High Yield Overview

REVISION TOTAL KNEE REPLACEMENT - TIBIAL COMPONENT

Medial parapatellar arthrotomy via previous incision, with extensile exposure options (quadriceps snip, V-Y turndown, tibial tubercle osteotomy) | Advanced

Mnemonic

A-O-R-IAORI

Mnemonic

S-T-E-MSTEM

Critical Danger Structures

Danger 1

Popliteal artery. Location: Posterior to tibia in popliteal fossa, 1-2cm from posterior tibial cortex in flexion. Protection: Flex knee during posterior work, use Hohmann retractors with care, finger palpation before posterior resection.

Danger 2

Common peroneal nerve. Location: Winds around lateral fibular neck, 2-3cm distal to fibular head. Protection: Avoid valgus correction >10° at once, protect lateral structures, release tourniquet before closure to check vascularity.

Danger 3

Patellar tendon. Location: Inserts on tibial tubercle, at risk during exposure and extensile approaches. Protection: Careful eversion, tibial tubercle osteotomy if needed (12cm length), protect insertion during all exposure maneuvers.

Danger 4

Medial collateral ligament. Location: Superficial MCL attaches to medial tibial metaphysis 6cm below joint, deep to pes anserinus. Protection: Preserve during tibial preparation, subperiosteal dissection if exposure needed.

Danger 5

Tibial cortex integrity. Location: Thin anterior and medial cortex, especially with osteopenia or osteolysis. Protection: Avoid eccentric reaming, use intramedullary guide carefully, stop at cortical chatter, assess for stress risers post-operatively.

AORI Bone Defect Classification

Type 1: Intact Metaphysis

Minor cancellous defects only
Intact peripheral cortical rim
No subsidence or significant osteolysis
Treatment: Standard primary-sized components

Type 2A: Damaged Metaphysis, Intact Rim

Cancellous bone loss but cortical rim intact
Cavitary defects without segmental loss
Treatment: Cement fill, screws, small modular augments (5-10mm)

Type 2B: Rim Deficient One Condyle

Unilateral cortical rim deficiency
Requires structural support on affected side
Treatment: Metal augments, tantalum cone, metaphyseal sleeve

Type 3: Rim Deficient Both Condyles

Bilateral cortical rim loss
Massive metaphyseal bone loss
Treatment: Large cones/sleeves both sides, structural allograft, hinged prosthesis, or megaprosthesis

Key Exam Points:

Always classify defects AFTER cement removal (true defect revealed)
Posterior defects often underestimated - palpate carefully
Document with photographs for surgical planning

Operative Technique

Step 1: Exposure and Arthrotomy

Exposure and Arthrotomy: Use most lateral viable skin scar to reduce wound complications. Develop full-thickness fasciocutaneous flaps to allow medial and lateral mobilization. Perform medial parapatellar arthrotomy extending proximally 5-6cm above patella into quadriceps tendon. Excise hypertrophic synovium and scar tissue. Assess extensor mechanism integrity - document pre-operative extensor lag.

Exam Pearl

Technical Tip: EXAM KEY: In stiff knees, start with lateral release of patella from gutter before attempting eversion. Document extensor lag pre-operatively. Consider quadriceps snip (45° angle from proximal VMO) if patella won't evert safely. Tibial tubercle osteotomy (TTO) is last resort - increases infection risk and requires fixation. Always preserve patellar tendon insertion - avulsion is catastrophic.

Dangers at this step

Patellar tendon avulsion during forced eversion (disaster - avoid by extensile exposure)
Fracture of attenuated patella with thin bone stock
Injury to MCL during aggressive medial dissection
Skin necrosis if previous incision not respected

Step 2: Component Removal - Polyethylene Insert

Component Removal - Polyethylene Insert: Remove polyethylene insert first using curved osteotome or dedicated extraction tools. Flex knee to 90° and deliver insert anteriorly. Inspect for backside wear, delamination, and locking mechanism failure. Document wear pattern - asymmetric wear suggests instability or malalignment.

Exam Pearl

Technical Tip: EXAM KEY: Document wear pattern meticulously - asymmetric wear suggests instability or malalignment. Burnishing on backside suggests micromotion at locking mechanism. Send explant for analysis and wear measurement. Photograph all components for medicolegal documentation and registry reporting. Consider sending periprosthetic tissue samples for frozen section if infection suspected.

