Does repeat tibial tubercle osteotomy or intramedullary extension affect the union rate in revision total knee arthroplasty? A retrospective study of 74 patients

Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty?

PURPOSE

Surgical approach can impact the reliability of the debridement after a chronic total knee periprosthetic joint infection (PJI), a factor of utmost importance to eradicate the infection. The most adequate knee surgical approach in cases of PJI is a matter of debate. The purpose of this study was to determine the influence of performing a tibial tubercle osteotomy (TTO) in a two-stage exchange protocol for knee PJI treatment.

METHODS

Retrospective cohort study examining patients managed with two-stage arthroplasty due to chronic knee PJI (2010-2019). Performance and timing of the TTO were collected. Primary end-point was infection control with a minimum FU of 12 months and according to internationally accepted criteria. Correlation between TTO timing and reinfection rate was reviewed.

RESULTS

Fifty-two cases were finally included. Overall success (average follow-up: 46.2 months) was 90.4%. Treatment success was significantly higher among cases addressed using TTO during the second stage (97.1% vs. 76.5%, p value 0.03). Only 4.8% of the patients relapsed after performing a sequential repeated TTO, that is, during both first and second stages, compared to 23.1% cases in which TTO was not done (p value 0.28). No complications were observed among patients in the TTO group with a significant decrease in soft tissue necrosis (p: 0.052).

CONCLUSION

Sequential repeated tibial tubercle osteotomy during a two-stage strategy is a reasonable option and offers high rates of infection control in complex cases of knee PJI with a low rate of complications.

Tibial Tubercle Osteotomy in Revision Total Knee Arthroplasty for Periprosthetic Infection: Indications and Outcomes

BACKGROUND

Adequate exposure is essential in revision total knee arthroplasty (RTKA). Tibial tubercle osteotomy (TTO) enhances exposure, but its use is controversial in the setting of periprosthetic infection. The purposes of this study were to determine (1) the rates of complications and revisions due to TTO during RTKA in the setting of a periprosthetic infection, (2) the rate of septic failure, and (3) functional outcomes at a minimum 2-year follow-up.

METHODS

A single-center retrospective study from 2010 to 2020 was performed. The cases of a total of 68 patients who received a TTO during RTKA in the setting of periprosthetic infection with a minimum follow-up of 2 years (mean, 53.3 months; range, 24 to 117 months) were analyzed. Complications and revisions due to TTO were reported. The functional outcomes were assessed using the Knee Society Score (KSS) and range of motion.

RESULTS

Seven knees (10.3%) had complications secondary to the TTO (3 had fracture-displacement of the TTO; 2, nonunion; 1, delayed union; and 1, wound dehiscence). The mean time to union (and standard deviation) was 3.8 ± 3.2 months (range, 1.5 to 24 months). Two knees (2.9%) underwent a TTO-related revision (1 had wound debridement, and 1 had tibial tubercle osteosynthesis). Eighteen knees (26.5%) had recurrence of infection requiring revision: 17 were managed with debridement, antibiotics, and implant retention (DAIR), and 1 had 2-stage RTKA. Flexion improved after surgery (from a mean of 70° to a mean of 86°; p = 0.009), as did the KSS knee (46.6 to 79; p < 0.001) and function (35.3 to 71.5; p < 0.001) subscores. Overall, 42.6% of infected knees managed with RTKA with the TTO procedure were considered successful without any complication at the last follow-up. Only 2 knees (2.9%) required revision related to the TTO.

CONCLUSIONS

TTO in RTKA involving periprosthetic infection is an effective surgical exposure aid and has excellent rates of union (97.1%) despite the presence of infection. However, the risk of failure because of persistent or recurrent infection remains high in the first 2 years following RTKA for infection.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Contemporary outcomes of tibial tubercle osteotomy for revision total knee arthroplasty

Aims

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years' minimum follow-up, and to identify the risk factors of failure.

Methods

Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years' follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m2 (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion.

Results

The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011).

Conclusion

TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term.

