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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 4  |  Page : 282-289

Staying safe from pitfalls in primary knee replacements

1 Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
2 Department of Orthopaedics, Sri Dhaatri Orthopaedic, Maternity and Gynaecology Center, Vijayawada, Andhra Pradesh, India
3 Department of Orthopaedics, JIPMER, Puducherry, India

Date of Submission15-Jan-2021
Date of Decision27-May-2021
Date of Acceptance31-May-2021
Date of Web Publication19-Jul-2021

Correspondence Address:
Rajkumar Gangadharan
Department of Trauma and Orthopaedics, Aintree University Hospitals, Lower Lane, Liverpool, L9 7AL
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_5_21

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With increasing numbers of primary knee replacements and the growing concerns of revision knee replacements, research is now tending to look back and look forward for all that is possible to reduce the complications and improve patient satisfaction in this highly successful surgery. The clinician must make a comprehensive assessment of the patient, identify the real needs and optimize the risks of this major surgery, against real benefits. This article reviews relevant aspects of preoperative, intraoperative, and postoperative care that practically influence a successful outcome that every potential candidate for knee replacement rightfully deserves.

Keywords: Complications, knee arthroplasty, outcomes, risk factors, safety

How to cite this article:
Gangadharan R, S. Kambhampati SB, Menon J. Staying safe from pitfalls in primary knee replacements. Apollo Med 2021;18:282-9

How to cite this URL:
Gangadharan R, S. Kambhampati SB, Menon J. Staying safe from pitfalls in primary knee replacements. Apollo Med [serial online] 2021 [cited 2022 Nov 28];18:282-9. Available from: https://apollomedicine.org/text.asp?2021/18/4/282/321833

  Introduction Top

A perfect outcome in medicine, though aspirational is often difficult to achieve. The number of primary knee replacements has been steadily increasing over the years globally, perhaps matching predicted numbers from the United States.[1] Despite large numbers and remarkable success, a consistently perfect outcome in primary total knee replacements (TKRs) is yet to be realized. The standards of such highly specialized and skilled surgical procedures can be negatively influenced by compromises in any of the smaller, seemingly unassuming aspects of care. This paper attempts to highlight the relevant areas in the patient's journey receiving a primary TKR, that are likely to influence the outcome. Although the recommendations appear prescriptive, the authors' aim is to expand the readers' perspective in providing comprehensive care and identifying the avoidable pitfalls in the ever-evolving field of arthroplasty. We have also collated information that would allow surgeons to engage patients more in the decision-making process as well as permit a more objective path for assessing outcomes.

We have summarized the likely influencers of the outcome as modifiable and nonmodifiable patient and surgical factors. There are no absolute nonmodifiable surgical factors, although very few factors can be graded as relatively nonmodifiable. Surgeons and establishments should welcome change in their perspectives and embrace a culture of constant improvization and learning in these key areas. This article is based on pertinent high-quality publications, guidelines and registry data, retrieved by selective literature search and the authors' collective experience.

Factors influencing outcomes of primary TKR have been classified and discussed under headings as given in [Table 1].
Table 1: Classification of Factors that influence outcomes of primary knee replacement

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  Patient Selection and Optimization Top

Right patient and symptoms

It is very important to select the right patient for surgery. Very young patients, <45 years, who may be managed with alternative options should be considered less favorably for joint replacement and other alternative options should be aggressively explored. The results of TKR in this age group, although promising, show high loosening and revision rate of 8.8%.[3] It is also important to consider psychological aspects of the patient and their capacity to co-operate with postoperative rehabilitation as outcomes heavily depend on these factors,[4] including lower socioeconomic status. Although a systematic review has shown no longitudinal association between preoperative psychosocial factors,[5] and postoperative functional recovery in joint arthroplasty, the authors recommend exercising caution in considering surgery in patients with limited capacity or cognition. Referred pain from the hip and spine should be ruled out as the main source of pain in the knee, before proceeding to TKA.

