Osteotomies for Cartilage Protections - IASM
Osteotomies for Cartilage Protections - IASM
Osteotomies for Cartilage Protections - IASM
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<strong>Osteotomies</strong> <strong>for</strong> <strong>Cartilage</strong><br />
<strong>Protections</strong><br />
Jeffrey Halbrecht, , MD<br />
San Francisco, Ca
ACI/Osteotomy<br />
Osteotomy:<br />
Optimal Patient Selection<br />
• Mechanical axis falls within<br />
involved compartment<br />
• Mild joint space narrowing<br />
– Or physiologic varus<br />
• Opposite compartment intact<br />
• Response to unloading trials<br />
– Bracing, lateral heel wedges<br />
• Not obese<br />
• Compliance<br />
• Nicotine use
Types of <strong>Osteotomies</strong><br />
• Unload femoral-tibial<br />
joint<br />
– Varus<br />
• HTO<br />
– Opening wedge<br />
– Closing wedge<br />
– Valgus<br />
• Distal femoral osteotomy<br />
– Opening wedge<br />
– Closing wedge<br />
• Varus HTO<br />
• Unload Patello-femoral femoral joint<br />
– Anteriorization<br />
– Medialization<br />
– Antero-medialization
VARUS KNEE<br />
Why Osteotomy <strong>for</strong> Chondral Protection?<br />
Medial Joint Loading: A Quick Biomechanical Review…<br />
• Normal wb loads<br />
– Normal joint mechanics:<br />
• external varus moment throughout stance phase of gait<br />
• This results in normal increase med comp loads<br />
• Medial 60 %, lat 40% ( Kettelkamp 1976)<br />
• OA situation:<br />
– Increased varus moment due to narrowing of joint space<br />
as mech allignment shifts towards varus<br />
• Harrington IJ: 1983<br />
– Also, altered gait causes increased adductor moment,<br />
increased knee loading rate, and shift in load bearing<br />
contact location to less tolerant (thick) cartilage (<br />
Andriacchi 2005, 2006)
Benefit of HTO on artic ctlg…<br />
• Decrease med comp loads<br />
– results in med. loads of 50% or less (Kettelkamp<br />
Best results >5 deg anat valgus ---<br />
• Allows regeneration of cartilage<br />
Kettelkamp 76)<br />
– Fibrocartilage cover best with valgus > 5 (Koshino<br />
Knee 2003)<br />
• Improves results of microfx<br />
– Clinical scores (Steadman AJSM 2004)
HTO: Biomechanical Goals<br />
• Goal <strong>for</strong> chondral protection<br />
different than with OA!<br />
• OA:<br />
– Coventry:<br />
• anatomic valgus 10 deg<br />
• Mechanical valgus 3-55 deg<br />
– Noyes:<br />
• 62% tibial width<br />
• ( 3.5 deg valgus mech axis)<br />
• Chondral Protection:<br />
– Restore mech axis<br />
• 0-22 degrees valgus mech. Axis<br />
• 50-55%<br />
55% tibial width<br />
OA<br />
Ctlg protection
Indications: When to add an HTO<br />
• My indications<br />
• Varus allignment<br />
– > 5 always<br />
– 3-55 sometimes<br />
• Very large lesions<br />
– 0-22 usually not<br />
• Compare to other<br />
side !<br />
– Less aggressive with<br />
bilateral tibia vara<br />
to your ACI
Pre op planning:<br />
All patients!<br />
• Long leg bilateral WB x-rayx<br />
ray<br />
• Measure mechanical axis<br />
• 45 degree flexion WB x-rayx<br />
ray
Opening vs Closing Wedge<br />
• Clinical results = but closing wedge<br />
slightly more accurate<br />
(Brouwer<br />
JBJS (B) 2006)<br />
• Clinical results =<br />
(Hoell<br />
Arch Ortho Tr Surg 2005)<br />
• BUT……<br />
……..
