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IC 203-2023: High Tibial Osteotomy: How to Get it ...
IC 203 - High Tibial Osteotomy: How to Get it Righ ...
IC 203 - High Tibial Osteotomy: How to Get it Right and Avoid Complications (Case based lecture) (3/5)
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Video Transcription
Those are big boy, those are big boy cases. And we're this, this is a tibial osteotomy lecture, but the question becomes sometimes when is a tibial osteotomy not sufficient? When do you need to go to a dual level osteotomy? I'll go quickly through this, because it's gonna tie in well to Seth's talk and to Anil's talk, which is, it all comes down to planning. It all comes down to knowing the limitations of just doing it on one side. Big corrections, weird hinge access, where am I gonna get a complication? Where is the deformity? How much slope am I correcting? If you tie all those concepts in together, I think the concept for dual level becomes more apparent. So I have nothing to disclose. As it pertains to this, Anil touched on this and Seth in the 101 talk, which is know what your landmarks are, know what your measurements are. The ideal idea is that you end up with an 87 degree medial proximal tibial angle, 87 degree lateral distal femoral angle, but at the end of the day, you want a straight leg and you want a joint line that is parallel to the ground. I still think joint line obliquity is difficult to get right. I think we all struggle with that a little bit because if you have a really valgus leg or a very varus leg and then you make it straight, that leg is now gonna come back in and that joint line is gonna come with it. So accounting for where that new leg position is in space, I think is still somewhat of a challenge and I'll show you there are some strategies to do that. I'm gonna show you this case. This is the case that Anil said he's seen about 50 times because I presented it and then I gave it to Alaya and he's presented it a bunch of times, but I did add another case into here to get your guys' thoughts, just to change it up a little bit. So this is a 44-year-old male. He's a complicated case orthopedic surgeon, great skier, tibial plateau fracture that of course went on to infection, ICU admission. He had adrenal shutdown. I mean, he had a septic process. It was really very challenging, but finally got it to heal. He was not my case. He presented to me like this and he presents with this asymmetric valgus deformity without arthritic change. Again, I think that you've seen getting out of that reflex of, oh, it's valgus, we should treat it on the femur is what we're all going to, more nuanced analysis-based corrections. And if you saw this and if I saw this 10 years ago, I think I probably would have said, oh, he's in valgus, let me consider a distal femoral osteotomy. But as you would expect, all the deformity in his case, the majority of the deformity in his case is gonna be on the tibial side because that's where his injury was. So he's in 12 degrees of valgus. He's got 43 millimeters of mechanical axis deviation. His femoral side is not that bad. He's 85 degrees and his medial proximal tibial angle is very high. So as you'd expect, most of the deformity is on his tibia. So this is him planned. I use PSI pretty liberally now. I've been doing that since 2020, so about three years. It's really opened up my eyes to where the deformity is. And as Seth indicated, it allows you to be more creative and nuanced with your reconstructions and your corrections. So this is, as I was planning him, I said, well, and he saw probably three or four different opinions all throughout the country. He's got the resources and obviously he's an orthopedic surgeon. You'd say, well, this is probably a closing wedge to high tibial osteotomy because he's all his deformities on the tibia. It's a pretty big resection, taking 13 millimeters of bone to get this. And now you're gonna create a joint line that's about five degrees off of parallel. And this is something that gives me a little bit of pause. This is very diseased bone. It's somewhat dysvascularized. It's been operated on several times. It's got bone graft in there, was infected at one point. His soft tissue envelope is maybe not ideal and I'm starting to wonder, I'm gonna create a five degree oblique joint line. I'm gonna operate on a tibia that's kind of compromised. Is there another option here that gives me a more parallel joint line and can eliminate some of my risk complication on the tibia? So what this all comes down to, I think, is joint line obliquity. In the last 10 years, we've drawn so much attention to slope, right? We talk about slope in the sagittal plane, but joint line obliquity is just slope in the coronal plane. I think it's something we need to pay more attention to. Anil alluded to this yesterday in one of our sessions, that Coventry told us 10 degrees is probably fine, but I think we're realizing that 10 degrees is probably way too much. And as you get to about four or five degrees of joint line obliquity, you start seeing a deterioration of radiographic and clinical outcomes. And what happens is, as you would expect, you have slope in the sagittal plane. That femur slides down that ramp. If it's increased slope, you're increasing stress on the ACL. If it's decreased slope, you're increasing stress on your PCL. In the coronal plane, as it slides down, it puts pressure on the down-sloping meniscus and the up-slope