 15° in relation to the tibia and thus the trochlear groove moves a
little laterally to help with patellar tracking.

Posterior rollback is a big deal for another reason. It determines the point of terminal flexion. In many
ways it’s the holy grail of TKA. Rollback is essential to achieve full deep flexion (which is seen with
squatting or deep bends). Without rollback, the back of the femoral diaphysis will impinge on the tibia
around 90°, however, if the distal femur moves posteriorly in relation to the tibia, it increases the
clearance before impingement, and thus allows for extra flexion. Ultimately, impingement does occur
(between the lateral tibia and the posterior cortex of the distal femur) and this marks terminal
flexion. We talk more about the importance of rollback when discussing TKA designs.
The medial and lateral tibial plateau are also shaped differently. The difference in the medial and
lateral tibia is best seen on a lateral x-ray of the knee (or in comparing slices of a CT scan). The lateral
tibial plateau is flat (or even slightly convex) and is designed this way to encourage LFC roll back during
knee flexion. In contrast the medial tibial plateau is dished (concave), allowing for less MFC rollback,
and enabling a pivot type motion whereby the LFC rotates around the stable MFC.

2. LIGAMENT STABILIZATION

The knee is only partially guided by the geometry of the articular surface. The surrounding ligaments
and muscles also play a central role.

Collateral Ligaments: control coronal plane stability.

The superficial MCL is the major medial stabilizer, originating at the medial epicondyle and traveling
deep to the pes muscles to insert broadly on the tibial 4.5 cm distal to the joint line. The deep MCL is
only a thickening of the capsule (as known as the medial capsular ligament). The posterior-medial
corner (posterior oblique ligament, semimembranosus, posterior horn medial meniscus) provide 30%
of valgus restraint in full extension and with greater flexion the MCL assumes more responsibility
- 60% in 5° flexion and 80% in 25° flexion.
The LCL ("fibular collateral ligament") provides lateral stability, originating proximal and posterior to
the lateral epicondyle and inserts on the lateral fibular head.

Cruciate Ligaments: provide stability in the sagittal plane.

The anterior cruciate ligament (ACL) prevents anterior subluxation of the tibia, particularly near
terminal extension - ACL is taut around 15° of flexion, which corresponds to the region where your
quad has the worst mechanical advantage to extend the leg, and thus exerts the greatest anterior
directed force on the proximal tibia. In ACL-deficient knee, full extension causes the femur to shifted
posteriorly due to un-resisted anterior pull on the tibia.

ACL function changes the location of cartilage wear. Wear occurs in the anterior-medial aspect of the
knee when the ACL is intact, however if the ACL is deficient, the tibia translates forward, and cartilage
wear occurs in the posterior-medial aspect of the knee. It’s important to recognize wear-pattern
differences when considering UKA.

In contrast the posterior cruciate ligament prevents posterior subluxation of the tibia. If the tibia
subluxes posteriorly, the femur is unable to achieve proper posterior rollback, which is essential for
achieving terminal flexion. We discuss in the Knee Design Section the importance of the PCL for TKA.

Meniscus: increase contact area to reduce joint forces

The menisci improve joint congruity by smoothing out the difference between relatively round
femoral condyles and flat tibial plateaus. The menisci increase the effective joint surface (a complete
meniscectomy reduces the contact area by 50%), which reduces contact forces. Menisci transmit 50%
of the load in extension and 90% in flexion by transferring axial load into hoop stress. Complete
meniscectomy increases joint forces by 2-3x, with 20% of people developing significant arthritis in just
3 years, and 100% of people develop significant arthritis by 20 years.

The medial meniscus is relatively stationary, similar to the MFC, and the posterior horn of the medial
meniscus can act as an A-to-P stabilizer, and is particular important where the ACL is absent. Over
time, the posterior horn of the medial meniscus becomes degenerated in people without an ACL.

3. MUSCLES

The muscles contribute to knee motion.

The Quad is the knee extensor and weakness/atrophy affects patellar tracking and is associated with
patellofemoral pain.

The Popliteus "unlocks" the knee as it begins to flex. In full extension there is close articular
congruency, however, as the knee enters flexion, the popliteus muscle externally rotates the femur
relative to the tibia, to decrease articular congruence and to enable normal condylar rollback and full
flexion. It is a posterior muscle, that crosses the knee from the medial tibia to the lateral femur, the
tendinous portion becomes intraarticular, runs just behind the lateral meniscus, and inserts at the
lateral femoral condyle (anterior and distal to the epicondyle).
 NATIVE KNEE ALIGNMENT

Let’s first talk about the alignment of the native knee, then compare it with the goals for TKA
alignment.

