• Article highlight
  • Article tables
  • Article images

Article History

Received : 05-02-2021

Accepted : 17-02-2021

Available online : 06-04-2021

Article Metrics

Downlaod Files


Article Access statistics

Viewed: 115

PDF Downloaded: 148

Patel, Pushkarna, Patel, and Dave: Outcome of technique of total knee arthroplasty by independent total femoral first followed by tibial cuts as a measured resection based on anatomical landmarks along with scientific soft tissue balancing: A surgicoclinical study


Total knee arthroplasty is one of the commonest orthopedic lifestyle surgeries now a days. It considerably decreases the morbidity associated with the knee joint arthritis & pain. Increased in the demand of the patients & life expectancy leads to increased number of total knee joint replacement surgeries throughout the country.1 The success of the total knee procedure depends on many factors, including patient selection, prosthesis design, the preoperative condition of the joint, surgical technique (including soft tissue balancing and limb alignment) and postoperative rehabilitation. The results of the total knee replacement (TKR) has been challenged by different techniques as measured resection, gap balancing, tibial cut parallel to the posterior femur cut, navigation & in the recent era by the robotics TKR.

The complications associated with TKR also at the rise with the rise of primary knee joint replacement surgeries that lead to early revision & crippling. Success of TKR depends on many factors including preoperative knee condition, proper patient selection & counseling, prosthesis related factors, surgical techniques & post operative care with rehabilitation & physiotherapy.

TKR has come across long ways since T. Gluck designed & implanted the e prosthesis made of ivory & fixed the implant with plaster of paris & colophony (pine resin).2 In 1971, Freeman and Swanson began using the Imperial College London Hospital (ICLH) knee.3 It sacrificed the cruciates completely & only relied on component geometry & soft tissue balancing but later on discontinued.

In the recent era the surgical navigation & now the robotics techniques all have been developed to reduce the errors related to surgical component alignment & help measure knee kinematics intraoperatively.4 As per our long years of training & evolution we developed a vision that success of TKR has not only lies on the knee balancing. It is rather reproducing dynamic knee kinematics as part of the lowerlimb engine.


To study the Total femoral cuts taken according to the anatomical landmarks followed by tibial cuts later on; according to the tibial cut standard directions & backed up by scientific soft tissue release according to the deformity indications with our special long term training in the field of knee joint reconstruction.

Materials and Methods

This is a retrospective study on (n=126) knees of 90 patients who underwent total knee replacement (TKR) from year January 2017 to December 2020. All cases were done by senior joint replacement surgeon & team with fast rehabilitation protocol. The patients were thoroughly informed & consented for the procedures.

All the patients who underwent TKR were between the age of 48 to 80. The mean age was (Mean=66 years). In the current study the 51 were females & 39 were males. Total number of knee replacement on 90 patients were (n=126) total knee replacement surgeries on knees. Out of (n=126) total knees the (n=86) were of female & (n=40) were of male knees. Out of (n=126) knees 91 had varus, 11 had valgus, 12 had flexion, 1 had recurvatum (<10 degree) & 11 had varus-flexion combined deformities (Table 1 ). Preoperatively the knees classified by Kellgren & Lawrence knee arthritis classification system5 (Figure 1).

Table 1

We have simply classified knee arthritis according to the knee deformities


% of patients

Age <65(n=51)

Age >65(n=75)



24.60% (n=31)

47.6% (n= 60)



2.38% (n= 3)

6.35% (n= 8)



7.14% (n= 9)

2.38% (n= 3)

Varus –Flexion


6.35% (n= 8)

2.38% (n= 3)




0.79% (n=1)

Any Other




Graph 1

Percentage of males & females with Kellgren & Lawrence classification


We have chosen the femur first approach with all the femur condylar cuts to be taken first than the soft tissue balancing & tibial cuts. First cut was distal femur cut with 5-7 degree valgus in varus knees & the valgus distal femur cut kept less i.e. 3-4 degree in varus knees. Trans epicondylar exis (TEA) was taken as a reference for the anteroposterior (AP) cut; as an AP cut was taken with 3 degree of external rotation in flexion. In our study we have used the anterior referencing zig for the femora cuts. Tibial cut was taken perpendicular to the tibial axis with rough reference to the second metatarsal for the rod. The tibial perpendicular cut to the long axis was doubly checked with alignment rod always.

