Timing of tibial tubercle osteotomy in two-stage revision of infected total knee arthroplasty does not affect union and reinfection rate. A systematic review

Abstract

Background: Tibial tubercle osteotomy (TTO) in two-stage infected revision total knee arthroplasty (RTKA) could be applied at either first, second, or in both stages, and may remain preliminary fixed or unfixed until the second stage. The primary aim of the review was to identify any correlation between the timing of TTO and osteotomy union as well as reinfection rate.

Methods: Medline, Scopus, and CENTRAL were searched up to March 2020. All TTO cases were divided into three groups; Group A: TTO in both stages, left unfixed in first stage; Group B: TTO in both stages, preliminary fixed in first stage; Group C: TTO only in second stage.

Results: Eight studies with 199 patients were included. Apart from two cases in Group C, all the osteotomies achieved bone healing (p = 0.99). There were 29 (15%) reinfections (nine percent in Group A, 13% in Group B, and 16% in Group C, p = 0.67) and 16 (nine percent) knees with proximal avulsion/migration of the tibial tubercle (8.7% in Group A, 16.7% in Group B, and 0.8% in Group C, p = 0.02). Seventeen patients (11%) complained of anterior knee pain and 14 (nine percent) of them underwent hardware removal. However, no difference between groups was identified.

Conclusions: Preliminary fixation of the tibial tubercle with wires and/or screws at the first stage of RTKA does not increase the possibility of reinfection. Therefore, we propose that the tibial tubercle should be stable fixed from the first stage to maximize knee performance in the intermediate period.

Keywords: Complications; Exposure; Infection; Outcomes; Revision total knee arthroplasty; Surgical approach; Tibial tubercle osteotomy.