The Mechanical Axis of the leg is a line drawn from the centre of the hip to the centre of the ankle. This
line should cross through the centre of the knee. This means that the knee has neutral alignment.

The Anatomic Axis is the centre of the bones making up the leg, and the anatomic axis of the femur is
6° from the mechanical axis while the anatomic axis of the tibia is in line with the mechanical
axis. Therefore, the Knee Angle (referring to the Femoral-Tibial Angle: FTA) is 6° valgus (relative to the
mechanical axis).

We also need to consider the joint line itself. The joint line is variable person-to-person, however, on
average it’s in about 3° of varus (relative to the mechanical axis). On the tibial side, it means the tibial
articular surface is in 3° varus, while on the femoral side, the femoral articular surface is in 3° of
valgus. Now we need to combine everything together. On the femoral side, the joint line is in 9° of
valgus relative to the anatomic axis (that’s 6° from the femoral centre to the mechanical axis and then
3° more from the mechanical axis to the line across the distal femoral condyle). On the tibial side, the
joint line is in 3° of varus relative to the anatomic axis (that’s 0° from the tibial centre to the mechanical
axis because these two are parallel, and then 3° from the mechanical axis to the tibial joint line).
In a standard TKA (we describe in more detail below) these angles are simplified by cutting the tibia
perpendicular to the mechanical/anatomic axis, which is 0°. All of the femoral cuts are then adjusted
to line up with this tibial cut.

KNEE DEFORMITY.

A Varus knee (due to common medial sided DJD) will deviate laterally with respect to the mechanical
axis due to narrowing of the medial compartment and gradual attenuation of the lateral soft tissue.

A Valgus knee will deviate medially (the knock-kneed appearance on clinical exam) due to narrowing
of the lateral compartment and attenuation of the medical soft tissue. If the compartments are equal,
and there is no gross bony deformity, the knee should not be angulated and should remain cantered
within the mechanical axis.
 TKA ALIGNMENT
Correct alignment of the TKA implant is critical to restoring function and maximizing longevity. TKA
Malalignment is associated with early loosening (due shear stresses at the bone-implant interface),
accelerated poly wear (due to uneven stress distribution), and increased pain (due to abnormal
stresses on the surrounding soft tissue envelope).

However, there are two schools of thought regarding the target of TKA implantation: 1) Mechanical
Axis Alignment and 2) Kinematic Axis Alignment (also referred to as Anatomic Alignment).

1. MECHANICAL ALIGNMENT

The goal of TKA alignment is to restore the normal mechanical axis. This is not achieved however by
attempting bone cuts that recreate the exact joint line between tibia and femur, which would be 3°
tibial varus and 3° femoral valgus in the native knee. Instead, both the distal femur and the tibia are
cut to be perpendicular (0°) to the mechanical axis.

The femur cut ("distal femoral cut") uses an intramedullary guide based on the anatomic axis. The
angle of the medullary canal (anatomic axis) is used to determine the angle of the cut, and therefore,
the angle of the joint line (around 3°) can be pretty much ignored here.

Let’s look at it again with a different diagram.

The tibial cut is a little more straight forward because the mechanical axis and the anatomic axis are
the same.
The tibia is cut at 0° (perpendicular to mechanical/anatomic axis), while the native tibia joint line is in
slight varus (roughly 3°). This means that we are over-resecting the lateral side (anatomically the
lateral side is slightly higher giving that 3° varus, so with a cut at 0° you are resecting slightly more
lateral tibia).

Theoretically over resecting lateral tibial bone causes some varus laxity. You can compensate by
performing a medial release of soft tissue (such as taking down some of the deep MCL); or adjust the
bony cuts on the femoral side by a) under-resect the lateral distal femur (decrease the valgus angle
slightly to 6° based on the intramedullary femur guide, instead of cutting the femur at 9°) to reconcile
the extension gap, and b) balance the flexion gap by adding 3° of external rotation (this technique was
originally implemented to compensate for the tibial cut and the improved patellar tracking is just an
added bonus). Thus, the femoral cuts reflect a slight variation from the anatomic ideal as
compensation for the tibial cut.

