- Assistance provided by Michael Berend MD.
- Prophylactic Antibiotics:
- ref: Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic Infection.
- Incision: (Surgical Approach for Primary TKR);
- w/ more than one longitudinal incision, choose the more lateral incision since a larger medial flap tends to have a better blood supply;
- longer incisions tend to cause less tension on the skin
- if unsure, perform a "sham" incision through skin and down to fascia and then evaluate wound healing in that location prior to performing revision TKA;
- all medial and lateral dissection must be subfascial (subcutaneous dissection will lead to wound slough);
- as with a primary approach, it is necessary to elevate the capsular attachments to the proximal tibia, both medially and laterally;
- Clean the Gutters:
- adhesions in the lateral gutter are intraarticular and are distinct from a contracted lateral retinaculum, and therefore a simple lateral
retinacular release does not adress lateral gutter adhesions;
- the lateral gutter adhesions can be placed under tension by hyperflexing the knee and by applying a Hohman retractor around the lateral femoral condyle;
- the adhesions can then be released with cautery;
- Patellar Eversion:
- the first goal is to evert the patella without avusing the patellar tendon from the tibial tubercle;
- incision through the quadriceps tendon should extend through the mid-portion (rather than the medial third) to improve exposure and
to take tension off of the patellar tendon;
- before everting the patella, debride scar from the suprapatellar pouch, the medial and lateral gutters and joint lines, and the patellar tendon;
- also consider early lateral retinacular release for optimal exposure;
- one useful technique is to retract the knee laterally (w/o patellar eversion) and to then flex the knee;
- this places signficant strain on the patellar tendon but not enought to cause distal rupture;
- after 10 min, enough stress relaxtion of the patellar tendon will occur which will then usually allow safe eversion of the patella;
- if eversion continues to be difficult, extension of the longitudinal quadriceps division proximally, debridement of tibial and patellar osteophytes, and a lateral retinacular release helps;
- increased subperiosteal exposure of the proximal tibia is also helpful;
- the lateral aspect should be exposed to Gerdy's tubercle (do not elevate the ITB insertion);
- medial exposure elevating the superficial and deep attachments of the MCL can increase external rotation of the tibia to help patellar eversion;
- as pointed out by Laskin RS (1998), placement of a smooth pin through the center of the patellar ligament into the tibial tubercle
will act as a stress reliever and prevent complete avulsion of the patellar tendon;
- ref: Management of the patella during revision total knee replacement arthroplasty.
- additional measures:
- "transverse quadriceps snip":
- transverse incision extends across the proximal quadriceps (superiorly and laterally) which extends lateral to the longitudinal incision;
- w/ transverse snip, eversion of the patella is not necessary, rather it can simply be retracted to the side (hence there is no stress on the patellar tendon);
- alternatively an oblique cut across the proximal quadriceps tendon angled distally;
- this can be extended as far as is needed to get the patella out of the way;
- when using a "snip", eversion of the patella is not necessary since it often can simply be retracted to the side (hence there is no stress on the patellar tendon);
- theoretically there does not need to be any reduction of postoperative physical therapy;
- Coonse-Adams quadriceps turndown:
- the quad snip can be extended distally to the lateral aspect of the patella to complete a quadripceps turndown;
- of course, the greater the snip, the more morbidity to the patient;
- w/ a full turndown, the leg should be kept in extension for 2 weeks postoperatively before reinitiating rehabilitation;
- references:
- The extensile rectus snip exposure in revision of total knee arthroplasty.
- Surgical exposures in revision total knee arthroplasty.
- tibial tubercle osteotomy
- begin by subperiosteally dissecting 5cm distal to the tubercle medially;
- pre-drill 2-3 holes for re-attachment.
- use an oscillating saw or an osteotome to create an osteotomy on the medial side of the tubercleabout 6-7cm in length, 2cm wide, and 9-10mm at its thickest point;
- begin the osteotomy about 1 cm distal to the tibial plateau so the bone acn "key in" when the osteotomy is repaired and proximal migration will not occur;
- leave the lateral soft-tissue hinge intact;
- repair with two 6.5 or 7.3 mm screws directed around the tibial stem or with 3- 16 gauge wires;
- keep cement out of the osteotomy site;
- references:
- Extended tibial tubercle osteotomy in total knee arthroplasty.
- Exposure in difficult total knee arthroplasty using tibial tubercle osteotomy.
V-Y quadricepsplasty in total knee arthroplasty.
Position of the popliteal artery in revision total knee arthroplasty