Dangers at this step

Scratching or damaging well-fixed components if planning to retain
Losing locking mechanism pieces into knee joint
Missing signs of infection (purulent fluid, soft tissue quality)

Step 3: Assessment of Tibial Component Fixation

Assessment of Tibial Component Fixation: Assess tibial baseplate stability with curved osteotome around periphery. Check for micromotion, subsidence (compare to radiographs). If loose, proceed with extraction. If well-fixed and well-positioned, may retain and only revise femoral/poly - but threshold for removal should be low in revision setting.

Exam Pearl

Technical Tip: EXAM KEY: Indications to revise well-fixed tibial component: malalignment more than 3° varus/valgus, rotation more than 10° internal, posterior slope error more than 5°, subsidence more than 2mm, osteolysis requiring access, need for higher constraint stem. If retaining, thoroughly clean backside and check locking mechanism. Low threshold for removal - single best time to address is now.

Dangers at this step

Creating bone defects during assessment of well-fixed components
Missing fracture lines in osteopenic bone during manipulation
Underestimating extent of osteolysis behind well-fixed component

Step 4: Tibial Baseplate Removal

Tibial Baseplate Removal: Use flexible osteotomes to disrupt cement-bone interface circumferentially. Work from anterior to posterior. Use slap hammer with tibial extraction device or Gigli saws underneath baseplate. Avoid excessive force. Extract in flexion with gentle rocking motion. For well-fixed cementless components, Gigli saws safer than osteotomes.

Exam Pearl

Technical Tip: EXAM KEY: For well-fixed cemented components, use ultrasonic cement removal (UCS) first if available - faster, safer, preserves bone. For cementless ingrown components, Gigli saws are safer than osteotomes. Windows in sclerotic bone may be needed to access cement-bone interface. Preserve bone stock - this is the critical step. Takes 15-30 minutes; do not rush.

Dangers at this step

Tibial plateau fracture propagating to articular surface or tubercle
Posterior cortical breach with vascular injury
Avulsion of MCL or patellar tendon during extraction
Fracture through osteopenic or osteolytic bone

Step 5: Cement Removal

Cement Removal: Remove all cement and fibrous membrane down to bleeding bone. Use narrow osteotomes, curettes, high-speed burr, and ultrasonic cement removal tools (Midas Rex). Work systematically from anterior to posterior. Preserve cortical shell and metaphyseal bone stock. Use pulsatile lavage after cement removal.

Exam Pearl

Technical Tip: EXAM KEY: Complete cement removal is critical for achieving fixation and assessing true bone defects. Use headlight and loupe magnification. Cement restrictor deep in canal may need drill or flexible osteotome. Send tissue samples for culture (minimum 5 samples even in 'aseptic' revision - culture-negative PJI in 10-15%). Use vancomycin powder before closure.

Dangers at this step

Cortical perforation during aggressive cement removal
Propagating undetected fractures
Thermal injury from high-speed burr (irrigate constantly)
Posterior capsule penetration with vascular injury

Step 6: Bone Defect Assessment (AORI Classification)

Bone Defect Assessment (AORI Classification): Classify tibial defects using AORI system after ALL cement removed - cannot assess true defect with cement in situ. Type 1: Intact metaphysis. Type 2A: Damaged metaphysis with intact peripheral rim. Type 2B: Damaged metaphysis, deficient rim one condyle. Type 3: Deficient both condyles requiring major reconstruction.

Exam Pearl

Technical Tip: EXAM KEY: Map defects with bone loss diagram documenting anteroposterior depth and mediolateral width. Measure depth from nearest intact bone surface. Uncontained (peripheral rim deficient) defects more than 5mm need structural support - cannot fill with cement alone. Contained defects less than 5mm can use cement or morsalized graft. Check for cavitary vs segmental patterns. Posterior defects are common and often underestimated - assess with finger palpation.

