Osteotomiesabout the Knee

Geoffrey F Dervin, MD, MSc

Associate Professor

Chairman, Division of Orthopaedic Surgery

University of Ottawa

Outline• General indications• Technical issues• Associated ligamentous deficiencies• complications

Symptomatic medial OA

• UNI ?

• HTO ?

• TKR ?

• How to decide ?

• Who to decide ? Surgeon or patient

BS. 50 yo active male tennis playerDisabling medial pain

B.S. 50 yo active male tennis playerDisabling medial pain

Degenerative medial Meniscal tear

After partial resection

….but 3 months post scope - still very symptomatic

Solution : Open wedge osteotomy

IndicationsBest patient:

• Moderate OA …Grade 3 or focal area of grade 4 kissing lesion

• ROM 10 – 100 minimum

• Not obese

• Active ….physiologically young – sportive

• Non smoker

Major determinants in deciding whether to offer HTO for medial OA :

1. Patient needs , expectations

2. Patient age

3. Disease severity

4. Patient preference

Indications• Best patient…..rarely exists

• Compromise some indications if younger, i.e. accept worse severity

• Act as a bridge to total knee replacement

Issues in selection: Patient expectations

Compliance with rehab a concern ?

– Lean to UNI

• Pain relief needed

– Expect a little less with HTO

• ADLs wishes….sports..

– Permit a little more with HTO

Issues in selection: Age !Life Remaining

35 40 50 60 70 80 85

18 years

23 years

32 years

40 years

Courtesy J Rudan

PL – 44 yo female

PL

PL

Goals of osteotomy: 1.Correction of coronal alignment

• Some discretion based on OA severity

• More extensive the bone loss – more lateral desired mechanical WBL

Goals of osteotomy: 2.Correction of sagittal

alignment

Tibial slope

Posterior Tibial Slope1.Take midpoint of lateral tibia 1.Take midpoint of lateral tibia at 10 and 20 cm inferior to at 10 and 20 cm inferior to tibial plateautibial plateau

2. Draw perpendicular line2. Draw perpendicular line

3. Trace line along posterior 3. Trace line along posterior plateauplateau

4. Measure angle subtended 4. Measure angle subtended between linesbetween lines

10cm &20 cm

Posterior Tibial SlopeNormative Data - Sagittal PlaneNormative Data - Sagittal Plane

StudyStudy Slope AngleSlope Angle

Lecuire, 1980Lecuire, 1980 6 °6 °Bonnin, 1990Bonnin, 1990 10 10 ++ 3.1° 3.1°Paley, 1992Paley, 1992 10 °10 °Insall, 1993Insall, 1993 10 °10 °Dejour, 1994Dejour, 1994 10 10 ++ 3.1° 3.1°Paley, 1994Paley, 1994 9 9 ++ 3° 3°

10cm &20 cm

10°± 2°

Tibial vs. Meniscal SlopeJenny JY et al Jenny JY et al

Rev Chirurg Orthop 1997, 83; 435-438.Rev Chirurg Orthop 1997, 83; 435-438.

• Posterior horn of Posterior horn of menisci thickermenisci thicker

• Bony slope mean 84.4Bony slope mean 84.4ºº ± 2.9 SD± 2.9 SD

• Meniscal slope 90.5Meniscal slope 90.5º ± º ± 4.1 SD4.1 SD

Bony slope Meniscal slope

Sagittal wear patterns in OA of knee Anteromedial osteoarthritis of the knee

White, Ludkowski, Goodfellow JBJS 73 B(4): 1991

• Medial compartment arthrosis – 46 specimens

• ACL intact • Deepest erosion anterior

to midpoint• Posterior tibial plateau

consistently spared

Sagittal wear patterns in OA of ACL intact knee

Anteromedial osteoarthritis of the knee White, Ludkowski, Goodfellow

JBJS 73 B(4): 1991

• Medial compartment arthrosis – 46 specimens

• ACL intact • Deepest erosion

anterior to midpoint• Posterior tibial

plateau consistently spared

Posterior

Anterior

Sagittal wear patterns in OA of ACL intact knee

Anteromedial OA

Posterior

Lateral

Anterior

Medial

Sagittal wear patterns in OA of knee – standard anteromedial ( excessive)

