Introduction: A tibial tubercle osteotomy can be used in the exposure of severe articular deformity and the tight knee in total knee arthroplasty, especially revision surgery. This osteotomy has been popularised by Dr. L. Whiteside [1] who described transosseous wiring to secure the osteotomy following joint reconstruction. Other fixation techniques including the use of cables and screws may provide options for this technique. The current study exmained 3 different fixation methods for tibial tubercle osteotomy using an in-vitro sheep model. Materials and Methods: Tibial tubercle osteotomies (5 cm in length) were performed in ten adult sheep tibias. The osteotomies were fixed sequentially using circumferential Dall-Miles cables (Howmedica, Ritherford, NJ) (Fig. 1), transosseous wires and lastly 2 AO screws. Testing of each fixation configuration was performed using an MTS 858 Mini Bionix servo hydraulic testing machine (MTS Systems Corporation, USA). The loading regime used a cyclic 200 N load applied along the line of the patellar tendon with micromotion measured at the osteotomy and adjacent bone using optical sensors (MEL, Bahnhofstr, Germany). Data was analyzed using ANOVA. Micromotion at the end of the osteotomy fragment was recorded for 150 cycles for each tibia following reconstruction with cables, wires, and screws in succession. Results: Cable fixation provided the most stable construct followed by screws and wires respectively. Wire fixation had the greatest variation in micromotion (370 microns). The ovine tibia model provides a reproducible bone bed to evaluate different fixation strategies for tibial tubercle osteotomy. Clinically, differences may even be marked considering anatomic and bone quality issues as well as magnitude of the load that have not been addressed in this in-vitro study. Discussion: Fixation of the osteotmoy is an important surgical technique. Wolff et al. found that major complications related to the surgical technique occurred in 23% of the knees performed in 26 cases [2]. Reis et al. [3] observed fixation with 3 or 4 titanium screws was sufficient after a follow-up period of 18 months. Twenty-nine of the osteotomies healed primarily. One patient developed postoperative displacement of the tibial tubercle requiring additional screw and suture fixation. This study has shown that micromotion of a tibial tubercle osteotomy fixation in sheep is dependent upon fixation technique. Cables provided the most stable fixation compared to screws and wires in an ovine tibial model

Aim: A study to determine the results of tibial tubercle osteotomy in a series of revision and difficult primary total knee replacements. Method: A consecutive series of total knee replacements in which tibial tubercle osteotomy was performed were reviewed retrospectively. 18 revision knees and 5 primary knee replacements were identified. All of the operations performed were by the senior author. The technique was the same in all cases, involving 9cm osteotomy with screw fixation. In cases with marked restricted flexion and patella baja, the tubercle was deliberately moved proximally to gain length in the extensor mechanism. Results: All osteotomies had united by 8–12 weeks as assessed on a lateral radiograph. Range of movement increased on average 45° in the revisions, and by 60° in the primaries. An active extensor lag in 4 cases (all deliberate proximalisations) post operatively which all recovered. 5 patients underwent MUA for stiffness at 12 weeks. Conclusion: Tibial tubercle osteotomy allows predictable extensile exposure in primary and revision total knee replacement. It also allows lengthening of a contracted extensor mechanism. Union rate was excellent and complications low. It allows preservation of the quadriceps mechanism and a normal post-operative rehabilitation

Aim: The purpose of this study was to determine the long-term results of tibial tubercle osteotomy in a series of revision and difþcult primary total knee replacements. Method: A consecutive series of total knee replacements in which tibial tubercle osteotomy was performed were reviewed retrospectively. 18 revision knees and 5 primary knee replacements were identiþed. All of the operations performed were by the senior author. The technique was the same in all cases, involving 9cm osteotomy with screw þxation. In cases with marked restricted ßexion and patella baja, the tubercle was deliberately moved proximally to gain length in the extensor mechanism. In 3 revisions the index component had a porous in-growth stem. The osteotomy facilitated explantation. Results: All osteotomies had united by 8–12 weeks. Range of movement increased on average 45û in the revisions, and by 60û in the primaries. An active extensor lag in 4 cases (all deliberate proximalisations) post operatively which all recovered.5 patients underwent MUA for stiffness at 12 weeks. Conclusion: Tibial tubercle osteotomy allows predictable extensile exposure in primary and revision total knee replacement. It also allows lengthening of a contracted extensor mechanism. Union rate was excellent and complications low. It allows preservation of the quadriceps mechanism and a normal postoperative rehabilitation

