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Distal femur resections - extra-articular resection with a mobile knee

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Indications

Discuss indications and more general concerns.

Preoperative Planning

Material to be reviewed and conditions to be addressed before surgery. Include any exams preformed under anesthesia

Positioning

Describe and provide OR photos to illustrate positioning

Approach

Consider the various approaches. Provide links to relevant anatomy and surgical approaches.

Techniques

1.  Surgical incision allows access to the anterior proximal tibia

2.  The quadriceps tendon, patella, patellar ligament, tibial tubercle and 14 cm of tibial crest distal to the top of the tubercle is exposed.

3.  An extended tibial tubercle osteotomy is performed releasing 10 cm of the anterior cortex of the tibia, the bone is elevated proximally.

4.  The tibial tubercle is lifted superiorly and the patellar ligament is dissected free from the fat pad.

5.  The vastus lateralis and medialis are gently elevated off of the knee capsule and their insertion onto the patella is defined.

6.  Once the interval between the knee joint, capsule and patella is defined a patellar osteotomy is performed.  Approx 10 cm of patella is preserved.

7  Now the harder part, the quadriceps tendon is slowly elevated, a thin portion of the tendon is retained as this portion is inside the joint, the vastus muscles are slowly elevated and this portion of the dissection is carried out up to the top of the suprapatellar pouch.

8.  Once you have cleared the suprapatellar pouch, the femur is osteotomized and the knee is extended and the posterior dissection is begun, once completed the tibial osteotomy can be performed from the anterior or posterior side.

9.  At the completion of the reconstruction, the tibial tubercle and anterior tibial cortex is fixed with thin twisted wire.  I usually do not see the cement or prosthesis, if I do the osteotomy fragment was too deep.

Pearls and Pitfalls

Tips and problems to avoid

Postoperative Care

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Outcome

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Complications

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References

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