Biomechanical analysis of tibial tray fractures post total knee arthroplasty

The fracture of the tibial tray is a rare complication post total knee arthroplasty. We present the case of a 74-year-old lady who had pain in the left knee due to an anteromedial fracture of her metal tibial tray post total knee arthroplasty with a kinematic (Howmedica) prosthesis. There are 25 reported cases of fractures of the posterior-medial aspect of the tibial tray. This is the first case describing an anteromedial tibial tray fracture. We performed a retrieval analysis of the polyethylene component and the fractured tibial base plate and reviewed the literature to determine the predisposing factors contributing to tibial tray fractures. Tibial component malalignment, excessive polyethylene wear and subsequent bone lysis, inherent metallurgical weakness and certain design features of the tray have been identified as the possible contributing factors to failure in this case.     

Fracture of the patella after total knee arthroplasty

Patellar fracture after knee arthroplasty was found in 11 patients (12 knees) during a 15-year period. Causes of this fracture include trauma, technical factors, and biophysical factors. The incidence of this infrequent complication was significantly increased after patella resurfacing and revision arthroplasty. Minimally displaced, non-comminuted fractures were immobilized, whereas displaced, comminuted fractures with loose patellar prostheses were treated operatively. At a mean follow-up period of 28 months, the average knee score was 75 points. The average arc of motion was 87 degrees, and six of the 11 patients have returned to their prefracture functional level. Treatment should be individualized on the basis of fracture displacement, comminution, and button fixation.     

Fracture of the tibial tray following PCA knee replacement

We report two cases in which fracture of the tibial metal tray was thought to be due to improper design of the tray and heavy polyethylene wear. The bone beneath the fractured portion of the tray was deficient and had been replaced by granulomatous fibrous tissue including numerous polyethylene wear particles and foreign-body giant cells. Osteolysis occurred as a tissue reaction to these particles.     

胫骨高位截骨术后全膝关节置换的疗效分析

[目的]目前采用胫骨高位截骨术治疗膝关节内侧间室骨性关节炎已在临床广泛开展,对于其中预后不佳者可采用全膝关节置换,本文对其临床效果进行分析.[方法]对38例胫骨高位截骨术后接受全膝关节置换术患者进行回顾分析.术后随访时间平均8年,对其中期疗效进行评估.[结果]特种外科住院评分由术前平均39分提高到术后平均86.5分.优良率达87%.[结论]与未接受过胫骨高位截骨术患者相比,胫骨高位截骨术后接受全膝关节置换的中期疗效令人满意.     

Complications in total knee arthroplasty after high tibial osteotomy

The outcome of total knee arthroplasty (TKA) after high tibial osteotomy remains uncertain. Compared with primary TKA, the results in some studies are not significantly different. Others report adverse effects on the outcome. The purpose of this study was to determine (1) the middle- and long-term survival of TKA performed after high tibial osteotomy, (2) their clinical and radiographic results, and (3) what complications could be expected in this group of patients.The study group comprised 31 patients (34 knees) undergoing cemented TKA after high tibial osteotomy. Average follow-up was 8 years (range, 6-213 months). Survival of the TKA was estimated using the Kaplan-Meier method. Outcomes were documented using the Hospital for the Special Surgery score. The results showed that the Kaplan-Meier survival rate was 82% at 5 years and 76% at 10 years. Excellent and good clinical results were obtained in 67% of patients. Complications occurred in 12 (35%) knees: stiffness in 4, aseptic loosening in 2, patellofemoral subluxation in 1, instability in 1, inexplicable pain in 1, and deep infection in 3.Great care with technical details is necessary when high tibial osteotomy is indicated because a future conversion to TKA may occur.     

Condylar total knee arthroplasty after failed proximal tibial osteotomy

Data were collected retrospectively on thirty-five patients who had a failed osteotomy of the proximal part of the tibia for unicompartmental osteoarthrosis of the knee that was treated with a cruciate condylar, total condylar, kinematic condylar, or cemented porous-coated anatomical total knee prosthesis. The patients were evaluated clinically and roentgenographically before and after the arthroplasty. The minimum period of follow-up was twenty-nine months (mean, forty-four months). On the basis of the knee-rating scale of The Hospital for Special Surgery, 89 per cent of the patients had either an excellent or a good result after the arthroplasty. No result was a failure. One patient had loosening of the patellar component, but no other loosening was identified. The results of total knee arthroplasty after osteotomy of the proximal part of the tibia were found to be comparable with the results after arthroplasty in knees that had not had a prior osteotomy. The intraoperative and postoperative rates of complications were not higher, and no untoward technical difficulties were encountered at surgery. These data support the clinical impression that an osteotomy of the proximal part of the tibia does not "burn any bridges" insofar as a future successful arthroplasty is concerned.     

