Total Knee Arthroplasty in End-Stage Knee Osteoarthritis with Tibia Stress Fractures – A Propensity Score Matched Comparative Study

Document Type : RESEARCH PAPER

Authors

1 All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India

2 Assistant Professor, department of orthopedic, AIIMS Jodhpur, India

10.22038/abjs.2024.78268.3601

Abstract

Objectives: Knee osteoarthritis (KO) is a leading contributor to disability years, with a prevalence ranging from 22% to 39%. Tibia stress fractures (TSFs) are well-described for end-stage arthritis patients undergoing TKA. Literature is ambiguous, with a wide range of management options. This study primarily aims to compare and determine the clinical, functional, and radiological outcomes of TSFs in end-stage KO treated with TKA by propensity score-based matching.
Methods: It is a retrospective, single-center, comparative study conducted at University Teaching Hospital. The institutional medical records (IMRs) database was inquired. The TSF group included all patients of end-stage KO who underwent primary TKA with TSFs, and the TKA group included matched patients without TSF. Cases were 3:1 (TKA: TSF) propensity score-matched (PSM). The primary outcome was a PSM comparison of patient-reported outcome measures (PROMs) and 1-year Postoperative Complications and Adverse Events (POCAE). PROMs included the knee society score (KSS), patient satisfaction (PS), and KSS functional activities (FA) score.
Results: Study includes thirty-seven patients. Both groups showed no statistically significant difference in KSS FA and KSS PS scores. At the final follow-up, MCID for KSS FA was achieved by 31 patients (96.9%) in the TSF group compared to 92 patients (95.83%) in the TKA group. MCID for KSS PS was achieved by 29 patients (90.63%) in the TSF group compared to 91 patients (94.79%) in the TKA group.
Conclusion: End-stage KO patients with coexisting TSFs who undergo primary TKA with stem/ plate fixation as per fracture location may expect favorable PROMs, POAECs, radiological outcomes, and rates of achieving the MCID at a minimum 2-year follow-up. Accurate management of such cases results in excellent outcomes and minimized revision rates. All patients achieved complete bone union. These results were comparable to the PSM control group.
        Level of evidence: III

