HTO Syllabus

2014-07-01

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6/30/2014

Fixed Unicompartmental Knee

Arthroplasty in Young Osteoarthritic Knee

F. Benazzo, SMP Rossi, M. Ghiara

Clinica Ortopedica e

Traumatologica

Università degli Studi di Pavia

Fondazione IRCCS Policlinico

San Matteo

Direttore: Prof. F. Benazzo

Disclosure

•LimaCorporate Consultant, Conceptor

•Zimmer Consultant, Conceptor

•Ceramtec Consultant

•Fidia Consultant

UNI and Young Patients

Focus on

•Dilemmas

•Indications and contraindications

•Implant selection with specific indications

•Up-to-date indications (combined implants,

ACL reconstruction, postrauma/osteotomy)

•Return to sport

6/30/2014

2012

- Surgeons, given identical information, do not concur

on treatment for patients with the same pathology.

- Decision making process heavily influenced by

radiographic findings but individual surgeons are

consistent with their own treatment choice.

-Consensus treatment for medial osteoarthritis of

the knee remains in question.

Dilemmas

- If a more standardised approach to offering this surgical care is to be

achieved, then improved decision support for patients around this

specific treatment choice will be required.

- Comprehensive comparative data across the three treatment options

(UKA;TKA;HTO) is not available.

Uni vs TKR

•preservation of bone stock and soft tissues,

•more natural gait pattern and kinematics,

•improved range of motion

•reduced operative time

•reduced incision size.

Dilemmas

6/30/2014

Gait:

No differences were noted between the groups

(UKA or HTO) other than at 3 months after surgery

when there was a significant difference in the time-

distance variable of gait in favor of UKR. This

became insignificant at 1-year and 5-year follow-up

Borjesson M, Weidenhielm L, Mattsson E, Olsson E:

Gait and clinical measurements in patients with knee osteoarthritis after surgery: a prospective 5-

year follow-up study.

Knee 2005, 12:121-127

Dilemmas

Indications

Classic:

•Unicompartmental degenerative disease (medial or

lateral) with mild degeneration of the opposite side

•Painful osteonecrosis/osteochondritic involvement of the

femoral condyle, with or without rim narrowing

6/30/2014

Indications

Classic:

•Deformity of the anatomical axis of the limb due to

narrowing of the joint line for the degenerative disease

and not to deformity of the tibia (schuss x-rays view)

•Deformity correctable manually (stress x-rays) and

therefore surgically, with the thickness of the implant

Indications

Classic:

•Healthy (functionally valid) ACL

•Full or almost full flexion (ROM almost normal)

•Finger sign positive

•Age > 60 years

•BMI < 30

•Varus /valgus deformity < 10°

•Flexion contracture < 10°

6/30/2014

Indications

Enlarged:

•Age < 60 years

•BMI >30 … < 32

•Presence of degenerative patello-femoral joint

without anterior knee pain (no full-thickness

chondral lesions or lateral facet involvement)

Indications

Enlarged:

•ACL deficient knee frequent in young patients

- low demanding patients  tibial slope < 7°

- Possibility of ACL reconstruction together with the

UNI

Indications

ACL and Tibial slope:

->7° should be avoided

- particularly if the anterior cruciate ligament is absent at

the time of implantation.

- An intact anterior cruciate ligament, even when partly

degenerated, was associated with the maintenance of

normal anteroposterior stability of the knee for an average

of sixteen years following unicompartmental knee

arthroplasty.

Hernigou P, Deschamps G:

Posterior slope of the tibial implant and the outcome of unicompartmental knee arthroplasty.

J Bone Joint Surg Am 2004, 86:506-511

6/30/2014

Implant selection

1) Resurfacing

2) Measured resection

Different philosophies

Slightly different indications

Choice is a matter of age

Implant selection

Resurfacing:

-“la uni c’est du resurfaçage” by Philippe Cartier

 bone sparing and of respecting the joint

physiology

 respect of the so called “Cartier angle”(angle

of tibial varus deviation)

 Reaming of the cartilage surface on the

femoral side.

