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Operative Strategies for Management
of Knee Osteoarthritis
Dr. A.K.Venkatchalam
MJRC Clinic, Chennai
Goals of Osteoarthritis Treatment
The treatment is directed at symptoms and slowing progress of
the condition
R elieve pai...
Surgery
Indications
• Pain refractory to conservative measures
• Functional disability of the patient to carry out routine...
Surgery
Surgical Methods
Arthrodesis
(rarely used)
Total Knee
Arthroplasty
Unicondylar Knee
Arthroplasty
High Tibial
Osteo...
• Considered in treatment for uni-compartmental
osteoarthritis of knee usually with concomitant varus or
valgus deformity
...
High Tibial Osteotomy
Indications
Classic: Age <60 year
Varus <15°
Contraindications
Absolute:
 Diffuse osteoarthritis
 ...
Guiding Principles
• Static and dynamic angle measurement
• Ligamentous laxity
• Antero-posterior instability
• Patient fa...
Four basic types
1. Lateral closing wedge osteotomy
2. Medial opening wedge osteotomy
3. Dome osteotomy
4. Medial opening ...
Lateral Closing Wedge Osteotomy
• Described by Coventry et al.
• Measure the amount of correction needed to achieve
normal...
If tibia is 57 mm wide, width of wedge=degrees of correction
OR
Length = Diameter of tibia x 0.02 x Angle
Lateral Closing ...
Types of Closing Wedge Osteotomy
Above tibial tubercle
 Large cancellous
surface
 Close to deformity
 Time honored
 Mi...
Incision Positioning transverse osteotomy guide
Lateral Closing Wedge Osteotomy
Placement of oblique osteotomy
guide & performing osteotomy
Application of compression
clamp & L- plate
Lateral Closing We...
 Completion of osteotomy requires disruption of proximal
tibio fibular joint or removal of infero medial portion of
fibul...
 Described by Hernigou
 Preferred method by most
surgeons nowadays.
 Synthetic bone substitute may
or may not be used d...
Medial Opening Wedge Osteotomy
 A tourniquet is used
 The skin incision is placed vertically, on the medial side of the ...
 Great care is taken not to damage the lateral cortex
 The tibia is manually wedged to the point of desired
correction, ...
Lateral Closing Wedge
Osteotomy
 Time honored
 Commonly available
jig
 Higher union rate
 Fixation covered with
soft t...
 Described by Maquet
 Determine the angle of correction
 Midline vertical incision
 Curved line is marked on bone with...
Dome Osteotomy
 Two K-wires inserted parallel to each other on either
side of osteotomy
 Complete the osteotomy using osteotome
 Dista...
 Described by Turi
 Medial opening wedge osteotomy with application of
dynamic external fixator
 At 7th postoperative d...
 Position the fixator over the leg
to check the position of the pin
clamps, osteotomy site and
hinge
 Osteotomy site is ...
Fixator secured with K-wires Proximal fixator pin inserted
Opening Wedge Hemicallotasis
Medial and lateral
proximal fixator pins
Distal fixator pin placed
Opening Wedge Hemicallotasis
Osteotomy guide attached Series of holes drilled at
osteotomy site
Opening Wedge Hemicallotasis
Holes connected with
osteotome
Distraction of osteotomy
Opening Wedge Hemicallotasis
 Passive motion is started immediately after surgery
 Ambulation is begun on 2nd day, allowing weight
bearing to toleran...
Complications of High Tibial Osteotomy
 Recurrence of deformity
 Peroneal nerve palsy ( lateral closing wedge)
 Knee st...
Distal Femoral Osteotomy
 Indicated in active patients younger than 65
years with valgus angulation <15 degree
 Indicate...
Knee Arthroplasty after HTO
 Ideal HTO for TKR:
 Opening wedge osteotomy above the tibial
tubercle and a lax medial coll...
