Osteoarthritis in the young
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Transcript of Osteoarthritis in the young
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OA in the ‘Young”
Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader Knee Surgeon
South West London Elective Orthopaedic Centre Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva)
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Purpose
Not to give you a lecture on OA
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Purpose The importance of realignment procedures in combination with multi-ligament surgery and chondroplasty
Ligament reconstruction, Chondral procedures and even meniscal repairs are all doomed to failure in Malaligned knees
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28 yrs old man Neglected multilligament when he was 18
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ICRC Weapon wounded Trauma Training Centre in Tripoli/Lebanon
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Realignment Procedures (Osteotomy)
Aims of osteotomy
Unload the affected compartment by slightly overcorrecting into valgus/varus
Unloading any ligament reconstruction in patients with a varus thrust
Improve AP instability & reduce translational forces by changing the tibial slope
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Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial
compartmental osteoarthritis of the knee.
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Varus malalignment in revision ACL
22% of Revision ACL reconstruction patients
have varus malalignment
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Mechanical Axis & Joint orientation angle of the knee
Vertical axis
mLDFA=87ºMPTA=87º1.2º Varus
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POSTGRAD ORTH Deiary Kader
Mechanical Axis of the Lower Limb
The line from the centre of the femoral head to the centre of the ankle plafond is called the Mechanical axis of the lower limb
Normal MAD = 4-8mm medial
Mechanical Axis deviation MAD
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33%20
5%
The Weight Bearing Line in %
X
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Double Varus 1- Varus alignment
Progressive medial joint narrowing
2- Lateral tibio-femoral opening LCL laxity >5 mm laxity ( stress radiograph)
Varus thrustCurtesy of Prof Reha
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Triple VarusVarus alignment
Lateral tibio-femoral opening
Posterolateral corner laxity Increased Ext-Rotation/Hyperextension
Varus recurvatum deformityCurtesy of Prof Reha
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Decision makingPrimary varus knees: ACLR alone Cruciate reconstruction with/without HTO
Double varus knees: HTO alone HTO first + cruciate & PLC later if required
Triple varus knees: ALL HTO first + Cruciate & PLC later
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11 eligible studies (218 knees)
Curtesy of Prof Reha
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Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965
(Coventry, 1965).
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OPEN Wedge HTO 1987The open-wedge high tibial osteotomy gained recognition after the encouraging reports of
(Hernigou et al., 1987).
Wedges of bone that were obtained from the iliac crest were inserted into the defect
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Open W HTO
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The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
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Proximal or High Tibial Osteotomy (HTO)
The IDEAL candidate for HTO
Age <60 years
Isolated medial OA (GI-III)
BMI<30
FFD & Varus of <15°
>120° flexion knee
Patients should be Able to use crutches Have no major varicose veins or peripheral vascular disease
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Valgus deformity of 12º or more needs distal femoral varus producing osteotomy to address a lateral femoral condyle deficiency and to prevent joint line obliquity and gradual lateral tibial subluxation.
Distal Femur Osteotomy for Valgus Malalignment
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Osteotomy Planning Final alignment should create 10º–13° valgus.
Overcorrection of 3º–5º above the 6º–7º normal
valgus angle
62.5% across tibial plateau from medial side
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Compensating for Abnormal AP Laxity
ACL Rupture PCL Rupture
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HTO ComplicationsInadequate valgus correction
Overcorrection – PFJ derangement
Alteration in patella height
Intra-articular fracture
Osteonecrosis of the tibial plateau
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HTO ComplicationsVascular injuries
Peroneal nerve palsy
Delayed or non-union
Compartment syndrome
TKR more difficult
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Fibular osteotomy, Separating tibiofibular joint Contracture of the patellar tendon, patellar baja leg shortening Nerve injuries
Varus laxity (loose LCL)
High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up* ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ Bone Joint Surg Am, 2000 Jan
Closed wedge HTO Disadvantages
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Open wedge HTO Advantages
Easier to achieve precise angular correction
Preserves bone stock (subsequent TKR easier)
Makes tightening of the MCL easier
Allows LCL or PLC Recon
No risk to peroneal nerve
Less dissection
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Open wedge HTO Disadvantages
Requires a bone graft (substitute, autograft, Allo)
I incidence of non-union and delayed union
Large correction may affect leg lengthening
Loss of fixation
Worsens patella Baja
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Outcome
Obesity and inadequate correction were negative prognostic factors. Age < 50 years is a positive prognostic factor Joint line preservation is key to success.
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RCT 92 pts and 6 years FU OW-HTO vs CW-HTO
More Complications in open WHTO & more conversion to TKR in closed WHTO
SEPT 2014
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THANK YOU