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 short term data suggests more rapid recovery long term data needed to compare outcomes to traditional exposures 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Parapatellar Approach Derek T. Bernstein Stephen Incavo Recon - TKA Templating Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek T. Bernstein Stephen Incavo Recon - TKA Peroneal Nerve Palsy Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall William Gallivan Recon - TKA Coronal Plane Balancing
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next (OBQ18.113) When compared to a median parapatellar approach which of the following approaches may lead to higher rates of component malposition? QID: 213009 Type & Select Correct Answer 1 Quadriceps sparing 59% (1260/2129) 2 Lateral parapatellar 27% (571/2129) 3 Midvastus 10% (205/2129) 4 Quadriceps snip 2% (42/2129) 5 V-Y turndown 2% (36/2129) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.214) The use of vancomycin impregnated bone cement during total knee arthroplasty is most strongly recommended for which of the following patients? QID: 3307 Type & Select Correct Answer 1 68-year-old male undergoing second stage of revision arthroplasty for deep infection 92% (3093/3347) 2 Primary TKA in a 55-year-old female with BMI of 40 1% (17/3347) 3 Primary TKA in a diabetic 70-year-old male 4% (135/3347) 4 67-year-old male with posttraumatic arthritis and retained hardware undergoing primary TKA 1% (30/3347) 5 53-year-old female with rheumatoid arthritis undergoing primary TKA 1% (50/3347) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ06.118) During a minimally invasive total knee arthroplasty with a quadriceps-sparing approach, the exposure is found to be limited and causing difficulties with jig alignment. What is the optimal next step? QID: 304 Type & Select Correct Answer 1 Conversion of the exposure to a subvastus approach 11% (332/2923) 2 Tibial tubercle osteotomy 3% (93/2923) 3 Conversion of the exposure to a two-incision approach 1% (35/2923) 4 Conversion of the exposure to a standard parapatellar arthrotomy 82% (2398/2923) 5 Ligament release to improve exposure 2% (53/2923) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (42) Podcasts (1) Orthopaedic Summit Evolving Techniques 2020 Pro: Bilateral Knee Arthroplasty Not Worth The Risk Nor The Outcome - William Jiranek, MD William Jiranek Recon - TKA Approaches 3 weeks ago 64 views 4.0 (1) Login to View Community Videos Login to View Community Videos 2022 California Orthopaedic Association Annual Meeting Contemporary Debates TKA; Q&A - Adam Sassoon, MD Adam Sassoon Recon - TKA Approaches 4 weeks ago 15 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2022 California Orthopaedic Association Annual Meeting Cemented Proponent - Erik Zeegan, MD Erik Zeegen Recon - TKA Approaches 4 weeks ago 11 views 0.0 (0) Recon⎪TKA Approaches Orthobullets Team Recon - TKA Approaches Listen Now 15:46 min 5/13/2020 373 plays 5.0 (2) See More See Less
rapidly progressive knee pain/deformity (C1973) Tim S. Kavanaugh Recon - TKA Approaches E 7/20/2014 294 4 3 Osteoarthritis bilateral knee joint (C1666) Recon - TKA Approaches E 10/24/2013 442 2 5