Dr. Mark Pagnano’s Tips and Tricks for Revision TKA

    At ICJR’s Winter Hip & Knee Course, Mark W. Pagnano, MD, from Mayo Clinic in Rochester, Minnesota, shared the tried-and-true techniques he relies on for surgical management of revision total knee arthroplasty (TKA) patients.

    A wide exposure is needed.

    A revision procedure is no time to fixate on making a small incision. Dr. Pagnano makes a long midline incision – generally 6 to 8 inches long – by proximally and distally extending the most lateral anteriorly based prior incision.

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    Use a curved osteotome for exposing the lateral side of the tibia.

    Slide a ¾-inch curved osteotome next to the implant to elevate any remaining cement and/or heterotopic bone.

    Use a narrow, flexible saw blade to get under the tibial tray.

    A standard, thick saw blade will not cut through the cement interface as effectively as a narrow, flexible blade, Dr. Pagnano said. A narrow blade can also be more easily manipulated in the back of the knee, causing less damage to the soft tissue.

    Disimpact the tibial tray using a thin punch placed laterally, not medially.

    As a starting point, use a narrow rongeur to make a small notch under the lateral edge of the anterior tibial tray. Then, make a nick through the retinaculum lateral to the patellar tendon. Slide a narrow, square-tip impactor under the patellar tendon and into the notch under the tibial tray. This provides the angle needed for applying enough force to disimpact the tray.

    Avoid valgus of tibial stems and sleeves.

    To compensate for the tendency of the stems and sleeves to fall into valgus, Dr. Pagnano deliberately forces reamers and broaches into varus. Doing so, he said, will more consistently place the revision components in proper alignment.

    Click the image above to hear more from Dr. Pagnano about revision TKA.


    Dr. Pagnano has disclosed that he receives royalties from DePuy and Stryker.