The big question here is why change the tibia cut to begin with? If the non-anatomic tibia cut leads
you down this path of compromise and compensation, why not just cut the tibia in 3° of
varus? Basically, surgeons are hedging. We operate in the real world, and our cuts aren't always
perfect. Studies have demonstrated we can expect up to 3° error (either varus or valgus) in 30% of
tibial cuts. If 0° is the target of our tibial cut, then variations off that target (3° varus to 3° valgus) still
allow for stable implants. In contrast, if 3° varus is the target tibial cut and the error range remains 3°,
then implants will be regularly inserted with up to 6° of varus. Too much varus shifts the mechanical
axis away from the centre of the knee toward the medial compartment. Too much varus also causes
a deeper medial cut, exposing excess cancellous bone to abnormally high forces. The medial
metaphyseal bone gets abruptly weak when the implant sits >10 mm below the joint line. If too much
stress is placed onto the medial tibial plateau, there is added risk of medial sided collapse and aseptic
loosening. Therefore, the designing surgeons recognized the inherent error rate and decided to make
the target a safer angle of 0°. The non-anatomic cuts in TKA are performed to maximize the number
of stable implants.

2. KINEMATIC ALIGNMENT

Some surgeons think that mechanical axis is important, but restoring anatomic alignment around the
knee is more important. They believe that all of the non-anatomic cuts made to the femur and tibia
have a cumulatively detrimental impact on postop TKA function. Therefore, they cut the femur in 9°
valgus and the tibia in 3° varus to re-establish the normal joint line.

Proponents of this technique argue that despite older studies showing that over 3.9° of tibial varus
leads to increased failure, recent studies on kinematic alignment of the tibia at 3 and 6 years show no
evidence of adverse effect of tibial positioning [1, 2] [3-5]. Furthermore, when comparing kinematic
and mechanical alignment approaches, both show similar mechanical angle (hip-knee-ankle) and knee
angle, with the femur being cut on average with 2° more valgus and the tibia with 2° more varus. [6].
 TKA BONE CUTS

We now apply the understanding knee alignment to make our bone cuts.

In this discussion, to explain the goal of each cut in the simplest manner, we will be talking about the
"Measured Resection" technique of making bone cuts to achieve "Mechanical Alignment". There is
also a "Gap Balancing" technique to bone cuts (the difference is discussed here).

1. TIBIAL CUT.

The tibial cut is aimed at 0 degrees (perpendicular to the mechanical axis). The tibial cut is arguably
the most important bone cut in TKA because it affects both the Flexion and Extension gap. Think of it
as the foundation upon which you build the TKA. The tibia affects both the Flexion and Extension gap
because it articulates with the Distal Femoral Condyles in Extension, and the Posterior femoral
condyles in Flexion. Contact Point changes significantly for the femur during the knee arc of motion,
it changes much less for the tibia.

note: the contact point does change for the tibia (see Kinematics section) and you can make changes
to the tibial slope that only affect the flexion gap. This is a more technically advanced concept. The
anterior tibia is the major contact point during extension, and the posterior tibia is the major contact
point during flexion, and therefore, if you increase the tibial slope you can actually increase the flexion
gap and not the extension gap thru the tibia cut alone.)
It is also important to establish proper rotation of the tibial component. A good landmark for rotation
is to align the anterior aspect of the tibial component with the medial 1/3 of the patellar tendon. If
the tibial component is internally rotated, the tibia bone is now relatively externally rotated compared
to the femur, which will rotate the tibial tubercle laterally, and thus increase the Q angle and increase
risk for dislocation.

2. DISTAL FEMORAL CUT

When you cut the Distal Femur, you are affecting 3 things: 1) Mechanical Alignment; 2) Extension gap;
3) the Joint Line Height

Mechanical Alignment. The goal is to place the TKA in neutral mechanical alignment. The knee is
typically in neutral mechanical alignment when the "knee angle" (tibio-femoral angle) is 6° valgus. The
tibial is cut at 0° relative to both the mechanical axis and the anatomic axis (they are parallel). The
femur is classically cut based on an intramedullary referencing system that is guided by the medullary
canal which is the same as the anatomic axis. The difference between the anatomic axis and the
mechanical axis is about 6°, and that is commonly what the guide is set to. The exact measurements
should be calculated preoperatively as part of the templating.
Extension Gap. If bone cuts are done correctly (0 for tibia and 6 for femur), the tibia and distal femoral
cuts should be parallel to form a nice rectangle, indicating a balanced extension gap. If the gap is
trapezoidal, it indicates soft tissue imbalance that requires adjustment (discussed later).

