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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