In such patients, surgical treatment of choice is total knee arthroplasty(TKA). In the United States and in Japan, it is the gold standard of treatment in these decades. We place the cobalt-chrome alloy as the femoral component because is rigid and hardly wear. We then place the titanium-alloy as the tibial component because titanium is more favored by the bone for bone ingrowth. We then place the cross-link ultra high molecular weight polyethylene which is more durable then the one before. And we finish by placing the ultra high molecular weight polyethylene over the surface of patella.

Minimally Invasive Total Knee Arthroplasty

Total knee arthroplasty can also be made by MIS - Minimally Invasive Surgery- like total hip arthroplasty. If you want to cut the tibia from the front for correct bone cut, you may need eight to nine centimeter incision. If you accept cutting the tibia from the lateral side, you can minimize it down to six to seven centimeters with some special tools. Our preference is to make the tibial bone cut in front from anterior because we want a reproducible result avoiding varus-valgus malalignment.

These two pictures are the ones showing ten-year post-operative wound as big as eleven to thirteen centimeters. We were encouraged with the success of minimally invasive total hip arthroplasty (MITHA) and we wanted the similar advancement for the knees. We have developed and/or modified some conventional surgical instruments and reconsidered the order of the osteotomy and finally made it possible to do the operation with eight to nine centimeter skin incision while still making the tibial cut from front for correct osteotomy.

Here I show the surgical procedure of the minimally invasive total knee arthroplasty (MITKA).

First, three-inch anterior straight skin incision is made.

Distal osteoarthritic surface of the femur (thigh bone) is cut and removed.

Distal end of the osteotomized femur appears like this in minimally invasive total knee arthroplasty.

Anterior, posterior and chamfer cut of the femur is made either with a specially designed femoral cutting guide for MITKA or with a conventional femoral cutting guide when applicable. More accurate osteotomy is made with the conventional femoral cutting guide because it is larger and easier to aim the correct direction for osteotomy. It is extremely important to prevent the bone saw blade to be bent or the blade going forward to an undesired direction while the bone saw is proceeding through the osteotomy line.

Appearance of the cut surface of the femur.

Femoral component is impacted after placing the tibial base plate.

Proximal tibial cut is made from right in front of the tibia (shin bone) in order to avoid varus-valgus mal-positioning of the tibial component. Here again, driving the saw through the correct osteotomy line is of extreme importance as in the femoral cut.

Tibial base plate is placed.

Patella (knee cap) can be grabbed with patella clamp usually after the osteotomy of the distal end of the femur or sometimes after both the femoral and tibial osteotomies are completed.

Patellar component is cement-fixed.

Patella is brought back over the femoral component and the tracking is usually very good with minimally invasive total knee arthroplasty.

Finally, the capsule and the skin are closed.

Every surgeon would want to avoid suboptimal positioning of the implants. Extremely minimally invasive total knee arthroplasty is not ideal because the results are not reproducible. Long-term results are more important than short-term results as the total knees are expected to be used for decades. What is important to do is to do the most accurate operation first and then think about trying to make the incision smaller. When you change the order of the osteotomy, there is a way to make the surgical intervention smaller even when you are using the conventional cutting guides. Early short-term good results mainly come from quadriceps sparing.

Ambulation one week post MITKA
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Full squat is sometimes important especially in Asia and Islamic countries. Thanks to the development of new knee implant designs and the improved surgeon's skills and new tools for operations, many patients are getting a better range of motion after total knee arthroplasty. Some people can make "Asian squat" with full flexion knees as in this movie(884KB).



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