Complications with OW HTO: 3 Common Mistakes & How I Avoid Them - PowerPoint PPT Presentation

Complications with OW HTO: 3 Common Mistakes & How I Avoid Them Anil Ranawat, MD Hospital for Special Surgery New York, NY

HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. ANIL RANAWAT, MD Disclosure: I DO have a financial relationship with Smith and Nephew, Stryker Mako, Conformis, Elesevier and Arthrex

Renaissance HTO is experiencing a rebirth akin to the cultural movement beginning in Italy in the late Middle Age encompassing a revival of classical principles and modern ideas - Philipp Lobenhoffer, Chairman Knee Expert AO Group

Why I Love OW Osteotomy Preserves cruciates • Concomitant – collateral or • cartilage procedures Aid ACL and PCL def. • No activity restriction • Can delay need for • arthroplasty Arthroplasty is Not always • best option!

What is bad about Osteotomy  Limited Indications  Under/Over correction  Intra-articular Fractures  Patella Baja/anterior knee pain  Nonunion, fixation failure  Immobilization  Conversion to TKA 5 Complications with HTO: 3 Common Mistakes & How I Avoid Them

Outline: 3 Common Mistakes 1. Indications / Pre-operating Planning 2. Surgical Technique – Correction/Slope – Nonunion/Delayed Union 3. Post-operative Care 6 Complications with HTO: 3 Common Mistakes & How I Avoid Them

1. Indications / Pre-operative Planning  Biggest mistake : amount and location of VARUS  Assess amount of varus  >10º not all on tibia  Location of varus  > 20% of varus on femur  Ideal Patient for isolated OW  <87º of MPT Angle (CORA) and under <10º deformity 7 Complications with HTO: 3 Common Mistakes & How I Avoid Them

Too much deformity (>10º not all on tibia) Goal of all Osteotomy = Joint line should be parallel to the floor 8 Complications with HTO: 3 Common Mistakes & How I Avoid Them

Ideal deformity (<10º - all on tibia) Goal of all Osteotomy = Joint line should be parallel to the floor 9 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Surgical technique  Biggest mistake #1 : BAD exposure AND coronal and sagittal correction is based on wedge height in 3 planes  Slope neutral 1:2 ratio (ant-post)  Slope reducing 1:3 ratio  If wedge gap opens too quick – check for fracture into joint or lateral hinge 10 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Correct Exposure 11 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Graduated Osteotomes 12 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Understand your gap 13 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. If Pin placement is off? Too Flat and Distal Too Oblique and Proximal Lateral hinge violation Intra-articular Fracture   No subluxation, but Minimal step-off, ORIF, increased BMI then recut or accept 14 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Surgical technique  Biggest mistake #2 : delayed / nonunion  Use rigid fixation  AO technique  Over – correct, then compress = tension band technique  Use allograft/BMAC  Progressive Weight-bearing 15 Complications with HTO: 3 Common Mistakes & How I Avoid Them

2. Over-correct, then Compression plating Goal of all OW Osteotomy = COMPRESSION AT OSTEOTOMY SITE 16 Complications with HTO: 3 Common Mistakes & How I Avoid Them

3. Post-operative Care  Biggest mistake : inappropriate WB and PT  Early WBAT has shown increased bone healing  CPM all patients minimize baja = better func.  Medication: Ca/Vit D for all, ? Bone stimulator, DVT prophylaxis 17 Complications with HTO: 3 Common Mistakes & How I Avoid Them

4. Conclusion 3 common mistakes with OW HTO 1. Inadequate templating  Look for CORA 2. Improper Surgical technique  Understand EXPSOURE, gap height, pin placement and compression technique 3. Bad Post-operative Protocol  <Aggressive WB, CPM and meds 18 Complications with HTO: 3 Common Mistakes & How I Avoid Them

Why I love OW HTO? • Biomechanically sound • Maintains high function • Versatile / Durable • Bone Preserving • Reproducible technique with less complications with improved fixation Should be a tool in armentarium of all knee surgeons!

Thank You!