The operative knee is marked.
Patient receives spinal or general anaesthesia, often combined with a femoral/sciatic nerve block for pain control.
The patient is positioned supine with a tourniquet applied to the thigh.
The entire leg is cleaned with antiseptic solution.
Sterile drapes are applied, exposing only the surgical knee.
A midline skin incision (10–12 cm) is made over the front of the knee.
A medial parapatellar arthrotomy is performed to open the joint and evert (turn) the patella to access the joint surfaces.
The worn-out cartilage and a thin layer of underlying bone are removed from:
Distal femur (thighbone end)
Proximal tibia (shinbone top)
Undersurface of the patella (sometimes, depending on surgeon preference)
The resection is guided by precise cutting blocks to ensure alignment and balanced load distribution.
A guide is inserted into the femoral canal to determine anatomical alignment.
Cutting jigs are attached to shape the distal femur accurately.
Bone cuts include:
Distal femoral cut
Anterior cut
Posterior cut
Two chamfer cuts
These cuts create a perfect fit for the femoral metal component.
A tibial cutting block is placed to remove the damaged joint surface with correct slope and alignment.
A flat surface is created to accept the tibial baseplate.
If using a stem or keel, the tibia is prepared by punching or drilling to secure the implant.
The patella is everted.
A thin layer of bone is removed, and a plastic patellar button is sized and prepared.
Drill holes are made to accept the patellar component.
Trial (temporary) femoral, tibial and patellar components are inserted.
The knee is moved through full range of motion to assess:
Alignment
Soft-tissue balance
Stability in flexion and extension
Patellar tracking
Ligament releases or adjustments are made if required.
Implants may be:
Cemented (most common)
Uncemented (porous coating for bone in-growth)
Hybrid
Bone cement is applied to the tibial surface.
The tibial metal baseplate is pressed into position.
Cement is applied to the femoral cuts.
The metal femoral component is positioned and impacted for secure fixation.
A highly durable polyethylene insert is locked into the tibial baseplate.
Insert thickness is chosen to ensure balanced gaps and stable knee motion.
If resurfaced, the patellar button is cemented into place.
Patellar tracking is checked again.
The knee is taken through bending and straightening to verify:
Smooth articulation of components
Proper ligament tension
Full motion without impingement
Stability in extension and flexion
Any adjustments are made before closure.
The joint is thoroughly irrigated.
The arthrotomy (joint opening) is closed in layers.
Drain may be inserted depending on surgeon preference.
Subcutaneous tissues and skin are closed with sutures or staples.
A sterile dressing is applied.
A compression bandage is used to reduce swelling.
Some centres apply a knee immobilizer for the first few hours.
Patient is transferred to recovery.
Pain control, antibiotics, and blood-thinning medication are administered.
Physiotherapy begins within 24 hours focusing on:
Early walking
Gentle knee bending
Strength activation
Partial Knee Replacement (PKR), also called Unicompartmental Knee Replacement, is a precise and minimally invasive procedure that replaces only the diseased portion of the knee joint. Below is the comprehensive, detailed procedure exactly as performed in a modern orthopedic operating theatre.
The patient undergoes pre-operative assessment including X-rays/MRI to confirm that only one knee compartment is affected.
The surgical plan is finalized, including implant size and compartment selection (medial, lateral, or patellofemoral).
The patient is prepared for surgery under sterile conditions.
PKR is performed under either:
Spinal anesthesia, or
General anesthesia
A regional nerve block may also be used to reduce postoperative pain.
The patient is placed in a supine position on the operating table.
A small incision (6–10 cm) is made on the front of the knee, directly over the affected compartment.
Soft tissues are gently separated while preserving:
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)
Lateral soft-tissue structures
Minimal dissection ensures less bleeding and faster recovery.
The surgeon confirms intra-operatively that arthritis is confined to one compartment only.
The intact cartilage, ligaments, and menisci in the unaffected compartments are preserved.
The damaged cartilage and bone surfaces in the affected compartment are carefully identified.
Specialized precision instruments are used to remove only the diseased cartilage and a thin layer of underlying bone.
The cuts are made with millimeter accuracy to ensure perfect implant alignment.
Care is taken to preserve as much healthy bone as possible.
The bone surfaces are shaped to match the contour of the metal implant.