Osteotomies and Total Knee Arthroplasty: Systematic Review and Meta-Analysis

Total knee replacement (TKA) is a frequent modality performed in patients with osteoarthritis. Specific circumstances can make it much more difficult to execute successfully, and additional procedures such as osteotomy may be required. The aim of this study was to perform a meta-analysis and systematic review of osteotomies combined with TKA.

METHODS

In June 2022, a search PubMed, Embase, Cochrane, and Clinicaltrials was undertaken, adhering to PRISMA guidelines. The search included the terms "osteotomy" and "total knee arthroplasty".

RESULTS

Two subgroups (tibial tubercle osteotomy and medial femoral condyle osteotomy) were included in the meta-analysis. Further subgroups were described as a narrative review. The primary outcome showed no significant difference in favor to TTO. Secondary outcomes showed improved results in all presented subgroups compared to preoperative status.

CONCLUSION

This study showed a significant deficit of randomized control trials treated with osteotomies, in addition to TKA, and a lack of evidence-based surgical guidelines for the treatment of patients with OA in special conditions: posttraumatic deformities, stiff knee, severe varus, and valgus axis or patella disorders.

Tibial Tubercle Screw Fixation on Custom Metaphyseal Cone: Surgical Tip in Severe Metaphyseal Tibia Bone Loss

Tibial tubercle osteotomy (TTO) facilitates exposure in knee arthroplasty revision. However, it comes with complications, especially if it invades the intramedullary canal. Most revisions are characterized by compromised femur and/or tibia bone stock, and the use of metaphyseal cones or sleeves for implant fixation has become increasingly frequent. Several methods of fixation of the tibial tubercle have been proposed, such as screw fixation, cerclage wiring, and suture repair. Despite screws providing the strongest fixation for TTO, their placement around a tibial intramedullary stem or a metaphyseal tibial cone may be difficult. We described the use of a custom-made metaphyseal tibial cone with holes in its anterior surface that allow the surgeon to achieve accurate TTO fixation by screws.

Outcomes in revision total knee arthroplasty (Review)

Revision total knee arthroplasty (TKA) is a challenging surgical procedure. Although good results are presented, the outcomes are worse in comparison with those of primary TKA, with a higher failure rate. The main reasons for the failure of revision TKA include: sepsis, loosening and instability. There are multiple variables linked to these results, and it is difficult to determinate the exact cause as it is often a multifactorial issue. These variables may be related to the quality of the index-procedure (TKA), to the revision procedure or to patient characteristics. The purpose of this review was to highlight the outcomes of revision knee arthroplasty and main factors that may influence the results. Considerable progress has been made during the last 30 years regarding infection treatment and prevention, complex revision prosthetic design and surgical technique development. Although the outcomes have improved over time, patients who undergo revision TKA may need further re-operations in the future.

Timing of tibial tubercle osteotomy in two-stage revision of infected total knee arthroplasty does not affect union and reinfection rate. A systematic review

BACKGROUND

Tibial tubercle osteotomy (TTO) in two-stage infected revision total knee arthroplasty (RTKA) could be applied at either first, second, or in both stages, and may remain preliminary fixed or unfixed until the second stage. The primary aim of the review was to identify any correlation between the timing of TTO and osteotomy union as well as reinfection rate.

METHODS

Medline, Scopus, and CENTRAL were searched up to March 2020. All TTO cases were divided into three groups; Group A: TTO in both stages, left unfixed in first stage; Group B: TTO in both stages, preliminary fixed in first stage; Group C: TTO only in second stage.

RESULTS

Eight studies with 199 patients were included. Apart from two cases in Group C, all the osteotomies achieved bone healing (p = 0.99). There were 29 (15%) reinfections (nine percent in Group A, 13% in Group B, and 16% in Group C, p = 0.67) and 16 (nine percent) knees with proximal avulsion/migration of the tibial tubercle (8.7% in Group A, 16.7% in Group B, and 0.8% in Group C, p = 0.02). Seventeen patients (11%) complained of anterior knee pain and 14 (nine percent) of them underwent hardware removal. However, no difference between groups was identified.

CONCLUSIONS

Preliminary fixation of the tibial tubercle with wires and/or screws at the first stage of RTKA does not increase the possibility of reinfection. Therefore, we propose that the tibial tubercle should be stable fixed from the first stage to maximize knee performance in the intermediate period.

