primary’and’revision...primary’tka’approaches general’principles • skin’incision >...
TRANSCRIPT
![Page 1: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/1.jpg)
Approaches to the Knee JointPrimary and Revision
E. Verhaven, M. Thaeter
23rd April, 2013, Vienna
St. Nikolaus-‐HospitalOrthopaedics & TraumatologyBelgium
![Page 2: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/2.jpg)
APPROACHES
• Primary TKA-‐ Medial Parapatellar (MPP)
-‐ Subvastus (SV)
-‐ Midvastus (MV)
-‐ Lateral Approach (Keblish)
2
![Page 3: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/3.jpg)
• Revision TKA-‐ MPP
-‐ Quadriceps Snip
-‐ V-‐Y Quadricepsplasty (V-‐Y Turndown)
-‐ Tibial Tubercle Osteotomy (TTO)
3
APPROACHES
![Page 4: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/4.jpg)
PRIMARY TKA APPROACHES
GENERAL PRINCIPLES
• SKIN INCISION-‐ Type• standard anterior midlineincision
• medial parapatellar incision-‐ beMer oriented in relaNonto the cleavage lines about the knee
-‐ less tension during flexion: medial to the skin stress zone
4
![Page 5: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/5.jpg)
PRIMARY TKA APPROACHES
GENERAL PRINCIPLES
• SKIN INCISION-‐ Length• no influence on pain• no influence on early recovery• skin corners:
-‐U: under tension
-‐V: no tension
5
![Page 6: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/6.jpg)
PRIMARY TKA APPROACHES
GENERAL PRINCIPLES
• SOFT TISSUE DISSECTION-‐ blood supply to the skin:supplied by perforaNngarteries, superficial to thedeep fascia
-‐ creaNon of full-‐thicknessskin flaps, deep to the fascia
6
![Page 7: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/7.jpg)
PRIMARY TKA APPROACHES
GENERAL PRINCIPLES
• MIS TKA-‐ DefiniNon• short skin incision• no eversion of the patella (beMer flexion, beMer Q-‐force, less patella baja)
• minimizing dissecNon in the suprapatellar pouch
• sparing of the Q-‐muscle
7
![Page 8: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/8.jpg)
PRIMARY TKA APPROACHES
PRE-‐OP PLANNING
• MEDICAL HISTORY-‐ peripheral vascular disease
-‐ poorly controlled Diabetes Mellitus
-‐ chronic corNcosteroid use
-‐ inflammatory arthriNs (soYer bones)
➯ no MIS TKA
8
![Page 9: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/9.jpg)
PRIMARY TKA APPROACHES
9
PRE-‐OP PLANNING
• PHYSICAL EXAMINATION-‐ previous skin incisions: skin bridges ≤ 4 cm should be avoided
-‐ obesity/muscularity (MIS TKA?, submuscular approach?)
-‐ knee sNffness (MPP)
• RADIOGRAPHS-‐ patella baja (MPP)
-‐ VR/VL deformity
-‐ bone loss
![Page 10: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/10.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
• iniNally described by von Langenbeck (1878)
• modified by Insall (1971)
10
Standard Approach for TKA
• versaNle
• extensile
• standard (>4 cm)/MIS (2-‐4 cm)
![Page 11: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/11.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
INDICATIONS• primary and revision TKA
• regardless of preop. ROM
• short stature
• obese paNents
• muscular lower extremiNes
• previous HTO or femoral osteotomy
• patella alta/baja
11
![Page 12: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/12.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
CONTRAINDICATIONS• previous surgery using a lateral approach (compromise blood supply to the patella)
12
![Page 13: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/13.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
ADVANTAGES• water Nght closure of the arthrotomy
-‐ reducNon of postop. hematoma
• lesser risk of infecNon• less postop. blood loss (need transfusion)• faster rehabilitaNon
DISADVANTAGES• standard MPP: high tendon cut (> 4 cm)
➯ many adhesions, esp. suprapatellar pouch
13
![Page 14: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/14.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
PITFALLS/COMPLICATIONS• closure of the arthrotomy in flexion
-‐ avoids patella baja
-‐ avoids overNghtening of the medial side
• avoid lateral release too close to the patella
14
![Page 15: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/15.jpg)
