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Why and when you should correct alignment
Ronald van Heerwaarden
Centre for Deformity Correction &
Joint Preserving Surgery
Mill, The Netherlands [email protected]
Why • Effects of malalignment • Principles of alignment correction • Effects of malalignement correction When • Why and when – joint preservation • Timing of surgery • Cases Conclusions
Why and when you should correct alignment
Osteoarthritis as a disease of mechanics
Felson 2013, Brouwer 2007, Sharma 2001, 2009, 2010, 2012, Cerejo 2002 Framingham, MOST, other studies
A frontal plane deformity more than 3° leads
to osteoarthritis and should be corrected
4 degrees of deformity: increases 3 x risk for OA Progression of OA 10 to 20 x faster with deformity present
Effects of Malalignment
F a s t e r
Malignment progression following other knee injuries
ACL rupture
I
Medial menuscus rupture
I
Cartilage damage
I
Malalignment progression
Vicious Circle of increasing joint damage
Effects of Malalignment
meniscus
cartilage
ligaments
alignment
Principles of alignment correction
Osteoarthritis as a disease of mechanics
Correction of WBL
WBL position at the knee joint
defines cartilage loading
Deformity analysis and
Planning of correction
Principles of alignment correction
Goal: re-align leg (N/unloading + retain joint line orientation
WBL position at the knee joint
defines cartilage loading Babis et al. JBJS 2002 Double level osteotomy of the knee: a method to retain joint-line obliquity.
Effects of alignment correction 5 years 10 years > 10 years
Insall 85% 66%
Yashuda 63% 18%
Berman 77% 62% 59%
Rudan 78% 70%
Matthews 50% 28%
Rininapoli 73% 46%
Ivarsson 57% 43%
Hernigou 90% 45%
Aglietti 96% 78% 57%
Levigne 69% 54%
Gstöttner 94% 80% 54%
Van Raaij 75%
Akizuki 98% 90%
Flecher 85%
Billings 85% 53%
Effects of alignment correction
HTO unloaded an osteochondral defect of the medial condyle efficiently
- peak edge loads reduced Mina, Garrett et al AJSM 2008
Effects of alignment correction
Time 0 12 months 72 months
Kröner, Berger et al, CORR 2006
Bone marrow edema completely resolves after successful valgus OT correction
Arthroscopic 2nd-look average of 2 years after HTO in 146 knees: new growth of cartilage seemed to occur in the ulcerative lesion with exposed subchondral bone Koshino et al. 2003 Knee
ACI + HTO for varus and medial femoral condyle cartilage defects significantly better survival after 6 yrs compared to without HTO.
Bode et al. 2013 Arch Orthop Trauma Surg.
76 % return to regular sports participation after mean 6.9 yrs AOTS + HTO.
Minzlaff et al. 2016 KSSTA
Effects of alignment correction
meniscus
cartilage
ligaments
alignment
“Young patients with old knees”
Why and WHEN you should correct alignment
1. What is the present status of the joint ?
When you should correct alignment
Timing of surgery for alignment correction
meniscus
cartilage
ligaments
alignment
2. What is the present status of the cartilage ?
-chondral / osteochondral / osteoarthritis
3. What is the present alignment of the leg and the joint ?
4. Staged or combined
1. Lateral meniscus tear – no suturing possible
- lateral compartment chondral/osteochondral damage
- valgus leg alignment
Candidate for alignment correction
When you should correct alignment
Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined
2. ACL rupture – post partial medial meniscectomy
- medial osteoarthritis symptomatic
- varus leg alignment
Staged HTO first – ACL reconstruction if necessary
Combined ACL-HTO
3. OCD isolated lateral femoral condyle
- meniscus and ligaments intact
- neutral leg alignment
No candidate for alignment correction / future candidate
When you should correct alignment
Timing of surgery for alignment correction joint – cartilage – alignment – staged/combined
4. Bi/tricompartmental OA
- post medial/lateral meniscectomy + ACL reconstuction
- varus leg alignment symptomatic
Neutralizing alignment correction – salvage procedure.
Why and when you should correct alignment
Conclusion: Re-alignment comes first in a patient with
cartilage damage or any other joint
damage having a malaligned leg.
Conclusion: Timing of correction whether staged or
combined depends on joint factors, grade of
cartilage damage and alignment
Knee joint
distraction
Exception
Books
Books and Courses
Basingstoke Osteotomy Masterclass Northern Course – Newcastle Hannover – Osteotomy - HKA Course National courses
ESSKA Osteotomy Committee
ESSKA approved courses on
Osteotomies around the knee
Roadmap Europe / Worldwide
Thank you for your attention