Tibial tubercle osteotomy in revision total knee arthroplasty: A systematic review

BACKGROUND

Tibial tubercle osteotomy (TTO) is a well-established surgical technique to deal with a stiff knee in revision total knee arthroplasty (RTKA). However, several reports have described potential osteotomy-related complications such as non-union, tibial tubercle migration and fragmentation, and metalware related pain.

AIM

To evaluate the literature and estimate the efficiency of TTO in RTKA in terms of osteotomy union, knee mobility and complications.

METHODS

MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were investigated for completed studies until February 2020. The principle outcome of the study was the incidence of union of the osteotomy. Secondary outcomes were the knee range of motion as well as the TTO-related and overall procedure complication rate.

RESULTS

Fifteen clinical studies with a total of 593 TTOs were included. The TTO union rate was 98.1%. Proximal migration and anterior knee pain were the most common TTO-related complications accounting for 6.9% and 6.4% of all cases, respectively. However, only 2.2% of cases suffering from anterior knee pain needed hardware removal. Knee flexion was improved from 82.9° preoperatively to 100.1° postoperatively and total knee range of motion was increased from 73.4° before surgery to 97° after surgery. Stiffness requiring manipulation under anesthesia was recorded in 4.6% of cases. No major complications were reported.

CONCLUSION

The current systematic review supports the use of TTO in RTKA, as it is associated with high union rate, significant improvement in knee motion and low osteotomy-related complication risk that rarely leads to secondary tibial tubercle procedures.

Tibial Tubercle Osteotomy in Total Knee Arthroplasty: Midterm Results Experience of a Monocentric Study

Purpose  Difficult primary total knee arthroplasty (TKA) and revision TKA may be high demanding, especially during joint exposure. Aim of this article is to evaluate the clinical and radiological outcomes of a series of patients, who underwent TKA and revision TKA, where tibial tubercle osteotomy (TTO) was performed.

Methods  We retrospectively reviewed a cohort of 79 consecutives TKAs where TTO was performed. Patients were assessed clinically and radiographically at their last follow-up (mean, 7.4 ± 3.7 years). Clinical evaluation included the Knee Society Score (KSS), the pain visual analogue scale (VAS), and range of motion. Radiological assessment included the evaluation of radiolucent lines, osteolysis, cortical bone hypertrophy, time of bone healing of the TTO fragment, and the hardware complication.

Results  KSS raised from 40.7 ± 3.1 to 75 ± 4.3 ( p  < 0.0001). Knee flexion increased from 78.7 ± 9.9° to 95.0 ± 9.5° ( p  < 0.0001), and VAS improved from 7.9 ± 0.9 to 3.8 ± 1 ( p  < 0.0001). No signs of loosening or evolutive radiolucency lines were found. Osteolytic areas around the stem were detected. No significant association was found between the implant design and the outcomes, while aseptic loosening showed significantly better results. Complications were: 4 painful hardware, 3 late periprosthetic infections, 1 extension lag of 5°, and 3 flexion lag.

Conclusion  Our experience suggests the use of TTO to improve the surgical approach in difficult primary TKA or revision TKA. A precise surgical technique leads to good results with low risk of complications.

Level of Evidence  Level IV, therapeutic case series.

Tibial tubercle osteotomy (TTO) in total knee arthroplasty, is it worth it? A review of the literature

INTRODUCTION

Tibial tubercle osteotomy (TTO) is a well-established extensile approach to improve joint visualization and implant removal. Despite this, TTO is a challenging technique with a long learning curve and potential pitfalls. Complications are not infrequent, even if performing the correct surgical steps. Aim of this paper is to review the current literature about TTO, its safeness and reliability, and finally the complications rate.

MATERIALS AND METHODS

We performed a systematic review of the available English literature, considering the outcomes and the complications of TTO. The combinations of keyword were "tibial tubercle osteotomy", "total knee arthroplasty", "total knee revision", "outcomes", "complication" and "surgical approach".

RESULTS

From the starting 322 papers available, 26 manuscripts were finally included. Most of the papers show significant improvements in clinical outcomes, both in primary and in revision procedures. Radiographic fragment healing is close to 100%. Related complications can range from 3.8-20%.

