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Role of Osteotomy in ACL and PCL Deficient Patients Satyam PatelFeb. 2007 mod. from Cole BeavisNov. 2002.

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Presentation on theme: "Role of Osteotomy in ACL and PCL Deficient Patients Satyam PatelFeb. 2007 mod. from Cole BeavisNov. 2002."— Presentation transcript:

1 Role of Osteotomy in ACL and PCL Deficient Patients Satyam PatelFeb mod. from Cole BeavisNov. 2002

2 Outline Natural history of ACL and PCL deficient patients Principles of osteotomy in management of knee instability and malalignment Management of combined knee instability and malalignment Not discussed / deferred to future talk : role of osteotomies in management of collateral ligament related instability about the knee.

3 Natural History of ACL/PCL Deficient Knee Literature somewhat difficult to interpret –Variety of factors influence natural history Meniscal tears Chondral damage from original injury Heterogeneous population (grades I-III) Types of conservative treatments –Outcome measures often difficult to measure return to sport return to previous function

4 Natural History of ACL Deficient Knee Generally agreed upon principles –Gait altered quadriceps avoidance –Repeated episodes of subluxation Meniscal and chondral damage –Degenerative changes present in most patients within 6-10 years of injury Worst in subset of patients with meniscal injury Medial compartment > lateral compartment

5 Natural History of ACL Deficient Knee Dejour - from Fu Knee Surgery …osteophyte and superficial destruction of cartilage are likely to develop within 10 years in knees with ACL rupture. Significant arthrosis develops after longer periods (20-30 years). An additional meniscal lesion or meniscectomy constitutes a turning point in the evolution of arthrosis. The meniscal factor is not the main factor; it is a contributory factor in the evolution of arthrosis in the ACL deficient knee.

6 Natural History of PCL Deficient Knee Commonly reported in the literature that the natural history of isolated PCL deficiency is benign Controversial Cadaveric and clinical studies have shown high incidence of patellofemoral joint and medial compartment arthrosis

7 Natural History of PCL Deficient Knee Miller, Bergfeld, Fowler, Harner, Noyes (ICL 99) …degenerative change is probably inevitable, and that current surgical techniques cannot forestall it. PCL injuries may not be as benign as we previously thought, especially with advanced (grade 3) injuries.

8 Principles of Tibial Osteotomy

9 Coventry –established high tibial osteotomy as a treatment for unicompartmental OA Goal of osteotomy –to transfer joint forces from the arthritic compartment to the more normal compartment

10 Principles of Tibial Osteotomy Mechanical axis line drawn from the center of hip rotation through the center of the knee to the center of the ankle mortise a normal axis is a straight line Anatomic axis (tibiofemoral angle) obtained by the intersection of the lines drawn along the shaft of the femur and tibia normally 5-7 degrees of valgus

11 Principles of Tibial Osteotomy Anatomic –Comparison of femoral and tibial shafts –5 - 7º valgus Mechanical –Line of ground reaction force transmission –0 - 1º varus

12 Principles of Tibial Osteotomy Mechanical Axis –Location determines percentage of load carried in each compartment –In the normal knee 60% of weight bearing is through the medial compartment

13 Principles of Tibial Osteotomy Type of osteotomy –Medial compartment OA with varus deformity valgus-producing osteotomy –Lateral compartment OA with valgus deformity varus-producing osteotomy –Alteration in tibial slope for ligamentous deficiency Extension type for ACL deficient Flexion type for PCL deficient

14 Principles of Tibial Osteotomy Type of osteotomy ExtensionValgus

15 Principles of Valgus Tibial Osteotomy Indications for valgus osteotomy –pain unresponsive to conservative measures –isolated medial compartment OA –age < 60 –no more than of varus on WB film –pre-op ROM > 90 –<15 of flexion contracture

16 Principles of Valgus Tibial Osteotomy Contraindications: –narrowing of the lateral compartment –lateral tibial subluxation > 1cm –flexion contracture > 15 degrees –ROM < 90 degrees –> 20 degrees of correction needed –large varus thrust –inflammatory arthritis –tricompartmental arthritis –severe patellofemoral disease

17 Principles of Valgus Tibial Osteotomy Aim for mechanical axis to pass through medial 1/3 of lateral compartment Determine amount of correction –Multiple recommendations for post-op valgus anatomic alignment Fu5 - 13º Vainionppa> 7º Insall10º Keene7 - 13º –Most common reason for failure of osteotomy is undercorrection

