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Workflow Analysis of a Total Knee Arthroplasty (TKA) surgical

By Stepes

1. Background
Total Knee Arthroplasty(from now on referred to as TKA) is a surgery which
replaces the weight-bearing(tibiofemural) surfaces of the knee with metal and
polyethylene prosthetics to relieve knee pain. It has been practiced in different forms
for around 50 years with varying degrees of success. Since then the techniques as well
as the implants have improved significantly giving very good results and satisfied
It is usually performed to alleviate pain and unstable and deformed knees.
This usually results from osteoarthritis(Fig.1) which is observed in around 66% of
people over 65 years but from which only around 50% show symptoms and have to
get operated. The operation is also performed in other cases such as bone dysplasias
and reymatoid arthritis.
Patients who choose undergo surgery have preoperatively strong aches, which
often keep them awake at night and disturb most of their daily activities. For the
doctor to agree to perform the surgery he has first to rule out any other possible
diseases and exhaust all other traditional therapies which could help like anti-
inflammatory medications, braces, analgesics or for obese patients which often suffer from knee
problems weight loss. Often doctors prescribe rehabilitation with a physiotherapists as this might help
strengthening the knee and provides a wider range of motion and flexion.
The reason for this is both the high cost of the operation(in the US around $40.000) and the
great amount of postoperative pain caused by the surgery. Another reason is that the
mean lifetime of such prostheses is around 10-15 years after which sometimes the bone
reacts to some elements of the cement used and can cause serious problems. Also the
polyethylene used in the prostheses has to be replaced after some time due to

2. Reasons for Computer Assistance

Until recently the main manner of positioning the implants on the bones was
mostly through the plan done by the doctor based on CT scans, by experience and by
using accurate sawing jigs specifically designed for this kind of operation. For a TKA, this
type of error in alignment of the implants is defined as a variation of more than 3 Figure 1: Osteoarthritic knee
degrees from the planned alignment.
That is why there has been a movement lately towards computer aided navigation in TKA
surgeries. This is a passive form of assistance where the computer is used to calculate the best rotation,
translation and cuts for the placement of the prosthetic. There are also other forms of assistance which
are semipassive, like the computer controlling the movement range of the saw and the positioning of
the jigs, but they won’t be analysed in this article.
Computer aided navigation(CAN) becomes very important if we consider the risks involved in
malalignment which are believed to be long term wear of the materials, osteolysis(in which the bone is
destroyed by the organism) and of course the risk of the prostheses loosening.
Another important reason to use CAN TKA is because it can significantly help in minimally
invasive TKA surgeries where the viewing and operating field is severely restricted (Minimally Invasive
TKA are becoming more common due to less post-op pain and quicker recovery times while also
reducing some long-term complications of the patella. But if they are better than traditional TKA’s still
remains to be seen).
There are different ways in which the surgery can get enhanced by computers. Some systems
are image based while others imageless. Image based ones use CT scans and fluoroscopy to guide saw
and implant positioning while imageless ones use infrared markers positioned on the bones and other
tools used by the doctor to help the computer scan the surface of the bone.

3. Analytical Surgery Workflow

3.1 Preoperative Preparations

To prepare for the operation, the patient has to go
through some exams. These include blood exams, urine tests,
more importantly radiographs of the knee for anterioposterior
view, lateral view, patellofemoral view, long leg radiographs
and standing or knee under flexion radiographs. These help the
doctor have a general view of the anatomy of the person and
the conditions of the knee before the operation to be able to
prepare accordingly and develop an initial plan.
In this initial plan the doctor can use the patient data to
select the best implant for the patient according to his anatomy Figure 2: Knee anatomy
from an Implant Template Repository as proposed in DICOM
supplement 131. Then he can fit the template components 2D or 3D models onto the patient
data(radiographs, 3D models) to make an initial plan for the positioning of the implant and the cutting
jigs. From this plan the doctor can make an Implantation Plan SR Document as proposed in DICOM
supplement 134 which will include the proposed plan, the selected Implant Template Components and
the Implant Assembly which shows how the components can be assembled together. This information
will be passed on later to the navigation system.
For the operation good cardiopulmonary function is required for the anesthesia which is often
dangerous for elder people and some blood loss is to be expected, so often the patient has to give two
units of his blood some time prior to the operation in case it is needed during the operation.
Figure 3: infrared marker array Figure 4: Camera detecting markers

Before the operation the patient is given antibiotics and is then anesthetized and taken to the
operation room. His leg is again cleaned with a betadine solution to decrease chances of infection. It is
of extreme importance to keep the knee from getting infected and for this reason the rest of the body is
sealed off with lots of sterile drapes only exposing the part of the knee that has to be opened. For the
same reason the whole surgical team has to wear protective clothing and gloves too and all the
equipment has to be sterilized. Computers and other machines have to be sealed with plastics too.

