Tibial tubercle osteotomy in revision total knee arthroplasty: A systematic review

Table 1 Summary of studies characteristics

Ref.	n	TTOs	Mean age (yr)	Males/ Females	Mean follow-up (mo)	Outcome measures
Barrack et al[17], 1998	15	15	NR	NR	30 (24-48)	ROM, KSS, Subjective satisfaction and function questionnaires
Bruni et al[19], 2013	39	39	72 ± 6	11/28	144 ± 24	ROM, VAS, KSS, Complications
Chalidis et al[2], 2009	74	87	60 (29-89)	35/39	49 (6-108)	ROM, Complications
Choi et al[10], 2012 (1)	36	51	67 (38-87)	20/16	57 (7-126)	ROM, KSS, Complications
Choi et al[11], 2012 (2)	13	26	60 (38-85)	9/4	56 (15-126)	ROM, KSS, Complications
Chun et al[18], 2019	31	31	73.8 ± 7.5	5/26	62.4 (36-210)	ROM, KSS, HSS, Complications
Hocking et al[1], 2007	52	52	NR	NR	NR	ROM, KSS, Complications
Le Moulec et al[12], 2014	63	63	72 ± 11.3	29/36	27.8 ± 10.7	ROM, IKS, Patellar height, Complications
Mendes et al[4], 2004	64	67	65.6 (35-93)	25/39	30 (5-60)	ROM, KSS, Complications
Punwar et al[6], 2016	38	42	66 (33-92)	24/14	6-24	OKS, ROM, Walking status, Complications
Segur et al[13], 2014	26	26	73 (64-88)	12/14	40.8 (28.8- 3.2)	KSS, WOMAC, ROM, Complications
Sun et al[3], 2014	21	21	70.1 ± 7.7	6/15	48.1 ± 17.2	ROM, KSS, HSS, Complications
Van den Broek et al[14], 2006	37	37	54.2 (37-78)	NR	28.4 (12-46)	ROM, KSS, VAS for satisfaction, Complications
Vandeputte et al[16], 2017	13	13	53.6 (34-71)	5/8	24	ROM, KSS, Complications
Zonnenberg et al[15], 2014	23	23	69.6 (43-84)	7/16	16.1 (1-43)	KSS, ROM, SF-36, Complications

TTO: Tibial tubercle osteotomy; NR: Not reported; ROM: Range of motion; KSS: Knee society score; VAS: Visual analogue scale; HSS: Hospital for special surgery score; OKS: Oxford knee score; WOMAC: Western Ontario and McMaster universities osteoarthritis index; IKS: International knee society score; SF-36: 36-item short form health survey.

Table 2 Surgery parameters

Ref.	TTO length (cm)	Fixation	Approach	Oscillating saw or osteotome
Barrack et al[17], 1998	10	Wires	Medial parapatellar	Saw
Bruni et al[19], 2013	8-10	Wires	Medial parapatellar	Both
Chalidis et al[2], 2009	10.6 (7.9-15.3)	Wires (n = 16)	Medial parapatellar	Both
		Screws (n = 9)
		Wires and screws (n = 59)
Choi et al[10], 2012 (1)	8	Wires (n = 49)	Medial parapatellar	Both
		Screws (n = 2)
Choi et al[11], 2012 (2)	8	Wires (n = 25)	Medial parapatellar	Both
		Screws (n = 1)
Chun et al[18], 2019	10	Screws	Medial parapatellar	Both
Hocking et al[1], 2007	5-8	Wires	Medial parapatellar	Both
Le Moulec et al[12], 2014	7.7 ± 1.6	Wires	Medial parapatellar	Both
Mendes et al[4], 2004	8-10	Wires (n = 66)	Midvastus (n = 40)	Saw
		Wires and screw (n = 1)	Medial parapatellar (n = 19)
			Subvastus (n = 40)
			Not noted (n = 4)
Punwar et al[6], 2016	7	Screws	Medial parapatellar	Both
Segur et al[13], 2014	10	Wires (n = 25)	Medial parapatellar	Saw
		Nonabsorbable sutures (n = 1)
Sun et al[3], 2014	6-8	Screws	Medial parapatellar	Saw
van den Broek et al[14], 2006	6-8	Screws (n = 36)	Medial parapatellar	Both
		Wires (n = 1)
Vandeputte et al[16], 2017	6-8	Wires or screws	Medial parapatellar	Saw
Zonnenberg et al[15], 2014	4-8	Absorbable sutures	Medial parapatellar	Osteotome

