Revision TKR Surgical Approach

                                                                                                       - 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

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, March 27, 2012 4:38 pm