Proximal tibia stress fracture with Osteoarthritis of knee - Radiological and functional analysis of one stage TKA with long stem

Management of proximal tibial stress fracture associated with advanced knee osteoarthritis: A systematic review

PURPOSE

Tibial stress fracture associated with knee osteoarthritis is an unusual and difficult clinical scenario. There is no clear existing treatment guideline for this uncommon clinical disease. The aim of this study is to review the impact of various treatment options for patients with advanced knee osteoarthritis associated with proximal tibial stress fracture.

METHODS

The study was performed using the databases of PubMed and Scopus. Methodological index for non-randomized studies score was used to evaluate the included studies' bias. The concluded data included the treatment approach, reported outcome measure, and time to fracture union. The literature search was started in December 2021 and accomplished in January 2022. A narrative description of the different methods and comparison of their results were done.

RESULTS

Out of total assessed 69 studies, 9 studies were included in our review. The commonest treatment approach used was total knee arthroplasty by long tibial stem extension. The mean preoperative knee society score and knee functional score were 30.62 and 23.17, respectively. The mean postoperative knee society knee score was 86.87, while the functional score was 83.52. The average reported time to achieve fracture union was 4 months (a range of 2.07 - 5.50 months).

CONCLUSION

The optimal clinical outcome for treating either acute or mobile tibial stress fracture in patients with advanced knee osteoarthritis can be achieved with long stem total knee arthroplasty. However, due to heterogeneity of data, comparison of different treatment options for chronic proximal tibial stress fracture mal-union/non-union coexisting with knee osteoarthritic and such inferences need to be judged cautiously.

Multifocal stress fractures in a patient with rheumatoid arthritis

Stress fractures are often associated to activities that requires repetitive stress such as running. However, insufficiency-type stress fractures can also occur in patients with risk factors such as rheumatoid arthritis. Diagnosis of stress fracture would require a thorough clinical evaluation along with radiological imaging. However, this may be difficult due to how it mimics other musculoskeletal problems. The case of a woman in her 60s presenting with 2 months of severe ipsilateral right knee and ankle pain is used as an example. Based on initial clinical assessment and plain radiograph, her provisional diagnosis was osteoarthritis or inflammatory arthritis secondary to rheumatoid disease. However, MRI scan revealed that she had multifocal stress fractures in her knee, ankle and foot. Hence, we hope that this case study can allow clinicians to consider multifocal stress fracture as a possible diagnosis in patients with risk factors and to have lower threshold in performing MRI scans.

Single-stage long-stem total knee arthroplasty in severe arthritis with stress fracture: a systematic review

PURPOSE

Proximal tibia stress fractures present a challenge when performing total knee arthroplasty (TKA) in knee arthritis (KA). The literature on treatment modalities for stress fractures with arthritis is varied and not systematically reviewed. We aimed to answer the questions: (1) Is long-stem TKA sufficient for stress fractures in arthritic knees? (2) Should stress fracture and KA be addressed simultaneously? (3) What is the role of augmentative procedures in stress fractures with knee arthritis? (4) Can a unified algorithm be established?

METHODS

The PubMed and Cochrane databases were searched for keywords such as stress fracture, knee arthritis and total knee arthroplasty, published from January 1995 to 29 May 2022. A total of 472 records were screened down to 13 articles on the basis of our selection criteria. Ten data items were recorded from the included studies. The methodological index for non-randomised studies (MINORS) score for the included studies was 17 ± 3.

RESULTS

We found long-stem TKA to be sufficient for most cases and advocated for single-stage treatment of stress fractures and arthritis. Augmentative procedures play a role in the treatment, and a unified algorithm was drafted to guide treatment.

CONCLUSION

Single-stage management of advanced KA with a stress fracture causes less morbidity than a staged procedure. Long-stem TKA, with or without an augmentative procedure, is an excellent option.

Total knee arthroplasty with long tibial stem for tibial stress fractures with knee osteoarthritis: Two birds with one stone

PURPOSE

The treatment and outcome of tibial stress fractures concomitant with knee osteoarthritis (OA) are complicated. The aim of this study was to evaluate the functional and radiological outcome of total knee arthroplasty with long tibial stem as a treatment for patients having knee OA and tibial stress fracture.

METHODS

Patients who were diagnosed to have proximal tibia stress fracture along with knee OA at our institution between June 2013 and November 2018 were included in our study. All patients underwent total knee arthroplasty with long tibial stem. Preoperative and postoperative functional assessments were done according to range of movement of the knee joint, knee society score and knee injury and OA outcome score. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.

RESULTS

Twelve patients were included in the study. All patients were found to have stress fractures in the proximal half of tibia and extra-arthrosis. Four patients had non-union/delayed union, and 8 patients had acute fractures. The average preoperative range of movement was 88.1°, which improved to 116.3° at 3 months following surgery. It was found that the fracture has healed in all cases. Mean knee society score improved from 32.9 preoperatively to 89.3 at 1 year follow-up. Knee injury and OA outcome score improved from a mean score of 28.3 preoperatively to 81.1 at 1 year follow-up.

