OKOJ, Volume 6, No. 4

Surgical Exposures in Revision Total Knee Arthroplasty

Revision total knee arthroplasty is a demanding procedure that requires attainment of adequate surgical exposure to achieve a successful outcome. In the revision setting, the anatomy of the soft-tissue envelope has been disrupted by prior surgery and subsequent formation of scar tissue. Sufficient exposure must be achieved to enable implant removal, restoration of the joint line, balancing of the soft-tissue structures that confer stability to the joint, and proper alignment of revision implant components. Potential complications attributable to lack of adequate surgical exposure include iatrogenic disruption of the infrapatellar ligament, injury to the collateral ligaments, wound necrosis, neurovascular injury, and implant malalignment. Preoperative assessment should include a thorough history; physical examination; documentation of range of motion, stability, and prior scars; radiographic analysis; and evaluation for infection. This article will address strategies for extensile surgical exposure in revision total knee arthroplasty, including extracapsular and intracapsular approaches, excision of scar tissue, patellar turndown, rectus snip, epicondylar osteotomy, circumferential femoral exposure, and tibial tubercle osteotomy.

    • Keywords:
    • TKA

    • total knee replacement

    • knee replacement

    • knee replacement surgery

    • artificial knee

    • total joint arthroplasty

    • total joint replacement

    • extensile exposures

    • Subspecialty:
    • Adult Reconstruction

Syndactyly of the Hand

Syndactyly of the hand is a congenital anomaly characterized by an abnormal connection between adjacent digits. Simple syndactyly, which involves a soft-tissue connection between digits, occurs with an approximate incidence of 2 to 3 per 10,000 live births and tends to happen in families. Mild simple syndactyly that does not interfere with function does not require treatment. However, simple syndactyly of any considerable degree warrants surgical reconstruction of the web space for improved function and appearance. In most instances, reconstruction for simple syndactyly can be delayed until the child is 18 months of age, but release of border digits should be performed within the first few months of life to prevent development of a progressive tethering deformity. Reconstruction of the commissure is the most technically challenging aspect of the procedure. A local dorsal flap is recommended for commissure reconstruction to avoid the use of skin graft within the web space and to recreate the normal dorsal-to-palmar commissure slope. Full-thickness skin grafting is almost always required to cover residual uncovered areas. Complex syndactyly, which involves fusion of adjacent phalanges or interposition of accessory bones, warrants special surgical consideration. Strict guidelines for surgical reconstruction of complex syndactyly do not exist, however, and treatment must be individualized. Following reconstruction, patients should be assessed periodically because late complications such as web creep can occur.

    • Keywords:
    • webbed fingers

    • simple syndactyly

    • incomplete simple syndactyly

    • complete simple syndactyly

    • complex syndactyly

    • complicated syndactyly

    • Apert syndrome

    • Polands syndrome

    • amniotic constriction band syndrome

    • synpolydactyly

    • cleft hands

    • symbrachydactyly

    • spade hand

    • mitten hand

    • spoon hand

    • rosebud hand

    • hoof hand

    • central deficiency

    • symphalangism

    • Subspecialty:
    • Hand and Wrist

Acromioclavicular Joint Injuries

Injuries to the acromioclavicular (AC) joint are common (approximately 9% of shoulder girdle injuries) and occur most often in young men. A blow to the lateral acromion as a result of direct trauma, such as falling off a bicycle, or a superiorly directed force from the upper arm that pushes the humeral head under the acromion are typical mechanisms of AC joint injury. Injury to the AC joint is understood as a sequential loss of joint stabilizers (AC and coracoclavicular [CC] ligaments). The classification of AC joint injury reflects this anatomic progression of injury and is useful for guiding treatment. Type I and II AC joint injuries are considered incomplete lesions and may be treated conservatively with ice, rest, and immobilization, followed by physical therapy. Type IV, V, and VI injuries are complete injuries that usually require surgical intervention. The treatment of type III AC joint injuries is controversial. Currently, there is no consensus on patient selection, timing of intervention, and choice of surgical fixation. The augmented Weaver-Dunn procedure is currently the gold standard of surgical treatment of AC joint separations. In the traditional Weaver-Dunn, the AC joint is resected and the CA ligament is transferred to the end of the clavicle to provide stability in the horizontal and vertical planes. Most surgeons now add a nonbiologic or biologic augmentation. An alternative surgical intervention is anatomic CC ligament reconstruction, which is designed to closely approximate the intact state and may provide better stability.

    • Keywords:
    • AC joint injury

    • shoulder separation

    • shoulder dislocation

    • AC separation

    • AC joint disruption

    • acromioclavicular disruption

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow