Does a lateral tibial plateau fracture (Takeuchi type III) occuring during opening wedge high tibial osteotomy induce a higher revision rate to total knee arthroplasty.

BACKGROUND AND AIM: High tibial osteotomies (HTO) are effective procedures to treat younger patients affected by moderate but symptomatic arthritis. Open-wedge HTO (OW-HTO) is more often performed compared to a closing wedge osteotomy to treat varus arthritis of the knee due to a lower incidence of complications and better results: lateral hinge fracture (LHF) is the most common complication of OW-HTO. Intra articular fractures of the lateral tibial plateau (Takeuchi type III) appear as a particularly serious complication due to its extension to the subchondral bone of the compartment towards which the load is shifted. Aim of our study, is to assess if an intra articular fracture of the lateral tibial plateau occurring during an OW-HTO leads to an higher risk of failure and to an early conversion to a total knee arthroplasty. METHODS: Between January 2013 and December 2018 114 patients underwent OW-HTO at our Orthopaedic Department. All the patients underwent the same surgical procedure performed by a skilled knee surgeon: a subcutaneous-medial locked plate (Tomofix®, Synthes, Solothurn, Switzerland) has been used in all the procedures to stabilize the osteotomy. Clinical and radiographic follow up has been performed at one, three, six and twelve months postoperatively afterwards annually. We retrospectively reviewed all the intra operative fluoroscopy of patients to detect those affected by an intra articular fracture of the lateral tibial plateau occurred intra operatively. RESULTS: A LHF occurred in 11 out of 114 patients (9.65%) who underwent an OW-HTO; in particular nine patients (7.9%) had a Type III LHF. In all cases such complication has been detected intra operatively. In the subgroup of patients who experienced an intra articular fracture of the tibial plateau at the last follow up only one patients underwent to a revision with a total knee arthroplasty; in other words, the survivorship of an OW-HTO complicated by a LHF type III resulted 89% at a mean follow-up of 5 years. In 103 patients without an intraoperative fracture, the percentage of patients free from revision at the last follow up resulted of 92%. CONCLUSIONS: Takeuchi type III fracture is an uncommon but serious complication to manage: in our case series we found that an early recognition and a correct treatment of this occurrence don't lead to a premature conversion to a knee arthroplasty if compared with an uncomplicated osteotomy. Further studies are necessary to establish specific subjective outcomes after OW-HTO burdened by an intra articular fracture of the lateral plateau.

External fixation can be an option for proximal humerus fractures Neer 3-4.

BACKGROUND: Proximal humeral fractures (PHF) account for 4-6% of all fractures and 25% of humeral fractures. While conservative treatment is the gold standard for simple fractures, there is no consensus about the best treatment choice for complex PHF in the elderly. Recently a new external fixator was introduced in clinical practice for treatment of complex PHF.  Aim of the study was to evaluate the functional results of this therapeutic approach. METHODS: Data were retrospectively analyzed. Inclusion criteria were: three- and four- parts PHF according to Neer, treatment with closed reduction and external fixation, normal Abbreviated Mini Mental Test score, independence in the daily living, non-pathological fracture, glenohumeral joint with moderate osteoarthritic changes and availability of clinical and radiological follow-up. For each patient demographic data, comorbidities, surgery time and estimated blood loss were recorded. Clinical and radiological evaluation were performed at 1, 2, 6, 12 months. RESULTS: 17 patients were enrolled. Mean age was 69.7 years. Fractures were classified according to Neer as type III in 10 cases and type IV in 7 cases. The mean operating time was 22 minutes. Mean Constant score value at follow up was 74 ±11,52 at 2 months, 82 ± 11,16 at 6 months and 85 ± 9,86 at 12 months. CONCLUSION: These preliminary results show that the studied system is easy to use, minimally invasive, effective in reducing surgical and hospitalization time. The results in terms of functional recovery are encouraging, showing a reduced number of complications.

Rotational alignment of the tibial component in total knee arthroplasty: the anterior tibial cortex is a reliable landmark.

