Updated: 10/28/2018

TKA Approaches

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Questions
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Cases
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https://upload.orthobullets.com/topic/5031/images/medial_parapatellar.jpg
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
  • 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
    • staged
      • one 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
    • routine use in all TKA increases the risk of aseptic loosening 
    • reduces deep infection in revision TKA
    • indications for use in primary TKA are controversial
 

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Technique Guides (3)
Questions (5)

(OBQ13.108) When performing a total knee arthroplasty on a 60-year-old female patient, a surgeon chooses not to resurface the patella. Instead, he performs a patelloplasty by excising the marginal osteophytes and reshaping the patella. All of the following statements comparing the results of patelloplasty to patella resurfacing are true EXCEPT: Review Topic

QID: 4743
1

There is no difference in relative risk of anterior knee pain.

44%

(1858/4250)

2

There is no difference in relative risk for revision surgery involving the tibial and femoral components.

5%

(203/4250)

3

There is an increased risk that she will need secondary resurfacing.

26%

(1099/4250)

4

No difference in rates of patellar avascular necrosis or patellar tendon injury.

20%

(854/4250)

5

Total knee arthroplasty improved function regardless of whether the patella was resurfaced.

5%

(217/4250)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(OBQ10.214) The use of vancomycin impregnated bone cement during total knee arthroplasty is most strongly recommended for which of the following patients? Review Topic

QID: 3307
1

68-year-old male undergoing second stage of revision arthroplasty for deep infection

93%

(2324/2502)

2

Primary TKA in a 55-year-old female with BMI of 40

0%

(9/2502)

3

Primary TKA in a diabetic 70-year-old male

4%

(95/2502)

4

67-year-old male with posttraumatic arthritis and retained hardware undergoing primary TKA

1%

(18/2502)

5

53-year-old female with rheumatoid arthritis undergoing primary TKA

2%

(44/2502)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 304
1

Conversion of the exposure to a subvastus approach

11%

(227/2000)

2

Tibial tubercle osteotomy

3%

(68/2000)

3

Conversion of the exposure to a two-incision approach

1%

(22/2000)

4

Conversion of the exposure to a standard parapatellar arthrotomy

82%

(1639/2000)

5

Ligament release to improve exposure

2%

(33/2000)

ML 2

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PREFERRED RESPONSE 4
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CASES (2)
Topic COMMENTS (9)
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