Lateral subvastus approach with tibial tubercle osteotomy for primary total knee arthroplasty: clinical outcome and complications compared to medial parapatellar approach

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Lateral versus medial approach for total knee arthroplasty for valgus knee deformity shows comparable functional outcomes, hip-knee-ankle angle values, and complication rates: a meta-analysis of comparative studies

INTRODUCTION

The aim of this meta-analysis of comparative studies was to update the current evidence on functional and radiographic outcomes and complications between medial and lateral approaches for total knee arthroplasty (TKA) for valgus knee deformity.

MATERIALS AND METHODS

The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of ten studies were included. The methodological quality of the included studies was assessed. Data extracted for quantitative analysis included the Knee Society score (KSS), range of motion (ROM), surgical time, hip-knee-ankle angle (HKA), and number and types of complications. Random- and fixed-effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs). The Mantel-Haenszel method was adopted.

RESULTS

A total of 1008 patients were identified, of whom 689 and 319 underwent TKA for valgus knee deformity with lateral and medial approach, respectively. The mean age was 70 ± 9.5 and 67.3 ± 9.6 years for the lateral and medial approaches, respectively. The mean follow-up was 37.8 ± 21.9 and 45.9 ± 26.7 months for the lateral and medial approach groups, respectively. Significantly higher functional outcomes were found for the medial approach, as measured by the postoperative KSS (MD = 1.8, 95% CI [0.48, 3.12], P = 0.007) and flexion ROM (MD = 3.12, 95% CI [0.45, 5.79], P = 0.02). However, both of these differences were lower than the minimal clinically important difference. Comparable surgical time and postoperative HKA angle values (MD = 0.22, 95% CI [- 0.30, 0.75], P = 0.40) between the two surgical approaches were found. The incidence of periprosthetic joint infections, fractures, transient peroneal nerve injuries, and deep vein thrombosis was comparable.

CONCLUSION

This meta-analysis of comparative studies showed that when lateral and medial approaches are used for total knee arthroplasty for valgus knee deformity, comparable functional outcomes in terms of the KSS and ROM, surgical time, and postoperative hip-knee-ankle angle values can be expected. Similar rates of periprosthetic joint infection, fracture, and peroneal nerve injury were also found.

LEVEL OF EVIDENCE

I.

PROSPERO REGISTRATION NUMBER ID

CRD42023392807.

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.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression

BACKGROUND

Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA.

METHODS

The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression.

RESULTS

In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively.

CONCLUSION

Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

[Extended access to revision knee replacement : Intraoperative possibilities for improved joint exposure in complex knee arthroplasty procedures]

In most cases, a standard access via a medial parapatellar arthrotomy with a carefully performed release technique is sufficient for a good exposure of the knee joint in the revision situation. Crucial steps are targeted scar removal, sufficient soft tissue release and recreation of the shifting layers. Tuberosity osteotomy is an effective option for extended exposure at the distal joint region, facilitating a patella replacement to correct abnormalities in the patellofemoral joint. Extended exposure to the proximal joint is possible with the rectus snip and the VY plasty technique. Due to the rather poor results, a quadriceps turndown should be seen more historically and should no longer be used. In extreme cases, a femoral peel or an osteotomy of the medial epicondyle can help achieve the reconstruction of a joint. The latter techniques are reserved for selected cases and always require a linked implant.

Lateral subvastus approach: A cadaveric examination of its potential for total knee arthroplasty

BACKGROUND

Lateral approaches to total knee arthroplasty (TKA) provide good surgical exposure and may provide greater ease of soft tissue balancing in patients with a valgus deformity; however, little is known about the versatility in non-valgus knees. The present study evaluated if a lateral subvastus approach can achieve adequate surgical exposure while maintaining less soft tissue damage compared with the medial parapatellar approach in knees without any significant deformity.

METHODS

Using paired fresh-frozen cadaveric knees, the present study provides the first specimen-matched, side-by-side comparison of the lateral subvastus approach to the standard medial parapatellar approach to TKA. Ten knees were selected to undergo a lateral subvastus approach; the contralateral knee had a medial parapatellar approach as control. Incision length, surgical exposure and iatrogenic soft tissue damage were compared between the two approaches.

RESULTS

The lateral subvastus approach was successfully performed using an incision length that was not different from that used in the medial parapatellar approach (p > 0.05). The resultant surgical exposure was comparable between approaches (p > 0.05). The risk of the approach included tearing of the vastus lateralis fibers, and/or abrasion of the iliotibial tract/patellar ligament.

