2/7/2018. Osteotomies About the Knee. Editorial Board AJSM Social Media. Consultant. <55 yrs old 55 yrs old >75 yrs old

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1 21st Annual Orthopaedic & Sports Medicine Conference February February Disclosures Osteotomies About the Knee Dr Alan Getgood MD MPhil FRCS(Tr&Orth) DipSEM Assistant Professor Complex Knee and Sport Medicine Orthopaedic Sport Medicine Fellowship Director The Fowler Kennedy Sport Medicine Clinic University of Western Ontario London, Ontario Canada Research Support Canadian Foundation for Innovation ISAKOS/OREF Musculoskeletal Transplant Foundation Canadian Institute for Health Research Arthritis Society Ontario Research Fund Smith & Nephew Inc. Arthrex Inc. Conmed Inc. Depuy Synthes Inc. Eupraxia Inc. SBM Inc. Editorial Board AJSM Social Media Consultant Smith & Nephew Inc. Conmed Inc. Depuy Synthes Inc. Ferring Inc. Ossur Inc. Bare Bone Facts Knee Preservation Timeline <55 yrs old 55 yrs old >75 yrs old Younger Patient Demand for Primary and Revision Joint Replacement: National Projections from 2010 to 2030 The Journal of Arthroplasty, Volume 24, Issue 2, Pages e34 e34 S. Kurtz, E. Lau, K. Ong, K. Zhao, M. Kelly, K. Bozic By 2030, the demand for TJA by patients <65y is projected to be 52% of primary THAs and 55 62% of primary or revision TKAs Osteotomy/ Joint Preservation Osteotomy UKA TKA The future demand was projected to grow the fastest for the 45 54y age category for primary TKA, which was anticipated to grow from 59,077 in 2006 to 994,104 (17 times) by Young, active Demanding Jobs Sport Active, manual work Retired, Sedentary Treatment Strategy: Aim to stay in the green zone: HTO vs. UKA Romain Seil

2 HTO vs. UKA Why not UKA? Would you rather revise an HTO or a UKA? Swedish Registry LHSC Data Kaplan-Meier Survival (All Revisions for Surgeries 10 years or Greater from the time of surgery) Cumulative Survival 92.9% TKA 80.6% UKA Survival Time (Years) Australian Registry: % Revised Australian Registry: Age Cumulative Percent revised Log-rank test for equality over strata p-value < Hazard Ratio (adjusted for age and sex; Unicompartmental for OA V Total Knee for OA = 2.02; 95% CI (1.90,2.14) p-value < n= 45,615 n= 494,571 years since primary procedure 21.0% 7.3% UKA TKA 15 yrs % UKA in Australia 15.1% in % in % in % in 2015 < 55 yo 32.5% rev rate at 15 yrs > 75 yo 9.3% rev rate at 13 yrs, 32.5% (15.7) 24.6% (9.9) 16.8% (6.5)? (3.2) Higher Revision rate for UKA is offset by greater patient satisfaction? What are we trying to achieve? Distribution of Satisfaction (%) Very Satisfied Satisfied Uncertain Dissatisfied (12,298) (7,860) NO! Swedish Registry TKA (12,298) & UKA (7,860) IDENTICAL Robertsson et al, Acta Orthop Scand, Coronal plane To reduce the external knee adduction moment (varus knee) or abduction moment (valgus knee) 2. Sagittal plane Alter tibial slope to reduce tibial translation and achieve sagittal balance 2

3 Re alignment Osteotomy Does it work? Reduction in knee adduction moment (KAM) in the varus knee correlates with KOOS MCID Why is it KAM important? What happens to Articular Cartilage after HTO? Tibiofemoral contact stresses related to progression of OA Segal et al (2009) Increase in AC loss Rate of AC loss directly correlates to peak knee adduction moment Teichtahl et al. (2009) Foroughi et al. (2009) Increase in adduction moment Increase in adduction of tibia Decrease in medial proximal tibial articular angle Improvement in quality and volume of repair tissue Evidence HTO Evidence Varus osteotomy 70% 10 yr survivorship 3

4 HTO + cartilage repair Coronal Alignment Effect on Collaterals and Cruciates What are we trying to achieve? Sagittal Alignment 1. Coronal plane To reduce the external knee adduction moment (varus knee) or abduction moment (valgus knee) 2. Sagittal plane Alter tibial slope to reduce tibial translation and achieve sagittal balance Posterior slope results in increased shear strain on ACL In stance (loading 3x body weight) ACL must resist 0.5 body weight An increase in 4 o slope with 200N axial load results in increase of 3mm anterior translation Giffin et al. AJSM Biplanar Osteotomy () General Indications for Osteotomy Sagittal plane Reduce shear strain on ACL or PCL by reducing or increasing the posterior tibial slope respectively Alters tibiofemoral contact pressure 1mm of = 1 o of slope change Coronal alignment Ligament instability (chronic) OA Cartilage repair Meniscus transplant Sagittal alignment Tibial slope ACL/PCL Patellofemoral disease TTO 4

