We identified 26 tibial tubercle osteotomies (TTOs) performed in 23 revision knee arthroplasties between 2009 and 2013. Average age at last operation was 66 (33–92). Mean follow-up period was 14 months (3–33). Eleven TTOs were performed in 10 knees for single stage revisions and 15 TTOs were performed in 13 knees for 2 stage revisions in the setting of deep infection. In this infected subset 11 patients had a TTO performed at the first stage. This osteotomy was left unfixed to avoid leaving metalwork in a potentially contaminated wound, reopened, and then definitively secured with screws at the second stage. Our technique involves fashioning a long 7×1cm tibial tuberosity osteotomy without a proximal step-cut. All osteotomies united with no fractures. Minor proximal migration was noted in one case associated with screw loosening. There was no proximal migration noted in the 2 stage cases where the osteotomy had been left initially unfixed. There were no extensor lags. We conclude that TTO is a safe and reproducible procedure when adequate exposure cannot be obtained in revision knee arthroplasty. In 2 stage revisions sequential osteotomies does not decrease union rates and leaving the osteotomy unfixed after the first stage does not cause any issues

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

Patients with recurrent patella instability, who have an abnormal patellofemoral alignment (patella height or tibial tubercle-trochlear groove (TTTG) distance), benefit from tibial tubercle transfer along with medial patellofemoral ligament (MPFL) reconstruction. Between July 2008 and April 2013, 18 patients (21 knees) with recurrent patellar instability underwent combined MPFL reconstruction and tibial tubercle transfer. All patients had abnormal patellofemoral alignment in addition to MPFL insufficiency. 15 patients (16 knees) with a mean age of 24 years (16–41) had a mean follow up of 26 months (6–55). We assessed the outcome using KOOS, KUJALA, activity level and patient satisfaction scores. All patients had a stable patella. There was a significant improvement in outcome scores in 12 out of 15 patients. At final follow up KOOS score had improved from 68.25(44 to 93.9) to 77.05(48.8 to 96.4) and KUJALA score had improved from 63.3(41–88) to 78.06 (45 to 99). 9 patients showed excellent results and achieved at least a pre-injury level of activity. 4 of these had activity level better then preoperative level. 6 patients had a lower activity level than pre-injury (1 – ongoing physiotherapy, 1 – because of lack of confidence, and 4 – Life style modification). 14 patients were satisfied and happy to recommend this procedure. There were 3 postop complications, with 2 cases of stiffness and 1 case of non-union of the tibial tuberosity. Our prospective study has shown that restoration of tibial tubercle-trochlear groove index, Patella height and Medial Patellofemoral Ligament reconstruction yields good results in carefully selected patients.

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Achievement of adequate exposure in revision total knee arthroplasty is critical as it reduces the surgical time, enhances the ability for both component removal and reconstruction, and avoids devastating complications such as extensor mechanism disruption. However, this can be challenging as prior multiple surgeries and limited mobility contribute to a loss of tissue elasticity, thickened capsular envelope, and peri-articular soft tissue adhesions. A thorough pre-operative assessment of a patient's past surgical history, comorbidities, pre-operative radiographs (i.e. the presence of severe patella baja), and physical examination including range of motion, prior incisions, and soft tissue pliability are useful in determining the appropriate surgical techniques necessary for a successful revision. A systematic approach to the ankylosed knee is critical. Most techniques are geared towards mobilization of the extensor mechanism to safely displace the patella for component exposure. The initial exposure should consist of a long skin incision, a subperiosteal medial release, and debridement of suprapatellar, medial, and lateral adhesions to the femoral condyles. A lateral capsular release can prove helpful in further mobilization of the extensor mechanism. When performing a medial parapatellar arthrotomy it's important to keep in mind further extensile exposure techniques that may be required. For example, the arthrotomy should not extend proximally into the vastus intermedius or rectus femoris in the event that a quadriceps snip technique is to be used as this can compromise the ability to repair this exposure. Despite a large exposure and release of adhesions, sometimes the extensor mechanism remains at risk of rupture and adequate visualization cannot be obtained. In this event, extensile exposures such as a quadriceps snip, quadriceps turndown or tibial tubercle osteotomy are considered. The location of the patella often dictates the best exposure option as severe patella baja may not be overcome with a proximally based release. The quadriceps snip is most commonly used and provides improved exposure without the necessity of modifying the patient's post-operative rehabilitation. In addition, it can be extended to a quadriceps turndown which vastly improves visualization, but at the expense of needing to immobilise the knee post-operatively. A tibial tubercle osteotomy can also be used and provides excellent exposure especially in the case of severe patella baja or when removal of a cemented tibial stem is required. It preserves the extensor muscles, but risks include increased post-operative wound drainage due to limited soft tissue coverage, failure of fixation, or fracture of the tibial tubercle fragment or tibial shaft. Exposure in revision total knee arthroplasty is critical. Fortunately, this can be reliably achieved with a systematic approach to the knee and through the use of several extensile exposures at the surgeon's discretion