Body mass index

Patients will gain weight following knee arthroplasty,[6] causing further implications in patients with high body mass index (BMI). Studies[7],[8] have confirmed several complications in morbid obesity, including erythema, gastrointestinal, respiratory and extra-surgical site infections (SSIs), following lower limb arthroplasty. Surgeons should also be aware of the implants in the market that are specifically contraindicated in obese patients,[9] to avoid litigation. Additional careful examination of the limbs is required preoperatively to assess the limb girth, skin condition and assess ease of tourniquet application. Other problems to be addressed include difficult regional anesthesia, additional positioning supports, specialized operative tables and large incisions for relatively small size components, long operative times, and potentially more blood loss.

  Pain and patient satisfaction Top

Pain from knee osteoarthritis arises from several factors. Studies have identified different patient characteristics based on their physical status, level of emotional problems and objective structural damage seen radiologically.[10] Patients can be categorized to one of the three classes (1-3) depending on the high or low prevalence of emotional problems and structural damage. Kittelson et al.[11] identified four different phenotypes, based on co-morbidities, knee joint sensitivity, levels of psychological distress and radiological joint disease.

It is not uncommon to see patients with severe radiological changes, for example, a high Kellgren-Lawrence Score,[12] reporting relatively less pain. In such cases, any other validated lower limb functional score would help to assess the need for offering a knee replacement in advanced disease, with instability or deformity, as a major symptom. Knee stiffness per se, without pain or instability, causes a higher prevalence of postoperative stiffness.[13],[14],[15] The most important risk factor for developing postoperative knee stiffness is compromised preoperative range of movements. Only 71.4% of the patients with < 90° of range of motion ROM preoperatively achieved a range over 90° postoperatively.[16]

Not all patients are satisfied with primary knee replacements, ranging from 76% in 2006[17] 82%–89% in 2010.[18] It is very important to have realistic expectations preoperatively to have a “satisfied” patient.

Role of infection in knee arthroplasty

A multi-faceted strategy is required to combat infection in arthroplasty.[19] Several risk factors have been identified,[20],[21] that are associated with prosthetic joint infection (PJI) [Table 2]. Any history of previous septic arthritis is a relative contraindication and should be treated with extreme caution and well-planned staged procedures.[22],[23] Any illness or surgical procedures that produce bacteremia peri-operatively increases the chances of PJI. There is a firm belief among the majority of orthopaedic surgeons[24] that invasive dental procedures predispose to PJI. It would be safe to recommend that any such invasive procedure be postponed, whenever possible, for at least 8–12 weeks following TKR.
Table 2: Risk factors for prosthetic joint infection

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Elderly patients often harbor urinary infection due to stasis and incontinence. There is no advantage in treating asymptomatic bacteriuria with antibiotics before joint replacement surgery.[25] Simple screening questions (dysuria, frequency, temperature) will identify symptomatic patients. If symptomatic, appropriate empirical antibiotics should be then given, until they are asymptomatic. If symptoms persist, despite two courses of uroseptic treatment, patients should be referred on for urological management and their knee replacement surgery should be postponed until the full clearance is obtained.

Uncontrolled, long-standing diabetes mellitus is a risk factor for mortality and infection. The risk of infection requiring re-operation rises with increasing glycated hemoglobin (HbA1c) levels.[26] A recent multicentric study[27] recommends that screening of all patients undergoing TKR using Fructosamine Binding Globulin levels.

Specialized theatre environment for orthopedic procedures, were developed to reduce the number of bacterial load per cubic micron. However, the concept of laminar flow theatres has been challenged more recently, with evolving evidence that refutes actual clinical benefit in reducing the infection rates, inviting further research.

  Preoperative Factors Top

Common risks of any of the anesthetic modality should also be included in the consenting process. It is important that the patient, and family in select cases, understand the procedure, its complications and outcomes specifically in relation to that patient during consenting. Optimization of comorbidities is mandatory for successful outcomes. Reverse transcriptase-polymerized chain reaction has become mandatory in the preoperative evaluation for the foreseeable future of the post-COVID era. The presence of these viral markers including blood-borne viruses necessitates the use of protective gear for the personnel.

