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Total Knee Arthroplasty Total Knee Arthroplasty associated with osteotomyassociated with osteotomy
in cases of major deformities in cases of major deformities(19 knees)(19 knees)
Total Knee Arthroplasty Total Knee Arthroplasty associated with osteotomyassociated with osteotomy
in cases of major deformities in cases of major deformities(19 knees)(19 knees)
JL. LERAT, A. GODENÈCHEJL. LERAT, A. GODENÈCHE
Service de Chirurgie Orthopédique et de Médecine du Sport Service de Chirurgie Orthopédique et de Médecine du Sport
Lyon – FranceLyon – France
ISAKOS ISAKOS JUNE 2001JUNE 2001 MONTREUX MONTREUX
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23 cases of major deformities > 20° 11 valgus : 22° ± 3 12 varus : 26° ± 3
Good corrections - Good results obtained with post. cruciate retaining TKR
Similar to other TKR’s in our series
Even in case of major deformity TKR is possible :
Intra-articular deformities
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23 cases of major deformities > 20°
Good corrections - Good results obtained with post. cruciate retaining TKR
Similar to other TKR’s in our series
Even in case of major deformity TKR is possible :
Intra-articular deformities
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It is possible to correct the deformity in doing TKA (sometimes with tightening ligaments of the convexity)
PCL may be preserved
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The questionThe question is :is :
How to correct a major extra-articular deformityHow to correct a major extra-articular deformity ((± articular deformity) ± articular deformity)
by a total Knee Replacement ?by a total Knee Replacement ?
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Typical cases are represented by tibial deformitiesTypical cases are represented by tibial deformities (following osteotomies or fractures)(following osteotomies or fractures)
ValgusValgus Varus Varus
ProfileProfile
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After a failed osteotomy it is possible to do a TKR in the majority of the cases (except in case of severe valgus)
But the results are not so good as primary TRK (literature)
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In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
• Usual cuts for the femur. Minimal cut for the tibia: Trapezoidal space
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In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
• Usual cuts for the femur. Minimal cut for the tibia• Large release of the concavity in order to obtain rectangular space• A correction of 20° corresponds to a release of 30 mm ! (Wolf)
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ADVANTAGESADVANTAGES• 1 operation1 operation• No major difficulties No major difficulties • Immediate weight bearing Immediate weight bearing
In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
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DISADVANTAGESDISADVANTAGES
• Excessive polyethylene thicknessExcessive polyethylene thickness• Limb lengthening Limb lengthening • Peroneal nerve tension and stretchingPeroneal nerve tension and stretching
(palsy : 4 % in literature)(palsy : 4 % in literature)• PCL sacrifice PCL sacrifice • More constrained prosthesisMore constrained prosthesis• Poor ligament isometricity Poor ligament isometricity • Possible instability (literature)Possible instability (literature)
In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
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Symposium SO.F.C.O.T - Paris - 1990
Typical case :
Patella infera, Pain++ Peroneal nerve palsy
Poor flexion : 70°
Acceptable solution for Acceptable solution for Unacceptable for major deformitiesUnacceptable for major deformities minor deformities minor deformities
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Second alternative : Second alternative : Bone graft Bone graft and thinner polyethylene plateauand thinner polyethylene plateau
Drawbacks are similar and walking is delayed Drawbacks are similar and walking is delayed
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Excessive valgus or varus make a new osteotomy necessaryExcessive valgus or varus make a new osteotomy necessary
In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed
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External tibial torsion is 0 External tibial torsion is 0 degree instead of 30° on the degree instead of 30° on the
other sideother side
Vicious rotation makes a new osteotomy necessaryVicious rotation makes a new osteotomy necessary
In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed
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Old case of rickets Previous Femoral fracture
osteotomy and tibial osteotomy
Femoral deformities make new osteotomy necessaryFemoral deformities make new osteotomy necessary
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2 possible options :2 possible options :
1 - Two-steps 1 - Two-steps with osteotomy first, and then TKA with osteotomy first, and then TKA
2 - 2 - TKA and osteotomy in a single operationTKA and osteotomy in a single operation
In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed
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1 - OSTEOTOMY First and TKA later1 - OSTEOTOMY First and TKA later
• Simplicity
• Rapid healing of the osteotomy
• The results are sometimes good enough for TKA to be unnecessary or delayed
• 2 consecutive operations (6 to 12 months)
• 2 anesthesias, 2 rehabilitation tasks, DVT risk
ADVANTAGESADVANTAGES
DISADVANTAGESDISADVANTAGES
This choice had been made for 67 young patients previously operated by osteotomy
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it is always possible to do an iterative osteotomy particularly in a young patient
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After a failed osteotomy it is possible to do a second osteotomy for a young patient
3 months 1 year
But elderly patients with severe arthritis need TKR
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• First report : JL LERAT : 1991
SOF.C.O.T Annual Meeting, Paris, 1991
Symposium : “ Failed HTO”
(2 cases operated on in 1990)
• WOLF and HUNGERFORD : 2 cases in 1991
• UCHINOU : 1 case in 1996• HUNGERFORD : “14th Annual Current Concepts in Joint
Replacement” in Cleveland, Dec 1997
2 - OSTEOTOMY + TKA2 - OSTEOTOMY + TKA
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1/ Correction of a tibial valgus deformity1/ Correction of a tibial valgus deformity
1 - Femoral cuts as in usual cases2 - Tibial cut is parallel to the condylar line3 - Ligament balance is easy to ensure4 - Spacer in place (or definitine implant in
the case of short stem)
4 - Osteotomy (fluoroscopic control) 5 - Tibial component is put into place 6 - Fixation with 2 or 3 staples
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Fer… F - 73 years13 years after first osteotomy
218° 182°
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W...