PRIMARY TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
RESULTS• MPP/SV/MV
-‐ MPP: ↑ lateral releases (standard version)
-‐ ROM/KSS/stair climbing: comparable
15
![Page 16: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/16.jpg)
PRIMARY TKA APPROACHES
16
SUBVASTUS APPROACH (SV)• iniNally described by Erkes (1929)• described by Hofmann in the English Literature (1991)
-‐ only Q-‐sparing technique (preservesthe inserNon of the VMO)
-‐ preservaNon of the patellar blood supply
-‐ standard/MIS
![Page 17: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/17.jpg)
17
PRIMARY TKA APPROACHES
SUBVASTUS APPROACH (SV)
INDICATIONS• preop. ROM > 90°
• VR/VL deformity < 15°
• flexion deformity < 20°
![Page 18: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/18.jpg)
18
PRIMARY TKA APPROACHES
SUBVASTUS APPROACH (SV)
CONTRAINDICATIONS (rela[ve rather than absolute)• very obese/very muscular paNents
• patella baja• marked knee sNffness
• short femur
• previous HTO (infrapatellar scarring/patella baja)
• revision surgery: not proximally extensile
![Page 19: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/19.jpg)
19
PRIMARY TKA APPROACHES
SUBVASTUS APPROACH (SV)
RESULTS• SV/MPP
-‐ SV during early postop. period:
• beMer knee flexion
• earlier straight-‐leg raising
• less blood loss
• less postop. pain
• shorter hospital stay
![Page 20: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/20.jpg)
20
PRIMARY TKA APPROACHES
SUBVASTUS APPROACH (SV)
PITFALLS/COMPLICATIONS• SV hematoma
-‐ excessive retracNon VMO (control bleeding in the posterior VMO liY-‐off area)
-‐ no water Nght closure of the arthrotomy
• risk of patellar tendon avulsion (pin through the patellar tendon into the prox. Nbia)
• higher levels muscle enzymes (CPK/Myoglobin) in SV/MV (stretching/cujng of the muscle)
![Page 21: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/21.jpg)
21
PRIMARY TKA APPROACHES
SUBVASTUS APPROACH (SV)
PITFALLS/COMPLICATIONS• ↓ adequate exposure of the lateral compartment
-‐ avoid varus resecNon of the Nbia
-‐ avoid underresecNon of the prox. Nbia
-‐ avoid medializaNon of the Nbial tray
![Page 22: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/22.jpg)
22
PRIMARY TKA APPROACHES
MIDVASTUS APPROACH (MV)
• iniNally described in 1997 as analternaNve to the SV
• combines advantages of MPP/SV
-‐ divides VMO in its midsubstance, in line withits fibers (2 cm split at the superomedialcorner of the patella)
-‐ no disrupNon of the VMO inserNon into theQ-‐tendon
-‐ easier visualizaNon of patellar tracking
![Page 23: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/23.jpg)
23
PRIMARY TKA APPROACHES
MIDVASTUS APPROACH (MV)
INDICATIONS/CONTRAINDICATIONS• Idem SV
![Page 24: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/24.jpg)
24
PRIMARY TKA APPROACHES
MIDVASTUS APPROACH (MV)
PITFALLS• VMO:
-‐ innervated by terminal branches femoral nerve
-‐ safe dissecNon zone = 4,5 cm
• not proximally extensile
![Page 25: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/25.jpg)
25
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)• direct approach: opNmal exposure of the concave side contractures and the sequenNal soY Nssue releases
• extensive lateral release with exposure (opNmizes patellar tracking)
• less skin undermining
• internally rotates the Nbia: improved access to the pathologic PL corner
• preserves vascular supply to the patella (medial side untouched)
![Page 26: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/26.jpg)
26
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)• ensures covering of the deep lateral soY Nssue gap (joint seal)• fixed VL knee: requires more complex soY Nssue and bone management than VR knee
-‐ Nbiofemoral malrotaNon
-‐ deficiency of the lateral femoral condyle
-‐ soY Nssue contractures (PL, ITB, lateral reNnaculum)
-‐ patella: deformed/small/subluxated/patella alta
-‐ osteopenia (females/RA)
![Page 27: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/27.jpg)
27
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE1. IlioNbial band release and lengthening
