Conservative Surgery for Knee Conservative Surgery for Knee ArthritisArthritis

Mark S. Sanders MD FACSMark S. Sanders MD FACSSanders Clinic for Orthopaedic Sanders Clinic for Orthopaedic Surgery and Sports MedicineSurgery and Sports Medicine

Gainesville, TexasGainesville, Texas

We are indebted to Dr. Mark Coventry of the Mayo Clinic We are indebted to Dr. Mark Coventry of the Mayo Clinic who first described osteotomy for degenerative arthritis. who first described osteotomy for degenerative arthritis. The original paper published in 1965 continues to be The original paper published in 1965 continues to be clinically relevant.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 47:984-990

Incidence of Total Knee Incidence of Total Knee ReplacementReplacement

According to the NIH, approximately According to the NIH, approximately 300,000 TKR surgeries are performed 300,000 TKR surgeries are performed in the United States per year.in the United States per year.

This number is expected to increase This number is expected to increase several fold as the baby boomer several fold as the baby boomer generation ages.generation ages.

Total Knee ReplacementTotal Knee ReplacementWhy not just do it?Why not just do it?

One of the most reliable operations One of the most reliable operations in Orthopaedic Surgeryin Orthopaedic SurgeryReasonable expectation of Reasonable expectation of survivorship to 25 yearssurvivorship to 25 yearsBut life expectancy continues to But life expectancy continues to increaseincreaseIndications for TKA seem to include Indications for TKA seem to include younger and younger people each younger and younger people each yearyear

The Knee SocietyThe Knee SocietyAmerican Academy of American Academy of Orthopaedic SurgeonsOrthopaedic Surgeons

TKA patients must avoid:TKA patients must avoid:– High Impact Occupations and SportsHigh Impact Occupations and Sports– Farming, Ranching are high risk Farming, Ranching are high risk

occupationsoccupations

TKA patients may participate in:TKA patients may participate in:– Golf, Doubles Tennis, Croquet, Golf, Doubles Tennis, Croquet,

Shuffleboard, downhill skiing on Shuffleboard, downhill skiing on groomed runsgroomed runs

Is there something truly less Is there something truly less “Invasive” out there?“Invasive” out there?

In patients ≤ 60 yrs, alternatives to In patients ≤ 60 yrs, alternatives to TKA deserve considerationTKA deserve consideration

OsteotomyOsteotomy

Unicompartmental knee replacementUnicompartmental knee replacement

Arthroscopic Debridement?Arthroscopic Debridement?

Arthroscopic Debridement?Arthroscopic Debridement?IT JUST DOESN’T WORKIT JUST DOESN’T WORK

““In a controlled trial involving In a controlled trial involving patients with osteoarthritis of the patients with osteoarthritis of the knee, the outcomes after knee, the outcomes after arthroscopic lavage or arthroscopic arthroscopic lavage or arthroscopic débridement were no better than débridement were no better than those after a placebo procedure”.those after a placebo procedure”.

Moseley, RB et al., Arthroscopic Surgery for Osteoarthritis of the Moseley, RB et al., Arthroscopic Surgery for Osteoarthritis of the KneeKnee NEJMNEJM 2002 2002 359: 1169-1170 359: 1169-1170

Unicompartmental knee replacementUnicompartmental knee replacement

Good pain relief in appropriate casesGood pain relief in appropriate casesGood survivorshipGood survivorshipBut it’s still a knee replacementBut it’s still a knee replacementThe same activity restrictions applyThe same activity restrictions applyCan not be successfully installed in Can not be successfully installed in the ACL deficient kneethe ACL deficient kneeConsidered by many as the “First Considered by many as the “First arthroplasty on a young person, and arthroplasty on a young person, and the first and last on an older person.”the first and last on an older person.”

Osteotomy: The IndicationsOsteotomy: The IndicationsActive lifestyle Active lifestyle ≤ ≤ 60 yrs60 yrsSingle compartment disease Single compartment disease Opposite compartment intact or with Opposite compartment intact or with minimal changesminimal changesVarus or valgus deformityVarus or valgus deformity≤ ≤ 10° loss of full extension10° loss of full extension≥ ≥ 90° flexion90° flexion

Survivorship:Survivorship: End point considered at occurrence of TKA End point considered at occurrence of TKA

87% survivorship@5 yrs 87% survivorship@5 yrs 66% survivorship@10 yrs 66% survivorship@10 yrs Breakdown:Breakdown:– 51% survivorship@10 yrs in obese patients51% survivorship@10 yrs in obese patients– 91% survivorship@10 yrs with normal BMI91% survivorship@10 yrs with normal BMI– 94% survivorship@10 yrs with maintenance of 94% survivorship@10 yrs with maintenance of

valgus correction valgus correction

Coventry MB, Ilstrup DM, Wallrichs SL.Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy: a Proximal tibial osteotomy: a critical long-term study of eighty-seven cases. critical long-term study of eighty-seven cases. J Bone Joint Surg [Am]J Bone Joint Surg [Am] 1993;75-A:196–2011993;75-A:196–201

