JBJS | Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Specialized Exposure for Revision Total Knee Arthroplasty: Quadriceps Snip and Patellar Turndown*†

The Journal of Bone & Joint Surgery, Volume 81, Issue 1

Instructional Course Lecture | January 01, 1999

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Specialized Exposure for Revision Total Knee Arthroplasty: Quadriceps Snip and Patellar Turndown*†

ROBERT L. BARRACK, M.D.†, NEW ORLEANS, LOUISIANA

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An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone & Joint Surgery. 1999; 81:138-141

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Introduction

Introduction | References

Adequate exposure of the knee is the first step in the successful performance of a revision total knee arthroplasty. In order to safely and expeditiously remove the implants that are in place and insert trial and actual components, flexion well beyond 90 degrees (to about 110 degrees) is needed¹³. In addition, it is preferable to be able to evert the patella and dislocate the tibia anteriorly. If a patient has less than 80 to 90 degrees of passive flexion under anesthesia, the standard medial parapatellar approach may not provide adequate exposure. Initially, it is useful to start the midline incision more proximally than the previous incision in order to establish normal tissue planes proximal to the extensor mechanism. It is also useful to take additional time to define the borders of the rectus femoris tendon and the vastus lateralis and medialis insertions into the patella. The medial parapatellar capsular incision begins at the proximal extent of the rectus tendon and ends distally one centimeter medial to the tibial tubercle. After a medial arthrotomy, release of any adhesions in the suprapatellar pouch and the medial and lateral gutters should be performed. Careful release or excision of scarred or contracted tissue leads to increased flexion and easier eversion of the patella and provides adequate exposure in many patients. Access to the lateral gutter is more difficult after a standard medial arthrotomy. A medial capsular release from the tibia is typically extended past the mid-coronal plane, usually to the posteromedial corner of the knee just anterior to the semimembranosus insertion. External rotation of the tibia after medial release and clearing of the gutters and the suprapatellar pouch usually increases knee flexion to some degree. The next maneuver that improves exposure is the application of traction on the patella as the knee is flexed and an attempt is made to evert the patella. This places the fibers of the patellofemoral ligament, which extends from the lateral epicondyle to the lateral border of the patella, under tension. This band of tissue has been described as a separate entity from the lateral retinaculum⁶. Routine release of these fibers assists in patellar eversion, allows easier lateral retraction of the patella (thus improving exposure), and often improves patellar tracking^6,9. After all of these maneuvers, passive knee flexion and patellar eversion are assessed. If the knee cannot be flexed well beyond 90 degrees without excessive tension on the patellar ligament (patellar tendon) and patellar eversion is not possible, additional steps must be taken in order to accomplish these goals.

There are two basic approaches to achieving more flexion: it can be achieved proximally through the extensor mechanism or distally through the tibial tubercle. If the proximal approach is elected, the options include dividing the quadriceps tendon, the lateral retinaculum, or the vastus lateralis tendon, or some combination of the three. Isolated division of the rectus tendon to improve exposure during knee arthroplasty has been called the quadriceps snip and is attributed to Insall⁵. Early on, this was described as a transverse cut across the proximal portion of the rectus tendon⁹ (Fig. 1). Later, it was modified to be a 45-degree oblique incision extending from the lateral aspect of the quadriceps tendon proximally to the medial aspect of the quadriceps tendon distally⁴ (Fig. 2). This incision has a number of potential advantages in that it is directed in line with the vastus lateralis muscle and away from the lateral superior genicular artery and the vastus lateralis tendon. It also provides more leeway in closing the defect⁴. If adequate exposure is not obtained with the quadriceps snip, it can be combined with a lateral retinacular release placed longitudinally approximately one centimeter lateral to the lateral border of the patella⁹ (Fig. 3). A more recent modification of the quadriceps snip angles the lateral portion of the 45-degree oblique incision distally rather than proximally⁹ (Fig. 4). This has the advantage of being more extensile (versatile) because it can more easily be converted into a complete patellar turndown. The advantages of the quadriceps snip are that it is technically easy, it spares the major vascular supply to the patella (the lateral superior genicular artery), it has not been associated with postoperative complications such as extension lag, and the postoperative rehabilitation does not have to be modified.