Dangers at this step

Underestimating defect depth leading to undersizing
Missing posterior or posteromedial defects
Misclassifying contained vs uncontained defects
Inadequate debridement before assessment

Step 7: Canal Preparation for Stem

Canal Preparation for Stem: Use flexible reamers starting 1-2mm larger than canal diameter. Ream to cortical chatter in 1mm increments. For press-fit stems, ream to exact stem diameter (line-to-line). For cemented stems, over-ream 2mm for cement mantle. Aim for 4-6cm of diaphyseal contact with short stems, 10-15cm with long stems.

Exam Pearl

Technical Tip: EXAM KEY: Short stems (50-75mm) for AORI 1-2A provide rotational control. Long stems (100-150mm) for AORI 2B-3 bypass defect by 2 cortical diameters and achieve diaphyseal fixation. Press-fit preferred for long-term fixation (biological). Offset stems available for canal deformity. Curved stems for anterior tibial bow. Check alignment with intramedullary rod on fluoroscopy.

Dangers at this step

Anterior cortical perforation (tibial bow in sagittal plane - apex anterior)
Lateral cortical perforation (varus bowing in coronal plane)
Fracture propagation in osteopenic bone
Creating false passage in deformed or sclerotic canals

Step 8: Proximal Tibial Preparation

Proximal Tibial Preparation: Use intramedullary alignment with stem trial as reference. Set posterior slope 3-7° (match pre-operative slope if functional, increase if PCL deficient). Adjust varus/valgus to neutral mechanical axis. Resect minimum bone (typically 2-4mm more than primary to achieve flat surface on bleeding bone).

Exam Pearl

Technical Tip: EXAM KEY: Reference off of intact plateau (usually lateral in varus knees). Goal: perpendicular to mechanical axis in coronal plane (87° to anatomical axis), 3-7° posterior slope in sagittal plane. Proximal tibial angle should be 87° (3° varus). Use intramedullary guide for alignment with extramedullary check if significant deformity. Preserve peripheral rim where possible.

Dangers at this step

Excessive resection compromising metaphyseal bone stock
Resecting into defect (losing peripheral rim support)
Saw blade penetration posteriorly injuring popliteal vessels
Creating varus or valgus malalignment affecting stability

Step 9: Defect Reconstruction

Defect Reconstruction: Based on AORI classification: Type 2A - use screws and cement or small augments (5-10mm). Type 2B - use metal augments (blocks or wedges) on deficient side, or tantalum cone. Type 3 - use large cones, metaphyseal sleeves, or structural allograft. Augments should be fully supported by host bone peripherally. Secure with screws if possible.

Exam Pearl

Technical Tip: EXAM KEY: Metal augments: sized to fill defect, screw fixation to host bone, cement to baseplate. Tantalum cones: press-fit into defect achieving biological fixation, baseplate cemented into cone. Sleeves: bridge defect, achieve diaphyseal press-fit, baseplate cemented into sleeve. Avoid structural allograft if possible due to resorption and collapse risk. Tantalum cones now preferred with more than 95% 5-year survival.

Dangers at this step

Undersizing augments leading to subsidence
Screw penetration of posterior cortex during augment fixation
Incomplete seating of cones or sleeves
Thermal necrosis during cement polymerization on large surface area

Step 10: Trial Reduction and Assessment

Trial Reduction and Assessment: Insert tibial trial baseplate with stem and augments/cone. Insert femoral trial and appropriate polyethylene thickness. Reduce knee through full ROM. Assess: stability (no lift-off), alignment (neutral mechanical axis), patellar tracking, flexion-extension gap balance (within 2mm), ROM (target 0-120°).

Exam Pearl

Technical Tip: EXAM KEY: Stress test in extension and 30° flexion - maximum 5mm opening with varus/valgus stress indicates adequate constraint. Check extension gap (0°) vs flexion gap (90°) - should be equal ±2mm. If extension gap tight, recut tibia or downsize femur distally. If flexion gap tight, increase posterior slope or add distal femoral augment. Assess constraint need: CCK if MCL incompetent (more than 5mm laxity), RHK/hinge if global instability.

Dangers at this step

Overstuffing joint leading to stiffness and patella baja
Accepting instability (leads to early failure)
Undersizing poly leading to accelerated wear
Missing subtle malalignment or malrotation

Step 11: Final Implant Preparation

Final Implant Preparation: Prepare bone surfaces by pulsatile lavage and dry with suction and swabs. Pack defects with antibiotic-loaded cement (if cemented) or leave clear for press-fit components. Prepare cement using high viscosity, third-generation technique. For hybrid fixation: insert press-fit stem first, then cement baseplate to stem and bone.

