1. Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees)
JL. LERAT, A. GODENÈCHE, B MOYEN
Service de Chirurgie Orthopédique et de Médecine du Sport
Lyon – France
SOFCOT, Paris Nov 1998
EFORT, Bruxelles 3-8 Juin 1999

2. 23 cases of major deformities > 20°
Intra-articular deformities
Even in case of major deformity TKR is possible :
23 cases of major deformities > 20°
11 valgus : 22° ± varus : 26° ± 3
Good corrections - Good results obtained with post. cruciate retaining TKR
Similar to other TKR’s in our series

3. 23 cases of major deformities > 20°
Intra-articular deformities
Even in case of major deformity TKR is possible :
23 cases of major deformities > 20°
Good corrections - Good results obtained with post. cruciate retaining TKR
Similar to other TKR’s in our series

4. The question is : How to correct a major extra-articular deformity (± articular deformity) by a total Knee Replacement ?

5. Typical cases are represented by tibial deformities (following osteotomies or fractures)
Valgus Varus
Profile

6. The limit of ligament release
In cases of overcorrected valgus
Complete lateral ligament release is necessary
Usual cuts for the femur. Minimal cut for the tibia: Trapezoidal space
Large release of the concavity in order to obtain rectangular space
A correction of 20° corresponds to a release of 30 mm ! (Wolf)

7. 1 operation
No major difficulties
Immediate weight bearing
ADVANTAGES

8. DISADVANTAGES Excessive polyethylene thickness Limb lengthening
Peroneal nerve tension and stretching
(palsy : 4 % in literature)
PCL sacrifice
More constrained prosthesis
Poor ligament isometricity
Possible instability (literature)

9. Symposium SO.F.C.O.T - Paris - 1990
Acceptable solution for Unacceptable for major deformities minor deformities
Typical case :
Patella infera, Pain ++ Peroneal nerve palsy Poor flexion : 70°

10. Excessive valgus or varus make a new osteotomy necessary
In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed
Excessive valgus or varus make a new osteotomy necessary

11. In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed
Vicious rotation makes a new osteotomy necessary
External tibial torsion is 0 degree instead of 30° on the other side

12. Femoral deformities make new osteotomy necessary
Old case of rickets Previous Femoral fracture osteotomy and tibial osteotomy

13. In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed
2 possible options :
1 - Two-steps with osteotomy first, and then TKA
2 - TKA and osteotomy in a single operation

14. 1 - OSTEOTOMY First and TKA later
ADVANTAGES
Simplicity
Rapid healing of the osteotomy
The results are sometimes good enough for TKA to be unnecessary or delayed
2 consecutive operations (6 to 12 months)
2 anesthesias, 2 rehabilitation tasks, DVT risk
DISADVANTAGES
This choice had been made for 67 young patients previously operated by osteotomy

15. 2 - OSTEOTOMY + TKA First report : JL LERAT : 1991
SOF.C.O.T Annual Meeting, Paris, 1991
Symposium : “ Failed HTO”
(2 cases operated on in 1990)
WOLF and HUNGERFORD : 2 cases in 1991
UCHINOU : 1 case in 1996
HUNGERFORD : “14th Annual Current Concepts in Joint Replacement” in Cleveland, Dec 1997

16. 1/ Correction of a tibial valgus deformity
1rst method
1 - Femoral cuts as in usual cases 2 - Tibial cut is parallel to the condylar line 3 - Ligament balance is easy to ensure 4 - Spacer in place (or definitine implant in the case of short stem)
4 - Osteotomy (fluoroscopic control) 5 - Tibial component is put into place 6 - Fixation with 2 or 3 staples

17. 2 d method : using a tibial component with short stem or pegs
Osteotomy is performed after TK implantation

18. Fer… F - 73 years 13 years after first osteotomy
182°
218°
Fer… F - 73 years 13 years after first osteotomy

19. W... F - 60 years HKA : 191° Weight-bearing: 2 months

20. In case of a rotational deformity, osteotomy is performed lower down in the metaphysis
It is necessary to remove the anterior tibial tubercule
A plate is used for fixation ± staples

21. 2/ Correction of a femoral deformity
Flexion 90°
Extension
1 : Anterior and post cuts are parallel to the tibial cut
2 : The distal femoral cut is done parallel to the tibial cut in extension 3 : Spacer and ligament balance 4 : TKA is fitted

22. Osteotomy is performed when the implants are placed
Resection
Addition
Graft with the bone resulting from the cuts

23. 138°
180°
Fl : 115°
Be M - 75 years Previous femoral ost. at 20 years
TKA + ost. Graft after 4 months (non union) Healing : 7 m.

24. 166° 180° Prat..... H - 75 years old 55 years after 1st osteotomy
TKR + opened osteotomy

25. Material 19 TKA + Osteotomy (18 patients)
Mean age : 72 years ± 6 ( )
13 females - 5 males

26. Material Varus knee (22°± 9) 8 cases Valgus knee (7°± 10) 9 cases
2 excessive tibial varus
1 old tibial fracture
3 previous femoral osteotomy
1 old femoral fracture
1 old history of rickets
Valgus knee (7°± 10) 9 cases
8 HTO, 1 excessive valgus
Rotation (25°) + varus : 2 knees
2 previous HTO

27. Technical characteristics
17 cementless TKA, 2 cemented
14 PCL retaining prosthesis
3 two CL retaining prosthesis
2 hinged TKR
Osteotomies
Tibia : 13
Opened osteot. : 3 Closed osteot. :8 Rotation : 2
Femur : 6
Opened osteot. : Closed osteot. : 3

