Advertisement for orthosearch.org.uk
Orthopaedic Proceedings Logo

Receive monthly Table of Contents alerts from Orthopaedic Proceedings

Comprehensive article alerts can be set up and managed through your account settings

View my account settings

Visit Orthopaedic Proceedings at:

Loading...

Loading...

Full Access

General Orthopaedics

EXPOSURE OPTIONS: GETTING THERE SAFELY

Current Concepts in Joint Replacement (CCJR) – Winter 2014



Abstract

Minimal or Less Invasive Approaches

Limited medial parapatellar incision – 2–3 inch medial incision; Best for unicompartmental implant; patellar visualization poor; Less invasive but limited visualization therefore overall joint inspection is compromised.

MIS TKR approaches - Mini midvastus approach popularised by S.B. Haas - Ideal BMI 30 or less; Incision length 10cm; Vastus incision about 2–3cm; Vastus incision beyond 5–6cm places motor branch to VMO at risk; Coupled with downsized cutting blocks, allows predictable ability to perform TKR; Sliding window concept; Patella eversion not necessary.

Mid Subvastus approach – 10cm skin incision; Sub vastus dissection up to septum (watch for bleeders!); VERY difficult in muscular males!

Standard Incisions

Standard medial parapatellar approach - Familiar to most surgeons; Medial arthrotomy facilitates exposure for almost all procedures; Can become more extensile by incising the quad tendon further proximal; Release of posteromedial capsule and semi-membraneosus allows exposure posteriorly.

Quad snip - Used occasionally in the fixed varus, flexion contracted knee; More commonly used in revisions; Allows patella eversion without risk of distal avulsion; Motor strength appears to return to baseline level postoperatively.

V-Y quadriceps turndown - Technique: initial medial parapatellar arthrotomy, an oblique tenotomy angled toward the tendinous portion of the vastus lateralis and then extended distally; The quadriceps segment is than retracted downward to expose the joint; Tenotomy is closed with robust non-absorbable sutures holding the knee in extension; Postoperative flexion is dictated by integrity of repair while flexing knee at time of closure. Disadvantages include extensor lag, as well as effecting ultimate ROM.

Tibial tubercle osteotomy a la Whiteside - Medial arthrotomy; Tubercle segment is 6–8cm long, 2cm wide and 1–1.5cm thick; Segment is beveled distally so as to avoid stress riser; Leave lateral soft tissue intact; Closure with wires preferred although screws or cables have been used as well.