Exam Pearl

Technical Tip: EXAM KEY: Third generation cementing for tibial: clean dry bone, cement gun application, pressurization, component insertion in doughy phase. For hybrid: insert press-fit stem first, then cement baseplate to stem and bone. Use antibiotic cement (1g vancomycin + 3.6g tobramycin per 40g cement) even in aseptic revision - reduces reinfection rate. Remove excess cement before polymerization.

Dangers at this step

Cement extrusion posteriorly into neurovascular structures
Air entrapment in cement creating weak spots
Early polymerization before component insertion
Inadequate cement penetration into cancellous bone

Step 12: Tibial Component Insertion

Tibial Component Insertion: Insert stem first (if press-fit hybrid), then apply cement to tibial surface and undersurface of baseplate. Insert baseplate onto stem and impact gently into position. Check rotation (aligned with medial 1/3 of tibial tubercle, approximately 18° external relative to posterior tibial cortex), AP position (centered), and complete seating.

Exam Pearl

Technical Tip: EXAM KEY: Rotation: align tibial baseplate with femoral component in neutral flexion gap, typically 15-20° external rotation relative to posterior tibial cortex. Alternative landmark: medial border of tibial tubercle. AP position: baseplate should cover maximal tibial surface without overhang. Overhang anteriorly irritates patellar tendon, posteriorly risks neurovascular compression. Pressurize cement and remove excess.

Dangers at this step

Component malrotation (internal rotation causes medial poly wear and anterior knee pain)
Incomplete seating leaving gap under baseplate
Anterior overhang damaging patellar tendon
Posterior overhang with neurovascular compression
Cement extrusion into posterior capsule

Step 13: Polyethylene Insert Insertion and Final Reduction

Polyethylene Insert Insertion and Final Reduction: Clean and dry tibial baseplate locking mechanism meticulously. Insert polyethylene insert ensuring proper locking - audible click and visual confirmation. Test that poly cannot be removed with traction. Reduce knee and assess final stability, ROM, patellar tracking. Document final construct.

Exam Pearl

Technical Tip: EXAM KEY: Poly thickness selection: should provide stability without overstuffing. Minimum 10mm for PS, 12-15mm for CCK (taller post), 15-20mm for hinges. Final assessment: no varus/valgus laxity more than 5mm at 0° or 30°, no AP laxity more than 5mm at 90°. ROM: target 0-120°, minimum 0-110°. Patellar tracking: should track centrally without subluxation or tilt. Lateral release if persistent lateral subluxation.

Dangers at this step

Poly insert not fully locked (dislocation, wear, failure)
Overstuffing causing limited flexion and patellofemoral problems
Accepting instability requiring early re-revision
Missing patellar maltracking requiring lateral release

Step 14: Final Assessment and Closure

Final Assessment and Closure: Perform final check: ROM 0-120°, stable through arc, patellar tracking central, no impingement. Remove all loose cement, bone fragments, debris with thorough lavage (6-9L). Meticulous hemostasis. Insert deep drain. Close capsule and extensor mechanism in flexion with interrupted figure-of-8 sutures (No.2 Ethibond). Close subcutaneous layers and skin.

Exam Pearl

Technical Tip: EXAM KEY: Tranexamic acid: 1g IV at induction, 1g at closure reduces blood loss by 40%. Drain for 24-48h in revisions due to dead space. Close arthrotomy with interrupted figure-of-8 to prevent disruption. Test closure by extending knee fully - should hold without tension. Apply compression dressing. Extended knee brace for 24h to protect extensor mechanism if TTO performed.

Dangers at this step

Retained cement or debris causing third-body wear
Inadequate hemostasis causing hematoma and infection risk
Wound closure under tension risking dehiscence
Damage to extensor mechanism during closure

Step 15: Post-Operative Protocol and Follow-Up

Post-Operative Protocol and Follow-Up: Elevate leg, apply ice. TED stockings and prophylactic anticoagulation (apixaban 2.5mg BD or enoxaparin 40mg daily) for 35 days per Australian guidelines. IV antibiotics 24-48h. Immediate quadriceps isometrics. Mobilize day 1 with physiotherapy - WBAT with frame for cemented/hybrid, protected weight-bearing for press-fit. CPM if available. Drain removal 24-48h.

