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Conservative Surgery for Knee Arthritis

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Title: Conservative Surgery for Knee Arthritis


1
Conservative Surgery for Knee Arthritis
  • Mark S. Sanders MD FACS
  • Sanders Clinic for Orthopaedic Surgery and Sports
    Medicine
  • Gainesville, Texas

2
  • We are indebted to Dr. Mark Coventry of the Mayo
    Clinic who first described osteotomy for
    degenerative arthritis. The original paper
    published in 1965 continues to be clinically
    relevant.

Coventry, M. Osteotomy of the Upper Portion of
the Tibia For Degenerative Arthritis of the
knee A PRELIMINARY REPORT. J. Bone and Joint
Surgery 1965 47984-990
3
Incidence of Total Knee Replacement
  • According to the NIH, approximately 300,000 TKR
    surgeries are performed in the United States per
    year.
  • This number is expected to increase several fold
    as the baby boomer generation ages.

4
Total Knee ReplacementWhy not just do it?
  • One of the most reliable operations in
    Orthopaedic Surgery
  • Reasonable expectation of survivorship to 25
    years
  • But life expectancy continues to increase
  • Indications for TKA seem to include younger and
    younger people each year

5
The Knee SocietyAmerican Academy of Orthopaedic
Surgeons
  • TKA patients must avoid
  • High Impact Occupations and Sports
  • Farming, Ranching are high risk occupations
  • TKA patients may participate in
  • Golf, Doubles Tennis, Croquet, Shuffleboard,
    downhill skiing on groomed runs

6
Is there something truly less Invasive out
there?
  • In patients 60 yrs, alternatives to TKA deserve
    consideration
  • Osteotomy
  • Unicompartmental knee replacement
  • Arthroscopic Debridement?

7
Arthroscopic Debridement?IT JUST DOESNT WORK
  • In a controlled trial involving patients with
    osteoarthritis of the knee, the outcomes after
    arthroscopic lavage or arthroscopic débridement
    were no better than those after a placebo
    procedure.
  • Moseley, RB et al., Arthroscopic Surgery for
    Osteoarthritis of the Knee?. NEJM 2002 359
    1169-1170

8
Unicompartmental Total Knee
  • Good pain relief in appropriate cases
  • Good survivorship
  • But its still a knee replacement
  • The same activity restrictions apply
  • Can not be successfully installed in the ACL
    deficient knee
  • Considered by many as the First arthroplasty on
    a young person, and the first and last on an
    older person.

9
Osteotomy The Indications
  • Active lifestyle
  • 60 yrs
  • Single compartment disease
  • Opposite compartment intact or with minimal
    changes
  • Varus or valgus deformity
  • 10 loss of full extension
  • 90 flexion

10
Survivorship End point considered at occurrence
of TKA
  • 87 survivorship_at_5 yrs
  • 66 survivorship_at_10 yrs
  • Breakdown
  • 51 survivorship_at_10 yrs in obese patients
  • 91 survivorship_at_10 yrs with normal BMI
  • 94 survivorship_at_10 yrs with maintenance of
    valgus correction
  • Coventry MB, Ilstrup DM, Wallrichs SL. Proximal
    tibial osteotomy a critical long-term study of
    eighty-seven cases. J Bone Joint Surg Am
    199375-A196201

11
Types of OsteotomyCoventry Closing Wedge 1960s
http//www.eorthopod.com/images/ContentImages/knee
/knee_tibial_osteotomy/knee_tibosteo_surgery01.jpg
12
Disadvantages of Closing Wedge Osteotomy
  • Removes bone from metaphysis
  • Requires fibular osteotomy
  • Peroneal neuropathy 15
  • Lateral tibiofemoral instability 15
  • Pathologic lowering of patella
  • Increases difficulty of later TKA

13
Opening Wedge Osteotomy1990s
Noyes FR, Goebel SX, West J Opening wedge tibial
osteotomy The 3-triangle method to correct
axial alignment and tibial slope. Am J Sports Med
33378-387, 2005.)
14
Advantages of Opening Wedge Osteotomy
  • Adds bone to tibial metaphysis
  • No lateral knee instability
  • Rare peroneal neuropathy
  • Later TKA no more difficult than usual

15
Disadvantages of Opening Wedge Osteotomy
  • Requires iliac bone graft
  • Pathologic lowering of patella
  • Poor fixation techniques required post op
    immobilization

