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Osteotomy around the knee in young patients(cases)

Osteotomy around the knee in young patients(cases). M.M.Sajadi Knee fello Shahid Beheshti University O f M edical S ciences. The main indication for HTO is the correction of varus malalignment in medial unicompartmental osteoarthritis of the knee

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Osteotomy around the knee in young patients(cases)

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  1. Osteotomy around the knee in young patients(cases) M.M.Sajadi Knee fello ShahidBeheshtiUniversity Of Medical Sciences

  2. The main indication for HTO is the correction of varusmalalignment in medial unicompartmental osteoarthritis of the knee • In the 1990s, in sports medicine, in the treatment of ligamentous injuries led to a reappreciation of osteotomy

  3. Do you recommend osteotomy in young patient with malalignment without any symptom ?

  4. Malalignment? Osteoarthritis? Cosmetic?

  5. Malalignment cause osteoarthrosis? • Biomechanics studies? • Systematic reviews?

  6. New knowledge led to renewed interest in the influence of malalignment on the developmentand symptoms of osteoarthritis Osteotomies around the knee J.-M. Brinkman, P. Lobenhoffer, J. D. Agneskirchner, A. E. Staubli, J Bone Joint Surg [Br] 2008;90-B:1548-57 Cicuttini F, Wluka A, Hankin J, Wang Y. Longitudinal study of the relationship between knee angle and tibiofemoral cartilage volume in subjects with knee osteoarthritis. Rheumatology (Oxford) 2004;43:321-4

  7. knee adduction moment : combination of the ground reaction force, which passes medial to the center of the knee joint, and the perpendicular distance of this force from the center of the joint

  8. Logistic regression analysis showed that the risk of progression of knee OA increased 6.46 times with a 1% increase in adduction moment Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis T Miyazaki, M Wada, H Ann Rheum Dis 2002;61:617-622

  9. knee adduction moment : 60%-70% of total intrinsic knee compressive load to the medial tibiofemoralcompartment Medial tibiofemoral OA larger knee adduction moments resulting in increased medial compartment pressure

  10. Despite this! • There is no clear evidence Malalignment cause OA Because all previous studies have examined people with established disease J Orthop Res. 1996 Mar;14(2):289-95. Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: a critical analysis of the reliability of gait analysis data. Andrews M1, Noyes FR, Hewett TE, Andriacchi

  11. A systematic search Fourteen studies • knee adduction moment during gait appeared to be consistent across laboratories and computational methods. • Only two of the included studies that compared patients with OA to a control group reported a higher peak KAM for the OA group Knee. 2009 Oct;16(5):303-9. doi: 10.1016/j.knee.2008 ForoughiN, Smith R, Vanwanseele B.

  12. Why? • The toe out angle was predictive of the peak adduction moment only during late stance (R = -0.45, p < 0.001). J Orthop Res. 2002 Jan;20(1):101-7. The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP.

  13. Dynamic alignment • For athletes with genu valgus or genu varusto effectively participate in the repetitious running and jumping demands of many sports, compensatory alignment via the hips, ankle, subtalar, and midtarsal joints is needed Journal of Biomechanics 34 (2001) 1257–1267 Strategies of muscular support of varusandvalgus isometric loads at the human knee DavidG. Lloyda,ThomasS

  14. Compensatory alignment? • Muscles and ligaments control how the total joint force is shared between the articular surfaces. • In addition, cadaver studies and biomechanical models have shown that muscles can support varus or valgus (VV) moments at the knee Journal of Biomechanics 34 (2001) 1257–1267 Strategies of muscular support of varusandvalgus isometric loads at the human knee DavidG. Lloyda, Thomas S. Buchanan

  15. Lioyd and Buchanan have shown that, in total, muscles are activated to support about 15% of the static pure VV external loads Journal of Biomechanics 34 (2001) 1257–1267 Strategies of muscular support of varusandvalgus isometric loads at the human knee DavidG. Lloyda, Thomas S. Buchanan

  16. Association between mechanical axis and adduction moment • It only accounted for about 50% of its variation • Emphasizing the need for a dynamic evaluation of the knee joint loading environment. J Orthop Res. 2002 Jan;20(1):101-7. The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP

  17. Association between valgus and varusalignment and the development and progression of radiographic osteoarthritis of the knee Prospective studies

  18. 1051 participants followed 6.6 years • 38% NL alignment • 26% varus • 36% valgus Varusalignment is associated not only with progression of knee OA but also with development of knee OA. However, this association seems particularly applicable to overweight and obese persons Arthritis Rheum. 2007 Apr;56(4):1204-11 Brouwer GM, van Tol AW, Bergink AP, Belo JN

  19. Systematic review • Fourteen studies • Limited evidence for an association between knee malalignment and incident knee OA, because only 1 cohort study examined this relationship. • However, there was strong evidence based on 4 high-quality cohort studies that knee malalignment is an independent risk factor for progression of radiographic knee OA Arthritis Rheum. 2009 Apr 15;61(4):459-67. doi: 10.1002/art.24336. Does knee malalignment increase the risk of development and progression of knee osteoarthritis? A systematic review. TanamasS, Hanna FS, Cicuttini FM, Wluka AE, Berry P, Urquhart DM

  20. We selected 110 incident tibiofemoral(TF) OA case knees (76 subjects) and 356 random control knees (178 subjects). • Case knees did not have OA at baseline but had developed OA (Kellgren/Lawrence grade >2) at follow-up (mean of 8.75 years between examinations). • Control knees did not have OA at baseline. Hunter DJ, Niu J, Felson DT, et al. Knee alignment does not predict incident osteoarthritis: the Framingham osteoarthritis study. Arthritis Rheum.56(4):1212-8

  21. After adjustment for age, sex and BMI, there was no significant increase in incident OA in the highest quartile compared with the lowest quartile category for any of the alignment measures • We found that baseline knee alignment is not associated with either incidentradiographic TF OA or medial TF OA • These results suggest that malalignmentis not a risk factor for OA, but rather is a marker of disease severity and/or its progression

  22. Problems in studies • Because knee joint space consists of other structures such as menisci, joint space narrowing is not always a valid indicator of articular cartilage volume. • Cartilage volume will be a useful measure in studies of the pathogenesis of OA • Human tissues, including hyaline cartilage, respond to altered biomechanical variables such as the knee joint loads

  23. Limited prospective data are available • The long-term follow-up is needed • Difficult to interpret considering the bias inherent in patient selection • Direct clinical evidence of a cause-and-effect relationship between malalignment and arthrosis has not been possible OrthopClin North Am. 2009 Jul;36(3):367-77. TetsworthK, Paley D

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