Mædica – a Journal of Clinical Medicine [628584]

Mædica – a Journal of Clinical Medicine
STATE-OF-THE-ART TATE-OF-THE-ART
380 Maedica
A Journal of Clinical Medicine, Volume 8 No.4 201 3MAEDICA – a Journal of Clinical Medicine
2013; 8(4): 380-383
Extended Exposure in Difficult Total Knee Arthroplasty Using Tibial Tubercle Osteotomy
Radu RADULESCUa,b; Adrian BADILAb; Octavian NUTIUb; Ionut JAPIEb;
Silvia TERINTEb; Dragos RADULESCUa; Robert MANOLESCUb
a“Carol Davila” University of Medicine and Pharmacy Bucharest, Romania
bDepartment of Orthopaedic Surgery, Emergency University Hospital,
Bucharest, Romania
Address for correspondence:Adrian Badila, Department of Orthopedics and Traumatology, Emergency University Hospital, 169, Splaiul Independentei, Sector 5,
Bucharest.E-mail: [anonimizat]
Article received on the 6
th of March 2013. Article accepted on the 15th of October 2013.ABSTRACT
Objectives: In some total knee arthroplasty cases, the usual medial parapatellar approach does not
allow the appropriate patellar eversion and the desired exposure of the knee joint. Partial disinsertion of the patellar tendon doesn’t substantially improve the surgical exposure and can lead to extensor ap-paratus weakening and complete secondary ruptures, while the V-Y quadricipital plasty leads to post-op immobilization of the knee, which delays the functional rehabilitation, with negative impact on the range of motion. The tibial tubercle osteotomy, however, allows an extension of the approach in total knee ar-throplasty, without endangering the quadricipital extensor apparatus.
Material and Methods: In this study we analysed the post-operative results of 11 cases of primary
total knee arthroplasty in which a frontal plane osteotomy of the tibial tubercle was performed in ad-dition to the standard medial parapatellar approach, as a result of the patients associated conditions, like rheumatoid arthritis with an extension deficit higher than 150, previous knee synovectomy by ar-throtomy, progressive genu varum with more than 150 deviation, varus deviation of the lower limb with previous closing wedge proximal tibial osteotomy or patellar fractures with vicious consolidation.
Outcomes: Overall, the results were more than satisfactory with a significant increase in the patients
mean range of motion and Knee Society Score. There were some post-op issues in some of the patients, but they were adressed accordingly, having no long-term impact on the results.
Conclusions: We could thus conclude that, in special cases, the frontal plane tibial tubercle osteotomy
is an effective technique which can provide a wide approach with appropriate protection of the knee ex-tensor apparatus.
Keywords: arthroplasty, tibial tubercle osteotomy,
knee joint exposure, knee range of motion

EXTENDED EXPOSURE IN DIFFICULT TOTAL KNEE ARTHROPLASTY USING TIBIAL TUBERCLE OSTEOTOMY
381 Maedica A Journal of Clinical Medicine, Volume 8 No.4 201 3INTRODUCTION
The classic medial parapatellar ap-
proach frequently used in total knee arthroplasty (TKA) proves to be some times insufficient in difficult
ca ses with previous surgical proce-
dures on the knee extensor apparatus (1), pa-
tellar fractures with vicious consolidation, pa-tella baja, irreducible genu flexum (2-4), im por tant axial varus deformity (5), or rheuma-
toid arthritis (6). All these particular conditions in vol ve a difficult patellar eversion during sur-
gery and can lead to iatrogenic lesions of the pa tellar tendon with severe functional outcome
on the knee (7).
Different techniques, like controlled distal
partial disinsertion of the patellar ligament (8), “V” or “Y” plasty of the quadricipital tendon (1) and tibial tubercle osteotomy (9,10) are used to obtain a better eversion. Partial disinsertion of the patellar tendon doesn’t substantially im-prove the surgical exposure and can lead to extensor apparatus weakening and complete secondary ruptures. The V-Y quadricipital plas-ty is relatively safe, not technically demanding, but it implies post-op immobilization of the knee, which delays the functional rehabilita-tion, with negative impact on the range of mo-tion. Tibial tubercle osteotomy has its own complications like avulsion or fracture of the tubercle fragment. Whiteside technique (11) of tibial tubercle osteotomy with its subsequent changes proved to be the safest (12,13).

