High Tibial Osteotomy and UniKnee for PostGrad Orth FRCS Course
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The document discusses various treatment options for osteoarthritis of the knee, including high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA). It provides details on the surgical techniques, prerequisites, advantages, and disadvantages of both HTO (open vs closed wedge) and UKA. Key points covered include the ideal candidates for HTO, factors for successful osteotomy, complications rates between open vs closed wedge HTO, and that UKA provides better long-term functional results compared to HTO. Non-operative treatments such as weight loss, exercise and bracing are also summarized.
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High Tibial Osteotomy and UniKnee for PostGrad Orth FRCS Course
- 1. POSTGRAD ORTH Deiary Kader OA in the ‘Young” HTO & Uni Knee Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield Hospital
- 2. POSTGRAD ORTH Deiary Kader Postgraduate Orthpaedics FRCS(Tr&Orth) Revision Course Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield
- 3. POSTGRAD ORTH Deiary Kader HTO vs Uni?? What is the outcome of HTO and Uni? What do you require for a successful osteotomy? PLAN Varus OA in the Young
- 4. POSTGRAD ORTH Deiary Kader Must Know What is the None-operative Treatment for OA?
- 5. POSTGRAD ORTH Deiary Kader OA Nonoperative treatment Strategies may include Weight loss Exercise Patient education Analgesia, (NSAIDs) Bracing Intra-articular (IA) injections. Cochrane reviews Steroids (better than placebo but not longer than 4wks HA more prolonged effect than steriods
- 6. POSTGRAD ORTH Deiary Kader Weight loss causes a significant risk reduction of knee OA in the general population The reduction was greater in severe symptomatic OA than in asymptomatic radiographic OA Meta-analysis of 47 studies involving 446000 pts
- 7. POSTGRAD ORTH Deiary Kader m,Muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in mild to moderate OA of the knee
- 8. POSTGRAD ORTH Deiary Kader A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery Population was older male veterans The prevalence of mechanical symptoms was not provided Malalignment was not reported
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- 10. POSTGRAD ORTH Deiary Kader OSTEOTOMY 10
- 11. POSTGRAD ORTH Deiary Kader Osteotomy around the knee Aims of valgus osteotomy Unload the medial compartment by slightly overcorrecting into valgus Unloading any ligament reconstruction in patients with a varus thrust To change the tibial slope in order to reduce translational forces and improve AP instability
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- 13. POSTGRAD ORTH Deiary Kader HTO for varus Malalignment
- 14. POSTGRAD ORTH Deiary Kader Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965 (Coventry, 1965).
- 15. POSTGRAD ORTH Deiary Kader OPEN Wedge HTO 1987 The open-wedge high tibial osteotomy gained recognition after the encouraging reports of (Hernigou et al., 1987). wedges of bone that were obtained from the iliac crest were inserted into the defect
- 16. POSTGRAD ORTH Deiary Kader Open W HTO
- 17. POSTGRAD ORTH Deiary Kader TOMOFIX
- 18. POSTGRAD ORTH Deiary Kader Proximal or High Tibial Osteotomy (HTO) The IDEAL candidate for HTO Age <60 years Isolated medial OA Good ROM Less than 5 FFD knee >120 flexion knee Patients should be able to use crutches and have no major varicose veins or peripheral vascular disease
- 19. POSTGRAD ORTH Deiary KaderThe International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
- 20. POSTGRAD ORTH Deiary Kader Distal Femur Osteotomy for Valgus Malalignment
- 21. POSTGRAD ORTH Deiary Kader Lateral Open W DFO
- 22. POSTGRAD ORTH Deiary Kader Distal Femur Osteotomy Valgus deformity of 12º or more needs distal femoral varus producing osteotomy to address a lateral femoral condyle deficiency and to prevent joint line obliquity and gradual lateral tibial subluxation. ≈
- 23. POSTGRAD ORTH Deiary Kader Planning Standing, long leg radiographs in neutral rotation Measure the mechanical axis (normal = 1.2o varus) Anatomical axis (60-70 valgus) Measure the degree of deformity & plan the size of wedge necessary
- 24. POSTGRAD ORTH Deiary Kader Planning 62.5% across tibial plateau from medial side Final alignment should create 10º–13 valgus. Overcorrection of 3º–5º above the 6º–7º normal valgus angle Medial tibial cortex represents the apex of the bony wedge and should be left intact
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- 27. POSTGRAD ORTH Deiary Kader Tibial bone varus angle (TBVA) constitutional tibia varus malalignment when the TBVA angle measured more than 5º Mid Tibia Epiphysis
