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 Table of Contents  
Year : 2023  |  Volume : 38  |  Issue : 1  |  Page : 100-105

Single-stage bilateral revision knee arthroplasty with unilateral tibial tubercle osteotomy: A rare case study in the management of bilateral aseptic loosening with literature review

Department of Orthopaedics, Max Super Specialty Hospital, Delhi, India

Date of Submission27-Nov-2022
Date of Acceptance06-Jan-2023
Date of Web Publication20-Apr-2023

Correspondence Address:
Gaurav Govil
D-101, Sunshine Helios, Sector 78, Noida, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_42_22

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A revision total knee arthroplasty (Rev-TKA) for bilateral affection presents surgical complexities. Rev-TKA as a single stage has been rarely advocated. A 76-year-old woman presented with painful bilateral knees and a history of bilateral TKA done fourteen years ago. The right knee required unilateral tibial tubercle osteotomy with cerclage wire fixation to remove the incarcerated cemented tibial extension rod and extensile medial parapatellar approach for the left knee in single-stage. The osteotomy united at 14 weeks. At 2-year follow-up, range of movements improved, allowing pain-free walking without support and laxity. No radiological evidence of loosening or wear. Rev-TKA challenges include obtaining adequate joint exposure without compromising the integrity of the extensor mechanism. The crucial factors for achieving an uneventful single-stage surgery include thorough pre-operative planning, prophylactic thromboprophylaxis, measures to reduce blood loss, and meticulous execution of planned surgery. The bilateral Rev-TKA should be planned after the stratification of the risk-benefit ratio.

Keywords: Aseptic loosening, extensile approach knee, primary knee arthroplasty, revision arthroplasty, simultaneous, single-stage, tibial tubercle osteotomy, total knee arthroplasty, total knee replacement

How to cite this article:
Tomar L, Govil G, Dhawan P. Single-stage bilateral revision knee arthroplasty with unilateral tibial tubercle osteotomy: A rare case study in the management of bilateral aseptic loosening with literature review. J Bone Joint Dis 2023;38:100-5

How to cite this URL:
Tomar L, Govil G, Dhawan P. Single-stage bilateral revision knee arthroplasty with unilateral tibial tubercle osteotomy: A rare case study in the management of bilateral aseptic loosening with literature review. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:100-5. Available from: http://www.jbjd.in/text.asp?2023/38/1/100/374429

  Introduction Top

Primary TKA may fail due to septic loosening, aseptic loosening, or instability of the implanted prosthesis.[1] Aseptic loosening requires a complex, technically demanding Rev-TKA. The varied surgical challenges in revision knee surgery include obtaining adequate exposure by using extensile approaches, bone defect management by sleeves & augments, preserving knee joint function by protecting the extensor mechanism, and providing stable fixation for early rehabilitation.[2],[3]

The reconstructive arthroplasty surgeon may need extensile exposures for revision surgery. The tibial tubercle osteotomy (TTO) has been indicated for adequate surgical exposure of knee joints in infected and stiff knees.[4] It has also been used for the removal of cemented tibial extension rods. The reconstruction of the knee joint in a revision surgery requiring the removal of a well-fixed cemented tibial extension rod is a time-consuming and technically demanding procedure. The meticulous technique for creating adequate osteotomy and ensuring stable fixation avoids failure.[3]

The complex surgical technique, high complication rates, management of blood loss and thromboprophylaxis, and patient safety considerations in a revision surgery pose significant management challenges.[2] Bilateral affections are managed by staged procedures commonly.[5],[6] The single-stage bilateral Rev-TKA has been rarely advocated.[6] The literature on simultaneous revision is sparse.

We report a case study on the management of bilateral aseptic loosening with a single-stage bilateral Rev-TKA requiring TTO to remove the extension rod on the right side and extensile medial parapatellar (EMP) approach on the left side. The report highlights the feasibility, pre-operative planning, functional outcomes, and associated challenges in single-stage bilateral Rev-TKA management.

  Case Report Top

A 76-year-old woman presented with disabling bilateral knee pain for more than six months with limited mobility and assisted walking for the last two months. She had a history of bilateral TKA for advanced knee osteoarthritis fourteen years ago elsewhere. A history of prolonged rehabilitation phase in the immediate postoperative period was noted. On presentation, she had an abnormal gait pattern, unable to walk without support, and was unable to do everyday activities of daily living without pain and support. There has been no relief with conservative measures, including painkillers, oral steroids, braces, and physiotherapy. She presents with persisting disabling pain with marked affection for her quality of life.

