Osteotomies
About the Knee
Lyon, France
Oct. 2011
Mark Sanders, MD FACS
The Sanders Clinic for Orthopaedic Surgery
and Sports Medicine
Houston, Texas USA
Disclosures
• None to report
“Orthopaedics”
• Derived from Greek
– orthos ("correct," "straight")
– paideion ("child")
-Nicholas Andry, Orthopaedia: or the Art of
Correcting and Preventing Deformities in Children,
1741.
Patient #1
• 28 y/o F nurse, previously athletic, c/o bilat
multidirectional patella femoral instability,
L>R
• Multiple previous surgeries left knee
– Lateral retinacular release x2
– Medialization osteotomy of tibial tubercle
– Hardware removals, fasciotomy, “cleanouts”
• Physical Examination
– Increased femoral anteversion
– Increased tibial external torsion
Pre-op
Pre-op
Pre-op
Pre-op
Computerized Tomography
Results
• Femoral Anteversion: 50° R, 35° L
(Normal 9-22° - D. Paley)
• Tibial External torsion: 34° R, 39° L
(Normal 18-28° - D. Paley)
• TT-TG: 10mm R, 7mm L (Ideal tracking:
10-15mm - H. DeJour)
Synchronous Surgical
Treatment
• Spinal/epidural anesthesia
• Two lateral skin incisions
• 20° proximal femoral external rotation
osteotomy
• 15° proximal tibial internal rotation
osteotomy
• 6mm laterally directed tibial tubercle
osteotomy
• Distal ITB based LPFLR
• Immediate unrestricted active and active
5 mos.
post-op
5 mos.
post-op
5 mos.
post-op
5 mos.
post-op
Hardware
removal5 mos.
post-op
L
Hardware
removal5 mos.
post-op
Highly Satisfied Patient
• No further medial or lateral patella
instability
• Returned to light sports
• Couldn’t wait to have Proximal Femoral
Plate out
• Scheduled for opposite side surgery over
Christmas
Take Home Messages
• Repair/Reconstruct every deformity at one
surgical sitting
• Epidural and multimodal analgesia
• Immediate active and active-assisted
motion without CPM
• Early return to function
• Young people want hardware out,
especially Proximal Femoral Plate
Patient #2
• 24 y/o M, treated for congenital deformity of the
opposite femur. Underwent femoral
epiphysiodesis at Children’s Hospital
• Currently with two previous failed allograft
ACLRs
• Physical Exam
– Normal femoral and tibial version
–
–
–
–
Genu Valgus deformity
Asymmetric Hyperextension
PCL, PLC, MCL intact
4+ Anterior instability
Pre-op
mLDFA
76.5º
mLDFA
89.6º
Pre-op
RT
aPDFA
97.7º
Note: Anterior tibial
subluxation
RT
aPPTA
75.4º
Normal Values
aPDFA : 79 –
87º
aPPTA : 77 84º
Synchronous Surgical
Treatment
• Long lateral skin incision
• Opening wedge biplanar DFO for correction
of 10° distal extension and 10° valgus
deformity, using Freeze dried bone wedges
and lateral TomoFix™
• Joint leveling biplanar HTO to decrease
adverse tibial slope, and stabilized with
medial and lateral TomoFix™
• ACLR deferred until tibial and femoral
hardware could be safely removed
6 wks
post-op
RT
mLDFA
89.5º
6 wks
post-op
RT aPDFA
84.2º
Normal Values
aPDFA : 79 - 87º
aPPTA: 77 - 84º
RT aPPTA
79.3º
Pre-op
6 wks
post-op
This is a work in progress
• Immediate active and active-assisted knee
motion in combination with multimodal and
epidural analgesia considerably decreases
Perioperative pain and morbidity
• Post-op Lachman’s decreased from 4+ to
2+
• I will show further follow-up X-rays in
Davos in 2012
Patient #3
• 34 y/o M plant worker, previously athletic,
c/o constant medial knee pain. Reportedly
needs TKA.
• 9 previous surgeries, L knee
– Lateral retinacular release
– Multiple arthroscopies and “clean outs”
– Repair of quad tendon rupture
• Physical Examination
– Normal femoral and tibial version
– Genu varum, medial joint line tenderness
Pre-op
R
Pre-op
• R mLDFA 95°
• L mLDFA 94°
Synchronous Surgical
Treatment
• Long lateral skin incision
• Opening wedge biplanar DFO for
correction of 9° distal varus deformity,
using Freeze dried bone wedge and
opposite sided medial TomoFix™ applied
medially
• Distal ITB based LPFLR
• Epidural analgesia and multimodal pain
management
• Immediate active and active assisted
8 wks
post-op
R
8 wks
post-op
mLDFA 85º
Pre-op
8 wks
post-op
This too is a work in progress,
but...
• Varus at the femur occurs more commonly
than is generally believed (Van
Heerwarden)
• Correction is best applied at the CORA
• Correction at another area can lead to joint
line obliquity
• Alignment is of primary importance nothing we do succeeds without it.
Thank You for Your Kind
Attention
• Questions?