Implant selection

Measured resection:

- Implants and concepts that are

closer to a total knee design and

philosophy

- Tibial cut at 90° and a parallel cut

on the femoral side (based upon

the tibial cut)

6/30/2014

Implant selection

Indications

Our experience : resurfacing in case of more

degenerated OA with condylar recession

Less bone to be removed

Easier to avoid overcorrection

Resurfacing

Measured

resection Resurfacing

Measured

resection

Implant selection

Fixed vs mobile

- Good results with both implants

- Different philosophies

- Different techniques

6/30/2014

Implant selection

Indications:

•No specific indications according to each specific

design

Our opinion:

•ACL concomitant reconstruction, partially deficient

ACL: fixed bearing

•Lateral OA: fixed bearing

No matter the implant design

•Tibial sagittal plane: slope = native, mostly 3°-5°

•Tibial coronal plane: - 90°

- Pristine varus (Cartier angle)

•Osteophytes removal from tibia and femur: MCL

release

Surgical technique: medial Uni

No matter the implant design

•Femur: central /slightly lateral positioning of

the femoral component on the condyle,

avoiding notching with the tibial spine

•Balancing: slight looseness to avoid lateral

overloading (1-2 mm)

Surgical technique: medial Uni

6/30/2014

No matter the implant design

•Femur: no osteophyte removal from femoral

condyle. The osteophytic overgrowth can be

used to support the femoral component

particularly on hypoplastic condyles

•The component must be implanted as lateral

as possible

•Some remaining valgus (no full correction)

Surgical technique: lateral Uni

Up-to-date indications

Uni solo: “one finger sign” + slight AKP

with only medial facet involved

Beard et al

The influence of the presence and severity of pre-existing

patellofemoral degenerative changes on the outcome of the

Oxford medial unicompartmental knee replacement

Pre-operative clinical and radiological assessment of the

patellofemoral joint in unicompartmental knee replacement and its

influence on outcome JBJS Br, 2007 .

F. Benazzo, S. M. P. Rossi, L. Piovani, A. Combi, S. Perle

Bi-uni und bi-uni + femoropatellarer Gelenkersatz 2012

Up-to-date indications

6/30/2014

Up-to-date indications

Considerations

•Uni insufficient to improve patellar

tracking and provide pain relief if lateral

facet involved

•TKA is an overkilling solution: ACL

sacrificed, lateral compartment sacrificed

Up-to-date indications

6/30/2014

Up-to-date indications

Uni and acl: technical issues

•tunnel positioning

•approach

•stability of the implant

6 months

6/30/2014

Uni + ACL Trans-tibial approach

Problems:

•Tunnel widening

•Possible secondary impingement

with metal back

•Possible tibial baseplate

subsidence

Up-to-date indications

Our solution: Acl trans-am reconstruction

•Tunnel widening: unavoidable

•Prosthesis site placement: unchangeable

•Transfer tibial tunnel from medial site closer to tt,

producing an anatomic foot print

Move away tunnel

from prosthesis

Reduce likelihood of

impingement between

new-ACL and baseplate

Up-to-date indications

6/30/2014

Up-to-date indications

1 year

Lateral UNI

 Lateral arthritis: 10% of patients with knee OA

- Valgus knee

- Post-traumatic

- Post-osteotomy

Lateral UNI

6/30/2014

Lateral UNI

Follow-up 3

months

Lateral UNI

3.UNI

Lateral UNI

6/30/2014

Return to sport

- More patients returned to or increased sports

following UKA (P=.0003), but no sooner than TKA

patients.

- Patient-perceived Oxford and modified Grimby

scores were better and sporting activity was

greater following mini-incision UKA compared to

TKA.

Walton et al

Patient-perceived outcomes and return to sport and work: TKA versus mini-incision

unicompartmental knee arthroplasty.

J Knee Surg. 2006 Apr;19(2):112-6.

Return to sport

- The majority of patients returned to sports and recreational

activity UKA

- However, the numbers of different disciplines patients were

engaged in decreased as well as the extent of activities.

- Activities in which most patients participated were

primarily low- or midimpact.

- Patients scored higher on the SF-36 than age-related

norms, which might be due to the patient-selection process

for unicompartmental knee arthroplasty and geographical

differences.

Naal et al

Return to sports and recreational activity after unicompartmental knee arthroplasty.

