Abstract
Exposure in revision total knee replacement can be quite challenging due to scar formation from one or many previous incisions. Disruption of the patellar or quadriceps tendon during revision must be avoided at all costs and many surgical maneuvers have been described to permit safe exposure in order to remove the implants during the initial stage of reconstruction. Standard maneuvers include recreation of the medial and lateral gutters, patient dissection to allow the soft tissue to stretch over time and proximal medial exposure of the tibia and release of the semimembranosis tendon insertion.
There are three specialised techniques for exposure during revision total knee replacement: the quadriceps snip as described by Insall, the V-Y quadriceps turndown as described by Coonse and Adams, and the tibial tubercle osteotomy as described by Whiteside.
The quadriceps snip is a proximal lateral extension of the medial arthrotomy used during a standard approach. It is easy to perform and can be used for most revision situations. This is should be the standard first choice for gaining exposure in revision surgery. The V-Y quadriceps turndown is quite extensile and is a combination of a lateral retinacular release connected to the proximal portion of the medial arthrotomy. Although it allows excellent exposure in revision situations, it is associated with extensor weakness and extensor lag. The Whiteside tibial tubercle osteotomy is also a versatile approach. Care should be taken to preserve a lateral periosteal sleeve, and subsequent repair with wire presents the best healing possibility. It is quite elegant in providing access to the proximal tibia to facilitate removal of a well fixed, stemmed tibial component.
