Tibial shaft fracture following tibial tubercle osteotomy

Tibial tubercle osteotomy has been reported to be an excellent exposure for a very stiff primary or revision knee requiring total knee arthroplasty. In 1993, the Center for Hip and Knee Surgery performed 657 primary and 16 revision total knee arthroplasties, using tibial tubercle osteotomy in 9 cases, 2 of which sustained tibial shaft fractures, because of which the Center's experience is reviewed.     

The outcome of sequential repeated tibial tubercle osteotomy performed in 2-stage revision arthroplasty for infected total knee arthroplasty

Thirteen patients with infected total knee arthroplasty treated by 2-stage revision requiring tibial tubercle osteotomy in both stages for extensile exposure were retrospectively analyzed. The preoperative mean range of knee motion improved from 60° (range, 30°-90°) to 94° (range, 70°-120°) at latest follow-up. The Knee Society knee scores and function scores were 39 and 18 preoperatively and 78 and 67 at latest follow-up, respectively. Although proximal migration occurred in 3 cases and a partial proximal avulsion fracture of the osteotomy segment occurred in 1 case after the second-stage reimplantation, radiographic bony union was observed in all cases. Sequential repeated tibial tubercle osteotomy can be a useful extensile surgical approach in staged revision for infected total knee arthroplasty with satisfactory clinical and radiographic outcomes.     

The treatment of nonunion of proximal tibial osteotomy with internal fixation

Nonunion of proximal tibial osteotomy is a rare occurrence. Treatment goals should emphasize preservation of proximal tibial bone stock in view of possible subsequent total knee arthroplasty (TKA). Previous reports, in mostly smaller series, have emphasized the use of external fixation in the management of this problem. There have been no previous reports regarding the use of internal fixation in the treatment of nonunion occurring after tibial osteotomy performed proximal to the tibial tubercle. In this report, the results of internal fixation in the treatment of six cases of nonunion after proximal tibial osteotomy are analyzed with regard to functional and roentgenographic results. Healing of the nonunion was obtained in all six patients. Realignment of angulatory deformities was uniformly achieved. Achievement of union and correction of axial malalignment, in addition to creating an improved substrate for later TKA, provided other objectives as well. Elimination of pain and instability at the nonunion site allowed these patients to derive some of the intended benefits from the original osteotomy.     

Extended tibial tubercle osteotomy in total knee arthroplasty

Thirty tibial tubercle osteotomies were performed to obtain exposure and facilitate patellar tracking in 29 patients who underwent total knee arthroplasty. The thickness and width of the bone fragment were gradually tapered from proximal to distal. Fixation was obtained with three or four titanium screws. Average follow-up period was 18 months. Twenty-nine of the osteotomies healed primarily. In one patient, postoperative displacement of the tibial tubercle developed requiring additional screw and suture fixation. Extended tibial tubercle osteotomy is a useful technique during difficult total knee arthroplasty. Poor tibial bone stock is a relative contraindication. The authors recommend that a long tapered bone fragment that is 1.5 to 2 cm thick at the level of the tibial tubercle be elevated and fixation achieved with screws.     

Exposure in difficult total knee arthroplasty using coronal tibial tubercle osteotomy

Exposure in a total knee arthroplasty can be challenging regardless of whether it is a difficult primary or a revision. Various techniques both proximal and distal to the patella have been described and implemented to gain exposure and improve knee flexion. When patella eversion is not possible due to previous surgery or severe preoperative knee flexion contracture, a coronal tibial tubercle osteotomy may be utilized. We present successful results utilizing the coronal tibial tubercle osteotomy procedure. The technique involved in this series is based on that described by Whiteside. It involves the development of a long lateral musculoperiosteal flap incorporating the tibial tubercle and anterior tibia, and leaving the proximal tibial cortex intact. This is extended along the tibia distally for 10 cm. It finishes by gradually osteotomising the anterior surface of the tibial crest. The tubercle is reattached with wires at the end of the procedure. This technique minimizes complications that have been associated with the tibial tubercle osteotomy. The 10 knees in 9 patients, who had total knee arthroplasty with a coronal tibial tubercle osteotomy, were reviewed pre and postoperatively. All knees were assessed using the Hospital for Special Surgery knee score (HSS). The scores averaged 43.6 preoperatively (range, 29 57) and 79.2 postoperatively (range, 67 90), and the mean range of motion was 59.5 degrees preoperatively and 78.0 degrees postoperatively. There were no cases of extension lag. Fixed flexion deformity was present in 3 cases postoperatively. Average time to union at the proximal and distal ends of the osteotomy was 8 and 24 weeks respectively. There was no evidence of nonunion and no other significant complications occurred.     