CONCLUSION

TTO may be necessary to correct pathological tuberosity position or patella tracking. However, TTO is a challenging technique to improve the surgical approach during total knee arthroplasty. A strict surgical technique can lead to better results and to minimize complications. However, it is not clear if the improved outcome can outweigh the longer surgery and the higher risk of pitfalls.

Tibial Tubercle Osteotomy in Revision Knee Arthroplasty

BACKGROUND

Obtaining adequate exposure while maintaining the integrity of the extensor mechanism is crucial to the success of revision knee arthroplasty. This is particularly important in infected cases where staged procedures are necessary. While the use of a long, tibial tubercle osteotomy (TTO) is an established method to improve exposure, controversy still exists concerning complication rates and sequential use.

METHODS

Forty-two TTOs were performed in revision knee arthroplasties between 2009 and 2015. Follow-up period ranged from 3 to 24 months. Twenty-four TTOs were performed for single-stage revisions, and 18 TTOs were performed for 2-stage infected revisions. In infected cases, the initial osteotomy was left unfixed between stages. Screws were used to fix the osteotomy flap in all cases.

RESULTS

All osteotomies united with no fractures, and there were no extensor lags. Minor proximal migration was noted in 1 case, and refixation was required in another. Greater range of motion (ROM) and improved Oxford Knee Scores were achieved in the single-stage revision group. In the infected 2-stage group, sequential use did not decrease union rates, and infection was eradicated in 14 of the 16 knees (88%).

CONCLUSION

We conclude that TTO is a safe and reproducible procedure when exposure needs improving in revision knee arthroplasty. In 2-stage revisions, sequential osteotomies do not decrease union rates, and leaving the osteotomy unfixed after the first stage does not cause any adverse issues.

Tibial Tubercle Osteotomy to Aid Exposure for Revision Total Knee Arthroplasty

Introduction

A tibial tubercle osteotomy can provide reliable and safe exposure during revision total knee arthroplasty with a high union rate, low complication rate, and predictable outcomes.

Indications & Contraindications

Step 1 Preoperative Planning Figs 1-A through 2-B

Determine the need for an extensile approach on the basis of the preoperative knee range of motion; position of the patella; bone quality; medical comorbidities; and cement mantle, tibial keel or stem, and thickness of the anterior tibial cortex.

Step 2 Incision and Arthrotomy

Create full-thickness subcutaneous flaps and perform a medial parapatellar arthrotomy with complete synovectomy and careful excision of scar tissue from the medial and lateral gutters.

Step 3 Incision Extension and Preparation for Tibial Tubercle Osteotomy Figs 3 and 4 Videos 1 2 and 3

Extend the skin and subcutaneous dissection distal to the tibial tubercle and mark the chevron osteotomy using electrocautery.

Step 4 Tibial Tubercle Osteotomy Fig 5 Videos 4 and 5

Perform the osseous cut for the tibial tubercle osteotomy with a thin saw blade in a medial-to-lateral direction, such that the fragment hinges on the lateral soft tissue and musculature.

Step 5 Revision Total Knee Arthroplasty Videos 6 and 7

With the knee maximally flexed and lateral subluxation of the extensor mechanism, for full visualization of the femoral and tibial components, remove the components and perform the knee revision.

Step 6 Preparation for Insertion of Tibial Component

The final tibial component should have a diaphyseal stem long enough to bypass the distal extent of the tibial tubercle osteotomy by at least 2 cortical diameters.

Step 7 Trialing and Insertion of Final Tibial Component Figs 6 and 7 Videos 8 9 and 10

When cementing the final tibial component, take care to remove cement anterior to the tibial stem that would otherwise impede complete reduction of the osteotomy fragment and interfere with osseous union at the osteotomy site.

Step 8 Reduction of Tibial Tubercle Osteotomy Fragment Figs 8 and 9 Videos 11 12 and 13

Manually position the osteotomized bone fragment over the tibia and obtain an anatomic reduction either freehand or using bone clamps, depending on the soft-tissue tension.

