Osteotomy for Varus Malalignment - Amazon S3...Varus Malalignment Osteotomy Indications for HTO:...
Transcript of Osteotomy for Varus Malalignment - Amazon S3...Varus Malalignment Osteotomy Indications for HTO:...
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Osteotomy for Varus Malalignment
Luís Eduardo P. Tírico, MD
Attending Physician, Knee Surgery
Orthopedic and Traumatology Institute
University of São Paulo, Brazil
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Tibial Osteotomy
• Medial Osteoarthritis
– Biological alternative to knee replacement
– Active patients
– Relatively young
– Does not preclude a future arthroplasty
• Symptomatic articular cartilage injuries and ligament reconstruction
– Protect repair
– Neutralize axial load
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Tibiofemoral
– Progression of OA (18 months)
• Medial - 4x higher with > 2° Varus
• Lateral – 5x higher with > 2° Valgus
• Malalignment > 5° = greater
deterioration
Sharma et al. JAMA 2001
Importance of Alignment
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Varus Malalignment Osteotomy
Indications for HTO:
- Mild to moderate medial OA
- Varus osseous malalignment
- Focal medial cartilage lesion
- Ligament reconstruction
- Menical repair or transplantation
- Patients desire to remain active; refusal of arthroplasty
Meidinger G et al. KSSTA 2011
Prodromos CC, Amendola A, Jakob RP.. Instr Course Lect. 2015
Noyes, F. Knee Disorders 2016, 2ed
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Where to?
OA Cartilage
Lesion
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Focal chondral lesion (treated)
Large degenerative lesion
Extensive Meniscectomy
Osteoarthritis
Where to correct?
Gomoll, A. 15 CBOT,
2014
Neutral alignment
Overcorrect 1-2°
Overcorrection (Fujisawa)
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Clinical Evaluation
- Gait (Dynamic
component – thrust)
- Ligament laxity
- Full limb aligment - Supine
- Double leg stance
- Single leg stance
Wang et al. 2016
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Preoperative Planning
• Identify source of malalignment
• Decide on femoral or tibial osteotomy
– Default is tibia in most cases
• Choose type of osteotomy
• Determine magnitude of correction
– Fujisawa point (30-40% lateral midpoint)
– Jakob modification (correction based on amount
cartilage remaining on medial side)
– Customized
• Choose type of fixation
Fujisawa et al. Orthop Clin North Am. 1979
Jakob and Murphy. Instr Course Lect, 1992
Bugbee WD.. 12 CBCJ , 2012
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Varus Malalignment Osteotomy
- Opening Wedge - Puddu
- Medial
- Graft
- Easier, more precise
- Closing Wedge - Coventry
- Lateral
- Fibula osteotomy, release TF
- Dome - Bigger deformities
- Supra tuberosity
- Infra tuberosity
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Preoperative Planning
6º 8º
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47o Problem of Euclid The Pythagorean Theorem
How big is my wedge?
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8º
How big is my Wedge?
91mm
Correct for
magnification 91mm – 11% = 81mm
Magnif.
Correct for
ligament
laxity, if
present
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1 degree = 1 mm not for everyone!
Preoperative Planning
56mm – 1º = 1mm
81mm – 1º = X
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Dome Osteotomy
15º Varus right
knee
Left size =
15mm Puddu
plate
Estimated
wedge 20mm
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Preoperative Planning
Sagittal Plane
• Tibial Slope
• Increase: ACL Strain
• Decrease: PCL Strain
• Ligament Status (ACL, PCL)
• Simultaneous ligament reconstruction
• Increase in tibial slope:
• Most commom technical error
• Benefit of navigation
• Nha et al. AJSM 2016 – Meta-analysis • OW – increase 2º, CW – decrease 2º
4º
2º
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• Estimate alignment
• Not very accurate
• Straight line
• Rotation sensitive
• Underestimate correction
if ligament laxity
Intraoperative Planning
Alignment
Rod Bovie Cord
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Intraoperative Planning
Navigation - Mechanical alignment
- Posterior slope
46 patients total
Under 0,5º - 6 patients - 13.0%
0,5º<x<1.5º - 9 patients – 19.6%
1.5º<x<2.5º - 17 patients - 37.0%
Over 2.5º - 14 patients – 30.4%
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Preop Planning vs Navigation
Demange MK, Tirico LE et al. Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-
wedge high tibial osteotomy: a report of eight cases. The Knee. 2011; 18: 387-91
Knee, 2011 • Prospective Study – HTO + ACL reconstruction (Anthony Plate)
• Radiographic Long Limb X-Rays preop vs Navigation alignment intra-op
• Postop Mechanical Axis (Mean) – 1.2º (SD 1.04º)
• Tibial slope
• Preop – 8.8º (SD 3.2º)
• Postop – 9.4º (SD 2.4º)
• Comparison estimated wedge vs used wedge (9 surgeons)
• 27% wedges ≤ 1mm
• 53% wedges 2 ≤ x ≤ 4mm
• 20% wedges ≥ 5mm No difference
≤1mm
2≤x≤4mm
≥5mm
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Opening Wedge Technique
• Small incision
• Single osteotomy
• Precise correction
• Corrects medial tibial deformity
• Preserves bone stock
• Simultaneous cartilage repair
and ligament reconstruction
• Defect management can be an
issue
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Opening Wedge Technique
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Types of Grafts
Bone graft (Auto or Allograft)
✔ Osteoconductive, osteoinductive, osteogenic properties, easy access
✖ Increase operative time, donor site morbitity
Synthetic bone substitute (Hydroxyapatite, β-tricalcium phosphate, both)
✔ Easy access
✖ Resistance to compressive loads, difficult to evaluate bone consolidation, biological degradability, cost
PRP and BMAC
✔ Bone graft augmentation, alone
✖ Cost, time to consolidate
D’Elia et al. Cartilage.2010
HTO – Bone graft vs PRP
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Complications
Lateral cortex
fracture
Intra-articular fracture
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Sagital alignment
Complications
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Results of HTO
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Results of HTO
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• HTO is useful in managing medial compartment OA
and cartilage lesions
• Correct preoperative planning is extremely important
• Some kind of intraoperative alignment verification
• Favorable long-term clinical outcomes
Summary
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Thank you