Extended Tibial Tuberosity Osteotomy: A Practical Tool for Implant Removal in Difficult Knee Revision Arthroplasties in Patients with Hemophilia

Background and Objectives: Hemophilic arthropathy, the end result of recurrent hemarthroses in patients with hemophilia, often necessitates total knee arthroplasty (TKA) using constrained implants to address severe deformities and joint destruction. Revision TKA is often required due to aseptic loosening, implant malposition, infection, or periprosthetic fractures. The extended tibial tuberosity osteotomy (ETTO) has emerged as a critical technique for the safe removal of well-fixed tibial stems in such complex cases, demonstrating high union rates and minimal complications. The aim of this study is to evaluate the safety, effectiveness, and clinical outcomes of the ETTO technique during complex revision TKA in patients with hemophilia. Materials and Methods: A retrospective analysis was conducted on seven male hemophilic patients who underwent revision TKA with ETTO between 2015 and 2023. The procedure involved the creation of an extended proximal tibial bone flap, laterally retracted to facilitate tibial stem exposure and removal. Postoperative outcomes included radiological confirmation of osteotomy union, assessment of complications, and evaluation of functional outcomes, including range of motion and extensor mechanism integrity. Results: Osteotomy union was achieved in all patients (mean age 57.5 ± 1.50 years and mean body mass index 26.07 ± 0.67 kg/m2) within four months, confirmed by radiographic evidence of bridging callus. No significant complications, such as nonunion, fragment displacement, or symptomatic hardware, were observed. There was one patient who experienced delayed wound healing, managed successfully with surgical debridement. Postoperative mean knee flexion was 92°, with no extensor lag reported. ETTO enabled safe tibial stem removal and successful revision arthroplasties in all cases. Conclusions: ETTO is a technically demanding but indispensable approach for addressing the challenges of revision TKA in patients with hemophilia. It allows for secure tibial stem removal while maintaining excellent union outcomes and a low rate of complications. Due to its complexity, ETTO should be performed by experienced surgeons in specialized centers.