Role of Osteotomy in ACL and PCL Deficient Patients - PowerPoint PPT Presentation

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Role of Osteotomy in ACL and PCL Deficient Patients

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Title: Role of Osteotomy in ACL and PCL Deficient Patients


1
Role of Osteotomy in ACL and PCL Deficient
Patients
  • Satyam Patel Feb. 2007
  • mod. from Cole Beavis Nov. 2002

2
Outline
  • 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.

3
Natural 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

4
Natural 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

5
Natural 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.

6
Natural 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

7
Natural 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.

8
Principles of Tibial Osteotomy

9
Principles 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

10
Principles 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

11
Principles of Tibial Osteotomy
  • Anatomic
  • Comparison of femoral and tibial shafts
  • 5 - 7º valgus
  • Mechanical
  • Line of ground reaction force transmission
  • 0 - 1º varus

12
Principles 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

13
Principles 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

14
Principles of Tibial Osteotomy
  • Type of osteotomy
  • Extension Valgus

15
Principles 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

16
Principles 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

17
Principles 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

18
Principles 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

19
Principles 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

20
Valgus Closing Wedge
21
Valgus Closing Wedge
  • Lateral wedge resection
  • Hinge on medial cortex
  • Can resect more bone anteriorly to decrease
    tibial slope (extension type osteotomy)
  • ACL deficiency

22
Valgus 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

23
Valgus Opening Wedge
24
Valgus Opening Wedge
  • Medially based wedge
  • Multiple variations in techniques
  • Can incorporate anterior opening wedge
  • Increases tibial slope (PCL deficiency)

25
Valgus Opening Wedge
  • Advantages
  • Useful with medial bone loss or MCL laxity
  • Tensions MCL
  • Drawbacks
  • Limited compression
  • Bone graft donor site morbidity

26
Fixation of Osteotomies
  • Cast
  • Staples
  • Plate
  • Compression, buttress
  • External fixator

27
Osteotomies and ACL / PCL Deficient Knees

28
Osteotomy 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

29
Osteotomy and ACL Deficient Knees
  • Osteotomy has been used in treatment of
    instability
  • Extension type to decrease tibial slope and
    anterior tibial translation

30
Osteotomy and ACL Deficient Knees
  • Osteotomy has been used in treatment of
    instability
  • Extension type to decrease tibial slope and
    anterior tibial translation

31
Osteotomy 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

32
Osteotomy and ACL Deficient Knees
  • Primarily instability
  • Pain Malalignment - ? ACL Reconstruction
  • Pain - Malalignment ? Osteotomy and
    Reconstruction
  • Pain - Malalignment - ? ACL Reconstruction
  • Pain Malalignment ? Osteotomy and
    Reconstruction

33
Osteotomy and ACL Deficient Knees
  • Primarily pain
  • Instability Malalignment - ? ACL
    Reconstruction
  • Instability - Malalignment
    ? Osteotomy
  • Instability - Malalignment -
    ? ?Arthroscopic debridement
  • Instability Malalignment
    ? Osteotomy and Reconstruction

34
Osteotomy 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

36
Osteotomy 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

37
Osteotomy 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

39
Osteotomy 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

40
Osteotomy 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

41
Osteotomy 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

42
Osteotomy 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

43
Biomechanical 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)

44
Biomechanical 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.

45
Biomechanical 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

46
Clinical 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

47
Clinical 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

48
Osteotomy 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.

49
Osteotomy 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.

50
References
  • 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

51
Clinical 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)
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