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CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 446, pp. 140–148
© 2006 Lippincott Williams & Wilkins
Cementless Fixation in Revision Total Knee Arthroplasty
Leo A. Whiteside, MD
A surgical approach to revision total knee arthroplasty that
includes minimal bone resection, minimal soft-tissue stripping, cementless fixation of the femoral and tibial components, and morselized allografting of defects was used and
evaluated in 105 patients (110 knees) with severe bone loss.
The patients were followed for 60 to 127 months postoperatively. Fixation included a tightly-fit fluted titanium stem in
the femoral and tibial canals and rim contact on the peripheral rim of the tibia. One tibia loosened and one knee failed
because of infection. Ligamentous stability and pain relief
were consistent through the followup period. At 10 years the
mean valgus laxity was 4° ± 2.5°, and the mean varus laxity
was 5.2° ± 3.3°. Mean Knee Society pain score was 47 ± 2.1.
Pain was mild in 28 knees, moderate in eight knees, and
severe in two knees. Evidence of bone healing occurred in the
bone defects that could be seen on radiographs. Increase in
radiodensity always was found at postoperative intervals
greater than one year. An approach to revision total knee
arthroplasty that maintains bone and soft tissue about the
knee establishes an effective and durable construct.
and durable knee and also improve the mechanical environment in cases of later revision. These basic principles
and techniques obviate high-risk, potentially destructive
techniques, such as massive allografting, cemented stems,
and fixed hinges that destroy additional bone and set the
stage for catastrophic failure.
Though massive allografts can incorporate and heal solidly to bone in the knee, the failure rate is high because of
immunocompatibility, resorption, and infection.5,8,10
Techniques that use the remnants of the patients’ own
bone, replace the remaining lost articular bone stock with
the implants themselves, and reconstruct bone stock with
demineralized or morselized allograft and bone marrow
autograft offer excellent early and long-term results.11,12,15
Function and durability of this construct has been excellent
and repeat revision rare using these techniques.11,12,15
Soft-tissue management in revision TKA correlates directly with exposure techniques and management of bone
stock. When the soft-tissue envelope is left attached to
carefully preserved bone stock of the femoral and tibial
metaphyses, the spacer effect of the implants can be used
to achieve stability in flexion and extension.15 Preoperative planning and templating cannot predict the size and
position of the implants because the radiographs and
physical examination do not provide adequate information
about the condition of the ligaments and bone stock to
predict ligament balance in flexion and extension. The
position of the patella is one of the least reliable preoperative predictors of correct joint line position for the new
implants because the patellar tendon often shrinks or elongates according to pathological conditions involved with
the previous implants.
We hypothesized that stability and ligament balance
could be achieved and that bone reconstruction could occur without the use of linked hinges or highly constrained
implants.
Level of Evidence: Therapeutic study, level II (prospective
study). See Guidelines for Authors for a complete description
of levels of evidence.
Failed total knee arthroplasty (TKA), when accompanied
by major bone loss and ligament imbalance, offers one of
the most difficult problems in reconstructive orthopaedic
surgery. Nevertheless, a strong and reliable capsular structure remains attached to bone remnants even in the most
severely damaged knees.11,12,15,16,18 Using these bone and
soft-tissue structures to fix the implants and balance the
knee can achieve the ultimate goal of a pain-free, stable,
From the Missouri Bone and Joint Research Foundation, Missouri Bone and
Joint Center, St. Louis, MO.
The author certifies that he has or may receive payments or benefits from a
commercial entity related to this work.
The author certifies that his institution has approved the human protocol for
this investigation and that all investigations were conducted in conformity
with ethical principles of research, and that informed consent was obtained.
Correspondence to: Leo A. Whiteside, MD, Missouri Bone and Joint Research Foundation, 1000 Des Peres Rd., Suite 150, St. Louis, MO 63131.
Phone: 314-775-0521; Fax: 314-775-0525; E-mail: info@mobojo.org.