The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A synovectomy is performed followed by debridement of all scar tissue, especially in the medial and lateral gutters. All peripatellar scar tissue is excised followed by release of scar tissue within the patellar tendon, allowing for displacement or everting of the patella. As patellar tendon avulsion at any time of knee surgery yields disastrous results, the surgeon should be continuously evaluating the patellar tendon integrity, especially while displacing/everting the patella and bringing the knee into flexion. If displacement/eversion is difficult, consider rectis-snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. The long-held requisite for patellar eversion prior to component removal is inaccurate. In most cases simple lateral patellar subluxation will provide adequate exposure. If a modular tibial system is involved, removal of the tibial polyethylene will decompress the knee, allowing for easier access to patellar, femoral, and tibial components. For patellar component removal, first identify the border of the patella, then carefully clean and debride the interface, preferably with electrocautery. If the tibial component is cemented all-polyethylene, remove using an oscillating saw at the prosthetic-bone interface. Debride the remaining cement with hand tools, ultrasonic tools, or burrs. Remove the remaining peg using a low-speed burr. If the tibial component is metal-backed, then utilise a thin saw blade or reciprocating saw to negotiate the undersurface of the component between the pegs. If pegs are peripherally located, cut with a diamond disc circular cutting tool. Use a trephine to remove the pegs. For femoral component removal, identify the prosthetic-bone/prosthetic-cement interface then remove soft tissue from the interface, preferably with electrocautery. Disrupt the interface around all aspects of the component, using any of following: Gigli saw for cementless components only, micro saw, standard oscillating saw, reciprocating saw, a series of thin osteotomes, or ultrasonic equipment. If the femoral component is stemmed, remove the component in two segments using an appropriate screwdriver to remove the screw locking the stem to the component. Remove the femoral component with a retrodriver or femoral component extractor. Debride cement with hand tools or burr, using care to avoid bone fracture. If a stem is present, then remove with the appropriate extraction device. If “mismatch” exists, where femoral (or likewise, tibial) boss is smaller in diameter than the stem, creating a cement block prohibiting stem removal, remove the cement with hand tools or burr. If the stem is cemented, use hand tools, ultrasonic tools, or a burr to debride the cement. Curette and clean the canals. For tibial component removal, disrupt the prosthetic-cement/prosthetic-bone interface using an oscillating or reciprocating saw. Gently remove the tibial component with a retrodriver or tibial extractor. If stem extensions are utilised, disengage and debride all proximal cement prior to removing the stem. If stem is present, then remove stem with appropriate extraction device. If stem is grit-blasted and well-fixed, create 8mm burr holes 1.5 to 2.5cm distal to tibial tray on medial aspect and a small divot using burr, then drive implant proximally with Anspach punch. Alternatively, a tibial tubercle osteotomy may be performed. If the stem is cemented, use hand tools, ultrasonic tools or burr to debride cement

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

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 manoeuvres 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