Sagittal wear patterns in OA of knee – standard anteromedial ( excessive)

Development of degenerative “cupula”

Sagittal wear patterns in OA of knee – ACL deficient - posteromedial

Anterior subluxation…

Posterior wear

Sagittal wear patterns in OA of knee – ACL deficient - posteromedial

Posterior

Contributors to AP Knee Stability:

• Cruciate Ligaments Cruciate Ligaments

• MenisciMenisci

• Joint CapsuleJoint Capsule

• Tibial slopeTibial slope

Radiographic Evaluation in isolated ACL RUPTURE (281 cases): Bonnin 1994

Surgically should aim to adjust sagittal slope according to patient

characteristics

• Ligamentous intact knee

• ACL deficient knee

• PCL deficient knee

Effects of Increasing Tibial Slope onthe Biomechanics of the Knee

J. Robert Giffin, MD, Tracy M. Vogrin, MS, Thore Zantop, Savio L-Y. Woo, PhD, DSc, and

Christopher D. Harner,* MD

• The American Journal of Sports Medicine, Vol. 32, No. 2; 376-82: 2004.

Effects of Increasing Tibial Slope onthe Biomechanics of the Knee

• The American Journal of Sports Medicine, Vol. 32, No. 2; 376-82: 2004.

Total AP laxity & in-situ forces unchangedTotal AP laxity & in-situ forces unchangedat the new anterior resting positionat the new anterior resting position

• The American Journal of Sports Medicine, Vol. 32, No. 2; 376-82: 2004.

Deflexion (Extension) Osteotomy

• First described by Slocum (1983)

– Dogs (tibial slope > 20°)

• Indications (humans):

– pre-osteoarthritis

– a large ATT (> 10°)

– excessive tibial slope (>13°)

Dejour 1994With ACL DEFICIENT KNEE

Surgically should aim to adjust sagittal slope according to patient

characteristics

ACL deficient knee – decrease slope

• PCL deficient knee – increase slope

• Ligamentous intact knee – maintain slope

Techniques

• Lateral closing wedge

• Medial opening wedge

– Acute opening

– Distraction osteogenesis

• Dome

Lateral closing wedge – current systems

• Accurate cuts• Accurate angle• Predetermined wedge apex• Tight closure• Rigid fixation• More likely to decrease slope

Rx of the Fibula options

• Take down tib./fib. joint• Shell out fib. head• Resect at fib. neck• Resect at prox. 1/3

Courtesy D Paley, Principles of Deformity Correction, Springer Verlag, 2002

Techniques – Domebest for severe deformities

Opening Wedge/Ext. Fix

• Pin placement• Corticotomy• Test distraction• Lock in compression

Opening Wedge/Ext. Fix

• Compress x 1 week• Open @ 1 mm/day• Correction + 1.0 mm• Lock• Fix. locked until bony healing (~10-12 wks)• Remove fix. but leave pins-1 wk.• Recheck correction• Remove pins

Advantages of Open Wedge/Ext. Fix

• No fibular osteotomy• Small skin incisions• Exact correction of deformity• No change in prox. tibia shape• No added lat. soft tissue lax.• No shortening of limb

Disadvantages of Open Wedge/Ext. Fix

• Frame worn medially• Pos. pin tract infection • Pos. joint infection• 2nd procedure to remove• Tightens ext. mech.• Time to healing

Opening wedge osteotomy - my preference

• Easier exposure

• Dial in correction intraoperatively

• Less distortion of proximal tibia anatomy

• PCL insertion preserved

Beware of sagittal slope – understand triangular shape of tibia

Beware of sagittal slope

MUST USE TAPERED WEDGE

Opening Wedge Tibial OsteotomyThe 3-Triangle Method to CorrectAxial Alignment and Tibial Slope

• Noyes et al, The American Journal of Sports Medicine, Vol. 33, No. 3; 378-87: 2005

Medial Opening WedgeMedial Opening Wedge

Cut Posterior cortex with microsagittal sawwith posterior protection

• Tapered wedges to prevent increasing posterior slope

Anterior Posterior

Opening Wedge Tibial Osteotomy

The 3-Triangle Method to Correct

Axial Alignment and Tibial Slope

Intact extensor mechanism

• 1 triangle technique to prevent

increasing posterior slope

Technical success features

• Intact lateral cortex• Long stable screw

purchase• Appropriate coronal

correction ( complete posterior osteotomy)

• Filled defect

Sagittal slope preserved – posterior placed plate

Advantages of Opening Wedge

• No fibular osteotomy• No change in prox. tibia shape• No added lat. soft tissue lax.• No shortening of limb• Fewer Neuro. Comps.