F - 60 years
HKA : 191°
Weight-bearing:
2 months
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• In case of a rotational deformity, osteotomy is performed lower down in the metaphysis
• It is necessary to remove the anterior tibial tubercule
• A plate is used for fixation ± staples
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2 : The distal femoral cut is done parallel to the tibial cut in extension 3 : Spacer and ligament balance 4 : TKA is fitted
1 : Anterior and post cuts are parallel to the tibial cut
Flexion 90°
2/ Correction of a femoral deformity2/ Correction of a femoral deformity
Extension
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Resection
Addition
Osteotomy is performed when the implants are placed
Graft with the bone resulting from the cuts
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Be... M - 75 years Previous femoral ost. at 20 years
TKA + ost. Graft after 4 months (non union) Healing : 7 m.
138°
Fl : 115°
180°
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Prat..... H - 75 years old
55 years after 1st osteotomy
TKR + opened osteotomy
166° 180°
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• 19 TKA + Osteotomy (18 patients)
• Mean age : 72 years ± 6 (60 - 80)
• 13 females - 5 males
MaterialMaterial
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• Varus knee (22°± 9) 8 cases – 2 excessive tibial varus
– 1 old tibial fracture
– 3 previous femoral osteotomy
– 1 old femoral fracture
– 1 old history of rickets
• Valgus knee (7°± 10) 9 cases – 8 HTO, 1 excessive valgus
• Rotation (25°) + varus : 2 knees– 2 previous HTO
MaterialMaterial
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17 cementless TKA, 2 cemented 14 PCL retaining prosthesis
3 two CL retaining prosthesis
2 hinged TKR
Osteotomies Tibia : 13
Opened osteot. : 3 Closed osteot. :8 Rotation : 2
Femur : 6
Opened osteot. : 3 Closed osteot. : 3
Technical characteristicsTechnical characteristics
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• Operation time : 153 ± 35 mn Similar to Teeny’s (16O mn) for a major varus series
Similar to Krackow’s (152 mn) for a major valgus series
• Blood loss : 1270 ± 570 ml (no difference between femoral and tibial osteotomies)
Technical characteristicsTechnical characteristics
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• Healing : 5 ± 4 months
• Complications • 1 non union (graft)
• 1 late fusion
• 1 early PE plateau wear
• Correction loss : 3.3° ± 2.9°
9 overcorrected HTO
• Follow-up = 45 ± 25 months
• IKS score preop = 87 ± 13
• IKS score post-op = 160 ± 21
• Flexion = 111°± 13
• Correction : Valgus 3° ± 3
RESULTSRESULTS
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• KRACKOWKRACKOW ((1991)1991)• IKS K score = 87.6IKS K score = 87.6
• Flexion = 103°Flexion = 103°
• MIYASAKAMIYASAKA (1997)(1997)
• IKS K score = 88.7IKS K score = 88.7
• Flexion = 101°Flexion = 101°
• LOTWOETLOTWOET (1997)(1997)
• IKS K score = 93.3IKS K score = 93.3
Comparison with the literatureComparison with the literature
9 overcorrected HTO TKA for valgus deformitiesTKA for valgus deformities
RESULTSRESULTS
• Follow-up = 45 ± 25 months
• IKS knee preop = 34 ± 11
• IKS Knee post-op = 86 ± 13
• Flexion = 111°± 13
• Correction : Valgus 3° ± 3
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Leg .. F - 75 years Previous HTO 6 years ago
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unipodal
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Ant drawer Post drawer
Standing position
INNEX mobile bearing knee
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• TEENY TEENY (1991)(1991)• IKS K score = 89IKS K score = 89
• Flexion = 98°Flexion = 98°
• LASKIN LASKIN (1996)(1996)• Flexion = 86°Flexion = 86°
• IKS K score = 86.4 IKS K score = 86.4 ± 12± 12
• Flexion = 111°Flexion = 111°± 10± 10
RESULTSRESULTS 8 major varus deformities TKA for varus deformities
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Lu.... 69 years Major varus deformity
T = 77°
153° 182°
Two cruciates retaining TKR
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Varus deformity following fractures of medial and lateral tibial plateaus
F - 80 years TKA + Opened HTO with graft and staples
