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February 19, 2016
Contributors: Mark P Figgie, MD; Lucian C Warth, MD; Douglas E Padgett, MD; Alberto Carli, MD; Alberto Carli, MD
The incidence of revision total knee arthroplasty (TKA) has increased steadily in the United States over the last decade. A 2010 study of the Nationwide Implant Sample Database found that the most common type (35.2%) revision TKA involved the removal of both the femoral and tibial components. For most orthopaedic surgeons, undertaking such a case is no small task, as it requires rigorous preoperative planning and thorough knowledge of knee anatomy. In light of the increasing incidence of revision TKA, we have created this video to demonstrate the key steps in exposing a previously operated knee and removing well-fixed components. We begin by reviewing the vascular supply to the anterior knee and how surgeons should choose a surgical incision to utilize. We then introduce our approach to systematically exposing the knee in a step-wise fashion: clearing the medial and lateral gutters, performing an anteromedial tibial release, and mobilizing the extensor mechanism. We also describe advanced techniques to mobilize the patella: the inside-out lateral release and the quadriceps snip. Removal of different polyethylene inserts are shown to demonstrate the variability in insert locking mechanisms. The second portion of the video is dedicated to removing well-fixed femoral and tibial components. We compare the difference in steps required to remove cemented and cementless components. The final portion of the video offers tips and tricks to removing a fully cemented stemmed tibial component. Through using first-person intraoperative perspective, we show how the surgeon should carefully manipulate high-speed burrs and trephines to remove implants while minimizing bone loss. We believe that good exposure is the cornerstone to success in revision TKA and we hope that aspiring arthroplasty surgeons find this video to be helpful in planning their next component revision.