Exam Pearl

Technical Tip: EXAM KEY: Post-op radiographs: AP, lateral, skyline views. Check mechanical alignment through knee center, component position, no fractures. Flexion to 90° by week 2, full extension immediately. Outpatient review 2 weeks (wound), 6 weeks (ROM, function, radiographs), 3 months, 1 year, then annually. Monitor for infection: CRP peaks day 2-3, should normalize by 3-4 weeks; ESR peaks week 1, normalizes by 6-8 weeks. Persistent elevation warrants investigation.

Dangers at this step

Wound dehiscence (especially with TTO or extensile exposure)
Deep infection (5-10% in revision TKR vs 1-2% primary)
Extensor mechanism failure or rupture
Periprosthetic fracture during early mobilization
DVT/PE (higher risk in revision surgery - 35 day prophylaxis mandatory)

Complications

Complications: Recognition, Prevention, and Management

Post-operative Care

Immediate (Days 0-3):

Leg elevation, ice therapy, compression dressing
IV antibiotics continued 24-48h
DVT prophylaxis (apixaban 2.5mg BD for 35 days or LMWH)
Drain removal at 24-48h when output less than 50mL/8h
Quadriceps isometrics, ankle pumps, SLR if able
Mobilize day 1 with frame - WBAT for cemented/hybrid

Early (Weeks 1-6):

Wound check at 2 weeks, suture removal
Radiographs at 6 weeks
Progressive ROM - goal 90° by 2 weeks, 120° by 6 weeks
Transition to single crutch/cane by 4-6 weeks
Outpatient physiotherapy for ROM and strengthening

Intermediate (Weeks 6-12):

Full weight-bearing without aids
Stairs, transfers, functional activities
Driving at 6-8 weeks (automatic, left knee) or 8-12 weeks (right knee)
Return to sedentary work 6-8 weeks, manual work 12+ weeks

Long-term:

Annual review with radiographs
Lifelong antibiotic prophylaxis for dental/invasive procedures
Report any concerning symptoms (pain, swelling, drainage) promptly
Activity modification - avoid high-impact sports

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"You are shown radiographs of a painful TKR 8 years post-primary surgery. There are radiolucent lines around the tibial component with subsidence. How would you assess and manage this patient?"

EXCEPTIONAL ANSWER

I would take a systematic approach to this patient with suspected tibial component failure. **History**: Duration and character of pain, mechanical symptoms, any preceding trauma, infection symptoms (fevers, night sweats, drainage), functional limitation, and expectations. **Examination**: Gait, alignment, ROM (typically preserved unless infection), stability, effusion, skin condition (previous scars, quality), neurovascular status. **Investigations**: Bloods including CRP, ESR, and FBC (elevated inflammatory markers suggest infection). Joint aspiration is MANDATORY - send for cell count (more than 3000 WCC suspicious, more than 10000 highly suggestive), differential (more than 80% PMN suspicious), Gram stain, culture, and crystal analysis. Imaging: weight-bearing AP, lateral, skyline views plus CT for bone loss assessment. **Classification**: After confirming aseptic loosening (negative aspiration), classify bone defects using AORI system on CT - this guides reconstruction strategy. **Management**: For AORI 2B-3 tibial defects as suggested by the radiographs, I would plan single-stage revision with: (1) extensile exposure if needed, (2) component removal preserving bone stock, (3) defect reconstruction with tantalum cone or metaphyseal sleeve, (4) long press-fit stem bypassing defect by 2 cortical diameters, (5) appropriate constraint selection based on ligament competence. Post-operatively: antibiotic prophylaxis, VTE prophylaxis for 35 days, staged rehabilitation.

VIVA SCENARIOStandard

EXAMINER

"Describe your approach to a patient requiring tibial component revision for aseptic loosening with AORI Type 2B bone loss affecting the medial tibial plateau."