CONCLUSION

Stress fractures can occur in the proximal tibia in patients with knee OA. Total knee arthroplasty with tibial stem provides a suitable solution for both conditions. Additional plating or bone graft is unlikely to be required.

Analysis of clinical and radiological outcomes of long tibial stemmed total knee arthroplasty in knee osteoarthritis complicated by tibial stress fracture

Objective

Knee arthritis associated with tibial stress fractures represents an uncommon and difficult clinical scenario to treat. The use of long, fluted tibial extension rods has been vital in the management of such cases owing to immediate fracture stability and single-stage surgery without the need to open the fracture site. This study investigates clinical and radiological outcomes following total knee arthroplasty using a tibial extension stem in cases of knee osteoarthritis with tibial stress fracture.

Methods

From February 2015 to December 2020, 17 patients who had total knee arthroplasty implanted with a long stemmed tibial component were included in the study. Patient data were analyzed for knee range of motion, deformities, Knee Society score, knee function score, and time to fracture union in the pre- and postoperative periods.

Results

The mean follow-up duration was 22.7 ± 11.68 months (range 12–60 months), and mean time to fracture healing was 10.23 ± 2.81 weeks (range 8–20 weeks). The preoperative mean fixed flexion deformity improved from 8.53 ± 3.43° to a mean of 0.29°, and knee flexion improved from 79.4 ± 13.90° to 125.29 ± 8.74° on postoperative assessment. The Knee Society score improved from a mean preoperative score of 18.94 ± 5.55 (range 8–28) to 89.41 ± 7.5 (range 74–102, p value < 0.001). Similarly, the knee function score improved significantly from a mean preoperative score of 15.5 ± 4.48 (range 8–26) to a mean of 85 ± 6.09 (range 72–94, p value < 0.001).

Conclusion

Total knee arthroplasty using long tibial extenders has been an effective and safe surgical option for patients with advanced osteoarthritis with tibial stress fractures.

An Early Experience with a Novel Technique of Total Knee Arthroplasty for Osteoarthritic Knee with Coexistent Traumatic Tibia Diaphysis Fracture

BACKGROUND

Treatment of tibia (upper third and diaphysis) fracture together with severe osteoarthritis (OA) poses challenge to an orthopedic surgeon. Traditionally, it is treated through three-stage surgeries, first fracture fixation followed by implant removal and finally surgery of total knee arthroplasty (TKA). Herein, we describe a novel TKA procedure using long-stemmed tibia component. This one-step technique not only addresses arthritis of the knee joint but also helps in assisting fixation of the fracture.

MATERIALS AND METHODS

We reported outcomes of three female non-diabetic patients with OA who developed tibia shaft fracture following trauma. Range of motion and quadriceps strengthening exercise were initiated immediately after the procedure. X-rays anteroposterior and lateral views of the operated limbs were obtained at post-operative week-6 and week-12. We allowed the patients' toe touch weight-bearing immediately after the surgery. The patients were progressed to full weight-bearing after confirming radiological union on the X-rays.

RESULTS

At follow-up, all treated patients were able to mobilize with good range of motion of the operated knee and with union of the fracture. The American Knee society scores and WOMAC pain and stiffness scores improved significantly.

CONCLUSION

This novel technique offers one-stage solution to the complex situation of osteoarthritis of the knee with associated tibia shaft fracture, thereby reducing future hospital admissions/surgeries and associated costs and complications. Further, it allows faster rehabilitation.

Management of early and late presenting tibial stress fracture with advanced osteoarthritis of the knee: A dilemma among arthroplasty surgeons in developing countries

BACKGROUND

Single-stage total knee arthroplasty (TKA) with long-stem is a viable option to treat proximal tibial stress fracture in advance knee osteoarthritis. However, in patients with old mal-united or non-united tibial fractures, treatment becomes complicated. Therefore, our aim in this study was to monitor clinical and radiological outcome in patients presenting early or late managed by single-stage long-stem TKA.

METHODS

This retrospective study included 24 consecutive patients; all were female. Patients with recent and mobile stress fracture (Group A) were treated with close reduction and long-stem tibial component. However, in patients with old, sclerotic or mal-united fractures (Group B), open reduction, partial fibulectomy and plating with bone grafting was also performed. Outcome was monitored by tibiofemoral angle, functional Knee Society score and time taken for union.

RESULTS

The mean age of patients was 62.34 years. There were 13 patients in Group A and 11 in Group B. The mean follow up was 42.79 months (range, 18-72 months). Knee Society score improved from 29.83 ± 6.10 to 91.57 ± 4.89 in Group A and from 27.21 ± 3.32 to 89.87 ± 3.89 in Group B. Tibiofemoral angle improved from 20.57 ± 3.00° to 0.80 ± 0.46° in 21 varus knees, whereas it improved from 22.33 ± 4.61° to 0.83 ± 0.28° in three valgus knees. Iatrogenic perforation of tibial cortex occurred in one case. Union of stress fracture was achieved in all cases with a mean duration of 4.70 months.

