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Anterior tibial tubercle osteotomy using cerclage wire fixation in total knee replacement: a modification of the usual technique

Authors:
Joan Manuel Burdeus González-Solís
Joan Manuel Burdeus González-Solís
Joan Manuel Burdeus González-Solís
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Iván Díez-Santacoloma
Iván Díez-Santacoloma
Iván Díez-Santacoloma
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Albert Isidro Llorens
Albert Isidro Llorens
Albert Isidro Llorens
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Abstract and Figures

Anterior tibial tubercle (ATT) osteotomy facilitates exposure in knee arthroplasty. However, it is not without complications. We have introduced some technical modifications that reduce the surgical aggression by designing a short osteotomy that does not invade the intramedullary canal, and synthesizing it with three cerclage wires with a particular layout that increases the solidity of the system. A retrospective review was performed on the surgical revision of total knee replacement cases intervened in our center that required an ATT osteotomy from February 2014 to February 2015, and who had a minimum clinical follow-up of 12 months. In all cases, there was an average proximal increase in ATT of 5 mm and, however, did not result in any loss of knee extension. All the osteotomies achieved complete bone consolidation at 3 months. There were no other complications. Our technique may be a valid option as it shows satisfactory results and demonstrates that a small increase in ATT does not affect the final clinical outcome.
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TECHNICAL NOTE •KNEE - ARTHROPLASTY
Anterior tibial tubercle osteotomy using cerclage wire fixation
in total knee replacement: a modification of the usual technique
Joan Manuel Burdeus Gonza
´lez-Solı
´s
1
•Iva
´nDı
´ez-Santacoloma
1
•Albert Isidro Llorens
1
Received: 28 July 2016 / Accepted: 11 October 2016 / Published online: 21 October 2016
Springer-Verlag France 2016
Abstract Anterior tibial tubercle (ATT) osteotomy facili-
tates exposure in knee arthroplasty. However, it is not
without complications. We have introduced some technical
modifications that reduce the surgical aggression by
designing a short osteotomy that does not invade the
intramedullary canal, and synthesizing it with three cer-
clage wires with a particular layout that increases the
solidity of the system. A retrospective review was per-
formed on the surgical revision of total knee replacement
cases intervened in our center that required an ATT
osteotomy from February 2014 to February 2015, and who
had a minimum clinical follow-up of 12 months. In all
cases, there was an average proximal increase in ATT of
5 mm and, however, did not result in any loss of knee
extension. All the osteotomies achieved complete bone
consolidation at 3 months. There were no other compli-
cations. Our technique may be a valid option as it shows
satisfactory results and demonstrates that a small increase
in ATT does not affect the final clinical outcome.
Keywords Knee Exposure Tubercle Osteotomy
Arthroplasty
Introduction
In prosthetic knee surgery, adequate exposure of the knee is
essential to successfully perform the surgical intervention.
However, occasionally exposure is difficult, particularly in
revision surgery of total knee replacement (TKR), due to
many factors associated with local fibrosis, a result of implant
failure, of an already resolved deep infection, or wear of the
polyethylene. This increases the risk of rotator cuff avulsion
on attempting to evert or lateralize the patella [1].
Several techniques have been described that, by acting on
the extensor mechanism, achieve improved exposure [2–4],
but many, and occasionally, severe complications have been
reported, mainly related to the loss of complete extension of
the knee, due to the caused tissue fibrosis, or with vascular
compromise of the patella, triggering a secondary necrosis [5].
Other techniques are based on acting distally to the knee
extensor mechanism, as is the case of osteotomy of the
anterior tibial tuberosity (ATT). In this way, preservation of
the vascularization of the patella is achieved, and the patellar
tendon remains intact. However, they are not free from
complications, such as problems with pain in the anterior
side of the knee due to the impact of the osteosynthesis
material, proximal migration of the ATT, fracture-avulsion
of the ATT, fracture of the ATT, fracture of the tibial shaft,
or loss of extensor mechanism function [6].
Several fixation methods of the ATT have been descri-
bed, such as the synthesis with cerclage wire [7,8]or
screws [9], or the use of different sutures [10,11].
