Welcome to the Total Knee Arthroplasty (TKA) Step-by-Step Surgical Photo Tour, a comprehensive intraoperative visual walkthrough curated by Dr. Joseph Bernstein, MD (University of Pennsylvania) and Dr. Christian Veillette, MD (University of Toronto) on OrthopaedicsOne. This 24-step curriculum documents the essential surgical milestones of a primary cemented tricompartmental total knee arthroplasty, featuring original intraoperative photography, anatomical landmarks, instrument positioning, soft-tissue balancing pearls, and closure protocols.
1. Surgical Workflow & Phase Overview
The procedural sequence is divided into five standardized operative phases designed to optimize mechanical alignment, joint stability, and soft-tissue balance:
| Surgical Phase | Tour Steps | Primary Clinical Objective | Critical Surgical Danger Zone |
|---|---|---|---|
| Phase 1: Setup & Exposure | Steps 1 to 6 | Stable positioning, extensile midline incision, and medial sub-periosteal sleeve release. | Patellar tendon avulsion; infrapatellar saphenous branch devascularization. |
| Phase 2: Cruciate & Meniscal Prep | Steps 7 to 9 | Controlled PCL release, external tibial rotation, and complete lateral meniscectomy. | Popliteus tendon transection; posterior neurovascular tethering. |
| Phase 3: Proximal Tibial Preparation | Steps 10 to 12 | Extramedullary resection perpendicular to shaft (10 mm cut), keel broaching, and flexion gap check. | Varus tibial malalignment; posterior cortical penetration. |
| Phase 4: Distal Femur, Cuts & Balancing | Steps 13 to 18 | Intramedullary 5° valgus cut, 5-in-1 finishing block, PS notch cut, and trial gap verification. | Anterior femoral notching; asymmetrical trapezoidal flexion gap. |
| Phase 5: Patella, Cementation & Closure | Steps 19 to 24 | Planar patellar cut, “no thumbs” tracking test, pressurized PMMA cementation, and layered closure. | Patellar maltracking; cement extrusion into posterior capsule. |
2. Visual Step-by-Step Gallery
Click any surgical card or thumbnail below to launch the detailed step walkthrough with high-resolution photography, anatomical commentary, and curator surgical pearls:
Step 1: Patient Positioning and Table Setup
Operating table configuration with an ipsilateral hip bump and a sterile paint-roller device placed at the level of the tibial tubercle to maintain stable knee flexion without assistant fatigue.
Step 2: Skin Marking and Incision
Anterior midline skin incision performed with the knee in active flexion, extending three finger-breadths superior and inferior to the patellar poles to prevent wound edge traction tension.
Step 3: Retinacular Dissection & Flap Elevation
Identification of the medial retinacular border using the posterior surface of the blade, executing clean superior and inferior sweeps to maintain a thick subcutaneous envelope.
Step 4: Medial Parapatellar Arthrotomy
Medial parapatellar capsular arthrotomy leaving a robust tissue cuff along the medial border of the patella for watertight layered closure, aided by a small Kocher clamp with lateral traction.
Step 5: Sub-periosteal Medial Release
Elevation of an uninterrupted sub-periosteal sleeve starting just medial to the tibial tubercle with electrocautery, transitioning to a Cobb elevator to reach the posterior-medial tibial border.
Step 6: Intercondylar Notch Osteophyte Debridement
Careful osteotome resection of impinging intercondylar notch osteophytes, opening anatomical visualization and granting unhindered access to the cruciate ligament insertions.
Step 7: Posterior Cruciate Ligament (PCL) Release
Electrocautery resection of the posterior cruciate ligament (PCL) footprint off the posterior slope of the proximal tibia, critical for posterior subluxation in posterior-stabilized designs.
Step 8: Tibial Subluxation & Hohmann Retractor Placement
Leverage on a blunt Hohmann retractor coupled with tibial external rotation to cleanly deliver the posterior-medial corner of the tibia into the surgical viewing corridor.
Step 9: Lateral Meniscus Excision
Circumferential sharp excision of the lateral meniscus from anterior horn to posterior horn, exposing the lateral tibial plateau and popliteus tendon hiatus.
Step 10: Extramedullary Tibial Alignment & Resection
Extramedullary cutting guide aligned with the tibial mechanical axis to resect approximately 10 mm of bone perpendicular to the mechanical shaft. Curator Pearl: Guide must be securely pinned prior to sawing.
Step 11: Tibial Component Preparation & Broaching
Drilling the proximal tibial canal followed by axial impaction of the tibial keel broach, matching rotational alignment with the medial third of the tibial tubercle.
Step 12: Distal Femoral Retractor & Flexion Gap Inspection
Placement of the distal femoral retractor to protect the resected tibial bone surface, tensioning the posterior capsule to permit direct visual assessment of the flexion gap.
Step 13: Retrograde Intramedullary Femoral Decompression
Retrograde insertion of the fluted T-handle reamer into the distal femur, entering 1 cm anterior to the PCL origin to decompress intramedullary pressure and confirm mechanical axis.
Step 14: Femoral Sizing & Rotation Assessment
Application of the femoral sizing guide resting against the posterior condyles to accurately assess anterior-posterior sizing and set 3 degrees of external rotation.
Step 15: Intramedullary Distal Femoral Resection (5° Valgus)
Intramedullary distal femoral resection block positioned in fixed 5 degrees of valgus, executing the distal femoral planar resection to restore anatomical joint alignment.
