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