Patients with severe anemia must be evaluated for etiology. Mild anemia is optimized with hematinics. Having an algorithm led Hb-screening and management program has shown to reduce transfusion, readmission, length of stay in hospital and costs.[28]

Patients with a higher risk of thrombosis or bleeding should receive the correct dose of thromboprophylactic medications, in consultation with medical or hematological experts, carefully titrated to counteract bleeding and/or reduce the risk of thrombosis.

Postoperative oxygen targets in chronic obstructive pulmonary disease should be modified. Patients with a history of previous malignancies, previous chemo/radiotherapy could have compromised their cardio-pulmonary or hepato-renal reserves and have a slightly higher risk of venous thromboembolism.

Anticoagulants, antiplatelet agents or biologics should be withheld before surgery with appropriate alternative options and restarted once the wound is healed, approximately at about 14 days postoperatively. Patients on long-term steroids should be individually assessed based on their equivalent prednisolone dosage, for potential increased requirements in the immediate postoperative period. The guidelines from a collaborative study by the American College of Rheumatology and the American Association of Hip and Knee Surgeons[29] provide seven such recommendations, admitting low or moderate-quality evidence. Clear, well-communicated protocols for these patients in high volume centers will help prescription or nursing errors, enhancing the patient experience.

Lifestyle habits such as smoking, drinking, and intravenous drug abuse have important intraoperative and postoperative implications and hence should be sought for and curtailed appropriately. Smokers have higher rates of medical complications and mortality than nonsmokers or ex-smokers and hence smoking cessation should be encouraged before offering knee replacement.[30]

Orthopedic assessment

Any preoperative deformity-fixed and correctable, laxity-coronal, sagittal or axial planes should be sought for. Proximal and distal joints should be examined, at least clinically. This would influence the decision to operate, anticipate technical difficulties and ensure ordering of appropriate implants and instrumentation. Quadriceps strengthening exercises should be initiated at the earliest opportunity. The neurovascular status of the limb should be evaluated and documented. If in doubt, angiograms should be done to detect vascular issues and addressed before surgery. Excessive vascular calcification should alert the surgeon to avoid tourniquet.

Pre-existing spinal deformities in the elderly, that compromise strength, position and rotation of the limb, should be actively looked for-example, lumbar lordosis that restricts knee extension, referred to as “Knee-spine syndrome”[31] or severe kyphoscoliosis. Such patients may require a more-constrained implant (in the severe kyphoscoliotic patient) or a realistic guarded expectation (in the lordotic patient).

The risk of foot drop following knee replacement is higher on correction of fixed flexion and/or fixed valgus deformities. Preoperative valgus deformity ≥10°, total tourniquet time >120 min, diagnosis of a preexisting neuropathy and rheumatoid arthritis, younger age and higher BMI[32],[33] have been identified as risk factors for common peroneal nerve palsy.

Younger patients often have a secondary cause for arthritis such as previous fractures, malunions and the corresponding deformities should be evaluated thoroughly. Elderly patients and patients with inflammatory arthritis may have arthritis of multiple joints and should have an appropriate plan to mobilize after surgery and listed only after exhausting all available medical control of the systemic disease.

Any extra-articular tibia vara should be measured using any of the four methods, as explained by Saibaba et al.[34] Any excessive measurements need to be treated with caution as conventional resection methods may not restore the desired mechanical axis of the limb in all cases.

Surgical planning

A plan for the type of implant and sizes may be made using templating software. Planning and equipment required should be checked before surgery to avoid intraoperative hiccups. The presence of previous metalwork in either femur or tibia may preclude the use of routine intramedullary alignment systems.

Bilateral simultaneous TKR is shown to have a higher incidence of complications compared to staggered same admission or sequential bilateral TKR. The severity of medical comorbidities or the impact of major complications should trump orthopedic heroism. Patients should be informed of the possible complications during consenting and the average longevity and survival of the implant used.

Risks and complications

The common complications are listed in the nonexhaustive [Table 3].
Table 3: Complications following total knee replacement

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Local complications

In the English Registry,[36] of those implants that were revised, the most common causes of revision are as follows: Loosening/lysis (40%), infection, pain, instability, malalignment, stiffness, wear, progression of the disease. American data[37] reported complications in about 5.6% of patients within 30 days from primary TKR.