of the tibial spine, and you start seeing these from a pressure mapping standpoint, again, at about four or five degrees, which gives me concern in this particular case. If you look at radiographic and clinical outcomes, you see parallels. You see deterioration of radiographic outcomes at about six degrees of slope, or joint line obliquity, I should say, at about four degrees in terms of clinical outcomes. So what happens? How do I predict it? I think it's still tough. Al and I have talked about this. I usually use any medial proximal tibial angle in excess of 95 as a threshold where I'm thinking about a dual-level osteotomy. Al, I think your threshold is even lower. I think you said 92 or 93. You start getting nervous about it. So I've slowly been bringing that number down. But that gives me concern that I'm gonna create an oblique joint line in a non-physiologic deformity. And this is what I was talking about. This is that varus knee. You see the correction. That leg now comes back under the patient, and you can see how that lower limb adduction angle actually affects your joint line where that leg comes back underneath his body weight. And it's something that I'm starting to play with a little bit. It's something where I think actually, Seth, when you were talking yesterday about modeling patellofemoral loads, that we can actually model better using PSI to see how that joint line is gonna change as you bring that leg back underneath that patient with your correction, especially these big corrections. And you can see this example here. This is from this article. You see that varus correction, and then as that leg comes back underneath, that gap between the two legs corrects, you see how that joint line comes with it and creates that lateral joint line obliquity. So if you look at dual-level osteotomy, it can be helpful in this case. So this is a paper, I think this was out of Japan, where they looked at 68 patients, 34 with opening wedge osteotomy, 34 with DLO, and they used 95 degrees of medial proximal tibial angle after correction as their threshold to consider doing a dual-level osteotomy. And you can see if they did HTO alone, you get about six degrees of joint line obliquity. If you do a dual-level, you get about two degrees of joint line obliquity. They didn't see a difference in patient-reported outcomes, but again, it's just starting to get your brain thinking, where do I need to do more than just the tibia? And I think it's in cases where you're gonna have a high risk of complication on the tibia, which this case is an illustration, in cases where you start getting an excess of four or five degrees of joint line obliquity. So let's go back to our case. So we remodeled them. This is, again, the utility of using PSIs. You can virtually plan this osteotomy in real time. So I said, you know what? I think we can do a small correction in the tibia. That creates less risk for me in terms of this infected, potentially dead bone. I can do a small opening wedge. Normally, I would take the bone out of the tibia and then move it to the femur. In this case, I didn't, because I didn't know that that bone was good. So we did a small correction on the tibia, small correction on the femur. I do all my distal femoral opening wedges in a biplanar fashion for stability, rotational control, healing, et cetera. So this is him. I don't use a rod for clinical decisions in the OR, but it's very illustrative for this case. So hardware's been removed. This is his weight-bearing axis. This is the wedge that we resected on the medial side. We close that down, plate it. You can see how his line has moved a little bit, but not sufficient, in my opinion. And then you add the distal femoral osteotomy and you get it straight down. And on clinical, this is his post-op six-month clinical exam. He's very, very happy. It correlates perfectly with our preoperative plan. Again, you can see the value and the strength of PSI in this clinical context. And this is him clinically sitting next to his son on the first picture on the left, and this is him after he's been corrected. And you can see how that right leg has gone from being in a very abducted position to a more normal, neutral position. So this is a, I added this one because I'm curious to get your guys' thoughts, how you guys would approach this. So this is a 34-year-old female. This is a subtle change on theme here because she's got a couple different things going on. So she's multiply failed ACL. 2005, she had a BTB. 2015, she had a revision with an allograft, had meniscal pathology. She retore it in 2018 and said, I'm done with this. I don't want to undergo any more surgery. She comes in with increasing complaints of medial-sided knee pain and instability. Does not have hyperextension. High-grade ACL exam with Lachman and Pivot. The rest of her exam is fairly normal. So she's in varus. She's got a failing medial compartment. She had a medial meniscectomy with that second surgery, and she's got very high tibial slope. So all things that Al just talked about, you can see that pretty significant subluxation on that weight-bearing lateral. She's got about 18 degrees of slope. Maybe it'd be smaller if we measured it in a short film. I do routinely do long-leg tibias anytime I'm considering a slope correction, but I think everybody would agree this is an elevated slope with subluxation on that lateral radiograph. This is her MRI. So you can see that medial compartment is failing. Full