The soft tissue release was done according to the extent of deformity. Tibial cut initially was taken minimal later on revised according to the need of the balancing. The extent of soft tissue release was determined by the deformity. We took the gradual approach which has a combination of measured resection & gap balancing both. The soft tissue balancing in our technique was achieved with the aim of rectangular flexion & extension gap which was measured by block to titrate the soft tissue balancing. Standard notch cut for the femur & keel cut for the tibia was taken. The tibial base plate is properly put with the alignment rod with due care not to fix the component in internal rotation. All the posterior & medial or lateral tibial & femoral osteophytectomy done. For varus deformity medial tibial plateau plasty was done. Thoroughly posteromedial & medial soft tissue releasing was done. No patellar resurfacing in our study but patelloplasty was done in all cases. No any degree of postoperative flexion deformity was accepted. No any case of rheumatoid arthritis in the series. We used same company primary metal back modular implant & highly crossed linked polyethylene insert in all cases. In (n=5) cases we used tibial rod where varus was >30 degree. We used vaccusuck drain for postoperative 48 hours period.


We did the post operative x-rays on the day of the surgery. On the next day we did the CBC, hemoglobin & routine blood investigations. Ankle pumping physiotherapy on the day of the surgery, knee bending on the next day of surgery & standing at next day of surgery done. We have used the tranexemic acid, intrawound our special bupivacaine & ketorolac cocktail injection, tourniquet for intraoperative blood loss control & strict antiseptic sterile discipline.6 The results was evaluated by oxford knee scores(OKS)7 (Figure 2). The OKS is freely available at “http://phi.uhce.ox.ac.uk/ox scores.php” and widely used in cohort studies and by some joint replacement registries.8, 9, 10 Completion and scoring of the OKS is simple; each of 12 questions carries equal weighting (1 to 5) to provide an overall score between 12 and 60.11

The outcome categories for the OKS have been reported based on the following cut points: excellent (>41), good (34–41), fair (27–33), and poor (<27).12, 13 For <65 years of age 35 had excellent, 13 had good, 3 had fair & no patient had poor results. For >65 years of age 51 had excellent, 18 had good, 5 had fair & 1 had poor result. No patient (n=0) had post-operative instability, No patient had patellar tracking problems, No (n=0) patient had infection or deep vein thrombosis. One (n=1) patient had post-operative fall at 24 hours postoperative that led to juxta prosthesis periprosthetic fracture at tibial site. That patient later on fixed with locking periprosthetic plate & united at 2 months which has led to poor patient psychological impact. Three (n=3) patient had superficial skin problems that later on cured by Ice pack application & vitamin E along with multivitamin support.

Graph 2

Percentage (%) of patients by Outcome of knee arthroplasty according to OKS (Oxford Knee Score) system



Bony landmarks such as the TEA,14, 15 the AP axis16, 17 and the posterior condylar axis 18, 19 are used to set femoral component rotation when using a measured resection technique. In our measured resection technique the bone cuts were placed before the gap balancing.

The trans epicondylar exis (TEA) is the line joining the medial epicondylar ridge to the lateral epicondylar prominence.14, 20 In the flexion extension axis of the TEA corresponds to the knee collateral ligaments origin20 The TEA is the good reference to determine the original neutral rotation of the femur component.14 Good patellofemoral tracking can be achieved by proper native femoral component placement with the reference of trans epicondylar exis & placing the femoral component parallel to the TEA.21, 22, 23, 24 A magnitude of femoral condylar lift off will be greatly decreased as noted by Insall et al.24 if the femoral component was placed parallel to the TEA axis in a kinematic analysis. If femoral component will be placed in parallel to the TEA it will be great aid in achieving rectangular flexion gap (90% using the TEA, 83% using the AP axis, and 70% using the posterior condylar axis) in an analysis performed by Olcott and Scott.23 When there is posterior condylar hypoplasia or erosion in advanced arthritis & even in the revision knee arthroplsty the TEA reference has played the major role.

Figure 1

Water proof disciplined sterile drapping


Figure 2

Drawing of TEA (trans epicondylar axis) & AP (Anteroposterior) axis


Figure 3

Distal femur cut taken in 5-7 degreevalgus for varus deformity. (2-3 degree less for valgus deformity).


Figure 4

Before distal femur cut estimation checking with fin


Figure 5

Distal femur zig for component mesurement & AP cut generally in 3 Degree external rotation


Figure 6

Tibial cut perpendicular to long axis of tibia with minimum 8 mm cut initially later on can be modified.