DOI: 10.1097/01.blo.0000218724.29344.89
MATERIALS AND METHODS
I reviewed prospectively collected data on a series of 110 knees
(105 patients; 61 women, 44 men) requiring revision arthroplasty
between January 1, 1989 and June 1, 2000. These knees were
140
Number 446
May 2006
operated on consecutively by the author and selected from a
database of 202 revision TKAs (195 patients) Only knees with
femoral or tibial defects classified as grade III or higher by the
Engh and Ammeen method4 and treated with a tightly fit fluted
diaphyseal stem and rim seating on remaining metaphyseal bone
were chosen. Thirty-five knees (35 patients) had this degree of
defect only in the femur, 42 knees (42 patients) had this degree
of defect only in the tibia, and 33 knees (28 patients) had this
degree of defect in the femur and the tibia. Followup was 60 to
127 months. All cases of revision TKA were operated with the
same surgical technique by the author, splitting the interval between the vastus medialis and rectus femoris. All but one knee
had revision with unconstrained implants. This knee was revised
with hinged implants because it was operated on for failure of
revision TKA and ligament balancing procedure. This knee became infected, was débrided, and ultimately was revised using
unconstrained implants. Eighteen patients were lost to followup
because of death unrelated to their arthroplasty. This left 92
patients (58 women and 34 men) in the study. The age range was
37–86 years (mean 73 ± 9 years).
The interval between the conjoined quadriceps tendon and
vastus medialis was used for exposure in all cases, and capsular
stripping was minimal. Problems of difficult exposure were
solved with the tibial tubercle osteotomy technique instead of
stripping soft tissue from bone.13,14,17 The medullary canals were
reamed to achieve tight fit at 150 to 200 mm depth. The reamers
were used for alignment, accepting cutting guides that were set
to resect as little bone as possible, and to align the tibial surface
perpendicular to the long axis of the bone and the femur in 5°
valgus to the reamer. In flexion, the surfaces of the femur were
aligned parallel with the epicondylar axis. The tibial tray size
was chosen by placing an assortment of trial components against
the remaining upper tibial bone stock to ensure good coverage.
Often the remaining tibial rim was less than 1⁄3 the original
circumference, and the fibular surface supported the posterolateral edge of the tibial tray.
Alignment of the knees and positioning of the implants are
equally important in flexion and extension. Regardless of the
implants chosen by the surgeon, the knee must be aligned correctly in the coronal plane so that the articular surface is perpendicular to the mechanical axis of the lower extremity in flexion and extension, and the tibia, patellar groove, and femoral
head remain in the median sagittal plane through the full arc of
flexion. Fortunately, the femoral epicondylar axis and medullary
canals of the femur and tibia can be relied upon as effective
alignment landmarks for the knee even after severe damage to
the architecture of the knee. The medullary canal of the femur
(Fig 1) and tibia (Fig 2) are the landmarks for extension, and the
epicondylar axis of the femur is the landmark for flexion (Fig 3).
Bone surface preparation usually was simple. Using the medullary reamer as an alignment landmark, the saw cut guide was
used to resect minimal bone from the femur and tibia. This often
left only a fraction of the metaphyseal rim to support axial load,
but this generally was sufficient (Fig 4). Preserving as much
bone as possible and leaving its ligamentous and capsular attachments intact allows the spacer effect of the implants to tension the ligaments without using additional constraint beyond a
deep-dish tibial polyethylene component.
Cementless Fixation in Revision TKA
141
Fig 1. Intramedullary alignment of the distal femoral and
proximal tibial surface resections is shown. The reamer is
aligned with the isthmus of the femoral medullary canal, and a
small amount of bone is resected from the distal metaphyseal
rim at a 5° valgus angle. If one side is severely deficient, the
intact rim provides sufficient distal fixation if tight fit in the
medullary canal is achieved. (Reprinted with permission from
Whiteside LA. Bone reconstruction and ligament balancing. In:
Whiteside LA, ed. Revision Total Knee Arthroplasty. Rosemont, IL: The American Academy of Orthopaedic Surgeons;
2003:1–16.)
142
Whiteside
Clinical Orthopaedics
and Related Research
The femoral component was rotationally aligned with the
epicondylar axis and finally seated on the distal femoral bone
surface. The trial tibial component was inserted and ligament
balancing completed by releasing abnormally tight medial or
lateral ligaments until the knee had correct ligament balance in
flexion and extension. The next step was to position the distal
joint surface correctly. This was done with the knee in flexion as
thicker tibial polyethylene spacers were added until the knee was
adequately stable in flexion. Next the knee was extended. If the
knee would extend fully and was stable, then the balancing procedure was finished. If the knee would not extend fully, the joint
surface was moved proximally by choosing a thinner femoral
Fig 2. The reamer is aligned with the isthmus of the tibial
medullary canal, and a small amount of bone is resected from
the proximal metaphyseal rim perpendicular to the long axis of
the tibia. (Reprinted with permission from Whiteside LA. Bone
reconstruction and ligament balancing. In: Whiteside LA, ed.