The Australian data[38] suggest that at 6 months following primary TKR, the most common minor complications were joint stiffness (18.5%), swelling (15.6%) and paraesthesia (15.6%), and the most common major complications were arthroplasty-related readmission (6.0%) and reoperation (2.5%). SSI accounted for 2.1% of re-admissions followed by manipulation under anesthesia (1.9%) and deep vein thrombosis (DVT) (0.4%). The most common reasons for reoperation following TKA were joint stiffness (1.5%) and SSI requiring surgery (0.5%). The 6-month mortality rate was found to be 0.2% as compared to 90-day mortality of 0.4%.[39]

Rarer pitfalls

Although extremely rare,[40] the risk factors for vascular injury are revision surgery, peripheral vascular disease, weight loss, renal failure, coagulopathy, and metastatic cancer.[41] Other reported complications include periprosthetic fracture (PPF),[42] dislocation/dissociation of components and implant fracture.

  Intraoperative Factors Top

These include anesthesia, theater environment equipment, personnel, implants and surgeon factors. Types of anesthesia affect outcomes variably. Epidural combined with spinal has lower chances of DVT compared to GA. However, epidural analgesia reduces mobility. Selective nerve blocks improve early mobility but need expert anesthetists adept at administering ultrasound-guided blocks.

Well-equipped kit and well-trained theatre personnel guarantee efficiency. The rate of complications is lower in high volume centers compared to low volume centers.[43] Similarly, surgeons who operate on higher volumes have a lower complication rate compared to those doing less.

Surgical technique

Primary knee replacement is mainly a soft tissue surgery which incorporates a few steps of bony resection and implantation. Surgeons offering knee replacement should be fully aware, adaptable and adequately trained in different techniques and have a stepwise approach in precisely delivering the intended stability, movement and independent ambulation. Some of the determining and controversial factors are summarized in [Table 4] and the Do's and Don'ts in [Table 5].
Table 4: Summary of controversies in primary total knee arthroplasty with a gist of sentinel papers - the favorable arms are highlighted in bold

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Table 5: Common do's and don'ts to avoid pitfalls in primary total knee replacement

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Ligament balancing

The spectrum of the complexity of knee replacements is reflected by various levels of constraint in design. Most knee replacements in several registries are either a posterior cruciate-retaining or sacrificing design. Further restraint becomes necessary if there is residual laxity of the lateral collateral ligament in full extension, or when there is mid-flexion instability, i.e., a nonhinged semi-constrained device. Augments are selectively used to restore the joint line to the optimal level. Best results are obtained when the joint line is restored to within 5 mm of the preoperative level.

An incompetent medial collateral ligament equates to a fully constrained implant. Surgical decisions are usually made preoperatively. Any untoward intraoperative event should not be ignored, allowing some steering away from the planned procedure, to avoid another mishap in the outcome.

Optimal angles for cuts

Distal femoral resection should be carefully performed as casual errors in the first step, can be compounded in subsequent resections.[59],[60] The arbitrary 5° distal femoral resection should be adjusted as per the patient's varus/valgus deformity and femoral length (patient's height), to avoid the undesirable excessive resection of condyles. When facilities are available, long leg views and preoperative measurements of the femoral-mechanical-anatomical axis will help guide the distal femoral resection angle.[61] Avoid anterior distal femoral notching, which per se is not a predictor of PPF; this should weigh against overstuffing the anterior compartment with a larger femoral component.

