Disclosures. Why Osteotomy? Osteotomies of the Knee Indications, Techniques and Outcomes

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1 Osteotomies of the Knee Indications, Techniques and Outcomes Tom Minas MD MS Director, Cartilage Repair Center BWH Associate Professor HMS, Boston Ma Disclosures Vericel ( formerly Genzyme Biosurgery) Consultant Elesevier Book royalties ConforMIS Inc., SAB member stocks and royalties Why Osteotomy? Simple procedure Biologic solution Preserves integrity of joint Amenable to salvage/conversion No implant related activity restrictions Favorable outcome data 1

2 Osteotomy Tibiofemoral Joint Preop Planning Assessment Anatomic situation Varus knee - tibia Valgus knee - femur Pathologic situation Cartilage repair Osteoarthritis Instability Mechanical Correction Correction for Valgus HTO Cartilage Repair Midline OA-lateral tibial spine 2 o overcorrected Aberrant anterior tibial artery 3-8% Klecker RJ, Winalski CS, Aliabadi P, Minas T. The aberrant anterior tibial artery: magnetic resonance appearance, prevalence, and surgical implications. Am J Sports Med Apr;36(4):

3 Pre-operative Planning Closing Wedge Valgus HTO Angular mechanical correction to lateral tibial spine (<15 o ) Leg length discrepancy (long leg or equal) Joint line obliquity (horizontal) Av Patient age my series 44 Coventry s 65 Revision pitfalls: HTO to TKR HTO + TTO - 30 YO Male 10 degree angular correction to lateral tibial spine 3

4 Set Up for Osteotomy Epidual Anaesthesia-now spinal/ga with preemptive analgesia and pericapsular infiltration Fluoroscopy C- arm Radiolucent table to include hip and ankle Tourniquet Thigh side post Foot post to allow 90 o flexion Oblique Midshaft Fibular Osteotomy avoid EHL motor branch 15 cms below fibular head interval between lateral and posterior mucle compartments Midline Skin Incision Anterior Muscle Takedown 4

5 Dissect anterior Fibular Head Posterior Dissection to protect NeuroVascular Structures (3% aberrant Tibialis Anterior Artery) TTO- elevate Tubercle to allow distal wedge and realign patella Calibrated Angular Osteotomy Guide (6 20 o ) 5

6 Removal Bone Wedge Don t break medial cortex (arrow) Plate Proximal Fixation, medial cortex drilling osteoclasis, and Gentle slow Compression HTO + TTO + Fibular Fixation 6

7 Postop Xrays Post operative care after closing wedge HTO Epidural anaesthesia,now pericapsular infiltration Drains under compartments and AB s x hours TEDS Stockings ASA 325mg bid x 3 weeks for DVT prophylaxis CPM x 3 wks, then stationary bike Touch-Partial (30%) WB, until radiographic healing, usually at 6-8 weeks Closing Wedge Tibial Valgus Osteotomy 7

8 Open Wedge Puddu Plate HTO Technique Advantages Popularized in France Puddu popularized accurate technique Technically less dissection Offers dial in correction on table Allows bi-planar correction Stabilizes medial pseudolaxity?easier conversion to TKR Disadvantages Need for bone graft Longer healing beware smokers 44 Year old Male Medial Left Knee pain Axial Correction 11 o Mechanical axis correction to neutral if no joint space narrowing Lateral tibial spine with OA narrowing Medial Pseudolaxity corrected with open wedge technique 8

9 Mechanical Correction Scaled digital xray measure 13 mm 11 o Skin Incision Medial Subvastus Exposure Bone graft from distal femur 9

10 Patellar tendon exposure Pes Tendons and Superficial MCL Takedown Protect Posterior NV Structures Sponge pack and patellar tendon Breakaway Pin Fluoroscopic CheckBreakaway Pin Osteotome Position after Saw 10

11 Opening Wedge Tines Plate Placement Between Tines after Handle removed Staple Fixation Supplement if Large Correction or Opposite Cortex Cracked 11

12 Autogenous Bone Graft OATS Harvesters from Distal Femur Cancellous Allograft Bone Supplement Final Appearance and Pes MCL Closure and Drains 12

13 ABG- Donor and Recipient Sites Opening Wedge HTO 1 cm LLD & sloped Joint Line SM S M L L L L Patellar Contact forces with Open Wedge HTO 13

14 Patellar forces and tracking with Open Wedge HTO Instability PCL laxity ACL laxity 54 year old male construction worker 14

15 Triple Varus with Pagoda deformity Retro tubercular osteotomy 15

16 Bilateral HTO - 10 years later with native knees Patello-Femoral Chondromalacia Underlying cause frequently maltracking dysplastic trochlea females more commonly affected traumatic dislocation 16

17 Investigations for P-F Joint X-rays- AP, Lat, Skyline CT scan-trochlear hypoplasia, subluxationquads +- contraction with IA contrast MRI arthrogram- IV Gadolinium 2- assess chondrosis localization Arthroscopic localization of chondral lesions, patella & trochlea TTO AMZ Fulkerson Osteotomy Correlation of Patellar Articular Lesions with Results from Amteromedial Tibial Tubercle Transfer,AJSM,vol25,no.4, ,1997 Good Poor 17

18 Results TTO Buuck DA, Fulkerson JP. Anteromedialization of the Tibial Tubercle:A 4 to 12 year Follow - Up.Op Tech Sports Med,Vol.8,No2(April),2000:pp patients,42 knees(6 bilat),av f/u 8.2 yrs G/E 86% subjective, av Lysholm score 83.5(15-100),7/36 heavy labour,9/36 mod work,18/36 light duty Distal Femoral Varus Osteotomy for Genu Valgum and Lateral OA Medial Closing Wedge Lateral opening wedge Reverse dome varus Proximal tibial varus 18

19 DFVO Closing Wedge Lateral Opening Wedge Femoral Varus 45 PA 30 yo female with preop LLD and valgus deformity with lateral OA 15 mm opening wedge DFVO with ICBG 34 YO male with collapse of ORIF lateral tibial plateau with valgus 19

20 Biologic Reconstruction with fresh LTP osteoarticular allograft 20 YO menisectomized valgus knee 2 years post op pain free and plays all sports 594 DFVO -Reverse dome 29 yo male Preop Plan Intraop Axis Postop AP 20

21 Proximal Tibial Varus Osteotomy for Lateral OA Results DFVO Healy,WL et al., DFVO,JBJS(A),1988, DFVO,av age 53yo,4yr f/u, 83% G/E HSS(65-86) 14/15 (93%) for OA G/E Finkelstein JA, Gross AE, Davis A. Varus Osteotomy of the Distal Part of the Femur,A survivorship Analysis.JBJS(A),1996, knees,kaplan -Meier 64% - 10 year survival av f/u 133 mos,13 ok,3 failed early(1-2 yrs),4 late(6-8 yrs) Summary - Osteotomies About the Knee Predictable results G/E 80% 5 year, 60% 10 year Maintain youthful QOL activity level low complication rate Plan for future reconstructions by osteotomy technique and skin incisions 21