In this article, we describe our ATT osteotomy tech-
nique with re-fixation by means of the use of cerclage
wires, and we demonstrate the clinical outcomes obtained
with this technique in TKR revision surgery.
Materials and methods
Patients
A retrospective review was conducted on the cases of TKR
revision surgery intervened in our center that required an
&Iva
´nDı
´ez-Santacoloma
idsantacoloma@gmail.com
1
Hospital Universitario Sagrat Cor, Barcelona, Spain
123
Eur J Orthop Surg Traumatol (2017) 27:705–709
DOI 10.1007/s00590-016-1870-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Finally, the knee is extended and the displaced fragment of tubercle is brought back to its anatomical location [12]. Several fixation methods of the ATT have been described, such as the synthesis with cerclage wire or screws, or the use of different sutures [13]. The aim of this paper is to evaluate the efficacy and safety of TTO as a useful surgical approach in difficult total knee arthroplasty, especially during revision surgery. ...
Tibial tubercle osteotomy (TTO) in total knee arthroplasty, is it worth it? A review of the literature
Article
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  • Mar 2018
  • ARCH ORTHOP TRAUM SU
Introduction: Tibial tubercle osteotomy (TTO) is a well-established extensile approach to improve joint visualization and implant removal. Despite this, TTO is a challenging technique with a long learning curve and potential pitfalls. Complications are not infrequent, even if performing the correct surgical steps. Aim of this paper is to review the current literature about TTO, its safeness and reliability, and finally the complications rate. Materials and methods: We performed a systematic review of the available English literature, considering the outcomes and the complications of TTO. The combinations of keyword were "tibial tubercle osteotomy", "total knee arthroplasty", "total knee revision", "outcomes", "complication" and "surgical approach". Results: From the starting 322 papers available, 26 manuscripts were finally included. Most of the papers show significant improvements in clinical outcomes, both in primary and in revision procedures. Radiographic fragment healing is close to 100%. Related complications can range from 3.8-20%. Conclusion: TTO may be necessary to correct pathological tuberosity position or patella tracking. However, TTO is a challenging technique to improve the surgical approach during total knee arthroplasty. A strict surgical technique can lead to better results and to minimize complications. However, it is not clear if the improved outcome can outweigh the longer surgery and the higher risk of pitfalls.
View
Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series
Article
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  • Aug 2023
  • EUR J ORTHOP SURG TR
Purpose Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA. Method Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures. Results Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection. Conclusion Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.
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Tibial Tubercle Screw Fixation on Custom Metaphyseal Cone: Surgical Tip in Severe Metaphyseal Tibia Bone Loss
Article
Full-text available
  • Jun 2022
Tibial tubercle osteotomy (TTO) facilitates exposure in knee arthroplasty revision. However, it comes with complications, especially if it invades the intramedullary canal. Most revisions are characterized by compromised femur and/or tibia bone stock, and the use of metaphyseal cones or sleeves for implant fixation has become increasingly frequent. Several methods of fixation of the tibial tubercle have been proposed, such as screw fixation, cerclage wiring, and suture repair. Despite screws providing the strongest fixation for TTO, their placement around a tibial intramedullary stem or a metaphyseal tibial cone may be difficult. We described the use of a custom-made metaphyseal tibial cone with holes in its anterior surface that allow the surgeon to achieve accurate TTO fixation by screws.
View
Comparison of quadriceps snip and tibial tubercle osteotomy in revision for infected total knee arthroplasty
Article
Full-text available
  • Oct 2014
  • INT ORTHOP
Purpose: Controversies exist regarding the ideal approach in a revision total knee arthroplasty for infection, providing adequate exposure with minimum complications. The purpose of this study was to compare the results of second stage revision total knee arthroplasty (TKA) between tibial tubercle osteotomy (TTO) and quadriceps snip (QS) approaches for infected TKA. Methods: The clinical and radiological outcomes of 27 patients of TTO and 21 patients of QS in second stage revision TKA for infected TKA were compared with an average follow up of 51 months. We evaluated the clinical outcomes including HSS score, WOMAC score, flexion contracture, and maximal flexion between two groups. The radiological outcomes in terms of femorotibial alignment, patellar height and complications were also compared. Results: At the final follow-up, KSS score, HSS score, WOMAC score, flexion contracture, and maximal flexion showed no statistically significant differences between the two groups. The femorotibial alignment and patellar height also showed no differences between the two groups. During the surgery, patellar tendon partial avulsion was more commonly observed in the QS group than in the TTO group (five vs two cases). Conclusion: Both tibial tubercle osteotomy and quadriceps snip in revision TKA were considered as good approaches without significant complications. However, cautious exposure of patellar tendon or strong fixation of the osteotomy is needed to minimize the complications.