Template guides ensure proper:
Alignment
Depth
Balance
The tibial and femoral sides are prepared individually based on the damaged compartment.
Trial (temporary) components are placed first to check:
Stability
Range of motion
Ligament tension
Tracking and alignment
The knee is flexed and extended multiple times to ensure smooth movement.
Once perfect fit is confirmed, the final implants are fixed into place:
Metal femoral component (on the thigh bone)
Metal tibial component (on the shin bone)
High-density polyethylene insert (acts as the new cartilage surface)
Cemented or uncemented fixation may be used depending on bone quality and implant design.
The surgeon checks the knee through the full range of motion to ensure:
Smooth gliding of implants
Proper balancing of ligaments
Equal weight distribution
The patella (kneecap) is inspected to ensure natural tracking.
Soft tissues and capsule are closed in layers.
Skin is closed using sutures or staples, followed by application of sterile dressing.
A smaller incision means minimal scarring and less postoperative discomfort.
The patient is shifted to recovery room.
Early mobilization begins within hours:
Ankle pump exercises
Walking with support (same day or next day)
Pain control and physiotherapy are initiated immediately.
Bilateral Knee Replacement involves replacing both knee joints in the same surgical sitting. The procedure is carried out under strict monitoring because it is more extensive than a single knee replacement.
The patient is assessed for suitability for simultaneous bilateral surgery.
Preoperative X-rays, implant planning, medical clearance, and blood tests are completed.
Anesthesia plan is finalized and the patient is positioned supine on the operating table.
Both legs are prepared and draped in a sterile field.
Surgery is performed under:
Spinal or epidural anesthesia, or
General anesthesia
A femoral or adductor canal nerve block may also be used for postoperative pain control.
Continuous monitoring of heart, lungs, and blood loss begins.
A midline skin incision is made over the first knee.
A medial parapatellar arthrotomy is performed to open the joint.
The patella is gently shifted aside while preserving tendon attachments.
Diseased joint surfaces from:
Distal femur
Proximal tibia
Undersurface of the patella (if needed)
are removed with precision instruments.
Cuts are performed using alignment jigs to maintain proper mechanical axis.
Femoral and tibial bone surfaces are shaped to fit the implants.
Trial components are placed to check:
Balance
Stability
Flexion-extension gap
Patellar tracking
Soft tissue releases are performed if required to achieve optimal alignment.
Cemented or cementless implants are positioned:
Femoral component (metal)
Tibial tray (metal)
Polyethylene insert
Patellar component (if resurfaced)
Excess cement is removed and the implant is secured.
The joint capsule and soft tissues are sutured in layers.
Skin is closed with staples or sutures.
A sterile dressing is applied.
Once hemostasis is confirmed in the first knee, the surgical team repositions for the second knee.
Instruments are re-sterilized or fresh trays are used.
The same sequence of steps (incision → bone cuts → trial implants → final implants → closure) is repeated for the second knee.
Both knees are checked for:
Alignment
Stability
Full range of motion
Patellar tracking
Compression bandages are applied to both knees to minimize postoperative swelling.
The patient is shifted to recovery, with continuous monitoring of vital signs and blood loss.
Pain control is initiated using nerve blocks, medications, and cold therapy.
Physiotherapy begins within 12–24 hours:
Ankle pumps
Assisted standing
Walking with support
Blood tests and X-rays are performed the same or next day to confirm implant position.
Robot-assisted knee replacement uses advanced robotic navigation or robotic-arm technology to improve precision, alignment, bone cutting accuracy, and implant positioning.
A detailed CT scan or 3D imaging of the knee is taken before surgery.
The robotic software creates a personalized 3D model of the knee joint.
The surgeon uses this model to plan:
Bone cuts
Implant size
Alignment
Soft-tissue balance
The operative plan is loaded into the robotic system.
Procedure is performed under:
Spinal/epidural anesthesia, or
General anesthesia
Peripheral nerve blocks may be added for postoperative pain control.
The patient is positioned supine on the operating table.
Robotic trackers or optical beacons are attached to the femur and tibia for real-time mapping.
The leg is sterilized and draped.
A midline incision is made over the knee.
A medial parapatellar arthrotomy exposes the joint.
Damaged cartilage and osteophytes are visualized.
The surgeon uses a special probe to touch predefined points on the femur and tibia.
This “registers” the patient’s anatomy with the robotic 3D model.
