1. Realignment Osteotomies of the Knee
Bill Wiley
ORV
April 17, 2003

2. Evaluation Overall alignment Range of Motion Knee Stability
Assessment of Leg Length

3. Indications Unicompartment Osteoarthritis Under 60 yoa Good ROM
No Flexion Contracture
Not Overweight
Unloading for Meniscal/Chondral Grafting
Relative for ACL or PLC deficient in Varus

4. Radiographs Full Length weight bearing AP 30 degree PA flex Lateral
Sunrise

5. Classification of Varus Knees
Noyes AJSM 2000
Primary Varus – tibiofemoral alignment due to loss of meniscal and articular cartilage (Bony)
Double Varus – bony and separation of the lateral tibiofemoral compartment due to soft tissues stretching out
Triple Varus – bony, soft tissue stretching, and chronic abnormalities resulting in recurvatum and external tibial rotation

6. Other Options to Consider
UKA
TKA

7. Conservative Measures
Shoe wedges
Unloader Braces

8. Templating
Anatomic Axis – in line with the shaft of the femur and tibia (avg of 5 to 6 degrees valgus)
Mechanical Axis – center of hip to center of ankle (normal is slightly in medial compartment)
Mechanical Axis of Femur (MAF) – CH to CK
Mechanical Axis of Tibia (MAT) – CK to CA
Mechanical Axis Angle (MAA)– angle btwn MAF and MAT (avg person is minus 1 degree, ie 1 degree varus, aka HKA angle)

10. Mechanical Axis

11. Anatomical Axis

12. Considerations for Varus Knee
Proximal Tibia
Closing Lateral Wedge
Opening Medial Wedge
With Plate
With External Fixator

13. Considerations for Valgus Knee
Distal Femur (for deformities > 10 deg)
Closing Medial Wedge
Done from medial side
Done from lateral side (Miniaci 1990)
Opening Lateral Wedge
Proximal Tibia (for deformities < 10 deg)

14. Hardware Options Opening Wedge Tibia Plates Arthrex Puddu Plate
EBI VS Plate (reported to be 3x’s stronger in resisted bending than Puddu and screw heads sit into plate with lower profile)

16. 15 degrees and higher have 3 holes on either side
EBI VS Plate
15 degrees and higher have 3 holes on either side

19. Hardware Options Lateral Closing Wedge Tibia Plates
Intermedics (Aaron Hoffman)
Depuy Chandler
Zimmer NexGen Osteotomy system (Noyes)

20. Intermedics

22. Depuy Chandler

23. Hardware Options Distal Femur Plates Blade Plate
95 Degree Condylar Plates (Richards, Synthes)

24. Issues with Varus Knee Closing Lateral Wedge Disadvantages
More extensive dissection
Disruption of tibiofibular joint or need to osteotomize the fibula
Shortens the leg
Patella infera due to patellar tendon contracture (however this is less with rigid fixation and early mobilization – Closkey CORR 2001)

25. Releasing the tether effect of fibula (Bauer JBJS(A) 1969)
Shaft Osteotomy
Excision of head
Separation of joint

26. Risk of damage to the peroneal nerve (Kirgis JBJS (A) 1992)

27. Issues with Varus Knee Opening Medial Wedge Disadvantages
Need for bone graft (ICBG or Allograft)
Slower Wt. Bearing
Patellar Infera due to raising of joint line (Wright AJKS 2001)

28. Issues with Valgus Knee
Usually a wear pattern in flexion on lateral femoral condyle
A. A straight closing medial wedge femoral osteotomy minimally addresses this issue
B. A slight IR on the distal femur would help to unload this compartment
- However this increases the lateral
compartment pressure in PF joint

29. Issues with Valgus Knee
Usually a wear pattern in flexion on lateral femoral condyle (cont.)
C. Varus Tibial Osteotomy – maintains varus alignment in both flex/extension
- However this creates an oblique joint
line

30. Issues with Valgus Knee
Plates do not sit well on the medial side
A. Do not make a complete cut on the distal femur
B. Put a plate on the lateral side using a closing medial wedge from lateral
- this can be difficult but the plate sits
down better
C. Do an opening wedge from lateral
- this requires bone graft

31. Issues with Valgus Knee
The medial plate translates the distal femur lateral
A. Place the plate lateral
B. Do not complete the distal femur cut
A medial plate has higher incidence of nonunion and plate breakage
- Place the plate lateral on the tension
side (Miniaci AJKS 1990)

32. Medial Plate
Lateral Plate

36. Degree of Correction Distal Femoral Osteotomy for Valgus deformity
No need for hypercorrection as in varus knee
Correct to 0 Degrees Tibiofemoral Angle (McDermott JBJS(A) 1988) or to Mechanical Axis at 50% tibial joint line

37. Degree of Correction High Tibial Osteotomy for Varus Knee
Coventry JBJS(A) 1985 – recommends correcting to 8 degrees of anatomic valgus based on a regression analysis of his cases
Dugdale and Noyes CORR 1992 – recommend using a WBL through a point 62 – 66% of tibial width in the lateral compartment.

