Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not? Sérgio Rocha Piedade a,b , Alban Pinaroli c , Elvire Servien c , Philippe Neyret c, ⁎ a Department of Orthopedics and Traumatology, School of Medical Sciences, State University of Campinas, UNICAMP b Post Doctorate Scholarship by CNPq — National Council for Scientific and Technological Development, Brazil c Centre Livet, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 8, rue de Margnolles, 69300 Caluire, France Received 18 March 2008; received in revised form 28 May 2008; accepted 9 June 2008 Abstract The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip–knee– ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30°, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group (p b 0.001, p = 0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups (p = 0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy (p = 0.001 and p ≤ 0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome. © 2008 Elsevier B.V. All rights reserved. Keywords: Tibial tubercle osteotomy; Total knee replacement; TKA 1. Introduction Good evidence exists in the literature to show that total knee arthroplasty (TKA) improves the adverse symptoms of knee arthritis [1,2]. Surgical technique and prosthetic design in TKA now offer total elimination of pain and an improved range of motion; all of which lead to maintaining independence and enhancing quality of life [3–7]. The survival of the knee prosthesis is determined by three major factors: re-establishing anatomical alignment, ligament balance and correct positioning of the implant [8,9]. Therefore the chosen surgical approach is of utmost importance. Adequate exposure is essential to balance ligaments and perform the accurate bony resections required to achieve the best post- operative outcome. The conventional surgical approach can cause difficulties when there are major deformities, such as valgus and varus knees and where there is limited range of motion, especially with restricted flexion associated with patella infera. In this situation, the knee extensor mechanism, in particular the patellar tendon, is subject to great tension forces during the surgical exposure [10]. When patella eversion is difficult, various techniques are described in the literature to enhance the surgical approach by allowing greater exposure and protecting the knee extensor Available online at www.sciencedirect.com The Knee 15 (2008) 439 – 446 ⁎ Corresponding author. Departement d'Orthopedie du Genou, Centre Livet Hôpital de la Croix Rousse, Hospices Civils de Lyon 8, rue de Margnolles, 69300 Caluire, France. Tel.: +33 4 72 07 19 89; fax: +33 4 72 07 24 04. E-mail address: martine.serrero@chu-lyon.fr (P. Neyret). 0968-0160/$ - see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2008.06.006