Joint Line. The femoral implant of every company... the depth of the distal femur is 9 mm (and thats
is also consistent for every femoral implant size: 1 - 10...small, medium, and large...a larger femoral
implant does not affect the size of the distal femoral condyle). Therefore the target depth for the
distal femoral cut is 9 mm. You will take 9 mm of bone and replace it with 9 mm of metal.

note: there are exceptions. Sometimes surgeons will intentionally change the depth of the distal
femoral cut. If there is a significant flexion contracture, resecting more distal femur will enlarge the
extension gap (without affecting the flexion gap) and will allow more knee extension. However, every
time you change the distal femur cut, you are also affecting the joint line. If you take a little extra
bone form the distal femur, you raise the joint line...the implant will always be 9 mm, so if you cut 11
mm and replace it will 9 mm of metal, you have raised the joint line 2 mm. In contrast, if you take
extra bone from the tibia, ie 11 mm, you can insert a bigger poly, ie an 11 mm instead of a 9 mm, and
thus the joint line is not affected. The difference is that there are many sizes of poly but there is only
one size for the distal femoral condyle of the implant: 9 mm. Importantly, some surgeons will also
take less than 9 mm of bone from the distal femoral cut. If there is significant bone loss, then taking
less bone will restore the normal joint line. If there is a pre-existing "patella baja" (i.e. the joint line is
too high relative to the patella), then taking 7 mm of bone, and adding the 9 mm of metal, will lower
the joint line by 2 mm.
3. ANTERIOR & POSTERIOR FEMORAL CUTS (FLEXION GAP, ROTATION)

The knee is flexed and you are looking at an axial view of the distal femur. The Anterior Cut is thru the
trochlear groove and the depth of this cut affects the patellofemoral joint. The Posterior Cut is thru
the Posterior Femoral Condyles and it affects the flexion gap. The Anterior and Posterior Cuts are
parallel and together they determine the rotation of the femoral implant.

Before making these cuts, the Implant Size must be determined with a sizing guide (see picture). The
anterior femur cut, the posterior femur cut, the anterior chamfer cut, and the posterior chamfer cuts
are all made through the appropriately-named "4-in-1 cutting guide". There is a 4-in-1 cutting guide
for each size femur. Therefore, you first get the size, then you figure out where to put the guide on
the distal femur and this is what determines both rotation and flexion gap.
Rotation. With the knee in flexion, you are looking at an axial view of the distal femur. Rotational
change occurs this axial plane, and the angle of the anterior and posterior cuts, relative to the
horizontal, determines rotation. The tibia was cut perpendicular to the mechanical axis, therefore, to
maintain neutral rotation in flexion, the posterior femoral cut should be parallel to this tibial cut to
create a Rectangular Flexion Gap.

However, in the native knee, the posterior femoral condyles are not equal size and therefore a line
across them is not parallel to the tibial cut, rather they are in 3° of valgus (to match the native tibial
plateau angle of 3° varus). You therefore cannot place a flat jig under the posterior femoral condyles
to obtain a neutral rotation (it will cause your cuts to be internally rotated by 3°). Instead you can
take a jig that has 3 ° of external rotation dialled into it as compensation, and place it under the
posterior femoral condyles to obtain a neutral rotation. Alternatively, you can use other landmarks
to orient the cutting jig to obtain neutral rotation. Whiteside’s line is a vertical line parallel to the
mechanical axis, or the Trans epicondylar Axis Line (line connecting the medial and lateral epicondyles)
is a horizontal line that is perpendicular to the mechanical axis. Use one of these 3 techniques to
obtain a neutral rotation.

clinical correlation. Neutral Rotation is particularly important for TKA because it affects patellar
tracking. Internal rotation of either the femoral or tibial component causes patellar malt racking. Mild
Internal Rotation of 1-4° causes some lateral patellar tilt/tracking; Moderate Internal Rotation of 5-8°
causes patellar subluxation and pain; Severe Internal Rotation > 8° can cause dislocation and failure.

Malrotation also affects the flexion gap. If you internally rotate the femur, it causes too much bone
to be taken off the lateral condyle and too little taken off the medial condyle, leading to a tight medial
side and loose lateral side.

Flexion Gap. Once rotation is obtained, the next step is to determine the depth of the Flexion Gap.
Not only does the Flexion Gap need to be rectangular (indication of rotation), but it also needs to be
the same size at the Extension Gap. Remember that the Extension gap was 9 mm. That is the target
of the Flexion Gap too. Therefore, we are trying to take about 9 mm of bone off the posterior femoral
condyles.

The simple way to do this is by Posterior Referencing. You place a jig behind the femoral condyles
and it measures 9 mm. You mark this spot with two pins, and then put the 4-in-1 cutting guide (for
the measured implant size) onto these two pins and start cutting.

