Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibia] tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip-knee-ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30 degrees, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibia] tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group (p<0.001, p=0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups (p=0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy (p=0.001 and p <= 0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome. (C) 2008 Elsevier B.V. All rights reserved.15643944

Is previous knee arthroscopy related to worse results in primary total knee arthroplasty?

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)According to literature, knee arthroscopy is a minimal invasive surgery performed for minor surgical trauma, reduced morbidity and shortens the hospitalization period. Therefore, this type of surgery before total knee arthroplasty (TKA) could be considered a minor procedure with minimum postoperative complication. A retrospective and cohort series of 1,474 primary TKA was performed with re-assessment after a minimum follow-up period of 2 years: 1,119 primary TKA had no previous surgery (group A) and 60 primary TKA had arthroscopic debridement (group B). All the patients underwent a clinical and radiological evaluation as well as IKS scores. Statistical analysis of postoperative complications revealed that group B had a higher postoperative complication rate (P < 0.01). In this group, 30% of local complications were re-operated and 8.3% of these cases underwent revision TKA (P < 0.01). The mean interval between arthroscopy and primary TKA was 53 months. However, statistical analysis did not reveal a direct correlation between arthroscopy/primary TKA interval and postoperative complications/failures (P = 0.55). The Kaplan-Meier survival curves showed a survival rate of 98.1 and 86.8% at 10 years follow-up for groups A and B, respectively. Our data allow us to conclude that previous knee arthroscopy should be considered a factor related to postoperative primary TKA outcomes as demonstrated by the higher rate of postoperative complications and failures (P < 0.001) as well as a worse survival curve than group A.174328333Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)National Council for Scientific and Technological Development, BrazilConselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

TKA outcomes after prior bone and soft tissue knee surgery

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Bone surgery around the knee joint could represent a more traumatic prior surgical procedure compared to soft tissue knee surgery and may predispose to differing postoperative total knee arthroplasty (TKA) outcomes. The objective of this study was to analyse the postoperative results as well as complications and failures in two groups of patients that had undergone knee surgery prior to primary TKA (bone surgery and soft tissue surgery) when compared to the no prior surgery group. A retrospective and cohort series of 1,474 primary TKA were evaluated at minimum follow-up period of 2 years: 1,119 primary TKA underwent no prior surgery (1,119 patients) (group A), 85 primary TKA (85 patients) (group B) had prior bone procedure [high tibial osteotomy (n = 64), tibial plateau fracture (n = 10) and patellar realignment (n = 11)], and third group of 146 primary TKA (146 patients) (group C) had undergone a soft tissue procedure [arthroscopy (n = 60) and menisectomy (n = 86)] before primary TKA. All the patients underwent a clinical and radiological evaluation as well as International Knee Society (IKS) scores. Preoperatively, group B had 40 % of cases classified as stage IV knee arthritis (p < 0.02); while 57 % of cases in group A showed higher levels of knee malalignment (p = 0.001) and group C had lower BMI (p = 0.001). Intraoperative complications revealed no difference. Although group B had the poorest postoperative mean values of knee flexion, TKA procedure improved the preoperative mean values of knee flexion in all the study groups. The postoperative complications were more prevalent in group C (p < 0.001), while the percentage of revision TKA was similar for all study groups (p = 0.5). At 120-month follow-up, the Kaplan-Meier survival curve rates showed no difference (p = 0.29). This study confirms that prior knee surgery could be considered a clinical condition predisposed to higher postoperative complication rate in primary TKA compared to the no prior surgery group. After analysing the three study groups, group C showed a higher rate of postoperative local complications and lower IKS knee scores, while the group B showed the poorest postoperative mean values of knee flexion as well as the need for extended surgical approach (TTO approach) was more prevalent in this study group. However, statistical analysis did not reveal a direct correlation between the type of prior knee surgery and TKA failures. IV.211227372743Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Transosseous suture loop technique for MPFL reconstruction.

