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Total Knee Arthroplasty associated with osteotomy in cases of major deformities 19 knees

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Total Knee Arthroplasty associated with osteotomy in cases of major deformities 19 knees

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    1. Total Knee Arthroplasty associated with osteotomy in cases of major deformities (19 knees) JL. LERAT, A. GODENÈCHE Service de Chirurgie Orthopédique et de Médecine du Sport Lyon – France ISAKOS JUNE 2001 MONTREUX

    2. 23 cases of major deformities > 20°

    3. 23 cases of major deformities > 20°

    4. It is possible to correct the deformity in doing TKA (sometimes with tightening ligaments of the convexity)

    5. The question is : How to correct a major extra-articular deformity (± articular deformity) by a total Knee Replacement ?

    7. After a failed osteotomy it is possible to do a TKR in the majority of the cases (except in case of severe valgus)

    12. Symposium SO.F.C.O.T - Paris - 1990

    13. Second alternative : Bone graft and thinner polyethylene plateau Drawbacks are similar and walking is delayed

    14. In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed

    15. In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed

    17. 2 possible options : 1 - Two-steps with osteotomy first, and then TKA 2 - TKA and osteotomy in a single operation In some extreme cases : Isolated TKR is impossible and associated osteotomy is needed

    18. 1 - OSTEOTOMY First and TKA later Simplicity Rapid healing of the osteotomy The results are sometimes good enough for TKA to be unnecessary or delayed 2 consecutive operations (6 to 12 months) 2 anesthesias, 2 rehabilitation tasks, DVT risk

    20. After a failed osteotomy it is possible to do a second osteotomy for a young patient

    21. First report : JL LERAT : 1991 SOF.C.O.T Annual Meeting, Paris, 1991 Symposium : “ Failed HTO” (2 cases operated on in 1990) WOLF and HUNGERFORD : 2 cases in 1991 UCHINOU : 1 case in 1996 HUNGERFORD : “14th Annual Current Concepts in Joint Replacement” in Cleveland, Dec 1997

    22. 1/ Correction of a tibial valgus deformity 1 - Femoral cuts as in usual cases 2 - Tibial cut is parallel to the condylar line 3 - Ligament balance is easy to ensure 4 - Spacer in place (or definitine implant in the case of short stem) 4 - Osteotomy (fluoroscopic control) 5 - Tibial component is put into place 6 - Fixation with 2 or 3 staples

    23. Fer… F - 73 years 13 years after first osteotomy

    24. W... F - 60 years HKA : 191° Weight-bearing: 2 months

    26. 2 : The distal femoral cut is done parallel to the tibial cut in extension 3 : Spacer and ligament balance 4 : TKA is fitted

    30. 19 TKA + Osteotomy (18 patients) Mean age : 72 years ± 6 (60 - 80) 13 females - 5 males

    31. Varus knee (22°± 9) 8 cases 2 excessive tibial varus 1 old tibial fracture 3 previous femoral osteotomy 1 old femoral fracture 1 old history of rickets Valgus knee (7°± 10) 9 cases 8 HTO, 1 excessive valgus Rotation (25°) + varus : 2 knees 2 previous HTO

    32. 17 cementless TKA, 2 cemented 14 PCL retaining prosthesis 3 two CL retaining prosthesis 2 hinged TKR Osteotomies Tibia : 13 Opened osteot. : 3 Closed osteot. :8 Rotation : 2 Femur : 6 Opened osteot. : 3 Closed osteot. : 3

    33. Operation time : 153 ± 35 mn Similar to Teeny’s (16O mn) for a major varus series Similar to Krackow’s (152 mn) for a major valgus series Blood loss : 1270 ± 570 ml (no difference between femoral and tibial osteotomies)

    34. Healing : 5 ± 4 months Complications 1 non union (graft) 1 late fusion 1 early PE plateau wear Correction loss : 3.3° ± 2.9°

    35. KRACKOW (1991) IKS K score = 87.6 Flexion = 103° MIYASAKA (1997) IKS K score = 88.7 Flexion = 101° LOTWOET (1997) IKS K score = 93.3

    36. Leg .. F - 75 years Previous HTO 6 years ago

    40. TEENY (1991) IKS K score = 89 Flexion = 98° LASKIN (1996) Flexion = 86°

    41. Lu.... 69 years Major varus deformity

    42. Varus deformity following fractures of medial and lateral tibial plateaus

    44. - First case of the series - Obesity (>100 Kg) - Recurrent varus - Wear of a too thin PE

    45. The 2 most recent cases had bone deformity + Laxity they need very constrained TKR

    46. The placement of the stem needs an osteotomy

    47. Particular case of a malunion above a TKA + Lateral laxity

    48. Particular case of a malunion above a TKA + Lateral laxity

    49. Particular case of a malunion above a TKA + Lateral laxity

    50. A single operation Joint line and ligament balance preserved

    55. 14.3° 16.4°

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