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Intraoperative assessment in revision total knee arthroplasty.

Careful intraoperative management of the patient being treated with revision total knee arthroplasty is critical for a successful result. Preoperative and intraoperative considerations must include the condition of the skin and subcutaneous tissues, the mode of operative exposure of the extensor mechanism, the need for component removal, collateral ligament integrity, and bone loss. Each of these components of the planning process and operative treatment must be performed in a meticulous manner. Failure of any component of intraoperative management can compromise the function of the revision total knee replacement.

Intact and healthy skin and subcutaneous tissues about the total knee arthroplasty are essential to prevent deep infection. Any skin defect may be a site of bacterial colonization and thus a portal of entry of infection into the joint. Small areas of skin necrosis frequently signal larger areas of underlying deep muscle or fascial necrosis, the extent of which can be underestimated. Adequate skin coverage serves as a barrier to infection and must be sufficiently supple to allow knee motion.

As there will always be at least one prior incision in the knee that is being treated with a revision operation, assessment and maintenance of the viability of the skin is essential. Several questions should be posed prior to the operation. When more than one prior incision is present, which incision should be used? How should prior traumatic defects in the skin and subcutaneous tissues be managed to minimize the risk of skin necrosis? How should a prior soft-tissue flap be managed at the time of revision to maintain its viability? When there are preexisting hazards to wound-healing, what type of soft-tissue reconstruction is advantageous? Should the soft-tissue reconstruction be performed prior to or at the time of revision? Knowledge of the mechanism of the blood supply to the skin and subcutaneous …