Step 9 Fixation of Tibial Tubercle Osteotomy Fragment Video 14

Obtain rigid fixation with a 6.5-mm screw proximally and 2 sets of doubled-over 18-gauge wires distally.

Step 10 Stressing the Osteotomy Site and Wound Closure Figs 10 11 and 12 Videos 15 and 16

Stress the osteotomy site by flexing the knee 90°, deflate the tourniquet, place a drain if needed, and close.

Step 11 Postoperative Restrictions and Protocol Figs 13-A and 13-B

Allow weight-bearing as tolerated and a 0° to 90° range of motion in a hinged knee brace.

Results

Tibial tubercle osteotomy to aid in exposure during revision total knee arthroplasty has been reported to yield favorable outcomes in the orthopaedic literature^7-18.

Pitfalls & Challenges

Comparison of quadriceps snip and tibial tubercle osteotomy in revision for infected total knee arthroplasty

PURPOSE

Controversies exist regarding the ideal approach in a revision total knee arthroplasty for infection, providing adequate exposure with minimum complications. The purpose of this study was to compare the results of second stage revision total knee arthroplasty (TKA) between tibial tubercle osteotomy (TTO) and quadriceps snip (QS) approaches for infected TKA.

METHODS

The clinical and radiological outcomes of 27 patients of TTO and 21 patients of QS in second stage revision TKA for infected TKA were compared with an average follow up of 51 months. We evaluated the clinical outcomes including HSS score, WOMAC score, flexion contracture, and maximal flexion between two groups. The radiological outcomes in terms of femorotibial alignment, patellar height and complications were also compared.

RESULTS

At the final follow-up, KSS score, HSS score, WOMAC score, flexion contracture, and maximal flexion showed no statistically significant differences between the two groups. The femorotibial alignment and patellar height also showed no differences between the two groups. During the surgery, patellar tendon partial avulsion was more commonly observed in the QS group than in the TTO group (five vs two cases).

CONCLUSION

Both tibial tubercle osteotomy and quadriceps snip in revision TKA were considered as good approaches without significant complications. However, cautious exposure of patellar tendon or strong fixation of the osteotomy is needed to minimize the complications.

Tibial tubercle osteotomy hinged on the tibialis anterior muscle and fixed by circumferential cable cerclage in revision total knee arthroplasty

BACKGROUND

Difficulties in knee exposure during revision total knee arthroplasty (RTKA) may require tibial tubercle osteotomy (TTO). The main objective of this study was to assess union after TTO hinged on the lateral soft tissues and fixed using circumferential cable cerclage during RTKA.

HYPOTHESIS

Non-union is uncommon with this technique.

PATIENTS AND METHODS

We retrospectively included consecutive patients who underwent RTKA between 2008 and 2010 with TTO. Chevron osteotomy was performed and the fragment was left hinged laterally on the tibialis anterior muscle then fixed using circumferential cerclage with one or two steel cables. The primary evaluation criterion was TTO union as assessed on radiographs. Secondary evaluation criteria were time to union, osteotomy fragment migration, patellar height, and the IKS score at last follow-up. We included 65 patients with a mean age of 72±11.3 years including 39 (60%) undergoing septic revision and 26 (40%) aseptic revision. Mean follow-up was 27.8±10.7 months; there was 1 early death, which was unrelated to the surgery, and another patient was lost to follow-up.

RESULTS

TTO union was achieved in 59/63 (93.7%) patients. Fragment migration occurred in 4 (6.3%) patients. Mean time to union was 16.9±5.1 weeks overall, 12.4±2.0 in the aseptic revision group, and 18.9±4.8 in the septic revision group (P=0.0005). Patellar height at last follow-up was not significantly changed compared to the preoperative value (P=0.09). At last follow-up, the mean IKS knee and function scores were significantly improved (P<10-5).

CONCLUSION

TTO hinged on the lateral soft tissues and fixed by circumferential cable cerclage ensured union in the vast majority of patients, with a low rate of tubercle migration.

LEVEL OF EVIDENCE

IV, retrospective study.

