Conservative Surgery for Knee Arthritis

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Conservative Surgery for Knee Arthritis

• Mark S. Sanders MD FACS
• Sanders Clinic for Orthopaedic Surgery and Sports
  Medicine
• Gainesville, Texas

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• We are indebted to Dr. Mark Coventry of the Mayo
  Clinic who first described osteotomy for
  degenerative arthritis. The original paper
  published in 1965 continues to be clinically
  relevant.

Coventry, M. Osteotomy of the Upper Portion of
the Tibia For Degenerative Arthritis of the
knee A PRELIMINARY REPORT. J. Bone and Joint
Surgery 1965 47984-990
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Incidence of Total Knee Replacement

• According to the NIH, approximately 300,000 TKR
  surgeries are performed in the United States per
  year.
• This number is expected to increase several fold
  as the baby boomer generation ages.

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Total Knee ReplacementWhy not just do it?

• One of the most reliable operations in
  Orthopaedic Surgery
• Reasonable expectation of survivorship to 25
  years
• But life expectancy continues to increase
• Indications for TKA seem to include younger and
  younger people each year

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The Knee SocietyAmerican Academy of Orthopaedic
Surgeons

• TKA patients must avoid
• High Impact Occupations and Sports
• Farming, Ranching are high risk occupations
• TKA patients may participate in
• Golf, Doubles Tennis, Croquet, Shuffleboard,
  downhill skiing on groomed runs

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Is there something truly less Invasive out
there?

• In patients 60 yrs, alternatives to TKA deserve
  consideration
• Osteotomy
• Unicompartmental knee replacement
• Arthroscopic Debridement?

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Arthroscopic Debridement?IT JUST DOESNT WORK

• In a controlled trial involving patients with
  osteoarthritis of the knee, the outcomes after
  arthroscopic lavage or arthroscopic débridement
  were no better than those after a placebo
  procedure.
• Moseley, RB et al., Arthroscopic Surgery for
  Osteoarthritis of the Knee?. NEJM 2002 359
  1169-1170

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Unicompartmental Total Knee

• Good pain relief in appropriate cases
• Good survivorship
• But its still a knee replacement
• The same activity restrictions apply
• Can not be successfully installed in the ACL
  deficient knee
• Considered by many as the First arthroplasty on
  a young person, and the first and last on an
  older person.

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Osteotomy The Indications

• Active lifestyle
• 60 yrs
• Single compartment disease
• Opposite compartment intact or with minimal
  changes
• Varus or valgus deformity
• 10 loss of full extension
• 90 flexion

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Survivorship End point considered at occurrence
of TKA

• 87 survivorship_at_5 yrs
• 66 survivorship_at_10 yrs
• Breakdown
• 51 survivorship_at_10 yrs in obese patients
• 91 survivorship_at_10 yrs with normal BMI
• 94 survivorship_at_10 yrs with maintenance of
  valgus correction
• Coventry MB, Ilstrup DM, Wallrichs SL. Proximal
  tibial osteotomy a critical long-term study of
  eighty-seven cases. J Bone Joint Surg Am
  199375-A196201

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Types of OsteotomyCoventry Closing Wedge 1960s
http//www.eorthopod.com/images/ContentImages/knee
/knee_tibial_osteotomy/knee_tibosteo_surgery01.jpg
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Disadvantages of Closing Wedge Osteotomy

• Removes bone from metaphysis
• Requires fibular osteotomy
• Peroneal neuropathy 15
• Lateral tibiofemoral instability 15
• Pathologic lowering of patella
• Increases difficulty of later TKA

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Opening Wedge Osteotomy1990s
Noyes FR, Goebel SX, West J Opening wedge tibial
osteotomy The 3-triangle method to correct
axial alignment and tibial slope. Am J Sports Med
33378-387, 2005.)
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Advantages of Opening Wedge Osteotomy

• Adds bone to tibial metaphysis
• No lateral knee instability
• Rare peroneal neuropathy
• Later TKA no more difficult than usual

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Disadvantages of Opening Wedge Osteotomy

• Requires iliac bone graft
• Pathologic lowering of patella
• Poor fixation techniques required post op
  immobilization

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The Biplanar Osteotomy

• Staubli AE, De Simon C, Babst R, Lobenhoffer P.
  TomoFix a new LCP-concept for open wedge
  osteotomy of the medial proximal tibia early
  results in 92 cases. Injury 200334(Suppl
  2)55-62.
• Image Courtesy of Synthes

