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The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.<\/jats:p><jats:p>Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.<\/jats:p><jats:p>When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.<\/jats:p><jats:p>Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30\u20139.<\/jats:p>","DOI":"10.1302\/0301-620x.97b10.36920","type":"journal-article","created":{"date-parts":[[2015,10,1]],"date-time":"2015-10-01T14:44:54Z","timestamp":1443710694000},"page":"30-39","update-policy":"https:\/\/doi.org\/10.1302\/crossmark-policy","source":"Crossref","is-referenced-by-count":62,"title":["The difficult primary total knee arthroplasty"],"prefix":"10.1302","volume":"97-B","author":[{"given":"A.","family":"Baldini","sequence":"first","affiliation":[{"name":"IFCA Institute, via del Pergolino 4, Florence 50139, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L.","family":"Castellani","sequence":"additional","affiliation":[{"name":"IFCA Institute, via del Pergolino 4, Florence 50139, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"F.","family":"Traverso","sequence":"additional","affiliation":[{"name":"Humanitas Clinical and Research Center, via Manzoni 56 Rozzano, Milan, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A.","family":"Balatri","sequence":"additional","affiliation":[{"name":"IFCA Institute, via del Pergolino 4, Florence 50139, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G.","family":"Balato","sequence":"additional","affiliation":[{"name":"IFCA Institute, via del Pergolino 4, Florence 50139, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"V.","family":"Franceschini","sequence":"additional","affiliation":[{"name":"\u201cSapienza\u201d University of Rome, via F. 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