Knee post-traumatic consequences: possible surgical approach and management when everything goes wrong
Post-traumatic osteoarthritis (PTOA) of the knee is a development of arthritis following an acute trauma, often associated with intraarticular fracture and ligament injury. The knee is affected in 12% of all cases of knee OA, the prevalence of PTOA after a fracture in the literature is between 21-44% and is the result of a combination of unfavorable factors. The number of surgical treatments for post-traumatic arthritis has increased slightly over the years, but is a demanding and common problem for the surgeon because it is associated with poorer outcomes and higher rates of complications. The reasons for this are likely multifactorial, due to technically challenging for the previous surgery and scarring, secondary deformity, bone loss, hardware retained, poor bone quality and ligament incompetence. The aim of this study is to review the possible surgical approaches in these cases, and the management of soft tissue and previous hardware.
Post-traumatic osteoarthritis (PTOA) of the knee is a development of arthritis following an acute trauma, often associated with intraarticular fracture and ligament injury 1. It usually occurs after a variety of joint injuries, like sports trauma, motor vehicle accident or fall and is considered a particular type of osteoarthritis. The main difference is that cartilage wear occurs as a result of acute damage and not gradually, as in the case of osteoarthritis 2,3 (Fig. 1).
Knee is affected in 12% of all knee OA cases, the prevalence of PTOA after a fracture in literature is between 21-44% 4 and is the result of a combination of unfavorable factors. A prior knee joint trauma increases the risk to develop PTOA by 3-6 times and with an early appearance of 10 years compared to those without history of injury 5.
The pathogenesis of PTOA is not fully understood, but is thought to be a combination of mechanical damage associated with ligamentous laxity and meniscal tears. The acute fracture severity and its reduction seems to be the most important factors leading to a good outcome, but the relative contribution of these factors to the subsequent progression of arthritis has not been well characterized 6,7. The articular injury to cartilage surface induces chondrocyte death or dysfunction, resulting in degeneration of the entire articular surface. Chondrocyte death progression can progress over 48 hours after trauma 8. Lower limb malalignment induced by insufficient reduction of the articular surface or by extraarticular deformity, ligamentous laxity due to mechanical imbalance, and meniscal tears can lead to a chronic abnormal stress on articular surfaces and cartilage degeneration 9. Specifically, the combination of instability and articular surface incongruity induces disproportion in contact stress areas and can anatomically shift the articular surface loading pattern, although there is no consensus on the maximal acceptable articular step-off 7. Secondly, the release of the pro-inflammatory cytokines interleukin-1 and tumor necrosis factor alpha along with intra-articular hematoma induces cartilage cell necrosis and improper cartilage healing 10. Other factors like patient age and BMI also contribute to poorer clinical outcomes and a higher risk of osteoarthritis.
The number of surgical treatments for post-traumatic arthritis has increased slightly during the years and is the third most common cause of total knee replacement after primary arthritis and rheumatoid arthritis 11. Treatment of early stages post-traumatic knee OA is a combination of activity modification, physical therapy, and anti-inflammatory medications 12. Management of PTOA is not different from primary osteoarthritis. However, when conservative treatment failed or in more advanced stages of OA, surgical options become an alternative solution for these patients 13.
PTOA is a demanding but common problem for the surgeon: total knee arthroplasty (TKA) is an option for the treatment of the end-stage, but, in the literature, ai associated with poorer outcomes and higher complication rates in these patients than in those treated with routine primary TKA 4. The reasons are likely multifactorial, due to technically challenging for the previous surgery and scarring, secondary deformity, bone loss, hardware retained, poor bone quality, and ligament incompetence 9,14. (Fig. 2) In particular, a prior surgical scar and retained metalwork increase the risk of wound breakdown and infection and must be managed carefully.
However, a more recent study reported no difference between TKA after PTOA and TKA for primary osteoarthritis in outcome scores 15. Lizaur-Utrilla et al. reported that TKA for PTOA after tibial plateau fracture has a significantly higher complication rate, but the complications observed were not severe and did not affect functional post-operative outcomes compared with primary TKA 16. However, there are other surgical techniques such as osteochondral autograft or allograft, osteotomies, or arthrodesis, which can be performed in these patients and make the appropriate surgical treatment challenging.