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Tibial Tubercle Osteotomy With Screw Fixation for Total Knee Arthroplasty
Article
Full-text available
  • Apr 2014
  • ORTHOPEDICS
This study investigated the efficacy of tibial tubercle osteotomy (TTO) with screw fixation as part of the surgical treatment of primary complicated total knee arthroplasty (TKA) and revision TKA. From January 2000 to April 2011, 15 patients (15 knees) underwent revision TKA and 20 patients (21 knees) underwent primary TKA. The average patient age was 68.7±8.7 years. Patients underwent follow-up at the authors' institution for an average of 60.6±32.9 months. Comparison of preoperative and postoperative Knee Society Scores and Knee Society Functional Scores showed significant postoperative improvement (P<.05). Moreover, postoperative range of motion of the knee improved from 88.5°±33.8° to 104.3°±18.2° (P<.05). Radiographic assessment showed that the average period to bone union was 10.8±5 weeks (range, 5-28 weeks), the average length of the bone fragment was 59.4±5.9 mm, the average width at the proximal end was 18.9±2.9 mm, and the average thickness at the proximal end of the osteotomy was 10.3±1.2 mm. Tibial tubercle osteotomy provided wide exposure for TKA while protecting the extensor mechanism. Solid bone-to-bone fixation was achieved using TTO with 2 screws, and although the overall complication rate was 8.3%, none of the complications were associated with TTO itself. It is recommended that the bone fragment be 60 mm long, 20 mm wide, and 10 mm thick at the proximal end. Appropriate size of the osteotomized bone and solid screw fixation are essential to prevent complications during this procedure.
View
Anterolateral approach using tibial tubercle osteotomy for total knee arthroplasty: Can we predict failure?
Article
Full-text available
  • Nov 2012
  • INT ORTHOP
Purpose: The purpose of this study was to identify predictive factors for the occurrence of complications in a consecutive series of patients who underwent step-cut tibial tubercle osteotomy (TTO) and subsequent screw refixation in primary total knee arthroplasty (TKA). Methods: Using standardised conventional radiographs, critical parameters including TTO length and depth, proximal abutment width (OT), and orientation and placement of fixation screws were measured in 422 patients (mean age of 71 years and a follow-up time range of one to five years) with two screw fixations. Results: Medial spatial orientation in the distal screw (11 %, p=0.046), the TTO length (<55.4 mm, p=0.013), the OT width (<14 mm, p=0.002) and the distance of the distal refixation screw from the TKA (<51.7 mm, p=0.003) were significant factors for the occurrence of complications. Conclusions: Age, gender, comorbidities, height, weight and/or the body mass index had no significant influence on the occurrence of complications. The TTO-related complication rate was 3 %. Consideration of these key surgical factors leads to improved outcomes.
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Tuberositas Osteotomy for Total Knee Arthroplasty: A Review of the Literature
Article
Full-text available
  • Sep 2010
Tibial tubercle osteotomy (TTO) is a well-known technique for improving exposure in difficult total knee arthroplasty (TKA). We have performed a review of the literature concerning this procedure with the purpose of evaluation using the clinical results and complication rates in primary and revision TKA using TTO. We conducted a search limited to the following databases: PubMed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and Embase. These were searched from 1979 to May 2009 to identify studies relating to the primary and revisions of TKA using a tuberositas osteotomy. Eighteen studies met the inclusion criteria including 823 cases. In 762 cases, a medial TTO was performed. Most patients had an improved knee function after TKA. Proximal migration of the osteotomized site (n=18), TTO-related pain (n=17), and avulsion fractures of the tubercle (n=13) were the most reported complications of this technique. TTO is a relatively safe and reproducible procedure for the enhancement of surgical exposure in difficult primary or revision TKA. Serious complications related to TTO were reported in 8 to 9% of all cases. Future studies should compare different fixation methods in a prospective randomized controlled way.