AJSM, 2007

Conclusion

•UKA is a valid option to address the

unicompartmental degenerated knee

•Age is not anymore a limitation, assuming that

surgery is correctly performed

•Young patients can benefit from this

procedure, including those who seek for sport

activities

6/30/2014

VuMedi Webinar

HTO vs UKR

Mobile UKR

D Murray

Disclosure:

Personal & Institutional support - Biomet

High Activity patients

•Concern

–? Causes UKR wear & failure

•Fixed bearing UKR

–Wear inevitable esp second decade

–Small contact area, high contact stress

–Thin polyethylene

•Normal Knee

–Wear prevented by meniscus

–Reproduce function of meniscus

Minimise wear

•Reproduce meniscus

–Full congruent contact in

all positions

•Only achieved with

–Mobile bearing

–Spherical femur

6/30/2014

Oxford knee 1976

Articulation unchanged

•Femur spherical (1mm error)

•Tibia flat

•Mobile Bearing

–Fully congruent - low wear

–Unconstrained - low loosening

20 year wear

in vivo

•RSA (Kendrick et al 2010)

•7 knees, Phase 2

•Wear 0.4mm (max 0.6mm)

•Rate 0.02mm/yr (max 0.03)

•Order of magnitude less than fixed

•Ideal for young active patients

Survival %

Years

Independent Results (Svard 2006)

683 Oxford UKR

20 yr survival 92% CI 15

Better than other UKR

No failures due to wear

OA progression 2% at 20 yrs

6/30/2014

Phase 1 study (Svard 2013)

•1983 to 1988 – 25 to 30 years ago

•125 implants (104 patients)

•80% Dead, alive reviewed mean 25yr

•90% Definitive knee replacement with no

revision & Good/Excellent HSS score

•No TKR has better results

Medial OA – optimal treatment

•Young (? <60 25% of cases)

–UKR v Osteotomy

–Debate – no good comparative evidence

•Old (? >60 75% of cases)

–UKR v Osteotomy

–UKR better - no debate

UKR v HTO in elderly

•UKR definite solution

–Rapid recovery, Low morbidity, Good function

–90% patients die with without revision and

with good clinical outcome

•HTO

–Results not so good

–15yr Comparative study (Weale 1994)

–Meta-analysis (Virolainen)

6/30/2014

UKR v HTO in young

Controversial issues

•Bone-on-bone or Partial thickness

•Activity level

•Extent of varus deformity

•ACL deficiency

UKR v HTO in young -

Indications

•Bone – on – bone medial OA

–UKR reliably relieve symptoms, good long

term results

–HTO – not so reliable

•Partial thickness cartilage loss

–Diagnose – Xray or arthroscopy

–UKR not reliable – contra-indicated

–? HTO ideal if associated with Varus

PTCL compared to Bone

Exposed (BE) & Bone loss (BL)

Groups

BLBEPTCL

OKS

p < 0.001

•PTCL worse score and

greater variability than BE or

BL (OKS 36 v 43)

•PTCL 21% worse or no

substantial improvement

(ΔOKS<6). BE & BL all

substantial improvement

•4 complications (pain

related) all PTCL (14%) Gulati et al (2010)

6/30/2014

Partial thickness loss

•UKR

–Not reliable – contraindicated

–Rare to have severe symptoms

•HTO

–PTCL + varus ? Best indication

–PTCL without varus ? Not indicated

Bone-on-bone HTO v UKR

•No RCT in young

•Age matched comparison (mean 55yr)

–Distraction osteoclasis 76, 6yr mean

–Oxford UKR 78, 6yr mean

–OKS (0-48) - HTO 27 UKR 38

–Perhaps not highly active

•HTO 10yr survival 66%

•Other series 60% - 80%

Oxford age < 60yrs

(mean 55, n=52, Price et al ESSKA 2000)

Years post operation

>60

<60

•15yr 92%

•No significant difference (p=0.8)

•Appears to be reliable in young

patients (50s)

6/30/2014

<50yr, 7 centre study

107 patients, Mean age 47

3 revisions: 2 for pain, 1 dislocation

7 yr survival = 98% (n=24)

10 yr survival = 91% (n=9)

High level activity

subgroup

•Does it compromise UKR

outcome?