Knee Arthroplasty
 Uni-compartmental (Uni-condylar) knee arthroplasty
 Total knee arthroplasty
Unicondylar Knee Arthroplasty
Indications
 Classically: uni-compartmental osteoarthritis of the knee in a low-
demand, el...
Joint Preserving
 ACL & PCL, lateral meniscus retained
 Minimal bone resection: 2-4 mm resected
 No overcorrection – lo...
MIS UKA
Unicondylar Knee Arthroplasty
Unicondylar Knee Arthroplasty
Erect
Postop xrays
Unicondylar Knee Arthroplasty
Post op after Uni knee
• Mobilized full weight bearing on same or next
day.
• Range of movement exercises commenced
• Pati...
Benefits
1. Short hospital stay
2. Full range of motion
3. Speedy recovery and ability to walk unaided
4. Sit cross-legged...
Candidate for TKR
 Tri compartmental arthritis.
 Quality of life severely affected.
 Pain severely affecting the activi...
Total Knee Arthroplasty
TKR consists of following:
 Cobalt chrome alloy or
alternate femoral component
 Cobalt chrome al...
The Incision
 Midline or medial skin incision is
with the knee in flexion.
 Sub fascial space is exposed
 Para patellar...
 The leg is then extended and patella is everted
 The knee is once again flexed and the anterior horn of
medial and late...
 The medial/lateral, antero-
posterior screws of the
ankle clamp are fine tuned
to align the proximal tibial
resection gu...
 Bony cuts are made at first in order chosen by surgeon
 The amount of tibial resection depends on which side of the
joi...
 A drill bit is used to create an
opening in the femoral canal.
 The valgus alignment guide is
then used and attached to...
 The extension gap is first measured. An extension spacer
corresponding to the minimal insert should be introduced
comfor...
 The flexion and extension gaps must be equal. Gap balancing is
done by soft tissue releases and/or bony cuts.
 If the e...
 Patellar resurfacing may be done on basis of intra op
finding
 First the patella is laterally retracted with the articu...
 With the knee flexed, appropriate femoral trials are placed
on the distal femur and proximal tibia.
 Appropriate spacer...
Total Knee Arthroplasty
 The femoral impactor is used to insert the
femoral implant.
 The tibial base impactor is used t...
Total Knee Arthroplasty
 The wound is thoroughly irrigated.
 Tourniquet is release and bleeding is
arrested.
 Closed-su...
Complications of TKA
 Thromboembolism
 Infection
 Patello-femoral complications
 Neurovascular complications
 Peripro...
Arthrodesis
Indications
• Severe disability in young & active
patient whose activity level might
be detrimental to the lon...
Post infectious knee with deficient
Extensor apparatus
Techniques of arthrodesis
Techniques of Arthrodesis
 External Fixation
 Intramedullary Nailing
 Plate Fixation
Dr.A.K.Venkatachalam is a fellow of the Royal college of surgeons of Glasgow and Post
graduate of the prestigious Universi...
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Osteo-arthritis Knee, strategies for management

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Strategies for management of Osteo-arthritis of knee. A talk given by Dr.A.K.Venkatachalam at the Joint Replacement conclave in Mumbai.