Fracture of the central polyethylene tibial spine in posterior stabilized total knee arthroplasty

Between 1993 and 1998, 332 I-BII (Insall Burstein II) prostheses were implanted in our department. We studied 5 cases of tibial polyethylene spine fractures. The fractures occurred 3 to 5 years following the surgery. All cases with fractures had mild medial laxity that was noted on follow-up of 2 to 3 years following arthroplasty. One also developed mild hyperextension. All the patients had a revision surgery. In 2 cases, the polyethylene was changed to a thicker one, together with medial reinforcement. Three cases were revised to a rotating hinge prosthesis.     

Clinico-radiological study of total knee arthroplasty after high tibial osteotomy

The results of total knee arthroplasty (TKA) after high tibial osteotomy (HTO) and problems encountered during the operation were investigated in 23 patients (28 knees). HTO was performed by Coventry's method in 18 knees and by Maquet's method in 10 knees. The mean interval from HTO to TKA was 86 months (range, 3 to 288 months) and the mean follow-up period after TKA was 25 months (range, 6 to 116 months). Radiological evaluation showed that the proximal part of the tibia was shifted and tilted lateroinferiorly after HTO. Thus, a tendency to patella infera was observed. Lateral shift of the proximal part of the tibia was more marked with Maquet's method than with Coventry's method (P < 0.01). Posterior inclination of the tibial articular surface before TKA was smaller in the patients who gained a range of motion of 90° or more after TKA than in those with less than 90° (P < 0.05). In patients with 70 points or more on the three-university score after TKA, there was no change in the joint line level between before and after TKA, while the joint line was significantly lower after TKA in those with less than 70 points (P < 0.01). When TKA is done after HTO, various technical problems may influence the outcome, such as correction of the soft tissue imbalance, in addition to difficulties with patellar eversion and exposure of the proximal part of the tibia. The clinical results of TKA after HTO tend to be slightly inferior to those of primary TKA, probably because of such technical problems. Received for publication on Nov. 12, 1998; accepted on June 22, 1999     

Mid-term results of total knee arthroplasty after high tibial osteotomy

Background The outcome of total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is still controversial. In order to determine if osteotomy has any effect on this outcome we performed a medium-term review of a cohort of patients with knee osteoarthritis. Materials and methods Thirty-two patients (38 knees), who were treated with a HTO before the TKA during the last 8 years, were compared with a matched group who underwent primary TKA. The knees were evaluated preoperatively and postoperatively according to the scoring systems of the Knee Society and Hospital for Special Surgery (HSS). The anteroposterior tibiofemoral alignment, the Insall–Salvati patellar position ratio, range-of-motion and the location of the lateral joint line, were also recorded. The patients were reviewed with a mean follow-up of 4.5 years after TKA. Results The preoperative and postoperative knee scores had no statistically significant differences between the two groups. So was the case with the intraoperative releases, blood loss, thromboembolic or neurologic complications and infection rates in either group. Access to perform the arthroplasty was reportedly more difficult and took an average of 25 min longer. A significant difference (p < 0.05) was detected in terms of impingement of the tibial stem on the lateral tibial cortex, patellar subluxation and patella baja between the two groups but this did not have any influence on the outcome of the prosthesis. Knee alignment and stability so as range of motion (ROM) measurements were also found with no statistical significance. Conclusion Although we did manage to detect statistically significant differences mainly in radiographic results between the two groups, this situation did not appear to influence the clinical outcome of the patients, however. The fact that most of the patients had good or excellent results at an average follow-up of 4.5 years suggests that HTO does not have a significant negative effect on later TKA.     

Technical considerations of total knee arthroplasty after proximal tibial osteotomy

Forty-five total knee replacements in forty-one patients who had continued to have progressive osteoarthritis after a proximal tibial osteotomy were evaluated prospectively. There were 51 per cent excellent, 29 per cent good, 4 per cent fair, and 16 per cent poor results after a minimum follow-up of two years. The resection of tibial bone that was produced by the osteotomy could not be related causally to the fair or poor clinical results that were found after arthroplasty. Radiographic study, however, showed that 80 per cent of the knees had patella infera before the arthroplasty, which may contribute to altered biomechanics of the patellofemoral joint of the arthroplasty. The procedure for total knee replacement is made more difficult by the previous osteotomy, and a custom-made prosthesis may be required. The clinical results that were obtained in this series are similar to those for the revision total knee arthroplasties that have been done at this institution, but they were not as satisfactory as those that were obtained after primary total knee replacement. Our results should be considered when a surgeon compares the advantages and disadvantages of proximal tibial osteotomy with those of total knee arthroplasty for an older patient who has unicompartmental osteoarthritis of the knee.     