•Analysis of 1000 Oxford UKR

with 5 to 15yr follow-up

•Overall with increased activity

–Increased 12yr survival (p=0.025)

–Increased OKS (p<0.01)

•High activity does not cause failure

•Pandit 2014

100

0-1 2 3 4 5 ≥6

Tegner

12yr survival

OKS

High level activity in UKR

•High activity group patients (Tegner ≥ 5)

–(Tegner 5 = Heavy labour, competitive cycle, jog

uneven ground)

–n=115

–12 year survival 97.3% (95%CI: 92-99).

–OKS 45 (SD 5)

–KSS-O 82 (SD 16) KSS-F 95 (10)

•Activity does not compromise outcome

•Not contraindication, can be recommended

6/30/2014

High activity in HTO

•Tegner score ≥ 5

•Bone on bone arthritis

•12 year survival ??? – not nearly 97%

•Mean 6 year clinical follow-up

–OKS ??? – not as good as 45

Activity - summary

•UKR function well so high activity

achieved

•High activity does not cause failure

•Is high activity so reliably achieved after

HTO and if so is long term survival so

good?

Tibia vara & medial OA

•Determine site and severity of deformity

•Intra-articular (usually 5º to 10º)

–Corrected by operation

•Extra-articular (usually 0º to 10º)

–Tibia vara

–Not corrected by operation,

•Alignment restored to pre-disease state

•? Does tibia vara compromise outcome?

6/30/2014

Tibia Vara & Oxford UKR

•Incidence of tibia vara

–5º tibia vara 20%

–10º tibia vara 5%

•Tibia vara

–Does not cause long term failure

–Does not compromise function

•Tibia vara not contra-indication

ACLD & medial OA

•Primary ACLD with

secondary medial OA

•Postero-medial tibial defect

•Combined UKR & ACLR if

–Young and active

–Bone on bone

–Normal MCL & lateral side

(stress Xray)

Technique

•Depends on presenting

symptoms

•Pain

–Simultaneous procedure

–Open, BTB

•Instability

–ACL first

–Arthroscopic, Hamstring

–UKR if symptoms persist

6/30/2014

Results

(Weston-Simons 2013)

•52 cases

•Mean age 51yr (36-57)

•Mean follow up 5yr (1 – 10)

•10yr survival 91%

–2 failures – infected, lat OA

•Mean OKS 41

•98% pleased

•Kinematically normal

Other factors to consider

•Predictability – UKR better

•Speed of recovery - UKR better

•Cosmesis - UKR better

•Ease of revision

–UKR usually simple (fracture & infection)

–HTO variable (? Opening wedge easier)

Summary

•Medial OA, bone-on-bone, intact ACL

–UKR better (function, survival, etc)

•Partial thickness loss

–UKR contraindicated

–? HTO if associated varus

•Very young (<40), Very high activity

(contact sport), ACLD deficient

–Still debatable (we do UKR)

6/30/2014

The Role of Osteotomy

around the knee

Hannover – München - Innsbruck – Bozen

Ph. Lobenhoffer

AO Trauma Europe

Disclosures:

I have no financial relationship to techniques or products mentioned

in this presentation

Frontal plane alignment Constitutional Varus

deformity:

•32% males

•17% females

Bellemans CORR 2012

HKA

0°

ALL

MALE

HKA: mechanical axis femur / tibia

Constitutional Varus

J. Victor CORR 2013

knee outwards

foot inwards

WBL shifts medial

6/30/2014

Constitutional Valgus

Knee inwards

foot outwards

WBL shifts lateral

Epidemiology

Osteoarthritis is a disease of mechanics

D.T. Felson JAMA 2013

4 degrees of deformity: 3 x risk for OA

Progression 10 to 20 x faster with deformity

Felson 2013, Brouwer 2007, Sharma 2001, 2009, 2010, 2012, Cerejo 2002 Framingham, MOST, other studies

