Patient with stiff knee 1 decade after TKA
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A 69-year-old woman was referred for evaluation of left knee pain. She had a total knee arthroplasty performed 13 years ago and subsequently underwent a one-stage revision surgery for infection 2 years later.
Her one-stage revision was complicated by patellar tendon rupture, which was fixed with FiberWire (Arthrex) through bone tunnels. Postoperatively, she was placed in extension for 8 weeks, which resulted in severely limited range of motion (ROM). During the last decade since her revision procedure, the patient has been experiencing continuous pain, discomfort and stiffness.
Source: Filippo F. Romanelli, DO, MBA
On physical examination, there was extensive scarring over the anterior aspect of the knee, which limited her active and passive ROM from full extension to 15° flexion. She was able to straight-leg raise and had no instability on varus/valgus stress tests. She was neurovascularly intact.
Radiographs demonstrated hardware loosening around the stem of both the tibial and femoral components of the implant. Additionally, severe patella baja (PB) was noted (Figure 1).
What are the best next steps in management of this patient?
See answer below.
Revision TKA with soft tissue procedures, tibial tubercle osteotomy
Given a history of previous infection, the patient was worked up for infection.
Inflammatory markers (C-reactive protein, erythrocyte sedimentation rate and interleukin-6) were within normal limits and nuclear studies did not reveal any signs of infection, but confirmed loosening of femoral and tibial components. After an extensive conversation about the risks and benefits of surgery, the patient opted to undergo a revision procedure.
Surgical procedure, details
The patient was booked for revision of left TKA, left knee soft tissue biopsy, left extensor mechanism repair vs. reconstruction, and left tibial tubercle osteotomy (TTO).
The patient was placed supine on a radiolucent table and was prepped and draped in sterile fashion. A sterile tourniquet was placed and inflated prior to incision. The previous surgical incision was excised and skin flaps were elevated distal to the tibial tubercle. A medial and lateral parapatellar arthrotomy was made. Fluid was collected for microbiology. A Synovasure (Zimmer Biomet) lateral flow test confirmed the absence of infection. Due to the limited range of motion of the patient, a TTO was performed. The patellar tendon insertion and width were identified and an 8-cm x 2-cm osteotomy was planned. A sagittal saw was utilized from the lateral to the medial aspect of the proximal tibia carefully incorporating the entire insertion of the patellar tendon (Figure 2). An oblique cut was made at the distal aspect connecting the medial and lateral osteotomies. A curved osteotome was then placed and used to elevate the osteotomy site. Further evaluation of the TTO showed the proximal aspect of the patellar tendon had calcified on the undersurface of the tendon. With careful dissection, the calcified tissue was sufficiently debrided from the patellar tendon to restore the appropriate Insall-Salvati ratio of 1.0 (Figure 3).
With adequate exposure, all scar tissue was excised and sent for culture and all TKA components were carefully removed utilizing reciprocating saws and osteotomes to minimize bone loss. The femur and tibia were then both reamed to accommodate the respective templated 10-mm x 160-mm and 10-mm x 110-mm stems. Cutting guides were placed to freshen the tibial and femoral surfaces accordingly to achieve balanced flexion and extension gaps without the use of any augments. Trial femoral and tibial components were then placed and, utilizing lateral fluoroscopy, the TTO was advanced 2 cm proximally and preliminarily fixed with a Weber clamp to restore the appropriate patellar height. ROM, implant stability and patellar tracking were found to be appropriate. After the trial implants were removed, the tibia and femur were prepared for final implantation of components. Tunnels were created in the posterior aspect of the proximal tibia utilizing a 2.5-mm drill bit. Two 1.6-mm cables were passed through these tunnels to help secure the osteotomy prior to placing the implants (Figure 4). The knee was irrigated. The appropriately sized stemmed femoral and tibial components were cemented using a hybrid technique (non-cemented stem).
The proximal cable was then tensioned with the tibial tubercle in the appropriate position and a 3.5-mm cortical lag screw was placed to stabilize the proximal TTO site. Next, a custom-contoured 2.4-mm LC-DCP Systems plate (DePuy Synthes) was placed in the distal aspect of the TTO prior to cement hardening to enhance fixation at the screw-cement interface. Once the cement was hardened, the knee was ranged and found to have full flexion and extension with appropriate patellar tracking (Figure 5). The wound was copiously irrigated and the medial arthrotomy was closed with range of motion preserved (Figure 6).
