Total knee arthroplasty with simultaneous tibial shaft osteotomy in patient with multiple hereditary osteochondromas and multiaxial limb deformity – a case report

Abstract

Background: Hereditary multiple osteochondromas (hereditary multiple exostoses, HME) is a rare genetic disease characterized by the development of benign osteocartilaginous tumors that may cause severe limb deformities and early onset osteoarthritis. Total knee arthroplasty (TKA) is the method of choice for the treatment of advanced gonarthrosis, however the surgical management with coexisting severe axial limb deformity remains unclear. Case presentation: 65-year-old man with HME and extra-articular multi-axial limb deformity was admitted to the orthopedic department due to chronic knee pain and limited range of motion caused by secondary osteoarthritis. Regarding to the clinical and radiological examinations, after preoperative planning he was qualified to a one-stage TKA combined with tibial shaft osteotomy (TSO). In a one year follow-up full bone union was confirmed with no signs of implant loosening or prosthesis displacement. Patient was very satisfied, did not report any joint pain and has sufficient range of motion without knee instability. Conclusion: The improvement of mechanical axis during TKA is a crucial factor for achieve operative success and long implant survival. Despite the higher risk of complication rate in comparison to two-stage treatment, one-stage TKA with simultaneous TSO should be a considerable method for patients with osteoarthritis and multiaxial limb deformities. This method can give a good clinical and functional outcomes, however should be performed subsequently to careful preoperative planning and proper patient qualification.

Total Knee Arthroplasty With Patient-Specific Instrumentation to Correct Severe Valgus Deformity in a Patient With Hereditary Multiple Exostoses

“…Surgical management of extra-articular deformity caused by HME in adults has reported techniques including TKA alone [ [13] , [14] , [15] ], TKA with osteotomy [ 16 ], as well as navigated TKA [ 17 ]. To our knowledge, there have been no reports of surgical techniques (eg, TKA using PSI) for management of extra-articular deformity caused by HME.…”

“…In patients with severe extra-articular deformities located distally to the joint line, additional extra-articular osteotomy may be required to restore the limb axis and mechanical load. This procedure is expected to improve the knee function and extend prosthesis survival, although it may involve a greater risk of complications [ 16 ]. One-stage TKA combined with tibial or femoral osteotomy is potentially riskier with respect to potential complications (eg, instability, nonunion, reoperation, limited ROM, infections, or fracture in the tibial plateau) [ [19] , [20] , [21] ].…”

“…To our knowledge, only 9 patients with knee deformity caused by HME have undergone total knee arthroplasty (TKA); all of these patients had valgus deformity [ [13] , [14] , [15] , [16] , [17] ]. Here, we describe a patient with HME who exhibited severe valgus deformity that was corrected by TKA using patient-specific instrumentation (PSI).…”

Overcoming the Technical Challenges of Total Knee Arthroplasty in Patients Affected by Hereditary Multiple Exostoses: Our Experience Managing the Bone Deformities

“…For cases with combined OA and extraarticular deformities, Grzelecki et al [13] proposed one stage TKA and tibial shaft osteotomy, with good results. They proposed the use of a stemmed prosthesis which provided the necessary xation at the osteotomy site without the need for additional means of osteosynthesis.…”

Shaft Fractures in Patients Requiring Primary or Revision Total Knee Arthroplasty Can Be Successfully Treated with Long-Stemmed Implants without Additional Fixation

“…A similar approach has been used with good results in patients with lower limb deformities and coexisting knee OA. In those cases, periarticular corrective osteotomies were performed and stabilized with long-stemmed TKA, with or without additional fixation [ 11 , 15 ].…”