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Scientific Articles   |    
Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Fixed Valgus Deformity Correction in Total Knee Arthroplasty
Bhava R.J. Satish, MS, DNB1; Jutty C. Ganesan, DNB, MCh2; Prakash Chandran, MS, FRCS3; Praveen L. Basanagoudar, MS, FRCS4; Damodarasamy Balachandar, MS2
1 Kalpana Medical Centre, Koundampalayam, Mettupalayam Road, Coimbatore 641 030, India. E-mail address: drbrjorthocentre@gmail.com
2 KR Hospital, Periyanaickenpalayam, Mettupalayam Road, Coimbatore 641 020, India
3 15, Cresswell Close, Callands, Warrington WA5 9UA, North Cheshire, United Kingdom
4 Sagar Hospital Banashankari, DSI Institutions Kumarasamy Layout, Bangalore 560078, India
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Based on an original article: J Arthroplasty. 2013 May 20. http://dx.doi.org/10.1016/j.arth.2013.04.037



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2013 Oct 23;3(4):e20 1-16. doi: 10.2106/JBJS.ST.M.00015
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Extract

Overview
Introduction

The lateral parapatellar approach provides direct access to the pathological area in a valgus knee deformity and allows sequential titrated release of contracted lateral soft tissues during total knee arthroplasty.

Step 1: Preoperative Planning

Differentiate the flexible and fixed components of the valgus deformity by clinical and radiographic examination.

Step 2: Expansile Lateral Arthrotomy

Open the knee joint from the lateral side by coronal z-plasty of the lateral retinaculum, oblique lateral tenotomy of the quadriceps tendon, and iliotibial band release.

Step 3: Quadriceps Snip and Joint Exposure

Perform a quadriceps snip and expose the knee joint.

Step 4: Tibial and Distal Femoral Cuts

Make proximal tibial and distal femoral cuts in appropriate alignment.

Step 5: Extension Gap Balancing

A rectangular extension gap is the goal.

Step 6: Flexion Gap Balancing

Determine the femoral component size and femoral rotation, and balance the flexion gap.

Step 7: Component Fixation

Confirm tibial rotational alignment, fix the components, and assess patellar tracking.

Step 8: Prosthetic Joint Closure

Perform closure of the prosthetic joint with expanded lateral structures.

Results

Between 2003 and 2009, thirty-two knees with clinical valgus deformity of >10° underwent total knee arthroplasty with an expansile lateral arthrotomy technique11.

Indications

Contraindications

Pitfalls & Challenges

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    Video 1 The technique of coronal z-plasty of the lateral retinaculum and capsule complex, which is also termed expansile lateral arthrotomy. The video shows a right knee (with the patient’s head on the right side and the foot on the left) with laterally reflected lateral skin and subcutaneous flap. The incision is over the lateral retinaculum and capsule complex 3 cm lateral to the lateral margin of the patella. The incision is kept superficial; undermining dissection is performed with a knife (sharp scissors can be used) separating the lateral retinaculum and capsule complex into two layers: superficial and deep. The superficial (retinacular) layer is worked up to the lateral margin of the patella. The deep (capsular) layer is released from the lateral margin of the patella, opening the joint. At the suprapatellar level, the lateral margin of the rectus tendon is incised obliquely to extend the arthrotomy. Inferiorly, most of the retropatellar fat pad is included in the deep layer. The iliotibial band and anterolateral aspect of the capsule are released in continuity as a sleeve from the proximal-lateral part of the tibia up to the midpart of the lateral tibial condyle. This arthrotomy along with the quadriceps snip will provide good joint exposure in fixed valgus arthritic knees.

    Running Time: 3:19

    Video 2 Preoperative gait of the patient with “windblown” knee deformities shown in Figs. 9-A, 9-B, and 9-C.

    Running Time: 0:27

    Video 3 Gait of the patient shown in Video 2 at five years postoperatively.

    Running Time: 0:09

    Video 4 Preoperative gait (seen from the front) of the patient with severe bilateral valgus deformity shown in Figs. 10-A through 10-D.

    Running Time: 0:17

    Video 5 Preoperative gait (seen from the back) of the patient with severe bilateral valgus deformity shown in Figs. 10-A through 10-D.

    Running Time: 0:13

    Video 6 Gait at 3.4 years postoperatively of the patient shown in Videos 4 and 5.

    Running Time: 0:18

    Video 7 Knee range of motion at 3.4 years postoperatively of the patient shown in Videos 4, 5, and 6.

    Running Time: 0:17

    References

    Accreditation Statement
    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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