Proximal fibular resection improves knee biomechanics and enhances tibial stress fracture healing in patients with osteoarthritis with varus deformity: a prospective, randomized control analysis

Abstract

Background: The present study aimed to evaluate the functional outcome of single-stage total knee arthroplasty using long-stem tibial component with proximal fibular resection (PFR) for patients with knee osteoarthritis with varus deformity associated with tibial stress fracture. Method: A cohort of 62 patients with a mean age 71.63 ± 7.40 years who met the criteria were randomized to a study group and a control group. Patients in the study group underwent single-stage total knee arthroplasty using long-stem tibial component with PFR. The control group received conventional treatment. All patients were followed at 1, 3, 6 and 12 month(s) after surgery. Standard anteroposterior and lateral weight bearing knee X-rays were analyzed. Western Ontario and Mc-master Universities Osteoarthritis Index score (WOMAC) and the visual analog scale (VAS) score were used to assess the functional outcome. The level of significance was set at p < 0.05 levels. Results: One patient in the study group was lost to follow-up, leaving 61 patients for final assessment. The WOMAC total score and mean VAS score were significantly better in study group than in control group at final follow-up (p < 0.05). All fractures were successfully united in a mean time of 12.26 ± 1.20 weeks in study group. A total of 16 patients in control group had delayed union, five had established nonunion and required further interventions. No complications relating to surgery was detected. Conclusion: Total knee arthroplasty with PFR for knee arthritis with varus deformity associated with tibial stress fractures restores limb alignment, improves biomechanics, enhances fracture healing and provides excellent functional outcome.

Single-stage long-stem total knee arthroplasty in severe arthritis with stress fracture: a systematic review

“…[ 28 ] 2018 15 (1/14) 15 65 3/12 20 ± 5 10 ± 2.5 31.5 a 87.6 a 10 Shah et al. [ 15 ] 2020 62 (20/42) 62 71.6 0/62 18.9 ± 1 (study), 18.3 ± 1.4 (control) 1.8 ± 3.1 (control) 1.7 (study) 54.7 ± 2.0 b (control), 54.1 ± 1.8 b (study) 26.9 ± 2.6 b (control), 19.9 ± 1.9 b (study) 11 Gill et al. [ 9 ] 2021 24 (0/24) 24 62.3 4/20 20.5 ± 3 ( n = 21) 22.3 ± 4.6 ( n = 3) 0.8 ± 0.4 ( n = 21) 0.8 ± 0.28 ( n = 3) 29.8 ± 6.1 a (group 1), 27.2 ± 3.3 a (group 2) 91.5 ± 4.8 a (group 1), 89.8 ± 3.8 a (group 2) 12 Pai et al.…”

“…[ 28 ] 15 PS 19.5 ± 2.6 weeks Pulmonary embolism ( n = 1) Stroke ( n = 1) Shah et al. [ 15 ] 31 31 5* PS PFC 12.2 ± 1.2 weeks 21.1 ± 5.16 weeks Gill et al. [ 9 ] 13 11 PS 16 CCK 5 RHK 3 20.4 weeks Anterior tibial cortex perforation ( n = 1) Pai et al.…”

“…classified patients similarly to Mullaji et al., but used plating and bone grafting in conjunction with TKA (with more reported complications in contrast to the other) [ 9 , 14 ].Shah et al. conducted a prospective randomised controlled trial with a sample size of 62 [ 15 ]. In the control group ( n = 31) (conventional treatment without fibular resection), the authors found delayed union and non-union in five patients and advocated for PFR for an early union.…”

“…The mean MINORS score was 17 ± 3 [mean standard deviation (SD) ± 2]. Major concerns were the lack of unbiased assessment of the study endpoint (no blinding), and only one randomised control study calculated sample size before the start of the study [ 15 ].…”

“…Management of proximal tibia stress fracture associated with severe KA is debatable, ranging from conservative management [ 10 ] to staged surgery involving corrective osteotomy followed by TKA [ 11 , 12 ], simultaneous long-stem TKA and internal fixation of stress fracture using plating [ 13 ], the use of long stem TKA alone [ 14 ] or the use of any of the above with augmentative procedures such as proximal fibular resection (PFR) [ 15 ] and/or plating and bone grafting [ 9 ].…”