Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees)

1
Total Knee Arthroplasty associated with
osteotomy in cases of major deformities(19
knees)

• JL. LERAT, A. GODENÈCHE
• Service de Chirurgie Orthopédique et de Médecine
  du Sport
• Lyon France
• ISAKOS JUNE 2001 MONTREUX

2
23 cases of major deformities gt 20
Intra-articular deformities
Even in case of major deformity TKR is possible
11 valgus 22 3 12 varus 26 3

Good corrections - Good results obtained with
post. cruciate retaining TKR Similar to other
TKRs in our series
3
23 cases of major deformities gt 20
Intra-articular deformities
Even in case of major deformity TKR is possible

Good corrections - Good results obtained with
post. cruciate retaining TKR Similar to other
TKRs in our series
4
It is possible to correct the deformity in doing
TKA (sometimes with tightening ligaments of the
convexity)
PCL may be preserved
5
The question is How to correct a major
extra-articular deformity ( articular
deformity) by a total Knee Replacement ?
6
Typical cases are represented by tibial
deformities (following osteotomies or fractures)
Valgus Varus
Profile
7
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)
8
In cases of overcorrected valgus Complete
lateral ligament release is necessary

• Usual cuts for the femur. Minimal cut for the
  tibia Trapezoidal space

9
In cases of overcorrected valgus Complete
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)

10
In cases of overcorrected valgus Complete
lateral ligament release is necessary

• 1 operation
• No major difficulties
• Immediate weight bearing

ADVANTAGES
11
In cases of overcorrected valgus Complete
lateral ligament release is necessary
DISADVANTAGES

• Excessive polyethylene thickness
• Limb lengthening
• Peroneal nerve tension and stretching
• (palsy 4 in literature)
• PCL sacrifice
• More constrained prosthesis
• Poor ligament isometricity
• Possible instability (literature)

12
Symposium SO.F.C.O.T - Paris - 1990
Acceptable solution for Unacceptable for major
deformities minor deformities
Typical case Patella infera, Pain
Peroneal nerve palsy Poor flexion 70
13
Second alternative Bone graft and thinner
polyethylene plateau Drawbacks are similar and
walking is delayed
14
In some extreme cases Isolated TKR is
impossible and associated osteotomy is needed
Excessive valgus or varus make a new osteotomy
necessary
15
In some extreme cases Isolated TKR is
impossible and associated osteotomy is needed
Vicious rotation makes a new osteotomy necessary
External tibial torsion is 0 degree instead of
30 on the other side
16
Femoral deformities make new osteotomy necessary
Old case of rickets Previous
Femoral fracture
osteotomy and tibial osteotomy
17
In some extreme cases Isolated TKR is
impossible and associated osteotomy is needed

• 2 possible options
• 1 - Two-steps with osteotomy first, and then TKA
• 2 - TKA and osteotomy in a single operation

18
1 - OSTEOTOMY First and TKA later
ADVANTAGES

• 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

DISADVANTAGES
This choice had been made for 67 young patients
previously operated by osteotomy
19
it is always possible to do an iterative
osteotomy particularly in a young patient
20
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
21
2 - OSTEOTOMY TKA

• 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

22
1/ Correction of a tibial valgus deformity

• 1 - Femoral cuts as in usual cases
• 2 - Tibial cut is parallel to the condylar line
• 3 - Ligament balance is easy to ensure
• 4 - 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

23
Fer F - 73 years13 years after first osteotomy
182
218
24

• W...
• F - 60 years
• HKA 191
• Weight-bearing
• 2 months

25

• 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

26
2 The distal femoral cut is done parallel to
the tibial cut in extension 3 Spacer and
ligament balance 4 TKA is fitted
2/ Correction of a femoral deformity
Flexion 90
Extension
1 Anterior and post cuts are parallel to the
tibial cut
27
Osteotomy is performed when the implants are
placed
Resection Addition
Graft with the bone resulting from the cuts
28
138
180
Fl 115
Be... M - 75 years Previous femoral ost.
at 20 years TKA ost. Graft after 4 months (non
union) Healing 7 m.
29
166
180
Prat..... H - 75 years old 55 years after 1st
osteotomy TKR opened osteotomy
30
Material

• 19 TKA Osteotomy (18 patients)
• Mean age 72 years 6 (60 - 80)
• 13 females - 5 males

31
Material

• Varus knee (22 9) 8 cases
• 2 excessive tibial varus
• 1 old tibial fracture
• 3 previous femoral osteotomy
• 1 old femoral fracture
• 1 old history of rickets
• Valgus knee (7 10) 9 cases
• 8 HTO, 1 excessive valgus
• Rotation (25) varus 2 knees
• 2 previous HTO

32
Technical characteristics

• 17 cementless TKA, 2 cemented
• 14 PCL retaining prosthesis
• 3 two CL retaining prosthesis
• 2 hinged TKR
• Osteotomies
• Tibia 13
• Opened osteot. 3 Closed osteot. 8
  Rotation 2
• Femur 6
• Opened osteot. 3 Closed osteot. 3

