Spontaneous patella fracture associated with anterior tibial tubercle pseudarthrosis in a revised knee replacement following knee Arthrodesis
© Manzotti et al.; licensee BioMed Central Ltd. 2013
Received: 1 May 2013
Accepted: 2 October 2013
Published: 6 November 2013
Conversion of a knee arthrodesis to a Total Knee Arthroplasty is an uncommon procedure. Revision Total Knee Arthroplasty in this setting presents the surgeon with a number of challenges including the management of the extensor mechanism and patella.
We describe a unique case of a 69 years old Caucasian man who underwent a revision Total Knee Arthroplasty using a tibial tubercle osteotomy after a previous conversion of a knee arthrodesis without patella resurfacing. Unfortunately 9 months following surgery a tibial tubercle pseudarthrosis and spontaneous patella fracture occurred. Both were managed with open reduction and internal fixation. At 30 months follow-up the tibial tubercle osteotomy had completely consolidated while the patella fracture was still evident but with no signs of further displacement. The patient was completely satisfied with the outcome and had a painless range of knee flexion between 0-95°.
We believe that patients undergoing this type of surgery require careful counseling regarding the risk of complications both during and after surgery despite strong evidence supporting improved functional outcomes.
KeywordsKnee Arthrodesis Arthroplasty Revision Complication Patella
Knee arthrodesis is an uncommon salvage operation. The restrictions to everyday life that result from a fused knee can lead to considerable patient dissatisfaction. This has led to patients seeking conversion of the arthrodesis to a total knee arthroplasty (TKA) and several authors underline how this conversion can result in a better functional result than a fused knee [1, 2]. No clear guidelines for this procedure are available in literature. Holden et al.  recommended that a constrained implant should be used in conversion of a fused knee to a TKA to compensate for the lack of soft tissue stabilizers. Kim et al.  proposed that even in the most straightforward cases a posterior stabilized TKA should be used.
All Authors point to a significant rate of complications such as early loosening, soft tissue necrosis and infections following conversion of a knee arthrodesis to a TKA [1, 2, 4, 5]. Henkel et al.  reported that 86% of their patients who underwent conversion of a knee arthrodesis to TKA required re-operation with complications including skin necrosis, extensor mechanism contracture, insufficient collateral ligaments, and adhesion/arthrofibrosis. Clemens et al.  reported a significant incidence of infection following skin necrosis after this surgery and suggesting an intra-operative gastocnemius transfer and skin graft. Management of the knee extensor mechanism is difficult in these operations and is often complicated by patella baja and knee stiffness [6–9]. A tibial tubercle osteotomy is usually advocated but may result in additional complications including tibial tubercle pseudarthrosis. The risk of tibial tubercle pseudarthrosis has been shown to some extent to be dependent on surgical technique [6–9].
No authors to our knowledge have reported a spontaneous patella fracture following conversion of a knee arthrodesis to a TKA. In the literature, patella fracture following revision TKA has a reported incidence ranging from 0.2% to 21% [10–13]. Ninety percent of these fractures occurred when the patella had been resurfaced (88%) often without specific trauma or significant symptoms [14–18]. Seijas et al.  reported 2 cases of atraumatic non-resurfaced patella fracture following a primary TKA in 2009 highlighting that this was an extremely uncommon event. Factors associated with atraumatic patellar fractures include patellar subluxation, improper patellar resection, vascular compromise, component designs and thermal necrosis [13, 15]. Even restoration of postoperative flexion in a previous stiff knee has been proposed as a potential cause of fracture [13, 15].
Non-operative treatment is advocated for minimally displaced fractures. For displaced fractures open reduction and internal fixation with revision of the patella component, with or without augmentation and patellectomy have been recommended [11, 12, 15–18]. To the best of our knowledge no report regarding the treatment either of a tibial tubercle pseudarthrosis or of an atraumatic patella fracture after a revision TKA following knee arthrodesis has been published in the literature. The aim of this case report is to illustrate a unique complex case of a patient presenting with these 2 conditions simultaneously.
Our case report deals with a healthy male who experienced an anterior tibial pseudarthrosis and a spontaneous patella fracture 9 months after revision TKA in which no resurfacing of the patella was performed. He had 50 years earlier undergone a knee arthrodesis and this was converted to a primary TKA in 1997. Following conversion of the knee arthrodesis to a TKA he achieved 75° of knee flexion for only a short period. His clinical result then progressively deteriorated and at presentation he had painful knee flexion to 20° only. Revision TKA resulted in 0-95° of painless knee flexion at 36 months follow-up. A possible explanation for the poor outcome achieved following the primary TKA may be the use of a cruciate retaining implant which is not usually recommended in conversion of a knee arthrodesis to a TKA . Pseudarthrosis of the tibial tubercle occurred despite only partial detachment probably because of use of too small a bone block and/or unstable fixation. According to the literature the use of staples and reabsorbable sutures may be inadequate fixation of a tibial tubercle osteotomy [4, 5]. We considered this was one of the causes of the pseudarthrosis and this has resulted in a change to a more stable fixation with either 4.5 mm canulated screws or metallic cables in all subsequent cases.
Both the tibial tubercle pseudarthrosis and patella fracture were simultaneously managed with open reduction internal fixation despite being minimally displaced. Complete tibial tubercle consolidation was obtained and despite incomplete radiographic patella fracture healing, both excellent knee function and patient satisfaction was achieved. We are uncertain if a non-operative treatment would have achieved a similar result.
In conclusion, we believe that where a revision TKA is required after a previous conversion of a knee arthrodesis, the patient requires careful counseling regarding the high rate of complications both during and after the operation. Furthermore the surgeon should be prepared to face a large number of different potential complications. However, in our patient even a less than perfect result achieved at revision TKA was preferred to the previous stiff painful knee replacement.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this Journal.
Total knee arthroplasty.
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