The robot now knows:
Exact joint geometry
Soft tissue tension
Alignment patterns
The system displays the live anatomy on a monitor.
Depending on the robotic platform (Mako, ROSA, NAVIO, CORI, etc.):
The robotic arm guides the surgeon’s hand.
The surgeon performs bone cuts within a virtual boundary created by the robot.
This prevents:
Overcutting
Damage to surrounding soft tissues
Misalignment
Traditional instruments are guided by real-time robotic navigation.
The system continuously tracks limb alignment and cutting angles.
Distal femoral cut
Proximal tibial cut
Chamfer cuts
Posterior condylar cuts
All done with millimetre-level precision.
Trial components are inserted.
Robotic software analyzes:
Flexion–extension balance
Gap balancing
Patellar tracking
Alignment of the limb in 3D
Adjustments are made digitally until perfect alignment is achieved.
Final implants (femoral, tibial, polyethylene insert ± patellar button) are placed.
Cemented or cementless fixation may be used depending on the plan.
The robot confirms final alignment and implant fit before closure.
Joint is irrigated thoroughly.
The capsule, soft tissues, and skin are closed in layers.
A sterile dressing is applied.
Patient is shifted to recovery with continuous monitoring.
Pain control is optimized with nerve blocks and medications.
Physiotherapy begins within 12–24 hours:
Assisted standing
Range-of-motion exercises
Walking with walker/crutches
Detailed MRI and X-rays are reviewed to confirm:
Complete or near-complete meniscus loss
Stable knee ligaments
Acceptable cartilage condition
The patient’s knee measurements are used to select a size-matched donor meniscus (allograft).
Graft preparation is coordinated with the tissue bank in advance.
Surgery is performed under:
Spinal anesthesia, or
General anesthesia
A regional nerve block may be added for pain control.
Patient lies supine with the knee in a leg holder.
The operative leg is sterilized and draped.
Two or more small arthroscopic portals are created.
A diagnostic arthroscopy is performed to:
Inspect cartilage
Confirm meniscal deficiency
Evaluate ligaments
Any loose bodies or damaged tissue are removed.
The remaining damaged meniscal tissue is debrided.
A clean, stable rim of capsule is preserved for graft attachment.
The tibial plateau is lightly prepared to create a proper bed for the new meniscus.
The donor meniscus is thawed and shaped to match patient anatomy.
If the technique requires bone plugs or bone bridge, precise cuts are made on:
Anterior horn
Posterior horn
Sutures are pre-placed along the periphery and horns for easier implantation.
Common techniques include:
Bone Plug Technique
Keyhole (Bone Bridge) Technique
Soft-Tissue–Only Meniscal Allograft
Two tibial tunnels are drilled:
One for the anterior horn
One for the posterior horn
These tunnels allow secure seating of bone plugs.
A single slot is created in the tibia for the bone bridge connecting both horns.
No tunnels; horns are fixed with sutures via incision or anchors.
The meniscus allograft is passed through an arthroscopic portal or mini-incision.
The graft is carefully guided into place using traction sutures.
Bone plugs or bone bridge are seated securely into their tunnels/slot under visualization.
The anterior and posterior horns are fixed with:
Interference screws
Sutures tied over bone bridges
Anchors or suspensory fixation devices
This ensures stable root attachment and prevents graft extrusion.
The meniscal rim is sutured to the capsule using an inside-out, outside-in, or all-inside technique.
Multiple fixation points are placed along the circumference to recreate natural hoop stresses.
Arthroscopic visualization ensures proper contour and alignment.
The surgeon cycles the knee through flexion–extension to check:
Stability of the graft
Motion smoothness
Absence of impingement
Additional stitches are added if needed.
The portals and any mini-incisions are closed with sutures.
A sterile dressing is applied.
A hinged knee brace is placed with limited motion allowed initially.
Patient is monitored until anesthesia wears off.
Knee is protected in a brace and non-weight-bearing is maintained for several weeks.
Early physiotherapy focuses on:
Controlled motion
Preservation of graft stability
Full rehabilitation progresses over several months.
With 9+ years of experience, Dr. Yogesh Jain provides expert care in sports injuries, arthroscopy, and trauma.
Copyright © 2025 Dr. Yogesh Jain. All Rights Reserved. | Designed by Artistry Media