- 28. POSTGRAD ORTH Deiary Kader ACL Rupture PCL Rupture
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- 31. POSTGRAD ORTH Deiary Kader Closed wedge HTO Surgical technique Arthroscopy Computer-aided measurement of the wedge size can be used A 10-mm wedge excision leads to 10º corrections in 57-mm- wide tibia An angular jig is more accurate
- 32. POSTGRAD ORTH Deiary Kader Closed wedge HTO Surgical technique Curved incision from the head of the fibula to 2 cm below the tibial tubercle. Peroneal nerve protected Excise the bare area of the fibula head Or proximal tibiofibula joint separated using a cob elevator A calibrated osteotomy guide must be used for the bone cut Leave 15–20 mm of tibial plateau to avoid fracture Fix with a plate or staples Rigid fixation+ early mobilisation eliminates patella ligament contracture DVT prophylaxis similar to post TKR
- 33. POSTGRAD ORTH Deiary Kader Sulzer Orthopedics, Zimmer
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- 35. POSTGRAD ORTH Deiary Kader Fibular osteotomy separation of the proximal tibiofibular joint, Contracture of the patellar tendon leading to patellar baja, leg shortening, and a high rate of other complications (Aydogdu et al., 2000; Kirgis & Albrecht, 1992; Tunggal et al., 2010) (Tables 9 and 10). Large corrections may cause marked shortening of the leg and a large offset of the tibia High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up* ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ Bone Joint Surg Am, 2000 Jan Closed wedge HTO Disadvantages
- 36. POSTGRAD ORTH Deiary Kader OPEN W HTO Surgical Techineque The MCL mobilize. Two 2.5-mm Kirschner wires mark the oblique osteotomy Starting proximal to the pes anserinus 4-5 cm distal to the joint line The wires to the tip of the fibula 10-15mm The osteotomy of the posterior two-thirds of the tibia Leave a 10-mm lateral bone bridge intact. Hinge on the lateral - not posterolateral - side of the tibia The second osteotomy begins in the anterior one-third of the tibia at an angle of 135° while leaving the tibial tuberosity intac
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- 43. POSTGRAD ORTH Deiary Kader Lateral Open Wedge Distal Femur ––single cut ––easier approach to femur ––easily adjustable correction ––supratrochlear area disrupted ––weak medial hinge point ––plate location complaints ––very unstable if hinge point fractures ––slowest bone healing role of grafts unclear
- 44. POSTGRAD ORTH Deiary Kader Methods of osteotomy Fixation Cast immobilization Staples Plate and screw External fixator Distraction osteogenesis. Correction can be adjusted after surgery. But pin tracts create a potential problem for subsequent TKA
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- 46. POSTGRAD ORTH Deiary Kader Complications Inadequate valgus correction Overcorrection – PFJ derangement Alteration in patella height Intra-articular fracture Osteonecrosis of the tibial plateau
- 47. POSTGRAD ORTH Deiary Kader Complications Vascular injuries – anterior tibial artery, popliteal artery Peroneal nerve palsy Delayed or non-union Compartment syndrome TKR more difficult Varus laxity (loose LCL)
- 48. POSTGRAD ORTH Deiary Kader Open wedge HTO Advantages Easier to achieve precise angular correction Preserves bone stock (subsequent TKR is technically easier) Makes tightening of the MCL easier Preserve the lateral side for LCL or posterolateral reconstruction if insufficient No risk to peroneal nerve Less dissection
- 49. POSTGRAD ORTH Deiary Kader Requires a bone graft (substitute, autograft, allograft) Increased incidence of non-union and delayed union Large correction may affect leg lengthening Loss of fixation and recurrence of varus deformity Worsens patella infra Open wedge HTO Disadvantages
- 50. POSTGRAD ORTH Deiary Kader OW-HTO vs CW-HTO RCT 92 pts and 6 years FU More Complications in open WHTO an more conversion to TKR in closed WHTO SEPT 2014
- 51. POSTGRAD ORTH Deiary Kader OW-HTO Delayed union/nonunion rates were 2.6%, 4.6%, and 4.5% for autograft, allograft bone, and synthetic bone substitutes, respectively Non-locking plates (n = 2,148) had a rate of delayed union/nonunion of 3.7% and a mean loss of correction over time of 0.5°. Locking plates (n = 681) had a rate of delayed union/nonunion of 2.6% and a loss of correction of 2.3°.
- 52. POSTGRAD ORTH Deiary Kader Coventry report Outcome 5-year survival of 87% 10-year survival of 66% However the 5-year survival was reduced down to 38% when valgus angulations at 1 year was less than 8º in a patient whose weight was more than 1.32 times the ideal weight.
