Converting the Osteotomized Knee to a TKA: Beware! How to Get a - - PowerPoint PPT Presentation

Converting the Osteotomized Knee to a TKA: Beware! How to Get a Good Result

Michael P. Bolognesi, MD Professor of Orthopaedic Surgery Division Chief, Adult Reconstruction Duke University Medical Center

Division of Adult Reconstruction

Disclosures

• Amedica - Stock Options, Surgical Advisory Board
• Zimmer Biomet - Royalties, Consulting Payments, Resident Educational

Support, Design Surgeon, Research Support

• Total Joint Orthopedics - Stock and Stock Options, Advisory Board

Member, Resident Educational Support, Consultant Payments, Design Surgeon

• Depuy - Research Support, Resident Educational Support, Principal

Investigator

• Exactech- Research Support, Resident Educational Support
• Stryker - Resident Educational Support
• Smith and Nephew- Resident Educational Support
• SPR- Research Support
• Omega - Fellowship Support- Fellowship Director
• North American Specialty Hopsital- Advisory Board

Not a straightforward TKA you have to think a little….

TKA is reputed to be difficult following HTO, requiring management of the previous scar, extra-articular deformity, possible retained hardware, patellar height and ligament balance.

• Scars for HTO can be transverse or longitudinal on medial
• r lateral aspect of the proximal tibia (lateral most scar)
• Patellar eversion is a challenge (infrapatellar and

periosteotomy site adhesion or patellar baja)

• Consider early release of the lateral retinaculum and

patellofemoral ligament, Rectus snip, V-Y plasty of quadriceps, and tibial tubercle osteotomy (TTO)

• Be cautious about the risk of avulsion of the tibial tubercle!
• Hardware removal if it interferes with the placement of the

tibial components.

• Simultaneous versus stage HWR and conversion to TKA (4-

6 weeks?)

Surgical Approach

• Coronal or rotational deformity of the tibial plateau and a

change in the posterior slope angle can occur

• Most deformities are close to the joint line and can be

corrected with the TKA.

• Severe deformities can lead to soft tissue imbalance and

ligamentous distortion.

• For severe malunion, derotational osteotomy or medial

transfer of the tibial tuberosity can be considered

• Translational and metadiaphyseal mismatch of the tibia.

(under- sizing or medial placement of the tibial component and the use of an offset stem)

• Resect proximal tibia conservatively initially

Anatomical Deformities

• Medial and lateral imbalance is frequently observed after

“normal” bone resection (asymmetric gap)

• Have to consider if the HTO under or over corrected the

alignment when performed.

• Undercorrection- medial release is critical
• Overcorrection (valgus deformity)- more difficult to

balance the LCL and PCL

• Special consideration and focus on achieving balanced

gaps as it can be harder in these cases.

Ligament Balance

• PCL substituting often recommended
• Degenerative changes in the PCL after HTO?
• Femoral and tibial component loosening with PCL retaining

prosthesis after HTO

• KSS, stability, ROM in PCL retaining TKA inferior to PCL

substituting TKA

• Changes in slope and effect on the PCL?
• Routine patella resurfacing recommended- high risk of

anterior knee pain and high revision rate for secondary resurfacing

• Nonunion after HTO or severe varus or valgus deformity-

consider stems and increasing constraint

Prosthesis Type

So does this mean they all do worse? What does the data say?….

Systematic literature reviews, meta- analyses and large-scale registries either find no difference between primary TKA and TKA following HTO

• r else report higher complications

rates following HTO

• Han JH, et al. Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus

closed wedge osteotomy. Knee Surg Sports Traumatol Arthrosc 2016;24:2567–77.

• Badawy M, et al. The risk of revision in total knee arthroplasty is not affected by previous high tibial
• steotomy. Acta Orthop 2015;86:734–9.
• Niinimaki T, et alTotal knee arthroplasty after high tibial osteotomy: a registry-based case-control study of

1036 knees. Arch Orthop Trauma Surg 2014;134: 73–7.

• vanRaaij TM, et al. Total knee arthroplasty after high tibial osteotomy. A systematic review. BMC

Musculoskelet Disord 2009;10:88.

• Gupta H, et al. Outcomes of total knee arthroplasty following high tibial osteotomy. Indian J Orthop

2013;47:469–73.

• Haslam P, et al. Total knee arthroplasty after failed high tibial osteotomy long-term follow-up of matched
• groups. J Arthro- plasty 2007;22:245–50.
• Kazakos KJ, et al. Mid- term results of total knee arthroplasty after high tibial osteotomy. Arch Orthop

Trauma Surg 2008;128:167–73.

• Efe T, et al. TKA following high tibial osteotomy versus primary TKA– a matched pair anal- ysis. BMC

Musculoskeletal Disord 2012;11:207.

• SaragagliaD, etal. Computer-assisted total knee replacement after medial opening wedge high tibial
• steotomy: medium-term results in a series of ninety cases. Int Orthop 2016;40:35–40.

Does techique matter? Medial versus lateral….

• 188 lateral closing-wedge HTOs and 77 medial opening-

wedge HTOs

• Functional outcomes for TKA after conversion similar for

lateral closing-wedge HTO and medial opening-wedge HTO

• Survivorship at 5 years also was similar between these

two cohorts.

• A retrospective multicenter (9 centers) study- 135 TKAs following HTO (58 OW

and 77 CW) at a minimum 5 years’ follow-up.

• The only technical differences concerned hardware removal, often performed in

two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group.

• Systematic review suggests that TKA after

medial opening and lateral closing wedge HTO showed similar performance.

• Clinical and radiologic outcome including

revision rates did not statistically differ from included studies.

• More surgical technical concerns in TKA

conversion from lateral closing wedge HTO than from the medial opening wedge HTO group.

Summary

• You will have to do this operation
• Generally accepted that TKA after closed wedge HTO is

technically more difficult.

• Consider surgical approach, anatomical deformities,

ligament imbalance, and selection of prosthesis types.

• Correction of deformity, lower amount of tibial bone

resection, sufficient polyethylene insert thickness, restoration of the joint line height, and adequate ligament balancing can be helpful in overcoming the technical challenges encountered in TKA following HTO.

• Look at the old incisions
• Is the HW in the way?
• Staged removal versus simultaneous removal at time of

conversion

• The anatomy (bone and ligament) have been altered so

respect that

• It will be harder that a routine TKA for run of the mill

degenerative arthritis… schedule a little more time?

• Consider thinking during the operation….

Converison for Dummies

Thanks!

Moving forward. Climbing higher.