CONCLUSION

Excellent results were obtained in both groups but were slightly lower in patients presenting late, therefore all efforts must be made to treat such cases as early as possible.

Association of osteoporosis and varus inclination of the tibial plateau in postmenopausal women with advanced osteoarthritis of the knee

Background

Although varus inclination of the tibial plateau has increasingly been recognized as a major risk factor in the progression of Osteoarthritis of the knee (OA knee), little attention has been placed on the development of the varus inclination of the tibial plateau. Osteoporosis is a disease characterized by low bone mass and may increase the risk of a stress fracture in the proximal tibia. To date, risk factors for varus inclination of the tibial plateau are rarely reported. In this study, we investigated Bone Mineral Density (BMD) as a risk factor of varus inclination of the tibial plateau in postmenopausal women with advanced OA knee.

Methods

A total of 90 postmenopausal women with varus OA knee who had received a total knee arthroplasty in our department between January 2016 and December 2019 were reviewed. Certain factors may correlate to inclination of the tibial plateau (Medial Tibial Plateau Angle, MTPA), including age, operation side, Kellgren-Lawrence grade of OA knee, BMD, Body Mass Index (BMI), Lateral Distal Femur Angle (LDFA), lower extremity alignment (Hip-Knee-Ankle angle, HKAA), and history of both spinal compression fracture and hip fracture were collected and analyzed.

Results

Osteoporosis, lower extremity varus malalignment and age were significantly associated with varus inclination of the tibial plateau (MTPA) (P = 0.15, 0.013 and 0.033 respectively). For patients with a lower extremity varus malalignment (HKAA < 175°), osteoporosis (T-score ≤ -2.5) was significantly associated with inclination of the tibial plateau. For patients with a normal lower extremity alignment (HKAA ≥ 175°), no significant association was found between osteoporosis (T-score ≤ -2.5) and varus inclination of the tibial plateau.

Conclusions

Osteoporosis, lower extremity varus malalignment and age are major risk factors for inclination of the tibial plateau in postmenopausal women with OA knee. More attention needs to be given to the progression of varus OA knee in postmenopausal women who simultaneously has osteoporosis and lower extremity varus malalignment.

Knee Rheumatoid Arthritis With Lateral Tibial Plateau and Tibial Stress Fractures Managed With One-Stage Knee Joint Replacement

Rheumatoid arthritis (RA) is a chronic systemic disease that causes progressive joint damage, bony defects, and ligament imbalance. These sequelae of RA present major difficulties to surgeons during hip or knee arthroplasty. The presence of coexistent periarticular fractures adds to these difficulties and represents a surgical dilemma. No guidance exists within the literature for the medical and surgical management of complicated cases of RA with coexistent fractures. So far, the evidence has focused on fixation techniques, arthroplasty, and conservative management for periarticular fractures of osteoarthritic joints without significant degeneration of anatomical structures. We report a case of advanced knee RA with associated ipsilateral tibial plateau fracture and a tibial shaft stress fracture that was treated successfully with a single-stage joint replacement procedure. The case study presents a well-planned, single-stage arthroplasty with a lateral parapatellar approach as a management option that allows for early weight-bearing and restoration of function and provides a detailed guide for surgeons when managing similar cases.

[Effectiveness of one-stage total knee arthroplasty with tibial stem extender for knee arthritis complicated with tibial stress fracture]

Abstract

To evaluate the early effectiveness of one-stage total knee arthroplasty (TKA) with tibial stem extender for knee arthritis complicated with tibial stress fractures.

Methods

Between January 2014 and November 2016, 12 patients (12 knees) with knee arthritis and tibial stress fractures underwent one-stage TKA with tibial stem extender. There were 5 males and 7 females with an average age of 71.5 years (range, 60-77 years). There were 8 cases with osteoarthritis and 4 cases with rheumatoid arthritis. The radiographic examination showed the 6 cases of intra-articular fractures and 6 of extra-articular fractures (including transverse fractures in 4 cases and short oblique fractures in 2 cases); 2 cases complicated with middle and upper fibular stress fractures; all patients of varus deformities. Preoperative Knee Society Score (KSS) clinical score was 31.5±8.4 and functional score was 33.3±9.0. The preoperative range of motion (ROM) of the knee was (65.6±9.6)°.

Results

All indexes healed primarily and no wound infection or skin necrosis occurred. All patients were followed up 36.5 months on average (range, 6-52 months). X-ray films showed that all fractures healed at 3-7 months (mean, 4 months); the position of the prosthesis was good, and no loosening or signs of infection occurred. At last follow-up, the KSS clinical score was 90.5±8.9 and functional score was 92.1±7.8; the ROM of the knee was (115.0±9.8)°. All indicators were significantly improved than those before operation ( t=40.340, P= 0.000; t=32.120, P=0.000; t=8.728, P=0.000).

Conclusion

One-stage TKA with tibial stem extender for patients with knee arthritis and tibial stress fractures can restore limb alignment, facilitate fracture healing, and obtain the satisfactory early effectiveness.