Osteotomies for Cartilage Protections - IASM

Osteotomies for Cartilage
Protections
Jeffrey Halbrecht, , MD
San Francisco, Ca

ACI/Osteotomy
Osteotomy:
Optimal Patient Selection
• Mechanical axis falls within
involved compartment
• Mild joint space narrowing
– Or physiologic varus
• Opposite compartment intact
• Response to unloading trials
– Bracing, lateral heel wedges
• Not obese
• Compliance
• Nicotine use

Types of Osteotomies
• Unload femoral-tibial
joint
– Varus
• HTO
– Opening wedge
– Closing wedge
– Valgus
• Distal femoral osteotomy
– Opening wedge
– Closing wedge
• Varus HTO
• Unload Patello-femoral femoral joint
– Anteriorization
– Medialization
– Antero-medialization

VARUS KNEE
Why Osteotomy for Chondral Protection?
Medial Joint Loading: A Quick Biomechanical Review…
• Normal wb loads
– Normal joint mechanics:
• external varus moment throughout stance phase of gait
• This results in normal increase med comp loads
• Medial 60 %, lat 40% ( Kettelkamp 1976)
• OA situation:
– Increased varus moment due to narrowing of joint space
as mech allignment shifts towards varus
• Harrington IJ: 1983
– Also, altered gait causes increased adductor moment,
increased knee loading rate, and shift in load bearing
contact location to less tolerant (thick) cartilage (
Andriacchi 2005, 2006)

Benefit of HTO on artic ctlg…
• Decrease med comp loads
– results in med. loads of 50% or less (Kettelkamp
Best results >5 deg anat valgus ---
• Allows regeneration of cartilage
Kettelkamp 76)
– Fibrocartilage cover best with valgus > 5 (Koshino
Knee 2003)
• Improves results of microfx
– Clinical scores (Steadman AJSM 2004)

HTO: Biomechanical Goals
• Goal for chondral protection
different than with OA!
• OA:
– Coventry:
• anatomic valgus 10 deg
• Mechanical valgus 3-55 deg
– Noyes:
• 62% tibial width
• ( 3.5 deg valgus mech axis)
• Chondral Protection:
– Restore mech axis
• 0-22 degrees valgus mech. Axis
• 50-55%
55% tibial width
OA
Ctlg protection

Indications: When to add an HTO
• My indications
• Varus allignment
– > 5 always
– 3-55 sometimes
• Very large lesions
– 0-22 usually not
• Compare to other
side !
– Less aggressive with
bilateral tibia vara
to your ACI

Pre op planning:
All patients!
• Long leg bilateral WB x-rayx
ray
• Measure mechanical axis
• 45 degree flexion WB x-rayx
ray

Opening vs Closing Wedge
• Clinical results = but closing wedge
slightly more accurate
(Brouwer
JBJS (B) 2006)
• Clinical results =
(Hoell
Arch Ortho Tr Surg 2005)
• BUT……
……..

Opening Wedge
Osteotomy
• Advantages
– no fib osteotomy
– no deformity prox tib
– Easier conv to TKR
– No added lateral laxity
– Same side incision
• Disadvantages
– Longer time to heal
– Prolonged non WB
– Need graft
– Risk non union
– Patella baja
– Change tib slope

Closing Wedge
Osteotomy
• Advantages
– No bone graft
– Earlier WB
– Rare non union
• Disadvantages
– Fibular osteotomy
– Deformity prox tib
– More difficult conv to
TKR
– Add’l Lateral incision
– Added lat. laxity

Opening Wedge: Ex Fix
• Ex Fix
– Advantages
• Obtain exact correction every time
• Minimal incision
• Early WB (2-4 4 wks)
• No residual hardware
– Disadvantage
• Pin care
• Medial frame against opp leg
• Unsightly
• 2 nd procedure ROH
• Frame on 12-16 16 wks

Opening Wedge: Ex Fix
• Initial compression
• Begin distraction 1 week
• 1mm /day
• Remove 12-16 16 weeks

Dome Osteotomy
• Technically demanding
• Biplanar correction
• No bone graft
• No effect on tibial slope
• No patella baja

HTO :
Avoiding
Complications

Closing Wedge
• Use rigid fixation
– Intermedics-Sulzer
Sulzer-
Centerpulse-Zimmer
• Compression
• Avoid violation
medial cortex
• Early wb
• No immobilization

Osteotomies: : Avoiding NV Injury
• Closing wedge:
– Peroneal nerve
– Assoc. proximal fib osteotomy
– Tight post op bandage
– Bleeding
• Use post retractor
• Prox tib fib joint disruption vs osteotomy
• Hemostasis
• No tight bandages
• No tourniquet ( my preference)
– Ant tib artery
• Stay sub periosteal
• Opening wedge
– no reports of per nerve injury
– Protect post tib artery with retractors!