Tibial tubercle osteotomy with absorbable suture fixation in revision total knee arthroplasty: a report of 23 cases

OBJECTIVE

Tibial tubercle osteotomy (TTO) is a well-known technique for improving exposure in difficult total knee arthroplasty (TKA). We have performed 23 revision TKAs with TTO. The tibial tubercle was fixated with only absorbable sutures afterwards. The aim of this study is to report on the clinical results and complications of this procedure.

METHODS

We retrospectively evaluated 23 patients (mean age 69.6 years, range 43-84 years) who underwent TTO with only absorbable suture fixation. Clinic charts were reviewed to identify any complications that occurred. Obvious proximal migration and union of the tibial tubercle was evaluated on the postoperative radiographs. Knee Society scores and SF-36 were assigned at latest follow-up.

RESULTS

The mean follow-up was 16.1 months (1-43). Two patients died of causes unrelated to surgery. In one case a fracture of the TTO occurred. No obvious migration of the osteotomy was detected. In two cases there was partial consolidation of the osteotomy, but without clinical consequences of pain or extension lag. In five patients a tibial plateau fracture occurred intraoperative which allowed partial weight bearing during 6 weeks. These fractures were not related to the surgical technique of the TTO. In 15 out of 23 patients a Knee Society Score could be assigned. The mean total knee score (maximum 200 points) after revision was 99.5 (17-166) (clinical KSS 52.1, functional KSS 47.3) at latest follow-up. SF-36 scores could be assigned to 16 patients; the mean SF-36 (maximum 100) was 88 (range 74-98).

CONCLUSION

Tibial tubercle osteotomy with only absorbable suture fixation is a reliable and simple method of fixation and provides adequate stability. It is a straightforward surgical technique which is less time-consuming and expensive compared with screw and cerclage wire fixation and no hardware removal will be necessary. Therefore, this method is a beneficial technique for the enhancement of surgical exposure in difficult revision TKA.

Lateral parapatellar approach with tibial tubercle osteotomy for the treatment of non-correctable valgus knee osteoarthritis: a retrospective clinical study

BACKGROUND

The aim of this retrospective study was to evaluate the efficacy of a lateral parapatellar approach combined with a tibial tubercle osteotomy (TTO) in patients undergoing total knee arthroplasty (TKA) with non-correctable valgus knee osteoarthritis.

METHODS

We studied 53 consecutive patients (57 knees) who had a primary TKA via lateral parapatellar approach with a global step-cut "coffin" type TTO over a 10-year period. All patients had non-correctable grade II valgus deformity according to the Ranawat classification. The average age of patients was 71 years (45 to 77) and the mean follow-up was 39 months (20 to 98).

RESULTS

Post-surgery, there was a significant improvement in knee extension (p=0.002), flexion (p=0.006), Knee Society Pain and Function Scores (p<0.001) and WOMAC Osteoarthritis Index (p<0.001). The tibiofemoral angle changed from a preoperative median value of 11 deg (10 to 17) to a postoperative value of 3.75 deg (0 to 9). Congruent patellar tracking was observed in all cases. All but one osteotomy united in a median period of 16.7 weeks (9 to 28) and no hardware removal was required. One knee developed infection treated with two-stage reconstruction. A proximal tibial stress fracture also occurred in a patient on long-term bisphosphonate therapy.

CONCLUSION

Lateral parapatellar approach along with TTO is an effective technique for addressing non-correctable valgus knee deformity during TKA.

Revision of infected total knee arthroplasty: two-stage reimplantation using an antibiotic-impregnated static spacer

BACKGROUND

A two-stage revision remains as the "gold standard" treatment for chronically infected total knee arthroplasties.

METHODS

Forty-five septic knee prostheses were revised with a minimum follow-up of 5 years. Static antibiotic-impregnated cement spacers were used in all cases. Intravenous antibiotics according to sensitivity test of the culture were applied during patients' hospital stay. Oral antibiotics were given for another 5 weeks. Second-stage surgery was undertaken after control of infection with normal erythrocyte sedimentation rate and C-reactive protein values. Extensile techniques were used if needed and metallic augments were employed for bone loss in 32 femoral and 29 tibial revisions.