Figure 7

Trial with components & alignment axis rod doubly checked


Figure 8

Axis alignment rod in extension checking


Figure 9

Lateral most margin of tibia cut marked to prevent excessive lateralization


Figure 10

Tibial Keel cut taken with due external rotation of component doubly checked with alignment rod


Figure 11

Rectangular Flexion gap


Figure 12

In a case of extreme patellar maltracking problem lateral retinacular release done with outside in technique.


Figure 13

Final component placements.


Figure 14

Post operative AP & Lateral x-rays with preoperative long leg scanogram


Figure 15

Implant component with polyethylene insert as well as optimized use of tibial rod in intraopertive varus instability & extreme osteoporosis


Anteroposterior Axis (AP axis) is helpful in setting the femoral rotation as it connects the center of the trochlear sulcus anteriorly and the midpoint of the posterior aspect of the intercondylar notch. It is influenced by the trochlear groove and intercondylar notch of the distal femur anatomy.25

The superficial medial collateral ligament is the primary stabilizer of the medial aspect of the flexion gap. The lateral aspect of the flexion gap is stabilized by the lateral collateral ligament and popliteus tendon. When the superficial medial tibial ligament is deficient, tensioning of the medial flexion gap will result in an excessive medial flexion gap. When superficial medial collateral ligament is deficient & if the femoral component is placed in parallel to the tibial cut in the flexion it has tendency for excessive internal rotation. When lateral collateral ligament & popliteus complex deficient in this situation it has tendency for excessive external rotation.

Table 2

Risk Ratio (RR) analysis of some complicating variables


Fair & Poor (OKS) (n=9)

Above good (OKS) (n=117)

Relative Risk (RR)





>65 (senility)



1.179 (>1)




0.566 (<1)

Non diabetic







Female (osteoporosis)



3.72 (>1)




2.515 (>1)

Non Tobacco






16.736 (>1)

Non Anxiety



We have found negative correlation with Anxious patients, Female patient, >65 years of age & tobacco for the success of TKR. Anxiety especially with the increasing age for dependency could be the major factor for fair to poor results. For male preponderance & <65 years aged patients we found great results especially. Study done by D. Dennis et al. showed gap balancing better than measured resection technique. Recently navigation & robotics arthroplasty showed improved results but the navigation & robotics knee replacement also showed increased operative time & learning curve with poor cost effectiveness. We have evaluated the results of TKR as a whole; rather than focused as an alignment we have an inference of a whole TKR surgery with alignment one of the major result driven factor. We studied the success of TKR as a multifactorial with soft tissue balance & measured resection in a gradual manner. Soft tissue balancing, measured resection, component placement, cementing technique, duration of surgery, tourniquet time, patellar handling, postoperative paincontrol, patient motivation & counseling, rehabilitation, infection control, soft tissue handling & surgeon experience all are importantly decides the longetivity & results of knee arthroplasty.


The clinical success of Total knee arthroplasty lies on pain free kinematics for maximum longer duration. Surgeon satisfaction & patient satisfaction factors are different variables for counting the success of TKR. Proper component resurfacing of distal femoral arthritic surface & tibial base plate measured resection are crucial bony factors for component implanting. Soft tissue balancing is the most crucial surgical expertise needed for successful outcome of TKR. Our study has not included the implant design related factors as all the patients were implanted same designs of implants it has been counted as a technique oriented inferences. Still we understood that knee cosidering dynamic component of lowerlimb as a most aggressive machine of human body is a example of perfect bony musculoskeletol integrity. Longetivity of implanted components & resurfaced knee lies on many other patient related factors as discussed. Our technique’s results are quite satisfactory but long years multicentric trials warranted in this scenario of increasing total knee arthroplasty in a polite, discipline, cost effective & rationale manner.

Source of Funding


Conflicts of Interest



Thanks to all my respected teachers to teach art of knee arthroplasty & beloved team members of my joint reconstruction surgery unit.



JA Pachore SV Vaidya CJ Thakkar HKP Bhalodia HM Wakankar ISHKS joint registry: A preliminary reportIndian J Orthop2013475505910.4103/0019-5413.118208


C Ranawat SOA Textbook. “History of Total Knee ReplacementThe Southern Orthopaedic Association and Data Trace Publishing Company2006


MA Freeman RC Todd P Bamert WH Day ICLH arthroplasty of the knee: 1968--1977J Bone Joint Surg197860-B33394410.1302/0301-620x.60b3.681410


RA Siston NJ Giori SB Goodman SL Delp Surgical navigation for total knee arthroplasty: A perspectiveJ Biomech20074047283510.1016/j.jbiomech.2007.01.006