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Osteo-arthritis Knee, strategies for management

  1. 1. Operative Strategies for Management of Knee Osteoarthritis Dr. A.K.Venkatchalam MJRC Clinic, Chennai
  2. 2. Goals of Osteoarthritis Treatment The treatment is directed at symptoms and slowing progress of the condition R elieve pain R estore function R educe disability R ehabilitation Goals: 4 R’s
  3. 3. Surgery Indications • Pain refractory to conservative measures • Functional disability of the patient to carry out routine day to day activities • Loose bodies or osteochondral fractures • Deformity usually genu varum • Progressive limitation of knee motion
  4. 4. Surgery Surgical Methods Arthrodesis (rarely used) Total Knee Arthroplasty Unicondylar Knee Arthroplasty High Tibial Osteotomy
  5. 5. • Considered in treatment for uni-compartmental osteoarthritis of knee usually with concomitant varus or valgus deformity • Biomechanics of osteotomy is; unloading of involved joint compartment by correcting malalignment and redistribution of the stress uniformly on the knee joint High Tibial Osteotomy
  6. 6. High Tibial Osteotomy Indications Classic: Age <60 year Varus <15° Contraindications Absolute:  Diffuse osteoarthritis  > Grade 2 changes in PF joint  Tibiofemoral subluxation  Inflammatory arthritis  Menisectomy in the compartment  Unrealistic expectation Relative:  Age >65 years  Obese (>1.32 x ideal bodyweight)  Poor ROM <90°  Non-specific knee pain
  7. 7. Guiding Principles • Static and dynamic angle measurement • Ligamentous laxity • Antero-posterior instability • Patient factors High Tibial Osteotomy
  8. 8. Four basic types 1. Lateral closing wedge osteotomy 2. Medial opening wedge osteotomy 3. Dome osteotomy 4. Medial opening hemicallotaxis High Tibial Osteotomy
  9. 9. Lateral Closing Wedge Osteotomy • Described by Coventry et al. • Measure the amount of correction needed to achieve normal angle then additional 3 to 5 degree of overcorrection is added. • Calculation of existing and desired mechanical axes by weight bearing full length x rays. • Calculating the size of wedge removed as roughly 1 degree of correction for 1 mm length at the base of the wedge (if the width of the tibial plateau is 57 mm).
  10. 10. If tibia is 57 mm wide, width of wedge=degrees of correction OR Length = Diameter of tibia x 0.02 x Angle Lateral Closing Wedge Osteotomy
  11. 11. Types of Closing Wedge Osteotomy Above tibial tubercle  Large cancellous surface  Close to deformity  Time honored  Minimal learning curve  Smaller incision Behind tibial tubercle  Stable fixation  No step off  Can displace tibial tubercle anteriorly- Macquet effect on patellofemoral arthritis  No patellar tendon scarring Below tibial tubercle • Large proximal fragment • Allows correction in multiple planes • No bone removed • Minimal incision • No retropatellar scarring • Normal Q-angle
  12. 12. Incision Positioning transverse osteotomy guide Lateral Closing Wedge Osteotomy
  13. 13. Placement of oblique osteotomy guide & performing osteotomy Application of compression clamp & L- plate Lateral Closing Wedge Osteotomy
  14. 14.  Completion of osteotomy requires disruption of proximal tibio fibular joint or removal of infero medial portion of fibular head  After osteotomy fragment are fixed with plate and screws  Passive ROM started immediately after surgery  Partial weight bearing on 2nd day  Full weight bearing after 6 weeks Lateral Closing Wedge Osteotomy
  15. 15.  Described by Hernigou  Preferred method by most surgeons nowadays.  Synthetic bone substitute may or may not be used depending on the plate design.  Tricortical illiac crest bone graft with supplemental cancellous bone graft can be used  Indicated when involved extremity is 2cm or more shorter and/or when there is an associated medial collateral ligament laxity Medial Opening Wedge Osteotomy
  16. 16. Medial Opening Wedge Osteotomy  A tourniquet is used  The skin incision is placed vertically, on the medial side of the tibia curve to the proximal and dorsal side.  The periosteum is then cut and partially stripped  K-wire is drilled under direct fluoroscopic control in an oblique manner and at an angle to the tibial axis aiming for the upper part of the fibular head. Cut is made only upto a pre determined point on the lateral tibial plateau based on pre op calculations.  When satisfactorily placed, the osteotomy is performed using an oscillating saw for the first part and finished using a chisel under fluoroscopic control.
