Quadriceps Snip in 321 Revision Total Knee Arthroplasties: A Safe Technique in a Matched Cohort Study

Clinical Outcomes of Total Knee Arthroplasty in Patients Who Have Hemophilic Arthropathy: A Prospective Study

PURPOSE

Total knee arthroplasty (TKA) is considered the gold standard treatment for patients who have advanced hemophilic knee arthropathy (HA). However, special considerations are required for these patients. This prospective study reports on the need for soft-tissue procedures, implant types, complication rates, mean 53.3 months implant survivorship, and patient-reported outcome measures (PROMs) of TKA in hemophilic patients.

METHODS

There were twenty primary TKAs that were performed on 15 hemophilic patients from 2012 to 2023. The mean follow-up was 53.3 months (range, 6 to 128; 33.5). The necessity for additional soft tissue procedures, implant type, complications, and revision rates were recorded. Knee Injury and Osteoarthritis Outcome Score, Knee Society Score, Hemophilia-specific Quality of Life Questionnaire for Adults, Haemophilia Activities List, and range of motion, were compared preoperatively and at the last follow-up.

RESULTS

At the last follow-up, implant survivorship was 90%. There were two revisions: one for aseptic loosening and one for periprosthetic joint infection. Additional soft tissue procedures included two quadriceps snips (10%). Tibial augments, tibial stubby stems, and both tibial and femoral traditional stems were used in one (5%), four (20%), and one (5%) TKAs, respectively. A constrained posterior-stabilized bearing was necessary in one case. Clinically and statistically significant improvements were found between the preoperative and final follow-up values of all PROMS, knee flexion (73 versus 108°, P < 0.001), and flexion contracture (11 versus 4°, P = 0.002).

CONCLUSION

This study showed that TKA, in patients who have HA, is a reliable treatment option that improves knee function and patients' QoL with acceptable implant survival rates at mid-term follow-up (mean 53.3 months). Standard implants and approaches can be used in most cases. Despite good outcomes, hemophilic patients carry additional risks for complications that require specific considerations. It is paramount for these patients to be treated in specialized centers by experienced surgeons to achieve good results.

Tips and Tricks to Save You During Revision Total Knee Arthroplasty

The number of revision total knee arthroplasties (TKAs) performed annually continues to rise. This article is a summary of a symposium on revision TKAs presented at the 2023 American Association of Hip and Knee Surgeons annual meeting. It will provide an overview of the surgical tips and tricks for exposure and component removal, use of metaphyseal fixation and stems to manage bone loss and optimize fixation, constraint in TKA, as well as how to manage extensor mechanism disruptions with a synthetic mesh reconstruction. LEVEL OF EVIDENCE: V.

Extensile Exposures in Revision and Complex Primary Total Knee Arthroplasty: A Review of Anatomy, Biomechanics, and Techniques

Developing adequate exposure when performing a revision total knee arthroplasty is critical to an efficient and safe intraoperative course. Proper planning and knowledge of the relevant anatomy are important when dissecting scar tissue associated with previous trauma or surgery and navigating bone loss. We present a review of the different total knee arthroplasty extensile exposure techniques that have been described in the literature. Specific exposures discussed include the femoral peel, banana peel, medial epicondylar osteotomy, quadriceps snip, tibial tubercle osteotomy, wandering resident, and the V-Y quadricepsplasty with patella turndown. Furthermore, we review the histological healing potential, biomechanical principles that drive post-operative expectations, post-operative rehabilitation protocols, and reported functional outcomes of each technique.

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.

Revision total knee arthroplasty longer term outcome and comparison between infection and aseptic loosening at mean follow-up of 10 years

Background:

Although the majority of total knee arthroplasty cases have good outcome and survival, some arthroplasty eventually required revision. While early outcomes of revision knee arthroplasty are well reported, there is relatively fewer literatures reporting on the longer term outcome of revision knee arthroplasty. This study aims to review the outcome of revision knee arthroplasty for a longer term, and also make comparison between the two common indications for revision arthroplasty of infection and aseptic loosening.

Methods:

This study reviews all total knee arthroplasty revision performed at a single center over a 11 year period. Of the 48 cases found, 35 cases not lost to follow-up had a mean follow-up duration of 10.6 years (SD 2.9) for aseptic loosening, and 10.1 years (SD 2.6) for infection. Data of initial arthroplasty, revision arthroplasty, demographics, follow-up outcome were obtained, analyzed and compared.

Results:

Revision arthroplasty due to infection had more cases that required use of varus/valgus constraints (p ∼ 0.008) and extensile surgical exposure of quadriceps snip (p ∼ 0.005) compared to aseptic loosening. The survival at 10 years for this study is 91% overall (aseptic loosening 93.3%, infection 89.3%). Infection cases had significant initial improvement for range of motion (p ∼ 0.001) and use of walking aid (p ∼ 0.04) at post-operation 1 year, but no significant differences between the infection and aseptic loosening cases at 5 years and 10 years follow-up. Comparison between the two groups on other factors including initial arthroplasty, operative details, demographics, post-operative details and X-rays showed no statistically significant difference.

[Application of quadriceps snip in complex total knee arthroplasty]

Objective

To explore the safety and effectiveness of quadriceps snip in complex total knee arthroplasty (TKA).

Methods

A clinical data of 19 cases (29 knees) with complex TKA assisted with quadriceps snip between January 2016 and May 2017 were retrospectively analyzed. There were 9 males (13 knees) and 10 females (16 knees). The age of patients ranged from 34 to 66 years (mean, 50.2 years). Four patients (8 knees) were ankylosing spondylitis, 5 patients (7 knees) were rheumatoid arthritis, and 10 patients (14 knees) were knee osteoarthritis. The average disease duration was 10.9 years (range, 8-15 years). There were 12 knees of Kellgren-Lawrence grade Ⅲ and 17 knees of Kellgren-Lawrence grade Ⅳ. The range of motion (ROM) of knee was (19.86±7.23)°. The clinical and function scores of knee society score (KSS) were 47.86±11.26 and 15.52±11.21, respectively. Postoperative complications, ROM, KSS scores, extensor lag, and prosthesis loosening were observed to evaluate the effectiveness.

Results

All incisions healed by first intention, and no infection or cardiovascular and cerebrovascular accidents occurred. All patients were followed up 25-39 months (mean, 30.3 months). At last follow-up, the ROM of knee was (91.03±7.30) °, the KSS clinical score was 83.62±9.99 and functional score was 66.38±7.89, showing significant differences when compared with preoperative ones ( P<0.05). Postoperative extensor lag (10°, 10°, 15°) occurred in 3 cases. There was no evidence of prosthesis loosening or osteolysis on X-ray films during follow-up.

Conclusion

The application of quadriceps snip in complex TKA can effectively improve the operative field exposure and reduce incidence of complications such as patella tendon tearing, patella fracture, and quadriceps tendon injury. The surgical technique of Krackow tendon suture can effectively guarantee early rehabilitation without occurrence of other complications.