Difficult exposures in total knee arthroplasty: the femoral peel

The exposure of the stiff ankylosed knee in primary and revision total knee replacement presents particular challenges to the bone dissection and ultimate success of the operation. A careful series of technical maneuvers are described to aid the surgeon's ability to properly expose the joint. Particular attention is given to the distal femur because this is the area where the collateral ligaments and posterior capsule are attached. It is also important because adherent scar tissue usually involves tethering of the soft tissue sleeve on the femur. This tissue affects motion to a greater extent than scarring around the proximal tibia. Exposure of the scarred ankylosed knee is the first step toward a successful operation.