  17. 17.  Great care is taken not to damage the lateral cortex  The tibia is manually wedged to the point of desired correction, and the osteotomy plate positioned and fixed  The osteotomy gap may or may not be filled with synthetic bone substitute/ tricortical illiac crest bone graft with supplemental cancellous bone graft  A drain is then placed subcutaneously and the wound closed Medial Opening Wedge Osteotomy
  18. 18. Lateral Closing Wedge Osteotomy  Time honored  Commonly available jig  Higher union rate  Fixation covered with soft tissue  Decreases tibial slope Medial Opening Wedge Osteotomy  Easy exposure  No fibular osteotomy required  Options of fixation wide  May increase MCL tension  Restores bone stock Advantages of Closing Vs Opening Wedge Osteotomies
  19. 19.  Described by Maquet  Determine the angle of correction  Midline vertical incision  Curved line is marked on bone with its dome just above tibial tuberosity  Multiple small drill holes made over this line Dome Osteotomy
  20. 20. Dome Osteotomy
  21. 21.  Two K-wires inserted parallel to each other on either side of osteotomy  Complete the osteotomy using osteotome  Distal fragment is rotated untill desired angle subtend by wire  Fix the osteotomy using staples or plate. Dome Osteotomy
  22. 22.  Described by Turi  Medial opening wedge osteotomy with application of dynamic external fixator  At 7th postoperative day, the fixator is distracted 0.25 mm four times a day until desired correction is obtained  It is a slow distraction at the osteotomy site and hence obviates the need of bone grafting Opening Wedge Hemicallotasis
  23. 23.  Position the fixator over the leg to check the position of the pin clamps, osteotomy site and hinge  Osteotomy site is below the tibial tuberosity  Make longitudinal incision just medial to tibial tuberosity up to 3-4 cm  Position of the fixator over the lateral tibial cortex at the level of osteotomy Opening Wedge Hemicallotasis
  24. 24. Fixator secured with K-wires Proximal fixator pin inserted Opening Wedge Hemicallotasis
  25. 25. Medial and lateral proximal fixator pins Distal fixator pin placed Opening Wedge Hemicallotasis
  26. 26. Osteotomy guide attached Series of holes drilled at osteotomy site Opening Wedge Hemicallotasis
  27. 27. Holes connected with osteotome Distraction of osteotomy Opening Wedge Hemicallotasis
  28. 28.  Passive motion is started immediately after surgery  Ambulation is begun on 2nd day, allowing weight bearing to tolerance with crutches  Seventh day after surgery, instruct the patient to distract the fixator 1 mm/day  After appropriate correction is achieved, fixator is locked  The fixator is removed after solid union is achieved Opening Wedge Hemicallotasis
  29. 29. Complications of High Tibial Osteotomy  Recurrence of deformity  Peroneal nerve palsy ( lateral closing wedge)  Knee stiffness  Patella baja  Intra-articular fracture  Non union  Infection  Osteo-necrosis of proximal fragment
  30. 30. Distal Femoral Osteotomy  Indicated in active patients younger than 65 years with valgus angulation <15 degree  Indicated when distal femoral malunion which leads to unicompartmental arthritic changes.  Medial opening wedge or lateral closing wedge.  Determine the size of wedge to be removed  Establish the angle of plate insertion  Osteotomy done and is fixed by plate and screws.
  31. 31. Knee Arthroplasty after HTO  Ideal HTO for TKR:  Opening wedge osteotomy above the tibial tubercle and a lax medial collateral ligament (MCL).  Obviates the problems:  Patella infera  Scarred patellofemoral ligament  Lifts the medial tibial condyle  Tightens MCL.  Restores almost normal alignment in relation to tibial shaft.
