Extensile Exposures



Extensile Exposures


Adam Hart

Robert T. Trousdale



Key Concepts



  • Indications of a potentially difficult exposure (Figure 60.1) during revision surgery should be sought preoperatively by considering:



    • The superficial exposure—Evaluation of the skin and location of prior incisions, which may mandate the approach used at revision or prompt the opinion/help of a plastic surgeon.


    • The deep exposure—Evaluation for prior surgeries and implants, limited preoperative range of motion, significant obesity, and patella baja.


  • Excellent exposure to the knee can be safely obtained by following a sequence of stepwise maneuvers described in this chapter, which consists of:



    • Skin and superficial dissection creating full-thickness skin flaps.


    • Medial arthrotomy and sequential soft tissue releases.


    • Removal of components.


    • Additional extensile exposures such as the quadriceps snip and tibial tubercle osteotomy.


Sterile Instruments and Implants



  • Perioperative—Consider using intraoperative blood salvage systems, tranexamic acid, tourniquet, Foley catheterization, intraoperative fluoroscopy or x-rays.


  • Extras—Consider a small blade saw, flexible osteotomes, and cerclage wires (for fixation of a tibial tubercle osteotomy).


Surgical Approaches



  • A midline incision (unless contraindicated by prior surgeries) with a medial parapatellar arthrotomy with subluxation of the patella is most commonly used. The sub- or midvastus and lateral parapatellar approaches are less extensile and therefore avoided for revision surgeries.


Preoperative Planning



  • Skin considerations—Careful evaluation of the skin for lesions, wounds, and prior incisions is mandatory. Generally, the cutaneous blood supply is from medial to lateral; therefore, the lateral-most acceptable longitudinal incision should be utilized. This also minimizes disruption of the lymphatic system, which drains from lateral to medial. A skin bridge of 7 cm is usually sufficient, and crossing incisions should be made at right angles (Figure 60.2). In complex cases, consultation with a plastic surgeon should be considered where soft tissue expanders or flaps may be necessary.


  • Physical examination—Patients with notable stiffness are most likely to have a difficult exposure. Examination of passive range of motion as well as laxity in the coronal and sagittal planes and extensor mechanism function are paramount.







    Figure 60.1 ▪ A 20-year-old patient with posttraumatic arthritis of his right knee following a motor vehicle accident, traumatic arthrotomy, and subsequent open reduction and internal fixation (hardware removed). Preoperative radiographs (A and B), photograph of planed incision (solid lines) (C), and photograph of healed incision 6 weeks after total knee replacement (D).


  • Radiographs—Evaluate the presence of deformity, bone quality, patella position, and current implanted components. A stemmed, cemented tibial component may prompt the use of a tibial tubercle osteotomy to facilitate implant and cement removal (Figure 60.3). Furthermore, review of prior operative reports is recommended to know exactly what components are implanted. Plan ahead to have the necessary instruments and parts needed during the revision surgery.


Bone, Implant, and Soft Tissue Techniques

Dec 14, 2019 | Posted by in ORTHOPEDIC | Comments Off on Extensile Exposures

Full access? Get Clinical Tree

Get Clinical Tree app for offline access