Title: Role of Osteotomy in ACL and PCL Deficient Patients
1Role of Osteotomy in ACL and PCL Deficient
Patients
- Satyam Patel Feb. 2007
- mod. from Cole Beavis Nov. 2002
2Outline
- Natural history of ACL and PCL deficient patients
- Principles of osteotomy in management of knee
instability and malalignment - Management of combined knee instability and
malalignment - Not discussed / deferred to future talk role of
osteotomies in management of collateral ligament
related instability about the knee.
3Natural History of ACL/PCL Deficient Knee
- Literature somewhat difficult to interpret
- Variety of factors influence natural history
- Meniscal tears
- Chondral damage from original injury
- Heterogeneous population (grades I-III)
- Types of conservative treatments
- Outcome measures often difficult to measure
- return to sport
- return to previous function
4Natural History of ACL Deficient Knee
- Generally agreed upon principles
- Gait altered
- quadriceps avoidance
- Repeated episodes of subluxation
- Meniscal and chondral damage
- Degenerative changes present in most patients
within 6-10 years of injury - Worst in subset of patients with meniscal injury
- Medial compartment gt lateral compartment
5Natural History of ACL Deficient Knee
- Dejour - from Fu Knee Surgery
- osteophyte and superficial destruction of
cartilage are likely to develop within 10 years
in knees with ACL rupture. Significant arthrosis
develops after longer periods (20-30 years). An
additional meniscal lesion or meniscectomy
constitutes a turning point in the evolution of
arthrosis. The meniscal factor is not the main
factor it is a contributory factor in the
evolution of arthrosis in the ACL deficient knee.
6Natural History of PCL Deficient Knee
- Commonly reported in the literature that the
natural history of isolated PCL deficiency is
benign - Controversial
- Cadaveric and clinical studies have shown high
incidence of patellofemoral joint and medial
compartment arthrosis
7Natural History of PCL Deficient Knee
- Miller, Bergfeld, Fowler, Harner, Noyes (ICL 99)
- degenerative change is probably inevitable,
and that current surgical techniques cannot
forestall it. PCL injuries may not be as benign
as we previously thought, especially with
advanced (grade 3) injuries.
8Principles of Tibial Osteotomy
9Principles of Tibial Osteotomy
- Coventry
- established high tibial osteotomy as a treatment
for unicompartmental OA - Goal of osteotomy
- to transfer joint forces from the arthritic
compartment to the more normal compartment
10Principles of Tibial Osteotomy
- Mechanical axis
- line drawn from the center of hip rotation
through the center of the knee to the center of
the ankle mortise - a normal axis is a straight line
- Anatomic axis (tibiofemoral angle)
- obtained by the intersection of the lines drawn
along the shaft of the femur and tibia - normally 5-7 degrees of valgus
11Principles of Tibial Osteotomy
- Anatomic
- Comparison of femoral and tibial shafts
- 5 - 7º valgus
- Mechanical
- Line of ground reaction force transmission
- 0 - 1º varus
12Principles of Tibial Osteotomy
- Mechanical Axis
- Location determines percentage of load carried in
each compartment - In the normal knee 60 of weight bearing is
through the medial compartment
13Principles of Tibial Osteotomy
- Type of osteotomy
- Medial compartment OA with varus deformity
- valgus-producing osteotomy
- Lateral compartment OA with valgus deformity
- varus-producing osteotomy
- Alteration in tibial slope for ligamentous
deficiency - Extension type for ACL deficient
- Flexion type for PCL deficient
14Principles of Tibial Osteotomy
- Type of osteotomy
- Extension Valgus
15Principles of Valgus Tibial Osteotomy
- Indications for valgus osteotomy
- pain unresponsive to conservative measures
- isolated medial compartment OA
- age lt 60
- no more than 10-15? of varus on WB film
- pre-op ROM gt 90
- lt15? of flexion contracture
16Principles of Valgus Tibial Osteotomy
- Contraindications
- narrowing of the lateral compartment
- lateral tibial subluxation gt 1cm
- flexion contracture gt 15 degrees
- ROM lt 90 degrees
- gt 20 degrees of correction needed
- large varus thrust
- inflammatory arthritis
- tricompartmental arthritis
- severe patellofemoral disease
17Principles of Valgus Tibial Osteotomy
- Aim for mechanical axis to pass through medial
1/3 of lateral compartment - Determine amount of correction
- Multiple recommendations for post-op valgus
anatomic alignment - Fu 5 - 13º
- Vainionppa gt 7º
- Insall 10º
- Keene 7 - 13º
- Most common reason for failure of osteotomy is
undercorrection
18Principles of Tibial Osteotomy
- Technique
- Preop plan with long leg weight bearing xrays
- Calculate size of wedge using bone width and
trigonometry - Traditionally, 1mm for 1º correction
- Only valid for a 56mm diameter metaphysis
