Deformity correction
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Deformity correction

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Deformity correction Deformity correction Presentation Transcript

  • Correction of Lower Limb Deformity Dr. J. Rawat
  • Source
  • DiagnosticDiagnostic Radiographs of the lower limbs: Long films Frontal plane (AP view)(Patella Forward) Sagittal plane (Lateral view) In case of Severe Rotational Deformity Hip Forward view(AP Femur)
  • DiagnosticDiagnostic
  • DiagnosticDiagnostic Patient with LLD Square the pelvis
  • DiagnosticDiagnostic AP view standing radiographs
  • DiagnosticDiagnostic Long LAT view radiograph
  • Deformity of the lower limb (Frontal Plane) MMechanical AAxis DDeviation (MAD) Malalignment
  • AXIS (mechanical + anatomical) • Mechanical Axis of the Lower Limb. • Mechanical Axis of Femur. • Anatomical Axis of Femur. (7degrees to AA) • Mechanical Axis = Anatomical Axis of Tibia. • If 1 limb is normal used as guide for correction.
  • MAT (Malalignment Test)MAT (Malalignment Test) Analyzing of the cause or the location of the malalignment !
  • MAT (Malalignment Test)MAT (Malalignment Test) Step:1 Measurement of the MAD Mechanical Axis Deviation = >15 mm medial < 1 mm lateral Mechanical Axis
  • Source of MAD (Varus) • Varus: Bony Malalignment Tibia vara (MPTA<85) Femoral Valgus Deformity(LTFA >90) Combination • Joint Surface Malalignment Depressed or deficient Lateral Tibial Plateau Depressed or deficient Lateral Femoral Condyl • Ligamentocapsular (interosseous) Malalignment Lateral Joint Laxity Medial Tibial Subluxation
  • Source of MAD (Valgus) • Varus: Bony Malalignment Tibia valga (MPTA>90) Femoral Varus Deformity(LTFA <85) Combination • Joint Surface Malalignment Depressed or deficient medial Tibial Plateau Depressed or deficient medial Femoral Condyl • Ligamentocapsular (interosseous) Malalignment Medial Joint Laxity Lateral Tibial Subluxation
  • Source of MAD (Valgus)
  • MAT (Malalignment Test)MAT (Malalignment Test) Step: 2. Measurement of the LDFALDFA = llateral ddistal ffemur aangle using the mechanical and anatomical axises.
  • MAT (Malalignment Test)MAT (Malalignment Test) (Step 2 Contd.) Measurement of the LDFALDFA = llateral ddistal ffemur aangle < 85° LDFA = Valgus deviation > 90° LDFA = Varus deviation of the femur
  • MAT (Malalignment Test)MAT (Malalignment Test) Step: 3. Measurement of the MPTAMPTA = mmedial pproximal ttibia aangle
  • MAT (Malalignment Test)MAT (Malalignment Test) Step 3 contd. Measurement of the MPTAMPTA = mmedial pproximal ttibia aangle > 90°MPTA = Valgus deviation < 90°MPTA = Varus deviation of the tibia
  • MAT (Malalignment Test)MAT (Malalignment Test) Step: 4. Measurement of the JLCAJLCA = jjoint lline ccovergence aangle Normal= 0-2 degrees Medial JLCA >2°: - lateral ligament hyperlaxity - medial loss of cartilage Lateral JLCA >2°: - medial ligament hyperlaxity - lateral loss of cartilage
  • MAT ( Malalignment Test)MAT ( Malalignment Test) •Malorientation of / around knee will change the MAD and MAT will be abnormal. •MalorientationMalorientation in the hiphip and ankle will cause no/minimalankle will cause no/minimal change in the MADand MAT may be normal.change in the MADand MAT may be normal. Malorientation-Test (MOT)Malorientation-Test (MOT) for ankle and hipfor ankle and hip
  • Malorientation-TestMalorientation-Test (MOT)(MOT) forfor a) ankle and b) hipa) ankle and b) hip
  • Malorientation-Test = MOTMalorientation-Test = MOT 1. Step: Measurement of the LPFA = lateral proximal femur angle (mechanical)
  • Malorientation-Test = MOTMalorientation-Test = MOT 2. Step: Measurement of the MPFA = medial proximal femur angle (anatomical)
  • Malorientation-Test = MOTMalorientation-Test = MOT 3. Step: Measurement of the LDTA = lateral distal tibia angle
  • Sagittal Plane ANSA = 165 -175 AMA= 7degrees MDA(mid diaphysial angle)=10 (Femur)
  • CORA •Angulation Correction Axis •Bisector Line
  • CORA • Femur
  • Osteotomy rule IOsteotomy rule I When the Osteotomy line, and ACA pass through the CORA realignment occurs without translation and only angulation is required to correct the deformity.