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Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: Does it matter?
Article
Full-text available
The purpose of this prospective consecutive multicenter study was to investigate whether the type of surgical approach (medial parapatellar (MPA) or lateral parapatellar with tibial tubercle osteotomy (TubOT)) influences the early clinical and radiological outcomes of primary total knee arthroplasty (TKA). Ligament balancing primary TKA with a rotating platform was performed in 143 knees (m:w = 1:1.6; mean age 69 +/- 8 years). The TKA was done by a lateral parapatellar subvastus approach with stepcut osteotomy of the tibial tubercle (53%; n = 76, group A) or medial parapatellar approach (47%; n = 67, group B). The outcome was assessed at 1 and 2 years postoperatively by the American Knee Society score (KSS) and the knee society total knee arthroplasty roentgenographic evaluation and scoring system (TKA-RESS). The patient's pain level and satisfaction was noted by a visual analogue scale (VAS). Data were analyzed by an independent statistician with a level of significance of p < 0.05. The Wilcoxon two sample test (two-sided) was used to investigate differences of patients between group A and B pre- and postoperatively. The paired t-test was used to evaluate differences over course of time within each group. For comparison of radiological alignment a Chi(2)-test was performed. Although having a lower degree of preoperative flexion (112 degrees +/- 15 degrees versus 115 degrees +/- 15 degrees) patients in group A showed a significantly (p = 0.027) higher degree of flexion (118 degrees +/- 10 degrees) at their last follow-up than patients in group B (114 degrees +/- 10 degrees). Patients in group A showed a significantly better mean VAS pain (p = 0.0001) and satisfaction (p = 0.0058) at 2 years follow-up. The pain free walking distance was significantly (p = 0.036) longer for group A than group B. Patients treated with a lateral approach were significantly more stable in terms of valgus stress (p = 0.049). The Knee society score was significantly (p = 0.0009) higher at two years follow up in group A compared to group B. The postoperative mechanical alignment and positioning of the prosthesis were not significantly different. Patients in group B presented with significantly (p = 0.0017) more tibial radiolucencies (> 2 mm) at their last follow-up than patients in group A. There was no prosthesis related revision in either group. The revision rate in group A (4%) was higher than in group B (1.5%), which was mainly due to two cases of traumatic secondary displacement of the tibial tubercle and need for refixation. The TubOT led to slightly better functional results and less pain two years after primary TKA. It is however not clear if the improved outcome can outweigh the longer operation time and higher risk of early complications and revisions. Long-term studies are necessary to show whether there is any difference in prosthesis longevity between both types of approach.
View
Does repeat tibial tubercle osteotomy or intramedullary extension affect the union rate in revision total knee arthroplasty?: A retrospective study of 74 patients
Article
Full-text available
  • Feb 2009
Tibial tubercle osteotomy (TTO) is an established surgical technique for exposing the stiff kneein revision total knee arthroplasty (RTKA). The osteotomy is usually performed through the anterior metaphyseal cancellous bone of the tibia but it can be extended into the intramedullary canal if tibial stem and cement removal are necessary. Furthermore, repeat osteotomy may be required in another RTKA. We assessed whether intramedullary extension of TTO or repeat osteotomy affected the healing rate in RTKA. We retrospectively evaluated 74 consecutive patients (39 women) with an average age of 60 (29-89) years who underwent 87 TTOs during RTKA. 1 patient had bilateral TTO.10 patients had repeat TTO and 1 patient received 3 TTOs in the same knee. The osteotomy was extramedullary in 57 knees and intramedullary in 30 knees. Osteotomy repair was performed with bicortical screws and/or wires. Bone healing occurred in all the cases. The median time to union was 15 (6-47) weeks. The median healing time for the extramedullary osteotomy group was 12 weeks and for the intramedullary osteotomy group it was 21 weeks (p = 0.002). Repeat osteotomy was not associated with delayed union. Neither intramedullary nor repeat osteotomy was found to increase the complication rate of the procedure. Reliable bone healing can be expected with intramedullary extension or repeat TTO in RTKA. However, intramedullary extension of the osteotomy prolongs the union time of the tibial tubercle.