![Page 28: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/28.jpg)
28
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE2. ReNnacular release and lateral arthrotomy• coronal plane Z-‐plasty expansion technique
• fat pad preservaNon
![Page 29: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/29.jpg)
29
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE2. ReNnacular release and lateral arthrotomy• osteoperiosteal elevaNon distal tubercle
3. Patellar dislocaNon medially and joint exposure
![Page 30: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/30.jpg)
30
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE4. Tibial sleeve release• osteoperiosteal release L → PL Nbia
![Page 31: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/31.jpg)
31
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE4. Tibial sleeve release• distal LCL release: enucleaNon of theproximal fibula/capsulotomy T-‐F joint
![Page 32: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/32.jpg)
32
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE4. Tibial sleeve release• femoral condylar slidingosteotomy (Brilhault)
![Page 33: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/33.jpg)
33
PRIMARY TKA APPROACHES
DIRECT LATERAL APPROACH (KEBLISH)
TECHNIQUE5. InstrumentaNon and prosthesis inserNon
6. SoY Nssue closure in flexion• 60° -‐> 90°
• distal-‐to-‐proximal closure
![Page 34: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/34.jpg)
34
REVISION TKA APPROACHES
CHALLENGES• mulNple earlier incisions
• lack of skin and soY Nssue pliability
• knee sNffness
• patella baja
• significant knee deformity
➯ extensile approaches
![Page 35: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/35.jpg)
REVISION TKA APPROACHES
GENERAL PRINCIPLESMPP ARTHROTOMY with all extensile exposures
INCISION• ideally: use earlier midline incision
• use most lateral and anterior incision with mulNple longitudinal prior incisions (preserve blood supply to the medial aspect of the lateral skin flap)
35
![Page 36: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/36.jpg)
36
REVISION TKA APPROACHES
GENERAL PRINCIPLESINCISION• maintain a skin bridge > 6 cm
• cross transverse incisions at 90° (no less than 60°)
SOFT TISSUE DISSECTION• limited subcutaneous dissecNon
• no wide skin flaps, esp. laterally
• skin flaps as thick as possible
• subfascial
![Page 37: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/37.jpg)
37
REVISION TKA APPROACHES
GENERAL PRINCIPLESPATELLA• respect/maintain vascular supply (osteonecrosis, #)
PATELLAR TENDON• avoid iatrogenic avulsion
SOFT TISSUE EXPANDERS• mulNple crossing incisions
• densily adherent soY Nssue
![Page 38: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/38.jpg)
38
REVISION TKA APPROACHES
MEDIAL PARAPATELLAR APPROACH (MPP)
• always start with a standard medialparapatellar arthrotomy
• excision fibrous adhesions in the supra-‐patellar pouch/medial and lateral guMers
• excision retropatellar fat pad(contracted/scarred)
• division lateral patellofemoral ligament
• eventually, lateral release
![Page 39: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/39.jpg)
REVISION TKA APPROACHES
39
MEDIAL PARAPATELLAR APPROACH (MPP)
• subperiosteal elevaNon of deep MCL/semi-‐membranosus inserNon to the PM corner
• release PCL, if present
• anterior subluxaNon of the Nbia bygradual flexion/ER
• removal of the modular PE insert
• lateral subluxaNon of the patella
-‐ knee flexion ≤ 90°-‐100°-‐ significant tension on the extensormechanism
➯ proceed to extensile approaches38
*
![Page 40: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/40.jpg)
40
REVISION TKA APPROACHES
QUADRICEPS SNIP• originally described by Insall
• proximal and lateral extension of thestandard MPP
-‐ proximal extension to the apex of the Q-‐tendon
-‐ lateral extension at a 45° angle into the vastus lateralis
• tension-‐reduced subluxaNon/eversion patella
• closure: 2-‐3 interrupted absorbable sutures atthe site of the snip
![Page 41: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/41.jpg)
41
REVISION TKA APPROACHES