Opening Wedge<br />
Osteotomy<br />
• Advantages<br />
– no fib osteotomy<br />
– no de<strong>for</strong>mity prox tib<br />
– Easier conv to TKR<br />
– No added lateral laxity<br />
– Same side incision<br />
• Disadvantages<br />
– Longer time to heal<br />
– Prolonged non WB<br />
– Need graft<br />
– Risk non union<br />
– Patella baja<br />
– Change tib slope
Closing Wedge<br />
Osteotomy<br />
• Advantages<br />
– No bone graft<br />
– Earlier WB<br />
– Rare non union<br />
• Disadvantages<br />
– Fibular osteotomy<br />
– De<strong>for</strong>mity prox tib<br />
– More difficult conv to<br />
TKR<br />
– Add’l Lateral incision<br />
– Added lat. laxity
Opening Wedge: Ex Fix<br />
• Ex Fix<br />
– Advantages<br />
• Obtain exact correction every time<br />
• Minimal incision<br />
• Early WB (2-4 4 wks)<br />
• No residual hardware<br />
– Disadvantage<br />
• Pin care<br />
• Medial frame against opp leg<br />
• Unsightly<br />
• 2 nd procedure ROH<br />
• Frame on 12-16 16 wks
Opening Wedge: Ex Fix<br />
• Initial compression<br />
• Begin distraction 1 week<br />
• 1mm /day<br />
• Remove 12-16 16 weeks
Dome Osteotomy<br />
• Technically demanding<br />
• Biplanar correction<br />
• No bone graft<br />
• No effect on tibial slope<br />
• No patella baja
HTO :<br />
Avoiding<br />
Complications
Closing Wedge<br />
• Use rigid fixation<br />
– Intermedics-Sulzer<br />
Sulzer-<br />
Centerpulse-Zimmer<br />
• Compression<br />
• Avoid violation<br />
medial cortex<br />
• Early wb<br />
• No immobilization
<strong>Osteotomies</strong>: : Avoiding NV Injury<br />
• Closing wedge:<br />
– Peroneal nerve<br />
– Assoc. proximal fib osteotomy<br />
– Tight post op bandage<br />
– Bleeding<br />
• Use post retractor<br />
• Prox tib fib joint disruption vs osteotomy<br />
• Hemostasis<br />
• No tight bandages<br />
• No tourniquet ( my preference)<br />
– Ant tib artery<br />
• Stay sub periosteal<br />
• Opening wedge<br />
– no reports of per nerve injury<br />
– Protect post tib artery with retractors!
Parameter<br />
Total Complications<br />
Patients<br />
HTO Complications<br />
Medial Opening Wedge<br />
Miller et al<br />
17 (35.4%)<br />
Gillogly<br />
16 (30.2)<br />
48 (ave. age 38 yrs)<br />
34 males, 14 females<br />
Hardware Failure 2: 4.2% 3: 5.6%<br />
53 (ave. age 38.1 yrs)<br />
31 males, 22 females<br />
Lateral Cortex<br />
Disruption<br />
2: 4.2% 2: 3.7%<br />
Delayed Union 2: 4.2% 4: 7.4%<br />
DVT<br />
Wound Infection<br />
Loss of Correction/<br />
Revision<br />
2: 4.2%<br />
0<br />
0<br />
1: 1.8%<br />
7: 14.2% 6: 11.3% (5/6 had<br />
allograft or bone<br />
substitute)
Medial Opening HTO<br />
• Incisions:<br />
Surgical Technique<br />
– Separate incision<br />
5-77 cm posterior<br />
to any anterior<br />
incision<br />
• Exposure:<br />
– Protection of<br />
neurovascular<br />
structures,<br />
Patellar tendon<br />
Courtesy of Scott Gillogly MD
Medial Opening HTO<br />
• Osteotomy Cut<br />
Positioning<br />
Surgical Technique<br />
– Coronal: aim at level<br />
of fibular head<br />
– Sagittal: : parallel to<br />
tibial slope<br />
– 2cm below joint<br />
– 1 cm from Lat cortex<br />
2 CM<br />
1CM<br />
Courtesy of Scott Gillogly MD
• Osteotomy<br />
Distraction<br />
Medial Opening Wedge<br />
Technique Cont.<br />
Courtesy of Scott Gillogly MD
Medial Opening HTO<br />