Types of OsteotomyTypes of OsteotomyCoventry Closing Wedge 1960sCoventry Closing Wedge 1960s

http://www.eorthopod.com/images/ContentImages/knee/knee_tibial_osteotomy/knee_tibosteo_surgery01.jpghttp://www.eorthopod.com/images/ContentImages/knee/knee_tibial_osteotomy/knee_tibosteo_surgery01.jpg

Disadvantages of Closing Wedge Disadvantages of Closing Wedge OsteotomyOsteotomy

Removes bone from metaphysisRemoves bone from metaphysis

Requires fibular osteotomyRequires fibular osteotomy

Peroneal neuropathy 15%Peroneal neuropathy 15%

Lateral tibiofemoral instability 15%Lateral tibiofemoral instability 15%

Pathologic lowering of patellaPathologic lowering of patella

Increases difficulty of later TKAIncreases difficulty of later TKA

Opening Wedge OsteotomyOpening Wedge Osteotomy1990s1990s

Noyes FR, Goebel SX, West J: Opening wedge tibial osteotomy: 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 33:378-387, 2005.The 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med 33:378-387, 2005.

Advantages of Opening WedgeAdvantages of Opening Wedge Osteotomy Osteotomy

Adds bone to tibial metaphysisAdds bone to tibial metaphysis

No lateral knee instabilityNo lateral knee instability

Rare peroneal neuropathyRare peroneal neuropathy

Later TKA no more difficult than Later TKA no more difficult than usualusual

Disadvantages of Opening Wedge Disadvantages of Opening Wedge OsteotomyOsteotomy

Requires iliac bone graftRequires iliac bone graft

Pathologic lowering of patellaPathologic lowering of patella

Poor fixation techniques required Poor fixation techniques required post op immobilizationpost op immobilization

The Biplanar OsteotomyThe 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 2003;34(Suppl 2):55-62.Image Courtesy of Synthes

AdvantagesAdvantagesof Biplanar Osteotomyof Biplanar Osteotomy

No need for iliac bone graft in nonsmokersNo need for iliac bone graft in nonsmokersStable fixation with locking TOMOFIX plate Stable fixation with locking TOMOFIX plate allows immediate ROM and partial weight allows immediate ROM and partial weight bearingbearingAllows correction of 10 degrees of fixed Allows correction of 10 degrees of fixed flexion contractureflexion contractureAnterior osteotomy can be made Anterior osteotomy can be made ascending or descending to prevent ascending or descending to prevent patella inferapatella inferaTibial slope can be adjusted to Tibial slope can be adjusted to accommodate for cruciate ligament accommodate for cruciate ligament insufficiencyinsufficiency

Biplanar OsteotomyBiplanar Osteotomy Ascending Anterior Cut Ascending Anterior Cut

 Lowers patella height Used for cases with patella alta or  Lowers patella height Used for cases with patella alta or corrections of 10 and undercorrections of 10 and under

Slide courtesy of Synthes

Ascending anterior cut

ascending anterior cut

Biplanar OsteotomyBiplanar OsteotomyDescending Anterior CutDescending Anterior Cut

Maintains preoperative patella height.Maintains preoperative patella height.Used for cases with patella infera or corrections of 10 and over to Used for cases with patella infera or corrections of 10 and over to

prevent patella inferaprevent 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

Disadvantages of Biplanar Disadvantages of Biplanar OsteotomyOsteotomy

HIGH RATE OF NONUNION IN SMOKERS

Presurgical Clinical Evaluation: Presurgical Clinical Evaluation: The HistoryThe History

Joint line painJoint line pain

Previous arthroscopic or open Previous arthroscopic or open meniscectomymeniscectomy

Development of deformityDevelopment of deformity

Lack of response to NSAIDs, Lack of response to NSAIDs, acetaminophen, bracing, shoe acetaminophen, bracing, shoe modificationsmodifications

Presurgical Clinical Evaluation:Presurgical Clinical Evaluation:Physical FindingsPhysical Findings

Joint line tendernessJoint line tenderness

Varus or valgus deformityVarus or valgus deformity

≤ ≤ 10 degrees fixed flexion10 degrees fixed flexion

Further flexion ≥ 90 degreesFurther flexion ≥ 90 degrees

Normal examination of opposite Normal examination of opposite compartmentcompartment