We identified 26 tibial tubercle osteotomies (TTOs) performed in 23 revision knee arthroplasties between 2009 and 2013. Average age at last operation was 66 (33–92). Mean follow-up period was 14 months (3–33). Eleven TTOs were performed in 10 knees for single stage revisions and 15 TTOs were performed in 13 knees for 2 stage revisions in the setting of deep infection. In this infected subset 11 patients had a TTO performed at the first stage. This osteotomy was left unfixed to avoid leaving metalwork in a potentially contaminated wound, reopened, and then definitively secured with screws at the second stage. Our technique involves fashioning a long 7×1cm tibial tuberosity osteotomy without a proximal step-cut. All osteotomies united with no fractures. Minor proximal migration was noted in one case associated with screw loosening. There was no proximal migration noted in the 2 stage cases where the osteotomy had been left initially unfixed. There were no extensor lags. We conclude that TTO is a safe and reproducible procedure when adequate exposure cannot be obtained in revision knee arthroplasty. In 2 stage revisions sequential osteotomies does not decrease union rates and leaving the osteotomy unfixed after the first stage does not cause any issues

Abstract. Introduction. Tibial tubercle osteotomy (TTO) is a complex surgical procedure with a significant risk of complications, which include nonunion and tibial fracture. To determine whether an additional suture tape augmentation can provide better biomechanical stability compared with standard screw fixation. Methods. Five matched pairs of human cadaveric knees were divided into 2 groups: the first group underwent standard TTO fixation with 2 parallel screws. The second group underwent a novel fixation technique, in which a nonabsorbable suture tape (FiberTape) in a figure-of-8 construct was added to the standard screw fixation. Tubercular fragment migration of >50% of the initial distalization length was defined as clinical failure Tubercular fragment displacement during cyclic loading and pull-to-failure force were recorded and compared between the 2 groups. Results. The augmented group showed less cyclic tubercular fragment displacement after every load level compared with the standard group, with statistically significant differences starting from 500 N (P < .05; power > 0.8). Mean ± standard deviation tubercular fragment displacement at the end of cyclic loading was 2.56 ± 0.82 mm for the augmented group and 5.21 ± 0.51 mm for the standard group. Mean ultimate failure load after the pull-to-failure test was 2475 ± 554 N for the augmented group and 1475 ± 280 N for the standard group. Conclusion. The specimens that underwent suture tape augmentation showed less tubercular fragment displacement during cyclic loading and higher ultimate failure forces compared with those that underwent standard screw fixation

Introduction and Objective. Difficult primary total knee arthroplasty (TKA) and revision TKA are high demanding procedures. Joint exposure is the first issue to face off, in order to achieve a good result. Aim of this study is to evaluate the clinical and radiological outcomes of a series of patients, who underwent TKA and revision TKA, where tibial tubercle osteotomy (TTO) was performed. Materials and Methods. We retrospectively reviewed a cohort of 79 consecutives TKAs where TTO was performed, from our Institution registry. Patients were assessed clinically and radiographically at their last follow-up (mean, 7.4 ± 3.7 years). Clinical evaluation included the Knee Society Score (KSS), the pain visual analogue scale (VAS), and range of motion. Radiological assessment included the evaluation of radiolucent lines, osteolysis, cortical bone hypertrophy, time of bone healing of the TTO fragment, and the hardware complication. Results. KSS raised from 40.7 ± 3.1 to 75 ± 4.3 (p < 0.0001). Knee flexion increased from 78.7 ± 9.9° to 95.0 ± 9.5° (p < 0.0001), and VAS improved from 7.9 ± 0.9 to 3.8 ± 1 (p < 0.0001). No signs of loosening or evolutive radiolucency lineswere found. Osteolytic areas around the stem were detected. No significant association was found between the implant design and the outcomes, while aseptic loosening showed significantly better results. Complications were: 4 painful hardware, 3 late periprosthetic infections, 1 extension lag of 5°, and 3 flexion lag. Conclusions. Our experience suggests the use of TTO to improve the surgical approach in difficult primary TKA or revision TKA. A strict surgical technique leads to good results with low risk of complications