Before the choice of surgical treatment, adequate surgical approach is crucial, and it must consider removal of prior hardware to reduce the risk of wound dehiscence and infection.
Previous incision performed for prior surgery represents a challenge for the surgeon and a risk factor for wound healing. Lonner et al. 4 reported that the main post-operative wound complications are infection (10%) and wound breakdown (6%) needing additional flap coverage (Fig. 3).
Other risk factors for skin necrosis are rheumatoid arthritis (RA), diabetes, steroid use, immunosuppression, malnutrition, and peripheral vascular disease 17,18. In the presence of a single previous incision, it should be used especially when is a longitudinal scar and can be fully incorporated in the TKA approach. This is associated with a lower rate of wound complications, such as skin necrosis between the incisions 19. Scott et al. 20,21 prospectively reviewed 888 patients between 1995 and 2008, finding that surgical scars and retained metalwork can increase the risk of wound breakdown and superficial infection after TKA. They found a lower rate of wound complications in patients with a longitudinal scar and this can be fully incorporated into the TKA approach. Especially in case of a single antero-lateral incision for lateral tibial plateau fracture, a Keblish approach can be used to perform hardware removal and TKA or osteotomy at the same time. Even in case of multiple incisions, the most lateral one should be performed to preserve the blood supply and oxygen tension to the medial flap 22. The Keblish approach was first described in 1991 and the author emphasized the advantages in the valgus knee 23. It allows a direct approach into the deformity and simplifies the patellar tilt and ligament balancing. Using this approach in PTOA patients, with multi-operated knees, the osteotomy of tibial tuberosity is often necessary due to stiffness or patella baja which limit exposure of articulation and increase the risk of patellar tendon injury 24.
In the presence of double incision, usually antero-lateral and postero-medial or posterior approach, a new median incision should be made. The distal part of the new median incision should merge in one of the previous two incisions 6. In case of prior transverse incision, due to an exposed fracture or previous cover flap, crossing previous incisions at angle > 60° and maintaining full thickness skin bridges of at least 7 cm are recommended to maintain adequate tissue perfusion (Fig. 5) 25,26. Alternatively, especially with previous pedicle flap or based on perforating arteries flap, it can be indicated to completely raise the previous flap from the underlying tissues to expose the joint surface without damaging vascularization (Fig. 6).
Problem wound: coverage option
In rarely complex situations, wound closure may be difficult due to retracting scars and a tissue expander or primary flap coverage is required (Fig. 7).
Soft tissue expansion, introduced in 1950s, is based on stretching the skin beyond its physiologic limit to induce higher mitotic activity and collagen synthesis. The effect is an increased surface area of the skin which allows tension-free wound closure. Usually, a tissue expander is inserted into subcutaneous pocket near the planned incision for 8 weeks 27-29. Skin grafting requires a well vascularized bed, no prosthesis exposure, and good soft tissue bulk that usually are not present in these types of patients. Instead, with wide soft tissue loss and exposure of the prosthesis, local flaps may be the best reconstructive option. Local flaps are raised on a vascular pedicle rotated in the required position 30.
Defects of the medial proximal tibia, tibia tubercle, patellar tendon, and patella can be covered by medial gastrocnemius muscle or musculo-cutaneous pedicle flap. The gastrocnemius has two heads, medial and lateral, with separated bloody supply and the medial one is the longer 31. Several authors evaluated the role of the gastrocnemius flap. Casanova et al. 18 stated that it provides a good quality soft tissue coverage for most of the defects; it also provides blood supply and increases the concentration of antibiotics. Furthermore, it can be easily mobilized to the knee region and fills the empty space around the prosthesis. The functional consequences at the harvest site are minimal, allowing for early mobilization and a reduced rate of arthrodesis after TKA failure 18. Ries et al. demonstrated that this flap has a high success rate for soft tissue coverage and a lower risk of failure compared to free flap 32.
More proximal defect may be treated with additional lateral gastrocnemius or fascio-cutaneous flap transposition, but the lack of muscle tissue is not good for local drainage.