Varus/ValgusVarus/Valgus

I used to mix these up all the timeI used to mix these up all the time

Varus = BowleggedVarus = Bowlegged

Valgus = Knock-kneedValgus = Knock-kneed

Remember vaLgusRemember vaLgus

The L is for lateralThe L is for lateral

Some patients think the terms Some patients think the terms bowlegged or knock-kneed are bowlegged or knock-kneed are offensiveoffensive

Varus ArthritisVarus Arthritis

Valgus ArthritisValgus Arthritis

Initial ImaginingInitial ImaginingRosenberg ViewRosenberg View

Must be done weight bearingMust be done weight bearing

Bilateral Views Offer Instant Bilateral Views Offer Instant ComparisonComparison

Rosenberg ViewRosenberg View

Normal Medial Compartment joint Normal Medial Compartment joint space ≥ 4mmsspace ≥ 4mmsNormal Lateral Compartment jointNormal Lateral Compartment joint

space ≥ 5mmsspace ≥ 5mms

Rosenberg, TD, et al. The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70:1479-1483

Subsequent ImagingSubsequent ImagingMRIMRI

Normal opposite compartmentNormal opposite compartment

Bone marrow edema on ipsilateral Bone marrow edema on ipsilateral sideside

Rule out unknown conditionsRule out unknown conditions

OrthoradiogramsOrthoradiograms

Willy Sutton: “Where the money is”Willy Sutton: “Where the money is”

One image includes hip through One image includes hip through ankleankle

Calculation of angular deformityCalculation of angular deformity

Available at NTMCAvailable at NTMC

Normal Orthoradiograms from Normal Orthoradiograms from PaileyPailey

Paley, D. (2003). Paley, D. (2003). Principles of Deformity CorrectionPrinciples of Deformity Correction.. Heidelberg, Germany: Springer-VerlagHeidelberg, Germany: Springer-Verlag

THE DEFORMITY MUST BE LOCATED.THE DEFORMITY MUST BE LOCATED.THE OSTEOTOMY MUST OCCUR THE OSTEOTOMY MUST OCCUR

THROUGH THE DEFORMED BONE OR THROUGH THE DEFORMED BONE OR AN OBLIQUE JOINT LINE WILL RESULT AN OBLIQUE JOINT LINE WILL RESULT

CAUSING FAILURECAUSING FAILURE SECONDARY TO SECONDARY TO SHEAR FORCESSHEAR FORCES

Normal Proximal Tibia MPTA 85-90° Normal Proximal Tibia MPTA 85-90°

Normal Distal Femur mLDFA 85-90° Normal Distal Femur mLDFA 85-90°

Joint line congruency angle ≤2°Joint line congruency angle ≤2°

82.9°

86°

2009 Gainesville, Texas

Correction of DeformityCorrection of DeformityUndercorrection leads to dissatisfaction and Undercorrection leads to dissatisfaction and failurefailure

Overcorrection leads to dissatisfactionOvercorrection leads to dissatisfaction

Correction of varus deformity to a mechanical Correction of varus deformity to a mechanical axis of 183-185° of mechanical valgus leads to axis of 183-185° of mechanical valgus leads to a survivorship of 94% at ten yearsa survivorship of 94% at ten years

Valgus deformity should only be corrected to Valgus deformity should only be corrected to neutral or 180°neutral or 180°

Coventry MB, Ilstrup DM, Wallrichs SL.Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy: a critical long-term study of Proximal tibial osteotomy: a critical long-term study of eighty-seven cases. eighty-seven cases. J Bone Joint Surg [Am]J Bone Joint Surg [Am] 1993;75-A:196–201 1993;75-A:196–201

Correction for Varus DeformityCorrection 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 271:105-121, 1991.

2009, Gainesville, Texas2009, Gainesville, Texas2009GainesvilleTexas

Surgical PreparationSurgical Preparation

Nasal MRSA screeningNasal MRSA screening

If positive treat with mupirocin and If positive treat with mupirocin and Hibiclens showersHibiclens showers

Antibiotic prophylaxis with Antibiotic prophylaxis with Vancomycin or ClindamycinVancomycin or Clindamycin

If MRSA negative prophylaxis with If MRSA negative prophylaxis with cephalexincephalexin

AnesthesiaAnesthesia

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

TourniquetTourniquet

Abandoning the tourniquet reduces Abandoning the tourniquet reduces the incidence of thromboembolic the incidence of thromboembolic disease and post tourniquet paindisease and post tourniquet pain

EBL for tibial osteotomy typically isEBL for tibial osteotomy typically is

< 100 ccs. So what is the tourniquet < 100 ccs. So what is the tourniquet for anyway?for anyway?

