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Surgical Approaches In Total Knee Arthroplasty

Surgical Approaches In Total Knee Arthroplasty. by Robert Wood and Thomas Thornhill presented by Sepein Chiang, DO. Introduction. Adequate exposure is essential Conventional midline incision, medial arthrotomy & lateral patellar eversion

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Surgical Approaches In Total Knee Arthroplasty

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  1. Surgical Approaches In Total Knee Arthroplasty by Robert Wood and Thomas Thornhill presented by Sepein Chiang, DO

  2. Introduction • Adequate exposure is essential • Conventional midline incision, medial arthrotomy & lateral patellar eversion • Must be prepared to convert to a more extensile exposure

  3. Blood Supply To The Knee • Superior medial & lateral geniculate arteries • Inferior medial & lateral geniculate arteries • Supreme geniculate artery • Recurrent anterior tibial artery

  4. Blood Supply To The Knee • Important to keep skin flaps as thick as possible • Standard medial parapatellar arthrotomy: the supreme geniculate, medial superior & inferior geniculates are sacrificed • Lateral meniscectomy: the lateral inferior geniculate is sacrificed • Try to preserve the lateral superior geniculate if a lateral release is needed

  5. Skin Incisions • Medial parapatellar skin incision was formerly the most common • Complications from having a large arthrotomy directly beneath the skin incision • Midline anterior longitudinal incision

  6. Skin Incisions • Soft tissue necrosis • Insall: “Sham incision” • Evaluate skin and soft tissue bleeding • Incorporate old scars • Use the most lateral skin incision possible

  7. Capsular Approaches • Medial parapatellar • Subvastus • Midvastus • Lateral parapatellar

  8. Medial Parapatellar Approach • Accurately identify junction of VMO, quadriceps tendon, the medial border of the patella and the tibial tubercle • Arthrotomy extends from the quadriceps tendon, around the medial patella and ends just medial to the patellar tendon and tibial tubercle

  9. Subvastus Approach • Maintains integrity of the extensor mechanism • Maintains vascularity to the patella • More accurate evaluation of patellofemoral tracking

  10. Subvastus Approach • L-shaped capsular incision with the proximal limb of the “L” coursing along the posterior border of the VMO • Inferior edge of the VMO is lifted off the periosteum • Extensor mechanism can be lifted anterolaterally

  11. Midvastus Approach • Preservation of blood supply • Improved patellofemoral tracking

  12. Midvastus Approach • Incise the VMO in line of its fibers at the superomedial pole of the patella • Extend incision distally to the medial border of the tibial tubercle • Engh: no difference in post-op ROM, time until pts were able to straight leg raise or radiographic patellar tilt

  13. Lateral Parapatellar Approach • Valgus deformity • Provides better exposure • Begins lateral to the quadriceps tendon and extends 1-2 cm lateral to the patella, through the medial edge of Gerdy’s tubercle and ends in the anterior compartment

  14. Extensile Exposures • Revision & some primary TKAs may require more exposure • Release adhesions and fibrosis in the medial & lateral gutters • Quadriceps snip, V-Y quadricepsplasty, tibial tubercle osteotomy

  15. Quadriceps Snip • Insall: Transverse cut across the prox portion of the rectus tendon • 45° oblique • Advantages: inline with vastus lateralis & away from superior lateral geniculate a.

  16. Modified Quadriceps Snip • Reverse 45° oblique • More extensile • Also preserves artery • Can be converted to a complete patellar turndown

  17. Modified Quadriceps Snip • Technically easy • Spares the superior lateral geniculate artery • May be converted to a patellar turndown • Post-op rehab does not need to be modified • Not associated with extension lag • Strength comparable to standard TKAs

  18. Patellar Turndown (V-Y Quadricepsplasty) • Insall in 1983 as modification of the Coonse & Adams approach • Oblique incision across the vastus lateralis tendon and lateral retinaculum • Wide exposure for the severe, ankylosed knee

  19. Difficulties • Reattachment at the appropriate tension • 10% - 15% incidence of extension lag of 10° or greater • Trousdale reported no weakness compared to standard TKAs • Risk of devascularizing the patella

  20. Modified Patellar Turndown (Modified VY Quadricepsplasty) • Scott & Siliski • Incision carried along the insertion of the vastus lateralis • Proximal to superior lateral genicular artery • No lateral release • Less extensive exposure

  21. Comparison • Maintenance of blood supply: theoretical advantage • Ritter: no difference in rate of patellar complications including radiolucency, loosening or fracture

  22. Post-op Rehab • Originally- 2 weeks of immobilization • Immediate passive motion 0° - 30° • Increase 10° per day until the point of tension

  23. Tibial Tubercle Osteotomy • Expose the knee 8-10 cm distal to the tibial tubercle • Arthrotomy distally to the tibial tubercle • Anterior crest of the tibia is cut transversely 8-10 cm distal to the tibial tubercle • Using osteotomes, separate the tubercle from the tibia

  24. Conclusions • Adequate exposure is critical to the success of TKAs • Standard medial parapatellar approach is usually sufficient • Subvastus, midvastus & lateral parapatellar approaches not as versatile • For difficult exposures: quadriceps snip, V-Y plasty and tibial tubercle osteotomy

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