The benefit of this technique is that you recreate the normal Posterior Condyle Offset. The posterior
condylar offset is important because its directly related to the arc of motion before impingement
occurs. Normal or increased offset recreates the normal arc of motion. Reduced offset positions the
posterior cortex of the femur closer to the back of the knee and impingement occurs early and this
decreases knee flexion.

The problem with posterior referencing is that the depth of the anterior cut is not measured directly
but rather determined by the size of the 4-in-1 cutting jig. Technically there should not be a problem
because you already sized the femur and so the 4-in-1 cutting jig should cut the right amount of
bone. However, in reality many femurs don't fit one size perfectly, and so the anterior cut may be too
shallow (this will cause overstuffing of the patellofemoral joint because you only take a little bit of
bone, and then replace it with a lot of metal) or it may be too deep (this will cause notching, which is
when the anterior cut not only removes that anterior curve of bone, but actually goes into the femoral
diaphysis and may increase risk for periprosthetic fracture).

The alternative is to use Anterior Referencing. This technique is effectively the opposite of posterior
referencing, whereby you directly measure the depth of the anterior cut using a boom that sits on the
anterior cortex and you place two pins which will hold the 4-in-1 cutting jig.

The benefit of this technique is that your anterior depth will be great (no notching, no overstuffing).

The potential problem is that the posterior femoral condyle cut will be more variable based on how
well the patient's femur anatomy matches the implant sizes. If the femur is big relative to the size of
the 4-in-1 guide, you will end up removing too much bone posteriorly, which will decrease the
Posterior Condyle Offset and may reduce range of motion. If the femur is small relative to the 4-in-1
guide, you will remove too little bone, and the Flexion Gap will be small relative to the extension gap.

Once the 4-in-1 cutting guide is properly oriented in depth and rotation, time to blast away.

4. PATELLAR RESURFACING
It’s important to recognize that patellar resurfacing is not required in knee replacements and not the
standard in many countries. Patellar resurfacing is the standard in the United States. So, let’s look at
the technical considerations.

Across most device companies, the standard thickness of the Patellar Button is 9 mm. The standard
patellar cut should thus be 9 mm. Measure the depth of the native patella, subtract 9 mm, and then
set the patellar cutting guide to that number (if the average patellar depth is 20 mm, the patellar
cutting guide is set to 11-12 mm, although many surgeons set it to 14 mm to avoid cutting the patella
too thin).

Its important to avoid cutting the patella too thin because there is an increased risk of fracture when
the patella is cut to < 12 mm of native patella. The standard prosthetic design has 3-pegs because
there is a lower risk of fracture compared to the single peg design.

5. CUTTING FOR KINEMATIC ALIGNMENT

The approach to the bone cuts for kinematic alignment is slightly different because the goal is to
maintain the native joint line.

The distal femoral cut is made using an intramedullary cutting guide that is parallel to the distal femur
joint line (which is 3° valgus). The posterior femoral cut is made using the posterior reference system
that is set to 0° rotation (unlike the mechanical alignment which is set to 3° of external rotation) so it
is in direct contact with both posterior condyles.

The tibial cut is more challenging. The axis of neutral rotation needs to be established before making
the tibial cut. This is because the cut is 3° of varus (not 0° as in the mechanical alignment approach)
and therefore, cutting this "off-plane" will cause abnormal kinematics. The tibia is then cut in slight
varus.
GAP BALANCE - SOFT TISSUE TENSION
One goal of TKA is to achieve balanced tension within the knee throughout range of
motion. This balanced tension is important for implant stability and longevity.
A balanced knee has rectangular Flexion and Extension gaps - the rectangle demonstrates
that the medial and lateral compartment share equal tension. A trapezoid means that one
side is looser (aka "opening up") and therefore, this side will experience less tension and this
may cause an unstable TKA and/or asymmetric wear and early failure.
The angle of bone cuts and the surrounding soft tissue tension can both affect the balance of
the flexion gap (90°) and extension gap (0°).
The balance of a gap is measured with a spacer block.
A balanced knee has equal sized Flexion and Extension gaps. A balanced knee has
rectangular Flexion and Extension gaps.
In the perfect world, you cut the femur, you cut the tibia and the result is a perfect rectangle
for the Flexion and Extension Gap. But in reality, trapezoidal flexion and extension gaps occur
despite perfect bone cuts because of soft tissue imbalance.
As a knee develops arthritis, it typically develops a concomitant deformity of either varus or
valgus. Over time, this deformity affects the tension of the ligaments around the knee. A
Varus Deformity (90% of cases) causes the lateral ligaments to stretch, while the medial
ligaments are taken off tension and become tight and stiff. A Valgus deformity places stress
on the medial ligaments and causes them to become stretched, while the lateral ligaments
are off tension and become tight.
The standard approach of Soft Tissue Balancing is to achieve equal medial and lateral tension
at 0° and 90°. These two reference points (0° & 90°) are used because its technically easiest
for surgeons during the procedure, but the goal is to stabilize the knee throughout the full
range of motion (every degree from 0° - 130°). It is clearly impractical to attempt to balance
the knee every 5°, yet the question remains whether these 2 check points are sufficient to
ensure a balanced knee.
The soft tissue is balanced in the knee by performing "releases" which take tension off the
tight structures and allow that side of the gap to open up to match the other side (there are
also reports of "tightening" the loose soft tissue, however, the results are less reproducible).