Opening wedge-disadvantages• Bone graft or substitute usually needed• NWB/PWB Status• Healing Time longer• Hardware can be irritable in medial

subcutaneous location• Best reserved for mild to moderate corrections

up to 12 degrees• Beware of increasing sagittal tibial slope…

Results: Personal experienceFirst 14 OW vs historical CW cases

Demographics

Open Wedge Closing Wedge

Patient Number 14 16

Age 51.9 9.5 44.8 7.3

Male / Female 10 / 4 13 / 3

Right / Left 5 / 9 9 / 7

Open Wedge Closing Wedge

Pre-Op 5.9 4.6° 8.9 2.9°

Post-Op 11.3 5.0° * 6.7 2.5° *

Results : Posterior tibial slope

Combined HTO/ACL reconstruction

Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up. Knee, 2004

Bonin N et al., Lyon, France

• 30 knees in 29 patients – ACL deficient, med comp OA (IDKC grade B and C)

• Mean age 30yrs (18-41yrs)• Simultaneous HTO/ACL reconstruction• Mean 12 year f/u (6-16yrs)• 5 knees progressed one arthritic grade• Stable – mean 3mm side to side difference in KT-1000• 84% moderate to intensive sports/activities

Combined HTO/ACL reconstruction

Outcome following simultaneous ACL reconstruction and medial opening wedge high

tibial osteotomy.Jerome J DaSilva, Nicolas Graveleau, Robert Litchfield, Peter Fowler, Robert Giffinfrom the Fowler Kennedy Sports Medicine Centre, London, Ontario

• 36 knees – med comp OA, ACL deficient, varus• Average age 37yrs (20-54yrs)• Mean f/u 3yrs (1 - 4.5yrs)• No progression of OA• Improved KOOS, WOMAC• 29 returned to previous sports• 7 had not returned to previous level – 2 no desire, 2 progressing,

2 symptomatic laxity, 1 infection

Combined HTO/ACL reconstruction

Tips for OW osteotomy & ACL:

1. Make osteotomy low enough on medial tibia

2. Keep tibial tunnel in untouched proximal tibial bone, easier by starting more obliquely

3. Anteromedial portal for femoral tunnel leaves more options for tibial tunnel

4. Order not critical

5. Keep tibial slope neutral or try to decrease a little

Combined HTO/ACL reconstruction

Patient AS

• 53 yo man fell off ladder

• Felt knee bend backward

• Referred for PCL reconstruction

Patient AS - Examination

• L knee

• 30 – 0 – 130 vs 10- 0 – 130 (R)

• Post drawer Grade1 - 2

• Other ligaments normal

Patient AS - Imaging

Patient AS - Imaging

Posterior stress views identical

Patient AS - Imaging

Normalposterior tibial slope

A.S. Summary

• Need to control hyperextension symptoms from primarily posterior capsular attenuation

• PCL (AL bundle) normal on Telos posterior stress view and clinical examination

• Rx options:• Brace locked at 10 º• Anterior OW osteotomy• Posterior capsular imbrication• Combined procedure most likely required

Contributors to AP Knee Stability:

• Cruciate Ligaments Cruciate Ligaments

• MenisciMenisci

• Joint CapsuleJoint Capsule

• Tibial slopeTibial slope

Triple varus knee

High Tibial Osteotomy

• Important surgical option in the treatment of the young patient with OA and malalignment

• Able to be combined with ACL reconstruction for instability• Results deteriorate with time – good pain relief and

restoration of function in 80-90% at 5yrs and 50-65% at 10yrs

BUT

Joint is preserved and activity encouraged• Later conversion to TKR should not be significantly

affected (Medial Opening Wedge better than Lateral Closing Wedge)

Thank you