In one study, objective assessment consisting of isokinetic testing of patients who had had a total knee arthroplasty with a quadriceps snip revealed that the involved knee was not as strong as the normal, contra-lateral knee⁴. However, with the numbers available for study, the authors could detect no significant difference (although there was a trend) in terms of peak torque (p = 0.06) or work (p = 0.07) between the knees that had been treated with a total knee arthroplasty through a standard approach and those treated with a total knee arthroplasty and a quadriceps snip⁴. In another review, the results of thirty-one revision total knee arthroplasties performed with a quadriceps snip were found to be equivalent to those of sixty-three revision total knee arthroplasties performed with a standard medial parapatellar approach; these results were measured in terms of the clinical, functional, and total scores of the Knee Society rating system; range of motion; extension lag; patellofemoral pain; and patient satisfaction². The quadriceps snip has been reported to be applicable to most, if not all, knees with limited motion⁴. Other authors have reported that this technique is effective only for knees with mild-to-moderate stiffness and that more extensive procedures are necessary for very stiff knees^9,13. In this scenario, the quadriceps snip can be combined with an osteotomy of the tibial tubercle or it can be converted to a patellar turndown.

In 1983, Insall performed a modification of the approach of Coonse and Adams⁴. This modification, the patellar turndown, consists of a standard medial parapatellar capsular incision combined with an oblique distal cut from the proximal extent of the arthrotomy across the rectus tendon, the vastus lateralis tendon, and the lateral retinaculum (Fig. 5). It provides rapid, wide exposure of knees that have a moderate-to-severe degree of stiffness and gives easy access to the lateral gutter through the oblique arm of the incision. This allows lysis of dense adhesions and rapid mobilization of the extensor mechanism. It releases all tension on the insertion of the patellar ligament and all but eliminates the risk of avulsion of the patellar ligament. This approach also allows for easy access to the central anterior portion of the proximal part of the tibia, which is particularly helpful during trial reductions because most revision tibial components are modular and require the tibial insert to be slid in parallel to the base-plate and directly from the front. This can place very high tension on the patellar ligament in a stiff knee as retractors are levered laterally to allow placement of the insert. The patellar turndown makes this potentially dangerous portion of the procedure safe and easy.

The site of the patellar turndown should be repaired with heavy, nonabsorbable suture. The so-called V-Y incision allows advancement of a centimeter or more, if necessary. The rectus and vastus lateralis tendons are repaired, but some or all of the lateral retinaculum is typically left open to improve flexion and patellar tracking. It is prudent to use three or four sutures and to test the tension of the repair during flexion. Releasing the tourniquet before testing the repair probably gives a more accurate estimate of the excursion of the extensor mechanism. Reattachment at the appropriate level of tension can be difficult. If the knee easily flexes beyond 90 degrees, the repair should be redone with less advancement. If the quadriceps is lengthened too much, an extension lag can result and may impair function. An extension lag of 10 degrees or more was reported in three of fourteen cases in one series² and in two of sixteen cases in another¹². Trousdale et al. reported severe weakness of knee extension after a V-Y quadricepsplasty compared with extension of the normal, contralateral knee (p < 0.05) but not compared with extension of a knee after a total knee arthroplasty¹². Garvin et al. reported similar findings with the quadriceps snip^4,12.

The patellar turndown approach necessitates a modification of the postoperative rehabilitation to protect the repair. Originally, two weeks of immobilization was recommended after a patellar turndown^1,5. More recently, immediate continuous passive motion starting at 0 to 30 degrees has been recommended¹². The point at which the original repair comes under tension should be noted, and passive motion with the continuous-passive motion machine can be increased 10 degrees per day until that degree of flexion is obtained². Active flexion and passive extension can be started immediately, but it is probably prudent to delay straight-leg raising and other active extension exercises until there has been adequate time for early healing of the tendon (normally within four to six weeks).

