Around the knee osteotomies fixation principles

1. Around the knee osteotomies fixation principles M.Moayedfar M.D Knee Surgery Fellow Shafa Hospital

2. Prox Tibial osteotomy fixation • Tomofix • Pudduplate • T buttress plate • Other implants

3. Distal femoral osteotomy plate • Tom0fix • Pudduplate • Condyllar plate • Other implant

4. TomoFix Medial High Tibial Plate

5. Monitor potential correction loss and the ventral bone contact of the ascending osteotomy.

6. Replace lag screw with a locking head screw

7. Puddu plates

8. Puddu plates 8

9. Failure of the implants • 55 patients by a spacer plate (Puddu plate) • 16% implant breakage (Gunter Spahn 2003)

10. Lateral High Tibia Application

11. Fixation stability of opening- versus closingwedge high tibial osteotomy • Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. • Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening wedge technique was more likely to produce the intended correction. (J. W. H. Luites et al.,2009)

12. TomoFix Medial Distal Femur

13. Lateral Distal Femur Application

14. Lateral cortical fracture Lateral cortical fracture is a severe complication that can occur during the surgical act, decreasing axial resistance (47%) and rotational resistance (54%) of the osteotomy. (Puddu,2000)

15. 51-year-old men with initially regular HTO (a, b), a secondary lateral cortex fracture and resulting non-union 6 months after surgery

16. Lateral cortical fracture When this complication occurs, it is necessary to add a lateral fixation (screw or hook) at the apex of the opening wedge, to increase the stability of the osteotomy. (Paccola & Fogagnolo, 2005)

17. Incidence of lateral cortex fractures and influence of fixation device on osteotomy healing Fracture of the lateral cortex in 21 patient(30.4 %) 10 patients, the fracture was visible on the radiographs at the 6-week follow-up. Non-union with the need for surgical treatment in three out of eight (37.5 %) patients using the newly locking plate (Maxi Plate), but no patients with a well-established locking plate (TomoFix) (0 out of 13, p = 0.023). (Dexel et all ,2015)

18. Lateral cortical fracture A lag screw pulls the distal osteotomy segment towards the plate…

19. Lateral cortical fracture which imposes pressure upon the lateral hinge

20. Bone graft • 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft. • 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation. • All osteotomies united within 12 weeks after surgery. Group B had slightly longer time to union than group A (10.3 weeks and 9.5 weeks, respectively; P = 0.125).

21. Bone graft • A significantly higher incidence of medial defects after osteotomy was reported in the locking compression plate group (P = 0.001). • Locking compression plate fixation without the use of bone grafts or bone substitutes provides a satisfactory union rate. (Chatorung et al 2012)

22. Bone graft • If the gap width exceeds 13 mm ,autogenouscancellous bone graft is harvested from iliac crest. (Osteotomies around the knee,2008)

23. Weight bearing • The amount of initial weight bearing that is allowed postoperatively depends strongly on the type of fixation used. • Noyes et al reported that full weight bearing was possible after 8 weeks in OW HTO fixated with a Puddu plate.

24. Comparison of theoretical fixation stability of three devices employed in medial opening wedge high tibial osteotomy: a finite element analysis Non of them warranted full weight bearing Highest fixation stability TomoFix plate Lowest for the first generation Puddu plate (Мaxim L Golovakhа 2014)

25. Weight bearing • Lobenhoffer et al and Staubli et al ,using Tomofix for fixation in OW HTO without filling the gap and without using a brace or cast, found that full weight bearing was possible at 8 weeks and 10 weeks, respectively. • full weight bearing after OW HTO has been reported; in a series of 57 OW HTOs again using Tomofix for fixation, full weight bearing after 2 weeks.(Takeuchi et al )

26. A retrospective analysis of medial opening wedge high tibial osteotomy for varus osteoarthritic knee • 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft augmentation (A) • 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation(B) • followed for at least 2 years (Pornrattanamaneewong C,2012)

27. All osteotomies united within 12 weeks after surgery • Group B had slightly longer time to union t

28. A total of 5 (8.3%) knees had complications. In group A, one knee had a superficial wound infection and another knee had a lateral tibial plateau fracture without significant loss of correction. • In group B, one knee had screw penetration into the knee joint and two knees had local irritation that required the removal of the hardware.

29. Take Home Message • Cheaper instruments could be used if some concerns about WB and grafting are observed • For each instrument proper instruction should be considered • In case of lat hinge fracture manage it according to the type of fixation • There is no need bone graft In tomofix med high tibial plate up to 13 mm gap however add autogenous or allogeneic bone graft with simple buttress plate