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

Tibial Tubercle Osteotomy: Indications, Outcomes, and Complications

PURPOSE OF REVIEW

The tibial tubercle osteotomy (TTO) is a versatile surgical technique used to treat a range of patellofemoral disorders, including patellar instability, painful malalignment, focal chondral defects, and patellar maltracking that have failed conservative therapies. TTO is a personalized procedure that can be tailored to the pathoanatomy of the patient based on physical examination and imaging. The complication rate associated with TTO strongly depends on the indication for surgery, the severity of the patient's condition, and the surgical approach. Despite the literature on TTO, to our knowledge, no single source has addressed the indications, techniques, outcomes, and complications of this procedure. The purpose of this article is to serve as such a valuable resource.

RECENT FINDINGS

Highlights from recent studies we would like to emphasize are two-fold. First, maintaining a distal cortical hinge yields lower complication rates than osteotomies involving complete tubercle detachment with classic or standard techniques. Second, based on current evidence, TTO consistently provides symptomatic relief, and most patients can return to work or sport at their pre-operative level within 3 and 6 months, respectively. TTO is a personalizable surgical technique that may be utilized for multiple patellofemoral disorders and is associated with good outcomes.

Incisional Management in the Multiply Operated Total Knee Arthroplasty

Total knee arthroplasty in the setting of multiple previous skin incisions can be a complex clinical scenario for the arthroplasty surgeon. Inappropriate incision choice can lead to devastating complications such as skin necrosis and its sequelae, including periprosthetic joint infection and the need for flap reconstruction. It is therefore critical for knee surgeons to understand the blood supply to the anterior aspect of the knee to prevent adverse outcomes. This article challenges some of the long-held dogma regarding incisional management for total knee arthroplasty and utilizes case examples to demonstrate that skin necrosis between parallel incisions can be avoided by utilizing an existing lateral incision with full-thickness subfascial skin flaps.

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.

A Reliable Surgical Approach to Revision Total Knee Arthroplasty

Backgroud

The surgical exposure obtained in revision total knee arthroplasty should facilitate the utilisation of instrumentation and implants, including adjuncts such as stemmed prostheses, bone allograft, and artificial augments. We have previously identified within this cohort of revision total knee arthroplasty patients a high satisfaction rate of 93.5% at a mean 6.5 years of follow-up and a high level of postoperative function. We, therefore, seek to describe in detail the operative technique and perioperative care and report the early postoperative complications.

Methods

We report on the surgical approach, closure technique, and postoperative care used by the senior author for revision total knee arthroplasty procedures. The patient demographics, intraoperative details, and postoperative outcomes are also reported. We aim to provide a clear description of the intraoperative technique and postoperative outcome, facilitating adoption or comparison with other surgeons or techniques. Patient inclusion criteria were revision total knee arthroplasty performed by the senior author using the PFC (Depuy) prosthesis at John Flynn Private Hospital with a minimum of 2-year postoperative follow-up. A retrospective chart review was combined with a structured telephone assessment questionnaire to assess outcomes.

Results

A total of 202 revision total knee arthroplasties were available for follow-up in 185 patients. The mean 1-year postoperative range of motion was 110°. Key features of surgical approach include incision planning, soft-tissue plane development, parapatellar scar debridement, safe removal of implants, management of bone defects, and closure technique. The overall 90-day complication rate was 9%, including 4.4% requiring manipulation under anaesthesia and 3% superficial surgical site infections (1 patient requiring intravenous antibiotics).

Conclusions

We suggest that the described technique is reproducible and reliable. It rarely requires modification and facilitates successful postoperative outcomes with a low complication rate. The adoption of this surgical technique allows surgeons to approach complex knee arthroplasty with confidence in the appropriate exposure of anatomy, facilitating subsequent steps in their arthroplasty procedures.

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.