33
Technical characteristics

• Operation time 153 35 mn
• Similar to Teenys (16O mn) for a major varus
  series
• Similar to Krackows (152 mn) for a major
  valgus series
• Blood loss 1270 570 ml
• (no difference between femoral and tibial
  osteotomies)

34
RESULTS

• Healing 5 4 months
• Complications
• 1 non union (graft)
• 1 late fusion
• 1 early PE plateau wear
• Correction loss 3.3 2.9

• 9 overcorrected HTO
• Follow-up 45 25 months
• IKS score preop 87 13
• IKS score post-op 160 21
• Flexion 111 13
• Correction Valgus 3 3

35
RESULTS
Comparison with the
literature 9 overcorrected HTO
TKA for valgus deformities

• KRACKOW (1991)
• IKS K score 87.6
• Flexion 103
• MIYASAKA (1997)
• IKS K score 88.7
• Flexion 101
• LOTWOET (1997)
• IKS K score 93.3

• Follow-up 45 25 months
• IKS knee preop 34 11
• IKS Knee post-op 86 13
• Flexion 111 13
• Correction Valgus 3 3

36
Leg .. F - 75 years Previous HTO 6 years ago
37
unipodal
38
Standing position
Ant drawer
Post drawer
INNEX mobile bearing knee
39
(No Transcript)
40
RESULTS
8 major varus deformities TKA for
varus deformities

• TEENY (1991)
• IKS K score 89
• Flexion 98
• LASKIN (1996)
• Flexion 86

• IKS K score 86.4 12
• Flexion 111 10

41
Lu.... 69 years Major varus deformity
153
182
T 77
Two cruciates retaining TKR
42
Varus deformity following fractures of medial
and lateral tibial plateaus
F - 80 years TKA Opened HTO with graft and
staples
43
179
F - 71 years Femoral fracture at 45
years Previous tibial osteotomy at 61 yrs Varus
at 2 levels
44
1 particular case of malrotation
2 previous tibial osteotomies with rotation in
the same patient

• 1 poor result
• 1 revised

• - First case of the series
• - Obesity (gt100 Kg)
• - Recurrent varus
• - Wear of a too thin PE

45
The 2 most recent cases had bone deformity
Laxity they need very constrained TKR
1st case
160
F 60 years. Poliomyelitis. Patella infera.
Quadriceps0. Varus 20 2 previous
osteotomies. Global arthritis. Ligamentous
laxity.
46
The placement of the stem needs an osteotomy
Grafting with the bone resulting from the cuts
47
Particular case of a malunion above a
TKALateral laxity
Bone deformity Laxity A very constrained
hinged TKR is needed
2d case
The particular shape of the femur dictates an
osteotomy
48
Particular case of a malunion above a
TKALateral laxity
Bone deformity Laxity Ligamentous laxity
needs a very constrained hinged TKR
2d case
The particular shape of the femur dictates an
osteotomy
49
Particular case of a malunion above a
TKALateral laxity
50
OSTEOTOMY TKA
ADVANTAGES

• A single operation
• Joint line and ligament balance preserved

DISADVANTAGES

• Technical difficulties
• Rather prolonged osteotomy fusion

51
INDICATIONS
Extra-articular deformity

Wear laxity

DEFORMITY
206
188
Stress radiography allows precise measurements of
ligamentous and bony deformities
Valgus stress Varus stress
52
INDICATIONS
Extra-articular deformity

Wear laxity

DEFORMITY
206
188
Stress radiography allows precise measurements of
ligamentous and bony deformities
Valgus stress Varus
stress
53
INDICATIONS
Extra-articular deformity

Wear laxity

DEFORMITY
54
INDICATIONS
Extra-articular deformity

Wear laxity

DEFORMITY

• Valgus def. 17 10 ( 9 to 30)
• Varus def. 22 9 (12 to 34)

Mean deformity in the serie
55
INDICATIONS
Extra-articular deformity

Wear laxity

DEFORMITY

• Valgus def. 17 10 ( 9 to 30)
• Varus def. 22 9 (12 to 34)

• 14.3
• 16.4

10 ??
Minimum deformity for indication ??
56
INDICATIONS
Opening or closing wedge osteotomy ?
- Length of the limbs - Bone is
available for grafting (bone cuts) Opening
HTO is difficult in previous valgus HTO
Opening HTO is easy for varus tibial deformities
Opening closing for femoral deformities
57
Conclusions

• Infrequent operation (19 knees)
• (during the same period by the same
  surgeon 840 TKA)
• Indicated in cases of severe gonarthrosis and
  major extra-articular deformity in elderly
  patients

58
Conclusions

• The results of these extreme cases are similar to
  those of simple TKA
• There are advantages in doing TKA and osteotomy
  in a single operation
• Preservation of the joint level (and PCL) and
  patellar height
• Good balance of the ligaments eliminating the
  need for highly
• constrained TKA
• It is also compatible with the performance of
  non cemented implants