18 Principles of Tibial Osteotomy Technique –Preop plan with long leg weight bearing xrays –Calculate size of wedge using bone width and trigonometry –Traditionally, 1mm for 1º correction Only valid for a 56mm diameter metaphysis

19 Principles of Tibial Osteotomy Level of Tibial Osteotomy –Above the tubercle (most common) High healing rates Limited degree of correction –Below the tubercle Greater range of correction More bone proximally for fixation Lower healing rates

20 Valgus Closing Wedge

21 Lateral wedge resection Hinge on medial cortex Can resect more bone anteriorly to decrease tibial slope (extension type osteotomy) –ACL deficiency

22 Valgus Closing Wedge Benefits –Can compress across osteotomy –Quadriceps pull compresses osteotomy –No bone graft harvest site –No risk of bone graft shifting –Inherently more stable Drawbacks –Shortens quads mechanism and leg –Infrapatellar scarring –Can unmask MCL laxity

23 Valgus Opening Wedge

24 Medially based wedge Multiple variations in techniques Can incorporate anterior opening wedge –Increases tibial slope (PCL deficiency)

25 Valgus Opening Wedge Advantages –Useful with medial bone loss or MCL laxity –Tensions MCL Drawbacks –Limited compression –Bone graft donor site morbidity

26 Fixation of Osteotomies Cast Staples Plate –Compression, buttress External fixator

27 Osteotomies and ACL / PCL Deficient Knees

28 Osteotomy and ACL Deficient Knees Valgus osteotomy described in treatment of unicompartmental arthrosis associated with ACL deficiency –Shift mechanical axis laterally and decrease force through diseased medial compartment

29 Osteotomy and ACL Deficient Knees Osteotomy has been used in treatment of instability –Extension type to decrease tibial slope and anterior tibial translation

30 Osteotomy and ACL Deficient Knees Osteotomy has been used in treatment of instability –Extension type to decrease tibial slope and anterior tibial translation

31 Osteotomy and ACL Deficient Knees Approach –Patients with arthritic, ACL deficient knee and failing conservative treatment 3 groups of patients 1.Primary symptom is instability 2.Primary symptom is pain 3.Both pain and instability

32 Osteotomy and ACL Deficient Knees Primarily instability Pain + Malalignment - ACL Reconstruction Pain - Malalignment + Osteotomy and Reconstruction Pain -Malalignment - ACL Reconstruction Pain +Malalignment + Osteotomy and Reconstruction

33 Osteotomy and ACL Deficient Knees Primarily pain Instability + Malalignment - ACL Reconstruction Instability - Malalignment + Osteotomy Instability - Malalignment - ?Arthroscopic debridement Instability + Malalignment + Osteotomy and Reconstruction

34 Osteotomy and ACL Deficient Knees Technique –Preoperative planning aiming for 8-10° of valgus –Initial arthroscopy Assess articular surfaces Address meniscal pathology –High tibial osteotomy Lateral closing wedge for most Medial opening wedge for MCL laxity Ensure fixation does not cross region of future tunnels


36 Osteotomy and ACL Deficient Knees Technique cont –ACL reconstruction follows osteotomy Staged or as part of same procedure Bone patellar tendon bone, hamstring and allograft have all been reported –Increased risk of patella baja with BTB

37 Osteotomy and ACL Deficient Knees Technique contd –Postop combined procedure CPM immediately postop Hinge brace locked in extension x 4 weeks; touch WB Brace unlocked and WB progressed from 4-8 weeks At 8 weeks postop brace discontinued and aggressive ACL rehab program x 3-6 months –Staged ACL follows 6 months after osteotomy Osteotomy hardware removed at time of ACL


39 Osteotomy and ACL Deficient Knees Outcomes –Return to pre-injury level is rare Few reports of patients returning jumping, pivoting sports –Those with severe pain should expect improvement 80-92% patient satisfaction –Maximal benefit obtained in patients wishing to return to light athletic activities 30-78% return to sports

40 Osteotomy and PCL Deficient Knees Few reports in literature –Similar indications as for ACL with symptomatic varus malalignment and unicompartmental disease PCL deficiency medial and patellofemoral arthrosis –Must select patients carefully –Also described as treatment of posterolateral instability with varus thrust in absence of arthrosis Correct mechanical axis prior to ligament reconstruction

41 Osteotomy and PCL Deficient Knees Increasing tibial slope has been shown to decrease tibial translation (sag) –Anterior opening wedge osteotomy –Anteromedial opening wedge to address tibial slope and varus malalignment

42 Osteotomy and PCL Deficient Knees Increasing slope by 50% resulted in shift of resting position of knee between 3-5mm (reduced posterior sag) Few reports and no long term results for this technique –Additional studies required