Older age and varus alignment lead to early failure in treating patellofemoral osteoarthritis with Fulkerson osteotomy

Background: It is unclear the risk factors for the failure of modified Fulkerson osteotomy. Methods: We retrospectively reviewed 40 patients who underwent the modified Fulkerson osteotomy from 1998 to 2015. There were 4 males and 36 females. The mean age of the study group was 50.2 ± 11.2 years. We used standard anteriorization measuring 10-15 mm and medialization measuring 10 mm while maintaining an intact periosteal sleeve. Results: Both the patellofemoral angle and the congruence angle improved significantly after 5.9 years. Preoperatively, the mean preoperative Lysholm score was 56.12, and the Knee Society score was 60.52. At the final follow-up, these scores improved significantly to 88.75 and 86.49, respectively. However, eight patients (20%) underwent total knee arthroplasty in the follow-up period, five of whom underwent the operation within 5 years. Comparing the survival and non-survival groups, there was a significant difference of an older age in the TKA conversion group (survival: 48.3 ± 11.1; non-survival: 57.8 ± 8.7, p = 0.03). For knee alignment, the non-survival group had a mean valgus femorotibial angle of 1.8° ± 4.9° preoperatively, and the survival group had a mean valgus angle of 6.4° ± 4.5° (p = 0.03). Conclusions: we found that patients with older age and those with varus alignment have an increased risk of deteriorated medial femorotibial cartilage.

Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis

Chronic patellar dislocation in the setting of severe knee osteoarthritis is a rare clinical problem. Surgical management often consists of total knee arthroplasty combined with realignment of the extensor mechanism. Several techniques have been described to anatomically restore the extensor apparatus, and literature regarding this topic consists mainly of case reports. We describe a technique using combined medial patellofemoral ligament reconstruction using allograft tissue and total knee arthroplasty with patellar resurfacing for the treatment of chronic patellar dislocation and severe osteoarthritis.

Impact of Tibial Tubercle Osteotomy on Final Outcome in Revision Total Knee Arthroplasty: Our Experience and Technique in Pakistan

Backgroud

Due to extensive fibrosis during revision surgery, adequate exposure is essential and it can be achieved with several extensile approach options, such as tibial tubercle osteotomy. Information regarding surgical exposure during revision arthroplasty is limited in developing countries, such as Pakistan, due to the lack of adequate data collection and follow-up. Therefore, the purpose of this study was to evaluate the impact of tibial tubercle osteotomy on final outcome of revision total knee arthroplasty (TKA).

Methods

A total of 231 revision TKAs were performed between January 2008 and December 2017. Twenty-nine patients underwent tibial tubercle osteotomy for adequate exposure during revision surgery. Of these, 27 patients with complete follow-up were included in our study. Factors examined include age at the time of revision surgery, gender, comorbidities, arthroplasty site (right or left), body mass index (BMI), and primary indications for the tibial tubercle osteotomy during revision TKA. Functional outcome was measured by using Knee Society score (KSS) at 3 months and the final follow-up. All statistical analysis was done using SPSS version 20.0 with a p-value < 0.05 considered significant.

Results

Out of 27 patients, 6 patients (22.2%) were men and 21 patients (77.7%) were women. Right knee revision arthroplasty was performed in 15 patients (55.5%), left knee revision arthroplasty was performed in 12 patients (44.4%), and bilateral revision surgery was performed in only 1 patient (3.7%). The mean BMI was 29.2 kg/m². We used a constrained condylar knee in 20 patients (74%), a rotating hinge knee in 5 patients (18.5%), and mobile bearing tray plus metaphyseal sleeves in 2 patients (7.4%). The KSS was 52.21 ± 4.05 preoperatively, and 79.42 ± 2.2 and 80.12 ± 1.33 at 3 months and 12 months, respectively. Radiological union was achieved in all patients at 3 months. Of 27 patients, only 1 patient (3.7%) had proximal migration of the osteotomy site at 6 months: the patient was asymptomatic and union was also achieved and, therefore, no surgical intervention was performed.

Conclusions

Tibial tubercle osteotomy during revision TKA can be a safe and reliable technique with superior outcomes and minimal complication rates.

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.

Revision of total knee arthroplasty with the use of patient-specific instruments: an alternative surgical technique

INTRODUCTION

Accuracy in the placement of components in revision total knee arthroplasty (R-TKA) surgery is sometimes challenging. The applicability of patient‑specific instruments (PSI) in knee surgery has progressively expanded to types of surgery other than primary arthroplasty. Could this assistive technology be used to facilitate accurate R-TKA surgery? The aim of the current manuscript is to describe this new application of PSI for revision of TKA-to-TKA and to provide a step-by-step technical guideline for use.