16
The Biplanar Osteotomy
  • Staubli AE, De Simon C, Babst R, Lobenhoffer P.
    TomoFix a new LCP-concept for open wedge
    osteotomy of the medial proximal tibia early
    results in 92 cases. Injury 200334(Suppl
    2)55-62.
  • Image Courtesy of Synthes

17
Advantagesof Biplanar Osteotomy
  • No need for iliac bone graft in nonsmokers
  • Stable fixation with locking TOMOFIX plate allows
    immediate ROM and partial weight bearing
  • Allows correction of 10 degrees of fixed flexion
    contracture
  • Anterior osteotomy can be made ascending or
    descending to prevent patella infera
  • Tibial slope can be adjusted to accommodate for
    cruciate ligament insufficiency

18
Biplanar osteotomy ascending anterior cut lowers
patella height. Used for cases with patella alta
or corrections of 10 and under
Ascending anterior cu t
ascending anterior cut
Slide courtesy of Synthes
19
Descending Anterior Osteotomy cut maintains
preoperative patella height. Used for cases
with patella infera or corrections of 10 and
over to prevent patella infera
Brinkman J-M, et al. Fixation stability of
opening- versus closing-wedge high tibial
osteotomy A RANDOMISED CLINICAL TRIAL USING
RADIOSTEREOMETRY J Bone Joint Surg Br, Nov 2009
91-B 1459 - 1465
20
Disadvantages of Biplanar Osteotomy
HIGH RATE OF NONUNION IN SMOKERS
21
Presurgical Clinical Evaluation The History
  • Joint line pain
  • Previous arthroscopic or open meniscectomy
  • Development of deformity
  • Lack of response to NSAIDS, acetaminophen,
    bracing, shoe modifications

22
Presurgical Clinical EvaluationPhysical
Findings
  • JOINT LINE TENDERNESS
  • VARUS OR VALGUS DEFORMITY
  • 10 degrees fixed flexion
  • Further flexion 90 degrees
  • Normal examination of opposite compartment

23
Varus/Valgus
  • I used to mix these up all the time
  • Varus Bowlegged
  • Valgus Knock-kneed
  • Remember vaLgus
  • The L is for lateral
  • Some patients think the terms bowlegged or
    knock-kneed are offensive

24
Varus Arthritis
25
Valgus Arthritis
26
Initial ImaginingRosenberg View
Must be done weight bearing
27
Bilateral Views Offer Instant Comparison
28
Rosenberg View
  • Normal Medial Compartment joint space 4mms
  • Normal Lateral Compartment joint
  • Space 5mms
  • Rosenberg, TD, et al. The Forty-Five-degree
    posteroanterior flexion weight-bearing radiograph
    of the knee. J Bone Joint Surg Am.
    1988701479-1483

29
Subsequent ImagingMRI
  • Normal opposite compartment
  • Bone marrow edema on ipsilateral side
  • Rule out unknown conditions

30
Orthoradiograms
  • Willy Sutton Where the money is
  • One image includes hip through ankle
  • Calculation of angular deformity
  • Available at NTMC

31
Normal Orthoradiograms from Pailey
Paley, D. (2003). Principles of Deformity
Correction. Heidelberg, Germany Springer-Verlag
32
THE DEFORMITY MUST BE LOCATED OSTEOTOMY MUST
OCCUR THROUGH THE DEFORMED BONE OR AN OBLIQUE
JOINT LINE WILL CAUSE FAILURE SECONDARY TO SHEAR
FORCES
  • Normal Proximal Tibia MPTA 85-90
  • Normal Distal Femur mLDFA 85-90
  • Joint line congruency angle 2

33
2009 Gainesville, Texas
86
82.9
34
Correction of Deformity
  • Under correction leads to dissatisfaction and
    failure
  • Over correction leads to dissatisfaction
  • Correction of varus deformity to a mechanical
    axis of 183-185 of mechanical valgus leads to a
    survivorship of 94 at ten years
  • Valgus deformity should only be corrected to
    neutral or 180

Coventry MB, Ilstrup DM, Wallrichs SL. Proximal
tibial osteotomy a critical long-term study of
eighty-seven cases. J Bone Joint Surg Am
199375-A196201
35
Correction for Varus Deformity
DeLee and Drez's Orthopaedic Sports Medicine, 3rd
ed. Redrawn from Dugdale TW, Noyes FR, Styer D
Pre-operative planning for high tibial
osteotomy Effect of lateral tibiofemoral
separation and tibiofemoral length. Clin Orthop
271105-121, 1991.)
36
2009, Gainesville, Texas
2009 Gainesville Texas
37
Surgical Preparation
  • Nasal MRSA screening
  • If positive treat with mupirocin and Hibiclens
    showers
  • Antibiotic prophylaxis with Vancomycin or
    Clindamycin
  • If MRSA negative prophylaxis with cephalexin