MATERIAL AND METHODS
We analyzed the results of 11 primary TKA,
where frontal plane tibial tubercle oste-
otomy was necessary, performed on 11 pa-tients aged 57 to 78 years (with a mean age of 71.2 years), 6 females and 5 males, with a fol-low up from 1 to 4 years (mean follow up of 35 months).
Patient’s associated conditions were: rheu-
matoid arthritis – 5 cases with an extension de-ficit higher than 150, previous knee synovec-tomy by arthrotomy – 2 cases (Figure 1), pro gressive genu varum with more than 150
de vi ation – 3 cases, varus deviation of the low-
er limb with previous closing wedge proximal ti bial osteotomy – 2 cases and patellar fractures
with vicious consolidation – 2 cases (in one case a dash board neglected fracture and in the other case a failed patellar osteosynthesis) with
se condary osteoarthritis (Figures 2 and 3).
Before surgery all patients presented pain
and functional impairment, with significant im-pact on their quality of life. Clinical examina-tion showed a mean range of motion of 63.6ș and a KSS (Knee Society Score) from 34 to 53 with a mean of 43.5 (Table 1).
In all cases, the difficult patellar eversion re-
quired a frontal plane tibial tubercle osteotomy in addition to the standard medial parapatellar approach. The approach is extended 10-12 cm distally on the anterior border of the tibia. The osteotomy line is marked using thin power drill holes and both the medial and lateral cortical bone are cut in a frontal plane with an oscillat-ing saw that passes through the cancellous me-taphyseal bone. The cut is oblique starting with a proximal curve above the tibial tubercle (to preserve the proximal anterior cortical bone) and ending 10-12 cm distally on the anterior tibial border. The osteotomy is performed from the medial side of the tibia, in order to preserve the lateral periostal and muscular insertions which will act like a hinge for externally dis-placing the extensor apparatus.
In all cases we used Nexgen (ZIMMER –
http://www.zimmer.com, Adress: Zimmer, Inc.
FIGURE 1. Rheumatoid arthritis with previous knee synovectomy –
1, 2 – pre-operative antero-posterior and lateral X-ray views; 3, 4 – post-operative antero-posterior and lateral X-ray views.
FIGURE 2. Knee osteoarthritis and malunion after patellar fracture
– 1, 2 – pre-operative antero-posterior and lateral X-ray views; 3,4 – post-operative antero-posterior and lateral X-ray views.

EXTENDED EXPOSURE IN DIFFICULT TOTAL KNEE ARTHROPLASTY USING TIBIAL TUBERCLE OSTEOTOMY
382 Maedica
A Journal of Clinical Medicine, Volume 8 No.4 201 3P .O. Box 708 1800 West Center Street Warsaw,
IN 46581-0708) PS (posterior stabilized) ce-mented Total Knee Prosthesis.
After prosthesis implantation, the tibial tu-
bercle is reattached and fixed with two or three bicortical screws at the tibial metaphyseal bone. To avoid the contact with the tibial com-ponent of the implant and to get good bicorti-cal fixation, the upper screws were introduced with an oblique tilt in the coronal plane.
Rehabilitation after surgery has no major
differences compared to the regular approach, except the limit of maximum 60° of flexion un-til 3 weeks from arthroplasty. No splints or or-thosis are needed. Active and passive mobiliza-tion of the knee using CPM (continuous passive motion) devices starts at 48h after surgery and progressive weight bearing is only limited by
pain. Also, a pre-op extension deficit implies the use of a post-op sand bag on the anterior aspect of the knee in order to avoid flexum re-currence.