28. Technical characteristics
Operation time : 153 ± 35 mn
Similar to Teeny’s (16O mn) for a major varus series
Similar to Krackow’s (152 mn) for a major valgus series
Blood loss : 1270 ± 570 ml
(no difference between femoral and tibial osteotomies)

29. RESULTS 9 overcorrected HTO Healing : 5 ± 4 months
Follow-up = 45 ± 25 months
IKS score preop = ± 13
IKS score post-op = 160 ± 21
Flexion = 111°± 13
Correction : Valgus 3° ± 3
Healing : 5 ± 4 months
Complications
1 non union (graft)
1 late fusion
1 early PE plateau wear
Correction loss : 3.3° ± 2.9°

30. RESULTS KRACKOW (1991) MIYASAKA (1997) LOTWOET (1997)
Comparison with the literature
9 overcorrected HTO TKA for valgus deformities
KRACKOW (1991)
IKS K score =
Flexion = 103°
MIYASAKA (1997)
IKS K score = 88.7
Flexion = 101°
LOTWOET (1997)
IKS K score = 93.3
Follow-up = 45 ± 25 months
IKS knee preop = ± 11
IKS Knee post-op = 86 ± 13
Flexion = 111°± 13
Correction : Valgus 3° ± 3

31. Leg .. F - 75 years Previous HTO 6 years ago

32. unipodal

33. INNEX mobile bearing knee
Standing position
Ant drawer
Post drawer
INNEX mobile bearing knee

35. RESULTS TEENY (1991) LASKIN (1996)
8 major varus deformities TKA for varus deformities
TEENY (1991)
IKS K score = 89
Flexion = 98°
LASKIN (1996)
Flexion = 86°
IKS K score = ± 12
Flexion = 111°± 10

36. Lu.... 69 years Major varus deformity
153°
182°
T = 77°
Two cruciates retaining TKR

37. Varus deformity following fractures of medial and lateral tibial plateaus
F - 80 years TKA + Opened HTO with graft and staples

38. 179° F - 71 years Femoral fracture at 45 years
Previous tibial osteotomy at 61 yrs
Varus at 2 levels

39. 1 particular case of malrotation
2 previous tibial osteotomies with rotation in the same patient
1 poor result
1 revised
- First case of the series
- Obesity (>100 Kg)
- Recurrent varus
- Wear of a too thin PE

40. The 2 most recent cases had bone deformity + Laxity they need very constrained TKR
1st case
160°
F : 60 years. Poliomyelitis. Patella infera. Quadriceps=0. Varus : 20° 2 previous osteotomies. Global arthritis. Ligamentous laxity.

41. The placement of the stem needs an osteotomy
Grafting with the bone resulting from the cuts

42. Particular case of a malunion above a TKA + Lateral laxity
Bone deformity + Laxity A very constrained hinged TKR is needed
2d case
Particular case of a malunion above a TKA + Lateral laxity
The particular shape of the femur dictates an osteotomy

43. Particular case of a malunion above a TKA + Lateral laxity
Bone deformity + Laxity Ligamentous laxity needs a very constrained hinged TKR
2d case
The particular shape of the femur dictates an osteotomy
Particular case of a malunion above a TKA + Lateral laxity

44. Particular case of a malunion above a TKA + Lateral laxity

45. OSTEOTOMY + TKA ADVANTAGES DISADVANTAGES A single operation
Joint line and ligament balance preserved
DISADVANTAGES
Technical difficulties
Rather prolonged osteotomy fusion

46. Extra-articular deformity
INDICATIONS =
Extra-articular deformity
DEFORMITY
Wear + laxity +
206°
188°
Stress radiography allows precise measurements of ligamentous and bony deformities
Valgus stress Varus stress

47. Extra-articular deformity
INDICATIONS
Extra-articular deformity =
DEFORMITY
Wear + laxity +
206°
188°
Stress radiography allows precise measurements of ligamentous and bony deformities
Valgus stress Varus stress

48. Extra-articular deformity
INDICATIONS
Extra-articular deformity =
DEFORMITY
Wear + laxity +

49. Extra-articular deformity
INDICATIONS
Extra-articular deformity =
DEFORMITY
Wear + laxity +
Valgus def. = 17°± 10 ( 9 to 30°)
Varus def. = 22° ± 9 (12 to 34°)
Mean deformity in the serie

50. Extra-articular deformity
INDICATIONS
Extra-articular deformity =
DEFORMITY
Wear + laxity +
Valgus def. = 17°± 10 ( 9 to 30°)
Varus def. = 22° ± 9 (12 to 34°)
14.3°
16.4°
5-7° ??
Minimum deformity for indication ??

51. Opening or closing wedge osteotomy ?
INDICATIONS
Opening or closing wedge osteotomy ?
- Length of the limbs
- Bone is available for grafting (bone cuts)
Opening HTO is difficult in previous valgus HTO
Opening HTO is easy for varus tibial deformities
Opening = closing for femoral deformities

52. Conclusions Unfrequent operation (19 knees)
(during the same period by the same surgeon : 840 TKA)
Indicated in cases of severe gonarthrosis and major extra-articular deformity in elderly patients

53. Conclusions
The results of these extreme cases are similar to those of simple TKA
There are advantages in doing TKA and osteotomy in a single operation :
Preservation of the joint level (and PCL) and patellar height
Good balance of the ligaments eliminating the need for highly
constrained TKA
It is also compatible with the performance of non cemented implants

54. Thank you