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