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

Patients with recurrent patella instability, who have an abnormal patellofemoral alignment (patella height or tibial tubercle-trochlear groove (TTTG) distance), benefit from tibial tubercle transfer along with medial patellofemoral ligament (MPFL) reconstruction. Between July 2008 and April 2013, 18 patients (21 knees) with recurrent patellar instability underwent combined MPFL reconstruction and tibial tubercle transfer. All patients had abnormal patellofemoral alignment in addition to MPFL insufficiency. 15 patients (16 knees) with a mean age of 24 years (16–41) had a mean follow up of 26 months (6–55). We assessed the outcome using KOOS, KUJALA, activity level and patient satisfaction scores. All patients had a stable patella. There was a significant improvement in outcome scores in 12 out of 15 patients. At final follow up KOOS score had improved from 68.25(44 to 93.9) to 77.05(48.8 to 96.4) and KUJALA score had improved from 63.3(41–88) to 78.06 (45 to 99). 9 patients showed excellent results and achieved at least a pre-injury level of activity. 4 of these had activity level better then preoperative level. 6 patients had a lower activity level than pre-injury (1 – ongoing physiotherapy, 1 – because of lack of confidence, and 4 – Life style modification). 14 patients were satisfied and happy to recommend this procedure. There were 3 postop complications, with 2 cases of stiffness and 1 case of non-union of the tibial tuberosity. Our prospective study has shown that restoration of tibial tubercle-trochlear groove index, Patella height and Medial Patellofemoral Ligament reconstruction yields good results in carefully selected patients.

Purpose: Problem : Infection in TKA is a devastating yet common complication. 2-stage reimplant procedures are performed in the treatment of this condition. Purpose:To evaluate the clinical, radiographic, complications, and patient satisfaction results of 2nd stage reimplantation revision TKA with the use of a TTO. Technical aspects of TTO length, fixation, bypass, and complications are reported.

Methods: From 1996–2004 our database identified 25 revision TKA (12% of 206 revision TKA) performed using a TTO. In 20/25 cases the procedure was a 2nd stage reimplant. Demographics, infecting organism, Gustillo grade, clinical, radiographic, AORI defects, complications, patient satisfaction were evaluated prospectively. All patients were followed until radiographic union of the TTO.

Results: At a mean follow up of 22 mo(range,6–84) no patients were lost to follow-up. 24 (96%)TTO’s healed - 1 requiring revision ORIF. Prior to reimplantation, patients had undergone a mean of 3.3 prior knee surgeries(range,2–8). Prior extensor mechanism procedures had been performed in 43% of knees. Methicillin resistant staphylococcus was the infecting organism in > 50% of knees. 19 knees had a static cement spacer removed at revision. Time to 2nd stage reimplant was 39 weeks(range,15–68). Poor preop range of motion and stiffness (mean arc 430 , range 10–950) improved significantly postop (mean flexion 880 p< .05). 13 (56%) knees required an adjunctive extensor procedure at the time of TTO. TTO length averaged 8.8cm(range,8–10). Screws(15 knees), 2mm cables(6), wires(4) were used for TTO fixation. Mean stem bypass of the TTO was 63mm (−20 to 100). 21 (84%) patients were satisfied with the procedure, despite 8 knees(32%) requiring further surgery. 6 (24%) TTO complications occurred; 1 escape requiring fixation. All TTO’s had healed at recent follow up.

Conclusions: TTO is a useful procedure for exposure in 2nd stage revision TKA. TTO union is predictable(96%), despite technical complications. Recurrence of infection requiring further surgery did not compromise TTO results. Prior/concurrent extensor mechanism procedures were noted frequently.

Funding : Other Education Grant

Funding Parties : Wright Medical Technologies

Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article: Bone Jt Open 2022;3(3):268–274

We present 10–15 year follow-up of 33 patients who underwent Elmslie-Trillat osteotomy for severe patellar subluxation or dislocation. In the literature it has been reported that tibial tubercle osteotomy predisposes to subsequent patella-femoral arthritis, however it has never been documented if pre-existent knee chondral damage has any role in this development. In our group all patients had pre-op knee arthroscopy performed and extant of chondral damage was documented. We preformed an evaluation by long-term follow-up to determine weather pre-op chondral damage was the cause of subsequent osteoarthritis of patella-femoral joint. All patients were invited to attend outpatient clinic for clinical examination and knee radiographs and assessed by an independent research surgeon. Mean age at follow-up was 43 years and average follow-up was 10.5 years (range 10–15 years). 90% follow-up was achieved. Knee function was assessed by clinical scores (Lysholm knee score, American Knee Score, Oxford Knee score, Tegner and Insall knee scores) and three radiographs (AP, Lateral and Merchant views). Four patients had developed significant arthritis and underwent joint arthroplasty. Majority of patients reported good results with no further dislocation. However we noticed that extant of pre-op chondral damage was a significant factor in subsequent development of patella-femoral arthritis. We will present our data which is unique as no previous such long-term results have been reported for tibial tubercle transfers followed-up for more than 10 years and have pre-op arthroscopic documented chondral damage

