Total Knee Arthroplasty After Open Reduction and

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BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Total Knee Arthroplasty After Open Reduction and Internal Fixation of Fractures of the Tibial Plateau A MINIMUM FIVE-YEAR FOLLOW-UP STUDY BY KHALED J. SALEH, MD, MSC, FRCS(C), PAMELA SHERMAN, MD, PAM KATKIN, PA, RUSSELL WINDSOR, MD, STEPHEN HAAS, MD, RICHARD LASKIN, MD, AND THOMAS SCULCO, MD Investigation performed at the Hospital for Special Surgery, Cornell Medical Center, New York, NY, and the University of Minnesota, Minneapolis, Minnesota

Background: There is little information in the literature regarding the outcome of total knee arthroplasty following open reduction and internal fixation of fractures of the tibial plateau. The goal of this study was to evaluate the results of such procedures after a minimum of five years of follow-up. Methods: We retrospectively analyzed the outcomes of fifteen total knee arthroplasties performed at an average of 38.6 months (range, eight months to eleven years) after open reduction and internal fixation of a fracture of the tibial plateau in fifteen consecutive patients. The average duration of follow-up after the total knee arthroplasty procedures was 6.2 years (range, 5.4 to 11.1 years). The average age of the patients was fifty-six years (range, thirty-seven to sixty-eight years) at the time of the arthroplasty. We evaluated the outcomes on the basis of the Hospital for Special Surgery knee score, the Short Form-36 score, and radiographs of the knees. Results: The average Hospital for Special Surgery knee score was 51 points (range, 20 to 74 points) before the arthroplasty, and it increased to 80 points (range, 44 to 91 points) postoperatively. Four knees were scored as excellent, eight had a good result, one was rated as fair, and two had a poor result. The average Short Form-36 scores were 58.0 points for general health, 72.4 points for bodily pain, 72.1 points for mental health, 58.3 points for physical functioning, 84.6 points for physical role functioning, 81.0 points for social functioning, and 57.7 points for vitality. The average active postoperative arc of motion was 105° (range, 70° to 135°) compared with 87° (range, 20° to 125°) preoperatively. Incomplete radiolucencies were noted on all of the postoperative radiographs made after the total knee arthroplasties. There was a high rate of infection (three patients), patellar tendon disruption (two patients), and postoperative secondary procedures (three patients required closed manipulation). The patients with infection were considered to have a failure of treatment: two required arthrodesis, and one required a two-stage exchange. Conclusion: On the basis of our results, we concluded that total knee arthroplasty after open reduction and internal fixation of a fracture of the tibial plateau decreases pain and improves knee function, but the procedure is technically demanding and is associated with a high failure rate (five of fifteen).

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osttraumatic or secondary osteoarthritis may develop after a fracture of the tibial plateau as a result of (1) the alteration of the osseous anatomy leading to altered knee mechanics and loss of cartilage and bone, (2) cartilage damage as part of the initial injury, or (3) the presence of subchondral implants that may perforate the articular cartilage. Posttraumatic osteoarthritis combined with a compromised A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

soft-tissue envelope can predispose the patient to a less satisfactory functional outcome after any type of surgical intervention. Surgical options for prevention of posttraumatic arthritis range from arthroscopic débridement to arthrodesis. One option for the treatment of end-stage posttraumatic arthritis is total knee arthroplasty. There is little information in the literature regarding the outcome of total knee arthroplasty for posttraumatic arthritis after open reduction and internal fixation of fractures of the tibial plateau1-3. The goal of this study was to evaluate the results, after a minimum of five years of follow-up, of total knee

 THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG VO L U M E 83-A · N U M B E R 8 · A U G U S T 2001

arthroplasty in patients who had had previous open reduction and internal fixation of a fracture of the tibial plateau. Materials and Methods e identified fifteen consecutive patients who had undergone open reduction and internal fixation of a fracture of the tibial plateau and who eventually underwent a total knee replacement between 1986 and 1994, with a minimum five-year follow-up since the latter procedure. The institutional review board approved the study protocol, and all fifteen patients gave their informed consent. The average age of the four men and eleven women was fifty-six years (range, thirty-seven to sixty-eight years) at the time of the arthroplasty. The total knee replacements (eleven left and four right) were performed at an average of 38.6 months (range, eight months to eleven years) after the open reduction and internal fixation. Fixation of the fracture was accomplished with a medial plate only in four patients, with a lateral plate only in seven, with both a medial and a lateral plate in three, and with screw fixation only in one. Between the time of the open reduction and internal fixation of the fracture and the time of the total knee arthroplasty, six patients had undergone nine procedures, including removal of implants (two), high tibial osteotomy (one), arthroscopy (two), and scar revision (one). All patients had pain as the primary symptom that led to the decision to undergo arthroplasty. Two fractures were not completely healed at the time of the total knee replacement. Before the arthroplasty, eleven of the fifteen patients had a flexion contracture, which ranged from 5° to 30° (average, 11°). Five of the fifteen patients demonstrated medial and/or lateral instability in the affected knee compared with the contralateral knee. Before the arthroplasty, the tibiofemoral alignment was measured on standing anteroposterior radiographs (14 × 17 in [35.6 × 43.2 cm]). Eleven of the fifteen patients had a valgus deformity ranging from 10° to 25°, one patient had a neutral alignment of 6°, and three patients had a varus alignment ranging from 4° to –8°.