Measured resection versus balanced resection

While the surgeons could use either of the resection principles, care must be exercised to deliver a well-balanced knee in extension and flexion, before definitive implantation. The gap balancing technique may be superior in achieving restoration of alignment and higher functional scores, with a compromise of a slightly elevated joint line.[62] Although there are technical differences in the levels of resected bones, more recent comparative studies have shown that there are no differences in functional scores.[63],[64]

Patellofemoral resurfacing versus unresurfacing

Debate flourishes on the suitability of resurfacing the patella. It is widely accepted that if there is no or minimal wear in the retropatellar surface, or if the patella is extremely thinned out, it could be left unresurfaced, as resurfacing is not completely free of complications, most commonly overstuffed anterior compartment. Patellar fractures constitute the second-most common site of PPFs, more common after resurfacing from 0.2% to 21% of cases compared to an unresurfaced patella (0.05%).[65]

Component rotation

Subtle rotational malalignment is a common obscured cause of unsatisfactory outcome caused by patellar maltracking. This can either be at the femoral or tibial component or both. Rotating platform designs promise an increasing range of movements, negating the need for precise positioning of the tibial component. There are in vitro studies that show their ability to decouple the complex kinematics to pure rotation, i.e., decreased wear of the dual-surface articulation, thereby decreasing the chances of aseptic loosening.[66] However, there is a risk of the inserts spinning out.

  Postoperative Factors Top

It is incumbent upon surgeons to provide proactive individualized care to aid complete rehabilitation. Effective pain management with comprehensive care all around can make a successful day-case TKR possible. At discharge, all medications should be clarified to patient on stop or re-start times.

An expected timeline of recovery and guidance should be provided to support and encourage functional activities. More importantly, precautionary guidance to red flags of infection or DVT should also be communicated.

Clear confirmed follow-up appointments for wound inspection, suture removal and patient feedback and possible participation in recording outcome measures should be encouraged. Patients may be followed up at year 1, 5, and 10, unless concerns. Helpline or a clear point of contact should be offered to report any problems or doubts, in the interim, or provide any constructive feedback.

  Conclusion Top

Elaborate observational studies throughout the world have identified specific factors that predispose to poor outcomes in knee arthroplasty. High volume surgical centers with well-established and constantly improvised care pathways should aim to excel giving comparable, if not better, standard of results. Meticulous patient selection, a thorough preoperative assessment aiming for optimization of medical conditions, careful preoperative planning, with efficient conduct and precise delivery of surgery in conjunction with standardized and individualized postoperative care and rehabilitation are the known pearls proven to avoid pitfalls in total knee arthroplasty.