38
Anesthesia
  • Spinal anesthesia reduces the incidence of
    thromboembolic disease in total joint
    replacement.

Hu, S., et al., Prevention of Venous
Thromboembolic Disease After Total Hip and Knee
Arthroplasty J. of Bone and Joint Surgery -
British Volume. 2009 91-B, Issue 7, 935-942
39
Tourniquet
  • Abandoning the tourniquet reduces the incidence
    of thromboembolic disease and post tourniquet
    pain
  • EBL for tibial osteotomy typically is
  • lt 100 ccs. So what is the tourniquet for
    anyway?

40
Diagnostic/Surgical Arthroscopy
  • Confirms diagnosis on affected side
  • Confirms normalcy of opposite side
  • Significant abnormality of opposite side
    contraindicates osteotomy
  • Joint debridement can be performed although it
    may not really be necessary

41
Medial Compartment OA
Findings in this case Exposed tibia and femoral
bone meniscectomy Psuedogout
42
Normal Lateral Compartment
43
Osteotomy Exposure
  • Midline or oblique medial incision
  • Extraperiosteal dissection
  • Inferior retraction of anserine tendons
  • Section of superficial MCL reduces contact forces
    on the medial side
  • Retractor placed posteriorly to protect
    neurovascular bundle

44
Biplanar Tibial Osteotomy
  • Oblique posterior 2/3rds of tibia at level of
    tibial tubercle from medial to lateral
  • Osteotomy is incomplete and retains intact
    lateral one centimeter of tibia
  • Osteotomy of anterior 1/3 of tibia including
    tibial tubericle is made either ascending or
    descending

45
Tibial Osteotomy
  • Spreader chisel is carefully inserted into
    posterior osteotomy and opened to appropriate
    degree of correction under fluoroscopic control
    with plastic deformation of the lateral cortex.
  • The anterior osteotomy slides maintaining bone to
    bone contact.
  • TOMOFIX plate is applied

46
Schematic of Biplanar Osteotomy
Slide courtesy of Synthes
47
Typical Post Op Appearancenote valgus correction
48
Computer Navigation
  • Is currently under study. Preliminary results
    indicate that accuracy of correction is improved
    by these methods
  • Current cost is in excess of 100,000 but
    improvements continue to occur in the system
  • Hard to know when to purchase
  • We probably will be using it within a couple of
    years
  • Wang, G. et. al. A fluoroscopy-based
    surgical navigation system for high tibial
    osteotomy Source Technology and Health Care 2005
    Volume 13 ,  Issue 6  Pages 469 - 483  

49
Post Op Management
  • immediate ROM exercises in the RR.
  • Cryotherapy is utilized
  • Thromboembolic Prophylaxis
  • Not Necessary
  • CPM Machine
  • Parental analgesics
  • Oral analgesics stronger than Class Three
  • Femoral or epidural blocks
  • Discharge from hospital next morning

50
Thromboembolic Prophylaxis
  • Spinal anesthesia
  • Foot pumps
  • TED hose
  • Immediate ROM and ambulation with partial weight
    bearing by next morning
  • ASA for ordinary risk cases
  • Warfarin for high risk cases

51
Bone Healing
  • Primary Bone healing occurs between 3 and 12
    months in nearly 100 of cases without tobacco
    use/abuse
  • Iliac bone grafting is necessary in larger
    corrections than 13

Brinkman J-M, et al. Fixation stability of
opening- versus closing-wedge high tibial
osteotomy A RANDOMISED CLINICAL TRIAL USING
RADIOSTEREOMETRY J Bone Joint Surg Br, Nov 2009
91-B 1459 - 1465
52
Typical 12 Months Post OP
53
Nonunion typical of Tobacco abuse
Courtesy of Alex Staubli, MD
54
Osteotomy is a viable treatment option
  • Active patients with physiological age 60
  • Unicompartmental knee arthritis
  • Ligamentous imbalance
  • Biplanar osteotomy allows precision correction
    and when repaired with TOMOFIX is stable and
    tolerates accelerated rehabilitation without loss
    of correction in nonsmokers

55
Questions?
  • If no one asks any, then the presentation was
    completely ineffective

56
Thank You for your attention
  • Information for patients has been included in
    your handout.
  • Merry Christmas!
  • Happy New Year!
  • Mark S. Sanders, MD FACS
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