Understanding Osteotomy: Wake Up USA! Everyone Does It, Get - - 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

Understanding Osteotomy: Wake Up USA! Everyone Does It, Get Comfortable

• 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

Bare Bone Facts

• By 2030, the demand for TJA by patients <65y is projected to

be 52% of primary THAs and 55-62% of primary or revision TKAs

• The future demand was projected to grow the fastest for the

45-54y age category for primary TKA, which was anticipated to grow from 59,077 in 2006 to 994,104 (17 times) by 2030.

Younger Patient Demand for Primary and Revision Joint Replacement: National Projections from 2010 to 2030 The Journal of Arthroplasty, Volume 24, Issue 2, Pages e34-e34

• S. Kurtz, E. Lau, K. Ong, K. Zhao, M. Kelly, K. Bozic

Knee Preservation Timeline… Osteotomy/ Joint Preservation Osteotomy UKA TKA

<55 yrs old 55 yrs old >75 yrs old Young, active Demanding Jobs Sport Active, Retired, manual work Sedentary

Treatment Strategy: Aim to stay in the green zone:

Romain Seil 2015

HTO vs. UKA

• Would you rather

revise an HTO or a UKA?

HTO vs. UKA

Swedish Registry LHSC Data

Why not UKA?

92.9% TKA 80.6% UKA

Kaplan-Meier Survival (All Revisions for Surgeries 10 years or Greater from the time of surgery) Cumulative Survival Survival Time (Years)

years since primary procedure Cumulative Percent revised

Log-rank test for equality over strata p-value < 0.001 Hazard Ratio (adjusted for age and sex; Unicompartmental for OA V Total Knee for OA = 2.02; 95% CI (1.90,2.14) p-value < 0.001

n= 45,615 n= 494,571

21.0% 7.3%

UKA TKA

15 yrs

Australian Registry: % Revised

• % UKA in Australia

– 15.1% in 2003 – 9.7% in 2007 – 5.7% in 2012 – 4.8% in 2015

32.5% (15.7) 24.6% (9.9) 16.8% (6.5) ? (3.2)

Australian Registry: Age

• < 55 yo – 32.5% rev rate

at 15 yrs

• > 75 yo – 9.3%

rev rate at 13 yrs,

TKA (12,298) & UKA (7,860)

Swedish Registry

Satisfied Dissatisfied Very Satisfied Uncertain

Distribution of Satisfaction (%)

(12,298) (7,860)

Robertsson et al, Acta Orthop Scand, 2000

IDENTICAL

Higher Revision rate for UKA is offset by greater patient satisfaction?

NO!

What are we trying to achieve?

1. Coronal plane correction

– To reduce the external knee adduction moment (varus knee) or abduction moment (valgus knee)

2. Sagittal plane correction

– Alter tibial slope to reduce tibial translation and achieve sagittal balance

Re-alignment Osteotomy

Does it work?

Reduction in knee adduction moment (KAM) in the varus knee correlates with KOOS MCID

What happens to Articular Cartilage after HTO?

Improvement in quality and volume of repair tissue

Evidence - HTO

70% 10 yr survivorship

Evidence – Varus osteotomy

HTO + cartilage repair

Coronal Alignment - Effect on Collaterals and Cruciates

What are we trying to achieve?

1. Coronal plane correction

– To reduce the external knee adduction moment (varus knee) or abduction moment (valgus knee)

2. Sagittal plane correction

– Alter tibial slope to reduce tibial translation and achieve sagittal balance

• Sagittal plane correction
• Reduce shear strain on ACL or

PCL by reducing or increasing the posterior tibial slope respectively

• Alters tibiofemoral contact

pressure

• 1mm of correction = 1o
• f slope change

Biplanar Osteotomy (correction)

• Coronal alignment

– Unicompartmental OA – Joint restoration – Ligament instability

• Sagittal alignment

– Tibial slope – Posterior/anterior wear – ACL/PCL Indications for Realignment Osteotomy

Joint Restoration Philosophy

Biomechanics

• Realignment Osteotomy
• Ligament Reconstruction
• Meniscus Allograft

Transplantation

Biology

• Articular

Cartilage Repair

• Adjuvant

Therapies

• Fluoroscopy from ipsilateral

side

• Stand on contralateral side
• MOWHTO

– Distal MCL release – Posterior Retractor – Biplane Osteotomy

• Increased surface area
• Greater rotational control
• Slope

– Maintain: Y1 = Y2 x2 – Increase: Y1 = Y2 – Decrease: Y1 < Y2 – You have to destabilize the lateral hinge

Surgical Pearls for Osteotomy

• Fluoroscopy from ipsilateral

side

• Stand on contralateral side
• MOWHTO

– Distal MCL release – Posterior Retractor – Biplane Osteotomy

• Increased surface area
• Greater rotational control
• Slope

– Maintain: Y1 = Y2 x2 – Increase: Y1 = Y2 – Decrease: Y1 < Y2 – You have to destabilize the lateral hinge

Surgical Pearls for Osteotomy

Surgical Technique

Summary

• Osteoarthritis on the rise – will effect more younger

individuals

• We are aware of the treatment gap for OA….
• Osteotomy a key component to address that gap
• Aim to keep young patients in the green/preservation

zone

• Indications remain consistent – education is the key….

Thank you!

‘Fake Knees are NOT the answer…..’