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Surgical Considerations All of the knees were aspirated preoperatively, and all cultures of the aspirate were negative. Two patients had only a skin incision done preoperatively in preparation for the total knee arthroplasty to confirm the vascular integrity of the surgical flap. One incision healed uneventfully, and the other healed slowly and required a myocutaneous flap procedure, which was done simultaneously with the total knee arthroplasty. That patient had had an infection after the open reduction and internal fixation, which was treated with chronic antibiotic suppression (Augmentin [amoxicillin and clavulanate potassium]) for 107 months. Preoperative cultures performed after discontinuation of the antibiotics were negative, as were intraoperative gram stains and cultures. A midline incision with a medial arthrotomy, incorporating a portion of the previous scar whenever possible, was performed in all patients. Eight patients who had had lat-

TO T A L K N E E A R T H RO P L A S T Y A F T E R O P E N R E D U C T I O N A N D I N T E R N A L F I X A T I O N O F F R A C T U RE S O F T H E T I B I A L P L A T E A U

eral incisions from the previous operations required medial adjustment of the new midline incision to increase the skinbridge distance. Some incisions had a transverse component (a hockey-stick-shaped incision), making incorporation difficult. Lateral retinacular release of the patella was performed in five patients, and a limited quadriceps release (rectus snip) was performed in one patient. The internal fixation implant had been removed prior to the arthroplasty in two patients and was removed at the time of the arthroplasty in thirteen. Five of the fifteen patients had an uncontained bone defect of the lateral tibial plateau requiring autogenous bonegrafting. Metal wedges were used in two of the fifteen patients, and one of these patients required additional morselized bone graft. Two of the fifteen patients had ununited fracture fragments that required open reduction and internal fixation with screws. If there was ligamentous instability, a constrained condylar knee prosthesis was used. If osseous deficiency was such that metal augmentation was necessary, a stemmed component was used. A constrained condylar knee prosthesis was used in eight patients, one of whom received a Total Condylar III implant (Johnson and Johnson, New Brunswick, New Jersey) and seven of whom received a Constrained Condylar Knee replacement (Zimmer, Warsaw, Indiana). Three patients were treated with a posterior stabilized knee prosthesis (Insall-Burstein II; Zimmer), and two received a posterior-cruciate-sparing knee replacement (Genesis I; Richards Medical, Memphis, Tennessee). Two custom-designed constrained condylar knee prostheses (Hospital for Special Surgery, New York, NY) were necessary: to correct malunion in one patient and to treat substantial bone loss in the other. Clinical results were assessed on the basis of Hospital for Special Surgery knee scores obtained before the arthroplasty and at an average of 6.2 years (range, 4 to 11.1 years) after it as well as with use of Short Form-36 (SF-36) scores obtained by telephone at an average of 7.7 years (range, 5.4 to 13.2 years) after the arthroplasty4,5. Standing anteroposterior and lateral radiographs on 14 × 17-in (35.6 × 43.2-cm) film were assessed with use of the Knee Society radiographic criteria6 at an average of 4.7 years (range, three to nine years) after the arthroplasty. Results our of the fifteen patients had poor wound-healing and prolonged drainage for more than seven days and were treated with oral antibiotics and daily sterile dressings until the wound closed completely. Of these four patients, three had a fulminant infection. Two of them, who had diabetes, required removal of the prosthesis; an Escherichia coli infection had developed in one, and a Streptococcus faecalis infection had developed in the other. Knee arthrodesis was performed in both patients. The third patient was successfully treated with a two-stage exchange arthroplasty after an appropriate course of intravenous antibiotics. That patient had received chronic suppression of infection with oral antibiotics preoper-

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 THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG VO L U M E 83-A · N U M B E R 8 · A U G U S T 2001

Fig. 1-A


Fig. 1-B

Fig. 1-A Anteroposterior radiograph of the knee of a sixty-seven-year-old woman who had sustained a fracture of the left tibial plateau fifteen months before presentation. The fracture extended into the metaphyseal-diaphyseal junction and did not unite after open reduction and internal fixation. Fig. 1-B Lateral radiograph made before the arthroplasty, demonstrating the nonunion.