Retrieval study of tibial baseplate fracture after total knee arthroplasty

Twenty-five cases of fractured metal tibial baseplates were reviewed from retrieved knee arthroplasty. A total of 74 cases have been reported, including the 25 in this series. Baseplate fracture is an avoidable problem with careful choice of prosthesis, attention to surgical detail, and satisfactory postoperative follow-up. There is a relatively short duration of symptoms before fracture, (mean, 10.8 months; range, 1-36 months). Patients should also be advised to self-report if there is sudden onset of pain or any symptoms of instability or mechanical failure, such as squeaks, clicks, or swelling. Early revision should be considered if there is concern about potential baseplate fracture as delay may compromise the ultimate result. A classification for these baseplate fractures is proposed, and the multifactorial etiology is discussed.     

A study of the effect of tibial tray rotation on a specific mobile bearing total knee arthroplasty

We presumed that a particular mobile-bearing knee prosthesis would cope with tibial tray rotation about its longitudinal axis. We studied the tibiofemoral and patellofemoral joints to assess this. The prosthesis was mounted on a specially designed jig. The tray was externally rotated in 5 degrees increments and put through a range of flexion. We found that increasing tibial tray rotation caused excessive polyethylene loading and, eventually, medial femoral component liftoff. The patellofemoral joint showed increasing lateral patella facet contact. Surprisingly, this mobile-bearing prosthesis could not cope with tibial tray rotation. It required the tibial tray to be neutrally aligned to the femoral component to avoid excessive polyethylene loading.     

Fracture of highly cross-linked all-polyethylene patella after total knee arthroplasty

Recent advances in polyethylene fabrication have led to the introduction of highly cross-linked polyethylene tibial and patellar components for use in total knee arthroplasty (TKA) with the goal of reducing wear-related osteolysis. However, some reports suggest decreased mechanical strength as a result of the additional thermal and sterilization treatments in the manufacturing of implants. Complications related to the patella are among the most common causes of failure in TKA, but patellar component fracture is rare. The authors report a case of a highly cross-linked all-polyethylene patellar component that failed as a result of fracture in vivo in a patient 3 years after TKA.     

Similar outcome for total knee arthroplasty after previous high tibial osteotomy and for total knee arthroplasty as the first measure

Background and purpose — Patients having a total knee arthroplasty (TKA) after a previous high tibial osteotomy (HTO) constitute a minor group among those undergoing primary TKA for knee osteoarthritis (OA). There have been few reports on whether such patients differ pre- and postoperatively from those who undergo TKA as the first measure. We evaluated patient characteristics, knee-related pain, function, quality of life, and general health before and 1 year after TKA surgery in these 2 groups of patients.

Patients and methods — We included 119 HTOs that were operated on for knee OA in the Skåne region, Sweden, in the period1998–2007 and that had been converted to a TKA during 2009–2013 (the C group). We also included 5,013 primary TKAs performed for knee OA in the same region, during the same period, and in patients of the same age range (42–82 years) (the P group). The patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EQ-VAS preoperatively and 1 year after the TKA surgery, when they were also asked about their satisfaction with the surgery. Case-mix variables available were Charnley category, American Society of Anesthesiologists (ASA) classification, sex, age, and body mass index (BMI).

Results — Most of the HTOs were performed using open-wedge osteotomy with external fixation (81 of 119). Compared to the P group, the patients in the C group were more often men, were younger, and were healthier (according to the ASA classification). With respect to pre- and postoperative knee-related pain, function, quality of life, and general health, the 2 groups had similar mean values without any statistically significant differences. A similar proportion of patients in the 2 groups were satisfied with the surgery 1 year postoperatively (82% vs. 80%).

Interpretation — Our findings indicate that HTO is a reasonable alternative for delaying TKA surgery in younger and/or physically active OA patients.     

胫骨冠状面弯曲导致全膝关节置换术后胫骨假体力线不良

目的:探讨行全膝关节置换术(total knee arthroplasty,TKA)患者中胫骨冠状面弯曲对胫骨假体对线的影响.方法:自2019年7月至2021年4月,选取全膝关节置换术治疗的100例膝关节骨性关节炎患者,术前摄下肢全长X线片并测量胫骨冠状面弯曲角度(tibial bowing angle,TBA),TB...     

Functional outcome of total knee arthroplasty after high tibial osteotomy.

