Purpose of study: To evaluate the ‘Open book’ technique (described below) for the extended approach in Total Knee arthroplasty with respect to its efficacy and outcome.

Summary: Adequete exposure in revision knee arthroplasty can be technically very demanding. Various techniques have been described to aid in exposure. These include Tibial tubercle osteotomy, V–Y quadricepsplasty, rectus snip and Patellar turn-down approach.

Since 1998 the senior author (TJW) occasionally has combined a Tibial crest osteotomy and Rectus Snip-‘Open Book Approach- in revision Knee Arthroplasty where exposure was made difficult by scarring and fibrosis.

The Tibial crest osteotomy is performed as described by Whiteside and this is combined with a 3 cm oblique Rectus snip proximally. This enables the surgeon to reflect the extensor mechanism as if opening a book. This approach protects the patellar blood supply by minimising soft tissue retraction and by making the rectus snip proximal, the feeding vessels in the quadriceps are not distributed.

Methods and Materials: Eight patients requiring Revision Knee arthroplasty in whom the ‘open book’ technique for extended approach to the Knee were reviewed for an average of 4.5 years. The patients were evaluated clinically and radiologically at final follow-up.

Results: All patients made good recovery of range of motion with little evidence of an extensor lag. There was no incidence of refracture, slippage or non-union of the osteotomy.

Conclusions: We concluded that, the ‘Open-Book’ technique is useful in the extended approach of Total Knee arthroplasty resulting in improved clinical outcome with no adverse effects.

We report the results of a prospective randomised trial which assessed the role of the posterior cruciate ligament (PCL) following total knee replacement (Genesis I; Smith and Nephew, Memphis, Tennessee). Over a four-year period, 211 patients underwent total knee replacement by the senior author (TJW). They were randomised at surgery to have the PCL either retained, excised or substituted with a posterior stabilised insert. If it was not possible to retain the ligament due to soft-tissue imbalance, it was released from its tibial insertion until suitable tension was obtained. This created a fourth group, those who were intended preoperatively to have the ligament retained, but in whom it was partially released as a result of findings at the time of surgery.

All patients were evaluated using the Knee Society rating system (adapted from Insall). A total of 188 patients (212 knees) was available for follow-up at a mean of 3.5 years after surgery. Preoperatively, there was a varus deformity in 191 knees (90%) and a valgus deformity in 21 (10%).

There were no statistical differences in the knee or function scores or the range of movement between the excised, retained and substituted groups. There were, however, significantly worse knee and function scores in the group in whom the PCL was released (p = 0.002).

Decreasing proprioception of the knee is multifactorial and is a function of age and degenerative joint disease. Soft-tissue release during total knee replacement may have an influence. We have quantified soft-tissue imbalance at the time of knee replacement and attempted to eliminate it at full extension, using established methods.

We studied the influence of residual soft-tissue imbalance on postoperative proprioception, assessing this in 38 patients before total knee replacement and at three and six months postoperatively.

We found that proprioception improved in varus knees at three and six months after soft-tissue balancing procedures. Knees balanced in full extension and in flexion (< ±2°) showed a significant improvement in proprioception (p < 0.0005) whereas those which were not balanced in flexion but fully balanced in extension had no significant improvement. We conclude that soft-tissue balance in both flexion and extension is important to allow satisfactory postoperative proprioception of the knee.