why and when you should correct alignment · why •effects of malalignment •principles of...
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Why and when you should correct alignment
Ronald van Heerwaarden
Centre for Deformity Correction &
Joint Preserving Surgery
Mill, The Netherlands [email protected]
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Why • Effects of malalignment • Principles of alignment correction • Effects of malalignement correction When • Why and when – joint preservation • Timing of surgery • Cases Conclusions
Why and when you should correct alignment
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Osteoarthritis as a disease of mechanics
Felson 2013, Brouwer 2007, Sharma 2001, 2009, 2010, 2012, Cerejo 2002 Framingham, MOST, other studies
A frontal plane deformity more than 3° leads
to osteoarthritis and should be corrected
4 degrees of deformity: increases 3 x risk for OA Progression of OA 10 to 20 x faster with deformity present
Effects of Malalignment
F a s t e r
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Malignment progression following other knee injuries
ACL rupture
I
Medial menuscus rupture
I
Cartilage damage
I
Malalignment progression
Vicious Circle of increasing joint damage
Effects of Malalignment
meniscus
cartilage
ligaments
alignment
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Principles of alignment correction
Osteoarthritis as a disease of mechanics
Correction of WBL
WBL position at the knee joint
defines cartilage loading
Deformity analysis and
Planning of correction
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Principles of alignment correction
Goal: re-align leg (N/unloading + retain joint line orientation
WBL position at the knee joint
defines cartilage loading Babis et al. JBJS 2002 Double level osteotomy of the knee: a method to retain joint-line obliquity.
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Effects of alignment correction 5 years 10 years > 10 years
Insall 85% 66%
Yashuda 63% 18%
Berman 77% 62% 59%
Rudan 78% 70%
Matthews 50% 28%
Rininapoli 73% 46%
Ivarsson 57% 43%
Hernigou 90% 45%
Aglietti 96% 78% 57%
Levigne 69% 54%
Gstöttner 94% 80% 54%
Van Raaij 75%
Akizuki 98% 90%
Flecher 85%
Billings 85% 53%
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Effects of alignment correction
HTO unloaded an osteochondral defect of the medial condyle efficiently
- peak edge loads reduced Mina, Garrett et al AJSM 2008
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Effects of alignment correction
Time 0 12 months 72 months
Kröner, Berger et al, CORR 2006
Bone marrow edema completely resolves after successful valgus OT correction
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Arthroscopic 2nd-look average of 2 years after HTO in 146 knees: new growth of cartilage seemed to occur in the ulcerative lesion with exposed subchondral bone Koshino et al. 2003 Knee
ACI + HTO for varus and medial femoral condyle cartilage defects significantly better survival after 6 yrs compared to without HTO.
Bode et al. 2013 Arch Orthop Trauma Surg.
76 % return to regular sports participation after mean 6.9 yrs AOTS + HTO.
Minzlaff et al. 2016 KSSTA
Effects of alignment correction
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meniscus
cartilage
ligaments
alignment
“Young patients with old knees”
Why and WHEN you should correct alignment
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1. What is the present status of the joint ?
When you should correct alignment
Timing of surgery for alignment correction
meniscus
cartilage
ligaments
alignment
2. What is the present status of the cartilage ?
-chondral / osteochondral / osteoarthritis
3. What is the present alignment of the leg and the joint ?
4. Staged or combined
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1. Lateral meniscus tear – no suturing possible
- lateral compartment chondral/osteochondral damage
- valgus leg alignment
Candidate for alignment correction
When you should correct alignment
Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined
2. ACL rupture – post partial medial meniscectomy
- medial osteoarthritis symptomatic
- varus leg alignment
Staged HTO first – ACL reconstruction if necessary
Combined ACL-HTO
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3. OCD isolated lateral femoral condyle
- meniscus and ligaments intact
- neutral leg alignment
No candidate for alignment correction / future candidate
When you should correct alignment
Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined
4. Bi/tricompartmental OA
- post medial/lateral meniscectomy + ACL reconstuction
- varus leg alignment symptomatic
Neutralizing alignment correction – salvage procedure.
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Why and when you should correct alignment
Conclusion: Re-alignment comes first in a patient with
cartilage damage or any other joint
damage having a malaligned leg.
Conclusion: Timing of correction whether staged or
combined depends on joint factors, grade of
cartilage damage and alignment
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Knee joint
distraction
Exception
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Books
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Books and Courses
Basingstoke Osteotomy Masterclass Northern Course – Newcastle Hannover – Osteotomy - HKA Course National courses
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ESSKA Osteotomy Committee
ESSKA approved courses on
Osteotomies around the knee
Roadmap Europe / Worldwide
Thank you for your attention