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Osteotomies About the Knee Lyon, France Oct. 2011. Mark Sanders, MD FACS The Sanders Clinic for Orthopaedic Surgery and Sports Medicine Houston, Texas USA. Disclosures. None to report. “Orthopaedics”. Derived from Greek orthos ("correct," "straight") paideion ("child")

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osteotomies about the knee lyon france oct 2011
Osteotomies About the Knee Lyon, France Oct. 2011

Mark Sanders, MD FACS

The Sanders Clinic for Orthopaedic Surgery

and Sports Medicine

Houston, Texas USA

disclosures
Disclosures
  • None to report
orthopaedics
“Orthopaedics”
  • Derived from Greek
    • orthos ("correct," "straight")
    • paideion ("child")

-Nicholas Andry, Orthopaedia: or the Art of Correcting and Preventing Deformities in Children, 1741.

patient 1
Patient #1
  • 28 y/o F nurse, previously athletic, c/o bilat multidirectional patella femoral instability, L > R
  • Multiple previous surgeries left knee
    • Lateral retinacular release x2
    • Medialization osteotomy of tibial tubercle
    • Hardware removals, fasciotomy, “cleanouts”
  • Physical Examination
    • Increased femoral anteversion
    • Increased tibial external torsion
    • Medial patella instability
computerized tomography results
Computerized Tomography Results
  • Femoral Anteversion: 50° R, 35° L (Normal 9-22° - D. Paley)
  • Tibial External torsion: 34° R, 39° L (Normal 18-28° - D. Paley)
  • TT-TG: 10mm R, 7mm L (Ideal tracking: 10-15mm - H. DeJour)
synchronous surgical treatment
Synchronous Surgical Treatment
  • Spinal/epidural anesthesia
  • Two lateral skin incisions
  • 20° proximal femoral external rotation osteotomy
  • 15° proximal tibial internal rotation osteotomy
  • 6mm laterally directed tibial tubercle osteotomy
  • Distal ITB based LPFLR
  • Immediate unrestricted active and active assisted hip, knee, and ankle motion
  • 10 kg weight bearing with crutches for 6 wks until early union determined
  • Bony union, off crutches at 3 months
slide11

5 mos.

post-op

slide12

5 mos.

post-op

slide13

5 mos.

post-op

slide14

5 mos.

post-op

slide15

Hardware

removal-

5 mos.

post-op

L

slide16

Hardware

removal-

5 mos.

post-op

highly satisfied patient
Highly Satisfied Patient
  • No further medial or lateral patella instability
  • Returned to light sports
  • Couldn’t wait to have Proximal Femoral Plate out
  • Scheduled for opposite side surgery over Christmas
take home messages
Take Home Messages
  • Repair/Reconstruct every deformity at one surgical sitting
  • Epidural and multimodal analgesia
  • Immediate active and active-assisted motion without CPM
  • Early return to function
  • Young people want hardware out, especially Proximal Femoral Plate
patient 2
Patient #2
  • 24 y/o M, treated for congenital deformity of the opposite femur. Underwent femoral epiphysiodesis at Children’s Hospital
  • Currently with two previous failed allograft ACLRs
  • Physical Exam

–Normal femoral and tibial version

    • Genu Valgus deformity
    • Asymmetric Hyperextension
    • PCL, PLC, MCL intact
    • 4+ Anterior instability
slide20

Pre-op

mLDFA

76.5º

mLDFA

89.6º

slide21

Pre-op

RT aPDFA

97.7º

Normal Values

aPDFA : 79 – 87º

aPPTA : 77 - 84º

Note: Anterior tibial

subluxation

RT aPPTA

75.4º

synchronous surgical treatment1
Synchronous Surgical Treatment
  • Long lateral skin incision
  • Opening wedge biplanar DFO for correction of 10° distal extension and 10° valgus deformity, using Freeze dried bone wedges and lateral TomoFix™
  • Joint leveling biplanar HTO to decrease adverse tibial slope, and stabilized with medial and lateral TomoFix™
  • ACLR deferred until tibial and femoral hardware could be safely removed
slide23

6 wks

post-op

RT mLDFA 89.5º

slide24

6 wks

post-op

RT aPDFA

84.2º

Normal Values

aPDFA : 79 - 87º

aPPTA: 77 - 84º

RT aPPTA

79.3º

slide25

Pre-op

6 wks

post-op

this is a work in progress
This is a work in progress
  • Immediate active and active-assisted knee motion in combination with multimodal and epidural analgesia considerably decreases Perioperative pain and morbidity
  • Post-op Lachman’s decreased from 4+ to 2+
  • I will show further follow-up X-rays in Davos in 2012
patient 3
Patient #3
  • 34 y/o M plant worker, previously athletic, c/o constant medial knee pain. Reportedly needs TKA.
  • 9 previous surgeries, L knee
    • Lateral retinacular release
    • Multiple arthroscopies and “clean outs”
    • Repair of quad tendon rupture
  • Physical Examination
    • Normal femoral and tibial version
    • Genu varum, medial joint line tenderness
    • Medial patella femoral instability
slide29

Pre-op

  • R mLDFA 95°
  • L mLDFA 94°

ºº

synchronous surgical treatment2
Synchronous Surgical Treatment
  • Long lateral skin incision
  • Opening wedge biplanar DFO for correction of 9° distal varus deformity, using Freeze dried bone wedge and opposite sided medial TomoFix™ applied medially
  • Distal ITB based LPFLR
  • Epidural analgesia and multimodal pain management
  • Immediate active and active assisted unrestricted motion of hip, knee, and ankle
  • 10 kg weight bearing with crutches for six weeks until early union determined
slide31

8 wks

post-op

R

slide32

8 wks

post-op

mLDFA 85º

slide33

Pre-op

8 wks

post-op

this too is a work in progress but
This too is a work in progress, but...
  • Varus at the femur occurs more commonly than is generally believed (Van Heerwarden)
  • Correction is best applied at the CORA
  • Correction at another area can lead to joint line obliquity
  • Alignment is of primary importance - nothing we do succeeds without it.