RESULTS

The average interval between the first-stage resection and reimplantation was 4.4 months. Significant improvement was obtained with respect to visual analog scale pain and clinical and functional scores, and infection was eradicated in 95.6% of cases following a two-stage revision total knee arthroplasty. Radiographic evaluation showed suitable alignment without signs of mechanical loosening.

CONCLUSIONS

This technique is a reasonable procedure to eradicate chronic infection in knee arthroplasty and provides proper functional and clinical results. However, it sometimes requires extensile surgical approaches that could imply arduous surgeries. Metallic augments with cementless stems available in most of the knee revision systems are a suitable alternative to handle bone deficiencies, avoiding the use of bone allografts with its complications.

Tibial tubercle osteotomy or quadriceps snip in two-stage revision for prosthetic knee infection? A randomized prospective study

BACKGROUND

Although 7% to 38% of revision total knee arthroplasties (RTKAs) are attributable to prosthetic knee infections, controversy exists regarding the best surgical approach while reducing the risk of extensor mechanism complications and the reinfection rate.

QUESTIONS/PURPOSES

We compared The Knee Society Score(©) (KSS), incidences of complications, maximum knee flexion, residual extension lag, and reinfection rate in patients with prosthetic knee infections treated with two-stage RTKAs using either the tibial tubercle osteotomy (TTO) or the quadriceps snip (QS) for exposure at the time of reimplantation.

METHODS

We prospectively followed 81 patients with chronic prosthetic knee infections treated between 1997 and 2004. Patients were randomized to receive a TTO or QS for exposure at the time of reimplantation. All patients had the same rehabilitation protocol. The minimum followup was 8 years (mean, 12 years; range, 8-15 years).

RESULTS

Patients in the TTO group had a higher mean KSS than the QS group (88 versus 70, respectively). Mean maximum knee flexion was greater in the TTO group (113° versus 94°); with a lower incidence of extension lag (45% versus 13%). We observed no differences in reinfection rate between groups.

CONCLUSIONS

We found the TTO combined with an early rehabilitation protocol associated with superior KSS did not impair extensor mechanism function or increase the reinfection rate. We believe a two-stage RTKA with TTO is a reasonable approach for treating prosthetic knee infections.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The outcome of sequential repeated tibial tubercle osteotomy performed in 2-stage revision arthroplasty for infected total knee arthroplasty

Thirteen patients with infected total knee arthroplasty treated by 2-stage revision requiring tibial tubercle osteotomy in both stages for extensile exposure were retrospectively analyzed. The preoperative mean range of knee motion improved from 60° (range, 30°-90°) to 94° (range, 70°-120°) at latest follow-up. The Knee Society knee scores and function scores were 39 and 18 preoperatively and 78 and 67 at latest follow-up, respectively. Although proximal migration occurred in 3 cases and a partial proximal avulsion fracture of the osteotomy segment occurred in 1 case after the second-stage reimplantation, radiographic bony union was observed in all cases. Sequential repeated tibial tubercle osteotomy can be a useful extensile surgical approach in staged revision for infected total knee arthroplasty with satisfactory clinical and radiographic outcomes.

Predisposing factors which are relevant for the clinical outcome after revision total knee arthroplasty

PURPOSE

The objective of this study was to investigate the outcome of revision total knee arthroplasty (TKA) in relation to the cause of index failure, the characteristics of the index procedure, and the elapsed time between index TKA and revision.

METHODS

A retrospective review based on a prospective database was performed on 146 consecutive revision TKA's. Variables tested were the cause of index failure; the elapsed time between the index and revision procedure; patient age at time of revision; partial or total revision of the implants; the performance of a tibial tubercle osteotomy; the presence of radiolucent lines; postoperative patellar tracking; and coronal plane alignment. Outcomes were measured with the Knee Society Knee Score (KS), Function Score (FS), and X-ray evaluation.

RESULTS

Mean KS improved from 27.6 (SD 21.6) to 71.5 (SD 24.2) after revision (P < 0.0001), mean FS from 27.5 (SD 22.7) to 53.3 (SD27.7), P < 0.0001. Overall survival rate was 90% at 5 years and 85% at 10 and 14 years. The cause of index failure had no significant influence on any of the outcome parameters. Significantly, better outcomes were noted for partial revisions and for revisions in older patients. Early revisions (<2 years) were mostly performed for infection and instability, whereas late revisions (>2 years) were mostly performed for polyethylene wear and loosening. The survival rate for late revisions was significantly better than for early revisions (P = 0.002).