High tibial osteotomy combined with anterior displacement of the tibial tubercle for osteoarthritis of the knee

Summary Eighty-nine knees with medial tibiofemoral and patellofemoral osteoarthritis were treated by high tibial osteotomy between 1972 and 1978, and 71 were followed up for at least 5 years, the average being 6 years and 9 months. There was no significant loss of motion as recorded before and after operation. In most patients pain decreased or disappeared, and walking ability was regained. Evaluation using the Japanese rating system showed that there were Good and Fair results in 86% of the cases. The average tibio-femoral angle in the Good group was 169±5°. The angles in the Poor group varied over a wide range. There were serious complications such as nonunion, malunion and infection in a few cases. In Group 1 (30 knees) high tibial osteotomy alone was performed. In Group 2 (41 knees) there were associated osteoarthritic changes in the patellofemoral joint and a high tibial osteotomy was combined with anterior displacement of the tibial tubercle (ventralisation). In comparison, Group 2 had better results with regard to both clinical and radiological evaluation.Read at the 16th Congress of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie, London, England, 5th October, 1984     

Open-wedge retro-tubercular tibial osteotomy: an innovating technique

Open-wedge tibial osteotomy for varus correction is a common orthopedic procedure. The rate of complications remains significant: loss of correction, nonunion, patellar infera... We propose a new open-wedge technique for tibial osteotomy which has several advantages: less risk of patella infera, improved bone healing, excellent mechanical stability. The osteotomy involves two cuts with an anterior portion ending distally to the tibial tubercle. This preserves the integrity of the patellar tendon and maintains contact between the proximal tibia and the tibial tubercle. Adjunction of an anteroposterior screw adds stability. The anterior plane of the osteotomy provides an excellent surface contact favoring bone healing. The posterior plane is the same as with a "classical" open-wedge osteotomy. The lateral cortical must always remain intact (hinge). The technique described here does not require any specific instrumentation and is compatible with most of the available osteosynthesis implants.     

Tibial plateau fracture following oblique osteotomy of the tibial tubercle: a case report

Oblique osteotomy of the tibial tubercle is a preferred technique in patellofemoral disorders, resulting in a satisfactory clinical outcome. However, postoperative fractures of the proximal metaphysis of the tibia may often develop. An incomplete fracture of the lateral tibial plateau occurred in a 23-year-old female patient following an oblique osteotomy of the tibial tubercle. There was no history of trauma. The patient had undergone two operations in the same knee due to patellar instability. She also had bilateral high congenital hip dislocation. The correct diagnosis could only be made by computed tomography. Complete union was obtained following six weeks of plaster cast fixation. Due to inherent biomechanical limitations, complications may arise following oblique osteotomy of the tibial tubercle even adequate care is given to the surgical technique.     

Total knee arthroplasty after failed high tibial osteotomy

The objective of this review was to propose surgical techniques for different technical problems in total knee arthroplasty after high tibial osteotomy and to discuss the literature on the subject. Whereas early results of high tibial osteotomy in the treatment of unicompartmental osteoarthritis of the knee were promising, long-term follow-up indicates recurrence of symptoms and finally the need for total knee replacement in most cases. One of the major problems caused by high tibial osteotomy is an extraarticular deformity difficult to correct with ligament balancing. Based on the parameters “valgus angle”, “ROM” and “patella position”, the knees were evaluated and classified, then surgical techniques for the different grades of this classification were described. Most studies show that arthroplasty in a knee after osteotomy is more prone to complications such as persisting pain, malalignement and infections. After reviewing the literature, the overall results of total knee arthroplasties after failed high tibial osteotomy were found to be inferior to that after primary total knee arthroplasty. We concluded that total knee arthroplasty after failed high tibial osteotomy is technically more demanding than primary arthroplasty and that the use of the appropriate technique, determined by meticulous preoperative planning, is crucial for the outcome of the procedure.     

