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

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 Even in case of major deformity TKR is possible : Intra-articular deformities

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

It is possible to correct the deformity in doing TKA (sometimes with tightening ligaments of the convexity) PCL may be preserved

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

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)

In cases of overcorrected valgus Complete lateral ligament release is necessary Usual cuts for the femur. Minimal cut for the tibia: Trapezoidal space

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)

ADVANTAGES 1 operation1 operation No major difficultiesNo major difficulties Immediate weight bearingImmediate weight bearing In cases of overcorrected valgus Complete lateral ligament release is necessary

DISADVANTAGES Excessive polyethylene thickness Limb lengthening Limb lengthening Peroneal nerve tension and stretching Peroneal nerve tension and stretching (palsy : 4 % in literature) (palsy : 4 % in literature) PCL sacrifice PCL sacrifice More constrained prosthesis More constrained prosthesis Poor ligament isometricity Poor ligament isometricity Possible instability (literature) Possible instability (literature) In cases of overcorrected valgus Complete lateral ligament release is necessary

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

Second alternative : Bone graft and thinner polyethylene plateau Drawbacks are similar and walking is delayed

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

External tibial torsion is 0 degree instead of 30° on the other side Vicious rotation makes a new osteotomy necessary In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed

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

2 possible options : 2 possible options : 1 - Two-steps with osteotomy first, and then TKA 2 - TKA and osteotomy in a single operation In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed

1 - OSTEOTOMY First and TKA later 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 ADVANTAGES DISADVANTAGES This choice had been made for 67 young patients previously operated by osteotomy

it is always possible to do an iterative osteotomy particularly in a young patient

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

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 OSTEOTOMY + TKA

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

Fer… F - 73 years 13 years after first osteotomy 218° 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 : The distal femoral cut is done parallel to the tibial cut in extension 3 : Spacer and ligament balance 4 : TKA is fitted 1 : Anterior and post cuts are parallel to the tibial cut Flexion 90° 2/ Correction of a femoral deformity Extension

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

Be... M - 75 years Previous femoral ost. at 20 years TKA + ost. Graft after 4 months (non union) Healing : 7 m. 138° Fl : 115° 180°

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

19 TKA + Osteotomy (18 patients) Mean age : 72 years ± 6 ( ) 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 Material

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 (16O 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) Technical characteristics

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 RESULTS

KRACKOW ( 1991)KRACKOW ( 1991) IKS K score = 87.6IKS K score = 87.6 Flexion = 103°Flexion = 103° MIYASAKA (1997)MIYASAKA (1997) IKS K score = 88.7IKS K score = 88.7 Flexion = 101°Flexion = 101° LOTWOET (1997)LOTWOET (1997) IKS K score = 93.3IKS K score = 93.3 Comparison with the literature Comparison with the literature TKA for valgus deformities 9 overcorrected HTO TKA for valgus deformities RESULTS Follow-up = 45 ± 25 months IKS knee preop = 34 ± 11 IKS Knee post-op = 86 ± 13 Flexion = 111° ± 13 Correction : Valgus 3° ± 3

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

unipodal

Ant drawerPost drawer Standing position INNEX mobile bearing knee

TEENY (1991)TEENY (1991) IKS K score = 89IKS K score = 89 Flexion = 98°Flexion = 98° LASKIN (1996)LASKIN (1996) Flexion = 86°Flexion = 86° IKS K score = 86.4 ± 12IKS K score = 86.4 ± 12 Flexion = 111° ± 10Flexion = 111° ± 10 RESULTS 8 major varus deformities TKA for varus deformities

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

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

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

- First case of the series - Obesity (>100 Kg) - Recurrent varus - Wear of a too thin PE 1 poor result1 poor result 1 revised1 revised 2 previous tibial osteotomies with rotation in the same patient 1 particular case of malrotation

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

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

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

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

Particular case of a malunion above a TKA + Lateral laxity

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

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

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

INDICATIONS Wear + laxity DEFORMITY Extra-articular deformity + =

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

Valgus def. = 17° ± 10 ( 9 to 30°)Valgus def. = 17° ± 10 ( 9 to 30°) Varus def. = 22° ± 9 (12 to 34°)Varus def. = 22° ± 9 (12 to 34°) Wear + laxity 14.3°16.4° DEFORMITY Extra-articular deformity + = Minimum deformity for indication ?? 10° ?? INDICATIONS

- 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 Opening or closing wedge osteotomy ? INDICATIONS

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 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 Conclusions