With increasing demands and dissemination of services rolled out to many centers of the country, it becomes imperative to carefully regulate the care provided. We hope that enrolment and active participation in the Indian Joint Registry would throw light on long term data from the sub-continent.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-5.  Back to cited text no. 1
Elsiwy Y, Jovanovic I, Doma K, Hazratwala K, Letson H. Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: A systematic review. J Orthop Surg Res 2019;14:15.  Back to cited text no. 2
Castagnini F, Sudanese A, Bordini B, Tassinari E, Stea S, Toni A. Total knee replacement in young patients: Survival and causes of revision in a registry population. J Arthroplasty 2017;32:3368-72.  Back to cited text no. 3
Wylde V, Trela-Larsen L, Whitehouse MR, Blom AW. Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement. Acta Orthop 2017;88:530-6.  Back to cited text no. 4
Bletterman AN, de Geest-Vrolijk ME, Vriezekolk JE, Nijhuis-van der Sanden MW, van Meeteren NL, Hoogeboom TJ. Preoperative psychosocial factors predicting patient's functional recovery after total knee or total hip arthroplasty: A systematic review. Clin Rehabil 2018;32:512-25.  Back to cited text no. 5
Riddle DL, Singh JA, Harmsen WS, Schleck CD, Lewallen DG. Clinically important body weight gain following knee arthroplasty: A five-year comparative cohort study. Arthritis Care Res (Hoboken) 2013;65:669-77.  Back to cited text no. 6
D'Apuzzo MR, Novicoff WM, Browne JA. The John Insall Award: Morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res 2015;473:57-63.  Back to cited text no. 7
Friedman RJ, Hess S, Berkowitz SD, Homering M. Complication rates after hip or knee arthroplasty in morbidly obese patients. Clin Orthop Relat Res 2013;471:3358-66.  Back to cited text no. 8
Craik JD, Bircher MD, Rickman M. Hip and knee arthroplasty implants contraindicated in obesity. Ann R Coll Surg Engl 2016;98:295-9.  Back to cited text no. 9
Pan F, Tian J, Munugoda IP, Graves S, Lorimer M, Cicuttini F, et al. Do knee pain phenotypes have different risks of total knee replacement? J Clin Med 2020;9:632.  Back to cited text no. 10
Kittelson AJ, Stevens-Lapsley JE, Schmiege SJ. Determination of pain phenotypes in knee osteoarthritis: A latent class analysis using data from the osteoarthritis initiative. Arthritis Care Res (Hoboken) 2016;68:612-20.  Back to cited text no. 11
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494-502.  Back to cited text no. 12
Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86:1479-84.  Back to cited text no. 13
Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004;12:164-71.  Back to cited text no. 14
Manrique J, Gomez MM, Parvizi J. Stiffness after total knee arthroplasty. J Knee Surg 2015;28:119-26.  Back to cited text no. 15
Lizaur A, Marco L, Cebrian R. Preoperative factors influencing the range of movement after total knee arthroplasty for severe osteoarthritis. J Bone Joint Surg Br 1997;79:626-9.  Back to cited text no. 16
Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall Award: Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 2006;452:35-43.  Back to cited text no. 17
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not? Clin Orthop Relat Res 2010;468:57-63.  Back to cited text no. 18
Dobson PF, Reed MR. Prevention of infection in primary THA and TKA. EFORT Open Rev 2020;5:604-13.  Back to cited text no. 19
Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Foguet P, Porter M, et al. Risk factors associated with revision for prosthetic joint infection following knee replacement: An observational cohort study from England and Wales. Lancet Infect Dis 2019;19:589-600.  Back to cited text no. 20
Hwang JS, Kim SJ, Bamne AB, Na YG, Kim TK. Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes? Clin Orthop Relat Res 2015;473;1726-31.  Back to cited text no. 21
Bauer T, Lacoste S, Lhotellier L, Mamoudy P, Lortat-Jacob A, Hardy P. Arthroplasty following a septic arthritis history: A 53 cases series. Orthop Traumatol Surg Res 2010;96:840-3.  Back to cited text no. 22
Ni M, Fu J, Deng T. Clinical effects of staged joint replacement in patients with septic arthritic knee. J Orthop Surg Res 2020;15:525.  Back to cited text no. 23
McNally CM, Visvanathan R, Liberali S, Adams RJ. Antibiotic prophylaxis for dental treatment after prosthetic joint replacement: Exploring the orthopaedic surgeon's opinion. Arthroplast Today 2016;2:123-6.  Back to cited text no. 24
