A 52-year-old man with no related previous medical historical past introduced to the clinic with continual proper knee ache and problem ambulating since a bike accident 3 years prior that occurred within the nation from which he emigrated.
Per the affected person, after his accident he was taken to an area hospital the place he was recognized with a knee fracture and given crutches to help with ambulation, however no additional nonoperative or operative interventions have been pursued. Since his damage, he had been ambulating with nice problem attributable to ache and deformity, requiring a cane for help. He immigrated to the US 1 yr previous to preliminary presentation and has been unable to work attributable to purposeful limitations. He’s shelter-domiciled and smokes one-half of a pack of cigarettes every day.
Through the bodily examination, he walked with an antalgic gait and couldn’t take greater than two steps with out his cane. His proper decrease extremity confirmed valgus alignment whereas weight-bearing. The pores and skin was intact. The correct knee was globally tender to palpation. His passive vary of movement within the knee was 0° to 130°, however he skilled vital ache all through. He was capable of carry out a straight leg increase, although with a 15° extensor lag. There was laxity famous with valgus stress and the anterior drawer take a look at. In any other case, he was neurovascularly intact distally.
Radiographs obtained at his first go to exhibit a chronic-appearing comminuted, bicondylar tibial plateau fracture with shaft extension and proof of bony resorption (Figures 1A to 1C). CT additional demonstrates the complicated bicondylar tibial plateau fracture with impaction and incongruency of the joint line, a sagittal break up and continual fragmentation with no considerable bony bridging between any of the fragments, according to nonunion (Figures 2A to 2D).
What are the following greatest steps in administration of this affected person?
See reply beneath.
Complicated complete knee arthroplasty
The numerous surgical issues for this affected person’s case embody the potential coronal and sagittal aircraft instability within the knee, restoring decrease extremity mechanical alignment, reaching sufficient fixation of implants given the compromised joint line and diminished metaphyseal bone inventory, the potential for extensor mechanism dysfunction and the potential of this being a septic nonunion. Inflammatory markers have been drawn and have been inside regular limits.
Supply: Benjamin C. Schaffler, MD; Jack R. Zhong, MD; Nicole Rynecki, MD; and Vinay Ok. Aggarwal, MD
The 2 operative choices for this affected person are open discount and inner fixation (ORIF) of the tibial plateau or complicated complete knee arthroplasty. ORIF could be unlikely to be passable given the diploma of bone resorption, continual adjustments to the fracture fragments and posttraumatic arthritic adjustments within the knee. Thus, complicated TKA was undertaken to enhance this affected person’s ache and performance.
Surgical method
The affected person was positioned supine on a radiolucent desk. A midline longitudinal incision with a medial parapatellar arthrotomy was carried out. The femoral canal was drilled and sequentially reamed to accommodate a femoral stem. An intramedullary information was used to evaluate rotation, and an ordinary 4-in-1 chopping information was utilized for the femoral cuts.
Consideration was then directed to the tibia. Intraoperatively, the proximal tibia was discovered to include intensive fibrous tissue and scarring, with no proof of osseous therapeutic between fracture fragments. The joint floor was compromised, and the displaced cortical fragments, together with dense scar tissue and sclerosis, obstructed the conventional intramedullary canal pathway.
To regain entry, a small entry level was created utilizing a bur, and a ball-tip guidewire was launched. Radiography confirmed right guidewire positioning inside the tibial intramedullary canal. All reaming for the long-stemmed tibial part was carried out beneath fluoroscopic steerage.
After sequentially reaming with versatile after which inflexible reamers within the applicable place of impartial tibial intramedullary alignment, a tibial chopping information was connected to the reamer and a neutrally aligned tibial reduce was made based mostly on the place of the reamer. Alignment was confirmed on biplanar fluoroscopy. The tibial metaphysis was then ready for a cone, which was carried out fastidiously to keep away from full disruption of the tibial tubercle fragment. Good match was achieved with a cone to unitize the proximal tibial fragments to the tibial metadiaphysis.
After implant trialing, the limb was assessed for alignment, extension, flexion, rotation and patellar maltracking, and all have been discovered to be sufficient. The ultimate cone was impacted. The lengthy, press-fit tibial stem was impacted by means of the cone and, on the stage of the cone, was cemented with hybrid method to attain union between the tibial baseplate and cone proximally. After impaction of the femoral part, a varus-valgus constrained polyethylene liner was inserted. The knee was copiously irrigated, and the wound was closed with the help of cosmetic surgery by way of gastrocnemius rotational flap.
Supply: Benjamin C. Schaffler, MD; Jack R. Zhong, MD; Nicole Rynecki, MD; and Vinay Ok. Aggarwal, MD
Postoperatively, the affected person recovered effectively. He was non-weight-bearing for the primary 2 weeks postoperatively per cosmetic surgery protocol to make sure vascularization and incorporation of his rotational flap. He progressed to weight-bearing as tolerated with a rolling walker after his first postoperative go to. Radiographs right now demonstrated revision elements in good place (Figures 3A to 3C). At his 3-month follow-up go to, he was ambulating with a cane. He had achieved full passive vary of movement, equal to preoperatively. He was capable of straight leg increase with out extensor lag. By 6 months postoperatively, he was capable of ambulate with none assistive units and reported no ache.
