Extensile Surgical Approaches for Revision Total Knee Arthroplasty

    Exposure of the knee joint in a revision procedure can be difficult. At ICJR’s Philadelphia Revision Course, Craig Israelite, MD, discussed the challenges, such as stiffness, component malposition, and technical errors, and the goals of obtaining adequate exposure and minimizing complications.

    Dr. Israelite, from the Department of Orthopedic Surgery at the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, explained that extensile exposures may be proximal, such as the quadriceps snip and V-Y turndown, or distal, such as the tibial tubercle osteotomy.

    In 90% or more of revision cases, a medial parapatellar arthrotomy – the standard approach for revision knee procedures – is all that needs to be done. Dr. Israelite offered these tips for a medial parapatellar arthrotomy.

    • Extend more proximally into the tendons for good visualization
    • Move cautiously as the patella may have only a superior lateral geniculate blood supply remaining
    • For deep dissection-medial, Dr. Israelite starts with medial release in extension, removes the capsule under the extensor mechanism, incises and bluntly dissects the layer, and continues to the joint line to establish the medial gutter.
    • For deep dissection-lateral, Dr. Israelite repeats the procedure on the lateral side, bluntly dissects the pseudo capsule, removes fibrous tissue around the patella, and releases any fibrous adhesions deep to the patellar tendon. Once the lateral gutter is established, he looks for the lateral patellofemoral ligament, with the knee still in flexion.
    • To evaluate, slowly flex the knee while externally rotating the tibia, which reduces stress on the extensor mechanism. If needed:
      • Continue the medial release posteriorly around the tibial back corner
      • Consider a lateral retinacular release for subluxation of the patella
      • Consider removing modular polyethyelene

    If the medial parapatellar arthrotomy is not sufficient, the surgeon has several options for more extensile exposure.

    Quadriceps Snip

    • Generally used only when more exposure is needed
    • Carry arthrotomy in a superior and lateral direction at a 45-degree angle
    • No change in postoperative routine
    • No change in cybex testing postoperatively compared with other side total knee arthroplasty

    Quadriceps V-Y Turndown

    • Continue arthrotomy in a 45-degree distal medial direction
    • Repair primarily or extend to lengthen the tendon
    • Changes and may slow down the rehabilitation process; causes extensor lag
    • Knee immobilized postoperatively, restricted flexion for 6 weeks

    Tibial Tubercle Osteotomy

    • Associated with small number of complications
    • Perform 8- to 10-cm osteotomy down medial side, leaving periosteal hinge laterally
    • Use wires to reattach osteotomy
    • Useful for well-fixed tibial stems or patella baja
    • Requires a variable amount of immobilization

    Dr. Israelite briefly discussed the patellar tendon peel or “banana peel,” a partial “peeling” of the patellar tendon that he said may happen inadvertently. The repair is through bone tunnels or side to side soft tissue repair.

    Dr. Israelite’s presentation can be found here.