Cordero-Ampuero J, González-Fernández E, Martínez-Vélez D, Esteban J. Are antibiotics necessary in hip arthroplasty with asymptomatic bacteriuria? Seeding risk with/without treatment. Clin Orthop Relat Res 2013;471:3822-9.  Back to cited text no. 25
Cancienne JM, Werner BC, Browne JA. Is there an association between hemoglobin A1C and deep postoperative infection after TKA? Clin Orthop Relat Res 2017;475:1642-9.  Back to cited text no. 26
Shohat N, Tarabichi M, Tan TL, Goswami K, Kheir M, Malkani AL, et al. John Insall Award: Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty: A prospective multicentre study. Bone Jt J 2019;101-B7 Suppl C:3-9.  Back to cited text no. 27
Pujol-Nicolas A, Morrison R, Casson C, Khan S, Marriott A, Tiplady C, et al. Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty. Transfusion (Paris) 2017;57:3049-57.  Back to cited text no. 28
Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and knee surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol 2017;69:1538-51.  Back to cited text no. 29
Matharu GS, Mouchti S, Twigg S, Delmestri A, Murray DW, Judge A, et al. The effect of smoking on outcomes following primary total hip and knee arthroplasty: A population-based cohort study of 117,024 patients. Acta Orthop 2019;90:559-67.  Back to cited text no. 30
Murata Y, Takahashi K, Yamagata M, Hanaoka E, Moriya H. The knee-spine syndrome. Association between lumbar lordosis and extension of the knee. J Bone Jt Surg Br 2003;85:95-9.  Back to cited text no. 31
Rodríguez-Merchán E, Corte-Rodríguez HD, Encinas-Ullán C. Peroneal nerve palsy after total knee arthroplasty: Prevalence, risk factors, diagnosis and management. In: Rodríguez-Merchán E, Gómez-Cardero P, editors. Comprehensive Treatment of Knee Osteoarthritis. Springer International Publishing: Springer; 2020.  Back to cited text no. 32
Park JH, Restrepo C, Norton R, Mandel S, Sharkey PF, Parvizi J. Common peroneal nerve palsy following total knee arthroplasty: Prognostic factors and course of recovery. J Arthroplasty 2013;28:1538-42.  Back to cited text no. 33
Saibaba B, Dhillon MS, Chouhan DK, Kanojia RK, Prakash M, Bachhal V. Significant incidence of extra-articular tibia vara affects radiological outcome of total knee arthroplasty. Knee Surg Relat Res 2015;27:173-80.  Back to cited text no. 34
Springer BD, Cahue S, Etkin CD, Lewallen DG, McGrory BJ. Infection burden in total hip and knee arthroplasties: An international registry-based perspective. Arthroplast Today 2017;3:137-40.  Back to cited text no. 35
NJR Editorial Board and Contributors. 17th Annual NJR Report. 17th ed. Pad Creative Ltd; 2020. Available from: https://reports.njrcentre.org.uk. [Last accessed on 2021 Jan 20].  Back to cited text no. 36
Belmont P, Goodman G, Waterman B, Bader J, Schoenfeld A. Thirty-day postoperative complications and mortality following total knee arthroplasty: Incidence and risk factors among a national sample of 15,321 patients. J Bone Jt Surg Am 2014;96:20-6.  Back to cited text no. 37
Heo SM, Harris I, Naylor J, Lewin AM. Complications to 6 months following total hip or knee arthroplasty: Observations from an Australian clinical outcomes registry. BMC Musculoskelet Disord 2020;21:602.  Back to cited text no. 38
Singh JA, Lewallen DG. Ninety-day mortality in patients undergoing elective total hip or total knee arthroplasty. J Arthroplasty 2012;27:1417-22.  Back to cited text no. 39
Lin YC, Chang CH, Chang CJ, Wang YC, Hsieh PH, Chang Y. Vascular injury during primary total knee arthroplasty: A nationwide study. J Formos Med Assoc 2019;118:305-10.  Back to cited text no. 40
Ko LJ, DeHart ML, Yoo JU, Huff TW. Popliteal artery injury associated with total knee arthroplasty: Trends, costs and risk factors. J Arthroplasty 2014;29:1181-4.  Back to cited text no. 41
Benkovich V, Klassov Y, Mazilis B, Bloom S. Periprosthetic fractures of the knee: A comprehensive review. Eur J Orthop Surg Traumatol 2020;30:387-99.  Back to cited text no. 42
Soohoo NF, Zingmond DS, Lieberman JR, Ko CY. Primary total knee arthroplasty in California 1991 to 2001: Does hospital volume affect outcomes? J Arthroplasty 2006;21:199-205.  Back to cited text no. 43
Verra WC, van den Boom LGH, Jacobs W, Clement DJ, Wymenga AAB, Nelissen RGHH. Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis. Cochrane Database of Systematic Reviews 2013, Art. No.: CD004803.  Back to cited text no. 44