Revision Total Knee Arthroplasty. Rosemont, IL: The American Academy of Orthopaedic Surgeons; 2003:1–16.)
Whereas varus-valgus alignment was fairly simple, joint-line
position required trial-and-error and empirical decision making.
The process began with the surgeon choosing the largest size
femoral component that would fit reasonably on the medial and
lateral rims of the distal femur (Fig 5). Once the size was determined, the trial femoral implant was inserted (along with its
stem) so that the anterior flange was flush with the anterior
cortex of the femur. In some cases, the anterior bow of the femur
pushed the femoral component anteriorly and prevented seating
of the flange when the stem fit tightly in the medullary canal. In
these cases, an offset stem was necessary to achieve this correct
position. Ten knees (10 patients) required femoral stems with
posterior offset of the femoral component, and one tibia required
a stem with medial offset of the component. Femoral build-up
modules were chosen to place the joint surface approximately
equidistant from epicondylar attachment of the ligaments in flexion and extension (Fig 6).
Fig 3. The epicondylar axis of the femur is the most reliable
landmark for alignment of the revision knee in flexion. A perpendicular to this line passes through the hip, so resection of
the femoral surface parallel to this line will place the joint surface in correct varus-valgus alignment in flexion.
Number 446
May 2006
Cementless Fixation in Revision TKA
143
Fig 4. Soft-tissue envelope is shown attached to the epicondylar areas of the femur and spreading across the tibial metaphysis. Though the posterior capsule can stabilize the knee
in extension, only the epicondylar soft-tissue structures can
stabilize the knee in flexion. (Reprinted with permission from
Whiteside LA. Bone reconstruction and ligament balancing. In:
Whiteside LA, ed. Revision Total Knee Arthroplasty. Rosemont, IL: The American Academy of Orthopaedic Surgeons;
2003:1–16.)
augment module or by resecting more distal bone. If the knee
hyperextended, the articular surface was moved distally with a
thicker distal femoral augmentation module. Femoral position
was adjusted until balance was appropriate in flexion and extension. If the ligaments had been left attached to the epicondylar
surfaces of the femur and metaphyseal flare of the tibia, the joint
surface remained equidistant from the epicondyles in flexion and
extension and stable through the full arc of flexion.
Fixation of the implants depended on a semi-rigid stem,
tightly fixed into the diaphysis. A smooth stem with distal flutes
provides excellent fixation without stress-relieving the periarticular bone. A slot in the distal 1⁄4 of the stem provides enough
Fig 5. Anterior view of the knee in flexion with trial revision
components in place. The femoral component covers the mediolateral dimension of the distal femoral surface fully with
minimal overhang. Despite major deficiency of bone in the
proximal tibia, the tibial trial component is stabilized adequately with rim support and stem fixation. The joint is stabilized in flexion with as thick a tibial polyethylene trial component as is necessary to achieve stability. (Reprinted with permission from Whiteside LA. Bone reconstruction and ligament
balancing. In: Whiteside LA, ed. Revision Total Knee Arthroplasty. Rosemont, IL: The American Academy of Orthopaedic
Surgeons; 2003:1–16.)
144
Whiteside
Clinical Orthopaedics
and Related Research
Fig 6. Lateral view of a revision femoral component using a posterior-offset module for the femoral stem. The anterior femoral
flange lies in line with the anterior femoral cortex, and the diaphyseal stem engages the femoral isthmus. The component size has
been chosen to restore posterior offset and to cover the medial-to-lateral extent of the distal femoral surfaces. The distal and
posterior surfaces are placed approximately equidistant from the epicondylar ligament attachments (arrows A and B). Posterior
offset (arrow C) has been reestablished to ensure maximum flexion without impingement. (Reprinted with permission from
Whiteside LA. Bone reconstruction and ligament balancing. In: Whiteside LA, ed. Revision Total Knee Arthroplasty. Rosemont,
IL: The American Academy of Orthopaedic Surgeons; 2003:1–16.)
flexibility to allow safe insertion with minimal risk of fracture,
and also to allow bending and torsional stresses to be borne by
the diaphyseal bone. This fixation technique converts large peripheral defects to cavitary defects that can be filled with morselized cancellous bone or demineralized bone, and covered over
with the soft-tissue envelope (Fig 7).