Diagnostic/Surgical ArthroscopyDiagnostic/Surgical Arthroscopy

Confirms diagnosis on affected sideConfirms diagnosis on affected side

Confirms normalcy of opposite sideConfirms normalcy of opposite side

Significant abnormality of opposite Significant abnormality of opposite side contraindicates osteotomyside contraindicates osteotomy

Joint debridement can be performed Joint debridement can be performed although it may not really be although it may not really be necessarynecessary

Medial Compartment OAMedial Compartment OA

Findings in this case:Exposed tibia and femoral boneMeniscectomyPseudogout

Normal Lateral CompartmentNormal Lateral Compartment

Exposure for Exposure for Tibial OsteotomyTibial Osteotomy

Midline or oblique medial incisionMidline or oblique medial incision

Extraperiosteal dissectionExtraperiosteal dissection

Inferior retraction of anserine Inferior retraction of anserine tendonstendons

Section of superficial MCL reduces Section of superficial MCL reduces contact forces on the medial sidecontact forces on the medial side

Retractor placed posteriorly to Retractor placed posteriorly to protect neurovascular bundleprotect neurovascular bundle

Biplanar Tibial OsteotomyBiplanar Tibial Osteotomy

Oblique posterior 2/3rds of tibia at Oblique posterior 2/3rds of tibia at level of tibial tubercle from medial to level of tibial tubercle from medial to laterallateral

Osteotomy is incomplete and retains Osteotomy is incomplete and retains intact lateral one centimeter of tibiaintact lateral one centimeter of tibia

Osteotomy of anterior 1/3 of tibia Osteotomy of anterior 1/3 of tibia including tibial tubercle is made including tibial tubercle is made either ascending or descending either ascending or descending

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

Schematic of Biplanar Osteotomy Schematic of Biplanar Osteotomy

Slide courtesy of Synthes

Typical Post Op AppearanceTypical Post Op Appearancenote valgus correctionnote valgus correction

Computer NavigationComputer NavigationIs currently under study. Preliminary Is currently under study. Preliminary results indicate that accuracy of correction results indicate that accuracy of correction is improved by these methodsis improved by these methodsCurrent cost is in excess of $100,000 but Current cost is in excess of $100,000 but improvements continue to occur in the improvements continue to occur in the systemsystemHard to know when to purchaseHard to know when to purchaseWe probably will be using it within a We probably will be using it within a couple of yearscouple of years

Wang, G. et al. A fluoroscopy-based surgical navigation system for high tibial 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 osteotomy Source Technology and Health Care 2005 Volume 13 ,  Issue 6  Pages: 469 - 483  - 483  

Post Op ManagementPost Op ManagementImmediate ROM exercises in the RR. Immediate ROM exercises in the RR. Cryotherapy is utilized Cryotherapy is utilized Thromboembolic ProphylaxisThromboembolic ProphylaxisNot Necessary:Not Necessary:– CPM MachineCPM Machine– Parenteral analgesicsParenteral analgesics– Oral analgesics stronger than Class ThreeOral analgesics stronger than Class Three– Femoral or epidural blocksFemoral or epidural blocks

Discharge from hospital next morningDischarge from hospital next morning

Thromboembolic ProphylaxisThromboembolic Prophylaxis

Spinal anesthesiaSpinal anesthesia

Foot pumpsFoot pumps

TED hoseTED hose

Immediate ROM and ambulation with Immediate ROM and ambulation with partial weight bearing by next partial weight bearing by next morningmorning

ASA for ordinary risk casesASA for ordinary risk cases

Warfarin for high risk casesWarfarin for high risk cases

Bone HealingBone Healing

Primary Bone healing occurs Primary Bone healing occurs between 3 and 12 months in nearly between 3 and 12 months in nearly 100% of cases without tobacco 100% of cases without tobacco use/abuseuse/abuse

Iliac bone grafting is necessary in Iliac bone grafting is necessary in larger corrections than 13°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

Typical 12 Months Post OPTypical 12 Months Post OP

Nonunion typical of Tobacco abuseNonunion typical of Tobacco abuse

Courtesy of Alex Staubli, MD

Osteotomy is a viable treatment Osteotomy is a viable treatment optionoption

Active patients with physiological Active patients with physiological age ≤ 60age ≤ 60Unicompartmental knee arthritisUnicompartmental knee arthritisLigamentous imbalanceLigamentous imbalanceBiplanar osteotomy allows precision Biplanar osteotomy allows precision correction and when repaired with correction and when repaired with TOMOFIX is stable and tolerates TOMOFIX is stable and tolerates accelerated rehabilitation without accelerated rehabilitation without loss of correction in nonsmokersloss of correction in nonsmokers

Questions?Questions?

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

Thank You for your attentionThank You for your attention

““Information for patients” has been Information for patients” has been included in your handout.included in your handout.

Merry Christmas!Merry Christmas!

Happy New Year!Happy New Year! Mark S. Sanders, MD FACSMark S. Sanders, MD FACS