Osteotomies About the Knee Lyon, France Oct. 2011 Mark Sanders, MD FACS The Sanders Clinic for Orthopaedic Surgery and Sports Medicine Houston, Texas USA.

Osteotomies Osteotomies About the About the

Knee Knee Lyon, France Oct. 2011Lyon, France Oct. 2011

Mark Sanders, MD FACS

The Sanders Clinic for Orthopaedic Surgery

and Sports Medicine

Houston, Texas USA

Disclosures

• None to report

“Orthopaedics”

• Derived from Greek– orthos ("correct," "straight") – paideion ("child")

-Nicholas Andry, Orthopaedia: or the Art of Correcting and Preventing Deformities in Children, 1741.

Patient #1

• 28 y/o F nurse, previously athletic, c/o bilat multidirectional patella femoral instability, L > R

• Multiple previous surgeries left knee– Lateral retinacular release x2– Medialization osteotomy of tibial tubercle– Hardware removals, fasciotomy, “cleanouts”

• Physical Examination– Increased femoral anteversion– Increased tibial external torsion– Medial patella instability

Pre-op

Pre-op

Pre-op

Pre-op

Computerized Tomography Results

• Femoral Anteversion: 50° R, 35° L (Normal 9-22° - D. Paley)

• Tibial External torsion: 34° R, 39° L (Normal 18-28° - D. Paley)

• TT-TG: 10mm R, 7mm L (Ideal tracking: 10-15mm - H. DeJour)

Synchronous Surgical Treatment

• Spinal/epidural anesthesia• Two lateral skin incisions • 20° proximal femoral external rotation osteotomy• 15° proximal tibial internal rotation osteotomy• 6mm laterally directed tibial tubercle osteotomy• Distal ITB based LPFLR• Immediate unrestricted active and active assisted

hip, knee, and ankle motion• 10 kg weight bearing with crutches for 6 wks until

early union determined• Bony union, off crutches at 3 months

5 mos. post-op

5 mos. post-op

5 mos. post-op

5 mos. post-op

L

Hardware removal-5 mos. post-op

Hardware removal-5 mos. post-op

Highly Satisfied Patient

• No further medial or lateral patella instability

• Returned to light sports• Couldn’t wait to have Proximal

Femoral Plate out• Scheduled for opposite side surgery

over Christmas

Take Home Messages

• Repair/Reconstruct every deformity at one surgical sitting

• Epidural and multimodal analgesia• Immediate active and active-assisted

motion without CPM• Early return to function• Young people want hardware out,

especially Proximal Femoral Plate

Patient #2

• 24 y/o M, treated for congenital deformity of the opposite femur. Underwent femoral epiphysiodesis at Children’s Hospital

• Currently with two previous failed allograft ACLRs

• Physical Exam – Normal femoral and tibial version

– Genu Valgus deformity– Asymmetric Hyperextension– PCL, PLC, MCL intact– 4+ Anterior instability

mLDFA 76.5º

mLDFA 89.6º

Pre-op

RT aPDFA 97.7º

RT aPPTA 75.4º

Normal Values

aPDFA : 79 – 87º

aPPTA : 77 - 84º

Note: Anterior tibial subluxation

Pre-op

Synchronous Surgical Treatment

• Long lateral skin incision • Opening wedge biplanar DFO for

correction of 10° distal extension and 10° valgus deformity, using Freeze dried bone wedges and lateral TomoFix™

• Joint leveling biplanar HTO to decrease adverse tibial slope, and stabilized with medial and lateral TomoFix™

• ACLR deferred until tibial and femoral hardware could be safely removed

RT mLDFA 89.5º

6 wks post-op

RT aPDFA

84.2º

RT aPPTA

79.3º

Normal Values

aPDFA : 79 - 87º

aPPTA: 77 - 84º

6 wks post-op

Pre-op 6 wks post-op

This is a work in progress

• Immediate active and active-assisted knee motion in combination with multimodal and epidural analgesia considerably decreases Perioperative pain and morbidity

• Post-op Lachman’s decreased from 4+ to 2+

• I will show further follow-up X-rays in Davos in 2012

Patient #3

• 34 y/o M plant worker, previously athletic, c/o constant medial knee pain. Reportedly needs TKA.

• 9 previous surgeries, L knee– Lateral retinacular release– Multiple arthroscopies and “clean outs”– Repair of quad tendon rupture

• Physical Examination– Normal femoral and tibial version– Genu varum, medial joint line tenderness– Medial patella femoral instability

Pre-op

R

• R mLDFA 95°

• L mLDFA 94°

Pre-op

Synchronous Surgical Treatment

• Long lateral skin incision • Opening wedge biplanar DFO for correction of 9°

distal varus deformity, using Freeze dried bone wedge and opposite sided medial TomoFix™ applied medially

• Distal ITB based LPFLR

• Epidural analgesia and multimodal pain management

• Immediate active and active assisted unrestricted motion of hip, knee, and ankle

• 10 kg weight bearing with crutches for six weeks until early union determined

8 wkspost-op

R

8 wkspost-op

mLDFA 85º

Pre-op 8 wkspost-op

This too is a work in progress, but...

• Varus at the femur occurs more commonly than is generally believed (Van Heerwarden)

• Correction is best applied at the CORA

• Correction at another area can lead to joint line obliquity

• Alignment is of primary importance - nothing we do succeeds without it.

Thank You for Your Kind Attention

• Questions?