Her bilateral knees had varus angulation, unstable gait, laxity, and tenderness along the joint lines. There was no local site induration. The range of movements was painful and restricted with flexion from 10 to 60 degrees on the right knee and 5 to 70 degrees on the left knee. However, the neurological status of the lower limbs was well maintained. The radiograph of both the knees revealed varus angulation of the knee prosthesis, loosening of the implant, and bone osteolysis along with the prosthesis [Figure 1] and [Figure 2]. Osteoporosis presented additionally on the knee and pelvis radiograph. A lower limb scannogram revealed mal-alignment of both the knee joints. The acute phase reactants were within normal levels. The biochemical tests and viral markers were normal. The routine and microscopic urine examinations were normal. A screening Covid-19 antigen test was negative. She was planned for bilateral Rev-TKA for the management of bilateral aseptic loosening. Anesthetist workup was graded as American Society of Anaesthesiology grade 3.
Figure 1: Preoperative radiograph of bilateral knees in standing posture (anteroposterior view) shows bilateral knee varus angulation, extension rod in right knee (A) marked with thin white arrow, and marked area of lucency along implanted joint in left knee (B) marked with thick white arrow

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Figure 2: Preoperative radiograph of bilateral knees (lateral view) shows loosening of bilateral knee implant

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Combined spinal-epidural anesthesia, and prophylactic thromboprophylaxis, both mechanical and chemical, were used. A single-stage bilateral Rev-TKA was performed. The right knee was operated on first. A midline incision with extension of arthrotomy knee by medial parapatellar extension. Additionally, the right knee exposure required TTO with cerclage wire fixation to manage the removal of an incarcerated cemented tibial extension rod [Figure 3]. The pre-planned TTO of around 10 cm was created, an osteo-periosteal lateral-based flap was raised, and the temporary placement of cerclage wires for fixation was later aligned with further careful dissection along with the cemented prosthesis, followed to remove the extension rod. No iatrogenic fracture was noted. Patellar tracking and stability of osteotomy allowed knee flexion of about 100 degrees per-operatively. Left knee procedure followed after the closure of the right knee with EMP approach to manage the knee flexion. Metaphyseal and diaphyseal sleeves with extension rods from Depuy Synthes were used to reconstruct the bilateral knees. The total duration of surgery was 90 minutes for the right and 70 minutes for the left knee. Local tranexamic acid was used on both knees. Post-operatively one-unit blood transfusion was done, which was adequate to maintain the hemodynamic status.
Figure 3: Peroperative image with tibial tubercle osteotomy (A), cerclage wires along the osteotomy (B), and peroperative image after tibial implantation and closure of osteotomy (C) with cerclage wiring

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Meticulous pre-operative planning with an awareness of technical challenges allowed for an uneventful surgery. The implanted total knee was in good alignment on the postoperative radiograph [Figure 4] and [Figure 5]. Postoperative walker support walking was allowed from the second postoperative day. The functional knee brace was used for four weeks during ambulation. Follow-up visits were followed at 3, 6, and 12 weeks of surgery. The TTO showed union at 14 weeks follow-up. Her functional range of movements at three months follow-ups was from 0 to 110 degrees in both the knees, and there was no extensor lag. She progressed to pain-free independent ambulation with stable knees within the next three months. She had pain-less independent mobility at the last follow-up at two year with an excellent functional outcome.
Figure 4: Postoperative radiograph of right knee with tibial tubercle osteotomy fixation in anteroposterior (A) and lateral (B) view

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Figure 5: Postoperative radiograph of left knee in anteroposterior (A) and lateral (B) view

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  Discussion Top

Single-stage surgery for bilateral Rev-TKA is rarely performed and has been seldom reported. The advantages of the single-stage procedure include single hospital stay, single anesthesia, better rehabilitation, and reduced cost of operation and hospital stay.[2],[6] The sparse literature available for studies and case reports on single-stage bilateral Rev-TKA after 2004 are listed in [Table 1]. The retrospective study, which evaluated sequential bilateral Rev-TKA in 49 patients, reports that the authors did not require extensile approaches, either QS or TTO, for the exposure during the procedure.[2] Insall’s midline approach with medial parapatellar arthrotomy was used for exposure in the other studies.[5],[6] To the best of our knowledge, we report the case study for the first time in literature, with single-stage bilateral Rev-TKA. We required using bilateral extensile approaches with TTO on the right side to remove the tibial extension rod and EMP approach on the left side to manage the flexion deformity. The study highlights the feasibility and challenges for arthroplasty surgeons to operate bilateral aseptic loosening of primary TKA.
Table 1: Studies on single stage bilateral Rev-TKA

