Total Knee Arthroplasty Total Knee Arthroplasty associated with osteotomy associated with osteotomy in cases of major deformities in cases of major deformities (19 knees) (19 knees) JL. LERAT, A. GODENÈCHE JL. LERAT, A. GODENÈCHE Service de Chirurgie Orthopédique et de Médecine du Sport Service de Chirurgie Orthopédique et de Médecine du Sport Lyon – France Lyon – France ISAKOS ISAKOS JUNE 2001 JUNE 2001 MONTREUX MONTREUX
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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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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. GODENÈCHEJL. LERAT, A. GODENÈCHE
Service de Chirurgie Orthopédique et de Médecine du Sport Service de Chirurgie Orthopédique et de Médecine du Sport
Lyon – FranceLyon – France
ISAKOS ISAKOS JUNE 2001JUNE 2001 MONTREUX MONTREUX
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
It is possible to correct the deformity in doing TKA (sometimes with tightening ligaments of the convexity)
PCL may be preserved
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
After a failed osteotomy it is possible to do a TKR in the majority of the cases (except in case of severe valgus)
But the results are not so good as primary TRK (literature)
In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
• 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
• Usual cuts for the femur. Minimal cut for the tibia• 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
In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
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)
In cases of overcorrected valgus
Complete lateral ligament release is necessaryComplete lateral ligament release is necessary
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
Second alternative : Second alternative : Bone graft Bone graft and thinner polyethylene plateauand thinner polyethylene plateau
Drawbacks are similar and walking is delayed Drawbacks are similar and walking is delayed
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
it is always possible to do an iterative osteotomy particularly in a young patient
After a failed osteotomy it is possible to do a second osteotomy for a young patient
3 months 1 year
But elderly patients with severe arthritis need TKR
• 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
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.