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Exposure in revision

Agarwal, Anuj Jain

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Well planned, adequate
and safe exposure in critical to obtain success in revision total knee
arthroplasty. Due to previous surgery there is precarious vascularity of the
soft tissues around the knee. Also, previous surgery leads to scarring of
tissues to variable extent. To attain success in revision knee arthroplasty the
surgeon should devote adequate time in preoperative assessment of the patient
and plan about the skin incision, flaps and handling of extensor mechanism. By properly selecting and
implementing the plan, surgeon can avoid devastating complication of revision
knee arthroplasty which can range from wound slough, instability to even an
amputation1.   Certain groups of patients are at much higher
risk for complication including history of multiple procedures in the past,
rheumatoid arthritis, vasculitis, infected knees, history of corticosteroid
use, diabetes, Psoriasis, renal failure and AIDS2.

incision guidelines

Planning the right skin
incision is important to avoid wound complications3, 4.

Place the skin incision in flexion and
avoid vigorous retraction of skin during surgical exposure.

 Avoid small incision as they require more
retraction and may lead to complication.

large tissue flaps and if the skin is adhered to deep tissue, it must be freed
to allow adequate retraction.

multiple longitudinal skin incision is present

 Most lateral longitudinal skin should be

preserve an adequate blood supply and prevent marginal skin necrosis, a
distance of at least one-half the length of the planned incision must be
maintained between an old skin incision and the new incision.

new incision should intersect old incision at a right angle as much as
possible. A new incision should not be at acute angle to old incision, as the
peninsula of skin between the two incisions is susceptible to skin necrosis.

the synovial recesses over the femoral condyles

In most revision cases, there are adhesions between
capsular layers over the medial and lateral femoral condyles which limit the surgical
exposure, as the superficial tissue cannot be retracted away from the femur.
Vastus medialis and lateralis should be freed completely from adhesions to the
underlying femur with sharp dissection or cautery. Continue the dissection from
midline to periphery and avoid any iatrogenic injury to collateral ligaments. A
lateral retinacular release may improve exposure of the lateral synovial



the capsule

 In knees with extensive scarring due to infection debulking the
capsular envelope is necessary to allow adequate exposure.

the intrapatellar fat pad

Due to previous surgery
there is thick scar tissue that forms over patella and patellar tendon which
prevents retraction of patella due to loss of elasticity. Excising the scar
tissue from patella and patellar tendon allows better mobilization of patella

 Pinning tibial tuberosity

Pin the patellar tendon
at tibial tuberosity to prevent accidental avulsion of patellar tendon.


Due to previous surgery
and stiffness of knee, retraction of extensor mechanism places undue pressure
on patellar tendon insertion which may avulse. Conventional arthrotomy can be
done but usually additional procedure is required for adequate mobilization of
patellar tendon. Various procedures for relaxing extensor apparatus include quadriceps
snip, quadriceps turndown or a tibial tubercle osteotomy etc. have been
described. The choice of procedure has to be individualized for each patient.
Quadriceps snip is the most commonly performed procedure.

or distal procedure

In patients with
normally or high placed patella proximal procedures are more useful than a
distal procedure. However in cases of patellar baja, a distal procedure like
tibial tubercle osteotomy is better as no amount of proximal release will be
able to retract the extensor apparatus. Also while repairing the osteotomy
tibial tubercle can be mobilized proximally by 2 cm allowing better retraction
and knee range of motion.

snip approach (Fig 1)

Insall is credited with
extensive use of rectus snip approach5. This approach is also known
as quadriceps snip approach.


The technique involves using standard medial parapatellar
arthrotomy. The quadriceps snip portion of the exposure involves an incision
through the proximal part of the quadriceps tendon, beginning at the proximal
limit of the parapatellar incision and directed proximal and laterally into
vastus lateralis.





to perform

good exposure

blood supply coming from the lateral geniculate artery

Extensile: In case the exposure is insufficient
after the above technique then a quadriceps turndown may be carried out

affect on quadriceps strength

•       No change in post operative physiotherapy


•       Does not facilitate removal
of previously cemented tibial stem


quadriceps Turndown (Fig 2)

 This approach was first described by Insall 6
in 1983.