thickness cartilage loss. That root is compromised. ACL is out. You can actually see the subluxation on the tibia on the MRI. Again, probably at least a centimeter. I think in the interest of time, I'll move forward. But I love, Seth taught me this years ago, the problem list, I love it. I make all our fellows do it. And I think for these cases, it's illustrative too. So she's chronically ACL deficient. She's got elevated slope. She's got a medial meniscus root tear and a failing medial compartment and varus malalignment. So I think 10 years ago, Armando would say, well, this is easy. This is a biplanar opening wedge HTO. I'm gonna hit a home run. What I've realized is my ability to affect slope, especially more than like three or four degrees when I'm doing an opening wedge is compromised. I'm not as good as I thought. And this is gonna be a pretty big correction on the tibial side. But again, we plan it all. So you'll see, as a lot of these cases, and I think Seth presented this, the deformity is not just on the tibia. She's got a little bit of deformity in the femur, a little bit on the tibia, and she's got very elevated slopes on CT scan. She's 16 on the lateral side and 18 on the medial side. So I planned her. I said, oh, let's do an opening wedge. This is what it looks like. And this is where I'll show you my pain points. So now we're getting to 96 degrees of medial proximal tibial angle. So I think even if you use a high threshold of 95, she's in excess. This is too much. We're gonna create a lot of complications here. This could be a huge wedge, right? My risk of fracture here, either intra-articular or Takayuchi one is very, very high. You can see the joint line of obliquity. I don't know that I'm gonna achieve a significant slope correction either when I'm doing an opening wedge of this caliber, right? Am I gonna get an eight degree slope correction and not get a hinge fracture and not get a non-union and not get joint line of obliquity in this case? But I'll tell you, 10 years ago, I probably would have done this operation. I think all of us probably would, maybe not Al, but if Seth and Anil and I probably would have, right? So you start planning this out and I was like, I don't think that this is a good idea. We're gonna send you into these super physiologic ranges, 96 degrees medial proximal tibial. I'm supposed to get a five degree correction on slope. I frankly just don't, I don't know that I can do it. I'm not great at achieving it when I'm doing such a big opening wedge, right? And I'm gonna create a 13 millimeter correction, which is, as Al just indicated, my risk of an intra-articular fracture, Takayuchi-1 fracture, non-union, all the things go up dramatically when you start getting above 10 or 11. And the other thing too is, and Anil alluded to this too, the value of PSI is your ability to change your hinge axis. We can create novel hinge axis to affect slope. These are the ones where, personally, I've had intra-articular fractures. I've only had a couple, but that really beefy anterolateral hinge and these really big corrections are the ones where I can get a fracture into the joint. You can see that little crack as it extends just lateral to that tibial spine when I need to do something intraoperatively. So these are the ones that are my pain point at this current time, is big corrections with that anterolateral hinge where I think fracture, and this was not her case. This is another case that was similar, slope correction, coronoplane correction. So we decided to plan her with dual level. I think probably all of us would agree on the faculty, this is probably one where you wanna think about that in this case, small correction in the femur. And then additionally, I can achieve a better slope correction if I do an anterior closing wedge in the tibia, right? So I told her, I said, here's the problem. I'm gonna do a coronoplane correction with an HTL alone, right, if I did that opening wedge, I may increase your slope, not decrease your slope, and I'm gonna create joint line of liquidity, but rather I can do a small coronoplane correction, more reliable slope correction with a closing wedge in the tibia. I can take that bone out, do an opening wedge in the femur and get a very precise coronoplane correction. So it's a tough sell to patients. It's a tough enough sell to tell them you're gonna do an osteotomy, let alone an osteotomy on two different bones, but you can see that our numbers get back to more appropriate and physiologic ranges, and this is her post-op correction. She's perfectly neutral, but more importantly, her slope correction, this thing will play through, is much more reliable in this case. And I guarantee you, at least in my hands, that I'm not Al Getgood who does a billion of these, but I do about 60 or 70 of these a year. I'm not sure that I can get that slope correction if I was doing an opening wedge osteotomy currently. And her femoral side healed great. We actually have not gone on to a revision ACL. A lot of these slope correction patients seem to do okay without the ligament reconstruction. She was ACL deficient for four years before she presented to us. She was very happy with her relief of her medial-sided complaints and the stability that was afforded by the slope correction. So Neil asked us to talk about complications to keep in the interest of time. I've had, I do a lot of osteotomies. I've had almost every complication that you can think of other than a vascular