Table 3 Tibial tubercle osteotomy-related complications

Ref.	n	Non-unions	TT fractures	Proximal avulsion fractures	Metaphyseal tibial fractures	Proximal migration	Anterior knee pain
Barrack et al[17], 1998	15	-	-	-	-	-	3
Bruni et al[19], 2013	39	-	-	-	-	-	11
Chalidis et al[2], 2009	74	-	-	3	2	2	5
Choi et al[10], 2012 (1)	36	-	-	2	1	5	-
Choi et al[11], 2012 (2)	13	-	-	-	-	3	-
Chun et al[18], 2019	31	-	-	-	-	-	-
Hocking et al[1], 2007	52	-	1	1	-	10	-
Le Moulec et al[12], 2014	63	4	-	-	-	4	-
Mendes et al[4], 2004	64	2	-	-	1	13	11
Punwar et al[6], 2016	38	-	-	-	1	2	-
Segur et al[13], 2014	26	2	1	-	-	-	-
Sun et al[3], 2014	21	-	-	2	-	-	5
van den Broek et al[14], 2006	37	-	-	1	-	2	3
Vandeputte et al[16], 2017	13	-	-	-	-	-	-
Zonnenberg et al[15], 2014	23	3	1	-	-	-	-

TT: Tibial tubercle.

Table 4 Mean range of motion, flexion, extension lag and flexion contracture values

Ref.	n	Total ROM (°)		Flexion (°)		Extension lag	Flexion contracture
		Preop	Postop	Preop	Postop
Barrack et al[17], 1998	15	73	81			1.5°
Bruni et al[19], 2013	39			57	113	5 cases < 15°
Chalidis et al[2], 2009	74	60	95	80	95	2.5°	2.5°
Choi et al[10], 2012 (1)	36	40	92
Choi et al[11], 2012 (2)	13	60	94	68	95		1°
Chun et al[18], 2019	31	101	109		109		4°
Hocking et al[1], 2007	52				91	3 cases
Le Moulec et al[12], 2014	63	87.8	103.7			15 cases	10 cases
Mendes et al[4], 2004	64			101	107	3 cases < 15°
Punwar et al[6], 2016	38			85	95		15 cases
Segur et al[13], 2014	26			90	95	1 case < 5°
Sun et al[3], 2014	21		94.1		101.7		3.8°
van den Broek et al[14], 2006	37	81	93			1 case
Vandeputte et al[16], 2017	13
Zonnenberg et al[15], 2014	23	87.9	95.3

Table 5 Non-tibial tubercle osteotomy related complications

Ref.	Complications
Barrack et al[17], 1998	None reported
Bruni et al[19], 2013	MUA for stiffness (n = 3)
	Reinfections (n = 2)
	DVT (n = 1)
Chalidis et al[2], 2009	MUA for stiffness (n = 10)
	Skin necrosis (n = 1)
	Reinfections (n = 6)
Choi et al[10], 2012 (1)	MUA for stiffness (n = 2)
	Spacer subluxation (n = 1)
	Reinfections (n = 10)
Choi et al[11], 2012 (2)	MUA for stiffness (n = 2)
	Spacer subluxation (n = 1)
	Reinfections (n = 4)
Chun et al[18], 2019	Skin necrosis (n = 2)
Hocking et al[1], 2007	MUA for stiffness (n = 4)
Le Moulec et al[12], 2014	None reported
Mendes et al[4], 2004	MUA for stiffness (n = 9)
	Pain not associated to TTO (n = 2)
	Reinfection (n = 1)
	Delayed wound healing (n = 5)
	Transient peroneal nerve palsy (n = 3)
Punwar et al[6], 2016	Reinfections (n = 2)
Segur et al[13], 2014	Reinfections (n = 3)
Sun et al[3], 2014	Reinfection (n=1)
van den Broek et al[14], 2006	None reported
Vandeputte et al[16], 2017	None reported
Zonnenberg et al[15], 2014	MUA for stiffness (n = 1)
	Fractures of tibial plateau (n = 5)
	Patellar pain resolved with patellar resurfacing (n = 1)
	Wound leakage resolved conservatively (n = 5)

MUA: Manipulation under anesthesia; DVT: Deep vein thrombosis; TTO: Tibial tubercle osteotomy.