SURGICAL PEARLS: Tourniquet Use, Exposure, and Component Removal in Revision TKA
At ICJR’s Pan Pacific Orthopaedic Congress, Raymond H. Kim, MD, now with The Steadman Clinic in Vail, Colorado, offered his tips, tricks, and surgical pearls for draping the leg, using a tourniquet, achieving surgical exposure, and removing components in a revision total knee arthroplasty (TKA).
Tip 1: Drape the leg as if the patient will be undergoing a direct anterior approach total hip arthroplasty
Dr. Kim wants to see the alignment of the entire leg, from ankle to hip, and so he does not drape all the way to the knee. This allows him to more accurately assess alignment during the procedure.
Tip 2: Reconsider the use of a tourniquet
Similarly, use of a tourniquet impedes Dr. Kim’s ability to assess alignment and so he prefers tourniquet-less surgery.
In addition, he and his colleagues conducted a study of patients undergoing bilateral TKA, in which one leg had a tourniquet and the other did not. They found better quadriceps strength and less pain in the limb in which the tourniquet was not used or was used only for cementing the implant.
Tip 3: The rectus snip is generally all that’s needed for adequate exposure
The rectus snip is the workhorse of exposure in revision TKA, Dr. Kim said. He noted that tibial tubercle osteotomy and V-Y turndown are typically unnecessary in 99.9% of patients.
Tip 4: Aggressive synovectomy might not be needed – or it might be essential
Patients who are undergoing revision TKA due to an unstable knee may not need an aggressive synovectomy. But for patients with a stiff knee, be sure to do a thorough synovectomy and clear the medial gutters.
Tip 5: A simple technique can mobilize the extensor mechanism
To mobilize the extensor mechanism in some revision TKA patients, it may be necessary to use a knife to score the scar tissue behind the patellar tendon. This allows the extensor mechanism to evert or even mobilize, Dr. Kim said.
Tip 6: Component removal should be done as a stepwise progression
The goal is to remove the components with minimal bone loss, moving from tibial insert removal to femoral component removal, and then tibial component removal. Patience is needed, as well as a knowledge of the type of component and its geometry.
Click the image above to watch Dr. Kim’s presentation.