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F - 71 years Femoral fracture at 45 yearsF - 71 years Femoral fracture at 45 years
Previous tibial osteotomy at 61 yrsPrevious tibial osteotomy at 61 yrs
Varus at 2 levelsVarus at 2 levels
179°
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- First case of the series
- Obesity (>100 Kg)
- Recurrent varus
- Wear of a too thin PE
• 1 poor result1 poor result
• 1 revised1 revised
2 previous tibial osteotomies with rotation in the same patient
1 particular case of malrotation1 particular case of malrotation
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F : 60 years. Poliomyelitis. Patella infera. Quadriceps=0. Varus : 20° 2 previous osteotomies. Global arthritis. Ligamentous laxity.
The 2 most recent cases had bone deformity + Laxity they need very constrained TKR
160°
1st case
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Grafting with the bone resulting from the cuts
The placement of the stem needs an osteotomy
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Bone deformity + Laxity A very constrained hinged TKR is needed
Particular case of a malunion above a TKA
+Lateral laxity
The particular shape of the femur dictates an osteotomy
2d case
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Bone deformity + Laxity Ligamentous laxity needs a very constrained hinged TKR
Particular case of a malunion above a TKA
+Lateral laxity
The particular shape of the femur dictates an osteotomy
2d case
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Particular case of a malunion above a TKA
+Lateral laxity
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• A single operation
• Joint line and ligament balance preserved
ADVANTAGESADVANTAGES
DISADVANTAGESDISADVANTAGES
• Technical difficulties
• Rather prolonged osteotomy fusion
OSTEOTOMY + TKAOSTEOTOMY + TKA
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Valgus stress Varus stress
Stress radiography allows precise measurements of ligamentous and bony deformities
DEFORMITYDEFORMITY Wear + laxity = Extra-articular Extra-articular deformitydeformity+
206° 188°
INDICATIONSINDICATIONS
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INDICATIONSINDICATIONS
Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=
Stress radiography allows precise measurements of ligamentous and bony deformities
206° 188°
Valgus stress Varus stress
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INDICATIONSINDICATIONS
Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=
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• Valgus def. = Valgus def. = 17°17°± 10 ± 10 ( 9 to 30°)( 9 to 30°)
• Varus def. = Varus def. = 22°22° ± 9 ± 9 (12 to 34°)(12 to 34°)
Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=
Mean deformity in the serie
INDICATIONSINDICATIONS
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• Valgus def. = Valgus def. = 17°17°± 10 ± 10 ( 9 to 30°)( 9 to 30°)
• Varus def. = Varus def. = 22°22° ± 9 ± 9 (12 to 34°)(12 to 34°)
Wear + laxity
14.3°14.3°
16.4° 16.4°
DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=
Minimum deformity for indication ?? 10° ??
INDICATIONSINDICATIONS
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- Length of the limbs
- Bone is available for grafting (bone cuts)
Opening HTO is difficult in previous valgus HTO
Opening HTO is easy for varus tibial deformities
Opening = closing for femoral deformities
Opening or closing wedge osteotomy ?
INDICATIONSINDICATIONS
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• Infrequent operation (19 knees)
(during the same period by the same surgeon : 840 TKA)
• Indicated in cases of severe gonarthrosis and major extra-articular deformity in elderly patients
ConclusionsConclusions
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• The results of these extreme cases are similar to those of simple TKA
• There are advantages in doing TKA and osteotomy in a single operation :• Preservation of the joint level (and PCL) and patellar height
• Good balance of the ligaments eliminating the need for highly
constrained TKA
• It is also compatible with the performance of non cemented implants
ConclusionsConclusions