A frontal plane

deformity more than

3° leads to

osteoarthritis and

should be corrected

Biomechanical Study

6 human knees

Axial load in mechanical

testing system (mts) in

extension

Bi-cardanic fixation

Ligaments and menisci

intact

Agneskirchner, Hurschler*, Lobenhoffer , Arthroscopy 23, 2007

6/30/2014

Varus Malalignment

0% 50%

100%

medial lateral

Pressure++

Agneskirchner,

Hurschler, Lobenhoffer

Arthroscopy 23, 2007

Open wedge HTO

0% 50%

100%

WBL to 62%

HTO 9mm,

MCL 100% released

medial lateral

Pressure ++

Agneskirchner,

Hurschler, Lobenhoffer

Arthroscopy 23, 2007

Indication for osteotomy

•Congenital deformity

•Posttraumatic deformity

•Unilateral Osteoarthritis

6/30/2014

Frontal plane alignment and correction

Constitutional

deformity

Frontal plane alignment and correction

Intraarticular

defect

Patient criteria

Metaphyseal deformity (TBVA)

Tibial Bone Varus Angle

Bonnin,Orthopäde 2004

Niemeyer Arthroscopy 2009

Tibial

Bone

Varus

Angle

Good / excell.

10-y. results

>5° 83%

2-5° 71%

0-2° 56%

<0° 36%

TBVA

> 5°

TBVA

= 0°

6/30/2014

HTO Survival Rate

5 Jahre 10 Jahre > 10 Jahre

Insall 85% 66%

Yashuda 63% 18%

Berman 77% 62% 59%

Rudan 78% 70%

Matthews 50% 28%

Rininapoli 73% 46%

Ivarsson 57% 43%

Hernigou 90% 45%

Aglietti 96% 78% 57%

Levigne 69% 54%

Gstöttner 94% 80% 54%

Van Raaij 75%

Akizuki 98% 90%

Flecher 85%

Billings 85% 53%

Cochrane Database :

Brouwer et al 2007

Silver Evidence:

70% of patients benefit

from an osteotomy for 10

years

HTO Survival Rate

5 Jahre 10 Jahre > 10 Jahre

Insall 85% 66%

Yashuda 63% 18%

Berman 77% 62% 59%

Rudan 78% 70%

Matthews 50% 28%

Rininapoli 73% 46%

Ivarsson 57% 43%

Hernigou 90% 45%

Aglietti 96% 78% 57%

Levigne 69% 54%

Gstöttner 94% 80% 54%

Van Raaij 75%

Akizuki 98% 90%

Flecher 85%

Billings 85% 53%

Spahn G, KSSTA 2013

46 studies HTO

5-8 years after HTO:

91% no further surgery

9 – 12 years after HTO:

84% no further surgery

Valgus HTO Closed Wedge

Lateral translation of

shaft

Impaction medial

hinge

Loss of correction

Pape et al. Orthopäde 2/2004

42 Pat RSA-Analysis HTO

Convent. implant > 8° correction

week 0 – 3:

3 mm. fragment

movement

6/30/2014

HTO lateral closed wedge

Lesions of peroneal nerve

Coventry 1988 3.3%

30 Osteotomies

Jackson 1974 11,9 %

229 Osteotomies

Vainionpää 1981 2%

103 Osteotomies

Aydogdu 2000 27% (EMG)

11 Osteotomies

Kirgis, A., JBJS 1992

Motor branches of

peroneal nerve

endangered by

fibula osteotomy

No fibula osteotomy

No risk for peroneal nerve

No muscle detachment

Only 1 osteotomy cut

Intraoperative fine-tuning

No leg shortening

W. Blauth 1986

P.Hernigou 1987

GC Puddu 1999

Open Wedge HTO

•Stability

•Implant failure

•Slope increase

•Pseudarthrosis

Lobenhoffer KSSTA 2003, Paccola KSSTA 2004, Jakob A´scopy 2004

Problems Open Wedge Osteotomy

6/30/2014

Increased stability

Rapid healing full weight-bearing

Open wedge biplanar Tomofix

3 weeks postop

Locking

screws

Hannover 1998 – 2000: 101 HTO spacer plates 6 implant failures

Hannover 2001 – 2006: 807 HTO with Tomofix no implant failure Lobenhoffer KSSTA 2003

