Medial Arthrotomy

Chapter Synopsis

Patient selection and physical examination of the patient who is a candidate for a standard medial parapatellar arthrotomy in revision total knee arthroplasty (TKA) are discussed. Step-by-step surgical techniques for the standard medial parapatellar arthrotomy are described, including surgical “pearls” describing ways to increase the exposure without extension to further extensile approaches.

Important Points

A standard medial parapatellar arthrotomy is claimed to be used in most revision TKAs. However, adequate exposure in the strict standard medial parapatellar arthrotomy may be affected by several factors, including the cause of revision surgery, the condition of skin and soft tissue around the knee, the range of motion (ROM), and the change of the normal knee anatomy.

Surgical Pearls

The following sequential procedures are useful for increasing the surgical exposure in revision TKA using a standard medial parapatellar arthrotomy:

• Excision of thickened synovium and fibrous tissues and lysis or débridement of scarred tissue in both medial and lateral gutters

• Débridement of scarred tissue beneath the extensor mechanism, including scarred tissue at the patellar tendon, around the patella, and at the quadriceps tendon

• Release of the lateral retinaculum to increase patellar mobility

• Subperiosteal peel of the distal femur to increase visualization of the distal femur

• Extensile arthrotomy if the exposure is still limited

Surgical Pitfalls

Revision TKA under inadequate exposure may cause intraoperative complications ranging from skin problems to avulsion of the patellar tendon from the tibial attachment, which is a catastrophic problem. Avoidance of these complications by careful evaluation of the tension of the capsule and surrounding tissues is mandatory.