Identifying the ligaments that were excessively tight was
done with a formula that could be applied to all knees. Anterior
ligaments tighten in flexion and posterior ligaments tighten in
extension.7,9,15,18 Ligaments that attach near the epicondyles of
the femur are effective in flexion and extension. Structures that
bypass the distal femur entirely (iliotibial band, semimembranosus, pes anserinus) are effective as varus-valgus stabilizers only
in extension.15
The Advantim (Wright Medical Technology, Arlington, TN)
and Profix (Smith & Nephew Inc, Memphis, TN) total knee
systems were used. In each system the femoral component was
cobalt-chromium and the tibial component was a titanium tray,
both with sintered-bead porous surfaces. Seating these implants
on the rim of the femoral and tibial metaphyses resulted in cavi-
tary defects that often consisted of more than 2⁄3 the volume of
the metaphyseal bone. The defects were filled with a combination of morselized cancellous allograft, medullary reamings from
the patient’s own femur and tibia, and bone marrow aspirate
from the medullary canals.
In most cases (105 knees in 102 patients) a deep-dish or
conforming-plus tibial surface was needed to achieve posterior
stability of the tibial surface in flexion and extension, but none
of the knees required a stabilized condylar design (i.e. a large
tibial post captured rigidly by a femoral housing). One was salvaged with a hinge prosthesis. Even in cases with severe femoral
and tibial metaphyseal bone destruction including the femoral
epicondylar and tibiofibular joint, stability could be achieved
with the spacer effect of the implants without clinically noticeable leg lengthening.
Postoperatively, the patients were started on partial weightbearing, advancing as tolerated to full weightbearing in 6 to 12 weeks.
All patients could bear full weight by 8 weeks postoperatively.
Clinical evaluations and radiographic assessment of the knees
was done by the author or his surgical assistant at 1 month, 3
Number 446
May 2006
Cementless Fixation in Revision TKA
145
evidence of migration, but specific measurement of position relative to bone landmarks was not done for this study.
RESULTS
Fig 7. Tibial component positioned on carefully preserved
bone stock. This technique maintains attachment of the softtissue sleeve to bone and places the implants near the ideal
position for stability in flexion and extension. (Reprinted with
permission from Whiteside LA. Bone reconstruction and ligament balancing. In: Whiteside LA, ed. Revision Total Knee
Arthroplasty. Rosemont, IL: The American Academy of Orthopaedic Surgeons; 2003:1–16.)
months, 1 year, then at 3-year intervals. Varus and valgus laxity
was assessed manually in full extension and estimated in degrees. Anterior and posterior laxity was assessed manually at 90°
flexion and estimated in millimeters. The Knee Society scoring
system was used to grade each knee.6 The radiographs were
evaluated for radiolucent lines at all interfaces, and the width of
each radiolucent line was measured with a ruler and recorded.
The grafted areas were evaluated for signs of increasing radiodensity over a period of two or more office visits, suggesting
healing of the defect. The ends of the stems were evaluated for
radiolucent lines, pedestal formation, diaphyseal bone hypertrophy, and migration. The radiographs were inspected for gross
Knee stability and ligament balance were achieved with
the revision surgical technique described. Varus and valgus and anteroposterior stability did not change appreciably during the followup period. At 5 years after surgery,
mean valgus laxity was 3° ± 2.8° and mean varus laxity
was 4.8° ± 2.3°. The values at 10 years were a mean valgus
laxity of 4° ± 2.5° and a mean varus laxity of 5.2° ± 3.3°.
The conforming tibial articular surface was effective in
maintaining anteroposterior (AP) stability. Anterior laxity
at 5 years postoperative was 7.2° ± 3.1°, and at 10 years
was 6.6° ± 4.1°. None of the knees has symptomatic posterior laxity or rotational instability.
The bone grafting technique used in conjunction with
the implants provided a substrate for bone reconstitution.
Healing in grafted areas was difficult to assess radiographically, but when the defects could be imaged in profile, apparent increase in radiodensity always was found at
postoperative intervals greater than 1 year. This radiographic finding was present in 31 tibias (31 patients) and
28 femurs (28 patients) (Figs 8, 9).
One knee developed infection after hinge arthroplasty
and was revised in two stages to a non-linked cementless
implant. One tibial component was revised for loosening.
Mean Knee Society pain score was 47 ± 2.1 (out of 50).