Dialogue
Complicated TKA for extreme posttraumatic deformities calls for meticulous preoperative planning and a number of other crucial intraoperative issues. Satisfactory surgical publicity is important to visualise and mobilize all fracture fragments. Thorough debridement of fibrous tissue is important to advertise bony therapeutic and facilitate on-growth onto porous metaphyseal cones. Implant choice ought to guarantee stems are lengthy sufficient to bypass all fracture strains by a protected margin, minimizing the danger for stress risers and offering sufficient stabilization. On this case, a long-stemmed tibial implant was utilized to bypass the diaphyseal extension of the tibial fracture.
Given the complexity of such instances, surgeons have to be geared up with a full revision toolkit, together with metaphyseal cones, stemmed elements and varied ranges of constraint — all of which have been employed right here. Further implants, equivalent to hinged prostheses and proximal tibial replacements, might also be mandatory however weren’t required on this case. Since many hospitals don’t routinely inventory these elements, planning is essential.
When the tibial intramedullary canal is compromised by fracture fragments or sclerosis, using radiography and a ball-tipped guidewire can help in protected canal entry and correct alignment, decreasing the danger of cortical perforation. Subsequently, the operation needs to be carried out on a radiolucent desk, ought to this be wanted. Particular care needs to be taken when managing anterior fracture fragments involving the tibial tubercle, as in our case, to protect the integrity of the extensor mechanism.
In the US, it’s unusual for high-energy tibial plateau fractures, equivalent to this Schatzker VI, to be managed nonoperatively. Consequently, there’s restricted literature describing main complicated TKA for continual tibial plateau nonunions. Most comparable research contain instances of nonunion following failed ORIF or acute fractures.
Luigi Sabatini, MD, and colleagues just lately reported on 11 instances of main TKA for acute, non-reconstructable tibial plateau fractures in aged sufferers, permitting for instant weight-bearing and improved rehabilitation outcomes. At imply follow-up of 28 months, they’d two issues: one periprosthetic fracture and one periprosthetic femoral fracture. Nonetheless, these sufferers have been notably older and sure with poorer bone high quality than the affected person in our case.
Supply: Benjamin C. Schaffler, MD; Jack R. Zhong, MD; Nicole Rynecki, MD; and Vinay Ok. Aggarwal, MD
Equally, Chloe E.H. Scott, MD, FRCS, and colleagues described a sequence of main TKAs carried out for complicated, non-repairable tibial plateau fractures characterised by vital joint despair and metaphyseal bone loss, as seen in our case. They advocated for using revision elements and metaphyseal cones to attain fixation past the baseplate. Of their sequence, all 10 sufferers achieved radiographic union of the fracture fragments across the cone and osseointegration of the fragments onto the cone. There have been no main issues at imply follow-up of twenty-two.3 months.
In abstract, we current a case of complicated main TKA for continual nonunion following a Schatzker VI tibial plateau fracture, using a metaphyseal cone and long-stemmed tibial implant to attain hybrid fixation. The usage of revision-style implants and surgical ideas in main TKA for instances equivalent to this will efficiently restore limb alignment and joint line, alleviate ache, enhance perform and facilitate early postoperative weight-bearing.
Key factors:
- Complicated main TKA is an efficient surgical possibility for treating continual tibial plateau nonunions.
- Lengthy-stemmed implants can be utilized to attain diaphyseal fixation and bypass distal fracture extension into the tibial shaft.
- Cones or sleeves can be utilized to handle vital metaphyseal bone loss.
- Radiography and cannulation with a ball-tipped guidewire can help in figuring out the tibial intramedullary canal for reaming for the tibial stem in instances of proximal tibial deformity.
- Surgeons ought to have contingency plans and guarantee all implants and mega-prostheses can be found on standby, ought to the surgeon face intraoperative difficulties with revision implant fixation that precludes their use.
References:
For extra data:
Vinay Ok. Aggarwal, MD, might be reached at vinay.aggarwal@nyulangone.org.
Nicole Rynecki, MD, might be reached at nicole.rynecki@nyulangone.org.
Benjamin C. Schaffler, MD, might be reached at benjamin.schaffler@nyulangone.org.
Jack R. Zhong, MD, might be reached at jack.zhong@nyulangone.org.
Edited by Nicole Rynecki, MD, and Harold I. Salmons, MD. Rynecki is a chief resident in orthopedic surgical procedure at NYU Langone. She might be pursuing a sports activities drugs fellowship at Hospital for Particular Surgical procedure following residency completion. Salmons is a chief orthopedic surgical procedure resident on the Mayo Clinic. He might be pursuing an grownup reconstruction fellowship at Hospital for Particular Surgical procedure following residency completion. For extra data on submitting Orthopedics At present Grand Rounds instances, please e-mail orthopedics@healio.com.
Sources/Disclosures
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Skilled Submission
Disclosures:
Aggarwal studies being a paid advisor for Becton Dickinson, Hyperlink Bio, Smith & Nephew and Zimmer Biomet; and being a journal editor for Arthroplasty At present, Journal of Orthopedics and Associated Analysis and Bulletin for Hospital for Joint Illnesses. Rynecki studies being on the journal editorial board for Arthroscopy. Schaffler and Zhong report no related monetary disclosures.
