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

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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 [24],
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. ...
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