3.2 Intraoperative Workflow

After the preparation a tourniquet is applied to the leg of the patient to redirect blood flow from
the knee area. Cutting lines are drawn with a marker pencil on the knee as well as lines aiding the
matching of skin in the final suturing process. Then the knee is opened with a scalpel, the veins
cauterized with a bovie pencil, the patella moved aside, soft tissues between the bones are removed
and osteophytes are cut off.
Now the infrared trackers(Fig.3) are applied to the femoral and tibial bones. Their position is
tracked by a double camera system(Fig.4) which relays the information about their position to the
navigation computer. This helps the navigation computer model the bone kinematics. After that, to
improve the computer model of the bone surface, the surgeon has to touch different points on the bone
surfaces with a special infrared marker pen which gets registered by the cameras to complete the
The computer now calculates the best angles
and positions for the cutting jigs using the model it has
created as well as the Implantation Plan SR data about
the implant, the surgeon then drills a hole on the distal
femoral bone at the place where the jigs will be placed
and after the jig is positioned, he fastens it with pins to
the bone. One cut is made along the perpendicular of
the femoral mechanical axis using an oscillating saw and
two more cuts(Fig.5) with an angle for the positioning of
Figure 5: Saw cutting femoral bone along cutting jig
the prosthesis. After that, the same process is followed
for cutting the tibial bone with the help of navigation.
Often the back of the patella also needs to be cut, so the surgeon places it between specifically designed
prongs and proceeds with cutting it.
Figure 5: Femoral cut planning in OrthoPilot Figure 6: Knee gap checking in OrthoPilot

When all the bones have been cut according to the computed plan, more holes are drilled into
them and then the trial prosthetic components are added for testing. The surgeon checks if the
prosthesis are matching with the navigation computer model and then tests the knee movement. He
tests the range of motion, the flexion and the gaps between the components that need to be even. The
computer navigation already takes all that into account when making the plan so that no gaps occur that
could produce premature friction of the components and difficulties in motion.
If the results are satisfactory, the trial components are removed, a polymethyl methacrylate
cement is applied which will hold the final components in place and the final components are put into
position. The team stretches the patients leg out so that it applies pressure to the components and then
they have to wait 10-15 minutes for the cement to harden. Then the range of motion and angles of the
leg are checked again and if all is correct the marker arrays are removed from the bones, the patella put
back in position, the deep tissue and fat is sutured and then the skin too. Then the tourniquet is deflated
for accurate hemostasis and removed. The pulse on the foot is checked and the operation is finished
with success.

3.3 Postoperative Workflow

After the operation, the patient needs for 24 hours intensive care in which time he needs to be
correctly hydrated and given analgesics to stop the pain. These can either be given directly locally to the
knee if there are still drains attached, otherwise he needs to take global analgesics which is less
preferred due to the large amount that he has to take.
Soon after the recovery from the operation the patient needs to do simple knee exercises
usually with the help of a continuous passive motion machine. The second day the patient is advised to
stand on his leg and try walking around. Usually it takes between 5 and 14 days for the patient to be
discharged from the hospital if the wound is well healed and he can bend his knee at least by 90
degrees, and afterwards he needs to take good care of the knee by continuing exercises with a
physiotherapist and with the help of home support devices.
Afterwards the patient needs to be reviewed in intervals of first 6 weeks, then 3 months, 6
months, 1 year, 2 years and so on. The mean time until the prosthesis wear out is 15 years. Most
patients seem satisfied from the operation and can usually return to normal life activities as well as very
light sports.
4. Summary
Although traditional TKA was already a very successful operation, there is still place for
improvement. Some argue that the results right now are not much better than in the traditional TKA and
that it increases operation time, yet we still haven’t seen the full potential of computer aided TKA.
Specifically trained surgery teams have shown that they can finish the operation in the same time as the
traditional surgery. Also the results will improve much more in the future when more and more data can
be taken into account for the operation without big effort from the doctors. Thus better results can be
achieved as the whole process will be modeled around the specific patient.
Also with new DICOM standards on the way, the CAN TKA will become much more integrated
into the rest of the hospital system and will be more accepted. In addition there are emerging workflow
planners for CAN TKA already available like OrthoPilot which help organize the whole process even
more. Minimally invasive TKA’s which are becoming more popular are in dire need of CAN too which will
help them reach higher safety and acceptability.
After these aspects have been taken into account, a big scale statistic will be able to show the
real improvements over the traditional surgery.
Planning Phase
Implant Implantation
Choose optimal
Query Implant Template Plan SR
implant and align
Repository Repository Document
Preoperative with patient data
Supp.131 Supp.134

Start of OP

Preperartion. Apply Tourniquet Open knee,
Antibiotics, and sterile drapes cauterize veins

Apply reference Navigation System

arrays to femure
and tibia

Register knee bone model
position and
surface on

Apply the three
cutting jigs.

Check saw cut

accuracy with
Cut bones with

Check ligament
tension on model
Drill holes and
apply trial
components Check component
positioning on

Test alignment Check range of

and range of motion and gap
motion symmetry on

Check component
Apply cement and positioning on
add final model

Test alignment
and range of

Suture the wound

and deflate

End of OP

[1] http://de.wikipedia.org/wiki/Arthrose
[2] Simon H Palmer, et al. “Total Knee Arthroplasty”
[3] Edheads + COSI Virtual Knee Surgery,
[4] H. Bäthis, et al. “Alignment in total knee arthroplasty”
[5]Tim Alexander Walde ,et al. “Process Optimization in Navigated Total Knee Arthroplasty”
[6] “Computer Assisted Total Knee Replacement” 2 part video by http://www.orangeorthopaedics.com
[7] “Computer Assisted Navigation for Orthopedic Procedures of the Pelvis and Appendicular
[8] OrthoPilot® Navigation System
[9] “Computer-assisted TKA: Greater Precision, Doubtful Clinical Efficacy: Opposes”
[10] DICOM Supplement 131
[11] DICOM Supplement 134