43 Biomechanical studies Am J Sports Med Mar;32(2): Ten cadaveric knees were studied using a robotic testing system using three loading conditions: –(1) 200 N axial compression –(2) 134 N A-P tibial load –(3) combined 200 N axial and 134 N A-P loads Tibial slope was increased from 8.8 +/- 1.8 deg. to /- 2.1 degrees, –anterior shift of tibia relative to femur (3.6 +/- 1.4 mm). –Under axial compression, the osteotomy caused a significant anterior tibial translation up to 1.9 +/- 2.5 mm (90 degrees ). –Under A-P and combined loads, no differences were detected in A-P translation or in situ forces in the cruciates (intact versus osteotomy)

44 Biomechanical studies Results suggest that small increases in tibial slope do not affect A-P translations or in situ forces in the cruciate ligaments. However, increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that increasing tibial slope may be beneficial in reducing tibial sag in a PCL-deficient knee, whereas decreasing slope may be protective in an ACL- deficient knee.

45 Biomechanical studies Am J Sports Med Jun;34(6): cadaveric knees: valgus HTO + anatomic double bundle ACL reconstruction Anterior tibial translation and internal rotation decreased by 2mm and 2 degrees at low flexion angles vs. ACL intact knees In-situ forces in posterolateral graft became % higher than those in the posterolateral bundle of the intact ACL N.B. - may overconstrain knee and result in high forces in posterolateral graft, predisposing to graft failure

46 Clinical studies J Knee Surg Jan;16(1): Patients with ACL insufficiency, symptomatic medial OA, varus –14/26 recreational athletes - minimum 2 year follow-up 12 valgus HTO alonevs. 14 valgus HTO + ACLR No change in instabilityvs.grade 1 lachman 11/13 negative pivot 12/13 No ROM deficitsame OA progressionOA progression Overall 23/26 patients able to play recreational sports Good or excellent results seen more often in HTO + ACLR group

47 Clinical studies Knee 2004 Dec; 11(6): patients (30 knees) retrospectively reviewed Previous single-stage ACLR + valgus HTO 19/30 had previous medial meniscectomy 2/30 major complications --> stiffness 12yr f/u (6-16) –5/30 had progressed one arthritis grade –14/30 returned to intensive sports –11/30 played moderate sports –Avg. difference in anterior tibial translation (vs. Normal side) was 3mm

48 Osteotomy and ACL Deficient Knees Summary –Active patients with ACL deficiency and unicompartmental arthritis may benefit from ACL reconstruction, osteotomy or combination with improved pain and return to recreational activities –Radiographic (& clinical) progression of OA may be delayed or may be unchanged.

49 Osteotomy and PCL deficient knees Long-term data regarding the outcome of PCL deficiency vs. PCL reconstruction vs. PCL reconstruction & osteotomy is lacking. Short term follow-up reveals better knee scores and less subjective sense of instability.Am J Sports Med 1996;24: In the presence of varus deformity and decreased tibial slope correcting the varus deformity and increasing the tibial slope (e.g. anteromedial opening wedge) decreases the amount of posterior tibial sag. This should theoretically decrease the amount of quads force required to pull tibia anteriorly and thereby decrease rate of onset of patellofemoral arthritis. Valgus HTO unloads medial compartment and decreases medial OA.

50 References Dejour et al, ACL reconstruction combined with valgus tibial osteotomy. Clin Ortho : DeLee JC ed. Orthopaedic Sports Medicine. Pg Fu F ed. Knee Surgery. Pg Larson et al, PCl reconstruction: associated extra-articular procedures. Tech Ortho (2): Noyes et al, High tibial osteotomy in ligament reconstruction for varus angulated ACL deficient knees. Am J Sports Med (3): ONeil and James, Valgus osteotomy with ACL laxity. Clin Ortho : Vogrin et al, Biomechanics of PCL deficient knee. Tech Ortho (2): Williams et al, Management of unicompartmental arthritis in the ACL deficient knee. Am J Sports Med (5);

51 Clinical studies Z Orthop Ihre Grenzgeb Mar-Apr;140(2): Simultaneous arthroscopic cruciate reconstruction and closing wedge osteotomy –4/ /00 58 patients (avg. 33 y.o.) –49 ACL, 7PCL, 2 ACL & PCL –Avg. 7deg correction (mean malalignment 5 deg) –13 patients also had osteochondral allograft –2 had implantable collagen meniscus –Lysholm score (66 --> 81 --> 87 --> 93)

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