Introduction Surgical approach may be dictated by surgeon preference prior incisions degree of deformity patella baja patient obesity Incision planning if multiple incision, choose more lateral blood supply comes from medial side generally safe to cross previous transverse incisions at right angles ensure adequate skin bridge exact length of skin bridge needed is controversial Approaches "simple" primary knee arthroplasty approaches medial parapatellar midvastus subvastus minimally invasive "complex" primary or revision total knee arthroplasty medial parapatellar quadriceps snip V-Y turndown tibial tubercle osteotomy Standard Medial Parapatellar Approach Overview most commonly completed through a straight midline incision Advantages familiar for most orthopaedic surgeons excellent exposure even in challenging cases Disadvantages possible failure of medial capsular repair development of lateral patellar subluxation access to lateral retinaculum less direct may jeopardize patellar circulation if lateral release is performed Lateral Parapatellar Approach Overview useful for addressing lateral contractures but difficult eversion of patella makes exposure challenging Advantages useful for a fixed valgus deformity preserves blood supply to patella prevents lateral patellar subluxation allows direct access to lateral side in a valgus knee Disadvantages technically demanding medial eversion of patella is more difficult may require tibial tubercle osteotomy Midvastus Overview similar approach to medial parapatellar that spares VMO insertion and may lead to quicker recovery Advantages vastus medialis insertion on quad tendon is not disrupted potentially allows accelerated rehab due to avoiding disruption of extensor mechanism patellar tracking may be improved compared to medial parapatellar approach Disadvantages less extensile exposure difficult in obese patients exposure difficult with flexion contractures potential for partial VMO denervation Relative contraindications ROM <80 degrees obese patient hypertrophic arthritis previous HTO Subvastus Approach Overview muscle belly of vastus medialis is lifted off intermuscular septum Advantages patellar vascularity preserved extensor mechanism remains intact minimal need for lateral retinacular release Disadvantages least extensile Relative contraindications revision TKA large quadriceps previous HTO obese patient previous parapatellar arthrotomy Minimally Invasive Surgical Approach Overview often need special instruments for exposure and implant insertion technically demanding Outcomes data shows no clinically significant improvement in patient reported outcomes, gait patterns or quadriceps strength quadriceps-sparing approach may lead to high rates of component malposition Indications to convert to a standard parapatellar approach patellar tendon starts to peel off the tibial tubercle incision is too small for proper jig placement Extensile Exposures Quadriceps snip technique snip made at apex of quadriceps tendon obliquely across tendon at a 45-degree angle into vastus lateralis advantages no change in post-operative protocol minimal, if any, long-term consequences disadvantages not as extensile as a turndown or tibial tubercle osteotomy V-Y turndown technique straight medial parapatellar arthrotomy with diverging incision down the vastus lateralis tendon towards lateral retinaculum advantages allows excellent exposure allows lengthening of quadriceps tendon preserves patellar tendon and tibial tubercle disadvantages extensor lag may affect quadriceps strength knee needs to be immobilized post-operatively Tibial tubercle osteotomy technique 6-10 cm bone fragment cut from medial to lateral fixed with screws or wires advantages excellent exposure avoids extensor lag seen with V-Y turndown avoids quadriceps weakness disadvantages some surgeons immobilize or limit weight-bearing post-operatively tibial tubercle avulsion fracture non-union wound healing problems Bilateral Total Knee Arthroplasty Definitions simultaneous two surgeons performing the bilateral TKA at the same time sequential one surgeon performing one TKA and then the contralateral TKA under one anesthetic stage done surgeon performing each TKA under a separate anesthetic timing ranges from 3 days to one year in between each side Other Antibiotic loaded bone cement (ALBC) reduces deep infection in revision TKA indications for use in primary TKA are controversial in vitro studies have shown a theoretical risk of decreased cement strength with adding antibiotics (dilution) however, there are no current studies that have shown ALBC to increase the rate of aseptic loosening