There are other potential difficulties with the patellar turndown, including difficulty in using it more than once¹¹. If a knee is infected and repeated operative exposures are needed, performing and repairing a patellar turndown several times may be difficult. Another potential problem that has been noted is devascularization of the patella and the extensor mechanism by extending an oblique incision through the lateral retinaculum¹⁰. This invariably transects the lateral superior genicular artery. The patellar turndown approach is thought by some to spare the lateral inferior genicular blood supply to the extensor mechanism⁷. Other authors, however, have noted that this vessel is normally cut during a lateral meniscectomy¹³. Scott and Siliski modified the patellar turndown to avoid interruption of the vascular supply to the patella¹⁰. The distal extent of the incision that they described carried the apex distally for three centimeters along the insertion of the vastus lateralis muscle (Fig. 6). It therefore stops proximal to the lateral superior genicular artery and does not include a lateral retinacular release. Many patients with stiff knees have lateral retinacular tightness and associated maltracking of the patella that necessitate extensive lateral release. This approach was termed the modified V-Y quadricepsplasty¹⁰. Although it preserves the blood supply to the patella by sparing the lateral superior genicular artery, it does not provide as extensive an exposure and it does not relieve tension on the patellar ligament. Maintenance of the blood supply may be more of a theoretical advantage, as Ritter et al. found no difference in the rate of patellar complications, including radiolucency, loosening, and fracture, with preservation of the lateral superior genicular artery⁸. They concluded that preserving the lateral superior genicular artery was not necessary.

The combination of a quadriceps snip and a lateral retinacular release provides adequate exposure for most revision total knee arthroplasties². Conversion to a patellar turndown may be necessary for knees with moderate or severe stiffness. This approach greatly expedites the performance of a revision knee replacement in an ankylosed joint and minimizes the risk of avulsion of the patellar ligament, which is among the most devastating complications of knee arthroplasty. The reconstruction is performed proximally in the thigh, where the vasculature and soft-tissue coverage are excellent, so that problems related to wound-healing do not occur. The only important complications are weakness of extension and extension lag, which are transient most of the time and are rarely functionally debilitating in the few patients in whom they persist^2,12.

*Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 48, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1999.

†No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, SL32, New Orleans, Louisiana 70112.

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FIG1:: Fig. 1A: Drawing depicting the early quadriceps snip with transverse sectioning of the proximal portion of the rectus tendon. The incision is outlined by dotted lines. B: In some patients, patellar eversion is possible after completion of the quadriceps snip.

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FIG2:: Fig. 2A: Drawing depicting an early modification of the quadriceps snip extending obliquely from proximal to distal. The incision is outlined by dotted lines. B: Patellar eversion is possible after an incision is made extending along the fibers of the vastus lateralis.

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FIG3:: Fig. 3A: Drawing depicting a combination of the quadriceps snip and a lateral retinacular release. The incision is outlined by dotted lines. B: This combination provides adequate exposure for most revision total knee arthroplasties.

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FIG4:: Fig. 4A: Drawing depicting on oblique incision that is oriented distally. The incision is outlined by dotted lines. B: Exposure after a modified patellar turndown.

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FIG5:: Fig. 5A: Drawing depicting a patellar turndown transecting the rectus tendon, the vastus lateralis tendon, and the lateral retinaculum. The incision is outlined by dotted lines. B: The completed incision.

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FIG6:: Fig. 6 Drawing depicting how the incision for a modified V-Y quadricepsplasty curves along the edge of the vastus lateralis tendon, avoiding the lateral superior genicular artery. The incision is outlined by dotted lines.

References

Introduction | References

Aglietti, P.; Windsor, R. E.; Buzzi, R.; and and Insall, J. N.: Arthroplasty for the stiff or ankylosed knee. J. Arthroplasty,4: 1-5, 1989.41 1989 [PubMed]

Barrack, R. L.; Smith, P.; Munn, B.; Engh, G. A.; and Rorabeck, C.: Comparison for surgical approaches in TKA. Unpublished data.

Coonse, K., and and Adams, J. D.: A new operative approach to the knee joint. Surg., Gynec. and Obstet.,77: 344-347, 1943.77344 1943

Garvin, K. L.; Scuderi, G.; and and Insall, J. N.: Evolution of the quadriceps snip. Clin. Orthop.,321: 131-137, 1945.321131 1945

Insall, J. N.: Surgical approaches to the knee. In Surgery of the Knee, edited by J. N. Insall, R. E. Windsor, W. N. Scott, M. A. Kelly, and P. Aglietti, Ed. 2, vol. 1, pp. 135-148. New York, Churchill Livingstone, 1993.