CONCLUSION

Revision TKA leads to a significant reduction in symptoms and improvement in function. The worst results can be expected for early revisions in young patients. Revision TKA is a demanding procedure with variable results and should therefore be performed by experienced surgeons.

LEVEL OF EVIDENCE

Therapeutic study-Level IV.

Utility of tibial tubercle osteotomy in the setting of periprosthetic infection after total knee arthroplasty

PURPOSE

This study reports radiographic and clinical treatment outcomes of tibial tubercle osteotomy (TTO) used for two-stage revision total knee arthroplasty (TKA) in the setting of periprosthetic infection.

METHODS

Thirty-six patients with 51 TTOs used for infected TKA were retrospectively analysed from 2000 to 2010. In 15 of 36 patients, TTO was used in a sequential manner during both first and second stage procedures. The mean follow-up period was 57 months (range seven-126 months).

RESULTS

The mean pre-operative range of knee motion was 40° (range 10-90°), and at latest follow-up it was 92° (range 50-140°). The Knee Society knee scores and function scores were 47 and 9 pre-operatively and 82 and 72 at latest follow-up, respectively. Bony union was achieved in all cases except one nonunion of an avulsion fragment of the osteotomy segment without functional deterioration.

CONCLUSIONS

TTO can be a useful extensile surgical approach for treatment of infected TKA with satisfactory clinical and radiographic outcomes.

Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?

Background

The purpose of this prospective consecutive multicenter study was to investigate whether the type of surgical approach (medial parapatellar (MPA) or lateral parapatellar with tibial tubercle osteotomy (TubOT)) influences the early clinical and radiological outcomes of primary total knee arthroplasty (TKA).

Methods

Ligament balancing primary TKA with a rotating platform was performed in 143 knees (m:w = 1:1.6; mean age 69 ± 8 years). The TKA was done by a lateral parapatellar subvastus approach with stepcut osteotomy of the tibial tubercle (53%; n = 76, group A) or medial parapatellar approach (47%; n = 67, group B). The outcome was assessed at 1 and 2 years postoperatively by the American Knee Society score (KSS) and the knee society total knee arthroplasty roentgenographic evaluation and scoring system (TKA-RESS). The patient's pain level and satisfaction was noted by a visual analogue scale (VAS). Data were analyzed by an independent statistician with a level of significance of p < 0.05. The Wilcoxon two sample test (two-sided) was used to investigate differences of patients between group A and B pre- and postoperatively. The paired t-test was used to evaluate differences over course of time within each group. For comparison of radiological alignment a Chi²-test was performed.

Results

Although having a lower degree of preoperative flexion (112° ± 15° versus 115° ± 15°) patients in group A showed a significantly (p = 0.027) higher degree of flexion (118° ± 10°) at their last follow-up than patients in group B (114° ± 10°). Patients in group A showed a significantly better mean VAS pain (p = 0.0001) and satisfaction (p = 0.0058) at 2 years follow-up. The pain free walking distance was significantly (p = 0.036) longer for group A than group B. Patients treated with a lateral approach were significantly more stable in terms of valgus stress (p = 0.049). The Knee society score was significantly (p = 0.0009) higher at two years follow up in group A compared to group B. The postoperative mechanical alignment and positioning of the prosthesis were not significantly different. Patients in group B presented with significantly (p = 0.0017) more tibial radiolucencies (> 2 mm) at their last follow-up than patients in group A. There was no prosthesis related revision in either group. The revision rate in group A (4%) was higher than in group B (1.5%), which was mainly due to two cases of traumatic secondary displacement of the tibial tubercle and need for refixation.

Conclusions

The TubOT led to slightly better functional results and less pain two years after primary TKA. It is however not clear if the improved outcome can outweigh the longer operation time and higher risk of early complications and revisions. Long-term studies are necessary to show whether there is any difference in prosthesis longevity between both types of approach.