Revision knee arthroplasty is fraught with complications such as delayed wound healing, arthrofibrosis, increased chances of infection, instability and extensor mechanism disruption. The key to avoiding these complications is to handle the soft tissue with care and to have an adequate surgical exposure at the same time. As the number of revisions has gone up, there has been a renewed interest in getting the basics right to have an adequate surgical exposure. Numerous surgical approaches have been proposed and subsequently modified. We present a concise review of the various surgical approaches for a revision knee replacement.
KeywordsKneeArthroplastyRevisionExposures
J. N. Insall, R. Binazzi, M. Soudry, L. A. Mestriner, “Total Knee arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 192, No. 1,1985, pp. 13-22.
J. A. Rand and D. M. Ilstrup, “Survivorship Analysis of Total Knee Arthroplasty. Cumulative Rates of Survival of 9200 Total Knee Arthroplasties,” Journal of Bone and Joint Surgery, Vol. 73, No. 3, 1991, pp. 397-409.
R. L. Barrack, “Evolution of the Rotating Hinge for Complex Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 392, No. 11, 2001, pp. 292-299. doi:10.1097/00003086-200111000-00038
R. A. Berger, A. G. Rosenberg, R. M. Barden, M. B. Sheinkop, J. J. Jacobs and J. O. Galante, “Long Term Follow-Up of the Miller Galante Total Knee Replacement,” Clinical Orthopaedics and Related Research, Vol. 388, No. 7, 2001, pp. 58-67.
N. Hernigou, G. Mathieu, P. Filippini and A. Demoura, “Intra and Post Operative Fractures of the Femur in Total Knee Arthroplasty: Risk Factors in 32 Cases in French,” Revue de Chirurgie Orthopédique et Réparatrice de l’Appareil Moteur, Vol. 92, No. 2, 2006, pp. 140-147. doi:10.1016/S0035-1040(06)75699-9
E. M. Keating, J. B. Meding, P. M. Faris and M. A. Ritter, “Long Term Follow-Up of Non-Modular Total Knee Replacements,” Clinical Orthopaedics and Related Research, Vol. 404, No. 11, 2002, pp. 34-39. doi:10.1097/00003086-200211000-00007
D. R. Diduch, J. N. Insall, W. N. Scott, G. R. Scuderi and D. Rodrigues, “Total Knee Replacements in Young Active Patients,” Journal of Bone and Joint Surgery, Vol. 79A, No. 4, 1997, pp. 571-582.
F. Ewald and M. J. Christie, “Results of Cemented Total Knee Replacement in Young Patients,” Orthopedic Transactions, Vol. 11, No. 7, 1987, p. 442.
D. S. Hungerford, K. A. Krackow and R. V. Kenna, “Cementless Total Knee Replacement in Patients 50 Years Old and under,” Orthopedic Clinics of North America, Vol. 20, No. 2, 1989, pp. 131-145.
S. H. Stern, M. K. Bowen, J. N. Insall and J. R. Scuderi, “Cemented Total Knee Arthroplasty For Gonarthrosis in Patients 55 Years or Younger,” Clinical Orthopaedics and Related Research, Vol. 260, No. 11, 1990, pp. 124-129.
M. J. Stuart and J. A. Rand, “Total Knee Arthroplasty in the Young Adult,” Orthopedic Transactions, Vol. 11, 1987, pp. 441-442.
S. D. Stulberg, “Bi/Tricompartmental Degenerative Knee Disease in the Young Patient,” Journal of Orthopaedics, Vol. 18, No. 9, 1995, pp. 899-901.