VARUS CORRECTION.

Medial side is tight. Structures to release include anterior structures that affect flexion gap,
and posterior structures that affect extension gap. And this makes sense when you think of
flexion as the knee opening up in the front (hinged from the back) and therefore, structures
in the front (anterior) will become tight. The opposite, whereby extension hinges from the
front and opens in the back, will show posterior structures tight in extension. Anterior is
superficial MCL. Posteriorly you will release the posterior oblique ligament, and the
Semimembranosis, and remove any osteophytes as well.

VALGUS CORRECTION.

Only 10% of knee deformities that require TKA are done for the valgus knee. The Ranawat
classification [1] uses 3 grades to describe valgus deformity severity. Grade I is <10° valgus
deformity (normal valgus angle is ~ 6°), correctable alignment with stress, and intact MCL and
this type accounts for >80% of all valgus knees. Grade II is an angle 10° - 20° degrees, MCL is
attenuated but a firm endpoint, and this type accounts for 15% of valgus knees. Grade III is a
valgus angle >20° and absent or severely attenuated MCL. This grading scale helps to
determine the type of implants and correction that is required.
SOFT TISSUE CONSIDERATIONS.

If the MCL is intact, then a primary TKA poly insert can be used. If the MCL is elongated, a
constrained poly may be necessary to give sufficient coronal stability. Literature shows there
is a risk of recurrent valgus deformity after primary TKA when the MCL is deficient and primary
insert is used (even when satisfactory ligament balancing occurs at the time of
surgery) [2]. The use of constrained poly effective prevents this recurrence [3]. A constrained
insert absorbs more of the joint reactive forces, and the next question is whether stems are
necessary to increase the surface area of the bone-implant interface to absorb these greater
forces [4]. Some argue that an elongated MCL is still functional and a constrained insert
without stems is not at increased risk for loosening. If the MCL is completely absent, a hinge
prosthesis should be considered as excessive stress to a constrained insert may cause
significant wear and early loosening and post fracture.
MCL attenuation also adds significant challenge to gap balancing. In a varus knee, the tight
medial structures are released to match the normal or slight attenuated lateral side (the point
is that the lateral side is rarely significantly loose). In the valgus knee however, the MCL can
be significantly pathologic, and by releasing the lateral structures to match the elongated
MCL, you can significant increase the size of the gap (because you are using a very pathologic
structure as your target), and you may even lengthen the operative leg, require a large poly,
and put the peroneal nerve at risk for traction injury.
There is debate about the order of soft tissue releases to achieve a balanced gap. Releases
should be performed with the knee in extension and the balance should be rechecked after
every release. Ranawat recommends “inside-out” technique of pie-crusting the IT band, then
the LCL with a no. 15 blade, and making effort to preserve the popliteus. [1] The peroneal
nerve is at risk between IT band and Popliteus at the level of the tibial cut. Studies show that
LCL release provides the most correction, and some recommend releasing first in cases of
severe valgus deformity [5] [2].
BONE CONSIDERATIONS.

The valgus knee is uniquely different from the varus knee because bone loss occurs on the
lateral femur (in contrast to vaurs knee that shows anterior-medial tibial bone loss. The entire
Lateral Femoral Condyle can be significantly hypoplastic (posterior and distal femoral
condyles). This is important to identify if the surgeon is measuring femoral rotation by
posterior referencing, which typically add 3° to compensate for the difference in sizes
between the medial and lateral femoral condyle. In the case of a hypoplastic LFC, the
posterior referencing system may need to dial in 5° or more to prevent internal rotation of
the femoral component. Additionally, if there is more than 5 mm of deficient bone on the
posterior or distal femoral cut, augments should be considered because a cement mantle this
large will lead to early loosening. It is important not to chase a large bone defect. If the distal
femoral cut does not touch the lateral femur, do not resect additional distal femur because
this will raise the joint line, causing patella baja. Similarly, if there is tibial bone loss, measure
4-6 mm off the medial side (non-affected side) to determine the depth of the cut, attempting
to cut distal to the defect often removes excessive bone (“apb”: always preserve bone!). The
distal femoral cut is often made at only 3° as opposed to the standard 5 – 7° to avoid under-
correction of the deformity.