MPFL reconstruction has demonstrated a very high success rate with improved patella stability, physical function, and patient-reported outcomes. However technical error and a lack of consideration of anatomic risk factors have been shown to contribute to failure after MPFL reconstruction. Previous research has also reported a complication rate of 26% following surgery. The purposes of this study were to determine the re-dislocation rate, type and number of complications, and most common additional surgical procedures following MPFL reconstruction. Patients with symptomatic recurrent patellofemoral instability underwent an MPFL reconstruction (n = 268) and were assessed with a mean follow-up of 31.5 months (minimally 24-months). Concomitant procedures were performed in addition to the MPFL reconstruction in order to address significant anatomic or biomechanical characteristics. Failure of the patellofemoral stabilization procedure was defined as post-operative re-dislocation of the patella. Rates of complications and re-procedures were assessed for all patients. The re-dislocation rate following MPFL reconstruction was 5.6% (15/268). There were no patella fractures. A total of 49/268 patients (18.3%) returned to the operating room for additional procedures following surgery. The most common reason for additonal surgery was removal of symptomatic tibial tubercle osteotomy hardware in 24/268 patients (8.9%). A further 9.3% of patients underwent addtional surgery including revision MPFL reconstruction: with trochleoplasty 8/268 (3.0%), with tibial tubercule osteotomy 4/286 (1.5%) and with femoral derotation osteotomy 3/268 (1.1%); manipulation under anaesthesia for reduced knee range of motion 4/268 (1.5%); knee arthroscopy for pain 8/268 (3.0%); and cartilage restoration procedures 3/268 (1.1%). There was 1 case of wound debridement for surgical incision infection. MPFL reconstruction using an a la carte approach to surgical selection demonstrated a post-operative redislocation rate of 5.6%. The rate of complications following surgical stabilization was low, with the most common reason for additional surgery being removal of hardware

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Implant removal: Tips for removing stemmed implants; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (5) Preferred management of infection in the multiply operated knee; (6) The extensor mechanism: Preferred deficient patellar bone management; Preferred extensor mechanism deficiency management; (7) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?; (8) Post-operative management: wound management; knee range of motion

Following a careful in-depth preoperative plan for revision TKA, the first surgical step is adequate exposure. It is crucial to plan your exposure for all contingencies. Prior incisions have tremendous implications and care must be taken to consider their impact. Due to the medially based vascular supply to the skin and superficial tissues about the knee, consideration for use of the most LATERAL incision should be made. It is essential to avoid the development of flaps which may compromise the skin and soft tissue which can have profound implications. Exposure options can be broken down into either PROXIMALLY based techniques or DISTALLY based options. The proximal based techniques involve a medial parapatella arthrotomy followed by the establishment of medial and lateral gutters. An assessment of the ability to evert or subluxate the patella should be made. Care must be taken to protect the insertion of the patella tendon into the tibial tubercle. If the patella is unable to be mobilised, then extension of arthrotomy proximal is performed. If this is not adequate, then consider inside out lateral release. If still unable to mobilise, then a QUAD SNIP is performed. In rare instances, you can connect the lateral release with quad snip resulting in a V-Y quadplasty, which results in excellent exposure. Another option is to employ DISTALLY based techniques such as the tibial tubercle osteotomy technique described by Whiteside. A roughly 8cm osteotomy segment with distal bevel is performed. The osteotomy must be at least 1.5–2cm thick: too thin and risk of fracture increases. This approach leaves the lateral soft tissues intact and then a “greenstick” of the lateral cortex is performed with eversion of patella and the lateral sleeve of tissue. This technique is excellent for not only exposure but also in instances where tibial cement or a cementless tibial stem needs to be removed. Closure is accomplished with wires either through the canal or around the posterior cortex of the tibia

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Preferred management of infection in the multiply operated knee; (5) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?

Success in knee revision begins in the office. The initial evaluations determine the implant design and pre-operative diagnosis. The physical examination identifies the presence of instability, stiffness, extensor mechanism malfunction and previous incisions all of which influence the planned procedure. Prior to surgery arrangements are made to have all manner of revision implants, removal tools, and allograft material available. Removal of implants must be done with a focus on preserving bone stock and the extensor mechanism. Initial exposure involves release of the gutters, lateral subluxation of the patella and removal of the polyethylene insert. These maneuvers combined with a quadriceps snip provide exposure for implant removal in 80–90% of cases. More extensive exposure options include quadriceps turndown, tibial tubercle osteotomy, medial epicondylar osteotomy and a femoral peel. Tools needed for implant removal include thin osteotomes, offset osteotomes, thin saws and a high-speed bur. After polyethylene removal the femur followed by the tibia are removed. In many cases the existing well-fixed patellar component can remain. The implant cement or implant bone interface is approached for cemented and cementless implants, respectively. Tools are always directed parallel to the fixation surface. Offset osteotomes are helpful gaining access to the femoral notch when femoral pegs prevent access from the sides. Central keels or peripheral pegs can complicate tibial removal. Working completely around the keel from medial and lateral disrupts the peripheral tibial interface leaving just the central posterior metaphysis. Stacked osteotomes or a slap hammer can be used to lift the baseplate from the tibia