RESULTS
Clinical and radiological evaluations were
per formed at 6 weeks, 3, 6 and 12 months
after surgery. The range of motion increased from a mean of 63.6ș (with limits of 35-90) to 84.10 (with limits of 70-100). The KSS score increased from a mean of 43.5 (with limits of 34-53) to a mean of 78.7 (with limits of 69-90).
More than a half of the patients included in
this study (6 out of 11) had a residual 5 to 150 extension deficit but it should be taken into consideration the fact that 9 out of the 11 cases initially presented extension deficit (Table 1). A higher pre-op extension deficit made the reha-bilitation more difficult. The efficacy of the sand bag on the knee in preventing post-op knee flexum recurrence is controversial be-cause more than half of the patients tended to remove it during the night. We had one case (3
rd case of Table 1) of tubercular fragment frac-
ture at 12 weeks post-op with proximal migra-tion. Surgical reintervention was needed in or-der to reattach it with another screw and a bone staple, secured with a wire loop between the patella and the proximal tibia.FIGURE 3. Global knee post traumatic osteoarthritis – 1, 2 – pre-
operative antero-posterior and lateral X-ray views; 3, 4 – post-operative antero-posterior and lateral X-ray views.
TABLE 1. Pre- and post-operative ranges of motion and KSS value.
Ext. = Extension; Flex. = Flexion; KSS = Knee Society Score; Osteotomy = Closing wedge proximal tibial osteotomy;
Rheum. arth. = Rheumatoid arthritis; RoM = Range of motionCase DiagnosisPre-operative Post-operative
Ext. (°) Flex. (°) RoM (°) KSS Ext. (°) Flex. (°) RoM (°) KSS
1Rheum.arth.
Synovectomy- 20 80 60 39 -5 75 70 69
2Rheum.arth.
Synovectomy-15 50 35 47 -5 80 75 79
3 Rheum.arth. -15 60 45 50 0 90 90 80
4 Rheum.arth. -15 90 75 47 0 90 90 76
5 Rheum.arth. -30 70 40 34 -15 90 75 696 Genu varum > 150 -5 80 75 53 0 100 100 907 Genu varum > 150 0 90 90 48 0 95 95 83
8Genu varum > 150 +
neglected patellar fracture- 15 70 55 39 -5 80 75 73
9Osteotomy +
residual genu varum < 150-5 90 85 41 -5 90 85 80
10 Osteotomy 0 65 65 41 0 80 80 79
11Patellar fracture with
vicious consolidation-10 85 75 40 -5 95 90 88
Mean 63.6 43.5 84.1 78.7

EXTENDED EXPOSURE IN DIFFICULT TOTAL KNEE ARTHROPLASTY USING TIBIAL TUBERCLE OSTEOTOMY
383 Maedica A Journal of Clinical Medicine, Volume 8 No.4 201 3REFERENCES
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techniques of the tibial tubercle osteotomy. Clin Orthop Relat Res. 2004;
424:173-9.At 6 weeks no proximal migration of the tu-
bercular fragment was noted, regardless of the number of screws (there was no difference be-tween the 2 screws and the 3 screws fixation). The mean time until the consolidation of the osteotomy was 14.7 weeks. There were no cli-n ical or radiological signs of non-union or other
complications regarding wound healing, infec-tion or tibial fractures.

DISCUSSIONS
The tibial tubercle osteotomy allows an ex-
tension of the approach in total knee ar-
throplasty, without endangering the quadricipi-tal extensor apparatus. Previous studies showed that during surgery, a higher mechanic stress occurs on the supra-patellar part of the exten-sor apparatus than on the patellar tendon (14). Excessive traction during surgery may lead to rupture during rehabilitation. Furthermore, us-ing this technique (11) the correction of the eventual axial deviation of the extensor appa-ratus is possible as well, during tibial tubercle re-insertion. This technique uses bicortical screws or wiring for the fixation of the osteoto-my tranche. The screws make a better fixation but, due to the holes made in the cancellous bone, they weaken the tubercular fragment and can lead to its fracture.
The main disadvantage of the wires (even if
they preserve more the solidity of the bone) is their poor fixation that cannot prevent in all ca-
ses proximal migration of the fragment. White-side reported only 1 of 71 cases of proximal mi gration of the fragment (11). Also, the shorter
the fragment is, the looser the fixation. A 10 to 12 cm tranche can be easily fixed with 2 or even 3 bicortical screws that can provide the required stability. The osteotomy line must be initially marked with thin drill holes in order to prevent the fracture of the tubercular fragment or even of the tibial meta-diaphysis (15).

CONCLUSIONS
In special cases, the frontal plane tibial tuber-
cle osteotomy is an effective technique which
can provide a wide approach with appropriate protection of the knee extensor apparatus. An adequate length of the tubercular fragment can ensure a solid fixation with preferably 3 bicorti-cal screws in order to obtain the required sta-bility and a normal rehabilitation after total knee arthroplasty.
Conflict of interests: none declared.
Financial support: none declared.
Abbreviations list
CPM = Continuous passive motion
KSS = Knee Society ScorePS = Posterior StabilizedTKA = Total Knee Arthroplasty