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Primary TKA has been the standard technique to manage end-stage degenerative knee arthritis with successful functional outcomes.[7] The incidence of primary TKA has increased with an increasing need for Rev-TKA to manage the TKA failures.[8],[9] Rev-TKA may be required for the septic or aseptic loosening, instability, and mal-positioning of the prosthesis. In Rev-TKA, an extensile approach may be necessary to manage extensive fibrosis and limited patellar mobility and to facilitate the removal of implanted joints once the standard knee arthroplasty approaches give inadequate exposure.[1],[10],[11] The various extensile approaches available include the EMP approach, Insall’s quadriceps snip approach (QS), quadriceps turndown technique, V-Y quadriceps-plasty, and TTO.[3],[8],[10],[12],[13] The literature lacks clear indications for different approaches. The case-based decision has been widely advocated based on the surgeon’s experience and expertise in using these extensile approaches for Rev-TKA.[8]

The objective was to identify the studies detailing the evaluation, assessment, and decision-making for managing the bilateral single-stage Rev-TKA and studies describing the use of TTO in Rev-TKA. We reviewed the literature containing the terms “TTO,” “EMP,” “TKA,” “Primary TKA,” and “Revision TKA” from the search engines “Pub-Med” and “Google Scholar” for the articles published from 2004 onwards to April 2022. All studies identified by these searches were then reviewed. We excluded articles that focused on approaches other than TTO in Rev-TKA. Studies in languages other than English and those with animal or pediatric subjects were also excluded. The literature review for the studies describing the use of TTO for Rev-TKA have been tabulated in [Table 2]. The table elaborates on the average age of affection, sex preference, complications, and conclusions from the studies to present an overview of Rev-TKA. The review highlights the existing dilemma for clinicians’ decision-making.
Table 2: Studies on TTO for Rev-TKA

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The common indication for TTO include infected and stiff knees with a restricted pre-operative range of movements with 30 degrees of flexion as the critical range with 30-60 degrees as the preferred range, and beyond 60 degrees use of the EMP approach first has been advocated.[3],[8],[13] Other indications include removal of stem extensions, intraoperative conversion of inadequate exposure with EMP approach, risk of patellar tendon rupture with forced patellar eversion, and concomitant patella baja correction.[10],[12],[13] TTO has the advantages of providing broad direct exposure to the tibial canal, bone-to-bone union, and preserved quadriceps tendon without compromising the patellar blood supply.[9],[12],[13] However, TTO has inherent chances for complications such as non-union of osteotomy, anterior knee pain due to prominent hardware, and proximal migration of the inadequately stabilized implanted joint due to faulty techniques.[1],[8],[10],[12],[13],[14] The method for closure of TTO with either an ethibond suture, screws, or cerclage wiring has been reported with variable success rates.[1],[9],[11],[12],[13],[14],[15],[16] Risk factors associated with poor outcomes include osteoporosis, poor status of medical comorbidities impeding healing potential, and thin anterior tibial cortex as seen on lateral radiograph.[13] Post-operatively, TTO has shown improved functional outcomes and increased knee movements, with no additional changes in the rehabilitation program as are typically followed with a primary TKA.[3],[8],[10]

Rev-TKA poses additional significant challenges for managing metaphyseal and diaphyseal bone defects, osteoporosis, thin cortices, and pre-existing knee stiffness.[4],[8] The surgical considerations with TTO for Rev-TKA requiring the removal of an extension tibial rod include evaluating the pre-operative length of the rod, osteoporosis, predicting the use of tibial tubercle osteotomy, choosing appropriate specialized implants, and achieving adequate osteotomy fixation and knee stability.[4],[10] The removal of an extension rod may be liable for long operative periods, complicated extractions, susceptibility to iatrogenic fractures, and subsequent infections to warrant careful evaluation for the feasibility of single staged bilateral Rev-TKA. The pre-operative planning should identify the need for instrumentation for cement removal, metal cutting, and creating appropriate femoral or tibial osteotomy.[4] The factors in Rev-TKA which show improvement post-operatively include the pre-operative knee function and pain scores.[17]

Pre-operative planning, optimization of medical conditions, prophylactic thromboprophylaxis, measures to reduce blood loss, and meticulous execution of planned surgery are essential factors for an uneventful single-stage surgery.[5]

  Conclusion Top

Using extensile approaches with a well-timed, well-executed TTO/ EMP in Rev-TKA with early rehabilitation protocol will improve the overall function of the knee and the quality of life.