S. Kurtz, K. Ong, E. Lau, F. Mowat and M. Halpern, “Projections of the Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030, Journal of Bone and Joint Surgery, Vol. 89, No. 4, 2007, pp. 780-785. doi:10.2106/JBJS.F.00222
S. M. Kurtz, E. Lau, K. Ong, K. Zhao, M. Kelly and K. J. Bozic, “Future Young Patient Demand for Primary and Revision Joint Replacement: National Projections from 2010 to 2030,” Clinical Orthopaedics and Related Research, Vol. 467, No. 10, 2009, pp. 2606-2612. doi:10.1007/s11999-009-0834-6
G. R. Scuderi, J. N. Insall, R. E. Windsor and M. C. Moran, “Survivorship of Cemented Knee Replacements,” Journal of Bone and Joint Surgery, Vol. 71, No. 5, 1989, pp. 798-803.
M. A. Ritter, E. Campbell, P. M. Faris and E. M. Keating, “Long Term Survival Analysis of Posterior Cruciate Condylar Total Knee Arthroplasty: Ten Year Evaluation,” Journal of Arthroplasty, Vol. 4, No. 4, 1989, pp. 293-296. doi:10.1016/S0883-5403(89)80029-4
J. Wright, F. C. Ewald, P. S. Walker, W. H. Thomas, R. Poss and C. B. Sledge, “Total Knee Arthroplasty with the Kinematic Prosthesis. Results after Five to Nine Years: A Follow-Up Note,” Journal of Bone and Joint Surgery, Vol. 72, No. 7, 1990, pp. 1003-1009.
S. H. Stern and J. N. Insall, “Posteriorly Stabilized Results after Follow up of 9 Years,” Journal of Bone and Joint Surgery, Vol. 74, No. 7, 1992, pp. 980-986.
C. S. Ranawat, W. F. Flynn Jr., S. Saddler, K. K. Hansraj and M. J. Maynard, “Long term Results of Total Condylar Knee Arthroplasty: A Fifteen Year Survivorship Study,” Clinical Orthopaedics and Related Research, Vol. 286, No. 1, 1993, pp. 94-102.
M. A. Ritter, S. A. Herbit, E. M. Keating, P. M. Faris, J. B. Meding, “Long Term Survival Analysis of Post Cruciate Retaining Total Condylar Knee Arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 309, No. 12, 1994, pp. 136-148.
A. L. Malkani, J. A. Rand, R. S. Bryan and S. L. Wallrichs, “Total Knee Arthroplasty with the Kinematic Condylar Prosthesis,” Journal of Bone and Joint Surgery, Vol. 77A, No. 3, 1995, pp. 423-431.
K. P. Emerson, C. J. Moran and I. M. Pinder, “Survivorship Analysis of the Kinematic Stabilizer Total Knee Replacement; 10 to 14 Year Follow up,” Journal of Bone and Joint Surgery, Vol. 78B, No. 3, 1996, pp. 441-446.
D. J. Weir, C. G. Moran, I. M. Pinder, “Kinematic Condylar Knee Arthroplasty: A Fourteen Year Survivorship Analysis of 208 Consecutive Cases,” Journal of Bone and Joint Surgery, 78 B, No. 6, 1996, pp. 907-911.
J. A. Rand, B. F. Morrey, R. S. Bryan, “Patellar Tendon Rupture after Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 244, No. 7, 1989, pp. 233-238.
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.
P. A. Haertsch, “The Blood Supply to the Skin of the Leg: A Post Mortem Investigation,” British Journal of Plastic Surgery, Vol. 34, No. 4, 1981, pp. 470-477. doi:10.1016/0007-1226(81)90061-8
R. S. Laskin, “Soft Tissue Techniques in Total Knee Replacement,” In: R. S. Laskin, Ed., Total Knee Replacement, Springer-Verlag, London, 1991, pp. 41-53.
K. Vince, “Revision Knee Arthroplasty Technique,” Instructional Course Lectures, Vol. 42, 1993, pp. 325-339.
R. Scapinelli, “Blood Supply of the Human Patella: Its Relation to Ischemic Necrosis after Fracture,” Journal of Bone & Joint Surgery, British Volume, Vol. 49, No. 3, 1967, pp. 563-570.
E. T. Habermann, “The Infected Total Knee Arthroplasty,” In: R. S. Laskin, Ed., Total Knee Replacement, Springer-Verlag, London, 1991, pp. 241-252.
