Çankaya ortopedi · gelber pe. partial meniscus substitution with a polyurethane scaffold does not...
TRANSCRIPT
Dr. N. Reha Tandoğan
HTO combined with other procedures
Prof. N. Reha Tandogan, M.D
Ortoklinik / Çankaya Orthopaedics, Ankara
Dr. Asım Kayaalp Dr. Mümtaz AlpaslanDr. Mahmut Kış Dr. Kürşat Teker Dr. Altuğ Tanrıöver Dr. Şenol BekmezDr. Metin Polat Dr. Gürkan ErkulaDr. Mazhar Tokgözoğlu Dr. Bülent AtillaDr. Muharrem Yazıcı Phys. İpek İkizÇan
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Dr. N. Reha Tandoğan
Topics
HTO + ligament reconstruction
HTO + chondral resurfacing
HTO + Meniscal root repair
HTO + meniscal implants/allografts
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HTO + ACL RECONSTRUCTION
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Primary varus
Double varus
Triple varus Noyes FR. Am J Sports Med 2000
Chronic ACL insufficiency + Varus alignment
Elongation of lateral structures
Medial cartilage loss
Progressive varus + Lateral laxity
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Primary varus
Constitional tibio-femoral varus alignment
Medial meniscal tear/loss
Posteromedial cartilage damage
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Double Varus
1. Varus alignment
Proggresive medial joint narrowing
2. Lateral tibio-femoral opening
LCL laxity
More than 5 mm laxity on stressradiographs
Varus thrust +Lateral condylar lift-off
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Triple Varus
1. Varus alignment
2. Lateral tibio-femoral opening
3. Posterolateral laxity
Increased external rotation & hyperextension
Varus recurvatum deformityÇanka
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Decision making
Pain + Instability
Simultaneous/staged ACLR + HTO
Pain prominent but no instability
HTO only + Tibial slope correction
Treat additional intra-articular pathology
Cartilage regeneration
Meniscus implant/transplantÇanka
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Combined procedures
Primary & double varus
Simultaneous ACL reconstruction + HTO
Lateral surgery usually unnecessary
Triple varus
Staged Surgery : 1st HTO
ACLR + Lateral/posterolateral reconstruction at 6 months during implant removal
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How to decide for lateral surgery ?
ER-Recurvatum test (+)
Dial test (+)
10 mm(+) lateral opening in stress X-rays
12 mm(+) lateral opening at 30 degreesknee flexion during arthroscopy
Requires staged surgery
Noyes at al, Am J Sports Med, 2000
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Pre-op plan
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Biplanar osteotomy
Mini-invasive
Preserves bone stock
TT on the distal fragment for
corrections up to 15 mm
TT on the proxiaml fragment for
corrections greater than 15 mm(+)
to prevent patella infera
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Why open wedge biplanar ?Classic Biplanar Tunnel
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Fixation
Locking plates
Rigid fixation
Early weight-bearing• Lobenhoffer P :KSSTA, 2003 11(3):132-8
Spacer plates
Stability dependent on intactlateral cortex
Correction loss ?? Schröter S. Arthroscopy. 2011
;27(5):644-52.Çanka
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Posterior slope
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Li Y. Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in
young patients with anterior cruciate ligament-deficient knees: a systematic review.
Arthroscopy. 2015 Mar;31(3):507-19.
11 studies, 218 knees
85% IKDC A or B
Side to side difference 2.4mm
Return to recreational sports possible
Regression of OA symptoms
DVT 7%
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HTO+ACLR
No conversion to TKA at 6 years
Higher rate (18%)of ACL graft failure
Schuster P. Arthroscopy. 2015 Sep 15. pii: S0749-8063(15)00629-5.
Correct tibial slope if > 12°
Dejour D. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2846-52.
Return to competetive sports 45%
Trojani c. Orthop Traumatol Surg Res. 2014 Apr;100(2):209-12.
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Çankaya OrthopedicsExperience
31 simultaneous ACLR + HTO
29 open wedge biplanar
2 closed wedge
16 primary /15 revision ACLR
1-10 years follow-up
Single bundle hamstring autograft
No conversion to TKA
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HTO + CHONDRAL REPAIR
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Harris JD. Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction.
Knee. 2013 Jun;20(3):154-61.