Fractures of the prosthetic components after total knee arthroplasty (TKA) are rare but dangerous complications, sometimes difficult to diagnose and to manage. Aim of this study is to evaluate the incidence of component breakage and its treatment in our single institution's experience. We retrospectively review our institution registry. From 605 revision knee arthroplasties since 2000 to 2018, we found 8 cases of component breakage, of these 3 belonged to UKA, and 5 belonged to TKA. The UKA fractures were all on the metal tibial component; while 4 TKA fractures were ascribed to the liner (2 Posterior-Stabilized designs and 2 constrained designs) and only one case was on the femoral component. For every patient a revision procedure was performed, in two cases a tibial tubercle osteotomy was performed, while in one case (where the fracture was of the post cam) an arthroscopy was performed prior to the arthrotomy. All of the UKA fractures were treated with a standard revision implant. As regard the TKA, 2 liner fractures were treated with the only liner exchange, while the other 2 liner fractures and the fracture of the metallic component were treated with total knee revision. No intra- and post-operative complications were found. Component breakage after TKA is a serious complication. Its treatment, always surgical, can hide pitfalls, especially if the timing is not correct; indeed apart from the revision of one or more components, the surgeons must address any issues of management of bone defect and ligamentous stability

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Achievement of adequate exposure in revision total knee arthroplasty is critical as it reduces the surgical time, enhances the ability for both component removal and reconstruction, and avoids devastating complications such as extensor mechanism disruption. However, this can be challenging as prior multiple surgeries and limited mobility contribute to a loss of tissue elasticity, thickened capsular envelope, and peri-articular soft tissue adhesions. A thorough pre-operative assessment of a patient's past surgical history, comorbidities, pre-operative radiographs (i.e. the presence of severe patella baja), and physical examination including range of motion, prior incisions, and soft tissue pliability are useful in determining the appropriate surgical techniques necessary for a successful revision. A systematic approach to the ankylosed knee is critical. Most techniques are geared towards mobilization of the extensor mechanism to safely displace the patella for component exposure. The initial exposure should consist of a long skin incision, a subperiosteal medial release, and debridement of suprapatellar, medial, and lateral adhesions to the femoral condyles. A lateral capsular release can prove helpful in further mobilization of the extensor mechanism. When performing a medial parapatellar arthrotomy it's important to keep in mind further extensile exposure techniques that may be required. For example, the arthrotomy should not extend proximally into the vastus intermedius or rectus femoris in the event that a quadriceps snip technique is to be used as this can compromise the ability to repair this exposure. Despite a large exposure and release of adhesions, sometimes the extensor mechanism remains at risk of rupture and adequate visualization cannot be obtained. In this event, extensile exposures such as a quadriceps snip, quadriceps turndown or tibial tubercle osteotomy are considered. The location of the patella often dictates the best exposure option as severe patella baja may not be overcome with a proximally based release. The quadriceps snip is most commonly used and provides improved exposure without the necessity of modifying the patient's post-operative rehabilitation. In addition, it can be extended to a quadriceps turndown which vastly improves visualization, but at the expense of needing to immobilise the knee post-operatively. A tibial tubercle osteotomy can also be used and provides excellent exposure especially in the case of severe patella baja or when removal of a cemented tibial stem is required. It preserves the extensor muscles, but risks include increased post-operative wound drainage due to limited soft tissue coverage, failure of fixation, or fracture of the tibial tubercle fragment or tibial shaft. Exposure in revision total knee arthroplasty is critical. Fortunately, this can be reliably achieved with a systematic approach to the knee and through the use of several extensile exposures at the surgeon's discretion