The moderator will lead a structured panel discussion that explores how to manage challenges commonly found in the multiply revised knee. Topics covered will include: (1) Exposure in the multiply operated knee (when to use quad snip, tibial tubercle osteotomy, other techniques); (2) Implant removal: Tips for removing stemmed implants; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (4) Level of constraint (when to use posterior stabilised, constrained condylar, and hinge) and management of instability in multiply operated knees; (3) Management of bone loss in multiply operated knees (metal cones/sleeves vs. structural allograft vs. particulate graft); (5) Preferred management of infection in the multiply operated knee; (6) The extensor mechanism: Preferred deficient patellar bone management; Preferred extensor mechanism deficiency management; (7) When is it time to convert to a salvage procedure (i.e. fusion, resection arthroplasty, amputation)?; (8) Post-operative management: wound management; knee range of motion

Systematic surgical exposure during revision total knee arthroplasty is essential for revision surgery. Surgical exposure protects the extensor mechanism, facilitates safe implant removal and allows for accurate reimplantation of components. The pre-operative plan is critical to achieving appropriate exposure in the revision setting. Evaluating the skin and previous incisions will aid in the exposure technique selected. The key to revision total knee arthroplasty is systematic releases. Revision total knees can be exposed with a standard medial parapatellar arthrotomy, a proximal medial tibial peel, and a quad snip. This takes tension off the stiff knee, is easy to repair, and does not require limitation of rehabilitation protocols. The patella need not be everted in the revision surgery. The Banana Peel technique is very helpful for the stiff knee. The tibial tubercle osteotomy can also be utilised in patients with extreme stiffness and can aid in removal of well-fixed tibial stems. Keep the osteotomy long (8–10 cm) and leave a lateral soft tissue bridge. Other techniques such as the quadricepsplasty or V-Y turndown are rarely needed

Exposure for revision knee requires using the previous incision, employing the “quad snip”, the “Banana Peel”, or the tubercle osteotomy. The “quad snip” is a 45-degree incision of the proximal extensor mechanism that helps protect the distal insertion on the tubercle. The “banana peel,” is my exposure of choice and has been used extensively for revision total knee arthroplasty (TKA) for more than 20 years in my community. We retrospectively reviewed use of this technique in a cohort of 100 consecutive patients who underwent tibial-femoral stemmed revision TKA. The technique involves peeling the patella tendon as a sleeve off the tibia, leaving the extensor mechanism intact with a lateral hinge of soft tissue. A quadriceps “snip” must be done proximally to avoid excessive tension. No patient has ever reported disruption of the extensor mechanism or decreased ability to extend the operative knee. With a mean Knee Society score of 176 (range, 95–200). Post-operative motion was 106 degrees. No patient reported pain over the tibial tubercle. The “banana peel” technique for exposing the knee during the revision TKA is a safe method that can be used along with a proximal quadriceps snip and does not violate the extensor mechanism, maintaining continuity of the knee extensors. As a last resort, tibial tubercle osteotomy as described by Whiteside, is preferred for revising porous coated stemmed tibial components and is repaired with cerclage wire or cables. Keep the osteotomy fragment at least 8–10cm long leaving a lateral soft tissue attachment

Effectiveness of Liposomal Bupivacaine for Post-Operative Pain Control in Total Knee Arthroplasty: A Prospective, Randomised, Double Blind, Controlled Study. Pericapsular Injection with Free Ropivacaine Provides Equivalent Post-Operative Analgesia as Liposomal Bupivacaine following Unicompartmental Knee Arthroplasty. Total Knee Arthroplasty in the 21st Century: Why Do They Fail? A Fifteen-Year Analysis of 11,135 Knees. Cryoneurolysis for Temporary Relief of Pain in Knee Osteoarthritis: A Multi-Center, Prospective, Double-Blind, Randomised, Controlled Trial. Pre-Operative Freezing of Sensory Nerves for Post-TKA Pain: Preliminary Results from a Prospective, Randomised, Double-Blind Controlled Trial. Proximalization of the Tibial Tubercle Osteotomy: A Solution for Patella Infera during Revision Total Knee Arthroplasty. Treatment of Periprosthetic Joint Infection Based on Species of Infecting Organism: A Decision Analysis. Alpha-Defensin Test for Diagnosis of PJI in the Setting of Failed Metal-on-Metal Bearings or Corrosion. Risk of Reinfection after Irrigation and Debridement for Treatment of Acute Periprosthetic Joint Infection following TKA. Serum Metal Levels for the Diagnosis of Adverse Local Tissue Reaction Secondary to Corrosion in Metal-on-Polyethylene Bearing Total Hip Arthroplasty. Intra-Articular Injection for Painful Hip OA - A Randomised, Double-Blinded Study. Six-Year Follow-up of Hip Decompression with Concentrated Bone Marrow Aspirate to Treat Femoral Head Osteonecrosis. No Benefit of Computer-Assisted TKA: 10-Year Results of a Prospective Randomised Study