手术治疗肥胖成人胫骨结节撕脱骨折7例临床分析

背景：胫骨结节撕脱骨折多发生于青少年,较少见于成人。截至目前,有关成人胫骨结节撕脱骨折的报道罕见。目的：探讨切开复位接骨板螺钉内固定治疗肥胖成人胫骨结节撕脱骨折的疗效。方法：2008年9月至2013年6月行切开复位接骨板螺钉内固定治疗7例肥胖成人胫骨结节撕脱骨折患者,定期随访,按照HSS膝关节评分评估膝关节功能。结果：7例全部获得随访,随访时间为12~18个月,平均12.6个月。骨折均获得Ⅰ期愈合,愈合时间为9~15周,平均12周。膝关节屈伸活动范围平均125°,HSS评分均〉95分。结论：切开复位接骨板螺钉内固定治疗肥胖成人胫骨结节撕脱骨折的效果良好。     

Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy

The tibial tubercle osteotomy is gaining popularity for revision total knee arthroplasty; however, the potential for tubercle displacement has been a concern. This study compared the mechanical behavior of the tibial tubercle osteotomy after screw and cerclage wire fixation. Tibial tubercle osteotomy was done on 40 tibias from cadavers with equal numbers fixed by either screws or wires. Specimens were loaded cyclically to simulate straight leg raises and then loaded to failure with the patellar tendon oriented 0 degrees or 25 degrees from the tibial axis. Tibial tubercle osteotomy cyclic displacement was greater for wire constructs at 25 degrees than all other constructs. Failure loads were greater for screw constructs at 25 degrees than both wire constructs. Screw constructs failed at 1429 +/- 348 N (0 degrees) and at 1925 +/- 982 N (25 degrees). Wire constructs failed at 1072 +/- 260 N (0 degrees) and at 893 +/- 293 N (25 degrees). Bone mineral density correlated positively with failure loads. Straight leg raise (400 N) and knee extension (250 N) against gravity during rehabilitation should be feasible with either screw or wire fixation after tibial tubercle osteotomy. Special care should be taken for the large patient and patients with decreased bone density.     

A new surgical technique for tibial tubercle transfer in total knee arthroplasty.

Several methods are described for extensor mechanism realignment in total knee arthroplasty, including lateral release, medial reefing, V-Y quadricepsplasty, and tibial tubercle transfer. Each has its indications, merits, and pitfalls. The advantages of tibial tubercle transfer include precise realignment of the quadriceps mechanism, the ability to properly locate the patella proximally or distally, and maintenance of quadriceps power. The authors present a new technique for tibial tubercle transfer in total knee arthroplasty. Important points include (1) full-thickness medial and lateral soft tissue flaps that are anchored to bone and cover the transferred tubercle at the end of the procedure; (2) osteotomy of a long (10-cm) strip of tubercle and tibial crest; (3) placement of the osteotomized segment in a prepared, inset cancellous bone bed; and (4) fixation of the graft with multiple staples that hold the graft in place without being inserted through the graft. The method described will allow surgeons to perform tibial tubercle transfer reproducibly while avoiding the frequently cited complications of nonunion, loss of fixation, and wound slough.     

