Tibial tubercle osteotomy with absorbable suture fixation in revision total knee arthroplasty: a report of 23 cases.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

[A man with a painful neck]. / Een man met pijn in de nek.

A 45-year-old motorcyclist was hit by a car and presented to the emergency department with minor neck pain and radiating pain into both arms. Routine radiography did not show any pathology. Additional CT and MRI images revealed an anterolisthesis of Cvii-Thi with a bilateral facet dislocation and myelum compression.

[Fractures of the hamate bone and metacarpal bone: a rare combination]. / Fractuur van een os hamatum en een os metacarpale: een zeldzame combinatie.

BACKGROUND: Fractures of the hamate bone are rare, but are being seen more frequently due to the increasing popularity of racket sports and golf. CASE DESCRIPTION: A 43-year-old man presented at our emergency department with a swollen, painful left hand after hitting a concrete wall with his fist. X-rays and CT scans revealed comminuted fracture of the hamate bone and the base of the fourth metacarpal bone. Open reduction and internal fixation, using screws and Kirschner wires, were performed. The postoperative course was uneventful. At one-year follow-up the patient had regained full use of his hand. CONCLUSION: On conventional X-rays, 60% of wrist fractures are missed. If the clinical picture indicates a fracture of the hamate bone but conventional X-rays reveal no abnormalities then a supplementary CT-scan is advisable. Non-displaced fractures, or fractures with little displacement, can be treated conservatively, but surgical treatment is preferred in the case of displacement or non-union.

[Occlusion of the popliteal artery caused by bony exostoses]. / Occlusie van de A. poplitea door een exostose.

A 52-year-old woman without risk factors for vascular disease or preceding trauma presented with prolonged pain of the right knee radiating to the calf. Radiographs, duplex ultrasound and MR angiography revealed a popliteal artery occlusion resulting from two exostoses on the dorsal side of the proximal tibia. These exostoses were surgically removed. The postoperative course was uneventful. Six weeks after surgery, the patient reported having no more pain. Bony exostoses occur most frequently on the distal femur and the proximal tibia. In rare cases, they can cause vascular complications including stenosis, occlusion and venous thrombosis. In patients with incapacitating symptoms or vascular complications, surgical treatment is indicated. If an expectative course is opted for, monitoring for vascular complications and malignant degeneration must take place.

Tuberositas osteotomy for total knee arthroplasty: a review of the literature.

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.