BALANCING THE FLEXION AND EXTENSION GAP

Academic versus Practical Gap Balancing.
We have all studied this gap balancing matrix. And conceptually it is helpful. But many of the
squares in this chart recommend "augments" to treat flexion-extention imbalance which is
almost never done for a primary TKA in reality (revision TKA is a different story). Therefore,
the gap balancing techniques should be understood as slightly different in the primary and
revision setting.
In the primary setting, it is uncommon to see dramatic differences in flexion and extension if
the bone cuts were done properly so let’s throw augments out the window and see what is
left. When differences between flexion and extension are small, we can make some
generalizations and therefore simplify the options. A tight flexion gap and a loose extension
gap is similar. If we are not considering augments, we can only focus on increasing the flexion
gap (there is nothing we can do about reducing the extension gap). So, what are the options
for a tight flexion gap: 1) cut more posterior femoral condyle. much simpler right. Let’s look
at the converse: a tight extension gap and a loose flexion gap is similar. Again, we are not
considering augments for the loose flexion gap, so we can think of this problem also as a tight
extension, which has 2 options: 1) cut more distal femoral condyle; 2) release posterior
capsule. Generally, its preferred to first release posterior capsule because this doesn’t affect
the joint line.

In the revision setting, there is greater variability in the gap mismatch, there is often
significant bone loss and therefore, distal femur or posterior condyle augments are frequently
a good option. Thus, the more academic gap balance matrix can be used with all its varying
options.
PATELLAR TRACKING
The patella engages the trochlear groove in 20° flexion, as the knee continues to flex the
entire patella engages and the patella translates lateral and tilts medial. Patella is at greatest
risk of dislocating in 30° flex (as it begins to engage), and with further flexion, bony constraint
(anterior flange of LFC) prevents lateral instability.
The forces on Patellar tracking are represented via Q angle.
The Q angle represents the force of lateral subluxation, you want to minimize this force, so a
low Q angle is better. Internal rotation of the femoral component moves the patellar groove
medially relative to the tibial tubercle: this increases the Q angle. Medializing the femoral
component does the same thing. On the tibial side, internal rotation of the tibial component
causes the tibial tubercle to move lateral relative to the patellar groove and thus increase the
Q angle. Similarly, medializing the tibial component moves the tibial tubercle laterally.
The normal Q angle is about 14° in men, 17° in women.
The joint line height is another aspect of TKA that affects patellar tracking. The joint line
affects the tension of the entire extensor mechanism. Raising the joint line shortens the
length of the extensor mechanism and therefore changes where the patella transitions from
the trochlear groove (in extension) to the intercondylar notch (in flexion). Normally the
patella engages the trochlear groove at 15° flexion, enters the intercondylar notch at X°, but
in the case of Patella Baja (where an elevated joint line leads to a relatively low patella) the
patella enters the intercondylar notch earlier in flexion and impinges on the polyethylene
causing pain, osteolysis, and limits flexion.
Before final implantation of the components the patellar tracking should be tested. The
patella should remain within the trochlear groove, but if the patella subluxes laterally, first
release the tourniquet before making adjustments to your cuts because the tourniquet can
occasionally alter extensor mechanism tension and thus change the Q angle.
The overall goal is to avoid Internal Rotation of the components. This correlates with pain
and synovitis due to patellar mal tracking.
 TKA KINEMATICS

Normal range of motion is a key to patient satisfaction.