38. Degree of Correction
High Tibial Osteotomy for ACL Deficient Knee or PLC Deficient Knee
Noyes AJSM 2000
If knee is in varus and the cartilage surfaces are relatively well preserved then the restoration should be to a neutral position w/o overcorrection (ie 50% WBL)

39. General Rule of Thumb
The height of tibial wedge is based on 1 degree of angular correction is equal to 1 mm
This is true when the width of the tibial flare is 56mm (but in both M/F under correction would occur w/this formula)
Avg male it is 80 mm
Avg woman it is 70 mm

41. Wt. Bearing Line (WBL) Method
Determine Tibial Width (TW)
Draw the Mechanical Axis (CFH to CA)
Mark the point on the 66% point on the knee joint line
Draw lines from CFH and CA to the 66% point
The angle from the two lines give the angle of correction needed

42. Mechanical Axis

44. Wt. Bearing Line (WBL) Method
Confirmation at surgery
Using Fluoroscopy use either an alignment rod or bovie cord placed at CFH and CA
Confirm that the crossing point at the knee achieves the desired correction

50. Opening Medial Tibial Wedge
Hernigou JBJS(A) 1987
93 knees w/11.5 yr avg F/U
90% G/E result at 5 yrs
45% G/E result at 10 yrs (42 knees)
Deterioration occurred avg 7 yrs
Best results w/no deterioration in the 20 knees w/7 or more degrees anatomic valgus correction

51. Closing Lateral Tibial Wedge
Coventry JBJS(A) 1993
87 knees w/10 yr avg F/U
Used staple fixation , immobilized and protected WB for 5 wks
Endpoint of TKA or mod/severe pain
87% survival at 5 yrs
66% survivial at 10yrs
94% survival at 10 yrs when 8 or more degrees of anatomic valgus and w/in 1.17% of IBW

52. TKA after Osteotomy Haddad J Arth 2000
50 consecutive TKA p HTO compared to 50 age matched primary TKA (IB II, Kinemax, PFC)
Interval from HTO to TKA avg 7.3 yrs (2-12)
HTO TKA avg 23 minutes longer surgery (p<0.05)
Higher patellar subluxation in HTO grp (p<.05)
No difference in Revision Rate, KSS or HSS scores at avg F/U of 6.2 yrs

53. TKA after Osteotomy Meding JBJS(A) 2000
39 consecutive Bilateral TKA’s in which one side had previous HTO an avg 8.7 yrs earlier
Avg age at surgery 67 yrs
Avg F/U 7 yrs
KSS and Function scores not significantly different
Conclusions: No adverse effect from HTO

54. HTO vs. UKA Stukenborg-Colsman The Knee 2001 (Germany)
Prospective Randomized controlled study
HTO: 32 pts, avg age 67 at time of surgery
Lateral closing wedge, 1/3 tubular 5 hole plate
UKA: 28 pts, avg age 67 at time of surgery
Tubingen pattern sliding UKA (Aesculap)
KSS (Knee score, Fxn Score), Survival

55. HTO vs. UKA (cont.) Stukenborg-Colsman The Knee 2001 (Germany)
Results at 7.5 yrs KS FS
Survival
HTO 74 71
60%
UKA 76 59
77%
No statistically significant differences

56. HTO w/Instability Badhe KSSTA 2002
Mixed group of patients with mixed treatment methods makes this a difficult paper to draw conclusions
14 patients avg 2.8 yrs F/U
5 patients with “Double Varus” – Varus & ACL deficient
Treated with Closing lateral wedge HTO
ACL reconstruction w/BTB

57. HTO w/Instability Badhe KSSTA 2002 14 patients
9 patients with “Triple Varus”- PLC, PCL, Varus
6 treated with ligament reconstruction
4 closing wedge HTO
2 opening wedge HTO
3 treated w/HTO only
1 closing
2 opening

58. HTO w/Instability Badhe KSSTA 2002
Results (Cincinnati Knee Rating System)
Preop
Postop
Mean 53 74
DV-CW/ACL (5 pts) 55 80
TV-CW/LR (4 pts) 49 65
TV-OW/LR (2 pts) 77
TV-HTO (3 pts) 57 76

59. HTO w/Instability Badhe KSSTA 2002 Results Radiographic Alignment
Preop 5 degrees varus
Postop 6 degrees valgus