Keywords

Main Subjects

References

  1. Inacio MC, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage. 2017; 25(11):1797-1803. doi:10.1016/j.joca.2017.07.022.
  2. Wheeldon FT. Spontaneous fractures of the shin in the presence of knee deformities. Proc R Soc Med. 1961; 54(12):1108.
  3. Satku K, Kumar VP, Pho RW. Stress fractures of the tibia in osteoarthritis of the knee. J Bone Joint Surg Br. 1987; 69(2):309-311. doi:10.1302/0301-620X.69B2.3818767.
  4. Martin LM, Bourne RB, Rorabeck CH. Stress fractures associated with osteoarthritis of the knee. A report of three cases. J Bone Joint Surg Am. 1988; 70(5):771-774.
  5. Learmonth ID, Grobler G. Sequential stress fractures of the tibia associated with osteo-arthritis of the knee. A case report. S Afr J Surg. 1990; 28(2):75-77.
  6. Mullaji A, Shetty G. Total knee arthroplasty for arthritic knees with tibiofibular stress fractures: classification and treatment guidelines. J Arthroplasty. 2010; 25(2):295-301. doi:10.1016/j.arth.2008.11.012.
  7. Wang JW, Wang CJ. Total knee arthroplasty for arthritis of the knee with extra-articular deformity. J Bone Joint Surg Am. 2002; 84(10):1769-1774. doi:10.2106/00004623-200210000-00005.
  8. Cameron HU. Double stress fracture of the tibia in the presence of arthritis of the knee. Can J Surg. 1993; 36(4):307-310.
  9. Wolff AM, Hungerford DS, Pepe CL. The effect of extraarticular varus and valgus deformity on total knee arthroplasty. Clin Orthop Relat Res. 1991 ;( 271):35-51.
  10. Moskal JT, Mann III JW. Simultaneous management of ipsilateral gonarthritis and ununited tibial stress fracture: combined total knee arthroplasty and internal fixation. J Arthroplasty. 2001; 16(4):506-511. doi:10.1054/arth.2001.22276.
  11. Hendel D, Velan GJ, Weisbort M. Intra-articular tibial plateau stress fracture associated with osteoarthrosis and valgus knee deformity. J Arthroplasty. 1997; 12(6):713-715. doi:10.1016/s0883-5403(97)90149-2.
  12. Austin PC. Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biom J. 2009; 51(1):171-184. doi:10.1002/bimj.200810488.
  13. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott W. The new Knee Society Knee Scoring System. Clin Orthop Relat Res. 2012; 470(1):3-19. doi:10.1007/s11999-011-2135-0.
  14. Milgrom C, Giladi M, Stein M, et al. Medial tibial pain. A prospective study of its cause among military recruits. Clin Orthop Relat Res. 1986 ;( 213):167-171.
  15. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40(5):373-383. doi:10.1016/0021-9681(87)90171-8.
  16. Nishitani K, Yamamoto Y, Furu M, et al. The minimum clinically important difference for the Japanese version of the new Knee Society Score (2011KSS) after total knee arthroplasty. J Orthop Sci. 2019; 24(6):1053-1057. doi:10.1016/j.jos.2019.09.001.
  17. Maredupaka S, Meshram P, Chatte M, Kim WH, Kim TK. Minimal clinically important difference of commonly used patient-reported outcome measures in total knee arthroplasty: review of terminologies, methods and proposed values. Knee Surg Relat Res. 2020 9; 32(1):19. doi:10.1186/s43019-020-00038-3.
  18. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003; 41(5):582-592. doi:10.1097/01.MLR.0000062554.74615.4C.
  19. Sloan JA. Assessing the minimally clinically significant difference: scientific considerations, challenges and solutions. COPD. 2005; 2(1):57-62. doi:10.1081/copd-200053374.
  20. Healy WL, Della Valle CJ, Iorio R, et al. Complications of total knee arthroplasty: standardized list and definitions of the Knee Society. Clin Orthop Relat Res. 2013; 471(1):215-220. doi:10.1007/s11999-012-2489-y.
  21. Meneghini RM, Mont MA, Backstein DB, Bourne RB, Dennis DA, Scuderi GR. Development of a Modern Knee Society Radiographic Evaluation System and Methodology for Total Knee Arthroplasty. J Arthroplasty. 2015; 30(12):2311-2314. doi:10.1016/j.arth.2015.05.049.
  22. Mullaji A, Shah R, Bhoskar R, Singh A, Haidermota M, Thakur H. Seven phenotypes of varus osteoarthritic knees can be

 

        identified in the coronal plane. Knee Surg Sports Traumatol Arthrosc. 2022; 30(8):2793-2805. doi:10.1007/s00167-021-06676-8.

  1. Soundarrajan D, Rajkumar N, Dhanasekararaja P, Rajasekaran S. Proximal tibia stress fracture with Osteoarthritis of knee - Radiological and functional analysis of one stage TKA with long stem. SICOT J. 2018; 4:13. doi:10.1051/sicotj/2018006.
  2. Gill UN, Noor SS, Haneef M, Ahmed N, Iqbal F, Najjad MK. Management of early and late presenting tibial stress fracture with advanced osteoarthritis of the knee: A dilemma among arthroplasty surgeons in developing countries. Knee. 2021; 29:95-100. doi:10.1016/j.knee.2021.01.018.
  3. Shekhar S, Rai A, Prakash S, Khare T, Malhotra R. Single-stage long-stem total knee arthroplasty in severe arthritis with stress fracture: a systematic review. Knee Surg Relat Res. 2023; 35(1):4. doi:10.1186/s43019-023-00178-2.
  4. Goh GS, Liow MH, Chen JY, Tay DK, Lo NN, Yeo SJ. The patient acceptable symptom state for the knee society score, oxford knee score and short form-36 following unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2023; 31(3):1113-1122. doi:10.1007/s00167-021-06592-x.
  5. Lerman, J. Study design in clinical research: sample size estimation and power analysis. Can J Anaesth. 1996; 43(2):184-191. doi:10.1007/BF03011261.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 13, Issue 5
May 2025
Pages 281-290

Files

History

  • Receive Date: 11 March 2024
  • Revise Date: 02 October 2024
  • Accept Date: 28 December 2024

Share

How to cite

Statistics