  • Osteotomy rule IIOsteotomy rule II When the ACA is through the CORA but the osteotomy is at a different level, the axis will realign by angulation and translation at the osteotomy site.
  • Corollary to Rule IICorollary to Rule II If osteotomy passes through a different level than the CORA and the axis of correction(ACA) is on the osteotomy line then Translation Deformity will result.
  • Osteotomy rule IIIOsteotomy rule III If there is more than one CORA, complete realignment of Mechanical axis and Anatomical axis requires a separate osteotomies for each CORA with seperate Axis of Correction(ACA) for each CORA. The level and magnitude of one apex determining the level and magniture of the other apex
  • Corollary to Rule III If the Osteotomy is done through the Resolution point CORA rather than true multiple apices, then the mechanical axis and joint orientation will correct with a residual alteration in the Anatomical axis of the bone.(This may be a cosmetic problem.)
  • Conditions when Osteotomy not done at CORA • If CORA is at Joint Level • If CORA is at the Epiphysis in Children. • Skin and Soft tissue Consideration
  • Isolated Tibial Diaphysial Deformity • Step 0-Measure MAD • Step1 Draw Mechanical axis of Femur after conducting MAT,MOT. • Step2 Draw a line from Center of Ankle Plafond along Anatomical axis ofDistal Tibia. • Step 3 Find CORA and Angle of Deformity where this line meets the Extended Mechanical Axis of Femur.
  • Juxta Articular Tibial Deformity with a Normal Femur
  • Diaphiseal Femoral Deformity with Normal Tibia
  • Juxta Articular Femoral deformity with Normal Tibia
  • Anatomical Axis Method of Preop Planning for Femur
  • Conditions where Anatomical Axis used for Femur • Femoral Head deformed so mechanical axis cant be made. • Severe Rotational deformity of Femur. • CORA not corresponding to the apparent deformity
  • Combined Femoral And Tibial Deformity in the Absence of Normal Opposite Side
  • Level of Osteotomy
  • CORA not at Apex of Apparent Deformity
  • Order of Deformity Correction • 1st correct the Angular Deformity • 2nd correct the Length • 3rd correct the Rotation after the Angulation is Corrected. • Finally correct Translation
  • Effect of Rotation on Pre op Planning. • Tibia Rotation can be corrected through the CORA determined by Previous Method . • Can Alter Level of CORA in Femur. • Ext Rot leads to app shortening and Int Rot to app Lengthening of Femoral Neck
  • Compensating the Rotation • Clinically determine the Rotation deformity • Xray with the Hip forward position (Knee rotated) • Measure Distance from Mid Diaphysial line to Center of head of Femur. • Compare with same distance in Knee forward film. • Center of Femur head for mechanical axis line are shifted Medially or Laterally by the same distance
  • Sagittal Plane Correction
  • Sagittal Plane Deformity • Malalignment Better tolerated. • Compensated for by Hip,Knee,Ankle Subtalar and Midfoot. • Associated with late degenerative changes. • Malalignment Test • Malorientation Teat • Correction using Anatomical Axis • Soft tissue component of deformity should be corrected before osteotomy.