atively and had had a pre-arthroplasty skin incision that did not heal, thus necessitating a myocutaneous flap procedure simultaneously with the arthroplasty procedure. Postoperatively, a pseudomonas infection developed in this patient. The outcomes of these three patients were considered failures. Another patient required an exchange of the polyethylene thirteen years after the knee replacement (Figs. 1-A through 1-E). Two of the fifteen patients had a patellar tendon rupture within the first month after the arthroplasty. One rupture occurred intraoperatively while the surgeon was attempting to obtain exposure, and the other occurred thirty days postoperatively as a result of a fall. One of these patients required reconstruction with an extensor mechanism allograft7 and the other, with a semitendinosus autograft8. The average degree of flexion contracture improved from 15° (range, 5° to 30°) before the arthroplasty to 4° (range, 0° to 10°) after the arthroplasty. The average active postoperative arc of motion (excluding the knees that had an arthrode-

sis) was 105° (range, 70° to 135°) compared with 87° (range, 20° to 125°) preoperatively, an average increase of 18°. Lucencies were noted on the radiographs of all of the knees; however, they were incomplete and primarily located between the tibial base-plate and the plateau. Three of the fifteen patients required manipulation under anesthesia because of stiffness, and one of them required a second manipulation. As a result, all three patients had flexion of >90° (range, 95° to 120°) and nearly full extension (one had a 5° flexion contracture). One patient had persistent medial and lateral instability on examination but had no complaints. The average Hospital for Special Surgery knee score was 51 points (range, 20 to 74 points) before the arthroplasty and 80 points (range, 44 to 91 points) at the time of follow-up. Four of the fifteen patients had an excellent result; eight, a good result; one, a fair result; and two, a poor result. The average postoperative SF-36 scores (with higher scores indicating better function) were 58.0 ± 10.0 points for general health,

 THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG VO L U M E 83-A · N U M B E R 8 · A U G U S T 2001

Fig. 1-C

Fig. 1-D


Fig. 1-E

Figs. 1-C and 1-D Lateral (Fig. 1-C) and anteroposterior (Fig. 1-D) radiographs made two years after arthroplasty with use of a custom-made total knee implant. Fig. 1-E Radiograph made after a polyethylene exchange and screw removal performed thirteen years after the knee replacement.

72.4 ± 20.4 points for bodily pain, 72.1 ± 25.0 points for mental health, 58.3 ± 32.1 points for physical functioning, 84.6 ± 37.6 points for physical role functioning, 81.0 ± 23.5 points for social functioning, and 57.7 ± 26.0 points for vitality4,5,9,10. Discussion here are few reports in the literature regarding the outcome of total knee arthroplasty for posttraumatic arthritis after open reduction and internal fixation of fractures of the tibial plateau. Marmor1 reported satisfactory two-year results in fourteen of eighteen patients in whom posttraumatic knee arthritis had been treated with a modular unicondylar knee replacement. Of his eighteen patients, however, only nine had had open reduction and internal fixation. Other authors have reported worse outcome scores after total knee arthroplasties that followed a previous high tibial osteotomy11-14. For example, Katz et al.11 reported a matched cohort study comparing twenty-one patients who had undergone total knee arthroplasty after a failed high tibial osteotomy with twenty-one patients who had undergone the same procedure for primary osteoarthritis. Seventeen (81%) of the patients who had had a

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previous osteotomy had a good-to-excellent result compared with 100% of the patients with primary osteoarthritis. The infection rate (three of fifteen) in our study group was higher than that observed in other studies in which similar implants (total condylar and constrained condylar knee prostheses) were used15. We suspect that the higher infection rate is the result of the combination of soft-tissue compromise secondary to the initial trauma, implants, and subsequent operative procedures. The skin arterioles of the anterior aspect of the knee arise from a random array of terminal branches derived from the patellar arterial ring, which may have been violated by the index operation. Minimizing injury to the subfascial dermal plexus by minimizing flap elevation, avoiding excessive retraction, and using blunt dissection techniques decrease the risk of skin necrosis. The prior skin incision should be used whenever possible and may be extended for improved visualization if needed. When a patient has had multiple prior longitudinal skin incisions, the most lateral incision is usually preferred because the fascial perforators arise from the medial aspect of the knee8. Prior transverse incisions can be crossed at 90°.

