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OSTEOTOMIES ABOUT THE KNEE

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  1. OSTEOTOMIES ABOUT THE KNEE Rod Martin M.D. FRCS(C)

  2. Outline • Introduction • Distal Femoral Osteotomy • Proximal Osteotomies of the Tibia • Closing wedge osteotomy • Coventry • Slocum • HTO with jig & plate • Barrel-vault osteotomy • Opening wedge osteotomy

  3. OSTEOTOMIES ABOUT THE KNEE • Patients with malalignment and unicompartment disease • Varus(4X) & valgus(5X) OA • 2020 OA will have largest increase of new cases of any disease • Unicompartment OA 30-60 age group • High demand / middle aged athlete

  4. Indications Valgus deformity > 12 to 15 degrees Plane of the knee deviates from the horizontal >10 degrees 25-22 Varus Distal Femoral Osteotomy

  5. Distal Femoral Osteotomy • Reported success 71% - 86% • Poor results with RA • Satisfactory results with TKR 94% • (13 of 18 had complications) • Difficulty restoring desired 5-10 degrees valgus

  6. Coventry Medial or midline incision Rectus/medialis interval Insert blade at templated angle Osteotomy of femur Close wedge/secure plate 25-23 Coventry Distal Femoral Osteotomy

  7. Proximal Osteotomies of the Tibia • Treatment of unicompartmental OA • 80% satisfactory results @ 5 years • Varus deformity = medial OA • Valgus deformity = lateral OA • Osteotomy “unloads” the “overloaded”

  8. Proximal Osteotomies of the Tibia • Coventry (1965) • Medial closing wedge for valgus deformity • Lateral closing wedge for varus deformity • Advantages • Near the deformity • Cancellous bone heals quickly • Fragments held firmly by 1-2 staples • Permits evaluation of the knee through the same incision

  9. Proximal Osteotomies of the Tibia • Coventry (1979) • 80% at 5 years & 60% at 10 years (213 knees) • Recurrence of deformity = recurrence of pain • Minimum “overcorrection” 8 degrees valgus • >30% ideal body weight = high failure

  10. Proximal Osteotomies of the Tibia • Indications • Pain and disability • Unicompartment OA • Ability to use crutches post-op • Good vascular status

  11. Proximal Osteotomies of the Tibia • Contraindications • Narrowing of lateral compartment • Lateral tibial subluxation of > 1 cm • Medial compartment bone loss > 2-3 mm • Flexion contracture > 15 degrees • Knee flection < 90 degrees • Correction of > 10-15 degrees • Inflammatory arthropathies

  12. Proximal Osteotomies of the Tibia • Coventry correction formula • (1) Normal valgus (5-8 degrees) • (2) + amount of varus deformity • (3) + “overcorrection factor” of 3 to 5 degrees = total correction required (approx. 1 mm / degree)

  13. Proximal Osteotomies of the Tibia • 25-10

  14. Proximal Osteotomies of the Tibia (Coventry)

  15. Proximal Osteotomies of the Tibia (Coventry)

  16. Proximal Osteotomies of the Tibia (Slocum)

  17. Proximal Osteotomies of the Tibia (jig and plate)

  18. Proximal Osteotomies of the Tibia

  19. Proximal Osteotomies of the Tibia • Maquet (barrel-vault) osteotomy • Inherently stable • “extensive” degrees of correction possible • Technically difficult • Intraarticular fracture • Scarring about the patellofemoral mechanism

  20. Proximal Osteotomies of the Tibia (Barrel-vault)

  21. Proximal Osteotomies of the Tibia • Medial opening wedge osteotomy • Does not “shorten” the extremity • Correct medial laxity • Surgery directed to the diseased compartment • Corrects up to 15˚

  22. Proximal Osteotomy of the Tibia (opening wedge)

  23. conclusions • Delays/avoids arthroplasty • Refute claims osteotomies compromise arthroplasty • Second “wave” of osteotomies coming

  24. 43 year female with increasing knee pain

  25. M.B. 43 year female increasingknee pain

  26. Opening wedge HTO

  27. 6mos post op Resumed all adl’s “knee feels 75% better”

  28. Thank you