Krackow, K. A.: Surgical procedure. In the Technique of Total Knee Arthroplasty, pp. 168-237. Edited by E. A. Klein. St. Louis, C. V. Mosby, 1990.

Peters, P. C., Jr.: Surgical exposure for revision total knee arthroplasty. In Revision Total Knee Arthroplasty, pp. 195-204. Edited by G. A. Engh and C. H. Rorabeck. Baltimore, Williams and Wilkins, 1997.

Ritter, M. A.; Herbst, S. A.; Keating, E. M.; Faris, P. M.; and and Meding, J. B.: Patellofemoral complications following total knee arthroplasty. Effect of a lateral release and sacrifice of the superior lateral geniculate artery. J. Arthroplasty,11: 368-372, 1996.11368 1996 [PubMed]

Rosenberg, A. G.: Surgical technique of posterior cruciate sacrificing, and preserving total knee arthroplasty. In Total Knee Arthroplasty pp. 115-153. Edited by J. A. Rand. New York, Raven Press, 1993.

Scott, R. D., and and Siliski, J. M.: the use of a modified V-Y quadricepsplasty during total knee replacement to gain exposure and improve flexion in the ankylosed knee. Orthopedics,8: 45-48, 1985.845 1985 [PubMed]

Stiehl, J. B.; Anouchi, Y.; Dennis, D. A.; Greenwald, A. S.; Krackow, K. A.; Rosenberg, A. G.; Stulberg, S. D.; and and Whiteside, L. A.: Symposium: revision total knee replacement. Contemp. Orthop.,30: 249-276, 1995.30249 1995 [PubMed]

Trousdale, R. T.; Hanssen, A. D.; Rand, J. A.; and and Cahalan, T. D.: V-Y quadricepsplasty in total knee arthroplasty. Clin. Orthop.,286: 48-55, 1993.28648 1993 [PubMed]

Younger, A. S. E.; Duncan, C. P.; and and Masri, B. A.: Surgical exposures in revision total knee arthroplasty. J. Am. Acad. Orthop. Surgeons,6: 55-64, 1998.655 1998

Topics

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FIG4:: Fig. 4A: Drawing depicting on oblique incision that is oriented distally. The incision is outlined by dotted lines. B: Exposure after a modified patellar turndown.

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Aglietti, P.; Windsor, R. E.; Buzzi, R.; and and Insall, J. N.: Arthroplasty for the stiff or ankylosed knee. J. Arthroplasty,4: 1-5, 1989.41 1989 [PubMed]

Barrack, R. L.; Smith, P.; Munn, B.; Engh, G. A.; and Rorabeck, C.: Comparison for surgical approaches in TKA. Unpublished data.

Coonse, K., and and Adams, J. D.: A new operative approach to the knee joint. Surg., Gynec. and Obstet.,77: 344-347, 1943.77344 1943

Garvin, K. L.; Scuderi, G.; and and Insall, J. N.: Evolution of the quadriceps snip. Clin. Orthop.,321: 131-137, 1945.321131 1945

Krackow, K. A.: Surgical procedure. In the Technique of Total Knee Arthroplasty, pp. 168-237. Edited by E. A. Klein. St. Louis, C. V. Mosby, 1990.

Trousdale, R. T.; Hanssen, A. D.; Rand, J. A.; and and Cahalan, T. D.: V-Y quadricepsplasty in total knee arthroplasty. Clin. Orthop.,286: 48-55, 1993.28648 1993 [PubMed]

Younger, A. S. E.; Duncan, C. P.; and and Masri, B. A.: Surgical exposures in revision total knee arthroplasty. J. Am. Acad. Orthop. Surgeons,6: 55-64, 1998.655 1998

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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ROBERT L. BARRACK; Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Specialized Exposure for Revision Total Knee Arthroplasty: Quadriceps Snip and Patellar Turndown*†. The Journal of Bone & Joint Surgery. 1999 Jan;81(1):138-141.

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