Exposure of the Problem Knee: Stiffness, Previous Incisions
Kevin I. Perry
Key Concepts
Previous incisions or soft tissue coverage (Figure 47.1A and B) around a knee increase the risks of wound healing issues and periprosthetic joint infection.
In patients with compromised soft tissues, early motion must sometimes be delayed to ensure wound healing.
A sequential approach must be taken to obtain adequate exposure of the stiff knee.
Stiff knees often require a more extensile approach to protect the integrity of the extensor mechanism. Often a quadriceps snip and occasionally a tibial tubercle osteotomy will be performed to expose the knee.
Wound complications occur more frequently in patients with previous incisions and tenuous soft tissues around the front of the knee (Figure 47.2).
If the skin or soft tissues are tenuous after knee replacement, a period of immobilization is wise to promote wound healing.
Intraoperative use of laser angiography (if available) is useful to determine viability of the skin and soft tissues around the knee and help decide if muscle flap coverage is necessary.
Sterile Instruments and Implants
Instruments
Standard total knee arthroplasty (TKA) retractors and instruments
Sagittal saw
Implants
A full complement of constrained implants (posterior stabilized, varus-valgus constrained, hinged) should be available as the integrity of the collateral ligaments can be compromised during exposure of the stiff knee.
Position
Supine position on the operating table
Surgical Approaches
In general, the lateral-most incision that can safely access the knee is used.
Full-thickness flaps (down to the level of the fascia) are created and typically, a standard, median parapatellar arthrotomy is done.
Figure 47.1 ▪ Preoperative AP (A) and lateral (B) photographs demonstrating soft tissue coverage and split-thickness skin grafting around the front and lateral aspects of the knee.
Extensile exposures may be needed for the stiff knee: these include a quadriceps snip or, in rare cases, a tibial tubercle osteotomy. Those techniques are described in Chapter IV-B-2.Related posts:
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