The patient is a 68-year-old female who was referred 18 months after a total knee arthroplasty (TKA) because of complaints of pain and instability of her knee while ambulating. A TKA had been performed for osteoarthritis, and her perioperative course was unremarkable for wound drainage or difficulty with wound healing. She reported that she was compliant with her postoperative range-of-motion (ROM) rehabilitation but was unable to achieve flexion beyond 70 degrees despite postoperative manipulation.
The patient’s past history did not reveal any unusual disease or remote history that may have contributed to her knee problems.
The examination revealed a pleasant woman with a height of 63 inches and a weight of 190 pounds. Her body mass index was 33.7. The patient was afebrile. The knee was diffusely tender with a palpable effusion. The patient was able to extend her knee fully and had limited flexion to approximately 70 degrees. Ligamentous examination found her knee to be stable to varus and valgus stresses. Quadriceps strength was 4/5, and the peripheral neurocirculatory examination of the extremity was normal.
The radiographs, including weight-bearing anteroposterior and lateral views, revealed that the limb was well aligned ( Fig. 7.1 ). The components appeared to be well fixed and cemented on radiographs. Laboratory evaluation included a normal erythrocyte sedimentation rate (ESR) and normal C-reactive protein level. An aspiration of the knee included fluid that was yellow and had a white blood cell count of 1100 cells/μL.
The diagnosis was arthrofibrosis after TKA.
The patient consented for revision surgery and was brought to the operating room for that procedure. The surgical approach for the revision TKA was facilitated by removal of hypertrophic synovium and scar, allowing for reestablishment of the medial and lateral gutters of the knee. An additional exposure included an extensile release of the soft tissues from the proximal medial and posteromedial tibia. Finally, a quadriceps snip was performed because of the difficulty of the exposure. The knee components were revised without complications. Flexion and extension gaps were also restored.
The patient’s postoperative course has been unremarkable to date. The patient has occasional mild discomfort associated with prolonged activity but has been able to resume a normal walking program for pleasure and exercise. The patient reports that her knee is stable and she has been able to regain knee motion with full extension and flexion to approximately 105 degrees. Radiographs of the knee show the reconstructed components ( Fig. 7.2 ).
The chapter provides the reader with salient points about the surgical exposure in revision total knee arthroplasty (TKA). A case study and surgical technique are included in the chapter and provide information enabling the surgeon to more fully understand the nuances of the quadriceps snip for exposure in revision TKA.
The approach must be methodical with attention given to the details of soft tissue handling and release of the contracted tissue. The contracted tissue must be released because it limits the exposure during revision TKA, but the extensor mechanism must be protected.
Patient selection is critical for any surgical procedure and particularly for revision surgery. The patient whose knee is stiff, multiply operated, or previously revised is a patient who is a good candidate for the quadriceps snip technique.
Removal of hypertrophic synovium and scar allows for the medial and lateral gutters of the knee to be reestablished and for medial and posteromedial soft tissue release from the tibia.
Meticulous repair of the extensor mechanism and quadriceps snip should be performed.
Physical therapy is not restricted in this patient population.
An aggressive release of the lateral soft tissues can result in devascularization of the quadriceps tendon with ultimate tissue necrosis leading to an extensor lag. In our experience, this aggressive release has not been necessary, and in no instance has there been a significant extensor lag associated with necrosis of the quadriceps tendon.
The patellar tendon may become disrupted if attention to detail is neglected and the patellar tendon is disrupted.
Adequate exposure is one of the most common difficulties encountered in revision TKA. The quadriceps snip is a proximal soft tissue release that results in excellent exposure with minimal risk. The approach has gradually evolved from that initially described by Coonse and Adams in 1943 ( Fig. 7.3 ). Their approach was modified by lnsall in 1983 to allow extensive exposure while preserving the blood supply to the turned-down segment and maintaining the integrity of the vastus medialis ( Fig. 7.4 ). This modification, also known as the patellar turndown, was used until 1988 as a standard approach for treatment of a stiff, ankylosed, or revised knee when exposure is difficult. At that time, while assisting another surgeon, Insall noticed that the proximal portion of the quadriceps had been transected in an oblique fashion. The surgeons were impressed with the additional exposure provided. After completion of the observed surgical procedure, the tendon was repaired in a standard fashion. The patient’s postoperative course was uneventful, and motion was not impaired, emphasizing the innocuous nature of the quadriceps incision. Since that time, the procedure, now known as the quadriceps snip, has been refined and has provided an alternative to the patellar turndown ( Fig 7.5 ). This chapter describes the surgical technique and our experience with 129 patients who underwent this procedure from 1996 to 2006.