1. Osteotomies About the Knee Lyon, France Oct. 2011 Mark Sanders, MD FACS The Sanders Clinic for Orthopaedic Surgery and Sports Medicine Houston, Texas USA

2. Disclosures None to report

3. “Orthopaedics” Derived from Greek –orthos ("correct," "straight") –paideion ("child") -Nicholas Andry, Orthopaedia: or the Art of Correcting and Preventing Deformities in Children, 1741.

4. Patient #1 28 y/o F nurse, previously athletic, c/o bilat multidirectional patella femoral instability, L > R Multiple previous surgeries left knee –Lateral retinacular release x2 –Medialization osteotomy of tibial tubercle –Hardware removals, fasciotomy, “cleanouts” Physical Examination –Increased femoral anteversion –Increased tibial external torsion –Medial patella instability

5. Pre-op

9. Computerized Tomography Results Femoral Anteversion: 50° R, 35° L (Normal 9-22° - D. Paley) Tibial External torsion: 34° R, 39° L (Normal 18-28° - D. Paley) TT-TG: 10mm R, 7mm L (Ideal tracking: 10-15mm - H. DeJour)

10. Synchronous Surgical Treatment Spinal/epidural anesthesia Two lateral skin incisions 20° proximal femoral external rotation osteotomy 15° proximal tibial internal rotation osteotomy 6mm laterally directed tibial tubercle osteotomy Distal ITB based LPFLR Immediate unrestricted active and active assisted hip, knee, and ankle motion 10 kg weight bearing with crutches for 6 wks until early union determined Bony union, off crutches at 3 months

11. 5 mos. post-op

12. 5 mos. post-op

13. 5 mos. post-op

14. 5 mos. post-op

15. L Hardware removal- 5 mos. post-op

16. Hardware removal- 5 mos. post-op

17. Highly Satisfied Patient No further medial or lateral patella instability Returned to light sports Couldn’t wait to have Proximal Femoral Plate out Scheduled for opposite side surgery over Christmas

18. Take Home Messages Repair/Reconstruct every deformity at one surgical sitting Epidural and multimodal analgesia Immediate active and active-assisted motion without CPM Early return to function Young people want hardware out, especially Proximal Femoral Plate

19. Patient #2 24 y/o M, treated for congenital deformity of the opposite femur. Underwent femoral epiphysiodesis at Children’s Hospital Currently with two previous failed allograft ACLRs Physical Exam – Normal femoral and tibial version –Genu Valgus deformity –Asymmetric Hyperextension –PCL, PLC, MCL intact –4+ Anterior instability

20. mLDFA 76.5 º mLDFA 89.6 º Pre-op

21. RT aPDFA 97.7 º RT aPPTA 75.4 º Normal Values aPDFA : 79 – 87 º aPPTA : 77 - 84 º Note: Anterior tibial subluxation Pre-op

22. Synchronous Surgical Treatment Long lateral skin incision Opening wedge biplanar DFO for correction of 10° distal extension and 10° valgus deformity, using Freeze dried bone wedges and lateral TomoFix™ Joint leveling biplanar HTO to decrease adverse tibial slope, and stabilized with medial and lateral TomoFix™ ACLR deferred until tibial and femoral hardware could be safely removed

23. RT mLDFA 89.5 º 6 wks post-op

24. RT aPDFA 84.2 º RT aPPTA 79.3 º Normal Values aPDFA : 79 - 87º aPPTA: 77 - 84 º 6 wks post-op

25. Pre-op 6 wks post-op

26. This is a work in progress Immediate active and active-assisted knee motion in combination with multimodal and epidural analgesia considerably decreases Perioperative pain and morbidity Post-op Lachman’s decreased from 4+ to 2+ I will show further follow-up X-rays in Davos in 2012

27. Patient #3 34 y/o M plant worker, previously athletic, c/o constant medial knee pain. Reportedly needs TKA. 9 previous surgeries, L knee –Lateral retinacular release –Multiple arthroscopies and “clean outs” –Repair of quad tendon rupture Physical Examination –Normal femoral and tibial version –Genu varum, medial joint line tenderness –Medial patella femoral instability

28. Pre-op R

29. R mLDFA 95° L mLDFA 94° ºº Pre-op

30. Synchronous Surgical Treatment Long lateral skin incision Opening wedge biplanar DFO for correction of 9° distal varus deformity, using Freeze dried bone wedge and opposite sided medial TomoFix™ applied medially Distal ITB based LPFLR Epidural analgesia and multimodal pain management Immediate active and active assisted unrestricted motion of hip, knee, and ankle 10 kg weight bearing with crutches for six weeks until early union determined

31. 8 wks post-op R

32. 8 wks post-op mLDFA 85 º

33. Pre-op8 wks post-op

34. This too is a work in progress, but... Varus at the femur occurs more commonly than is generally believed (Van Heerwarden) Correction is best applied at the CORA Correction at another area can lead to joint line obliquity Alignment is of primary importance - nothing we do succeeds without it.

35. Thank You for Your Kind Attention Questions?