EXCEPTIONAL ANSWER

This is a significant bone defect requiring structural reconstruction. **Preoperative planning**: CT scan to precisely define defect extent, template for stem length (needs to bypass defect by 2 cortical diameters), assess canal diameter and any deformity, plan reconstruction options. Ensure infection excluded with aspiration. **Reconstruction strategy for AORI 2B**: The medial rim deficiency requires structural support - options include metal augments (for smaller defects up to 15mm), tantalum cone (my preference for this scenario), or metaphyseal sleeve. **Surgical technique**: (1) Exposure via previous incision with medial parapatellar arthrotomy, extensile if needed. (2) Remove tibial component preserving bone - use osteotomes, Gigli saws, avoid forceful extraction. (3) Complete cement removal and debridement to bleeding bone. (4) Assess true defect - confirm AORI 2B. (5) Prepare canal with flexible reamers to cortical chatter. (6) Size tantalum cone to fill medial defect - should be press-fit with 1-2mm interference. (7) Trial with stemmed baseplate cemented into cone, long stem (100-150mm) extending into diaphysis for additional fixation. (8) Assess stability and constraint requirement - likely PS or CCK depending on ligament competence. (9) Final implantation with hybrid fixation (press-fit stem, cemented baseplate into cone). (10) Layered closure, drain. **Post-operative**: Protected weight-bearing 6 weeks if large cone, then progress as tolerated.

VIVA SCENARIOStandard

EXAMINER

"During tibial component revision, you encounter unexpected findings. The tibial component is grossly loose with significant bone loss, and you discover purulent material in the joint despite negative preoperative aspiration. How do you proceed?"

EXCEPTIONAL ANSWER

This is a critically important scenario - unexpected infection during planned 'aseptic' revision. I would immediately modify my approach to a staged revision protocol. **Immediate actions**: (1) Obtain multiple tissue samples for culture (minimum 5 from different areas) before any antibiotic administration. (2) Send samples for frozen section histology if available - more than 5 PMN per high-power field suggests infection. (3) Complete thorough debridement of all infected and necrotic tissue. (4) Remove ALL components including cement - cannot leave any foreign material. **Wound management**: Copious pulse lavage (9L minimum), further debridement of unhealthy tissue. **Antibiotic spacer**: Insert static or articulating antibiotic cement spacer. Static spacer for severe bone loss or non-ambulatory patient. Articulating spacer maintains ROM and function. Cement loaded with high-dose antibiotics: typically 4g vancomycin + 4.8g tobramycin per 40g cement (higher than prophylactic dosing). **Post-operative**: IV broad-spectrum antibiotics initially (vancomycin + meropenem typically), then culture-directed therapy for minimum 6 weeks. Serial CRP monitoring - should normalize by 4-6 weeks. **Second stage**: Plan re-implantation at 8-12 weeks if: (1) CRP normalized, (2) wound healed, (3) aspiration of spacer negative, (4) patient fit for surgery. Re-aspirate 2 weeks before planned second stage. **Key learning**: 10-15% of 'aseptic' failures are culture-positive - always maintain high index of suspicion and be prepared to convert to staged approach.

Revision TKR - Tibial Component - Exam Summary

High-Yield Exam Summary

References

Anderson Orthopaedic Research Institute. AORI Bone Defect Classification for Revision Total Knee Arthroplasty. J Arthroplasty 1997.
Australian Orthopaedic Association National Joint Replacement Registry. Annual Report 2024. Hip, Knee & Shoulder Arthroplasty.
Vince KG, Abdeen A, Sugimori T. The unstable total knee arthroplasty: causes and cures. J Arthroplasty 2006;21(4 Suppl 1):44-49.
Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect 1999;48:167-175.
Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013;95-B(11):1450-1452.
Meneghini RM, Lewallen DG, Hanssen AD. Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement. J Bone Joint Surg Am 2008;90(1):78-84.
Lachiewicz PF, Soileau ES. Ten-year survival and clinical results of constrained components in primary total knee arthroplasty. J Arthroplasty 2006;21(6):803-808.
Morgan-Jones R, Oussedik SI, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J 2015;97-B(2):147-149.
Australian Commission on Safety and Quality in Healthcare. Clinical Care Standard: VTE Prevention. 2020.
Della Valle CJ, Berger RA, Rosenberg AG. Surgical exposures in revision total knee arthroplasty. Clin Orthop Relat Res 2006;446:59-68.

Revision Total Knee Replacement - Tibial Component