Twenty-eight knees (28 patients) had mild pain, eight
knees (eight patients) had moderate pain, and two knees
(two patients) had severe pain postoperatively. None of the
components except for the case of tibial component loosening has had radiographically apparent migration, progressive radiolucent lines, or pedestal formation around
the stem.
DISCUSSION
Durable fixation of the femoral and tibial components is of
paramount importance in revision TKA. No revision knee
is effective in the long term if fixation fails, and improving
bone stock to enhance the odds of success in cases of late
failure should be one of the main goals of revision TKA.
This paper reports that a revision technique that uses bone
preservation, ligament balancing, bone grafting, and osteointegration techniques to achieve stability postoperatively was effective in restoring patient knee function. Using techniques that do not consume additional bone stock
to achieve fixation is attractive, especially in view of the
substantial revision rate reported for revision TKA.10 Attempting to support massive implants on cement that is
supported by poor bone stock is mechanically unsound and
146
Whiteside
Fig 8A–B. (A) Postoperative lateral view of a knee at one
month after surgery. The line indicates the distal extent of the
patient’s own anterior femoral bone stock. The material under
the femoral flange is morselized cancellous allograft and demineralized alllograft bone. The posterior surfaces of the femoral component are seated against the remaining portion of the
femoral diaphysis. (B) Postoperative lateral radiograph of the
same case at two years after surgery. The bone graft has
consolidated. (Reproduced with permission from Whiteside
LA. Cementless revision total knee arthroplasty. In Callaghan
JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz TL,
eds. The Adult Knee. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003:1465–1472.)
fails at an unacceptably high rate.10 Avoiding deeply penetrated cement and extensive periosteal stripping offers
advantages in bone and soft-tissue preservation and in revision cases for infection after revision TKA.
This paper reports only the results gathered from a series of patients revised without the use of cement, so direct
comparisons with series that use cement fixation in revision cannot be made. The potential disadvantages of this
technique are tibial stem pain, which occurs frequently
Clinical Orthopaedics
and Related Research
when a long stem is used,2 and loss of diaphyseal bone
stock if failure or migration occurs.
Revision TKA requires correct alignment and ligament
balance in flexion and extension. Nothing less will produce a good knee. Long-term success depends on stability
achieved by secure attachments of ligament to bone. Attempting to stabilize the knee with a constrained condylar
type implant or linked hinge instead of ligament tension
will result in an increasing failure rate as time passes.
Rarely, massive avulsion of collateral and capsular ligament structures precludes balancing of the ligaments with
the spacer effect of the implants. Although none of these
cases are included in the present series, collateral ligament
reattachment and imbrication techniques are an important
part of the surgical armamentarium for ligament management in revision TKA.
Following the basic principles of bone reconstruction,
alignment, and ligament balancing procedures produces a
durable and effective joint. Success with this effort rests
with preserving the remaining bone stock with its capsular
and ligamentous attachments intact. The tibial tubercle osteotomy has been instrumental in allowing the surgeon to
achieve a stable joint supported by viable bone that is
capable of healing, filling in defects, and osseointegrating
with the implants. Even in cases of multiple revision previously stabilized with hinge arthroplasty, the soft-tissue
envelope can be tensioned to regain stability using rotationally unconstrained implants.1 Severely damaged bone
and soft tissue, when left in continuity and loaded appropriately, can function well and regenerate bone and ligamentous support for the knee so the failure rate will be
low. The stem is the key to success in fixation of implants
with rim deficiency. When the stem is tightly fit in the
medullary canal, axillary load-bearing is sufficient even
with a fraction of the original circumference of the rim.
Adding rim support did not result in additional stability in
an in vitro study of the biomechanics of fixation.3
The results of the cementless technique described appear to be superior to those of similar series of cemented
revision TKA. Failure rates of 19.2% when bulk allograft
was used and 42.9% when massive implants were used to
replace missing bone stock with an overall survivorship of
79.4% at 8 years was reported by Hockman et al.5 Sierra
et al reported mechanical failure rates of 11% at 5 years,
26% at 10 years, and 31% at 15 years10; over the past three
decades no improvement in survival occurred despite continued efforts to improve design and fixation using cemented implants. Another advantage of the osseointegration technique described in this report is improvement of
bone stock and soft-tissue integrity. If failure does occur,
the bone and soft tissues of the knee may be improved, and
aid in reconstruction.