19Principles of Tibial Osteotomy
- Level of Tibial Osteotomy
- Above the tubercle (most common)
- High healing rates
- Limited degree of correction
- Below the tubercle
- Greater range of correction
- More bone proximally for fixation
- Lower healing rates
20Valgus Closing Wedge
21Valgus Closing Wedge
- Lateral wedge resection
- Hinge on medial cortex
- Can resect more bone anteriorly to decrease
tibial slope (extension type osteotomy) - ACL deficiency
22Valgus Closing Wedge
- Benefits
- Can compress across osteotomy
- Quadriceps pull compresses osteotomy
- No bone graft harvest site
- No risk of bone graft shifting
- Inherently more stable
- Drawbacks
- Shortens quads mechanism and leg
- Infrapatellar scarring
- Can unmask MCL laxity
23Valgus Opening Wedge
24Valgus Opening Wedge
- Medially based wedge
- Multiple variations in techniques
- Can incorporate anterior opening wedge
- Increases tibial slope (PCL deficiency)
25Valgus Opening Wedge
- Advantages
- Useful with medial bone loss or MCL laxity
- Tensions MCL
- Drawbacks
- Limited compression
- Bone graft donor site morbidity
26Fixation of Osteotomies
- Cast
- Staples
- Plate
- Compression, buttress
- External fixator
27Osteotomies and ACL / PCL Deficient Knees
28Osteotomy and ACL Deficient Knees
- Valgus osteotomy described in treatment of
unicompartmental arthrosis associated with ACL
deficiency - Shift mechanical axis laterally and decrease
force through diseased medial compartment
29Osteotomy and ACL Deficient Knees
- Osteotomy has been used in treatment of
instability - Extension type to decrease tibial slope and
anterior tibial translation
30Osteotomy and ACL Deficient Knees
- Osteotomy has been used in treatment of
instability - Extension type to decrease tibial slope and
anterior tibial translation
31Osteotomy and ACL Deficient Knees
- Approach
- Patients with arthritic, ACL deficient knee and
failing conservative treatment - 3 groups of patients
- Primary symptom is instability
- Primary symptom is pain
- Both pain and instability
32Osteotomy and ACL Deficient Knees
- Primarily instability
- Pain Malalignment - ? ACL Reconstruction
- Pain - Malalignment ? Osteotomy and
Reconstruction - Pain - Malalignment - ? ACL Reconstruction
- Pain Malalignment ? Osteotomy and
Reconstruction
33Osteotomy and ACL Deficient Knees
- Primarily pain
- Instability Malalignment - ? ACL
Reconstruction - Instability - Malalignment
? Osteotomy - Instability - Malalignment -
? ?Arthroscopic debridement - Instability Malalignment
? Osteotomy and Reconstruction
34Osteotomy and ACL Deficient Knees
- Technique
- Preoperative planning aiming for 8-10 of valgus
- Initial arthroscopy
- Assess articular surfaces
- Address meniscal pathology
- High tibial osteotomy
- Lateral closing wedge for most
- Medial opening wedge for MCL laxity
- Ensure fixation does not cross region of future
tunnels
35 36Osteotomy and ACL Deficient Knees
- Technique cont
- ACL reconstruction follows osteotomy
- Staged or as part of same procedure
- Bone patellar tendon bone, hamstring and
allograft have all been reported - Increased risk of patella baja with BTB
37Osteotomy and ACL Deficient Knees
- Technique contd
- Postop combined procedure
- CPM immediately postop
- Hinge brace locked in extension x 4 weeks touch
WB - Brace unlocked and WB progressed from 4-8 weeks
- At 8 weeks postop brace discontinued and
aggressive ACL rehab program x 3-6 months - Staged
- ACL follows 6 months after osteotomy
- Osteotomy hardware removed at time of ACL
38 39Osteotomy and ACL Deficient Knees
- Outcomes
- Return to pre-injury level is rare
- Few reports of patients returning jumping,
pivoting sports - Those with severe pain should expect improvement
- 80-92 patient satisfaction
- Maximal benefit obtained in patients wishing to
return to light athletic activities - 30-78 return to sports
40Osteotomy and PCL Deficient Knees
- Few reports in literature
- Similar indications as for ACL with symptomatic
varus malalignment and unicompartmental disease - PCL deficiency ?? medial and patellofemoral
arthrosis - Must select patients carefully
- Also described as treatment of posterolateral
instability with varus thrust in absence of
arthrosis - Correct mechanical axis prior to ligament
reconstruction
41Osteotomy and PCL Deficient Knees
- Increasing tibial slope has been shown to
decrease tibial translation (sag) - Anterior opening wedge osteotomy
- Anteromedial opening wedge to address tibial
slope and varus malalignment
42Osteotomy and PCL Deficient Knees
- Increasing slope by 50 resulted in shift of
resting position of knee between 3-5mm (reduced
posterior sag) - Few reports and no long term results for this
technique - Additional studies required
43Biomechanical studies
- Am J Sports Med. 2004 Mar32(2)376-82.