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Advantagesof Biplanar Osteotomy

• No need for iliac bone graft in nonsmokers
• Stable fixation with locking TOMOFIX plate allows
  immediate ROM and partial weight bearing
• Allows correction of 10 degrees of fixed flexion
  contracture
• Anterior osteotomy can be made ascending or
  descending to prevent patella infera
• Tibial slope can be adjusted to accommodate for
  cruciate ligament insufficiency

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Biplanar osteotomy ascending anterior cut lowers
patella height. Used for cases with patella alta
or corrections of 10 and under
Ascending anterior cu t
ascending anterior cut
Slide courtesy of Synthes
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Descending Anterior Osteotomy cut maintains
preoperative patella height. Used for cases
with patella infera or corrections of 10 and
over to prevent patella infera
Brinkman J-M, et al. Fixation stability of
opening- versus closing-wedge high tibial
osteotomy A RANDOMISED CLINICAL TRIAL USING
RADIOSTEREOMETRY J Bone Joint Surg Br, Nov 2009
91-B 1459 - 1465
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Disadvantages of Biplanar Osteotomy
HIGH RATE OF NONUNION IN SMOKERS
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Presurgical Clinical Evaluation The History

• Joint line pain
• Previous arthroscopic or open meniscectomy
• Development of deformity
• Lack of response to NSAIDS, acetaminophen,
  bracing, shoe modifications

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Presurgical Clinical EvaluationPhysical
Findings

• JOINT LINE TENDERNESS
• VARUS OR VALGUS DEFORMITY
• 10 degrees fixed flexion
• Further flexion 90 degrees
• Normal examination of opposite compartment

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Varus/Valgus

• I used to mix these up all the time
• Varus Bowlegged
• Valgus Knock-kneed
• Remember vaLgus
• The L is for lateral
• Some patients think the terms bowlegged or
  knock-kneed are offensive

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Varus Arthritis
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Valgus Arthritis
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Initial ImaginingRosenberg View
Must be done weight bearing
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Bilateral Views Offer Instant Comparison
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Rosenberg View

• Normal Medial Compartment joint space 4mms
• Normal Lateral Compartment joint
• Space 5mms
• Rosenberg, TD, et al. The Forty-Five-degree
  posteroanterior flexion weight-bearing radiograph
  of the knee. J Bone Joint Surg Am.
  1988701479-1483

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Subsequent ImagingMRI

• Normal opposite compartment
• Bone marrow edema on ipsilateral side
• Rule out unknown conditions

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Orthoradiograms

• Willy Sutton Where the money is
• One image includes hip through ankle
• Calculation of angular deformity
• Available at NTMC

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Normal Orthoradiograms from Pailey
Paley, D. (2003). Principles of Deformity
Correction. Heidelberg, Germany Springer-Verlag
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THE DEFORMITY MUST BE LOCATED OSTEOTOMY MUST
OCCUR THROUGH THE DEFORMED BONE OR AN OBLIQUE
JOINT LINE WILL CAUSE FAILURE SECONDARY TO SHEAR
FORCES

• Normal Proximal Tibia MPTA 85-90
• Normal Distal Femur mLDFA 85-90
• Joint line congruency angle 2

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2009 Gainesville, Texas
86
82.9
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Correction of Deformity

• Under correction leads to dissatisfaction and
  failure
• Over correction leads to dissatisfaction
• Correction of varus deformity to a mechanical
  axis of 183-185 of mechanical valgus leads to a
  survivorship of 94 at ten years
• Valgus deformity should only be corrected to
  neutral or 180

Coventry MB, Ilstrup DM, Wallrichs SL. Proximal
tibial osteotomy a critical long-term study of
eighty-seven cases. J Bone Joint Surg Am
199375-A196201
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Correction for Varus Deformity
DeLee and Drez's Orthopaedic Sports Medicine, 3rd
ed. Redrawn from Dugdale TW, Noyes FR, Styer D
Pre-operative planning for high tibial
osteotomy Effect of lateral tibiofemoral
separation and tibiofemoral length. Clin Orthop
271105-121, 1991.)
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2009, Gainesville, Texas
2009 Gainesville Texas
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Surgical Preparation

• Nasal MRSA screening
• If positive treat with mupirocin and Hibiclens
  showers
• Antibiotic prophylaxis with Vancomycin or
  Clindamycin
• If MRSA negative prophylaxis with cephalexin

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Anesthesia

• Spinal anesthesia reduces the incidence of
  thromboembolic disease in total joint
  replacement.