In this case, an alternative can be the vastus lateralis muscle flap with distal pedicle. This is a salvage flap suitable for extensive longitudinal loss of knee tissue or reconstruction of extensor apparatus 33 Wang et al. 34 showed the constancy of the three perforating arteries from the superolateral geniculate artery in the distal quarter of the vastus lateralis, which makes it a reliable flap. It does not require microsurgery, but this type of flap is accompanied by a limitation of function of the harvest limb.
If the defect is too large and presents inadequate peripheral soft tissue, a free flap is more appropriate.
Limitations of tissue mobility, multiple previous incision and additional plastic surgery can lead to under-sizing the total knee prosthesis and reduction in active muscular strength and range of motion 35. The flap coverage gives the possibility to restore the correct joint volume and use an adequate size of TKA.
Remove or retain hardware?
The presence of hardware from previous surgery is a risk factor of post-TKA infection, along with male gender and high BMI 36. The removal of this has always been a debated topic and, currently, no clear indications are present in literature. Some surgeons prefer hardware removal, if possible, due to the lower risk of infection and mechanical instability 36,37.
Moreover, in these kinds of patients the presence of retained hardware of the prior surgery can hinder the intramedullary guides of TKA and the possibility of removing them should be considered 38 (Figs. 7-8). Hardware removal could be performed in either a staged or concurrent manner, and both have benefits and defects. Staged removal usually improves tissue healing and revascularization, as well as improved bone stock before arthroplasty 16. On the other hand, two different operations increase the risk of infection and compromise wound healing 39. However, the screw holes left from the hardware removal increases the stress riser and the risk of post-operative fracture in the concurrent removal manner with TKA. This can result in the need to use more complex and stable implants, limits post-surgery weight bearing, and delays the adequate rehabilitation protocol 40.
Smith et al. 39, in a retrospective review from 1998 to 2018, identified no significant difference in complications, reoperations, or revision between conversion TKA patients who underwent either concurrent hardware removal or staged hardware removal. Klatte et al. 41 reported on a group of conversion patients who underwent concurrent hardware removal and TKA, reporting a post-operative infection rate of 3% and mechanical complications in 5% of cases. However, in this study and many others, the data reflect a heterogenous group with different type, size, and location of hardware 3,42,43.
In our experience, we suggest hardware removal if it hinders the TKA positioning, such as in the case of proximal posterior tibia plate, and therefore on the planned surgical approach.
In case of young patients, it is also preferable to remove hardware in two stages, as early as possible, or with the first sign of osteoarthritis in order to achieve the best possible wound healing 44.
Furthermore, in case of multiple plate or screws, we do not suggest removing those far from the future surgical access, to prevent soft tissue devascularization and if they do not preclude the TKA implant. Accurate TKA pre-operative planning with a computer navigation system can be useful to understand which hardware can be left in place. Manzotti et al. 44 evaluated the use of computer navigation system for one-stage TKA without removal in post-traumatic knee arthritis with prior femoral fracture. They found that, with computer assistance, the results are reproducible and similar to primary routine TKA.
Post-traumatic osteoarthritis (PTOA) management of the knee is demanding for surgeons. Each patient must be carefully evaluated to choose the adequate surgical strategy on a case-by-case basis. Accurate radiographic and CT study, pre-operative planning, and selection of prosthesis type is critical, and should be decided according to the bone defect and knee stability. However, these cases have higher rate of possible complications compared with primary total knee arthroplasty due to the previous surgery and scarring, prior hardware, poor bone quality, and ligament incompetence. It is essential to assess which surgical approach should be used to reduce the risk of wound and decide to remove or retain prior implants to reduce the risk of post-operative infection. Unfortunately, there is no consensus in the literature, so that the management of these complex cases relies on the surgeon’s experience and patient characteristics.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subjects of this article.
Conflict of interest statement
The Authors declare no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
DB and PdB as designers of the study. MS, GS e PdB as revisors of the study.
All Authors have read and approved the manuscript.
This study was approved by the Istitutional Ethics Committe of AOU Careggi, Florence, Italy. The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki. Written informed consent was obteined from each patients for study participation and data publication.
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