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

Total Knee Arthroplasty Total Knee Arthroplasty associated with osteotomyassociated with osteotomy

in cases of major deformities in cases of major deformities(19 knees)(19 knees)

Total Knee Arthroplasty Total Knee Arthroplasty associated with osteotomyassociated with osteotomy

in cases of major deformities in cases of major deformities(19 knees)(19 knees)

JL. LERAT, A. GODENÈCHE, B MOYENJL. LERAT, A. GODENÈCHE, B MOYEN

Service de Chirurgie Orthopédique et de Médecine du Sport Service de Chirurgie Orthopédique et de Médecine du Sport

Lyon – FranceLyon – France

SOFCOT, Paris 10-14 Nov 1998

EFORT, Bruxelles 3-8 Juin 1999

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 TKR’s in our series

Even in case of major deformity TKR is possible :

Intra-articular deformities

23 cases of major deformities > 20°

Good corrections - Good results obtained with post. cruciate retaining TKR

Similar to other TKR’s in our series

Even in case of major deformity TKR is possible :

Intra-articular deformities

The questionThe question is :is :

How to correct a major extra-articular deformityHow to correct a major extra-articular deformity ((± articular deformity) ± articular deformity)

by a total Knee Replacement ?by a total Knee Replacement ?

Typical cases are represented by tibial deformitiesTypical cases are represented by tibial deformities (following osteotomies or fractures)(following osteotomies or fractures)

ValgusValgus Varus Varus

ProfileProfile

• Usual cuts for the femur. Minimal cut for the tibia: Trapezoidal space

In cases of overcorrected valgus Complete lateral ligament release is necessaryComplete 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)

ADVANTAGESADVANTAGES• 1 operation1 operation• No major difficulties No major difficulties • Immediate weight bearing Immediate weight bearing

DISADVANTAGESDISADVANTAGES

• Excessive polyethylene thicknessExcessive polyethylene thickness• Limb lengthening Limb lengthening • Peroneal nerve tension and stretchingPeroneal nerve tension and stretching

(palsy : 4 % in literature)(palsy : 4 % in literature)• PCL sacrifice PCL sacrifice • More constrained prosthesisMore constrained prosthesis• Poor ligament isometricity Poor ligament isometricity • Possible instability (literature)Possible instability (literature)

Symposium SO.F.C.O.T - Paris - 1990

Typical case :

Patella infera, Pain ++ Peroneal nerve palsy

Poor flexion : 70°

Acceptable solution for Acceptable solution for Unacceptable for major deformitiesUnacceptable for major deformities minor deformities minor deformities

Excessive valgus or varus make a new osteotomy necessaryExcessive valgus or varus make a new osteotomy necessary

In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed

External tibial torsion is 0 External tibial torsion is 0 degree instead of 30° on the degree instead of 30° on the

other sideother side

Vicious rotation makes a new osteotomy necessaryVicious rotation makes a new osteotomy necessary

In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed

Old case of rickets Previous Femoral fracture

osteotomy and tibial osteotomy

Femoral deformities make new osteotomy necessaryFemoral deformities make new osteotomy necessary

2 possible options :2 possible options :

1 - Two-steps 1 - Two-steps with osteotomy first, and then TKA with osteotomy first, and then TKA

2 - 2 - TKA and osteotomy in a single operationTKA and osteotomy in a single operation

In some extreme cases : Isolated TKR is impossible In some extreme cases : Isolated TKR is impossible and associated osteotomy is neededand associated osteotomy is needed

1 - OSTEOTOMY First and TKA later1 - 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

ADVANTAGESADVANTAGES

DISADVANTAGESDISADVANTAGES

This choice had been made for 67 young patients previously operated by osteotomy

• 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

2 - OSTEOTOMY + TKA2 - OSTEOTOMY + TKA

1/ Correction of a tibial valgus deformity1/ Correction of a tibial valgus deformity

1 - Femoral cuts as in usual cases2 - Tibial cut is parallel to the condylar line3 - Ligament balance is easy to ensure4 - 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

2 d method : using a tibial component with short stem or pegs

Osteotomy is performed after TK implantation

Fer… F - 73 years13 years after first osteotomy

218° 182°

W...