Sagittal Plane: Tibial Slope<br />
• Important to maintain normal<br />
slope<br />
• As posterior slope increases,<br />
lose extention!<br />
• Increasing post. slope<br />
promotes anterior translation<br />
(worsens ACL deficiency,<br />
diminishes PCL deficiency)<br />
Courtesy of Scott Gillogly MD
Medial Opening HTO<br />
Plate Placement and Fixation<br />
• Place fixation at or posterior<br />
to mid-line of tibia on lateral<br />
view<br />
• Fixation:<br />
– 1 st generation: Puddu Plate<br />
– 2 nd generation: Locking Puddu<br />
– 3 rd generation:<br />
• Rein<strong>for</strong>ced plates, stronger<br />
screws<br />
(EBI) (Synthes(<br />
Synthes)<br />
Courtesy of Scott Gillogly MD
Medial Opening HTO<br />
• Bone Grafting:<br />
• Allograft<br />
Surgical Technique<br />
• >7.5 mm of opening<br />
• Wedges, tricortical IC<br />
• cancellous chips,<br />
• Bone Paste, BMP<br />
• Autograft<br />
– Use <strong>for</strong> higher risk<br />
pts (smokers, obese)<br />
• Iliac Crest<br />
• Local Source: Distal<br />
Femur or Tibia ?<br />
Courtesy of Scott Gillogly MD
OW HTO: Avoiding<br />
Complications<br />
• Lateral cortical fx:<br />
– Leave 10mm bone<br />
– A/P drill hole ?<br />
• ( Kessler CORR 2002 CW med cortex)<br />
• Intra-articular<br />
articular fx<br />
– 2 cm below joint line<br />
– Slow distraction<br />
• Increased post slope<br />
– Sagital cut parallel to post slope<br />
– Angled wedge plate<br />
– Plate midline or post !<br />
– Post gap 2x ant (Noyes)<br />
• Non union<br />
– Stronger plate / screws <strong>for</strong> corections > 10mm ( EBI)<br />
– Bi/tri cortical graft….Autograft<br />
?
OW HTO: Dealing with<br />
Intraoperative Complications<br />
• Lateral cortical fx<br />
– Staple<br />
• Intra-articular<br />
articular fx<br />
– Stable non dislplaced-<br />
leave alone<br />
– Unstable /displaced: perc<br />
cannulated screw<br />
• Allignment:<br />
– check with flouro/ / leg<br />
loaded<br />
• Slope:<br />
– check pop ROM !<br />
– Check flouro<br />
– Change plate position more<br />
post. if necessary<br />
68<br />
68% reduction in<br />
torsional stiffness<br />
Miller AJSM 2005
Medial Opening HTO<br />
Summary<br />
• Careful Patient Selection: Cautious<br />
of BMI > 40, Smokers, Noncompliant<br />
• Sound Surgical technique: Always<br />
protect neurovascular structures,<br />
gradual opening wedge<br />
• If Lateral Cortex disrupted, fix it with<br />
Staple<br />
• Use stronger 2 nd or 3rd generation<br />
fixation methods<br />
• Protected weight bearing 8-12<br />
weeks<br />
• Reduce pitfalls and complications
Valgus Knee:<br />
Lateral Compartment Defect:<br />
• Correct alignment to<br />
neutral !<br />
• < 10 degrees<br />
– Prox tibia varus<br />
osteotomy<br />
• Closing wedge<br />
• Opening wedge<br />
• >10 degrees<br />
– Distal femoral osteotomy<br />
• Lateral opening wedge<br />
( < 15 degree?)<br />
• Medial closing wedge<br />
Lateral opening wedge osteotomy<br />
(Marti JBJS 2001)
THANK YOU
Case Study N.L.<br />
• 45 yo male<br />
• Injury during martial<br />
arts<br />
• MFC defect 4.0 CM x<br />
2.5 CM<br />
• 5’5”, , 255 lbs<br />
• Hx PMM 30%<br />
• G-2 2 Tibia
N.L.<br />
Non WB X-RAYX
N.L.<br />
• Long Leg WB X-RayX<br />
Ray
N.L. MRI
N.L.<br />
• Lateral<br />
Compartment
Our Plan<br />
• ACI<br />
• HTO opening wedge