Following a careful in-depth preoperative plan for revision TKR, the first surgical step is adequate exposure. The following steps should be considered: 1.) Prior incisions: due to the medially based vascular supply to the skin and superficial tissues about the knee, consideration for use of the most LATERAL incision should be made. 2.) Avoid the use of flaps which may compromise the skin and soft tissue. 3.) Exposure options can be broken down into: PROXIMALLY based techniques: medial parapatella arthrotomy, establish medial and lateral gutters, eversion or subluxation of the patella, extension of arthrotomy proximal, if unable to “mobilise” patella, consider inside out lateral release, if still unable to mobilise: QUAD SNIP, in rare instances, connect lateral release with quad snip resulting in a V-Y quadplasty, may now turn down for excellent exposure. DISTALLY based techniques: tibial tubercle osteotomy technique described by Whiteside, roughly 8 cm osteotomy segment with distal bevel, osteotomy must be at least 1.5–2 cm thick: too thin and risk of fracture increases, leave lateral soft tissues intact, greenstick” the lateral cortex with eversion of patella, closure with wires

After over 4 decades of experience with total knee arthroplasty, many lessons have been learned regarding surgical technique. These include exposure issues, alignment methods, bone preparation, correction of deformity, implantation techniques and wound closure. Where is the proper placement of the skin incision relative to the tibial tubercle? How does one safely evert the patella in the obese or ankylosed knee? Can a tibial tubercle osteotomy be avoided in the ankylosed knee? How does one protect the patellar tendon insertion from avulsing? How do you protect the soft tissues from debris and contamination and minimise the potential for infection? Can exposure be maintained if there are few surgical assistants? How do you find the lateral inferior genicular vessels and minimise postoperative bleeding? How do you know where to enter the intramedullary femoral canal for placement of the distal femoral alignment device? How can you avoid notching the anterior femoral cortex when in-between sizes or there is a pre-existing dysplastic trochlea? How can you correct a varus deformity without performing a formal MCL release? An inverted cruciform lateral retinacular release effectively corrects a severe valgus deformity and avoids the need for an LCL release. Trimming the posterior femoral condyles and removing posterior osteophytes is best accomplished using a trial femoral component as a template. Zone 4 femoral bone-cement radiolucencies can be minimised using the “smear” technique. The best indicator of potential postoperative flexion is not preoperative flexion but is intraoperative flexion against gravity measured after capsular closure

Success in knee revision begins in the office. The initial evaluations determine the implant design and pre-operative diagnosis. The physical examination identifies the presence of instability, stiffness, extensor mechanism malfunction and previous incisions all of which influence the planned procedure. Prior to surgery, arrangements are made to have all manner of revision implants, removal tools, and allograft material available. Removal of implants must be done with a focus on preserving bone stock and the extensor mechanism. Initial exposure involves release of the gutters, lateral subluxation of the patella and removal of the polyethylene insert. These maneuvers combined with a quadriceps snip provide exposure for implant removal in 80–90% of cases. More extensive exposure options include quadriceps turndown, tibial tubercle osteotomy, medial epicondylar osteotomy and a femoral peel. Tools needed for implant removal include thin osteotomes, offset osteotomes, thin saws and a high-speed bur. After polyethylene removal the femur followed by the tibia are removed. In many cases the existing well-fixed patellar component can remain. The implant cement or implant bone interface is approached for cemented and cementless implants, respectively. Tools are always directed parallel to the fixation surface. Offset osteotomes are helpful gaining access to the femoral notch when femoral pegs prevent access from the sides. Central keels or peripheral pegs can complicate tibial removal. Working completely around the keel from medial and lateral disrupts the peripheral tibial interface leaving just the central posterior metaphysis. Stacked osteotomes or a slap hammer can be used to lift the baseplate from the tibia