injury, knock on wood, but I know potentially my time will come. I tell our fellows all the time, like, what can go wrong? And it's, I say, osteotomies are really amazing and powerful tools. We just talked briefly about root tears. I think sometimes it's the only operation you need. In this case, for her ACL deficient knee, it was the only operation she's needed to date. And when they go well, they go really well. But when they go wrong, they can go really, really wrong. And these can be a slippery slope. So as we continue to push more and more osteotomy, I think it's important that you get the techniques down, that you use and leverage technology to create a safety and efficiency envelope, but risks are still there. It's not an insignificant operation. So I've had wound complications. This is me. This is an unforced error. This is a patient who had a BTB ACL reconstruction. It was a decade out, and I thought I could just do my regular intramedial incision. I created two, I essentially created a parallel incision to this, not recognizing that he had his hardware removed about a year before, and they had opened up this incision. The medial side of the knee can be very unforgiving, in my opinion, from a medial incision standpoint, and this went on to open up. Thankfully, this was just treated with local wound care, but it was very close to requiring a flap. I think we've all seen cases of our partners and friends that have required pretty significant soft tissue work for medial-sided wound complications. I had my first ever compartment syndrome this year. It's humbling. You know, you do a lot of these. You know, there's some days where I can do three or four osteotomies in a day, and you can fly through them pretty quickly. First ever, this was a closing wedge osteotomy. I maybe did too much. You know, I did a meniscus repair, LET, ACL reconstruction, slope correction, all in one setting. I felt that we were very efficient, but he developed a compartment syndrome. Thankfully, his muscle was healthy. He's actually gone on to heal very, very well, but this is about as humbling as it gets to get this complication. I've had interarticular fractures. I think we've hit that home in terms of interarticular extension, and Takeuchi-1 lateral hinge fractures, and I've had non-unions, and I think you just presented one of those. This is, I don't use fake bone anymore either. I think I use usually an Evans wedge, you know, and I soak it in autogenous BMAC to try to get the biology of it. I do think that the risk of non-union is increased when you get a hinge fracture, even with these more stable plates, and I think the tendency, depending on the hardware you use, is that if you get a hinge fracture, they tend to collapse into varus, so on the tibial side of its opening wedge, they lose correction, and on the femoral side, if you get a hinge fracture like this, they tend to overcorrect as they collapse into varus, but they are all humbling. I think we all have these. It's unfortunate when you get them, but you need to know how to identify them and how to minimize them, and I think that is minimized by planning in terms of avoiding some of the issues of over and under correction you've seen today, being mindful of joint line obliquity, knowing where your deformity occurs, being situationally aware, where are their previous incisions, what are their expectations, know your own limitations in terms of how much you can achieve in one setting. From a technical standpoint, if I'm doing dual level, I'm gonna do the biggest correction first, or closing wedge, because I'll take the bone out and then move it to the opening wedge if I'm doing an opening and a closing wedge, and I do like to assess in a stepwise fashion my correction after each step. In terms of avoiding complications, you've heard it many times today, preoperative planning, being mindful of their previous incisions in surgery, because that will affect it. Almost all these patients have failed previous surgeries. There's a nuance to the hinge access that we talked about in terms of your risk of a hinge fracture, and then again, attention to detail, and I think Seth really hit that home in his talk, so thank you. Thank you.
Video Summary
In this video, the speaker discusses tibial osteotomy and when a dual-level osteotomy may be necessary. They highlight the importance of planning and understanding the limitations of single-level osteotomy. Factors to consider include the correction needed, hinge access, deformity location, and slope correction. Joint line obliquity is also discussed as a challenge in achieving a straight leg and parallel joint line. The speaker presents two cases to illustrate their points, one with a valgus deformity and another with ACL deficiency and medial compartment failure. They demonstrate the use of preoperative planning and patient-specific instruments (PSI) to achieve the desired corrections. The incidence of complications in the speaker's practice is mentioned with examples such as wound complications, compartment syndrome, interarticular fractures, and non-unions. The importance of minimizing complications through careful planning, being aware of previous incisions, understanding hinge access, and attention to detail is highlighted.
Asset Caption
Armando Vidal, MD
Keywords
tibial osteotomy
dual-level osteotomy
single-level osteotomy limitations
joint line obliquity
preoperative planning
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