The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A synovectomy is performed followed by debridement of all scar tissue, especially in the medial and lateral gutters. All peripatellar scar tissue is excised followed by release of scar tissue within the patellar tendon, allowing for displacement or everting of the patella. As patellar tendon avulsion at any time of knee surgery yields disastrous results, the surgeon should be continuously evaluating the patellar tendon integrity, especially while displacing/everting the patella and bringing the knee into flexion. If displacement/eversion is difficult, consider rectis-snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. The long-held requisite for patellar eversion prior to component removal is inaccurate. In most cases simple lateral patellar subluxation will provide adequate exposure. If a modular tibial system is involved, removal of the tibial polyethylene will decompress the knee, allowing for easier access to patellar, femoral, and tibial components. For patellar component removal, first identify the border of the patella, then carefully clean and debride the interface, preferably with electrocautery. If the tibial component is cemented all-polyethylene, remove using an oscillating saw at the prosthetic-bone interface. Debride the remaining cement with hand tools, ultrasonic tools, or burrs. Remove the remaining peg using a low-speed burr. If the tibial component is metal-backed, then utilise a thin saw blade or reciprocating saw to negotiate the undersurface of the component between the pegs. If pegs are peripherally located, cut with a diamond disc circular cutting tool. Use a trephine to remove the pegs. For femoral component removal, identify the prosthetic-bone/prosthetic-cement interface then remove soft tissue from the interface, preferably with electrocautery. Disrupt the interface around all aspects of the component, using any of following: Gigli saw for cementless components only, micro saw, standard oscillating saw, reciprocating saw, a series of thin osteotomes, or ultrasonic equipment. If the femoral component is stemmed, remove the component in two segments using an appropriate screwdriver to remove the screw locking the stem to the component. Remove the femoral component with a retrodriver or femoral component extractor. Debride cement with hand tools or burr, using care to avoid bone fracture. If a stem is present, then remove with the appropriate extraction device. If “mismatch” exists, where femoral (or likewise, tibial) boss is smaller in diameter than the stem, creating a cement block prohibiting stem removal, remove the cement with hand tools or burr. If the stem is cemented, use hand tools, ultrasonic tools, or a burr to debride the cement. Curette and clean the canals. For tibial component removal, disrupt the prosthetic-cement/prosthetic-bone interface using an oscillating or reciprocating saw. Gently remove the tibial component with a retrodriver or tibial extractor. If stem extensions are utilised, disengage and debride all proximal cement prior to removing the stem. If stem is present, then remove stem with appropriate extraction device. If stem is grit-blasted and well-fixed, create 8mm burr holes 1.5 to 2.5cm distal to tibial tray on medial aspect and a small divot using burr, then drive implant proximally with Anspach punch. Alternatively, a tibial tubercle osteotomy may be performed. If the stem is cemented, use hand tools, ultrasonic tools or burr to debride cement

Exposure in revision total knee replacement can be quite challenging due to scar formation from one or many previous incisions. Disruption of the patellar or quadriceps tendon during revision must be avoided at all costs and many surgical maneuvers have been described to permit safe exposure in order to remove the implants during the initial stage of reconstruction. Standard maneuvers include recreation of the medial and lateral gutters, patient dissection to allow the soft tissue to stretch over time and proximal medial exposure of the tibia and release of the semimembranosis tendon insertion. There are three specialised techniques for exposure during revision total knee replacement: the quadriceps snip as described by Insall, the V-Y quadriceps turndown as described by Coonse and Adams, and the tibial tubercle osteotomy as described by Whiteside. The quadriceps snip is a proximal lateral extension of the medial arthrotomy used during a standard approach. It is easy to perform and can be used for most revision situations. This is should be the standard first choice for gaining exposure in revision surgery. The V-Y quadriceps turndown is quite extensile and is a combination of a lateral retinacular release connected to the proximal portion of the medial arthrotomy. Although it allows excellent exposure in revision situations, it is associated with extensor weakness and extensor lag. The Whiteside tibial tubercle osteotomy is also a versatile approach. Care should be taken to preserve a lateral periosteal sleeve, and subsequent repair with wire presents the best healing possibility. It is quite elegant in providing access to the proximal tibia to facilitate removal of a well fixed, stemmed tibial component

Exposure in revision total knee replacement can be quite challenging due to scar formation from one or many previous incisions. Disruption of the patellar or quadriceps tendon during revision must be avoided at all costs and many surgical maneuvers have been described to permit safe exposure in order to remove the implants during the initial stage of reconstruction. Standard manoeuvres include recreation of the medial and lateral gutters, patient dissection to allow the soft tissue to stretch over time and proximal medial exposure of the tibia and release of the semimembranosis tendon insertion. There are three specialised techniques for exposure during revision total knee replacement: the quadriceps snip as described by Insall, the V-Y quadriceps turndown as described by Coonse and Adams, and the tibial tubercle osteotomy as described by Whiteside. The quadriceps snip is a proximal lateral extension of the medial arthrotomy used during a standard approach. It is easy to perform and can be used for most revision situations. This is should be the standard first choice for gaining exposure in revision surgery. The V-Y quadriceps turndown is quite extensile and is a combination of a lateral retinacular release connected to the proximal portion of the medial arthrotomy. Although it allows excellent exposure in revision situations, it is associated with extensor weakness and extensor lag. The Whiteside tibial tubercle osteotomy is also a versatile approach. Care should be taken to preserve a lateral periosteal sleeve, and subsequent repair with wire presents the best healing possibility. It is quite elegant in providing access to the proximal tibia to facilitate removal of a well fixed, stemmed tibial component