  • Methods to Correct the Deformity • Osteotomy and Plating Single Deformity Metaphysial Correction • Osteotomy and Nailing Multi level osteotomy Diaphysial Correction • Fitbone Lengthening also required • Fixators Ring, Taylor Spatial Frame,Monorail
  • Example for reverse planningExample for reverse planning as described by Reiner Boungartas described by Reiner Boungart • 15 yo girl originally from Afghanistan. • Known case of Vit. D resistant rickets Clinical • Short stature: Ht = 141.2 cmShort stature: Ht = 141.2 cm Wt 42.5 kg • Has splayed wrists • Pain in the legs off and on. • No knee pain or instability at present.
  • Mechanical Axis Deviation (MAD) Lt = 40mm Medial Rt = 33mm Medial Normal = 8+/- 7 mm medial Mechanical Axis Femur: Lt = 20° Rt = 25° Tibia: Lt = 20° Rt = 14°
  • X-ray MeasurementsX-ray Measurements mLDFA [85 – 90] Lt = 95 Rt = 97 MPTA [85 – 90] Lt = 78 Rt = 80 JLCA [0 – 2] Lt = 2 Rt = 1
  • Measurements ContdMeasurements Contd mLPFA [85 – 95] Lt = 102 Rt = 105 aMPFA [79-89] Lt = 82 Rt = 70 aMNSA [125-135] Lt = 128 Rt = 123
  • Measurements ContdMeasurements Contd LDTA Rt = 90 Lt = 90 [86-92]
  • Sagittal planeSagittal plane • ANSAANSA Lt = 165 Rt = 165 Normal = 165-175 • Mid diaphysial Angle (MDA)Mid diaphysial Angle (MDA) Lt = 15 Rt = 15 Normal = 10
  • Sagittal planeSagittal plane PDFA Lt = 80 Rt = 80 Normal = 79-87 Mid diaphysial Angle (MDA) Lt = 8 Rt = 10 Normal = 0
  • Sagittal planeSagittal plane ADTAADTA Rt = 83 Lt = 84 Normal = 78-82
  • 2. Exact planning of the2. Exact planning of the deformity correctiondeformity correction - operative planning- operative planning Lengthening of 4cm at the femur Translation of 4 mm „Reverse planning“ – technique described by PD Dr. Baumgart in Bangkok November / 2003  Different planning!
  • Preoperative Planning-BasicsPreoperative Planning-Basics • At the end of the preoperative planning for leg lengthening, the mechanical axis pass the center of hip, ankle and knee • Analyze the bone which has to be corrected and mark the center of angulation (CORA) • Use the mechanical (= anatomical) axis of the tibia as orientation line for the correction, if there is no Tibia deformity (in the follow exmple-both Tibia and Femur-are deformed) • Be certain, that the mechanical lateral distal femur angle (mLDFA) is within the physiological range (85°-90°) before you start
  • Draw a target, vertical linetarget, vertical line on tracing paper representing the new mechanical axis and another line crossing at 87°. Evaluate the knee joint angle line very precisely and place this line on the crossing line, what this means, that knee joint is now orientated under 87° to the mechanical axis Reverse Planning- Step1Reverse Planning- Step1
  • Take over the target line representing the new mechanical axis, place the center of the knee joint on this line and continue the line distally. Mark the center of rotation of angulation (CORA). Mark the center of the ankle joint CA on this line in correct position according to the opposite length or to the desirable length. Reverse Planning TibiaReverse Planning Tibia Step 2aStep 2a CA
  • This should be the position of the ankle joint at the final result = CA . Choose an OT level near to the center of CORA in accordance with the locking performance of the nail and draw a transverse line to identify the level. Reverse Planning TibiaReverse Planning Tibia Step 2bStep 2b CA
  • Take an extra sheet and draw the distal part of the tibia ending within the OT- line. Draw the anatomical axis and the scaled nail borderline according to the diameter of the planned nail. The nail will always center in the diaphysis and simulate by drawing the bone reaming of the curved cortex. Lengthen the lines proximally out of the fragment. Reverse Planning TibiaReverse Planning Tibia Step 3Step 3
  • Take the extra sheet and place the center of the ankle joint exactly on the dedicated center CA which was found in step 2a so that 1. The entry point of the nail has to be near to the middle of the tibia head not damaging any cartilage 2.the lines of the nail coming out of the distal fragment enter the distal frontplane of the proximal tibia fragment at the OT- level Reverse Planning – TibiaReverse Planning – Tibia Step 4Step 4 CA
  • Shift the distal fragment upwards along the anatomical axis, because this will be thethe reverse actreverse act of lengthening over a nail. If the frontal planes of both fragments get into contact, mark the new center of the ankle joint CA´ . The position of the distal tibia fragment now is the postoperative position which is essential to get the exact position after the complete lengthening as planed. Reverse Planning TibiaReverse Planning Tibia Step 5Step 5 CA CA`
  • • The exact geometrical position (lat. or med. shift) • The angle of the frontal planes of the proximal + distal fragment • The position of the entry point of the nail Reverse Planning TibiaReverse Planning Tibia Evaluate All these landmarks must be exactly achieved intraoperatively visually and controlled on the screen with the Patella in front.