JH Kellgren JS Lawrence Radiological Assessment of Osteo-ArthrosisAnn Rheumatic Dis195716449450210.1136/ard.16.4.494


VA Patel VA Pushkarna How effective is intrawound vancomycin with multidiscipline approach for preventing surgical site infections (SSI) in arthroplasty and orthopedic surgeries: a study in non Covid 19 to Covid 19 eraIndian J Orthop Surg2020643031010.18231/j.ijos.2020.056


DW Murray R Fitzpatrick K Rogers H Pandit DJ Beard AJ Carr The use of the Oxford hip and knee scoresJ Bone Joint Surg200789-B81010410.1302/0301-620x.89b8.19424


V Wylde AW Blom SL Whitehouse AH Taylor GT Pattison GC Bannister Patient-reported outcomesafter total hip and knee arthroplasty. Comparison of midterm resultsJ Arthroplast20092422106


New Zealand Orthopaedic Association, New Zealand Joint Registry 2012, New Zealand Orthopaedic Association, 2013


DP Williams CM Blakey SG Hadfield DW Murray AJ Price RE Field Long-term trends in the Oxford knee score following total knee replacementBone Joint J201395-B1455110.1302/0301-620x.95b1.28573


J Dawson R Fitzpatrick D Murray A Carr Questionnaire on the perceptions of patients about total knee replacementJ Bone Joint Surg199880-B163910.1302/0301-620x.80b1.0800063


P Moonot G Medalla D Matthews Y Kalairajah R Field Correlation Between the Oxford Knee and American Knee Society Scores at Mid-Term Follow-UpJ Knee Surg200922032263010.1055/s-0030-1247753


PB Pynsent DJ Adams SP Disney The Oxford hip and knee outcome questionnaires for arthroplastyJ Bone Joint Surg200587-B2241810.1302/0301-620x.87b2.15095


RA Berger HE Rubash MJ Seel WH Thompson LS Crossett Determining the Rotational Alignment of the Femoral Component in Total Knee Arthroplasty Using the Epicondylar AxisClin Orthop Relat Res1993&NA;28640710.1097/00003086-199301000-00008


FM Griffin K Math GR Scuderi JN Insall PL Poilvache Anatomy of the epicondyles of the distal femurJ Arthroplast2000153354910.1016/s0883-5403(00)90739-3


PL Poilvache JN Insall GR Scuderi DE Font-Rodriguez Rotational Landmarks and Sizing of the Distal Femur in Total Knee ArthroplastyClin Orthopaed Relat Res1996331331354610.1097/00003086-199610000-00006


LA Whiteside J Arima The Anteroposterior Axis for Femoral Rotational Alignment in Valgus Total Knee ArthroplastyClin Orthop Relat Rese1995&NA;3211687210.1097/00003086-199512000-00026


JP Mantas RD Bloebaum JG Skedros AA Hofmann Implications of reference axes used for rotational alignment of the femoral component in primary and revision knee arthroplastyJ Arthroplast199274531510.1016/s0883-5403(06)80075-6


C Schnurr J Nessler DP König Is referencing the posterior condyles sufficient to achieve a rectangular flexion gap in total knee arthroplasty?Int Orthop20093361561510.1007/s00264-008-0656-2


P Aglietti L Sensi P Cuomo A Ciardullo Rotational Position of Femoral and Tibial Components in TKA Using the Femoral Transepicondylar AxisClin Orthop Relat Res2008466112751510.1007/s11999-008-0452-8


DR Diduch JN Insall WN Scott GR Scuderi Font-Rodri­guez D. Total knee replacement in young, active patients: long-term follow-up and functional outcomeJ Bone Joint Surg Am199779457582


MC Miller RA Berger AJ Petrella A Karmas HE Rubash Optimizing Femoral Component Rotation in Total Knee ArthroplastyClin Orthop Relat Res2001392392384510.1097/00003086-200111000-00005


CW Olcott RD Scott A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplastyJ Arthroplast200015122610.1016/s0883-5403(00)91051-9


JN Insall GR Scuderi RD Komistek K Math DA Dennis DT Anderson Correlation Between Condylar Lift-Off and Femoral Component AlignmentClin Orthop Relat Res20024034031435210.1097/00003086-200210000-00022


MA Katz TD Beck JS Silber RM Seldes PA Lotke Determining femoral rotational alignment in total knee arthroplastyJ Arthroplast2001163301510.1054/arth.2001.21456


© This is an open access article distributed under the terms of the Creative Commons Attribution License - Attribution 4.0 International (CC BY 4.0). which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.