Analysis of deformitiesPrinciples and technique in

deformity correctionSébastien LUSTIG MD, PhD, Prof

Lyon

Dealing with deformity

1. Analysis of deformity2. Frontal deformity

- High tibial osteotomy:- opening wedge- closed wedge

- Distal femoral osteotomy3. Sagittal deformity4. Horizontal deformity

Principles of Deformity Correctionby Dror Paley.

93°

87°

Constitutional (varus)

deformity

“Normal” Tibial Slope• Wide range reported & different

measurement techniques• 0 – 240

• Varies between races– Chinese (4-250)– Nigeria (0-240)– Japan (0-190)

• Important to assess each patient

Sometimes Obvious deformity

30° external rotation !

Sometimes tricky

A good exemple …

Male 45ys oldFemur fracture 20ys ago

Male 45ys oldFemur fracture 20ys ago

90°

76°

20°

CORONAL

SAGITTAL HORIZONTAL

CORONAL deformity

1 2 3 4

Osteotomies

Ahlback S: Osteoarthrosis of the Knee. A radiographic investigation. Acta Radiol Diagn. 1968

Ahlbäck

Ostéotomie tibiale de valgisation

Courtesy JN Argenson S parratte

If you want to avoid an oblique joint line

Try to correct the deformity where it is located

Septic history

High tibial osteotomy

• Four basic types of valgus proximal tibial osteotomy :– Lateral closed wedge osteotomy (Coventry)– Medial Opening wedge (Hernigou)– Dome osteotomy (Maquet)– Medial opening hemicallotasis (Turi)

- Pros :Shorter legLess malunionEasier to revise with a TKA

- Cons :Patella Baja

Opening Wedge HTO

AJSM 2012

Stress XRays

LL Standing XRays

Reducibility

Axis Angles

Deformity

Malunion 20°Wolff & al ; 1991 CORR

DAR : 2°DAR : 2°

DAR : 8°DAR : 8°

DAR : 18°DAR : 18°

DL 4 mm

DL 14 mm

DL

37 mm

20°

20°

20°

Coronal plane

Midshaft malunion 21°:

Knee varus extraraticular

deformity: 10.1°(wear » 6°)

21°

AFTm164°

mFA

mTA

Miniaci Method

Weight-bearing line method :

Choose the desired coordinate (50 to 75%)

Computer assisted surgery

Biplanar osteotomy with medial opening wedge.Tuberosity fragment stays with distal fragment.

Locking Tomofix plate is pretensioned and fixed for stability and early mobilization

3 months

3 months

- PROS :

Most significant correctionsLonger legLess non union (smoker ?)No patella BajaLess slope modifications

- CONS :Fibular nerve

Closed Wedge HTO

Size of bone wedge

60 ys, very activeBilateral HTO

Locked In Screws for stable fixation

« Safety distance » 7 to 11 mm

Prearthritis +

anterior chronic laxity

MFTOA + ACL deficiency

1° valgus

53 ys old, 1 year post ACL + HTO

pas de correction excessive …

Effect more pronounced in medial compartment

Opening Wedge HTO tends to increase slope

To maintain slope: Posterior gap should be twice as wide as the anterior gap

Distal Femoral Osteotomy

F=98°

186°

Femoral or Tibial O. ?

Distal Femoral Varus O + 10y

56

Alc…denise 60 Y

Distal Femoral Varus O + 10y

57

Jea…colette 72 Y

Tibial Varus O + 11y

1.The rationale

2.Surgical Technique

3.Results

Blade plate ortientation

95° Blade Plate

85°

85°

75°

75°

10° of correction

85° -10° = 75°

10° of correction

85° -10° = 75°

10°

Diaphysal deformity

Metaphysal deformity

Opening and closing wedge

CORONAL

SAGITTAL HORIZONTAL

Surgical technique

Surgical technique

ATT Proximal Transfer

Opening wedge

=

Surgical technique

+ -

CORONAL

SAGITTAL HORIZONTAL

Des…buno53 Y previous Fem. O in 1993 F+T fractures in 2005

79

External torsion +35°

80

External torsion +35°

WHEN ?OA and malunion - malrotation > 10 – 15 ° - Coronal deformity > 10 °

Combined osteotomy

Why a combined OSTEOTOMY ?

Femoral O. to adress the malunion

Tibial O. to adress the osteoarthritis

Double level osteotomy of the knee : a method to retain joint-line obliquity. Clinical resultsBabis GC, An KN, Chao EY, Rand JA, Sim FH. J Bone Joint Surg Am. 2002 Aug;84-A(8):1380-8.

Take home message

• Understand and correct the deformity where it is located.

• 3D analysis (coronal but also sagittal and horizontal ).

• Technical aspects ++

Thank You