- Ten cadaveric knees were studied using a robotic
testing system using three loading conditions - (1) 200 N axial compression
- (2) 134 N A-P tibial load
- (3) combined 200 N axial and 134 N A-P loads
- Tibial slope was increased from 8.8 /- 1.8 deg.
to 13.2 /- 2.1 degrees, - anterior shift of tibia relative to femur (3.6
/- 1.4 mm). - Under axial compression, the osteotomy caused a
significant anterior tibial translation up to 1.9
/- 2.5 mm (90 degrees ). - Under A-P and combined loads, no differences were
detected in A-P translation or in situ forces in
the cruciates (intact versus osteotomy)
44Biomechanical studies
- Results suggest that small increases in tibial
slope do not affect A-P translations or in situ
forces in the cruciate ligaments. - However, increasing slope causes an anterior
shift in tibial resting position that is
accentuated under axial loads. - This suggests that increasing tibial slope may be
beneficial in reducing tibial sag in a
PCL-deficient knee, whereas decreasing slope may
be protective in an ACL-deficient knee.
45Biomechanical studies
- Am J Sports Med. 2006 Jun34(6)961-7.
- 10 cadaveric knees valgus HTO anatomic double
bundle ACL reconstruction - Anterior tibial translation and internal rotation
decreased by 2mm and 2 degrees at low flexion
angles vs. ACL intact knees - In-situ forces in posterolateral graft became
56-200 higher than those in the posterolateral
bundle of the intact ACL - N.B. - may overconstrain knee and result in high
forces in posterolateral graft, predisposing to
graft failure
46Clinical studies
- J Knee Surg. 2003 Jan16(1)9-16
- 26 Patients with ACL insufficiency, symptomatic
medial OA, varus - 14/26 recreational athletes - minimum 2 year
follow-up - 12 valgus HTO alone vs. 14 valgus HTO ACLR
- No change in instability vs. grade 1 lachman
11/13 - negative pivot 12/13
- No ROM deficit same
- OA progression OA progression
- Overall 23/26 patients able to play recreational
sports - Good or excellent results seen more often in HTO
ACLR group
47Clinical studies
- Knee 2004 Dec 11(6)431-7
- 29 patients (30 knees) retrospectively reviewed
- Previous single-stage ACLR valgus HTO
- 19/30 had previous medial meniscectomy
- 2/30 major complications --gt stiffness
- 12yr f/u (6-16)
- 5/30 had progressed one arthritis grade
- 14/30 returned to intensive sports
- 11/30 played moderate sports
- Avg. difference in anterior tibial translation
(vs. Normal side) was 3mm
48Osteotomy and ACL Deficient Knees
- Summary
- Active patients with ACL deficiency and
unicompartmental arthritis may benefit from ACL
reconstruction, osteotomy or combination with
improved pain and return to recreational
activities - Radiographic ( clinical) progression of OA may
be delayed or may be unchanged.
49Osteotomy and PCL deficient knees
- Long-term data regarding the outcome of PCL
deficiency vs. PCL reconstruction vs. PCL
reconstruction osteotomy is lacking. - Short term follow-up reveals better knee scores
and less subjective sense of instability. Am J
Sports Med 199624415-426 - In the presence of varus deformity and decreased
tibial slope correcting the varus deformity and
increasing the tibial slope (e.g. anteromedial
opening wedge) decreases the amount of posterior
tibial sag. - This should theoretically decrease the amount of
quads force required to pull tibia anteriorly and
thereby decrease rate of onset of patellofemoral
arthritis. - Valgus HTO unloads medial compartment and
decreases medial OA.
50References
- Dejour et al, ACL reconstruction combined with
valgus tibial osteotomy. Clin Ortho 1994
299220-228 - DeLee JC ed. Orthopaedic Sports Medicine. Pg
1401-1441 - Fu F ed. Knee Surgery. Pg 859-876
- Larson et al, PCl reconstruction associated
extra-articular procedures. Tech Ortho 2001
16(2)148-156 - Noyes et al, High tibial osteotomy in ligament
reconstruction for varus angulated ACL deficient
knees. Am J Sports Med 2000 28(3)282-296 - ONeil and James, Valgus osteotomy with ACL
laxity. Clin Ortho 1992 278 153-9 - Vogrin et al, Biomechanics of PCL deficient knee.
Tech Ortho 2001 16(2)109-118 - Williams et al, Management of unicompartmental
arthritis in the ACL deficient knee. Am J Sports
Med 2000 28(5) 749-760
51Clinical studies
- Z Orthop Ihre Grenzgeb. 2002 Mar-Apr140(2)185-93
. - Simultaneous arthroscopic cruciate reconstruction
and closing wedge osteotomy - 4/96 - 12/00 58 patients (avg. 33 y.o.)
- 49 ACL , 7PCL, 2 ACL PCL
- Avg. 7deg correction (mean malalignment 5 deg)
- 13 patients also had osteochondral allograft
- 2 had implantable collagen meniscus
- Lysholm score (66 --gt 81 --gt 87 --gt 93)