QUADRICEPS SNIPADVANTAGES/RESULTS• easy to perform
• avoids lateral superior genicular artery (vascular supply to the patella)
• can be combined with lateral reNnacular releases
• can be combined with TTO
• can be extended to a Q-‐turndown procedure
![Page 42: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/42.jpg)
42
REVISION TKA APPROACHES
QUADRICEPS SNIPADVANTAGES/RESULTS• slightly beMer funcNonal outcome than other extensile exposures
• MPP/Q-‐snip: no difference KSS
• no extensor weakness/no extensor lag
• no modificaNon of the postop. rehab. protocol (standard physical therapy protocol)
• lowest complicaNon rate (delayed # Q-‐tendon)
![Page 43: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/43.jpg)
43
REVISION TKA APPROACHES
V-‐Y QUADRICEPSPLASTY (V-‐Y TURNDOWN)
• first described by Coonse & Adams (1943)
• modified by Insall (1984), ScoM & Siliski (1985)
-‐ redirecNon of the MPP laterally & distally at 45° from the apex of the Q-‐tendon, through the lateral reNnaculum, towards the proximal lateral Nbia (spares inferior lateral genicular artery)
![Page 44: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/44.jpg)
44
REVISION TKA APPROACHES
V-‐Y QUADRICEPSPLASTY (V-‐Y TURNDOWN)
• reflecNon of the extensor mechanism/patella distally
• V-‐Y lengthening during closure, if desirable
• release lateral reNnaculum is leY open
• closure in 90°
-‐ with mulNple nonabsorbable sutures
-‐ with acceptable tension on the sutures
![Page 45: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/45.jpg)
45
REVISION TKA APPROACHES
V-‐Y QUADRICEPSPLASTY (V-‐Y TURNDOWN)
ADVANTAGES• allows excellent exposure
• allows lengthening of the Q-‐tendon
• preserves patellar tendon/Nbial tubercle
DISADVANTAGES• postop. extensor lag up to 10°
• modified postop. rehab. protocol
-‐ no acNve extension/deep flexion 6 weeks
-‐ extension-‐brace 6 weeks
• possible devascularisaNon patella/extensor mechanism
![Page 46: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/46.jpg)
46
REVISION TKA APPROACHES
TIBIAL TUBERCLE OSTEOTOMY (TTO)• first described by Dolin (1983)• modified by Whiteside
-‐ osteotomy
• length: 5-‐8 cm• width: 2-‐3 cm• thickness: 0,5-‐1 cm
-‐ medial to lateral
-‐ oscillaNng saw, than completed with osteotome
-‐ lateral periosteum/soY Nssue pedicle: intact
![Page 47: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/47.jpg)
47
REVISION TKA APPROACHES
TIBIAL TUBERCLE OSTEOTOMY (TTO)• step-‐cut osteotomy proximally
• fixaNon with 3 wires
-‐ medial to lateral
-‐ through medullary canal behind stem
-‐ most proximal wire through TT itself at 45° (prevents prox. migraNon)
• use of long Nbial stem (bypasses osteotomy by ≥ 2 corNcal ∅)
![Page 48: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/48.jpg)
48
REVISION TKA APPROACHES
Medial ParapatellarArthrotomy
Proceed
Proceed
Quadriceps Snip
Tibial Tubercle Osteotomy
safe exposure
safe exposure
+ght
+ght
TIBIAL TUBERCLE OSTEOTOMY (TTO)
INDICATIONS• well fixed cemented Nbial stem
• knee ≤ 75° of flexion
• patella baja
• planned reconstrucNon withallograY/megaprosthesis
• failure to obtain adequateexposure with Q-‐snip
![Page 49: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/49.jpg)
49
REVISION TKA APPROACHES
TIBIAL TUBERCLE OSTEOTOMY (TTO)
RESULTS• less extensor lag, but worse KSS than other extensile exposures
-‐ more trouble with stairs/kneeling
-‐ worse ROM
• slight modificaNon of the postop. rehab. protocol
-‐ immediate full-‐weight bearing
-‐ unrestricted ROM exercises
-‐ no resisted extensor strengthening exercises 6 weeks
![Page 50: Primary’and’Revision...PRIMARY’TKA’APPROACHES GENERAL’PRINCIPLES • SKIN’INCISION > Type • standard#anterior#midline incision • medial#parapatellar#incision > beMer#oriented#in#relaon](https://reader036.vdocuments.mx/reader036/viewer/2022081409/608600a5a9f77a4d4844e910/html5/thumbnails/50.jpg)
50
REVISION TKA APPROACHES
TIBIAL TUBERCLE OSTEOTOMY (TTO)
COMPLICATIONS• loss of fixaNon (superior migraNon fragment)
• # of the osteotomy fragment
• prominent hardware under the skin
• distal wound healing problems