5 Joint Restoration Philosophy Other Considerations Biomechanics Realignment Osteotomy Ligament Reconstruction Meniscus Allograft Transplantation Symptoms Pain/instability or BOTH Patient factors Age Activity level/occupation Co morbidities BMI Smoker? Diabetes? Biology Articular Cartilage Repair Adjuvant Therapies Exhaust non operative treatment Physiotherapy Viscosupplementation Unloader brace/lateral heel wedge Weight loss Activity modification 1. Type of pathology 2. Site of pathology 3. Measure angles long leg alignment 4. Where is the deformity? 1. Type of pathology 2. Site of pathology 3. Measure angles long leg alignment 4. Where is the deformity? 5. How to correct it 1. Type of pathology 2. Site of pathology 3. Measure angles long leg alignment 4. Where is the deformity? 5. How to correct it 6. By how much 5

6 OA 62.5% Fugisawa point In ligament cases do not Fujisawa, over correct Y., Masuhara, K., and Shiomi, S.: The aim effect for of neutral high tibial alignment! osteotomy or osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop. Take lateral Clin. North laxity Am , into 1979 consideration 1mm of increased lateral compartment gapping = 1 o of OA 62.5% Fugisawa point In ligament cases do not over correct aim for neutral alignment! Take lateral laxity into consideration 1mm of increased lateral compartment gapping = 1 o of OA 62.5% Fugisawa point In ligament cases do not over correct aim for neutral alignment! Take lateral laxity into consideration 1mm of increased lateral compartment gapping = 1 o of OA 62.5% Fugisawa point In ligament cases do not over correct aim for neutral alignment! Take lateral laxity into consideration (double and triple varus) 1mm of increased lateral compartment gapping = 1 o of Tibial Slope Measurement Surgical Pearls for MOWHTO Lateral view, full extension weight bearing Tibial Slope Medial vs. Lateral Correction 1mm = 1 o 18 0 slope Fluoroscopy from ipsilateral side Stand on contralateral side MOWHTO Distal MCL release Posterior Retractor Biplane Osteotomy Increased surface area Greater rotational control Slope Maintain: Y1 = Y2 x2 Increase: Y1 = Y2 Decrease: Y1 < Y2 You have to destabilize the lateral hinge 6

7 Surgical Pearls for MOWHTO Surgical Pearls for MOWHTO Fluoroscopy from ipsilateral side Stand on contralateral side Fluoroscopy from ipsilateral side Stand on contralateral side MOWHTO Distal MCL release Posterior Retractor Biplane Osteotomy Increased surface area Greater rotational control MOWHTO Distal MCL release Posterior Retractor Biplane Osteotomy Increased surface area Greater rotational control Slope Maintain: Y1 = Y2 x2 Increase: Y1 = Y2 Decrease: Y1 < Y2 You have to destabilize the lateral hinge Slope Maintain: Y1 = Y2 x 2 Increase: Y1 = Y2 Decrease: Y1 > 2x Y2 You have to destabilize the lateral hinge Y2 Y1 Surgical Technique Rehabilitation TWB for 2 weeks in Tracker brace WBAT thereafter Wean off crutches Brace off once regained quad control Monitor lateral hinge pain Distal Femoral Varus Osteotomy Distal Femoral Varus Osteotomy Lateral Opening Easy approach One cut Able to titrate Stable locking implants Medial Closing Soft tissue coverage over plate Very stable fixation Early ROM and WB BUT Hardware issues with ITB Plate removal Loss of?... BUT Approach can be challenging if large VMO Less able to dial in 7

8 Tibial Based Varus Osteotomy?? Return to Sport after Osteotomy Lateral Opening Wedge HTO Mild Valgus (<5 0 ) Normal anatomic Lateral Distal Femoral Articular Angle (aldfa) (81 0 ) Small (<10mm) Want to correct mechanical axis through Flexion/Extension Mostly isolated cartilage wear/meniscus loss *Wrong number or no response after at least three attempts Witjes, Getgood et al. 2 nd place, John Joyce Award, ISAKOS 2017 Results: sports participation & impact of sports Summary Main sport ever (N=60): Highest impact: ever (n=60) since osteotomy (n=57) Osteoarthritis on the rise will effect more younger individuals volleyball baseball ringette fight sport rugby football running soccer ball hockey basketball icehockey fitness/weights rollerblading zumba/gymn snowboarding hiking badminton skiing walking biking/cycling golf high impact intermediate impact low 5 yrs level reduces to 80% Since osteotomy: 95% returned to sport (RTS) 60% to pre injury impact 14% to higher impact 53% high impact 5% (n=3) did not RTS All 3 had indication OA We are aware of the treatment gap for OA. Osteotomy a key component to address that gap Aim to keep young patients in the green/preservation zone Indications remain consistent education is the key. Address the pathology with an appropriate procedure Thank you! Fake Knees are NOT the answer.. 8