Post on 12-Jul-2015
Upper t ibial valgus Upper t ibial valgus osteotomy osteotomy
using a using a dynamic external f ixatordynamic external f ixator
George SapkasGeorge Sapkas
1st Orthopaedic Dept.1st Orthopaedic Dept.Medical School – Athens UniversityMedical School – Athens University
Bone deformedBone deformed
FractureFracture Abnormal growthAbnormal growth Osteoarthritis Osteoarthritis
Patients with medial compartment Patients with medial compartment degenerative diseasedegenerative disease
YoungYoungActive Active
advice:advice:
“to take it easy and wait unti l the “to take it easy and wait unti l the t ime is right for a total knee t ime is right for a total knee replacement”replacement”
Correction of the varus Correction of the varus deformitydeformity
A.A. Immediately at Immediately at operation by:operation by:
A.A. Step cut Step cut osteotomyosteotomy
B.B. Dome osteotomyDome osteotomyC.C. Removing or Removing or
adding a wedge of adding a wedge of bonebone
B.B. Partial osteotomy Partial osteotomy followed by followed by gradual gradual asymmetrical asymmetrical distraction of the distraction of the calluscallus
Osteotomy Osteotomy for for
osteoarthrit is of the kneeosteoarthrit is of the kneeJ. P. Jackson J.B.J.S. (Br) 1958J. P. Jackson J.B.J.S. (Br) 1958
Dome osteotomies Dome osteotomies forfor
varus and valgusvarus and valgusdeformitydeformity
J.P. Jackson, W. Waugh, J.P. Green J.P. Jackson, W. Waugh, J.P. Green J.B.J.S. (Br) 1969J.B.J.S. (Br) 1969
Upper t ibial osteotomy Upper t ibial osteotomy for osteoarthrit isfor osteoarthrit is
M.B. Coventry J.B.J.S. (Am) 1985M.B. Coventry J.B.J.S. (Am) 1985
Potential complications• Intra articular fractures through the
proximal fragment
• Avascular necrosis
• Delayed union
• Non union
• Peroneal palsy
• Compartment syndrome
Knee in varusKnee in varus
Unilateral frame distraction Unilateral frame distraction upper tibial osteotomyupper tibial osteotomy
… … the technique of hemicallotasis, the technique of hemicallotasis, or asymmetric distraction of the or asymmetric distraction of the developing callus following a developing callus following a corticotomy might be used to corticotomy might be used to achieve a valgus tibiaachieve a valgus tibia
Turi et al, Chir. Organs Nov 1987Turi et al, Chir. Organs Nov 1987
… … a method in which a unilateral a method in which a unilateral dynamic external f ixator is applied to dynamic external f ixator is applied to the medial aspect of the l imb and the medial aspect of the l imb and gradually distracted unti l the gradually distracted unti l the appropriate degree of valgus is appropriate degree of valgus is obtainedobtained
Pre-operative imaging studiesPre-operative imaging studies
Standing radiographsStanding radiographsincludingincluding
the hip and anklethe hip and ankle
Patient selectionPatient selection The knee should be mobileThe knee should be mobile Flexion deformity of up to 15Flexion deformity of up to 15 oo is is
acceptable acceptable Patient’s: age Patient’s: age
weight weight activity level activity levelage < 65 osteotomyage < 65 osteotomy
high activity levelhigh activity levelage > 65 T.K.R.age > 65 T.K.R.
