OA in the ‘Young”

Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course

Professor Deiary F Kader Knee Surgeon

South West London Elective Orthopaedic Centre Epsom & St Helier University Hospitals

Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva)

Purpose

Not to give you a lecture on OA

Purpose The importance of realignment procedures in combination with multi-ligament surgery and chondroplasty

Ligament reconstruction, Chondral procedures and even meniscal repairs are all doomed to failure in Malaligned knees

28 yrs old man Neglected multilligament when he was 18

ICRC Weapon wounded Trauma Training Centre in Tripoli/Lebanon

Realignment Procedures (Osteotomy)

Aims of osteotomy

Unload the affected compartment by slightly overcorrecting into valgus/varus

Unloading any ligament reconstruction in patients with a varus thrust

Improve AP instability & reduce translational forces by changing the tibial slope

Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial

compartmental osteoarthritis of the knee.

Varus malalignment in revision ACL

22% of Revision ACL reconstruction patients

have varus malalignment

Mechanical Axis & Joint orientation angle of the knee

Vertical axis

mLDFA=87ºMPTA=87º1.2º Varus

POSTGRAD ORTH Deiary Kader

Mechanical Axis of the Lower Limb

The line from the centre of the femoral head to the centre of the ankle plafond is called the Mechanical axis of the lower limb

Normal MAD = 4-8mm medial

Mechanical Axis deviation MAD

33%20

5%

The Weight Bearing Line in %

X

Double Varus 1- Varus alignment

Progressive medial joint narrowing

2- Lateral tibio-femoral opening LCL laxity >5 mm laxity ( stress radiograph)

Varus thrustCurtesy of Prof Reha

Triple VarusVarus alignment

Lateral tibio-femoral opening

Posterolateral corner laxity Increased Ext-Rotation/Hyperextension

Varus recurvatum deformityCurtesy of Prof Reha

Decision makingPrimary varus knees: ACLR alone Cruciate reconstruction with/without HTO

Double varus knees: HTO alone HTO first + cruciate & PLC later if required

Triple varus knees: ALL HTO first + Cruciate & PLC later

11 eligible studies (218 knees)

Curtesy of Prof Reha

Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965

(Coventry, 1965).

OPEN Wedge HTO 1987The open-wedge high tibial osteotomy gained recognition after the encouraging reports of

(Hernigou et al., 1987).

Wedges of bone that were obtained from the iliac crest were inserted into the defect

Open W HTO

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Proximal or High Tibial Osteotomy (HTO)

The IDEAL candidate for HTO

Age <60 years

Isolated medial OA (GI-III)

BMI<30

FFD & Varus of <15°

>120° flexion knee

Patients should be Able to use crutches Have no major varicose veins or peripheral vascular disease

Valgus deformity of 12º or more needs distal femoral varus producing osteotomy to address a lateral femoral condyle deficiency and to prevent joint line obliquity and gradual lateral tibial subluxation.

Distal Femur Osteotomy for Valgus Malalignment

Osteotomy Planning Final alignment should create 10º–13° valgus.

Overcorrection of 3º–5º above the 6º–7º normal

valgus angle

62.5% across tibial plateau from medial side

Compensating for Abnormal AP Laxity

ACL Rupture PCL Rupture

HTO ComplicationsInadequate valgus correction

Overcorrection – PFJ derangement

Alteration in patella height

Intra-articular fracture

Osteonecrosis of the tibial plateau

HTO ComplicationsVascular injuries

Peroneal nerve palsy

Delayed or non-union

Compartment syndrome

TKR more difficult

Fibular osteotomy, Separating tibiofibular joint Contracture of the patellar tendon, patellar baja leg shortening Nerve injuries

Varus laxity (loose LCL)

High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up* ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ Bone Joint Surg Am, 2000 Jan

Closed wedge HTO Disadvantages

Open wedge HTO Advantages

Easier to achieve precise angular correction

Preserves bone stock (subsequent TKR easier)

Makes tightening of the MCL easier

Allows LCL or PLC Recon

No risk to peroneal nerve

Less dissection

Open wedge HTO Disadvantages

Requires a bone graft (substitute, autograft, Allo)

I incidence of non-union and delayed union

Large correction may affect leg lengthening

Loss of fixation

Worsens patella Baja

Outcome

Obesity and inadequate correction were negative prognostic factors. Age < 50 years is a positive prognostic factor Joint line preservation is key to success.

RCT 92 pts and 6 years FU OW-HTO vs CW-HTO

More Complications in open WHTO & more conversion to TKR in closed WHTO

SEPT 2014

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THANK YOU