The risk-benefit ratio should be interpreted wisely for the needs and concerns of an individual plan for a single-staged Rev-TKA in a well-versed arthroplasty unit for good functional outcomes.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Consent for publication

The patient was informed that data from the case would be submitted for publication and patient gave the consent.

  References Top

Qazi AR, Iqbal F, Noor SS, Ahmed N, Uddin AA, Memon N, et al. Impact of tibial tubercle osteotomy on final outcome in revision total knee arthroplasty: Our experience and technique in Pakistan. Clin Orthop Surg 2021;13:53-9.  Back to cited text no. 1
Lonner JH, Jasko JG, Bezwada HP, Booth RE Jr. Morbidity of sequential bilateral revision TKA performed under a single anesthetic. Clin Orthop Relat Res 2007;464:151-6.  Back to cited text no. 2
Bruni D, Iacono F, Sharma B, Zaffagnini S, Marcacci M Tibial tubercle osteotomy or quadriceps snip in two-stage revision for prosthetic knee infection? A randomized prospective study. Clin Orthop Relat Res 2013;471:1305-18.  Back to cited text no. 3
Pasquier GJM, Huten D, Common H, Migaud H, Putman S Extraction of total knee arthroplasty intramedullary stem extensions. Orthop Traumatol Surg Res 2020;106:S135-S147.  Back to cited text no. 4
Dülgeroğlu T, Kozlu S, Demirkıran N Single-staged bilateral revision knee prosthesis results. Cureus 2019;11:e4699.  Back to cited text no. 5
Vaishya R, Agarwal AK, Jaiswal C, Vijay V, Vaish A Bilateral simultaneous revision total knee arthroplasty as a single staged procedure: A case report and review of literature. Cureus 2017;9:e1112.  Back to cited text no. 6
Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: A systematic review of retrospective studies. J Arthroplasty 2013;28:1141-7.  Back to cited text no. 7
Sun Z, Patil A, Song EK, Kim HT, Seon JK Comparison of quadriceps snip and tibial tubercle osteotomy in revision for infected total knee arthroplasty. Int Orthop 2015;39:879-85.  Back to cited text no. 8
van den Broek CM, van Hellemondt GG, Jacobs WC, Wymenga AB Step-cut tibial tubercle osteotomy for access in revision total knee replacement. Knee 2006;13:430-4.  Back to cited text no. 9
DeHaan A, Shukla S, Anderson M, Ries M Tibial tubercle osteotomy to aid exposure for revision total knee arthroplasty. JBJS Essent Surg Tech. 2016;6:e32.  Back to cited text no. 10
Punwar SA, Fick DP, Khan RJK Tibial tubercle osteotomy in revision knee arthroplasty. J Arthroplasty 2017;32:903-7.  Back to cited text no. 11
Biggi S, Divano S, Tedino R, Capuzzo A, Tornago S, Camera A Tibial tubercle osteotomy in total knee arthroplasty: Midterm results experience of a monocentric study. Joints 2018;6: 95-9.  Back to cited text no. 12
Chun KC, Kweon SH, Nam DJ, Kang HT, Chun CH Tibial tubercle osteotomy vs the extensile medial parapatellar approach in revision total knee arthroplasty: Is tibial tubercle osteotomy a harmful approach? J Arthroplasty 2019;34:2999-3003.  Back to cited text no. 13
Mendes MW, Caldwell P, Jiranek WA The results of tibial tubercle osteotomy for revision total knee arthroplasty. J Arthroplasty 2004;19:167-74.  Back to cited text no. 14
Le Moulec YP, Bauer T, Klouche S, Hardy P Tibial tubercle osteotomy hinged on the tibialis anterior muscle and fixed by circumferential cable cerclage in revision total knee arthroplasty. Orthop Traumatol Surg Res 2014;100:539-44.  Back to cited text no. 15
Deane CR, Ferran NA, Ghandour A, Morgan-Jones RL Tibial tubercle osteotomy for access during revision knee arthroplasty: Ethibond suture repair technique. BMC Musculoskelet Disord 2008;9:98.  Back to cited text no. 16
Kasmire KE, Rasouli MR, Mortazavi SM, Sharkey PF, Parvizi J Predictors of functional outcome after revision total knee arthroplasty following aseptic failure. Knee 2014;21:264-7.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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