Hu, S., et al., Prevention of Venous
Thromboembolic Disease After Total Hip and Knee
Arthroplasty J. of Bone and Joint Surgery -
British Volume. 2009 91-B, Issue 7, 935-942
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Tourniquet

• Abandoning the tourniquet reduces the incidence
  of thromboembolic disease and post tourniquet
  pain
• EBL for tibial osteotomy typically is
• lt 100 ccs. So what is the tourniquet for
  anyway?

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Diagnostic/Surgical Arthroscopy

• Confirms diagnosis on affected side
• Confirms normalcy of opposite side
• Significant abnormality of opposite side
  contraindicates osteotomy
• Joint debridement can be performed although it
  may not really be necessary

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Medial Compartment OA
Findings in this case Exposed tibia and femoral
bone meniscectomy Psuedogout
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Normal Lateral Compartment
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Osteotomy Exposure

• Midline or oblique medial incision
• Extraperiosteal dissection
• Inferior retraction of anserine tendons
• Section of superficial MCL reduces contact forces
  on the medial side
• Retractor placed posteriorly to protect
  neurovascular bundle

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Biplanar Tibial Osteotomy

• Oblique posterior 2/3rds of tibia at level of
  tibial tubercle from medial to lateral
• Osteotomy is incomplete and retains intact
  lateral one centimeter of tibia
• Osteotomy of anterior 1/3 of tibia including
  tibial tubericle is made either ascending or
  descending

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Tibial Osteotomy

• Spreader chisel is carefully inserted into
  posterior osteotomy and opened to appropriate
  degree of correction under fluoroscopic control
  with plastic deformation of the lateral cortex.
• The anterior osteotomy slides maintaining bone to
  bone contact.
• TOMOFIX plate is applied

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Schematic of Biplanar Osteotomy
Slide courtesy of Synthes
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Typical Post Op Appearancenote valgus correction
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Computer Navigation

• Is currently under study. Preliminary results
  indicate that accuracy of correction is improved
  by these methods
• Current cost is in excess of 100,000 but
  improvements continue to occur in the system
• Hard to know when to purchase
• We probably will be using it within a couple of
  years
• Wang, G. et. al. A fluoroscopy-based
  surgical navigation system for high tibial
  osteotomy Source Technology and Health Care 2005
  Volume 13 ,  Issue 6  Pages 469 - 483  

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Post Op Management

• immediate ROM exercises in the RR.
• Cryotherapy is utilized
• Thromboembolic Prophylaxis
• Not Necessary
• CPM Machine
• Parental analgesics
• Oral analgesics stronger than Class Three
• Femoral or epidural blocks
• Discharge from hospital next morning

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Thromboembolic Prophylaxis

• Spinal anesthesia
• Foot pumps
• TED hose
• Immediate ROM and ambulation with partial weight
  bearing by next morning
• ASA for ordinary risk cases
• Warfarin for high risk cases

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Bone Healing

• Primary Bone healing occurs between 3 and 12
  months in nearly 100 of cases without tobacco
  use/abuse
• Iliac bone grafting is necessary in larger
  corrections than 13

Brinkman J-M, et al. Fixation stability of
opening- versus closing-wedge high tibial
osteotomy A RANDOMISED CLINICAL TRIAL USING
RADIOSTEREOMETRY J Bone Joint Surg Br, Nov 2009
91-B 1459 - 1465
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Typical 12 Months Post OP
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Nonunion typical of Tobacco abuse
Courtesy of Alex Staubli, MD
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Osteotomy is a viable treatment option

• Active patients with physiological age 60
• Unicompartmental knee arthritis
• Ligamentous imbalance
• Biplanar osteotomy allows precision correction
  and when repaired with TOMOFIX is stable and
  tolerates accelerated rehabilitation without loss
  of correction in nonsmokers

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Questions?

• If no one asks any, then the presentation was
  completely ineffective

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Thank You for your attention

• Information for patients has been included in
  your handout.
• Merry Christmas!
• Happy New Year!
• Mark S. Sanders, MD FACS