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Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees) Total Knee Arthroplasty associated with osteotomy in cases of.

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Presentation on theme: "Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees) Total Knee Arthroplasty associated with osteotomy in cases of."— Presentation transcript:

1 Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees) 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° 11 valgus : 22° ± 3 12 varus : 26° ± 3 Good corrections - Good results obtained with post. cruciate retaining TKR Similar to other TKRs in our series Even in case of major deformity TKR is possible : Intra-articular deformities

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

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

7 ADVANTAGES 1 operation1 operation No major difficultiesNo major difficulties Immediate weight bearingImmediate weight bearing

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

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

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

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

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

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

14 1 - OSTEOTOMY First and TKA later 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 ADVANTAGES DISADVANTAGES This choice had been made for 67 young patients previously operated by osteotomy

15 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 OSTEOTOMY + TKA

16 1/ Correction of a tibial valgus deformity 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 1rst method

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 218° 182°

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

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

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

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

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

26 Varus knee (22° ± 9 ) 8 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 Material

27 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. : 3 Closed osteot. : 3 Technical characteristics

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

29 Healing : 5 ± 4 months Complications 1 non union (graft) 1 late fusion 1 early PE plateau wear Correction loss : 3.3° ± 2.9° 9 overcorrected HTO Follow-up = 45 ± 25 months IKS score preop = 87 ± 13 IKS score post-op = 160 ± 21 Flexion = 111° ± 13 Correction : Valgus 3° ± 3 RESULTS

30 KRACKOW ( 1991)KRACKOW ( 1991) IKS K score = 87.6IKS K score = 87.6 Flexion = 103°Flexion = 103° MIYASAKA (1997)MIYASAKA (1997) IKS K score = 88.7IKS K score = 88.7 Flexion = 101°Flexion = 101° LOTWOET (1997)LOTWOET (1997) IKS K score = 93.3IKS K score = 93.3 Comparison with the literature Comparison with the literature TKA for valgus deformities 9 overcorrected HTO TKA for valgus deformities RESULTS Follow-up = 45 ± 25 months IKS knee preop = 34 ± 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 Ant drawerPost drawer Standing position INNEX mobile bearing knee

34

35 TEENY (1991)TEENY (1991) IKS K score = 89IKS K score = 89 Flexion = 98°Flexion = 98° LASKIN (1996)LASKIN (1996) Flexion = 86°Flexion = 86° IKS K score = 86.4 ± 12IKS K score = 86.4 ± 12 Flexion = 111° ± 10Flexion = 111° ± 10 RESULTS 8 major varus deformities TKA for varus deformities

36 Lu years Major varus deformity T = 77° 153°182° 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 F - 71 years Femoral fracture at 45 years Previous tibial osteotomy at 61 yrs Varus at 2 levels 179°

39 - First case of the series - Obesity (>100 Kg) - Recurrent varus - Wear of a too thin PE 1 poor result1 poor result 1 revised1 revised 2 previous tibial osteotomies with rotation in the same patient 1 particular case of malrotation

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

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

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

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

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

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

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

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

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

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

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

51 - 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 Opening or closing wedge osteotomy ? INDICATIONS

52 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 Conclusions

53 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 Conclusions

54 Thank you


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