• 69 series, 4557 patients
• 5 year survival
• Isolated HTO : % 92.4
• HTO+ cartilage repair : %97.7
• HTO+ meniscus transplant : % 90.9
• Additional biological interventions have a positiveeffect on survival
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Chondral treatment optionscombined with HTO
Debridement
Thermal modification
Subchondral drilling/ microfracture
Cell free scaffolds
2nd generation ACI
Older patients
with OA
Younger patients
with traumatic
cartilage lesionsÇanka
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Schuster P. Open-Wedge High Tibial Osteotomy and Combined Abrasion/Microfracture in Severe Medial
Osteoarthritis and Varus Malalignment: 5-Year Results and Arthroscopic Findings After 2 Years.
Arthroscopy. 2015;31(7):1279-88.
91 pts 5 year f-up
HTO + Microfracture/abrasion
95% survival without arthroplasty
Better cartilage regeneration on the femoral sidecompared to tibia (87% vs 75%)
The effect of chondral resurfacing unclear
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Jung WH. Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial
osteotomy. Arthroscopy. 2014 Jan;30(1):72-9.
Fibrocartilage regeneration in 92% in the
femur vs. 69% on the tibia without cartilage
repair techniques.
Best results in 0-6 degrees valgus
No correlation with clinical outcome &
cartilage regenerationÇanka
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Spahn G. Cartilage regeneration after high tibial osteotomy. Results of an arthroscopic study.
Z Orthop Unfall. 2012; 150(3):272-9.
135 pts 2nd look at 18 months
Worst results with debridement, best results after
thermal chondral modification
Microfracture sucesssful in 2/3 femoral condyle,
1/3 tibial plateau
Partial restoration of cartilage in 60%
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Chondral procedures in older patients
Some form of fibrocartilage regeneration is usually seen
Better regeneration in the femoral condyle compared to tibia
Better MRI scores
No significant clinical difference with patientswithout chondral resurfacing Jung WH: Arthroscopy. 2015 Apr;31(4):673-9.
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HTO + MEDIAL MENISCAL ROOTREPAIR
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Medial meniscus radialposterior root tears
Meniscal extrusion, loss of transmission
circumferential hoop stresses.
Altered biomechanics, increased tibio femoral
pressures, rapid progression to OA
Bhatia S. Am J Sports Med. 2014;42(12):3016-30.
LaPrade RF. J Am Acad Orthop Surg. 2015 ;23(2):71-6.
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Medial meniscus radialposterior root tears
Meniscectomy may provide transient symptomaticrelief but hastens the progression of OA
Ozkoc G, Tandogan RN. Knee Surg Sports TraumatolArthrosc. 2008;16(9):849-54.
Repair with-pull-out sutures or suture anchorsrestores biomechanics and is indicated for patientswith early arthritic changes
Padalecki JR. Am J Sports Med. 2014;42(3):699-707.
Vyas D. Sports Med Arthrosc. 2012;20(2):86-94.
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Feucht MJ. Arthroscopic Transtibial Pullout Repair for Posterior Medial Meniscus Root Tears: A Systematic Review of Clinical,
Radiographic, and Second-Look Arthroscopic Results.Arthroscopy. 2015;31(9):1808-16.
7 studies 127 patients
Lysholm scores: 52 >>> 86
No progression of OA in 82%
Improvement in meniscal extrusion in 56%
2nd look : 62% complete healing, 34% Partial healing
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36y,Male
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11mm correction
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Arthroscopic trans-osseousrepair + HTO
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Simultaneous proximaltibial osteotomy
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MENISCAL ALLOGRAFTS
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Indications
Symptomatic patients withtotal meniscal loss
Age 45(-)
Cartilage damage ICRS I-II
Normal alignment (or osteotomy)
Stable knee (or ligamentreconstruction) Rosso F. Am J Sports Med.
2015;43(4):998-1007.Çanka
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Smith NA. Meniscal allograft transplantation in a symptomatic meniscal deficient knee: a systematic review.
Knee Surg Sports Traumatol Arthrosc. 2015;23(1):270-9.
35 studies, 1332 pts
Mean f-up 5.1 years
Lysholm score: 55.7 >> 81.3
IKDC score: 47 >> 70
Failure 10.6%
Complications 13.9%
5 year results good ….Çanka
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Results deteriorate at longterm f-up
Clinical benefit in 70% at 10 years
Verdonk P : JBJS Am : 2005;87:715-724
Worse results after 13 years
Van der Wal : Am J Sports Med. 2009;37(11):2134-9.
