why and when you should correct alignment · why •effects of malalignment •principles of...

Why and when you should correct alignment

Ronald van Heerwaarden

Centre for Deformity Correction &

Joint Preserving Surgery

Mill, The Netherlands r.vanheerwaarden@viasana.nl

Why • Effects of malalignment • Principles of alignment correction • Effects of malalignement correction When • Why and when – joint preservation • Timing of surgery • Cases Conclusions

Why and when you should correct alignment

Osteoarthritis as a disease of mechanics

Felson 2013, Brouwer 2007, Sharma 2001, 2009, 2010, 2012, Cerejo 2002 Framingham, MOST, other studies

A frontal plane deformity more than 3° leads

to osteoarthritis and should be corrected

4 degrees of deformity: increases 3 x risk for OA Progression of OA 10 to 20 x faster with deformity present

Effects of Malalignment

F a s t e r

Malignment progression following other knee injuries

ACL rupture

I

Medial menuscus rupture

I

Cartilage damage

I

Malalignment progression

Vicious Circle of increasing joint damage

Effects of Malalignment

meniscus

cartilage

ligaments

alignment

Principles of alignment correction

Osteoarthritis as a disease of mechanics

Correction of WBL

WBL position at the knee joint

defines cartilage loading

Deformity analysis and

Planning of correction

Principles of alignment correction

Goal: re-align leg (N/unloading + retain joint line orientation

WBL position at the knee joint

defines cartilage loading Babis et al. JBJS 2002 Double level osteotomy of the knee: a method to retain joint-line obliquity.

Effects of alignment correction 5 years 10 years > 10 years

Insall 85% 66%

Yashuda 63% 18%

Berman 77% 62% 59%

Rudan 78% 70%

Matthews 50% 28%

Rininapoli 73% 46%

Ivarsson 57% 43%

Hernigou 90% 45%

Aglietti 96% 78% 57%

Levigne 69% 54%

Gstöttner 94% 80% 54%

Van Raaij 75%

Akizuki 98% 90%

Flecher 85%

Billings 85% 53%

Effects of alignment correction

HTO unloaded an osteochondral defect of the medial condyle efficiently

- peak edge loads reduced Mina, Garrett et al AJSM 2008

Effects of alignment correction

Time 0 12 months 72 months

Kröner, Berger et al, CORR 2006

Bone marrow edema completely resolves after successful valgus OT correction

Arthroscopic 2nd-look average of 2 years after HTO in 146 knees: new growth of cartilage seemed to occur in the ulcerative lesion with exposed subchondral bone Koshino et al. 2003 Knee

ACI + HTO for varus and medial femoral condyle cartilage defects significantly better survival after 6 yrs compared to without HTO.

Bode et al. 2013 Arch Orthop Trauma Surg.

76 % return to regular sports participation after mean 6.9 yrs AOTS + HTO.

Minzlaff et al. 2016 KSSTA

Effects of alignment correction

meniscus

cartilage

ligaments

alignment

“Young patients with old knees”

Why and WHEN you should correct alignment

1. What is the present status of the joint ?

When you should correct alignment

Timing of surgery for alignment correction

meniscus

cartilage

ligaments

alignment

2. What is the present status of the cartilage ?

-chondral / osteochondral / osteoarthritis

3. What is the present alignment of the leg and the joint ?

4. Staged or combined

1. Lateral meniscus tear – no suturing possible

- lateral compartment chondral/osteochondral damage

- valgus leg alignment

Candidate for alignment correction

When you should correct alignment

Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined

2. ACL rupture – post partial medial meniscectomy

- medial osteoarthritis symptomatic

- varus leg alignment

Staged HTO first – ACL reconstruction if necessary

Combined ACL-HTO

3. OCD isolated lateral femoral condyle

- meniscus and ligaments intact

- neutral leg alignment

No candidate for alignment correction / future candidate

When you should correct alignment

Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined

4. Bi/tricompartmental OA

- post medial/lateral meniscectomy + ACL reconstuction

- varus leg alignment symptomatic

Neutralizing alignment correction – salvage procedure.

Why and when you should correct alignment

Conclusion: Re-alignment comes first in a patient with

cartilage damage or any other joint

damage having a malaligned leg.

Conclusion: Timing of correction whether staged or

combined depends on joint factors, grade of

cartilage damage and alignment

Knee joint

distraction

Exception

Books

Books and Courses

Basingstoke Osteotomy Masterclass Northern Course – Newcastle Hannover – Osteotomy - HKA Course National courses

ESSKA Osteotomy Committee

ESSKA approved courses on

Osteotomies around the knee

Roadmap Europe / Worldwide

Thank you for your attention