Number 446
May 2006
Cementless Fixation in Revision TKA
147
Fig 9A–B. (A) Anteroposterior radiograph of the tibia of the same case at one month after surgery. The long stem engages the
diaphysis of the tibia, and the distal slot is closed. Fresh graft is visible in the tibiofibular joint. The medial edge of the tibia and
upper surfaces of the fibular head support the tibial component until healing is complete. (B) Anteroposterior radiograph of the tibia
of the same case at two years after surgery. The slot in the stem is still closed, and the tibiofibular joint appears to be solidly
healed. (Reproduced with permission from Whiteside LA. Cementless revision total knee arthroplasty. In Callaghan JJ, Rosenberg
AG, Rubash HE, Simonian PT, Wickiewicz TL eds. The Adult Knee. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:1465–
1472.)
Acknowledgments
The author thanks William C. Andrea, MA, CMI, for preparation
of the illustrations, and Diane J. Morton, MS, for editorial assistance with manuscript preparation.
6.
7.
References
1. Barden B, Fitzek JG, Loer F. Rotating platform components for
revisions of hinged knee prostheses. Clin Orthop Relat Res. 2004;
423:144–151.
2. Barrack RL, Rorabeck C, Burt M, Sawhney J. Pain at the end of the
stem after revision total arthroplasty. Clin Orthop Relat Res. 1999;
367:216–225.
3. Conditt MA, Parsley BS, Alexander JW, Doherty SD, Noble PC.
The optimal strategy for stable fixation in revision total knee arthroplasty. J Arthroplasty. 2004;19(Suppl2):113–118.
4. Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternative for reconstruction. Instr
Course Lect. 1999;48:167–175.
5. Hockman DE, Ammeen D, Engh GA. Augments and allografts in
8.
9.
10.
11.
revision total knee arthroplasty: usage and outcome using one
modular revision prosthesis. J Arthroplasty. 2005;70:35–41.
Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee
Society clinical rating system. Clin Orthop Relat Res. 1989;248:
13–14.
Kanamiya T, Whiteside LA, Nakamura T, Mihalko WM, Steiger J,
Naito M. Ranawat Award Paper: Effect of selective lateral ligament
release on stability in knee arthroplasty. Clin Orthop Relat Res.
2002;404:24–31.
Peters CL, Erickson J, Kloepper RG, Mohr RA. Revision total knee
arthroplasty with modular components inserted with metaphyseal
cement and stems without cement. J Arthroplasty. 2005;20:302–
308.
Saeki K, Mihalko WM, Patel V, Conway J, Naito M, Thrum H,
Vandenneuker H, Whiteside LA. Stability after medial collateral
ligament release in total knee arthroplasty. Clin Orthop Relat Res.
2001;392:184–189.
Sierra RJ, Cooney WP IV, Pagnano MW, Trousdale RT, Rand JA.
Reoperations after 3200 revision TKAs: rate, etiology, and lessons
learned. Clin Orthop Relat Res. 2004;425:200–206.
Whiteside LA. Bone reconstruction and ligament balancing. In:
148
Whiteside
Whiteside LA, ed. Revision Total Knee Arthroplasty. Rosemont, IL:
The American Academy of Orthopaedic Surgeons; 2003:1–16.
12. Whiteside LA. Cementless revision total knee arthroplasty. In Callaghan JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz
TL, eds. The Adult Knee. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003:1465–1472.
13. Whiteside LA. Distal realignment of the patellar tendon to correct
patellar tracking abnormalities in total knee arthroplasty. Clin Orthop Relat Res. 1997;344:284–289.
14. Whiteside LA. Exposure in difficult total knee arthroplasty using
tibial tubercle osteotomy. Clin Orthop Relat Res. 1995;321:32–35.
Clinical Orthopaedics
and Related Research
15. Whiteside LA. Ligament balancing in revision total knee arthroplasty. Clin Orthop Relat Res. 2004;423:178–185.
16. Whiteside LA. Selective ligament release in total knee arthroplasty of the knee in valgus. Clin Orthop Relat Res. 1999;367:130–
140.
17. Whiteside LA, Ohl MD. Tibial tubercle osteotomy for exposure of
the difficult total knee replacement. Clin Orthop Relat Res. 1990;
260:6–9.
18. Whiteside LA, Saeki K, Mihalko WM. Functional medial ligament
balancing in total knee arthroplasty. Clin Orthop Relat Res. 2000;
380:45–57.
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