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Tibial tubercle osteotomy with absorbable suture fixation in revision total knee arthroplasty: A report of 23 cases
Article
  • Feb 2014
  • ARCH ORTHOP TRAUM SU
Tibial tubercle osteotomy (TTO) is a well-known technique for improving exposure in difficult total knee arthroplasty (TKA). We have performed 23 revision TKAs with TTO. The tibial tubercle was fixated with only absorbable sutures afterwards. The aim of this study is to report on the clinical results and complications of this procedure. We retrospectively evaluated 23 patients (mean age 69.6 years, range 43-84 years) who underwent TTO with only absorbable suture fixation. Clinic charts were reviewed to identify any complications that occurred. Obvious proximal migration and union of the tibial tubercle was evaluated on the postoperative radiographs. Knee Society scores and SF-36 were assigned at latest follow-up. The mean follow-up was 16.1 months (1-43). Two patients died of causes unrelated to surgery. In one case a fracture of the TTO occurred. No obvious migration of the osteotomy was detected. In two cases there was partial consolidation of the osteotomy, but without clinical consequences of pain or extension lag. In five patients a tibial plateau fracture occurred intraoperative which allowed partial weight bearing during 6 weeks. These fractures were not related to the surgical technique of the TTO. In 15 out of 23 patients a Knee Society Score could be assigned. The mean total knee score (maximum 200 points) after revision was 99.5 (17-166) (clinical KSS 52.1, functional KSS 47.3) at latest follow-up. SF-36 scores could be assigned to 16 patients; the mean SF-36 (maximum 100) was 88 (range 74-98). Tibial tubercle osteotomy with only absorbable suture fixation is a reliable and simple method of fixation and provides adequate stability. It is a straightforward surgical technique which is less time-consuming and expensive compared with screw and cerclage wire fixation and no hardware removal will be necessary. Therefore, this method is a beneficial technique for the enhancement of surgical exposure in difficult revision TKA.
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Comparison of Surgical Approaches in Total Knee Arthroplasty
Article
  • Nov 1998
  • CLIN ORTHOP RELAT R
A series of 123 revision total knee replacements performed at three centers and followed up for 2 to 4 years was evaluated. In cases in which exposure could be obtained with undue tension on the patellar tendon, the surgical approach was modified using either quadriceps turndown (14 cases) or tibial tubercle osteotomy (15 cases). The remaining 94 patients underwent a standard operative approach that consisted of a medial parapatellar capsular incision which in 31 cases was combined with a quadriceps snip. The results were compared using the Knee Society clinical score, a patient satisfaction survey, and a patellofemoral questionnaire. Postoperatively, the group of patients who had a quadriceps snip was equivalent to the group of patients who underwent a standard approach in every parameter measured, and the groups therefore were combined for comparison purposes. The patients who had quadriceps turndown and the tibial tubercle osteotomy had equivalent scores post-operatively both of which were significantly lower than the standard group. The group of patients who had quadriceps turndown had a significantly greater increase in arc of motion than the tibial tubercle osteotomy group. The tibial tubercle osteotomy group had a lower degree of extension lag but a higher percentage of patients who had difficulty with kneeling and stooping and a higher percentage of patients who had difficulty with kneeling and stooping and a higher percentage of patients who thought the surgery was unsuccessful in relieving pain and unsuccessful in returning them to normal daily activities.
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Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?
Article
  • Oct 2008
  • KNEE
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 tibial 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 tibial 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.
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Mechanics of the knee and problems in reconstructive surgery
Article
  • Sep 1978
Static force transmission at the knee is analysed using measurements from radiographs showing the position of the line of body weight and also the bones of the knee in their correct orientation during function. With this technique it is possible to suggest values for a variety of forces acting at the knee. During function the degree of knee flexion is not as important as the angle that the thigh makes with the vertical. The tension in the extensor mechanism is not the same above and below the patella. Failure to recognise these two features results in fundamental errors. The patella, the effects of patellectomy and of forward displacement of the attachment of the patellar ligament are discussed. The importance of the transmission of force in the coronal plane is emphasised with particular reference to total knee replacement. It is suggested that small errors of geometry, as seen in the anteroposterior radiograph, can produce large changes of load.
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