PURPOSE: to compare the anterior tibial surface curvature, the Akagi's line and the medial third of the tibial tubercle in order to assess which is the most reliable landmark for correct tibial component rotational positioning in total knee arthroplasty. METHODS: three independent investigators reviewed 124 knee MRI scans. The most suitable tibial baseplate tracing for the Nexgen Total Knee System (Zimmer, Warsaw, USA) was superimposed on the scan matching the anterior tibial cortex with the anterior aspect of the baseplate. The rotation of the tibial baseplate tracing was calculated with respect to the transepicondylar axis (TEA), the medial third of the tibial tubercle line, Akagi's line and the femoral posterior condylar axis (PCA). Customized software was created and used for analysis of the MRI datasets. The reliability of each measurement was then calculated by using the intraclass correlation coefficient for interobserver agreement. RESULTS: observer agreement on the position of the Akagi's line was within 3° in 64% of the cases and within 5° in 85% of the cases. Agreement on the position of the medial third of the tibial tubercle was within 3° in 29% of the cases and within 5° in 70% of the cases. Agreement on the localization of the anterior tibial surface curvature was within 3° in 89% of the cases and within 5° in 99% of the cases. Component alignment along the anterior cortex guaranteed full matching ± 3° with the epicondylar axis in 75% of the knees. CONCLUSIONS: the anterior tibial surface curvature was found to be a more reliable and more easily identifiable landmark for correct tibial component alignment than either Akagi's line or the medial third of the tibialtubercle. LEVEL OF EVIDENCE: level III, retrospective cohort study.

Patellofemoral function after total knee arthroplasty: gender-related differences.

The purpose of the study was to evaluate patellofemoral results in 2 comparable groups of 50 patients, men and women, undergoing total knee arthroplasty. The average follow-up was 6 years. The implant was posteriorly stabilized with a dome patellar arthroplasty. The patients were studied using Knee Society knee and functional scores and the Hospital for Special Surgery (HSS) patellar score. Radiologic study included standard and weight-bearing axial views and a computed tomographic scan to assess component rotation. The 2 groups achieved satisfactory and similar knee scores; women had a significantly lower functional and patellar scores. The incidence of lateral patellar tilt, subluxation, and lateral impingement was decreased in weight-bearing axial views compared with non-weight bearing. Medial bony impingement was evident only in weight-bearing views and correlated with pain (P < .05).

Total knee arthroplasty using a pie-crusting technique for valgus deformity.

UNLABELLED: Valgus deformity correction with total knee arthroplasty is challenging. We hypothesized selective release of the tight lateral structures (pie-crusting technique), and of the lateral retinaculum in case of patellar maltracking, would obtain and maintain correction of the frontal plane deformity, restore patellar tracking and function, and avoid the complications of the extensive releases, including lateral condyle avascularity and residual lateral instability. We followed 48 patients with 53 valgus knees who underwent TKA and were followed a minimum of 5 years (mean, 8 years; range, 5-12 years). Soft tissue balancing of the lateral structures was performed with the pie-crusting technique. We employed either a fixed posterior stabilized or a mobile implant. A lateral release was performed in 67% of the cases. We observed one postoperative complication, a transient postoperative peroneal nerve palsy that spontaneously completely recovered. In 51 of the 53 knees (96%) we achieved alignment within 5 degrees from neutral. One patient had varus instability in extension. No component was revised. The pie-crusting technique reliably corrects moderate to severe fixed valgus deformities with a low complication rate and reasonable mid-term results. The multiple punctures allow gradual stretching of the lateral soft tissues and preservation of the popliteus tendon reducing the risk of posterolateral instability. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Comparison of mobile-bearing and fixed-bearing total knee arthroplasty: a prospective randomized study.

The purpose of this prospective randomized study was to compare the postoperative recovery and early results of 2 groups of patients undergoing total knee arthroplasty: 107 patients received an established fixed-bearing posterior-stabilized prosthesis (Legacy Posterior Stabilized [LPS]), and 103 patients the meniscal-bearing prosthesis (Meniscal Bearing Knee [MBK]). Surgical procedures were the same for both groups except for posterior cruciate ligament management, which was sacrificed in the LPS group and spared but completely released from the tibia in the MBK group. At an average follow-up of 36 months, knee, function, and patellar scores were comparable in both groups. The LPS group showed a significantly higher maximum flexion than the MBK group (112 degrees vs 108 degrees). Using a fixed-bearing or a mobile-bearing design did not seem to influence the short-term recovery and early results after knee arthroplasty. Key words: total knee arthroplasty, mobile bearing, knee prosthesis, meniscal-bearing knee, posterior stabilized, prospective randomized.