Total knee replacement after failed tibial osteotomy: Results of a matched-pair study

Sixty-three total knee replacements were performed after a failed tibial osteotomy. The goal of this study was to compare the perioperative problems and the outcome of this group of patients (study group) to a group of patients with primary arthroplasties matched for age, gender, length of follow-up, weight, and preoperative Charnley class. Operative problems were more frequently encountered in the study group, with 7 tibial tubercle elevations and 15 lateral retinaculum releases needed, whereas lateral retinaculum release was necessary for only 1 knee in the control group. Outcome was assessed using both the International Knee Society (IKS) scoring system and Hospital for Special Surgery (HSS) knee score. The follow-up period averaged 4.6 years. The IKS score of the control group was significantly higher, averaging 80.9 ± 13.8, whereas it was 74.4 ± 14.8 for the study group (P = .0001). Among the parameters included in the knee score, only pain was significantly different with the control group (P = .03). The IKS function score and the HSS score were not statistically different. Conversion of a failed tibial osteotomy is a technically demanding procedure. Careful preoperative planning is needed. Results, especially on pain, appeared to be inferior to those for primary arthroplasties.     

Proximal tibial osteotomy in varusgonarthritis — Modified maquet technique

Surgical Principles In varus osteoarthritis of the knee the force of weight bearing, which normally passes through the centre of the weight bearing surfaces, is medially displaced [4, 8]. In order to redistribute the load evenly over a larger articular surface a modified Maquet upper tibial osteotomy via midline vertical incision is performed. By valgus overcorrection of 5°, the tibial plateau is tilted and this changes the mechanical axis in such a way, that the resultant forces pass through the centre of the knee joint and at a right angle to the plane tangential to the articular surfaces [7, 9]. The degree of correction (varus deformity + 5°) is determined preoperatively on the basis of a full length, single stance weight bearing film (120 cm × 30 cm, distance at least 3 m) [8]. The fibula is divided to allow adequate correction of the tibia; this is done by excising a segment of the fibula. Because of variations in the innervation of the extensor hallucis longus muscle this should be performed in a relatively safe area, about 160 mm distal to the fibular head [5] through a postero-lateral approach [4]. The size of the excised segment depends on the degree of correction required. A dome osteotomy (barrel vault osteotomy) above the level of the tibial tubercle allows a correction of up to 25°. The osteotomy is compressed with at least four staples in two different planes. Contrary to the technique described by Maquet [8] the distal tibial fragment is not advanced anteriorly.     

Revision strategy for malunited tibial plateau fracture caused by failure of initial treatment

ObjectiveThe aim of this study was to evaluate our treatment algorithm and results in revision surgery of malunited tibial plateau fracture after failure of initial treatment.MethodsOur revision strategy was as follows: First, we determined the presence of any infection. Second, we determined whether the patient required total knee arthroplasty (TKA). Third, based on the characteristics of the tibial plateau fracture malunion, patients underwent one of the following surgical methods to achieve reduction: original fracture line osteotomy, tibial tubercle + original fracture line osteotomy, fibula head + original fracture line osteotomy, and metaphyseal open window reduction rod technique. The results was assessed with healing time, Rasmussen score, knee range of motion and complication rates.ResultsA total of 25 patients 16 men and 9 women; Mean age: 47.4 years (range: 35–63 years) underwent tibial plateau fracture revision operation. The time interval between the two surgeries was 2–24 months. The follow-up time was 12–30 months, and the operation time was 120–300 min. All patients received bone union at the last follow-up. The healing time was 3–6 months. The postoperative Rasmussen score was 19–29 (mean 23.8) compared with 14.4 points before the operation (p < 0.05). The postoperative knee joint activity was 60–110° (mean 95.0°), compared with 57.8° before the operation (p < 0.05). Six patients still had a 2-mm collapse on the articular surface, and 4 patients still had slight valgus (<5°). Except for 2 TKA cases, fracture reduction was excellent in 15 cases and good in 8 cases, with a good rate of 100%. Superficial wound infections occurred in 3 patients.ConclusionBecause revision of tibial plateau fracture malunion caused by failure of initial treatment is difficult, it is necessary to create a detailed surgical plan before the operation. Satisfactory clinical effects can be obtained if the correct revision strategy is used. The key to success is adopting a proper revision strategy according to the unique characteristics of the patient's tibial plateau fracture malunion.Level of EvidenceLevel IV, Therapeutic Study.     