K. Coonse and J. D. Adams, “A New Operative Approach to the Knee Joint,” Gynecological Surgery, Vol. 77, No. 4, 1943, pp. 344-347.
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.
M. J. Stuart, “Anatomy and Surgical Approaches,” In: B. F. Morrey, Ed., Reconstructive Surgery of the Joints, Churchill Livingstone, New York, 1996, p. 1345.
R. Scott and J. Siliski, “The Use of a Modified V-Y Quadricepsplasty during Total Knee Replacement to Gain Exposure and Improve Flexion in the Ankylosed Knee,” Orthopedics, Vol. 8, No. 45, 1985, pp. 45-48.
M. A. Ritter, S. A. Herbst, E. M. Keating, P. M. Faris and J. B. Meding, “Patellofemoral Complications Following Total Knee Arthroplasty: Effect of Lateral Release and Sacrifice of the Superior Lateral Geniculate Artery,” Journal of Arthroplasty, Vol. 11, No. , 1996, pp. 368-372. doi:10.1016/S0883-5403(96)80024-6
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.
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.
R. E. Windsor and J. N. Insall, “Exposure in Revision Knee Arthroplasty: The Femoral Peel,” Techniques in Orthopaedics, Vol. 3, No. 1, 1988, pp. 1-4.
R. T. Trousdale, A. D. Hansen, J. A. Rand and T. D. Cahalan, “V-Y Quadricepsplasty in Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 286, No. 1, 1993, pp. 48-55.
R. A. Denham and R. E. D. Bishop, “Mechanics of the Knee and Problems in Reconstructive Surgery,” Journal of Bone & Joint Surgery, Vol. 60B, No. 3, 1978, pp. 345-352.
R. N. Levy, “Osteotomy of the Tibial Tubercle in Total Knee Replacement,” Journal of Bone & Joint Surgery, Vol. 65A, No. 8, 1983, pp. 1207-1208.
A. M. Wolff, D. S. Hungerford, K. A. Krackow and M. A. Jacobs, “Osteotomy of the Tibial Tubercle during Total Knee Replacement,” Journal of Bone & Joint Surgery, Vol. 71A, No. 6, 1989, pp. 848-852.
L. A. Whiteside and M. D. Ohl, “Tibial Tubercle Osteotomy for Exposure of the Difficult Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research, Vol. 260, No. 11, 1990, pp. 6-9.
M. D. Ries and J. A. Richman, “Extended Tibial Tubercle Osteotomy in Total Knee Arthroplasty,” Journal of Arthroplasty, Vol. 11, No. 8, 1996, pp. 964-967. doi:10.1016/S0883-5403(96)80138-0
L. Whiteside, “Exposure in Difficult Total Knee Arthroplasty Using a Tibial Tubercle Osteotomy,” Clinical Orthopaedics and Related Research, 1995, Vol. 32, No. 321, pp. 32-35.
M. Ritter, “Complications Following Total Knee Arthroplasty,” Journal of Arthroplasty, 1996:11,117. doi:10.1016/S0883-5403(96)80171-9
M. J. Stuart, “Anatomy and Surgical Approaches,” In: B. F. Morrey, Ed., Reconstructive Surgery of the Joints, Churchill Livingstone, New York, Vol. 9, 1996, p. 1345.
G. A. Rorabeck Engh and J. P. McCauley, “Joint Line Restoration and Flexion Extension Balance with Revision Total Knee Arthroplasty,” In: G. A. Engh and C. Rorabeck, Eds., Revision Knee Arthroplasty, Williams and Wilkins, Baltimore, 1997, p. 235.
P. Sharkey, D. Homesley, S. Shastri, S. Jacoby and W. Hozack and R. Rothman, “Results of Revision Total Knee Arthroplasty after exposure of the Knee with Extensor Mechanism Tenolysis,” Journal of Arthroplasty, Vol. 19. No. 6, 2004, pp. 751-756. doi:10.1016/j.arth.2003.12.084
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. 526-529.