low demandslow demandsM.B. Coventry J.B.J.S. (Am) 1985
Surgical Surgical techniquetechnique
Management Management of of
hemi-callotasishemi-callotasis
10th day:10th day: distraction is distraction is commenced commenced at the rate of at the rate of 1mm/day at 1mm/day at the medial cortexthe medial cortex
Distraction and alignment are checked Distraction and alignment are checked every few daysevery few days
Distraction and alignment are checked Distraction and alignment are checked every few daysevery few days
The patient has The patient has been bearing ful l been bearing ful l
weightweight
Usually with a caneUsually with a cane To walk for an hour or To walk for an hour or
two without the frame two without the frame before the screws are before the screws are finally removedfinally removed
The distraction stops The distraction stops when it is judged when it is judged
to be sufficientto be sufficient
RoentgenographicallyRoentgenographically Aesthetically Aesthetically ~10o Valgus Valgus
The frame is locked The frame is locked 3-4 wks thereafter 3-4 wks thereafter
or or 7-10 wks post surgery 7-10 wks post surgery
the frame the frame is isdynamiseddynamised
Dynamization collar incorporating a Dynamization collar incorporating a silicone cushion is attached to the silicone cushion is attached to the
male stemmale stem
Preventing collapse of more than Preventing collapse of more than 2mm at the osteotomy site2mm at the osteotomy site
The frame The frame is usually is usually
removed at removed at 12-14 wks12-14 wks
Axial loading of the Axial loading of the corticotomy sitecorticotomy site
Becomes progressively Becomes progressively mineralised and mineralised and corticocalizedcorticocalized
When callotasis is not When callotasis is not progressingprogressing
Reflected in serial x-rays Reflected in serial x-rays or or
By collapse of the By collapse of the corticotomy corticotomy on dynamizationon dynamization
The frame may be used in The frame may be used in compression for a few days compression for a few days and then re-distractedand then re-distracted
Full range of Full range of activit ies within activit ies within
six months of six months of surgerysurgery
Personal cases Personal cases
1515 pts pts 1111 F F 44 M M
Age Age 41 - 6241 - 62 (mean (mean 5252 yrs) yrs)Cause : OsteoarthritisCause : OsteoarthritisF-up : F-up : 1212 mts – mts – 99 yrs yrs
Loss of Loss of correction at correction at follow up ~ 2follow up ~ 2oo
One patient One patient progressed progressed
to to total knee arthroplasty total knee arthroplasty
– 9 yrs later – – 9 yrs later –
The total knee The total knee arthroplasty was arthroplasty was performed in a routine performed in a routine manner and presented manner and presented no technical diff icult iesno technical diff icult ies
Complications Complications
Neurovascular complications Neurovascular complications 0 0 Deep infections Deep infections 0 0 Skin and pin track problems Skin and pin track problems 20% 20%
(oral antibiotics)(oral antibiotics)
The overall satisfaction The overall satisfaction from the procedure is highfrom the procedure is high
90% of the pts 90% of the pts are pleasedare pleased
Conclusions Conclusions
Unilateral frame distraction Unilateral frame distraction
A.A. Proximal tibial Proximal tibial valgus osteotomy valgus osteotomy for medial for medial osteoarthritis of the osteoarthritis of the knee is a straight knee is a straight forward procedureforward procedure
B.B. It has particular It has particular
application in the application in the young age group young age group for whom joint for whom joint resurfacing is not resurfacing is not a rational a rational alternativealternative
C.C. The present method The present method
permits the angle of permits the angle of valgus correction valgus correction to be determined to be determined with a precision with a precision impossible impossible by the traditional by the traditional closing wedge closing wedge high tibial valgus high tibial valgus osteotomyosteotomy
… … tibio-femoral angle t ibio-femoral angle should notshould not only be corrected to normal i .e. 5only be corrected to normal i .e. 5 oo – 7– 7 oo of anatomical valgus but of anatomical valgus but overcorrected to 10overcorrected to 10 oo of anatomical of anatomical valgus (mechanical axis of 3valgus (mechanical axis of 3 oo – 5 – 5 oo ))
M.B. Coventry 1985M.B. Coventry 1985
… … although 5although 5 oo -14-14 oo of valgus of valgus correction is appropriate, the correction is appropriate, the passage of t ime since the passage of t ime since the operation was the most important operation was the most important factor in determing outcome factor in determing outcome
J.N. Insall et al J.B.J.S. (Am) 1984J.N. Insall et al J.B.J.S. (Am) 1984
… … the undercorrection is the undercorrection is associated with recurrence of pain associated with recurrence of pain
D.
““ exact post-operative exact post-operative alignment is the alignment is the prerequisite for the largest prerequisite for the largest possible relief of possible relief of symptoms”symptoms”
Corrected to 3Corrected to 3 o -o - 6 6 oo of valgus good result of valgus good result Under corrected less satisfactory Under corrected less satisfactory
resultsresults
P.H. Hernigan et al J.B.J.S. (Am) 1987
i .
i i .
Varus deformityE.
E.E. Tibial shortening Tibial shortening
does not occur in does not occur in the present the present technique which technique which preserves and preserves and enhances bone enhances bone stockstock
F.F. Ankle pain is thus avoided and Ankle pain is thus avoided and
complementary procedures or complementary procedures or eventual total knee replacement are eventual total knee replacement are facilitatedfacilitated
G.G. … … total knee total knee replacement is more replacement is more difficult and the difficult and the results are less results are less satisfactory after satisfactory after conventional conventional proximal tibial proximal tibial osteotomyosteotomy R.E. Windsor et al J.B.J.S. (Am) 1988
H.H. Overall this method by Overall this method by
whichwhich The bone stock is actually The bone stock is actually
enhanced enhanced The length is maintedThe length is mainted The ligamentous structures The ligamentous structures
around the knee remain around the knee remain undamagedundamaged
There not neurovascular There not neurovascular complications and complications and compartment syndromescompartment syndromes
IS SUPERIOR TO METHODS PREVIOUSLY DESCRIBED