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We recommend that preoperative aspiration as well as gram-staining and frozen-section analysis of intraoperative specimens for infection be performed for all patients. Joint aspiration should be done to rule out infection even if the surgeon believes that none exists. Cultures of specimens obtained with aspiration are not always positive when an infection exists because there are facultative anaerobes and gram-negative bacteria that grow only with difficulty on culture medium and in thioglycolate broth. Nevertheless, in many cases of infection the aspirated specimen will yield a positive result. Barrack et al.16 reported preoperative aspiration to have 75% sensitivity, 96% specificity, 90% accuracy, 84% positive predictive value, and 84% negative predictive value in sixty-nine knees, of which twenty were determined to be infected. To minimize the risk of infection, we recommend the use of antibioticimpregnated cement for implants in these patients. In our study, there were two cases of extensor mechanism disruption requiring reconstruction and secondary procedures. The rate of tendon rupture has been reported in the literature to range from 1.4% (four of 281) to 3.2% (one of thirty-one)17. Distal ligament avulsion occurs most frequently intraoperatively while the surgeon is struggling to obtain adequate exposure. Postoperatively, tendon ruptures may occur in patients who have diabetes or who are taking oral steroids, after lateral retinacular release (as a result of tendon devascularization), or after a traumatic event (hyperflexion). Other factors implicated in patellar tendon disruption include patella baja, marked varus deformity, and a previous tibial tubercle osteotomy. Primary repair and augmentation with autogenous tissue graft (semitendinosus, gracilis, or fascia lata), extensor mechanism allograft, bovine xenograft, or Dacron graft all have yielded unsatisfactory results. The best solution to this problem is prevention.


We acknowledge that the sample size of our study was small, which limits the number of potential conclusions that can be derived. However, on the basis of our results, we concluded that total knee arthroplasty decreases pain and improves knee function among patients who have sustained a fracture of the tibial plateau. The complication rate was higher and the outcome was poorer in this group than in patients who have had total knee arthroplasty without a prior fracture of the tibial plateau. For example, Insall et al.18 reported goodto-excellent results in 93% (129) of 139 patients treated with a total condylar knee prosthesis because of osteoarthritis of the knee. Our conclusion is supported by the low average SF-36 scores for physical functioning (58.3 points) and vitality (57.7 points) of our patients.

Khaled J. Saleh, MD, MSc, FRCS(C) Department of Orthopaedic Surgery and Clinical Outcome Research Center, University of Minnesota, 420 Delaware Street S.E., Box 492, Minneapolis, MN 55455. E-mail address: [email protected] Pamela Sherman, MD Pam Katkin, PA Russell Windsor, MD Stephen Haas, MD Richard Laskin, MD Thomas Sculco, MD Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. K.J. Saleh is supported by a career grant from the Orthopaedic Research and Education Foundation.

References 1. Marmor L. The Marmor modular knee in traumatic arthritis. Orthop Rev. 1979;8:35-44.

tion after knee replacement surgery. Med Care. 1995;33(4 Suppl):AS131-44.

2. Roffi RP, Merritt PO. Total knee replacement after fractures about the knee. Orthop Rev. 1990;19:614-20.

10. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Coxford R, Katz B, Bombardier C, Heck D, Freund D. Health-related quality of life after knee replacement. J Bone Joint Surg Am. 1998;80:163-73.

3. Wilkes RA, Thomas WG, Ruddle A. Fracture and nonunion of the proximal tibia below an osteoarthritic knee: treatment by long stemmed total knee replacement. J Trauma. 1994;36:356-07.

11. Katz MM, Hungerford DS, Krackow KA, Lennox DW. Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J Bone Joint Surg Am. 1987;69:225-33.

4. Ware JE Jr, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83.

12. Takai S, Yoshino N, Hirasawa Y. Revision total knee arthroplasty after failed high tibial osteotomy. Bull Hosp Jt Dis. 1997;56:245-50.

5. Ware J, Snow K, Kosinski M, et al. In: Ware J, editor. Reliability, precision, and data quality in SF-36 Health Survey, manual and interpretation guide. Boston: Nimrod Pr; 1993. p (2): 7:1-7:16. 6. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop. 1989;248:9-12. 7. Emerson RH, Head WC, Malinin TI. Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop. 1990;260:154-61. 8. Cadambi A, Engh G. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am. 1992;74:974-9. 9. Bombardier C, Melfi CA, Paul J, Green R, Hawker G, Wright W, Coyte P. Comparison of a generic and a disease-specific measure of pain and physical func-

13. Toksvig-Larsen S, Magyar G, Onsten I, Ryd L, Lindstrand A. Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy: a matched radiostereometric study. J Bone Joint Surg Br. 1998;80:295-7. 14. Windsor RE, Insall JN, Vince KG. Technical considerations of total knee arthroplasty after proximal tibial osteotomy. J Bone Joint Surg Am. 1988;70:547-55. 15. Engh GA, Ammeen DJ. Classification and preoperative radiographic evaluation: knee. Orthop Clin North Am. 1998;29:205-17. 16. Barrack RL, Jennings RW, Wolfe MW, Bertot AJ. The value of preoperative aspiration before total knee revision. Clin Orthop. 1997;345:8-16. 17. Laskin R. Management of the patella during revision total knee replacement arthroplasty. Orthop Clin North Am. 1998;29:355-60. 18. Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis. A report of two hundred and twenty cases. J Bone Joint Surg Am. 1979;61:173-80.