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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

Surgical Approaches In Total Knee Arthroplasty

by Robert Wood and Thomas Thornhill

presented by

Sepein Chiang, DO

introduction
Introduction
  • Adequate exposure is essential
  • Conventional midline incision, medial arthrotomy & lateral patellar eversion
  • Must be prepared to convert to a more extensile exposure
blood supply to the knee
Blood Supply To The Knee
  • Superior medial & lateral geniculate arteries
  • Inferior medial & lateral geniculate arteries
  • Supreme geniculate artery
  • Recurrent anterior tibial artery
blood supply to the knee1
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
skin incisions
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
skin incisions1
Skin Incisions
  • Soft tissue necrosis
  • Insall: “Sham incision”
  • Evaluate skin and soft tissue bleeding
  • Incorporate old scars
  • Use the most lateral skin incision possible
capsular approaches
Capsular Approaches
  • Medial parapatellar
  • Subvastus
  • Midvastus
  • Lateral parapatellar
medial parapatellar approach
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
subvastus approach
Subvastus Approach
  • Maintains integrity of the extensor mechanism
  • Maintains vascularity to the patella
  • More accurate evaluation of patellofemoral tracking
subvastus approach1
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
midvastus approach
Midvastus Approach
  • Preservation of blood supply
  • Improved patellofemoral tracking
midvastus approach1
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
lateral parapatellar approach
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
extensile exposures
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
quadriceps snip
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.
modified quadriceps snip
Modified Quadriceps Snip
  • Reverse 45° oblique
  • More extensile
  • Also preserves artery
  • Can be converted to a complete patellar turndown
modified quadriceps snip1
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
patellar turndown v y quadricepsplasty
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
difficulties
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
modified patellar turndown modified vy quadricepsplasty
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
comparison
Comparison
  • Maintenance of blood supply: theoretical advantage
  • Ritter: no difference in rate of patellar complications including radiolucency, loosening or fracture
post op rehab
Post-op Rehab
  • Originally- 2 weeks of immobilization
  • Immediate passive motion 0° - 30°
  • Increase 10° per day until the point of tension
tibial tubercle osteotomy
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
conclusions
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