How I Deal with the Valgus Knee in the 33 yr old Female Soccer - PowerPoint PPT Presentation

How I Deal with the Valgus Knee in the 33 yr old Female Soccer Player Dr Alan Getgood MD MPhil FRCS(Tr&Orth) DipSEM Assistant Professor Complex Knee and Sport Medicine Orthopaedic Sport Medicine Fellowship Director The Fowler Kennedy Sport Medicine Clinic University of Western Ontario London, Ontario Canada

Disclosures • Research Support • Editorial Board – Canadian Foundation for – AJSM Social Media Innovation – ISAKOS/OREF – Musculoskeletal Transplant Foundation • Consultant – Canadian Institute for Health – Smith & Nephew Inc. Research – Arthritis Society – Conmed Inc. – Ontario Research Fund – Depuy Synthes Inc. – Smith & Nephew Inc. – Arthrex Inc. – Ferring Inc. – Conmed Inc. – Ossur Inc. – Depuy Synthes Inc. – Eupraxia Inc. – SBM Inc.

Cause of Valgus Alignment • Constitutional – Most often femoral • Asymmetrical boney morphology – Growth arrest – Fracture malunion • Articular cartilage/lateral meniscus loss – OA – Traumatic

Presenting Symptoms/Indications • Lateral compartment pain • Complex pathology – Instability – Meniscus loss – Articular cartilage loss • Patella instability

The Complex Knee - Joint Restoration Philosophy • Realignment Osteotomy • Ligament Reconstruction Biomechanics • Meniscus Allograft Transplantation • Articular Cartilage Repair Biology • Adjuvant Therapies

Decision making…… 1. Type of pathology 2. Site of pathology 3. Measure angles – long leg alignment 4. Where is the deformity?

Decision making…… 1. Type of pathology 2. Site of pathology 3. Measure angles – long leg alignment 4. Where is the deformity? 5. How to correct it

Decision making…… 1. Type of pathology 2. Site of pathology 3. Measure angles – long leg alignment 4. Where is the deformity? 5. How to correct it 6. By how much

Distal Femoral Varus Osteotomy Lateral Opening • Easy approach • One cut • Able to titrate correction • Stable locking implants • BUT – Hardware issues with ITB – Plate removal – Loss of correction?....

Distal Femoral Varus Osteotomy Medial Closing • Soft tissue coverage over plate • Very stable fixation • Early ROM and WB • BUT – Approach can be challenging if large VMO – Less able to dial in correction

Evidence – Varus osteotomy • 64-82% survival @ 10 yrs • 45% @ 15 yrs • Significantly improved knee function (HSS scores) • Removal of hardware common

SR • 31 yr old soccer player • Lateral sided left knee pain • Previous subtotal lateral meniscectomy • Tender lateral joint line • Crepitus on pivot • No other instability

• Valgus alignment

Intra and post op films

Tibial Based Varus Osteotomy?? Lateral Opening Wedge HTO Mild Valgus (<5 0 ) • Normal anatomic Lateral Distal • Femoral Articular Angle (aLDFA) (81 0 ) Small correction (<10mm) • Want to correct mechanical • axis through Flexion/Extension Mostly isolated cartilage • wear/meniscus loss

Lateral Opening Wedge HTO • 23 pts, 24 knees • Mean correction 7.9mm • Significant improvement from baseline PROMs • Satisfactory radiographic correction

32 yr old Snowboard Cross Athlete • Lateral Compartment pain right knee when boarding – FLEXED POSITION • Stable knees • Bare bone lateral compartment degeneration • Deficient lateral meniscus

AP weight bearing

30 0 flexed PA weight bearing

Long leg alignment • mLDFA = 86.7 0 (85-90) • MPTA = 88.1 0 (85-90) • MAA = 1.5 0 valgus • MAD = 4.8mm • Slight valgus • NORMAL RANGE……

Lateral Opening Wedge HTO • Competed in following season Snowboard Cross World Cup Series

Return to Sport after Osteotomy * Wrong number or no response after at least three attempts Witjes, Getgood et al. 2 nd place, John Joyce Award, ISAKOS 2017

Results: sports participation & impact of sports Main sport ever (N=60): Highest impact: since osteotomy (n=57) ever (n=60) volleyball baseball ringette fight sport rugby football running soccer ball hockey Since osteotomy: basketball icehockey -95% returned to sport (RTS) fitness/weights rollerblading  60% to pre-injury impact zumba/gymn… snowboarding  14% to higher impact hiking badminton  53% high impact skiing walking -5% (n=3) did not RTS biking/cycling golf  All 3 had indication OA 0 2 4 6 8 10 12 high impact intermediate impact low impact @ mean 5 yrs level reduces to 80%

Summary • Address the pathology with an appropriate procedure • Femoral osteotomies are ‘efficient’ in extension but not in flexion • Tibial osteotomies are ‘efficient’ throughout the flexion range • Varus tibial osteotomy No more than 10 ° post-op obliquity • • Good option for return to sport

Thank you