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

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

How I Deal with the Valgus Knee in the 33 yr old Female Soccer Player

• Research Support

– Canadian Foundation for Innovation – ISAKOS/OREF – Musculoskeletal Transplant Foundation – Canadian Institute for Health Research – Arthritis Society – Ontario Research Fund – Smith & Nephew Inc. – Arthrex Inc. – Conmed Inc. – Depuy Synthes Inc. – Eupraxia Inc. – SBM Inc.

• Editorial Board

– AJSM Social Media

• Consultant

– Smith & Nephew Inc. – Conmed Inc. – Depuy Synthes Inc. – Ferring Inc. – Ossur Inc.

Disclosures

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

Biomechanics

• Realignment Osteotomy
• Ligament Reconstruction
• Meniscus Allograft

Transplantation

Biology

• Articular

Cartilage Repair

• 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

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 Distal Femoral Varus Osteotomy

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

Lateral Opening Wedge HTO

• Mild Valgus (<50)
• Normal anatomic Lateral Distal

Femoral Articular Angle (aLDFA) (810)

• Small correction (<10mm)
• Want to correct mechanical

axis through Flexion/Extension

• Mostly isolated cartilage

wear/meniscus loss

Tibial Based Varus Osteotomy??

• 23 pts, 24 knees
• Mean correction 7.9mm
• Significant improvement from baseline

PROMs

• Satisfactory radiographic correction

Lateral Opening Wedge HTO

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

300 flexed PA weight bearing

Long leg alignment

• mLDFA = 86.70 (85-90)
• MPTA = 88.10 (85-90)
• MAA = 1.50 valgus
• MAD = 4.8mm
• Slight valgus
• NORMAL RANGE……

• Competed in

following season Snowboard Cross World Cup Series

Lateral Opening Wedge HTO

Return to Sport after Osteotomy

* Wrong number or no response after at least three attempts

Witjes, Getgood et al. 2nd place, John Joyce Award, ISAKOS 2017

Results: sports participation & impact of sports

since osteotomy (n=57) ever (n=60)

2 4 6 8 10 12 golf biking/cycling walking skiing badminton hiking snowboarding zumba/gymn… rollerblading fitness/weights icehockey basketball ball hockey soccer running football rugby fight sport ringette baseball volleyball

high impact intermediate impact low impact

Main sport ever (N=60): Highest impact: Since osteotomy:

• 95% returned to sport (RTS)
• 60% to pre-injury impact
• 14% to higher impact
• 53% high impact
• 5% (n=3) did not RTS
• All 3 had indication OA

@ 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