Percutaneous Plate fixator Tomofix

Distance holders

•Subcutaneous

placement

•No compression of

MCL, Pes anserinus

Spontaneous bone healing

No substitute or graft necessary

2 Y. postop

Elastic

motion

induces

callus

formation

6/30/2014

Stability

RSA studies

Heerwaarden 2006:

42 cases open wedge Tomofix

no relevant migration,

no difference to closed wedge Tomofix

Heerwaarden Acta Orthop Scan2010:

14 vs 23 patients

full weight-bearing /partial weight bearing

no differences after one year

Immediate full weight bearing allowed

Brinkman, Lobenhoffer, Agneskirchner, Staubli, Wymenga, Heerwaarden JBJS (Br) 12, 2008

Functional outcome assessment in patients treated with open wedge

high tibial osteotomy (HTO) for knee osteoarthritis using TomofixTM.

533 patients, 3 centers, op. 4/2004 to 4/2006

75% follow-up rate, BMI 27, 9,8 mm opening

•D. Freiling

•S. Meyer

•S. Friedmann

•P. Lobenhoffer

•A.Staubli

•S. Schröter

•D. Hoentzsch

TomoFix TM retrospective study

AO Foundation

Clinical Investigation

Flörkemeier et al, KSSTA 1/2013

6/30/2014

Oxford Knee Score (OKS)

Subjective score

Internationally accepted

Available in Englisch

Translated/Validated by AOCID

12 questions, 5 answers

(excellent 4 P., bad 0 P.)

48 points: excellent result

0 points: bad result

 Comparison with Unicondylar

and Total Knee

 Present version of OKS:

 48 points best result

 0 points worst results

Ø 43 (0-48)

Results better than UKA, TKA

Ø 51,6 (20-60)

No correlation to age

6/30/2014

Ø 51,6 (20-60)

No correlation to stage of osteoarthritis

Activity

3 Mo.after Tomofix right side

6 Mo. after Tomofix both sides

3 Mo. after Tomofix right side

6 Mo. after Tomofix right side

Salzmann GM, Imhoff, AB et al AJSM 2009

65 patients Tomofix 36 months postop

91% engaged in sports activity

2 sessions /4 hours per week

Lysholm 70, Tegner 4,3

Downhill skiing, mountain biking

Studies Tomofix

6/30/2014

W., U., 51 y., male

former German champion 400 m running

orthopaedic surgeon

2 x arthroscopic debridement, medial

meniscectomy

Medial pain

ADL

MPTA 85°

W., U., 51 y.

PreOP Plan Software: 7° correction, 10 mm opening

W., U., 51 y.

6 days

postop

5 weeks

postop 6 days

postop

5 weeks

postop

FWB and working 5 weeks postop

6/30/2014

W., U., 51 y., male, 9 months postop

9 months postop: 10 days trekking up to 6000 m.

no pain!

Age of osteotomy patients

Hannover

Instability

Osteoarthritis

Instab + OA

Deformity

years

1100 patients

Mean age: 40,5 years

Effect of Tibial Slope on Stability

Flexion Osteotomy:

Slope increase

10°

Extension Osteotomy:

Slope reduction

PCL

Instability ACL

Instability

6/30/2014

•Human cadaver joints

•Flexion osteotomy

•Gradual increase of slope

(0°  5 °  10°  15° 

20°)

•Computer-regulated isokinetic

extension movement of knee

(Knee Kinemator)

Biomechanical Study

J. Agneskirchner, C. Hurschler, A. Imhoff, P. Lobenhoffer

Winner of AGA DonJoy Award 2004

Archives Orthop Trauma Surg 4/2004

Results Kinematics

Durchtrennung hinteres Kreuzband

PCL transsected

posterior

subluxation

of tibia

reduction by

slope increase

Slope reduction in

anterior knee instability

Tibial

Slope Anterior

Translation

force

0° 130 N

5° 235 N

10° 340 N

15° 443 N

20° 541 N

70 Kg, 20° Flexion, monopedal stance

10° slope

difference produce

6,8 mm. anterior

translation of tibia

in monopedal

stance

M. Bonnin, Lyon 1990

6/30/2014

Site of deformity

Femoral SCO correction

Single level osteotomy producing joint line obliquity

Not all

deformities

can be

adressed at

the tibia

The

importance

of the joint

line

What have

we learnt?