Discussion
Achieving adequate exposure in revision TKA (rTKA) that is complicated by deformity, fibrosis or PB can be challenging. Additionally, patients with history of previous patellar tendon injury, like the one presented, require additional caution to avoid disruption of the extensor mechanism when mobilizing or everting the patella. While alternative techniques to increase exposure of the knee during rTKA include proximal extensile approaches, these can be associated with extensor lag and quadriceps weakness and are generally not helpful in addressing the PB. The TTO can be a safe and effective technique to implement during rTKA that is complicated by limitations in motion, PB or overall limited joint exposure. The TTO is especially useful in restoring patella height in cases of PB caused by low Insall-Salvati ratios.
General usage of TTO has shown to improve clinical outcome scores and ROM in the setting of rTKA. A recent meta-analysis has shown that, on average, the use of TTO in rTKA procedures safely improves overall knee ROM by 23.6°, supporting its use in properly indicated patients. Despite the numerous benefits of rTKA, it is not without risks. Albeit infrequent, reported complications include nonunion, tibial tubercle fractures, migration, anterior knee pain and stiffness. Current studies have found an overall complication rate ranging from 0.5% to 6.9%, with a 98.1% union rate. In the setting of PB, studies have shown that TTO significantly improves ROM, functional outcome scores and pain scores with low rates of major complications, such as recurrence or nonunion.
Multiple TTO fixation methods have been described with no consensus on the optimal technique. Our patient was fixed with cerclage wire, lag screw and a distal custom-contoured plate and screws. Mechanical studies have shown that a two-screw technique provides stronger stabilization forces than utilizing cerclage wires alone. However, in the setting of rTKA, tibial stems create an additional challenge for screw positioning that is avoided by cerclage cables. Both screws and cerclage wires can be associated with pain that necessitates additional surgery for removal of hardware. The technique preferred by the senior author is a hybrid technique that uses both methods for maximum stability.
Key points
- Achieving adequate exposure in rTKA complicated by deformity, fibrosis or PB can be challenging.
- While alternative techniques to increase exposure during rTKA include proximal extensile approaches, these can be associated with extensor lag and quadriceps weakness and are generally not helpful in addressing PB.
- TTO can be a safe and effective technique to implement during rTKA that is complicated by limitations in motion, PB or overall limited joint exposure. It is especially useful in restoring patella height in cases of PB caused by low Insall-Salvati ratios rather than joint elevation (pseudo-PB).
- In the setting of PB, studies have shown that TTO significantly improves ROM, functional outcome scores and pain scores in affected patients.
- References:
- Barrack RL, et al. Clin Orthop Relat Res. 1998;doi:10.1097/00003086-199811000-00004.
- Biggi S, et al. Joints. 2018;doi:10.1055/s-0038-1661338.
- Chalidis B, et al. World J Orthop. 2020;doi.org/10.5312/wjo.v11.i6.294.
- Davis K, et al. Clin Orthop Relat Res. 2000;doi.org/10.1097/00003086-200011000-00033.
- Deane CR, et al. BMC Musculoskelet Disord. 2008;doi:10.1186/1471-2474-9-98.
- Di Benedetto P, et al. Acta Biomed. 2020;doi.org/10.23750/abm.v91i4-S.9705.
- Divano S, et al. Arch Orthop Trauma Surg. 2018;doi.org/10.1007/s00402-018-2888-y.
- Drexler M, et al. Knee Surg Sports Traumatol Arthrosc. 2013;doi:10.1007/s00167-012-2278-x.
- Giovagnorio F, et al. Radiol Med. 2017;doi.org/10.1007/s11547-017-0781-3.
- Kurtz S, et al. J Bone Joint Surg Am. 2007;doi.org/10.2106/jbjs.F.00222.
- Mendes MW, et al. J Arthroplasty. 2004;doi.org/10.1016/j.arth.2003.08.013.
- For more information:
- Suriya Baskar, BA, a research fellow; Frank A. Liporace, MD; Filippo F. Romanelli, DO, MBA; and Bishoy Saad, DO, an orthopedic surgeon and hand surgeon, can be reached at Jersey City Medical Center, 355 Grand St., Jersey City, NJ 07302. Baskar’s email: suriyabaskarresearch@gmail.com. Liporace’s email: liporace33@gmail.com. Romanelli’s email: romanelli.filippo@gmail.com. Saad’s email: bishoy21@gmail.com.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a chief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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