  • Take over the vertical target linevertical target line (()) of the tibia representing the mechanical axis, place the center of the knee joint and ankle joint on this line and continue the line proximally as the target line. Reverse PlanningReverse Planning Step 6Step 6
  • Mark the center of rotation of angulation (CORA). Mark the center of the hip joint CH´ on this line in correct position according to the opposite length or to the desirable length. Reverse Planning FemurReverse Planning Femur Step 7aStep 7a
  • This should be the position of the hip joint at the final result = CH´ . Choose an OT level near to the center of CORA in accordance with the locking performance of the nail and draw a transverse line to identify the level. Reverse PlanningReverse Planning Femur- Step 7bFemur- Step 7b CH CH´
  • Take an extra sheet and draw the proximal part of the femur ending with the OT-line. Draw the anatomical axis and the scaled nail borderline according to the diameter of the planed nail. The nail will always center in the diaphysis. Anatomical variations of the proximal femur such as coxa valga which could be an obstacle for antegrade nailing does not affect your planning for retrograde nailing. Lengthen the lines distally out of the fragment. Reverse Planning FemurReverse Planning Femur Step 8Step 8 CH CH´
  • Take the extra sheet and place the center of the hip joint (CH) exactly on the dedicated center CH´ which was found in step 7b so that 1. The entry point of the nail has to be in the middle of the condyles allowing the entry of a nail without damaging any cartilage or cruciate ligament 2.the borderlines of the nail coming out of the proximal fragment enter the proximal frontplane of the distal femur fragment at the OT- level Reverse Planning FemurReverse Planning Femur Step 9aStep 9a CH´
  • 3. The lateral proimal femur angle (LPFA) should be about 90° preventing an overtention or relaxation of the gluteus muscle –both should be examined clinically 4. After final position of the proximal femur fragment, the exitpoint of the nail at the distal femur fragment is defined and the entry point comes out exactly in the middle of the condyles. Reverse Planning FemurReverse Planning Femur Step 9bStep 9b CH´
  • Shift the proximal fragment downwards along the anatomical axis, because this will be the reverse actthe reverse act of lengthening over a nail. If the frontal planes of both fragments get into contact, mark the new center of the hip joint CH* . The position of the proximal femur fragment now is the postoperative position which is essential to get the exact position (=CH´) after the complete lengthening as planed. Reverse PlanningReverse Planning Femur- Step 10Femur- Step 10 CH´ CH*
  • Note: Evaluate...Note: Evaluate... - The exact geometrical position (lat. or med. shift) - The angle of the frontal planes of the proximal + distal fragment - The position of the entry point of the nail All the landmarks must be exactly achieved intraoperatively visually and controlled on the screen with the Patella in front.
  • Control of the mechanical axis intraoperatively under Imaging Intensifier with - grid - radiolucent rulers on the OT-table! 3. Exact intraoperative control3. Exact intraoperative control
  • Control of the mechanical axis intraoperatively under Imaging Intensifier with - grid - radiolucent rulers on the OT-table! 3. Exact intraoperative control3. Exact intraoperative control
  • Control of mechanical axis intraoperatively under Imaging Intensifier with - grid - radiolucent rulers on the OT-table! 3. Exact intraoperative control3. Exact intraoperative control