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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. GODENCHE Service de Chirurgie Orthopdique et de Mdecine 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 Teenys (16O mn) for a major varus series Similar to Krackows (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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