Waterson HB, Clement ND, Eyres KS, Mandalia VI, Toms AD. The early outcome of kinematic versus mechanical alignment in total knee arthroplasty: A prospective randomised control trial. Bone Jt J 2016;98-B:1360-8.  Back to cited text no. 45
Ofa SA, Ross BJ, Flick TR, Patel AH, Sherman WF. Robotic total knee arthroplasty vs conventional total knee arthroplasty: A nationwide database study. Arthroplast Today 2020;6:1001-8.e3.  Back to cited text no. 46
Kim YH, Park JW, Kim JS. Computer-navigated versus conventional total knee arthroplasty. J Bone Jt Surg 2012;94:2017-24.  Back to cited text no. 47
Powell AJ, Crua E, Chong BC, Gordon R, McAuslan A, Pitto RP, et al. A randomized prospective study comparing mobile-bearing against fixed-bearing PFC Sigma cruciate-retaining total knee arthroplasties with ten-year minimum follow-up. Bone Jt J 2018;100-B:1336-44.  Back to cited text no. 48
Tzatzairis T, Fiska A, Ververidis A, Tilkeridis K, Kazakos K, Drosos GI. Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature. J Orthop 2018;15:459-66.  Back to cited text no. 49
MacDonald SJ, Charron KD, Bourne RB, Naudie DD, McCalden RW, Rorabeck CH. The John Insall Award: Gender-specific total knee replacement: Prospectively collected clinical outcomes. Clin Orthop Relat Res 2008;466:2612-6.  Back to cited text no. 50
Sassoon A, Nam D, Nunley R, Barrack R. Systematic review of patient-specific instrumentation in total knee arthroplasty: New but not improved. Clin Orthop Relat Res 2015;473:151-8.  Back to cited text no. 51
Partridge TC, Baker PN, Jameson SS, Mason J, Reed MR, Deehan DJ. Conventional versus highly cross-linked polyethylene in primary total knee replacement. J Bone Jt Surg 2020;15:119-27.  Back to cited text no. 52
Vijaysegaran P, Knibbs LD, Morawska L, Crawford RW. Surgical space suits increase particle and microbiological emission rates in a simulated surgical environment. J Arthroplasty 2018;33:1524-9.  Back to cited text no. 53
Schiavone Panni A, Corona K, Giulianelli M, Mazzitelli G, Del Regno C, Vasso M. Antibiotic-loaded bone cement reduces risk of infections in primary total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc 2016;24:3168-74.  Back to cited text no. 54
Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty. J Bone Joint Surg Am 2019;101:112-8.  Back to cited text no. 55
Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: A randomised study. Br Med J (Clin Res Ed) 1982;285:10-4.  Back to cited text no. 56
Hussain N, Chien T, Hussain F, Bookwala A, Simunovic N, Shetty V, et al. Simultaneous versus staged bilateral total knee arthroplasty: A meta-analysis evaluating mortality, peri-operative complications and infection rates. HSS J 2013;9:50-9.  Back to cited text no. 57
Liu L, Liu H, Zhang H, Song J, Zhang L. Bilateral total knee arthroplasty: Simultaneous or staged? A systematic review and meta-analysis. Medicine (Baltimore) 2019;98:e15931.  Back to cited text no. 58
Reed SC, Gollish J. The accuracy of femoral intramedullary guides in total knee arthroplasty. J Arthroplasty 1997;12:677-82.  Back to cited text no. 59
Gangadharan R, Deehan DJ, McCaskie AW. Distal femoral resection at knee replacement – The effect of varying entry point and rotation on prosthesis position. Knee 2010;17:345-9.  Back to cited text no. 60
Deakin AH, Basanagoudar PL, Nunag P, Johnston AT, Sarungi M. Natural distribution of the femoral mechanical-anatomical angle in an osteoarthritic population and its relevance to total knee arthroplasty. Knee 2012;19:120-3.  Back to cited text no. 61
Huang T, Long Y, George D, Wang W. Meta-analysis of gap balancing versus measured resection techniques in total knee arthroplasty. Bone Joint J 2017;99-B:151-8.  Back to cited text no. 62
Tapasvi S, Shekar A, Patil S, Dipane M, Chowdhry M, McPherson EJ. Comparison of gap balancing vs measured resection technique in patients undergoing simultaneous bilateral total knee arthroplasty: One technique per knee. J Arthroplasty 2020;35:732-40.  Back to cited text no. 63
Moon YW, Kim HJ, Ahn HS, Park CD, Lee DH. Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016;95:e5006.  Back to cited text no. 64
Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome. Acta Biomed 2017;88:118-28.  Back to cited text no. 65
Fisher J, McEwen H, Tipper J, Jennings L, Farrar R, Stone M, et al. Wear-simulation analysis of rotating-platform mobile-bearing knees. Orthopedics 2006;29:S36-41.  Back to cited text no. 66


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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