6/30/2014

Femur biplanar closed wedge

osteotomy technique

post 2/3 femur: transverse bone cuts of closing

wedge along K-wires

ant 1/3 femur: ascending bone cut parallel to

posterior femur cortex

ww w.sportsclinicgermany.com

Design new Tomofix MDF plate

Less invasive

Optimized for

osteotomies

Optimal anatomic fit Even load distribution

for increased stability

Antecurvation

Twisted shaft

MIPO tapered tip

2 most proximal

holes allow

locking only

Twisted shaft ->

screws all point

in one direction

M.S., male, 46 y., tennis trainer

6/30/2014

M.S.,male, 46 y.

Double osteotomy

Femur closed wedge 7 mm

Tibia closed wedge 11 mm

LDFA 90°

MPTA 82°

Double osteotomy

1 week postop

Femur closed wedge

7 mm

Tibia closed wedge

11 mm

6/30/2014

Double osteotomy

4 days postop

Double osteotomy

6 weeks postop

Femur closed wedge

7 mm

Tibia closed wedge

11 mm

Double osteotomy

6 weeks postop

6/30/2014

Double osteotomy

6 weeks postop left side

Left side:

Femur closed wedge

7 mm

Tibia closed wedge

11 mm

Osteotomy versus Uni

Osteotomy

Uni

2013

2001 – 2013

2049 osteotomies

1752 Uni

2013:

20% DFO, DO

Key Points

Osteotomy around the knee works

Best indication metaphyseal deformity

HTO can treat ACL/PCL deficiency

Plate fixator/biplanar technique is safe

Osteotomy stimulates regeneration in

involved compartment

Renaissance of

osteotomy

6/30/2014

Technical Pearls in OW HTO

Avoiding Complications

Hatem Said

Prof. Orthopaedic & Trauma

Assiut University, Egypt

SICOT Editorial Secretary

No Financial Disclosures

Complications

1. Overstuffing the joint

2. Lateral cortex break (6-20%)

3. Intra-articular Fracture (3%)

4. Changing the slope (1%)

5. Delayed (12%) / Nonunion (3%)

6. Loss of correction (1%)

7. Joint Line Tilt.

Martin et al, JAAOS 2014

6/30/2014

Technique

Non- Locked - Short

Lateral Hinge

Locked T

No BG

1- Overstuffing

•Proper MCL release Lobenhoffer et al, 2007

MCL Release

6/30/2014

2- Lateral cortex break

• 1 cm from lat. Cortex

–Too short – Intra-artic fr.

•Lateral Hinge

– Non-Locked plates

•Locked plates:

–change principle - procedure

–Positional Fixation – plate

•Osteotomy too long

•Large opening

•Opening of lateral

cortex.

Lateral cortex break

Lat. break - Ttt

•Expose Lateral hinge

•Axial & Valgus Pr.

– Lat. cortex

•Staples

6/30/2014

Intraop 1 m

•Osteotomy:

–Too high

–Too short

•Use Image intensifier

•Saw Under Wire

3- Intra-articular fractures

Intra-articular Fr.

7 wks

6/30/2014

Displaced:

Loosen screws, valgus force, Lag screw.

Intra-op 5 weeks

4- Changing the slope

Medial

Ant

Post

Lateral

9 Deg.

6/30/2014

•Inc Slope:

–PCL deficient

•Dec Slope

–ACL Def

PCL/Varus:

15 Deg.

5- Delayed healing:

•65% Locked plates

–10% length

Roderer et al, 2014

6/30/2014

•Mechanical

–Inadequate fixation

–Lateral cortex break

•Not Biological

–No BG

•El-Assal et al. KSSTA 2010

5- Non Union

13 m

2.5 m

Long fixation + grafting

6/30/2014

6- Loss of Correction:

•Undercorrection

•Weak fixation

–Osteoporotic bone

•Locked plates

7- Joint Line Tilt:

Valgus 10

Summary

•MCL release

•Locked Plates:

–Lateral Cortex Break

–Intra-artic Fr.

•Slope

•Delayed / Nonunion

•Loss of correction

•Joint Line Tilt

HTO Syllabus

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