Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Fixed Valgus Deformity Correction in Total Knee Arthroplasty by Bhava R.J. Satish, Jutty C. Ganesan, Prakash Chandran, Praveen L. Basanagoudar, and Damodarasamy Balachandar JBJS Essent Surg Tech Volume 3(4):e20 October 9, 2013 2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20
2013 by The Journal of Bone and Joint Surgery, Inc. Assess surgical valgus, which is the residual valgus of an extended knee when manual varus strain is applied with the patient under anesthesia. Assess surgical valgus, which is the residual valgus of an extended knee when manual varus strain is applied with the patient under anesthesia. Clinical valgus is the maximal deformity seen on weight-bearing radiographs. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Separate the lateral retinaculum and capsule complex into two layers (coronal z-plasty).
Separate the lateral retinaculum and capsule complex into two layers (coronal z-plasty). This is a right knee with the patients head on the left side of the figure and the foot on the right side. (Figure on right reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Graphic representation of Fig. 2-A.
Graphic representation of Fig. 2-A. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Include the retropatellar fat pad in the lateral retinacular flap.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Release the iliotibial band from the Gerdy tubercle.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Expose the knee with flexion after the quadriceps snip (arrow) and patellar eversion.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Release the anterolateral aspect of the capsule adherent to the proximal part of the tibia.
Release the anterolateral aspect of the capsule adherent to the proximal part of the tibia. Note the release of the iliotibial band from the Gerdy tubercle and inclusion of the fat pad with part of the lateral meniscus in the lateral flap. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Subluxate the tibia forward by hyperflexing the knee and internally rotating the leg.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Make the proximal tibial cut perpendicular to the tibial axis.
Make the proximal tibial cut perpendicular to the tibial axis. Note the use of a left-sided cutting block for the lateral parapatellar approach to the right knee. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Make a distal femoral cut in 3 to 5 of valgus in relation to the anatomical axis.
Make a distal femoral cut in 3 to 5 of valgus in relation to the anatomical axis. The cutting block may not touch the lateral femoral condyle, and there is minimal or no removal of bone from the lateral condyle. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Perform extension gap balancing with the block.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Place the proper size femoral 4-in-1 cutting block after confirming rotation.
Place the proper size femoral 4-in-1 cutting block after confirming rotation. Align the posterior margin of the block parallel to the proximal tibial cut surface. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Perform flexion gap balancing with the block.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Align the tibial rotation with the trial femoral component and ankle center using an external alignment rod. Align the tibial rotation with the trial femoral component and ankle center using an external alignment rod. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Fix the original components and reduce the joint.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Assess the patellar tracking and the quadriceps snip repair.
Assess the patellar tracking and the quadriceps snip repair. Note the exceptionally good patellar tracking on this image. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. The quadriceps snip repair and good patellar tracking in another knee with the superficial retinacular layer attached to the lateral border of the patella. The quadriceps snip repair and good patellar tracking in another knee with the superficial retinacular layer attached to the lateral border of the patella. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Flex the knee 70 to 90 to start the joint closure.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Identify the previously separated coronal z-plasty layers of the lateral reticulum and capsular complex. Identify the previously separated coronal z-plasty layers of the lateral reticulum and capsular complex. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Suture the free margins of the z-plasty layers.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Depending on the defect on the lateral side, suture the free edges or overlap the edges of the z-plasty layers. Depending on the defect on the lateral side, suture the free edges or overlap the edges of the z-plasty layers. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Note the lateral expansion area at the completion of the z-plasty closure.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. In knees with a mild deformity, suture the proximal lateral tibial sleeve to the patellar tendon.
Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. In knees with a severe deformity, use the lateral fad pad to close the proximal-lateral tibial area.
In knees with a severe deformity, use the lateral fad pad to close the proximal-lateral tibial area. The white asterisks indicate the area of lateral expansion. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Preoperative clinical photograph and anteroposterior radiograph of a patient with windblown knees.
Preoperative clinical photograph and anteroposterior radiograph of a patient with windblown knees. The defect is seen on the lateral tibial condyle of the left valgus knee. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Intraoperative photographs showing a peripheral defect on the posterior aspect of the lateral tibial condyle, which was reconstructed with bone graft and screws. Intraoperative photographs showing a peripheral defect on the posterior aspect of the lateral tibial condyle, which was reconstructed with bone graft and screws. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Postoperative clinical photograph and anteroposterior radiograph made five years after a right total knee arthroplasty was performed with a medial arthrotomy and a left total knee arthroplasty was performed through a lateral approach. Postoperative clinical photograph and anteroposterior radiograph made five years after a right total knee arthroplasty was performed with a medial arthrotomy and a left total knee arthroplasty was performed through a lateral approach. The graft incorporated well with maintenance of femorotibial alignment. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Anteroposterior radiograph, made with the patient in a lying position, and preoperative clinical photograph, made with the patient standing, showing severe dysplastic valgus deformity of both knees. Anteroposterior radiograph, made with the patient in a lying position, and preoperative clinical photograph, made with the patient standing, showing severe dysplastic valgus deformity of both knees. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Preoperative clinical photograph of the patient lying supine.
Preoperative clinical photograph of the patient lying supine. The deformity measured 60 on the right side and 55 on the left side. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Postoperative clinical photograph and anteroposterior radiograph made 3.4 years postoperatively.
Postoperative clinical photograph and anteroposterior radiograph made 3.4 years postoperatively. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Axial view of both knees showing good patellar tracking.
Axial view of both knees showing good patellar tracking. (Reproduced, with permission from Elsevier, from: Satish BR, Ganesan JC, Chandran P, Basanagoudar PL, Balachandar D. Efficacy and Mid Term Results of Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Primary Total Knee Arthroplasty in Fixed Valgus Knees. J Arthroplasty May 20. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc. Attachment of the tendon of the popliteus just proximal to the lateral femoral condylar articular surface. Attachment of the tendon of the popliteus just proximal to the lateral femoral condylar articular surface. Bhava R.J. Satish et al. JBJS Essent Surg Tech 2013;3:e20 2013 by The Journal of Bone and Joint Surgery, Inc.