AREAS COVERED

We will describe the application and a detailed description of PSI technology to TKA revision surgery, step-by-step, from CT images acquisition for preoperative planning and PSI blocks production to the surgery.

EXPERT COMMENTARY

The system can facilitate the accomplishment of the bony cuts for optimal implant placement and that can be useful in minimally altering the femoral and the tibial joint line. It is obvious that technology alone will not replace surgical skill and that accuracy of the system will also depend on the quality of the CT images and the ability of the software to prevent metal artifacts. Despite that, our initial results are promising and prove that the concept of applying PSI technology to the R-TKA surgery is feasible.

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.

Total Knee Arthroplasty in Patients with Prior Femoral and Tibial Fractures: Outcomes and Risk Factors for Surgical Site Complications and Reoperations

Objective

To investigate the outcomes of total knee arthroplasty (TKA) in patients with a prior femoral or tibial fracture, and identify the risk factors for surgical site complications and reoperations.

Methods

Seventy‐one TKAs performed in 71 patients with a prior tibial or femoral fracture between January 2005 and December 2016 were reviewed retrospectively. Forty males (40 knees) and 31 females (31 knees) were included. The mean age at the time of TKA was 59.2 (range, 29–83) years. Outcomes were assessed using the Knee Society score before surgery and at the final follow‐up visit. The patients' satisfaction rates were evaluated. Complications and reoperations were recorded by clinical and radiographic assessment. Logistic regression analysis was used to identify the risk factors for surgical site complications and reoperations.

Results

The median follow‐up period was 4.7 (range, 3.2–7.1) years. The median knee range of motion increased from 90° preoperatively to 110° at the latest follow‐up. The Knee Society knee score and function score improved from 35 (30, 40) and 40 (30, 50) to 90 (82, 93) and 90 (65, 100), respectively. The degree of overall satisfaction after TKA surgery was very satisfied in 41 patients, satisfied in 20 patients, neutral in four patients, dissatisfied in four patients, and very dissatisfied in two patients. The overall satisfaction (very satisfied and satisfied) rate was 85.9% (61 knees). Twelve knees (16.9%) had 19 surgical site complications. Six knees (8.3%) underwent reoperations, including one revision due to periprosthetic joint infection, one debridement and implant retention for superficial infection, two debridements for delayed wound healing, one open reduction and internal fixation for supracondylar fracture, and one re‐fixation and bone grafting for hardware failure after a combined femoral shaft osteotomy and TKA. Preoperative patella baja was diagnosed in 12 knees, and was identified as a risk factor for surgical site complications and reoperations.

Conclusions

TKA for post‐fracture osteoarthritis significantly relieved pain and improved function, but the incidence of surgical site complications and reoperations was high. Preoperative patella baja was a risk factor for surgical site complications and reoperations.

A detaching, V-shaped tibial tubercle osteotomy is a safe procedure with a low complication rate

INTRODUCTION

In patients with recurrent patellar dislocations, a tibial tubercle osteotomy (TTO) can be indicated to correct patella alta or an increased trochlear groove-tibial tubercle distance. Several surgical techniques are described. Previous studies emphasize that detaching osteotomies results in devascularisation, which can lead to non-union and tibial shaft fractures. The aim of this study was to report the complication rates directly related to the surgical technique of a V-shaped TTO, where the tubercle is completely released from its periosteum using a step-cut osteotomy.

METHODS

The retrospective case series comprised a large cohort of 263 knees with patella alta in 203 patients who underwent a V-shaped TTO, with or without additional realignment procedures, between March 2004 and October 2017. Data were obtained from available patient files. Complications were defined as minor or major.

RESULTS

Thirteen major complications were registered (4.9%) including two tibial fractures (0.75%) and one non-union (0.37%). Five complications (1.9%) were defined as minor. Removal of the screws because of irritation or pain was seen in 22 cases (8.2%).

CONCLUSION

A V-shaped TTO is a safe procedure. The presumed higher risk for tibial fractures or pseudo-arthrosis could not be confirmed.