Parameter
Total Complications
Patients
HTO Complications
Medial Opening Wedge
Miller et al
17 (35.4%)
Gillogly
16 (30.2)
48 (ave. age 38 yrs)
34 males, 14 females
Hardware Failure 2: 4.2% 3: 5.6%
53 (ave. age 38.1 yrs)
31 males, 22 females
Lateral Cortex
Disruption
2: 4.2% 2: 3.7%
Delayed Union 2: 4.2% 4: 7.4%
DVT
Wound Infection
Loss of Correction/
Revision
2: 4.2%
0
0
1: 1.8%
7: 14.2% 6: 11.3% (5/6 had
allograft or bone
substitute)

Medial Opening HTO
• Incisions:
Surgical Technique
– Separate incision
5-77 cm posterior
to any anterior
incision
• Exposure:
– Protection of
neurovascular
structures,
Patellar tendon
Courtesy of Scott Gillogly MD

Medial Opening HTO
• Osteotomy Cut
Positioning
Surgical Technique
– Coronal: aim at level
of fibular head
– Sagittal: : parallel to
tibial slope
– 2cm below joint
– 1 cm from Lat cortex
2 CM
1CM
Courtesy of Scott Gillogly MD

• Osteotomy
Distraction
Medial Opening Wedge
Technique Cont.
Courtesy of Scott Gillogly MD

Medial Opening HTO
Sagittal Plane: Tibial Slope
• Important to maintain normal
slope
• As posterior slope increases,
lose extention!
• Increasing post. slope
promotes anterior translation
(worsens ACL deficiency,
diminishes PCL deficiency)
Courtesy of Scott Gillogly MD

Medial Opening HTO
Plate Placement and Fixation
• Place fixation at or posterior
to mid-line of tibia on lateral
view
• Fixation:
– 1 st generation: Puddu Plate
– 2 nd generation: Locking Puddu
– 3 rd generation:
• Reinforced plates, stronger
screws
(EBI) (Synthes(
Synthes)
Courtesy of Scott Gillogly MD

Medial Opening HTO
• Bone Grafting:
• Allograft
Surgical Technique
• >7.5 mm of opening
• Wedges, tricortical IC
• cancellous chips,
• Bone Paste, BMP
• Autograft
– Use for higher risk
pts (smokers, obese)
• Iliac Crest
• Local Source: Distal
Femur or Tibia ?
Courtesy of Scott Gillogly MD

OW HTO: Avoiding
Complications
• Lateral cortical fx:
– Leave 10mm bone
– A/P drill hole ?
• ( Kessler CORR 2002 CW med cortex)
• Intra-articular
articular fx
– 2 cm below joint line
– Slow distraction
• Increased post slope
– Sagital cut parallel to post slope
– Angled wedge plate
– Plate midline or post !
– Post gap 2x ant (Noyes)
• Non union
– Stronger plate / screws for corections > 10mm ( EBI)
– Bi/tri cortical graft….Autograft
?

OW HTO: Dealing with
Intraoperative Complications
• Lateral cortical fx
– Staple
• Intra-articular
articular fx
– Stable non dislplaced-
leave alone
– Unstable /displaced: perc
cannulated screw
• Allignment:
– check with flouro/ / leg
loaded
• Slope:
– check pop ROM !
– Check flouro
– Change plate position more
post. if necessary
68
68% reduction in
torsional stiffness
Miller AJSM 2005

Medial Opening HTO
Summary
• Careful Patient Selection: Cautious
of BMI > 40, Smokers, Noncompliant
• Sound Surgical technique: Always
protect neurovascular structures,
gradual opening wedge
• If Lateral Cortex disrupted, fix it with
Staple
• Use stronger 2 nd or 3rd generation
fixation methods
• Protected weight bearing 8-12
weeks
• Reduce pitfalls and complications

Valgus Knee:
Lateral Compartment Defect:
• Correct alignment to
neutral !
• < 10 degrees
– Prox tibia varus
osteotomy
• Closing wedge
• Opening wedge
• >10 degrees
– Distal femoral osteotomy
• Lateral opening wedge
( < 15 degree?)
• Medial closing wedge
Lateral opening wedge osteotomy
(Marti JBJS 2001)

THANK YOU

Case Study N.L.
• 45 yo male
• Injury during martial
arts
• MFC defect 4.0 CM x
2.5 CM
• 5’5”, , 255 lbs
• Hx PMM 30%
• G-2 2 Tibia

N.L.
Non WB X-RAYX

N.L.
• Long Leg WB X-RayX
Ray

N.L. MRI

N.L.
• Lateral
Compartment

Our Plan
• ACI
• HTO opening wedge