A normal arc of motion is the result of many of the technical considerations discussed in
former sections. It depends on matching flexion and extension gaps, normal condylar offset,
and restoration of the joint line. Let’s look at each of these variables.
1) Gap balancing. While loose gaps create instability, a tight gap limits motion. A tight
flexion gap prevents flexion. When trialling a tight flexion gap, the poly will lift off the tray or
get spit out. A tight extension gap limits full extension, and when trailing a tight extension
gap, the knee will not fully extend during a straight leg rise.
Remember the general rule that the tibia is responsible when the knee is tight in both flexion
+ extension, while the distal femur is responsible for extension only tightness, and the
posterior femur is responsible for flexion only tightness.
2) Posterior condylar offset. If you think about what causes a firm endpoint in knee flexion,
it is the posterior tibia impinging on the femur at roughly 140° flexion (in obese people, this
endpoint can occur earlier in the arc of motion due to entrapment of fat rolls). The posterior
condyle acts to maximize distance before impingement (similar to a larger femoral head when
discussing hip motion), therefore recreating the normal posterior condyle size with the
femoral implant is critical to maximize distance before impingement. Posterior condylar
offset is determined by the AP measurement of the femur (which is the size of the
femur). Femur size relates to the AP diameter. Under-sizing a femur (using an anterior
referencing system) will decrease the posterior condylar offset and decrease the arc of
motion because there is less offset between the posterior tibia and the posterior femur. A
posterior referencing system will guarantee normal offset, however, you can still under-size
the femur and cause notching of the anterior cortex.
3) Joint Line. Recreating a normal joint line also affects motion because it changes the
position of the patella during motion and affects the extensor mechanisms mechanical
advantage. When recreating the joint line during TKA, the patella is constant (doesn’t move)
but its relationship to the joint line changes. For example, if you remove 12 mm of distal femur
(remember all implants replace 9 mm of distal femur), then you’ve moved the joint line up by
3 mm, so the patella is now 3 mm lower in relation to the raised joint line. This is called
“Patella Baja”. In contrast, if the joint line is lowered, the patella is now relatively higher and
so it is called “Patella Alta”. In general it is difficult to lower the joint line (creating the relative
“Patella Alta”) because the poly inserts come in so many sizes (at 2 mm intervals) so if you
accidentally buzz two millimetres extra off the tibia, you will go up 2 mm on the poly, and
recreated the native joint line. In comparison, the femoral component is 9 mm always, so
taking 12 mm will raise the joint line (creating the Patella Baja), and while metal augments
can restore the joint line during a revision case, there are far viewer options (augments come
as 5 mm, 10 mm etc).
There are radiographic measures to determine the position of the joint line. The Insall-Salvati
Ratio can describe the relative position of the patella by measuring the distance between the
distal pole of the patella to the proximal tibia divided by the length of the patella itself. The
denominator (the patellar length) is constant. The distance of the patella from the tibia (the
patellar tendon length) is variable. If patella is sitting too close to the tibia, its sitting too low,
and therefore its Baja. There are other generalizable radiographic criteria. The Joint line is
10 mm above the fibular head, 25 mm below the lateral epicondyle, and 35 mm below the
medial epicondyle.
To understand why Patella Baja alters range of motion, we must first understand how the
patella functions overall. The patella increases the leverage of the quad muscle during leg
extension.
The joint line is determined by the distal femur cut, not the tibial cut. Why? Because every
femoral size has the same 9 mm of distal femur offset, while the tibia has many sizes of
polyethylene. If you cut the tibia too low, say cut 12 mm instead of the desired 9 mm, you
can build it back up by adding a 12 mm poly instead of the 9 mm poly you initially planned
for.
In contrast, if you accidentally place your distal femoral cutting jig to take off 11 mm, you
cannot compensate for that extra 2 mm because all sizes of the femoral component is 9 mm
of distal femur. Therefore, you have taken off 11 mm of bone, and only put back 9 mm of
metal, effectively raising the joint line by 2 mm. Now the joint line is sitting higher in relation
to the patella (or another way of saying this is that the patella is sitting lower in relation to
the joint line, aka a “patella baja”). The degree of Patella Baja is measured by the Insall-Salvati
ratio which compares the length of the patella (a constant and thus the denominator) with
the distance between the tibial tubercle and the inferior pole of the patella.
Patella Baja is rarely an issue in primary TKA. The rare circumstance occurs when the patient
has previously had a tibial tubercle osteotomy, or trauma to the patellar tendon that leads to
scarring and a pre-operative patella baja. In contrast, restoring the normal joint line is an
important consideration during revision surgery, when metaphyseal bone is lost after
explanting the femoral component. There are some landmarks to identify the native joint line
in cases of significant bone loss. The joint line is approximately 10 mm above the fibular head,
25 mm below the lateral epicondyle, 35 mm below the medial epicondyle, and with the leg in
extension the joint line should typically sit at the inferior pole of the patella. In cases of
revision surgery, distal femoral augments can be added to lower the joint line to the
appropriate position (again its almost never an issue raising the joint line). Remember that
adding distal femoral augments will close the extension gap without affecting the flexion gap.