Total Knee Arthroplasty associated with osteotomy in cases

Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees) JL. LERAT, A. GODENÈCHE, B MOYEN Service de Chirurgie Orthopédique et de Médecine du Sport Lyon – France SOFCOT, Paris 10 -14 Nov 1998 EFORT, Bruxelles 3 -8 Juin 1999

Intra-articular deformities Even in case of major deformity TKR is possible : 23 cases of major deformities > 20° 11 valgus : 22° ± 3 12 varus : 26° ± 3 Good corrections - Good results obtained with post. cruciate retaining TKR Similar to other TKR’s in our series

Intra-articular deformities Even in case of major deformity TKR is possible : 23 cases of major deformities > 20° Good corrections - Good results obtained with post. cruciate retaining TKR Similar to other TKR’s in our series

The question is : How to correct a major extra-articular deformity (± articular deformity) by a total Knee Replacement ?

Typical cases are represented by tibial deformities (following osteotomies or fractures) Valgus Varus Profile

The limit of ligament release In cases of overcorrected valgus Complete lateral ligament release is necessary • Usual cuts for the femur. Minimal cut for the tibia: Trapezoidal space • Large release of the concavity in order to obtain rectangular space • A correction of 20° corresponds to a release of 30 mm ! (Wolf)

ADVANTAGES • 1 operation • No major difficulties • Immediate weight bearing

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)

Symposium SO. F. C. O. T Acceptable solution for minor deformities - Paris - 1990 Unacceptable for major deformities Typical case : Patella infera, Pain ++ Peroneal nerve palsy Poor flexion : 70°

In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed Excessive valgus or varus make a new osteotomy necessary

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

Femoral deformities make new osteotomy necessary Old case of rickets Previous osteotomy Femoral fracture and tibial osteotomy

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

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 DISADVANTAGES • 2 consecutive operations (6 to 12 months) • 2 anesthesias, 2 rehabilitation tasks, DVT risk This choice had been made for 67 young patients previously operated by osteotomy

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 : “ 14 th Annual Current Concepts in Joint Replacement” in Cleveland, Dec 1997

1/ Correction of a tibial valgus deformity 1 rst method 1 2 3 4 - Femoral cuts as in usual cases Tibial cut is parallel to the condylar line Ligament balance is easy to ensure 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

2 d method : using a tibial component with short stem or pegs Osteotomy is performed after TK implantation

218° Fer… F - 73 years 13 years after first osteotomy 182°

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

• 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

2/ Correction of a femoral deformity Flexion 90° 1 : Anterior and post cuts are parallel to the tibial cut Extension 2 : The distal femoral cut is done parallel to the tibial cut in extension 3 : Spacer and ligament balance 4 : TKA is fitted

Osteotomy is performed when the implants are placed Resection Addition Graft with the bone resulting from the cuts

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.

166° 180° Prat. . . H - 75 years old 55 years after 1 st osteotomy TKR + opened osteotomy

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

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

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

Technical characteristics • Operation time : 153 ± 35 mn Similar to Teeny’s (16 O mn) for a major varus series Similar to Krackow’s (152 mn) for a major valgus series • Blood loss : 1270 ± 570 ml (no difference between femoral and tibial osteotomies)

RESULTS 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 • Healing : 5 ± 4 months • Complications • 1 non union (graft) • 1 late fusion • 1 early PE plateau wear • Correction loss : 3. 3° ± 2. 9°

RESULTS Comparison with the literature 9 overcorrected HTO TKA for valgus deformities • KRACKOW (1991) • • • Follow-up = 45 ± 25 months IKS knee preop = 34 ± 11 IKS Knee post-op = 86 ± 13 Flexion = 111°± 13 Correction : Valgus 3° ± 3 • IKS K score = 87. 6 • Flexion = 103° • MIYASAKA (1997) • IKS K score = 88. 7 • Flexion = 101° • LOTWOET (1997) • IKS K score = 93. 3

Leg. . F - 75 years Previous HTO 6 years ago

unipodal

Standing position Ant drawer Post drawer INNEX mobile bearing knee

RESULTS 8 major varus deformities • IKS K score = 86. 4 ± 12 • Flexion = 111°± 10 TKA for varus deformities • TEENY (1991) • IKS K score = 89 • Flexion = 98° • LASKIN (1996) • Flexion = 86°

Lu. . 69 years 153° Major varus deformity 182° T = 77° Two cruciates retaining TKR

Varus deformity following fractures of medial and lateral tibial plateaus F - 80 years TKA + Opened HTO with graft and staples

179° F - 71 years Femoral fracture at 45 years Previous tibial osteotomy at 61 yrs Varus at 2 levels

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 (>100 Kg) - Recurrent varus - Wear of a too thin PE

The 2 most recent cases had bone deformity + Laxity they need very constrained TKR 1 st case 160° F : 60 years. Poliomyelitis. Patella infera. Quadriceps=0. Varus : 20° 2 previous osteotomies. Global arthritis. Ligamentous laxity.

The placement of the stem needs an osteotomy Grafting with the bone resulting from the cuts

Bone deformity + Laxity A very constrained hinged TKR is needed 2 d case Particular case of a malunion above a TKA + Lateral laxity The particular shape of the femur dictates an osteotomy

Bone deformity + Laxity Ligamentous laxity needs a very constrained hinged TKR 2 d case Particular case of a malunion above a TKA + Lateral laxity The particular shape of the femur dictates an osteotomy

Particular case of a malunion above a TKA + Lateral laxity

OSTEOTOMY + TKA ADVANTAGES • A single operation • Joint line and ligament balance preserved DISADVANTAGES • Technical difficulties • Rather prolonged osteotomy fusion

DEFORMITY 206° INDICATIONS = Wear + laxity + Extra-articular deformity 188° Stress radiography allows precise measurements of ligamentous and bony deformities Valgus stress Varus stress

INDICATIONS DEFORMITY 206° = Wear + laxity + Extra-articular deformity 188° Stress radiography allows precise measurements of ligamentous and bony deformities Valgus stress Varus stress

INDICATIONS DEFORMITY = Wear + laxity + Extra-articular deformity

INDICATIONS DEFORMITY = Wear + laxity • Valgus def. = 17°± 10 • Varus def. = 22° ± + ( 9 to 30°) 9 (12 to 34°) Mean deformity in the serie Extra-articular deformity

INDICATIONS DEFORMITY = Wear + laxity • Valgus def. = 17°± 10 • Varus def. = 22° ± + ( 9 to 30°) 9 (12 to 34°) Minimum deformity for indication ? ? Extra-articular deformity 14. 3° 16. 4° 5 -7° ? ?

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

Conclusions • Unfrequent 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

Conclusions • The results of these extreme cases are similar to those of simple TKA • There 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

Thank you