Objectives. To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for arthroscopically diagnosed chondromalacia patellae. Methods. A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia, who had failed conservative management, underwent a modified Fulkerson tibial tubercle osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients exhibited signs of patellar maltracking or instability in association with their anterior knee pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)), with only one patient lost to follow-up. Results. A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from 39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-operatively. Overall patient satisfaction with good or excellent results was 72%. Patients with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less than younger ones. The outcome was independent of the grade of chondromalacia. Six patients required screw removal. There were no major complications. Conclusions. We conclude that this modification of the Fulkerson procedure is a safe and useful operation to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia patellae in adults, when conservative measures have failed

Background: Femoro-patellar arthritis (FPA) is less frequent than femoro-tibial arthritis, but still a challenging problem for orthopaedic surgeons. Several treatment have been described from lateral retinaculum release to TKR, with special features to patellar prosthesis. The purpose of this study was to evaluate a large consecutive series of femoro-patellar prosthesis (FPP), to learn about the late outcome, complications and performance. Material and Methods: Between 1992 and 2004, 60 prosthesis were performed by one of the authors in 55 patients with a mean age of 59 years; 44 were femal and 13 male, 5 had bilateral prosthesis. 62% had essential arthritis with trochlear dysplasia. 78% were graded Iwano III or IV. Resurfacing cemented Themis. ®. prosthesis was used in all cases, with a lateral approach associated with a tibial tubercle osteotomy to achieve correct aligment of extensor mechanism. None patient was lost to follow-up. Results: Mean follow-up was 10 years (46–218 months). During the study, 12 prosthesis were converted to TKR because of femoro-tibial arthritis; but the mean delay between FPP and TKR was 12 years. At revision, 48 FPP were evaluated by an independent examinator. IKS score raised from 106 to 157, knee score from 57 to 89 and function score from 49 to 78. Pain, ability to walk and to climb stairs were improved. Radiography did not demonstrate radio-lucent lines, wear or loosening. 95% had correct aligment of patellar button, without tilting. Survival rates of FPP were 89% at 10 years and 82% at 15 years. Conclusion: Resurfacing FPP is a reliable procedure offering good clinical performance and outcomes. The authors recommend the use of FPP for isolated FPA, without knee diformity, in association with tibial tubercle osteotomy

MPFL reconstruction has demonstrated a very high success rate with improved patella stability, physical function, and patient-reported outcomes. However technical error and a lack of consideration of anatomic risk factors have been shown to contribute to failure after MPFL reconstruction. Previous research has also reported a complication rate of 26% following surgery. The purposes of this study were to determine the re-dislocation rate, type and number of complications, and most common additional surgical procedures following MPFL reconstruction. Patients with symptomatic recurrent patellofemoral instability underwent an MPFL reconstruction (n = 268) and were assessed with a mean follow-up of 31.5 months (minimally 24-months). Concomitant procedures were performed in addition to the MPFL reconstruction in order to address significant anatomic or biomechanical characteristics. Failure of the patellofemoral stabilization procedure was defined as post-operative re-dislocation of the patella. Rates of complications and re-procedures were assessed for all patients. The re-dislocation rate following MPFL reconstruction was 5.6% (15/268). There were no patella fractures. A total of 49/268 patients (18.3%) returned to the operating room for additional procedures following surgery. The most common reason for additonal surgery was removal of symptomatic tibial tubercle osteotomy hardware in 24/268 patients (8.9%). A further 9.3% of patients underwent addtional surgery including revision MPFL reconstruction: with trochleoplasty 8/268 (3.0%), with tibial tubercule osteotomy 4/286 (1.5%) and with femoral derotation osteotomy 3/268 (1.1%); manipulation under anaesthesia for reduced knee range of motion 4/268 (1.5%); knee arthroscopy for pain 8/268 (3.0%); and cartilage restoration procedures 3/268 (1.1%). There was 1 case of wound debridement for surgical incision infection. MPFL reconstruction using an a la carte approach to surgical selection demonstrated a post-operative redislocation rate of 5.6%. The rate of complications following surgical stabilization was low, with the most common reason for additional surgery being removal of hardware