Patellar dislocation represents a rare but invalidating trauma. Indeed, 94 to 100% of patients suffer from medial patellofemoral ligament (MPFL) rupture just after the first patellar dislocation, and approximately half of these patients develop recurrent dislocations. MPFL reconstruction is a commonly performed surgery for patellofemoral instability. Anatomic reconstruction of the MPFL restores patellar stability in patients with recurrent patellar instability with neutral lower limb alignment. We describe a technique, which creates an anatomic reconstruction using trans-osseous suture loop. Conclusion: Compared to similar techniques, the described procedure has the following advantages: smaller tunnels, less donor side morbidity, reduced risk of graft failure, minimal invasiveness, more appealing cosmetic results and easily reproducible. Complications and outcomes of this technique, including the risk for patellar fracture, must be further evaluated in a larger patient cohort with longer follow-up

Intraoperative fractures and ligament tears during total knee arthroplasty. A 1795 posterostabilized TKA continuous series

Introduction. - Intraoperative fractures are a reported complication during the course of primary total knee replacement. Major ligament disruptions can also occur. Clinical data are lacking to tell how much these incidents affect implantation quality and outcome. Hypothesis. - A thorough knowledge of these occasional incidents helps proper decision making when confronted to such situations at surgery. Materials and methods. - This report is based on a series of primary, posterostabilized total knee arthroplasties (posterostabilized, mobile bearing TKA with a third median condyle from Tornier Laboratory). We studied all possible mechanical complications that developed during the course of arthroplasty and analyzed their cause. We compared the functional results of patients presenting these complications to those of the total series and to data from the literature. The entire operative reports for the 1795 TKA performed during this study were available and evaluated. A clinical and radiological review was performed for 1624 patients at an average follow-up time of 36.8 +/- 34 (2 - 193) months. Results. - At this last follow-up, the average International Knee Society (IKS) score was 91.2 (19 - 100) and the function score was 77.76 (0 - 100). One hundred and thirty-two patients were deceased (unrelated to TKA) at this last follow-up evaluation. A total of 69 mechanical complications were accounted for at the time of surgery (3.8%): 40 definite fractures or fissures around the knee (2.2%), 29 tendon or ligament disruptions or attenuations (1.6%). The risk of tibial cracks was statistically more significant, with the smaller sizes tibial trays (size 1) (p = 0.019) or when an anterior tibial tuberosity elevation had been performed (p = 0.02). Survival curve analysis (at an average seven and a half-years postoperative follow-up) showed that all prosthetic components were still present in 93.3% of cases in the series of patients with these peroperative complications, and in 93.8% of cases in the series of patients without these intraoperative complications; this survival rate amounted to 91.9% of cases at an average 16-years postoperative follow-up. Conclusion. - This large, homogeneous series of primary, posterostabilized TKA took on 3.8% of intraoperative bone or ligament complications. All these complications could be prevented by a rigorous surgical technique. The improvement of ancillary materials, the saws, and good knowledge of such complications by the surgeon are essential. Level of evidence: Level IV. Therapeutic Study. (C) 2009 Elsevier Masson SAS. All rights reserved.95318318

Revision after early aseptic failures in primary total knee arthroplasty

The purpose of this study was to evaluate cases of early aseptic failures presented during the first 5-year follow-up in a group of 981 primary total knee arthroplasty (primary TKA). Predisposing factors as well causes of failures and postoperative complications in different groups of aseptic failures were re-assessed and compared to a control group. A retrospective and cohort study compared one group of 944 primary TKA without surgical revision (890 patients) (Group A) with 22 primary TKA (22 patients) (Group B) that had revision TKA secondary to aseptic failure during the first five years follow-up. The cases of isolated patellar button replacement (n = 8) and infection (n = 7) were not considered in this study. All patients underwent a systematic assessment that included clinical and radiographic examinations, and IKS scores. Aseptic failure was more prevalent at the first 2-year follow-up (63%). TKA loosening (n = 11) and undiagnosed pain (n = 7) were considered the most frequent modes of failures, and laxity (n = 1) was a very rare early cause of failure. The aseptic failure group was characterized as average 5 years younger with a greater number of previous knee surgeries, lower IKS scores improvement, and more postoperative pain compared to control group, despite the fact that the aseptic failure group showed a prevalence of cases during the first 2-year follow-up. Inside this group, the undiagnosed pain group had lower improvement of IKS scores, a remarkable prevalence in prior surgical procedure (71%) and a minor mean interval between primary and revision TKA (11.6 months).17324825