Step 16: 5-in-1 Chamfer & Finishing Cuts
Application of the 5-in-1 femoral finishing guide flush with the cut distal femur, executing anterior, posterior, and chamfer bone cuts for reproducible implant seating.
Step 17: Cruciate-Substituting (PS) Notch Resection
Intercondylar box cut preparation for a posterior cruciate-substituting (PS) femoral housing, placed flush with the anterior cortex and shifted slightly lateral for optimized patellar tracking.
Step 18: Trial Reduction & Extension/Flexion Gap Balancing
Trial component insertion and dynamic assessment of rectangular gap stability in full extension (0°), mid-flexion (45°), and 90° flexion. Curator Pearl: Dynamic ligament balance verification.
Step 19: Patellar Planar Resection
Freehand or guided planar osteotomy of the everted patella, beginning inferiorly at the patellar nose to maintain uniform 12-15 mm residual bone thickness.
Step 20: ‘No Thumbs’ Patellar Tracking Assessment
Verification of central patellofemoral congruency through complete range of motion without manual digital pressure (‘no thumbs’ rule), ensuring absence of patellar tilt or subluxation.
Step 21: Component Cementation & Protective Sponge
High-pressure pulsed lavage bone drying followed by pressurization of PMMA cement. A protective laparotomy sponge is placed over the femoral component while curing.
Step 22: Patellar Clamp Compression
Patellar clamp application holding the knee in full axial extension with the foot dorsiflexed, maintaining uniform hydraulic compression under the polyethylene patellar button.
Step 23: Retinacular Closure & Gravity Flexion Test
Following watertight medial retinacular repair, the knee is allowed to flex freely under gravity alone to guarantee that unconstrained post-operative flexion is preserved.
Step 24: Final Layered Wound Closure
The finished surgical result: meticulous multi-layer anatomical closure from capsule to subcuticular skin, establishing a sterile hermetic barrier over the prostheses.
3. Complete Procedural Progression Matrix
| Step # | Surgical Milestone | Phase | Intraoperative Asset | Step Link |
|---|---|---|---|---|
| 1 | Patient Positioning and Table Setup | Phase 1 | Intraoperative Photo | Step 1 |
| 2 | Skin Marking and Incision | Phase 1 | Intraoperative Photo | Step 2 |
| 3 | Retinacular Dissection & Flap Elevation | Phase 1 | Intraoperative Photo | Step 3 |
| 4 | Medial Parapatellar Arthrotomy | Phase 1 | Intraoperative Photo | Step 4 |
| 5 | Sub-periosteal Medial Release | Phase 1 | Intraoperative Photo | Step 5 |
| 6 | Intercondylar Notch Osteophyte Debridement | Phase 1 | Intraoperative Photo | Step 6 |
| 7 | Posterior Cruciate Ligament (PCL) Release | Phase 2 | Text Instruction | Step 7 |
| 8 | Tibial Subluxation & Hohmann Retractor Placement | Phase 2 | Intraoperative Photo | Step 8 |
| 9 | Lateral Meniscus Excision | Phase 2 | Intraoperative Photo | Step 9 |
| 10 | Extramedullary Tibial Alignment & Resection | Phase 3 | Intraoperative Photo | Step 10 |
| 11 | Tibial Component Preparation & Broaching | Phase 3 | Text Instruction | Step 11 |
| 12 | Distal Femoral Retractor & Flexion Gap Inspection | Phase 3 | Intraoperative Photo | Step 12 |
| 13 | Retrograde Intramedullary Femoral Decompression | Phase 4 | Intraoperative Photo | Step 13 |
| 14 | Femoral Sizing & Rotation Assessment | Phase 4 | Text Instruction | Step 14 |
| 15 | Intramedullary Distal Femoral Resection (5° Valgus) | Phase 4 | Intraoperative Photo | Step 15 |
| 16 | 5-in-1 Chamfer & Finishing Cuts | Phase 4 | Intraoperative Photo | Step 16 |
| 17 | Cruciate-Substituting (PS) Notch Resection | Phase 4 | Intraoperative Photo | Step 17 |
| 18 | Trial Reduction & Extension/Flexion Gap Balancing | Phase 4 | Intraoperative Photo | Step 18 |
| 19 | Patellar Planar Resection | Phase 5 | Intraoperative Photo | Step 19 |
| 20 | ‘No Thumbs’ Patellar Tracking Assessment | Phase 5 | Text Instruction | Step 20 |
| 21 | Component Cementation & Protective Sponge | Phase 5 | Text Instruction | Step 21 |
| 22 | Patellar Clamp Compression | Phase 5 | Text Instruction | Step 22 |
| 23 | Retinacular Closure & Gravity Flexion Test | Phase 5 | Intraoperative Photo | Step 23 |
| 24 | Final Layered Wound Closure | Phase 5 | Intraoperative Photo | Step 24 |
4. Master Class Pro-Tip: Surgical Execution Pearls
In primary total knee arthroplasty, the extramedullary tibial guide must be securely pinned both proximally and distally prior to saw initiation; rotational drift during the tibial resection represents the most prevalent contributor to post-operative varus malalignment. Furthermore, verify patellar tracking under gravity flexion before definitive component cementation, ensuring the “no thumbs” criteria is achieved without lateral retinacular release.
Master Class Pro-Tip: Primary TKA Alignment & Dynamic Gap Balancing Pearls
5. Editorial Governance & Curation
Curated by Dr. Joseph Bernstein, MD (Director of Education) • Managing Editor: Dr. Christian Veillette, MD • OrthopaedicsOne Surgical Education Series • Adult Reconstruction: Knee
Last Updated on September 28, 2026
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