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 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
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Revision TKR Orthobullets Team Recon - High Tibial Osteotomy Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. TKA - Parapatellar Approach Derek Bernstein Stephen Incavo Recon - High Tibial Osteotomy Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek Bernstein Stephen Incavo Recon - TKA Axial Alignment
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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% (2043/4607) 2 There is no difference in relative risk for revision surgery involving the tibial and femoral components. 5% (227/4607) 3 There is an increased risk that she will need secondary resurfacing. 25% (1167/4607) 4 No difference in rates of patellar avascular necrosis or patellar tendon injury. 20% (916/4607) 5 Total knee arthroplasty improved function regardless of whether the patella was resurfaced. 5% (235/4607) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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% (2489/2679) 2 Primary TKA in a 55-year-old female with BMI of 40 0% (12/2679) 3 Primary TKA in a diabetic 70-year-old male 4% (101/2679) 4 67-year-old male with posttraumatic arthritis and retained hardware undergoing primary TKA 1% (20/2679) 5 53-year-old female with rheumatoid arthritis undergoing primary TKA 2% (45/2679) 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% (247/2160) 2 Tibial tubercle osteotomy 3% (73/2160) 3 Conversion of the exposure to a two-incision approach 1% (26/2160) 4 Conversion of the exposure to a standard parapatellar arthrotomy 82% (1768/2160) 5 Ligament release to improve exposure 2% (35/2160) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Login to View Community Videos Login to View Community Videos 2017 HSS Holiday Knee & Hip Course The PS Post in Total Knee Arthroplasty - David J. Mayman, MD Recon - TKA Approaches 9/5/2018 462 views Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques I No Longer Have My Patients Donate Autogenous Blood and Receive EPO Prior to TKA: I Was Wrong! - Fred Cushner, MD Fred D. Cushner Recon - TKA Approaches 4/30/2018 67 views Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques The Amniotic Stem Cell Patch: Arthrofibrosis and the Total Knee Replacement - Michael J. Kaplan, MD Michael Kaplan Recon - TKA Approaches 4/30/2018 75 views See More See Less
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