Worse results in lateral meniscal allografts
Hommen JP :Arthroscopy. 2007 ;23(4):388-93.
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Radiological results
Joint space narrowing in 48-75% cases after 10 years Verdonk P:Knee Surg Sports Traumatol Arthrosc. 2006 ;14(8):694-706
Hommen JP: Arthroscopy. 2007;23(4):388-93.
Graf KW. Arthroscopy. 2004;20(2):129-40.
Minimal chondroprotective effect in a meta-analysisof 1056 patients Smith NA. Knee Surg Sports Traumatol Arthrosc. 2015 Mar 19. [Epub
ahead of print]
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What is the effect of HTO?
Equally good results with or without HTO at 15 years, 28% conversion to TKA Kazi HA. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):303-9.
Better clinical results in MAT + HTO at 10 yearscompared to MAT alone Verdonk PC. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):694-706.
Largest decrease in medial pressure between neutral and 3 degrees of valgus, even neutral aligned knees could benefit from an HTO Van Thiel GS. J Knee Surg. 2011 Mar;24(1):45-53.
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MENISCAL IMPLANTS
Papalia R: British Medical Bulletin 2013; 107: 19–40
Vrancken ACT. International Orthopaedics (SICOT) (2013) 37:291–299Çanka
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Indications
Symptomatic young patients with
partial meniscal loss
Anterior & posterior roots should be
intact
Thin peripheral rim present
Cartilage damage ICRS I-II
Normal alignment or osteotomy
Stable knee or ligament reconstructionÇanka
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Menaflex (Ivy Sports Medicine)
Collagen meniscus implant (CMI)
Bovine Achilles tendon origin
Type I collagen + Glucoseaminoglycan
Seperate medial & lateral implants
FDA approval revoked after highcomplication rates and disappointingresults
Available in Europe
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Results
Clinical results better than partial menisecetomy
Failure and reoperation in 7-11% at 5-10 years
Clinical success 80%
MRI: Shrinkage in all, total loss in half the cases
Rodkey WG.J Bone Joint Surg Am 2008;90:1413–26.
Bulgheroni P. Knee 2010;17:224–9.
Zaffagnini S. Am J Sports Med 2011;39:977–85.
Monllau JC. Arthroscopy. 2011;27(7):933-43. Çanka
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Grassi A. Clinical outcomes and complications of a collagen meniscus implant: a systematic review.
Int Orthop. 2014;38(9):1945-53.
11 studies 396 patients
48% additional procedures (HTO, ACLR, microfracture)
Deterioration of clinical scores after 5 yearsbut still better than pre-op
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ACTIFIT (Orteq Sports Medicine)
Porous, synthetic polyester –polyurethane implant
Allows fibrocartialginousingrowth
Synthetic part degrades 4-6 years
Medial & lateral implant available
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Results
80-90% good results at 2-4 years
Good peripheral integration and healing to originalmeniscus in MRI’s Verdonk R. Am J Sports Med. 2012;40(4):844-53.
Verdonk R: Am J Sports Med. 2011;39(4):774-82.
Kon E. Knee Surg Sports Traumatol Arthrosc. 2012 Dec 6. [Epub
Extrusion and implant loss still a problem (5/18 cases) Schüttler KF. KSSTA 2015 Jul;23(7):1929-35.
Too early to speak about a chondroprotectiveeffect Çan
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Gelber PE. Partial meniscus substitution with a polyurethane scaffold does not improve outcome after an open-wedge
high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015 ;23(1):334-9.
60 HTO patients, 30 months f-up.
30 meniscectomy
30 Actifit
No difference in IKDC scores and VAS painscales
Similar patient satisfaction
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Post-op 13 months
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Harris JD. Biological knee reconstruction for combined malalignment, meniscal deficiency, and articular cartilage
disease. Arthroscopy. 2015;31(2):275-82.
Combined procedures: osteotomy +meniscal
transplant + cartilage restoration
Acceptable clinical results
Low conversion to arthroplasty (5,6%) but high rate
of re-operations (55%)
Arthrofibrosis most common (16%)
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Conclusion
Combined procedures have a positive effecton the results of HTO
However
Complex Surgery
Increased morbidity and complications
Expensive
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Thank you … Presentation can be downloaded at www.cankayaortopedi.comÇan
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