OBJECTIVE: To evaluate the functional outcome for patients who undergo total knee arthroplasty (TKA) after high tibial osteotomy (HTO). DESIGN: Retrospective matched cohort study. SETTING: University of Toronto affiliated hospital. PATIENTS: Twenty patients who underwent TKA after HTO and 20 matched patients who received a primary TKA. INTERVENTION: TKA. OUTCOME MEASURES: The Medical Outcomes Study Short Form (SF-36) health survey score and the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index. Univariate analyses were used to compare the case and control groups with respect to baseline variables using the t-test, chi2 test or Fisher's exact test. Functional outcomes were assessed by multivariate analyses. RESULTS: Operative problems were more frequently encountered in the study group, which had longer operative times (p < 0.0001), more difficulties with patellar eversion (p = 0.021) and an increased number of lateral releases performed (p = 0.0089). There were trends toward a significant difference in the pain (p = 0.07), function (p = 0.18) and stiffness (p = 0.14) categories of the WOMAC Osteoarthritis Index between the 2 groups, suggesting poorer functional outcomes of TKA after HTO, but the results did not reach statistical significance. A previous HTO does not affect the general health of patients after TKA, as there was no difference between the 2 groups in SF-36 scores. CONCLUSIONS: TKA after HTO is a technically more challenging procedure than primary TKA. The functional outcomes at a mean follow-up of 5 years after TKA in patients with a previous HTO tended to be inferior but the differences were not significant (p > or = 0.05).     

Wedged tibial components for total knee arthroplasty

Severe coronal deformity of the knee is frequently associated with erosion of one tibial condyle. This can cause problems with fixation and alignment during total knee arthroplasty. If the tibia is cut to the level of the more worn side, valuable bone is sacrificed; if the less worn side is chosen, the deficiency must be filled with bone-graft, cement, or a prosthesis. Tibial components with an integral polyethylene wedge on the undersurface were introduced in 1980 for use in patients with a bony deficit on one tibial condyle. The authors believe that the Denham prosthesis (Biomet, Wales, U.K.) was the first knee arthroplasty to offer such spacers. Twenty-six patients with preoperative varus deformity in whom a wedged component was used were compared with 29 historic control subjects. None of the wedged components loosened after a median follow-up period of 8 years compared with loosening in five of the control subjects (P = .01). In three of the control subjects a fractured triangle of cement was present on the radiographs. Use of the wedges was not accompanied by an improvement in postoperative alignment. The authors conclude that the wedges resulted in improved fixation that was independent of postoperative alignment.     

Proximal tibial fracture following total knee arthroplasty

The patient was a 74-year-old man, with a history of total knee arthoplasty 14 years earlier, after having sustained a pathological fracture of the proximal diaphysis of the left tibia following a fall. Given the unstable nature of the fracture and the severe osteolysis noted below the total knee arthroplasty, surgical management 1 day after the fall entailed packing cancellous bone graft into the defect and realigning the fracture.     

人工全膝关节置换术后早期胫骨内侧疼痛的病例对照研究

目的：比较人工全膝关节置换术（total knee arthroplasty,TKA）采用骨膜剥离器和电刀松解内侧副韧带及鹅足后发生膝前痛的差异.方法：2009年9月至2012年9月,选取解放军总医院行单侧初次膝关节置换的患者共220例,分为骨膜剥离器组和电刀组.骨膜剥离器组110例,男47例,女63例,平均年龄（58.8±17.2）岁,膝内翻（14.0±3.5）°,体重（65.6±12.8） kg,体重指数（body massindex,BMI） （26.6±3.6） kg/m2;电刀组110例,男49例,女61例;平均年龄（59.6±16.7）岁,膝内翻（15.0±4.7）°,体重（66.4±13.4） kg,BMI（27.4±4.1） kg/m2.平均随访时间24.6个月,术后评定两组患者末次随访时AKS膝评分、VAS疼痛评分和HSS评分.结果：两组患者术后切口均Ⅰ期愈合,无下肢深静脉血栓形成及肺栓塞发生.术后3例发生感染（电刀组2例,骨膜剥离器组1例）,行Ⅱ期翻修手术,使用TC3假体及抗生素骨水泥固定,随访期间未再发生感染.20例出现膝前区疼痛,其中电刀组4例,骨膜剥离器组16例,电刀组膝前区疼痛发生率低于骨膜剥离器组.末次随访时AKS膝评分和HSS评分电刀组高于骨膜剥离器组,VAS电刀组低于骨膜剥离器组.结论：与使用骨膜剥离器松解内侧副韧带及鹅足相比,使用电刀术后膝前痛发生率降低.