Surgical approaches for total knee arthroplasty

Abstract

There are various surgical approaches to the knee joint and its surrounding structures and such approaches are generally designed to allow the best access to an area of pathology whilst safeguarding important surrounding structures. Controversy currently surrounds the optimal surgical approach for total knee arthroplasty (TKA). The medial parapatellar arthrotomy, or anteromedial approach, has been the most used and has been regarded as the standard approach for exposure of the knee joint. It provides extensive exposure and is useful for open anterior cruciate ligament reconstruction, total knee replacement, and fixation of intra-articular fractures. Because this approach has been implicated in compromise of the patellar circulation, some authors have advocated the subvastus, midvastus, and trivector approaches for exposure of the knee joint. While these approaches expose the knee from the medial side, the anterolateral approach exposes the knee joint from the lateral side. With careful planning and arthrotomy selection, the anterior aspect of the joint can be adequately exposed for TKA in different clinical scenarios.

Keywords: Medial parapatellar approach; Surgical approach; Total knee replacement (TKR).

Fig. 1

Skin incision marked on the skin. Circle represents the patella and the straight line the skin incision. Horizontal lines across the vertical line help in achieving accurate closure.

Fig. 2

Clinical image depicting the incision for medial parapatellar approach.

Fig. 3

Modified Insall's approach. Electrocautery being used to elevate the extensor apparatus from the patella.

Fig. 4

(a) Front view of the knee showing the dissection for subvastus approach. (b) Side view of the knee showing the plane along which the vastus medialis is elevated off the medial intermuscular septum.

Fig. 5

Midvastus approach to the knee.

Fig. 6

Image depicting dissection for Trivector approach to the knee.

Fig. 7

Lateral parapatellar approach to the knee.