  32. 32. Knee Arthroplasty  Uni-compartmental (Uni-condylar) knee arthroplasty  Total knee arthroplasty
  33. 33. Unicondylar Knee Arthroplasty Indications  Classically: uni-compartmental osteoarthritis of the knee in a low- demand, elderly, thin patient (> 60 years) with competence of both the cruciate and collateral ligaments  Currently accepted patient selection criteria  Patients >60 years  <82 kg weight  Low level of activity  Minimal rest pain.  ROM - minimum arc of 90°  Flexion contracture <5°  Passively correctible angular deformity ≤ 10° varus or 15°valgus  Patello femoral change < Grade 2.  Uninvolved lateral compartment
  34. 34. Joint Preserving  ACL & PCL, lateral meniscus retained  Minimal bone resection: 2-4 mm resected  No overcorrection – load sharing Unicondylar Knee Arthroplasty
  35. 35. MIS UKA Unicondylar Knee Arthroplasty
  36. 36. Unicondylar Knee Arthroplasty
  37. 37. Erect Postop xrays Unicondylar Knee Arthroplasty
  38. 38. Post op after Uni knee • Mobilized full weight bearing on same or next day. • Range of movement exercises commenced • Patient is discharged in one or two days.
  39. 39. Benefits 1. Short hospital stay 2. Full range of motion 3. Speedy recovery and ability to walk unaided 4. Sit cross-legged on the floor 5. Reciprocal stair-climbing, brisk walking, jogging, golf 6. Joint preserving minimally-invasive operation 7. Documented 10 year success >90% 8. Future surgery facilitated, not compromised 9. Functional results are optimum and recovery speedy 10. Cosmetically acceptable for isolated medial OA Unicondylar Knee Arthroplasty
  40. 40. Candidate for TKR  Tri compartmental arthritis.  Quality of life severely affected.  Pain severely affecting the activities of daily living.  Evidence of significant radiographic changes of the knee. Total Knee Arthroplasty
  41. 41. Total Knee Arthroplasty TKR consists of following:  Cobalt chrome alloy or alternate femoral component  Cobalt chrome alloy or titanium tibial tray  UHMWPE tibial bearing component  UHMWPE patella component  CR or PS design depending on the disease and intra op findings. Both give satisfactory results.
  42. 42. The Incision  Midline or medial skin incision is with the knee in flexion.  Sub fascial space is exposed  Para patellar, mid vastus or sub vastus approaches on deeper plane.  The joint is then exposed by raising a medial fascio periosteal flap.  Deep dissection upto or beyond the MCL depending on the deformity. Total Knee Arthroplasty
  43. 43.  The leg is then extended and patella is everted  The knee is once again flexed and the anterior horn of medial and lateral menisci and anterior cruciate ligament are removed.  Posterior horns of menisci are excised after the femoral and tibial cuts are made.  Tibia is subluxated and rotated externally.  The lateral tibial plateau is exposed by partial excision of infra patellar fat pad. Total Knee Arthroplasty
  44. 44.  The medial/lateral, antero- posterior screws of the ankle clamp are fine tuned to align the proximal tibial resection guide perpendicular to the proximal tibia in the coronal and parallel to the fibula in the sagital plane. Tibial slope is provided as needed.  To check alignment to the ankle, an alignment rod is used. Total Knee Arthroplasty
  45. 45.  Bony cuts are made at first in order chosen by surgeon  The amount of tibial resection depends on which side of the joint is used for reference  If unaffected side is taken as a reference, usually 9-10 mm cut is taken which corresponds to the size of the implant  If affected side is taken as a reference, the amount of resection usually is 2 mm or less  Proximal tibial cut is taken perpendicular to its mechanical axis Total Knee Arthroplasty
  46. 46.  A drill bit is used to create an opening in the femoral canal.  The valgus alignment guide is then used and attached to the IM reamer. It then rests and is secured on the distal femoral condyle.  A distal femoral cut at 5 to 7 degree of valgus is made. Total Knee Arthroplasty
  47. 47.  The extension gap is first measured. An extension spacer corresponding to the minimal insert should be introduced comfortably. When extension space is achieved then proceed to AP and chamfer cuts.  The anterior and posterior femoral cuts determine the rotation of the femoral component and shape of the flexion gap.  A cut in 3 degrees of external rotation is made. More for valgus knees  Then flexion gap is measured.  Box cut is taken to accommodate post cam mechanism of PCL substituting design. Total Knee Arthroplasty