Make a standard medial parapatellar arthrotomy and if
exposure is difficult make a second incision at 45 degrees to the first
incision in the extensor mechanism. The dissection is carried down through the
tendinous insertion of vastus lateralis and lateral retinaculum. At the time of
the closure it is recommended to flex the knee to 90 degrees and reapproximate
the tendon thereby creating V-Y lengthening of the tendon. Scott et al7
 modified the approach by taking the
lateral limb of the incision underneath the edge of the vastus lateralis
through its tendinous insertion into the retinaculum and thereby have a
protective effect on the superior genicular artery.



You can
literally see everything

supply of the patella through the inferior lateral genicular artery is


•       Does not facilitate removal
of previously cemented tibial stem

•       Vascular supply to the
entire tongue is precarious

•       Extensor lag

•       Marked modification of post
op protocol

•       Protection
for 2 to 3 weeks in the post op period to allow the repair to heal.


Conditions with poor
quality of the proximal tendinous portion and limited contractility of the
quadriceps muscle

and Adams Approach 8

This was first described in 1943 by Adams et al. This
approach was used extensively till a modification was described by Insall as it
could not be extended from a standard medial parapatellar arthrotomy. This
approach is rarely performed now. Approach involves a V-Y turndown procedure of
releasing the extensor mechanism proximal to the quadriceps attachment of the
patella resulting in considerable scarring and weakness of the extensor
mechanism. The potential benefit of V-Y quadricepsplasty over snip technique
and tibial tubercle osteotomy is the ability to lengthen the quadriceps tendon,
get a wide exposure while maintaining the patella tendon tibial tubercle

Tubercle Osteotomy (Fig 3)

The original technique
described by Dolin9 had a high complication rate which included non
union and tendon rupture. The osteotomized fragment size was small (4.5 cm) and
was fixed with screws.

Technique (Whiteside modification)10

 After a standard medial parapatellar arthrotomy if exposure is difficult
a tubercle osteotomy is done with an oscillating saw from medial to lateral
side of the tibia. Then a curved osteotome is used to make a transverse
proximal cut above the attachment of the patellar tendon. The lateral
attachments of the muscles and periosteum are left intact. The size of the
osteotomized fragment is 8 cm in length, 2 cm wide and 1 cm thick. To prevent
the stress riser effect and oblique saw cut is made at the distal end of the
osteotomized fragment.

Postoperatively fixation with two or three circlage wires
is preferred .The drill holes are placed along the lateral edge of the tibial
tubercle and directed obliquely upwards to the posteromedial corner. After
passing the wires through these holes they are twisted down on the tuberosity


•       Extensive
exposure to the knee in patients with severe quadriceps contracture

•       Especially
useful for patients of fibrous ankylosis and in cases of knee arthrodesis

•       Facilitates removal of well
fixed cemented tibial stem





compromised skin there might be penetration with the wire

union of the osteotomy

fracture below osteotomy if long  stem is  not used



tibial bone defects

extensor mechanism

 Medial Epicondylar Osteotomy
(Engh et al)11

Rarely required


After the standard medial parapatellar arthrotomy knee is
placed in a fig of 4 position and flexed to 90 degrees. 1 cm of medial
epicondyle fragment is chiseled off the femur maintaining attachment of
adductor Magnus proximally and medial collateral ligament distally. If needed
posteromedial capsule can be stripped further. The dissection is carried out
posteriorly and laterally around femur and tibia and knee is opened by
externally rotating the knee and applying a valgus stress.

Peel (Windsor and Insall)12

This involves exposure
around the medial and lateral corners of the femur by carrying out a
subperiosteal elevation of the medial and lateral collateral ligaments. If required
origins of medial and lateral gastronemeus can be released.