- 53. POSTGRAD ORTH Deiary Kader Outcome Obesity and inadequate correction were negative prognostic factors. Age < 50 years to be a positive prognostic factor Joint line preservation is key to success.
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- 55. POSTGRAD ORTH Deiary Kader Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee.
- 56. POSTGRAD ORTH Deiary Kader Principles Uni Knee • Appropriate for 25% of osteoarthritic knees needing replacement • Never release the MCL • Polyethylene dislocation rate is 1/200 after medial compartment UKR (Oxford) • Polyethylene dislocation rate is 10% after lateral compartment UKR • Dislocation rate can be reduced by using a fixed bearing UKR.
- 57. POSTGRAD ORTH Deiary Kader ? What are the Absolute contraindications for doing Unicompartmental knee replacement? What are the Advantages and disadvantages?
- 58. POSTGRAD ORTH Deiary Kader Uni Knee Advantages • Retains knee kinematics • Restores function and range of movement • Rapid recovery: three times faster than after TKR • Less blood loss • Cost less than TKR (all factors considered) • Quicker operation than TKR • Quicker return to work than after TKR • High flexion lifestyle.
- 59. POSTGRAD ORTH Deiary Kader Uni Knee Advantages • Lower infection rate (halved) compared with TKR • Allows minimally invasive approach • Easier to revise than HTO • No patellar fractures or dislocations • Maximizes the longevity of total knee arthroplasty • Reduced incidence of DVT • Reduced mortality from pulmonary embolism
- 60. POSTGRAD ORTH Deiary Kader Prerequisites Intact ligaments (especially ACL and PCL) Correctable varus deformity Less than 10° FFD Flexion beyond 100° Preservation of the articular cartilage lateral compartment Clinically asymptomatic PFJ and contralateral compartment.
- 61. POSTGRAD ORTH Deiary Kader Contraindications Inflammatory arthritis Sepsis Young age High level of activity.
- 62. POSTGRAD ORTH Deiary Kader Relative contraindications ACL degeneration Chondrocalcinosis Lateral meniscectomy Osteonecrosis Combined obesity and small bone size in some women.
- 63. POSTGRAD ORTH Deiary Kader Management options for medial compartment OA • HTO suitable for high-demand, young patients • UKA (better functional results, much better 10-year survival – 98% versus 66%)
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- 65. POSTGRAD ORTH Deiary Kader THANK YOU
Editor's Notes
- Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make
- Nonoperative strategies may include patient education, exercise, weight loss, bracing, analgesia, non-steroidal antiinflammatory drugs (NSAIDs) and possibly intra-articular (IA) injections. Although many of these treatment methods are employed the evidence for their benefit is mixed.
- The mechanical theory for the increased prevalence of OA in obesity proposes that the extra force across a joint from increased body mass is the cause, however this theory is unlikely to explain the increased prevalence of OA found in the hands of those with a raised BMI [23]. Obesity is part of the diagnostic criteria for metabolic syndrome, which is linked with a chronic low-grade pro-inflammatory state [27]. This may provide a biochemical explanation for the link between obesity and OA [14]. Adipokines have been implicated as a potential mediator of this effect. Adipokines are cytokines that are predominantly released by adipose tissue into the bloodstream
- Opening wedge. The weight-bearing line is determined by measuring from the point located at 62.5% of the width of the tibial plateau to the center of the femoral head and from that point on the tibial plateau to the center of the ankle. The angle formed at the intersection of these lines (ie, α angle) represents the angle of correction. The osteotomy line (ab) is defined from medial (≈4 cm below the joint line [a]) to lateral (tip of the fibular head [b]). The line segment ab is transferred to the rays of the α angle from the vertex to obtain line segments aibi and aic. The distance bic corresponds to the opening that should be achieved medially at the osteotomy site. This distance is measured in millimeters.
- Tibial bone varus angle (TBVA) is the angle between a line from the centre of the tibial spines to a point midway the proximal tibia epiphysis, and the mechanical axis line of the
- Planning of a medial closing-wedge supracondylar osteotomy. A) The present mechanical axis is drawn from A, the center of the femoral head, to B, the centre of the ankle joint. Line B-C is of equal length as line A-B and passes the knee just medial of the medial eminence representing the desired postoperative mechanical axis. B) The hinge point of the osteotomy (D) is marked just proximal from the upper border of the lateral condyle and 0,5−1 cm within the lateral cortex. The angle of correction (α) is defined by line A-D between the present femoral head centre and the hinge point and line C-D connecting the new femoral head center position and the hinge point. C) Correction angle α is projected at the distal femur using two oblique down sloping lines of equal length converging at the hinge point. The distance measured between those 2 lines at the level of the medial cortex (arrows) represents the osteotomy wedge base length to be removed during surgery.