  48. 48.  The flexion and extension gaps must be equal. Gap balancing is done by soft tissue releases and/or bony cuts.  If the extension gap is smaller then remove more bone from distal femoral cut surface after posterior soft tissue release and osteophyte removal.  If the flexion gap is smaller then remove more bone from posterior femoral condyles.  If the flexion and extension gaps are equal, but not enough space for prosthesis, remove more bone from proximal tibia.  Medial and lateral spaces are also checked for equality. Soft tissue releases/ tightening may be used to achieve symmetry.  When flexion and extension gaps are equal and balanced, chamfer cuts can be done. Total Knee Arthroplasty
  49. 49.  Patellar resurfacing may be done on basis of intra op finding  First the patella is laterally retracted with the articular surface facing in the upward position.  Calipers are then used to determine the thicknes of the patella and the amount of bone that will be removed is calculated to leave at least 12 mm of patella behind.  The patella cutting guide is then placed ensuring the proper depth of cut.  Just sufficient bone is removed from the back side of the patella from below. Irrigation is used constantly during all bony cuts.  The patellar peg holding guide is then placed on the resected patella and the peg holes are then drilled. Total Knee Arthroplasty
  50. 50.  With the knee flexed, appropriate femoral trials are placed on the distal femur and proximal tibia.  Appropriate spacer block is placed.  Patellar insert is placed.  Alignment is checked with reference to TA tendon and 2nd toe distally and to the centre of the hip joint proximally.  Medio lateral stability is checked in extension, 30⁰, 60⁰ & 90 ⁰ flexion. In case of CR knee, POLO ( Pull out and Lift off tests are performed at 90 ⁰.  The knee is then put through a range of motions to confirm full extension and range of flexion.  Patellar tracking is checked at 90 ⁰ flexion and one towel clip at top of patella.  If everything is OK, trial components are removed after correct fit is confirmed.  The joint is then irrigated with a pulse lavage.  Real components are cemented in. Total Knee Arthroplasty
  51. 51. Total Knee Arthroplasty  The femoral impactor is used to insert the femoral implant.  The tibial base impactor is used to insert the metal tibial base.  The patellar implant is secured with bone cement and held in place using the patellar hoding clamp.  The tibial polyethylene insert is seated and locked into place on the metal tibial base.  The cement is hardened with the leg placed in full extension.  Excess cement is removed
  52. 52. Total Knee Arthroplasty  The wound is thoroughly irrigated.  Tourniquet is release and bleeding is arrested.  Closed-suction drainage according to surgeon’s preference.  The wound is closed in layers and a compressive dressing is applied.  Static quads and ankle pumps are commenced in the post op period as soon as the anesthetic has worn off.  Patient is mobilized full weight bearing on the same or next day.
  53. 53. Complications of TKA  Thromboembolism  Infection  Patello-femoral complications  Neurovascular complications  Periprosthetic fractures Total Knee Arthroplasty
  54. 54. Arthrodesis Indications • Severe disability in young & active patient whose activity level might be detrimental to the longevity of a TKR. • Infected TKR • Absent extensor mechanism • Hemophiliac knee • Failed revision • Neuropathic joint
  55. 55. Post infectious knee with deficient Extensor apparatus
  56. 56. Techniques of arthrodesis Techniques of Arthrodesis  External Fixation  Intramedullary Nailing  Plate Fixation
  57. 57. Dr.A.K.Venkatachalam is a fellow of the Royal college of surgeons of Glasgow and Post graduate of the prestigious University of liverpool. His journey in Orthopaedics began in 1984 and continues He has received training in Joint replacements, arthroscopy and regenerative medicine . He has been responsible for ushering in innovations in Joint replacements and regenerative medicine. Get in touch- E mail- drvenkat@kneeindia.com Dr.A.K.Venkatachalam MBBS, MS Orth, DNB Orth FRCS, M.Ch Orth Consultant in Orthopaedic surgery Chennai Meenakshi multi specialty hospital

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