F - 60 years

HKA : 191°

Weight-bearing:

2 months

• 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

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 deformity2/ Correction of a femoral deformity

Extension

Resection

Addition

Osteotomy is performed when the implants are placed

Graft with the bone resulting from the cuts

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°

Prat..... H - 75 years old

55 years after 1st osteotomy

TKR + opened osteotomy

166° 180°

• 19 TKA + Osteotomy (18 patients)

• Mean age : 72 years ± 6 (60 - 80)

• 13 females - 5 males

MaterialMaterial

• 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

MaterialMaterial

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 characteristicsTechnical 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)

Technical characteristicsTechnical characteristics

• 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

RESULTSRESULTS

• KRACKOWKRACKOW ((1991)1991)• IKS K score = 87.6IKS K score = 87.6

• Flexion = 103°Flexion = 103°

• MIYASAKAMIYASAKA (1997)(1997)

• IKS K score = 88.7IKS K score = 88.7

• Flexion = 101°Flexion = 101°

• LOTWOETLOTWOET (1997)(1997)

• IKS K score = 93.3IKS K score = 93.3

Comparison with the literatureComparison with the literature

9 overcorrected HTO TKA for valgus deformitiesTKA for valgus deformities

RESULTSRESULTS

• Follow-up = 45 ± 25 months

• IKS knee preop = 34 ± 11

• IKS Knee post-op = 86 ± 13

• Flexion = 111°± 13

• Correction : Valgus 3° ± 3

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

unipodal

Ant drawer Post drawer

Standing position

INNEX mobile bearing knee

• TEENY TEENY (1991)(1991)• IKS K score = 89IKS K score = 89

• Flexion = 98°Flexion = 98°

• LASKIN LASKIN (1996)(1996)• Flexion = 86°Flexion = 86°

• IKS K score = 86.4 IKS K score = 86.4 ± 12± 12

• Flexion = 111°Flexion = 111°± 10± 10

RESULTSRESULTS 8 major varus deformities TKA for varus deformities

Lu.... 69 years Major varus deformity

T = 77°

153° 182°

Two cruciates retaining TKR

Varus deformity following fractures of medial and lateral tibial plateaus

F - 80 years TKA + Opened HTO with graft and staples

F - 71 years Femoral fracture at 45 yearsF - 71 years Femoral fracture at 45 years

Previous tibial osteotomy at 61 yrsPrevious tibial osteotomy at 61 yrs

Varus at 2 levelsVarus at 2 levels

179°

- 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 malrotation1 particular case of malrotation

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

Grafting with the bone resulting from the cuts

The placement of the stem needs an osteotomy

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

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

Particular case of a malunion above a TKA

+Lateral laxity

• A single operation

• Joint line and ligament balance preserved

ADVANTAGESADVANTAGES

DISADVANTAGESDISADVANTAGES

• Technical difficulties

• Rather prolonged osteotomy fusion

OSTEOTOMY + TKAOSTEOTOMY + TKA

Valgus stress Varus stress

Stress radiography allows precise measurements of ligamentous and bony deformities

DEFORMITYDEFORMITY Wear + laxity = Extra-articular Extra-articular deformitydeformity+

206° 188°

INDICATIONSINDICATIONS

INDICATIONSINDICATIONS

Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=

Stress radiography allows precise measurements of ligamentous and bony deformities

206° 188°

Valgus stress Varus stress

INDICATIONSINDICATIONS

Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=

• Valgus def. = Valgus def. = 17°17°± 10 ± 10 ( 9 to 30°)( 9 to 30°)

• Varus def. = Varus def. = 22°22° ± 9 ± 9 (12 to 34°)(12 to 34°)

Wear + laxity DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=

Mean deformity in the serie

INDICATIONSINDICATIONS

• Valgus def. = Valgus def. = 17°17°± 10 ± 10 ( 9 to 30°)( 9 to 30°)

• Varus def. = Varus def. = 22°22° ± 9 ± 9 (12 to 34°)(12 to 34°)

Wear + laxity

14.3°14.3°

16.4° 16.4°

DEFORMITYDEFORMITY Extra-articular Extra-articular deformitydeformity+=

Minimum deformity for indication ?? 5-7° ??

INDICATIONSINDICATIONS

- 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 ?

INDICATIONSINDICATIONS

• 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

ConclusionsConclusions

• 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

ConclusionsConclusions

Thank you