1120 THE JOURNAL OF BONE AND JOINT SURGERY evision of a total knee arthroplasty may require an extensile approach to permit a satisfactory exposure without compromising the attachment of the patellar tendon. It has been assumed that a rectus snip is a relatively benign form of release, but the effect of using this approach on function, pain and patient satisfaction is not known. From January 1997 to December 1999, 107 patients who underwent revision of total knee arthroplasty were followed up at a minimum of two years (mean 40.5 months) and assessed by the Oxford Hip Score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short-Form (SF)- 12 and patient satisfaction. Co-morbidity, surgical exposure, the Hospital for Special Surgery (HSS) knee scores and the range of movement were also used. A standard medial parapatellar approach was used in 57 patients and the rectus snip in 50. The two groups were equivalent for age, sex and co-morbidity scores. The WOMAC function, pain, stiffness and satisfaction scores demonstrated no statistical difference. The use of a rectus snip as an extensile procedure has no effect on outcome. J Bone Joint Surg [Br] 2003;85-B:1120-2. Received 30 January 2003; Accepted after revision 23 June 2003 Adequate exposure is a prerequisite for revision arthroplasty of the knee. Flexion to 110˚ is desirable to allow safe deliv- ery of the components. Flexion of less than 90˚ under gen- eral anaesthesia indicates that a simple medial parapatellar approach may be inadequate. 1-2 To achieve more flexion will require freeing the proximal extensor mechanism or the insertion into the tibial tuberosity. The proximal approach may involve dividing the quadriceps mechanism, the lateral retinaculum, the tendon of vastus lateralis or a combination of the three. Isolated division of the rectus sheath, the ‘rec- tus snip’, has been attributed to Insall 3 who had been using it since 1988. Various modifications have been subsequently described 4 which provide excellent exposure of the knee without jeopardising the patellar tendon. Typically at the apical end of the standard medial parapatellar incision, the rectus portion is isolated and divided obliquely, extending superiorly and laterally (Fig. 1). 5 As this technique main- tains the musculotendinous bridge of vastus medialis and vastus lateralis, it allows a relatively easy repair and should allow normal post-operative rehabilitation. Objective measurement of isokinetic strength demon- strated that knees undergoing a rectus snip are not as strong as normal knees, but do not differ significantly from those which have had a standard medial parapatellar approach. 5 However, little evidence as to the comparable effects on function, pain and scores for satisfaction has been reported. 6,7 Patients and Methods Between January 1st 1997 and December 31st 1999, 117 patients consecutively underwent revision total knee arthro- plasty (TKA). Only three surgeons performed these pro- cedures. The clinical diagnosis was of aseptic loosening in 67 and second-stage reconstruction of infected cases in 50. Co-morbidity was based on recording scores of co-existing conditions and categorizing them as 0, 1, 2, 3+ as based on the Charlson index. 8 Pre-operative bone loss was assessed in both the tibia and the femur according to Engh’s classifica- tion and confirmed at removal of each component at the time of operation. 9 Surgical treatment. All the operations were carried out using the PFC total knee revision systems (DePuy, Warsaw, Indiana). The use of a medial parapatellar, or extensile R Knee The extensile rectus snip exposure in revision of total knee arthroplasty R. M. D. Meek, N. V. Greidanus, R. W. McGraw, B. A. Masri From the University of British Columbia, Vancouver, Canada R. M. D. Meek, MBChB, MD, FRCS (Tr & Orth), Clinical and Research Fellow Division of Lower Limb Reconstruction and Oncology, Department of Orthopaedics N. V. Greidanus, MD, MPh, FRCSC, Assistant Professor R. W. McGraw, MD, FRCSC, Emeritus Professor B. A. Masri, MD, FRCSC, Associate Professor and Head of Adult Recon- struction Department Division of Adult Lower Limb Reconstruction and Oncology Vancouver General Hospital, University of British Columbia, 910 West 10th Avenue, Suite 3114, Vancouver, V5Z 4E3, British Columbia, Canada. Correspondence should be sent to Mr R. M. D. Meek at the Southern Gen- eral Hospital, 1345 Govan Road, Glasgow G41 4TF, Scotland. ©2003 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.85B8.14214 $2.00