外侧闭合楔形胫骨近端截骨术的远期疗效分析

[目的]探讨胫骨近端截骨术治疗原发性胫骨近端骨性关节炎的远期疗效以及最佳的截骨矫正角度.[方法]自1985～1997年,79例(111膝)原发性骨性关节炎患者接受了胫骨近端截骨术.其中男5例(5膝),女74例(106膝);年龄37～70岁(平均55岁).根据术后胫股角(FTA)分为3组.Ⅰ组61膝FTA<7°;Ⅱ组23膝FTA7°～9°;Ⅲ组27膝FTA≥10°.所有病例术前、术后按特种外科医院评分系统(HSS)评分.[结果]术后随访2年4个月～14年1个月(平均9年6个月).术前HSS平均60分,术后1年平均94分,末次随访平均87分.采用2种方法判定手术失败:方法1为需行人工全膝火节置换术者,随访4年和14年手术成功率分别为99%和85%;方法2为需行人工全膝关节置换术者或术后HSS评分<60分,随访4年和14年手术成功率分别为96.4%和75.1%.[结论]胫骨近端截骨术是治疗单间室骨性关节炎的有效方法,但术后胫股角应矫正到外翻7°以上(范围10°～15°).     

Simultaneous transarticular intramedullary nailing of the tibia and total knee replacement in tibial nonunion and osteoarthrosis

The combined manifestation of a nonunion of the proximal tibia and an osteoarthrosis of both knee joints is not very common. Yet, this was a kind of "unhappy triad" for a 86 year old lady suffering from a nonunion after one year of conservative treatment of a proximal tibial shaft fracture. Her quality of life has already been reduced by a loss of visual power and she was completely invalidized. She was unable to walk and she was hospitalized for the whole period of time. The operative treatment consisted in an intramedullary tibial nailing through the resected tibial joint surface using an IMSC-nail and, simultaneously through the same surgical approach, in a partially cemented total knee joint replacement. After 5 months a replacement of the second knee joint also was performed and 6 weeks later the almost blind patient could be discharged for home again. After another 7 months a proximal femoral fracture of the first side was repaired using a proximal femural nail. Four years later she still is able to live on her own and runs her flat with only little external help. She can walk as far as 3 km and enjoys a good knee function.     

Total knee arthroplasty with long stem for treatment of nonunion after high tibial osteotomy

Nonunion is an uncommon complication of high tibial osteotomy (HTO), and thus literature regarding treatment of it is very limited. The usual treatment for nonunion after HTO is repeat fixation of the osteotomy site. When union is not achieved, hinge or constrained total knee arthroplasty (TKA) is used. We describe a patient for whom nonunion after HTO was successfully treated using long-stem TKA with bone graft to have the nonunion site unite simultaneously.     

Tibial fracture after transposition of the tibial tubercle

Eight weeks after transposition of the tibial tubercle for recurrent subluxation of the patella, the patient sustained a tibial fracture during rope jumping. In spite of consolidation of the osteotomy in the frontal plane, there remained a small gap in the anterior cortex in the transverse plane through which the tibia failed during bending stress.     

Simultaneous transarticular intramedullary nailing of the tibia and total knee replacement in tibial nonunion and osteoarthrosis

The combined manifestation of a nonunion of the proximal tibia and an osteoarthrosis of both knee joints is not very common. Yet, this was a kind of “unhappy triad” for a 86 year old lady suffering from a nonunion after one year of conservative treatment of a proximal tibial shaft fracture. Her quality of life has already been reduced by a loss of visual power and she was completely invalidized. She was unable to walk and she was hospialized for the whole period of time. The operative treatment consisted in an intramedullary tibial nailing through the resected tibial joint surface using an IMSC-nail and, simultaneously through the same surgical approach, in a partially cemented total knee joint replacement. After 5 months a replacement of the second knee joint also was performed and 6 weeks later the almost blind patient could be discharged for home again. After another 7 months a proximal femoral fracture of the first side was repaired using a proximal femural nail. Four years later she still is able to live on her own and runs her flat with only little extern help. She can walk as far as 3 km and enjoys a good knee function.