CONCLUSIONS

The lateral subvastus approach to TKA provided a comparable method to the standard medial parapatellar approach. Despite adequate exposure, the approach did risk soft tissue injury. Caution needs to be exercised to reduce the risk of iatrogenic injury to the vastus lateralis and surrounding ligaments. The successful implementation in this cadaveric study substantiates the need for further consideration of this approach in clinical practice.

Finite element study of the effects of fragment shape and screw configuration on the mechanical behavior of tibial tubercle osteotomy

PURPOSE

Tibial tubercle osteotomy (TTO) is a surgical technique used in the management of severe fractures of the knee joint and revision total knee arthroplasty. Limited research discusses the performance of the osteotomy and fixation of the TTO with screws. Therefore, this study investigated the effects of fragment shape and screw configuration on the mechanical behavior in the fixation of the TTO using the finite element (FE) method.

METHODS

FE TTO models with three fragment shapes and three screw configurations were developed. The three fragment shapes were a step cut, bevel cut, and straight cut. The screw configurations were two parallel horizontal and downward screws and two trapezoidal screws. A 1654-N upward tension force was applied on the tibia tubercle, and the distal end of the tibia was completely fixed.

RESULTS

The results indicated that the step cut resulted in higher stability than the bevel and straight cut, but the stress was higher as well. Among the screw configurations, two parallel downward screws resulted in the highest stability, given the same fragment shape. In the horizontal configuration, the step cut tibia developed the largest contact force to achieve stability of the bone fragment under loading.

CONCLUSION

The fragment shape with a step cut and fixation with two parallel horizontal or downward screws are suggested for TTO, while the trapezoidal screw configuration is not suggested. Furthermore, the downward screw configuration is a suitable strategy to reduce bone stress.

The lateral and medial approach in total arthroplasty for valgus knee: a meta-analysis of current literature

Aim: To compare the lateral and medial approaches of total knee arthroplasty (TKA) in the valgus knee. Materials & methods: An electronic search from the PubMed, Embase, Web of Science and Cochrane library was performed according to 'TKA', 'valgus', 'knee' and 'approach'. Subsequently, manual search was conducted from the reference lists in the identified studies. Results: Four randomized controlled trials and five cohorts were included. Better knee society score and function was noticed in patients after lateral approach. Similar postoperative valgus deformity, operative time, blood loss, Western Ontario and McMaster Universities Osteoarthritis Index, range of motion, pain and total complications in both groups. Conclusion: Compared with the medial approach for TKA in valgus knee, current data shows superior results after TKA by the lateral approach.

Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty

PURPOSE

The purpose of this study was to investigate if the type of approach [medial parapatellar approach (MPA) versus lateral parapatellar approach with tibial tubercle osteotomy (LPA)] influences rotation of femoral and/or tibial component and leg axis in total knee arthroplasty (TKA). It was the hypothesis that MPA leads to an internally rotated tibial TKA component.

METHODS

This study included 200 consecutive patients in whom TKA was performed using either a parapatellar medial (n = 162, MPA) or parapatellar lateral approach with tibial tubercle osteotomy (n = 38, LPA). All patients underwent clinical follow-up, standardized radiographs and computed radiography (CT). TKA components' position and the whole leg axis were assessed on 3D reconstructed CT scans (sagittal, coronal and rotational). Mean values of TKA component position and the whole leg alignment of both groups were compared using a t test. The tibial component was graded as internally rotated (<3° of external rotation (ER)), neutral rotation (equal or between 3° and 6° of ER) and externally rotated (>6° ER). The femoral component was graded as internally rotated [>3° of internal rotation (IR)], neutral rotation (equal or between -3° IR and 3° of ER) and externally rotated (>3° ER).

RESULTS

There was no significant difference in terms of whole leg axis after TKA between both groups (MPA: 0.2° valgus ± 3.4; LPA: 0.0° valgus ± 3.5). Means of tibial component rotation were 2.7° ER ± 6.1 (MPA) and 7.6° ER ± 5.4 (LPA). Patients of group LPA presented a significantly less internally rotated (LPA: 18.4%; MPA: 48.8%) and more externally rotated (LPA: 52.6%; MPA: 22.8%) tibial component (p < 0.001). No significant differences were seen for the femoral component position, tibial valgus/varus and tibial slope.

CONCLUSION

The type of approach (medial versus lateral) significantly influenced tibial TKA component rotation. It appears that a MPA tends to internally rotate the tibial TKA component and a LPA tends to externally rotate the tibial TKA. The anterior cortex should not be used as landmark for tibial TKA component placement when using the lateral approach with tibial tubercle osteotomy.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

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.