 Banana Peel Method (Lahav et al)13

 Initial exposure of the extensor mechanism is via the previously used
skin incision .This is followed with medial parapatellar arthrotomy to expose
the knee joint. A quadriceps snip is done proximally. A meticulous sharp
dissection is done on the anterior tibia and medial to patellar tendon-this is
the site of origin of the peel. At this stage patella is everted using minimal
force. The periosteal sleeve along with the patellar tendon is peeled off the
tibia as a single continuous layer. This is the most critical step as a
meticulous release of the single sleeve with the attachment of patellar tendon
maintains the extensor mechanism as a unit. The added advantage is that one can
extend the release as much distally and laterally as required for a complete
exposure of the components.






1) J. A. Rand, B. F. Morrey and R. S. Bryan, “Patellar
Tendon Rupture after Total Knee Arthroplasty,” Clinical Orthopae dics and Related Research, Vol. 244, No. 7,
1989, pp. 233- 238.

2) A. S. Younger, C. P. Duncan and B. A. Masri,
“Surgical Exposures in Revision Total Knee Arthroplasty,” Journal of the American Academy of
Orthopaedic Surgeons, Vol. 6, No. 1, 1998, pp. 55-64.

3) Windsor RE,
Insall JN, Vince KG. . Technical
considerations of total knee arthroplasty after proximal tibial
osteotomy. J Bone Joint Surg Am 1988;70-A:547–555.

4)Garbedian S, Sternheim A,
Backstein D. Wound healing problems in total knee arthroplasty. Orthopedics 2011;34:516–518.

5) K. L. Garvin, G. S. Scuderi and J. N. Insall,
“Evolution of the Quadriceps Snip,” Clinical
Orthopaedics and Related Research, Vol. 321, No. 12, 1995, pp. 131-137.

6) J. N. Insall, “Surgical Approaches,” In: J. N.
Insall, R. E. Windsor, W. N. Scott, M. A. Kelly and P. Aglietti, Eds., Surgery of the Knee, 2nd Edition,
Churchill Livingstone, New York, 1993, pp. 135-148.

7) R. Scott and J. Siliski, “The Use of a Modified V-Y
Qua- dricepsplasty during Total Knee Replacement to Gain Exposure and Improve
Flexion in the Ankylosed Knee,” Orthopedics,
Vol. 8, No. 45, 1985, pp. 45-48.

8) K. Coonse and J. D. Adams, “A New Operative
Approach to the Knee Joint,” Gynecological
Surgery, Vol. 77, No. 4, 1943, pp. 344-347.

9)  M. G. Dolin,
“Osteotomy of the tibial tubercle in total knee replacement,” Journal of Bone & Joint Surgery,
Vol. 65, No. 6, 1983, pp. 704-706.

10) L. A. Whiteside and M. D. Ohl, “Tibial Tubercle
Os-teotomy for Exposure of the Difficult Total Knee Arthro-plasty,” Clinical Orthopaedics and Related Research,
Vol. 260, No. 11, 1990, pp. 6-9.

11) G. A. Rorabeck Engh and J. P. McCauley, “Joint
Line Res-toration and Flexion Extension Balance with Revision Total Knee
Arthroplasty,” In: G. A. Engh and C. Rorabeck, Eds., Revision Knee Arthroplasty, Williams and Wilkins, Balti- more,
1997, p. 235.

12) R. E. Windsor and J. N. Insall, “Exposure in
Revision Knee Arthroplasty: The Femoral Peel,” Techniques in Orthopae dics, Vol. 3, No. 1, 1988, pp. 1-4.

13) A. Lahav and A. Hoffman, “The ‘Banana Peel’
Exposure Method in Revision Total Knee Arthroplasty,” American Journal of Orthopedics, Vol. 36, No. 10, 2007, pp.



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