Giles R Scuderi MD Disclosures Consultant and Royalties Zimmer Biomet Consultant Medtronic Convatec Pacira Force Therapeutics Research Support Pacira Society BOD Op Walk USA Book Royalties ID: 1010626
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1. Conversion of Proximal Tibial Osteotomy to TKAGiles R. Scuderi, MD
2. DisclosuresConsultant and RoyaltiesZimmer BiometConsultantMedtronicConvatecPaciraForce TherapeuticsResearch SupportPaciraSociety BODOp Walk USABook RoyaltiesElsevierSpringerThiemeWorld Scientific
3. Proximal Tibial OsteotomyIndications:Young active patients with medial arthritis and varus mal-alignmentTechniques:Opening medial wedge osteotomyClosing lateral wedge osteotomy
4. Proximal Tibial OsteotomyOpening medial wedge osteotomyPrecise intra-operative correctionNo violation of the proximal tibial-fibular jointNo change in the length of the lateral collateral ligamentComparison of opening and closing wedge osteotomyMore complications with opening wedgeMore conversations to TKA with closing wedge Duivenvoorden, et al: JBJS 96A, 2014
5. Survivorship of Proximal Tibial OsteotomyHistorical dataRitter: results of HTO decline at 6 yearsCurrent dataDuivenvooreden: within 6 years conversion to TKALateral closing wedge osteotomy 22%Medial opening wedge osteotomy 8%Ritter & Fechtman: J Arthroplasty 3(4), 1988Duivenvoorden, et al: JBJS 96A, 2014
6. Survivorship of Proximal Tibial OsteotomyLong Term5 years: 71-95%10 years: 51-98%Reasons for failureProgression of arthritisLoss of correction angleOther variablesAgeGenderBMIGrade of preop arthritisPreop ROMCorrection angleSong et al: Knee Surg Relat Res: 28(2), 2016
7. Failure of Proximal Tibial OsteotomySurgical ComplicationsUnder and over correction of limb alignmentFracture of the opposite cortexIntra-articular fractureChange in tibial slopeNon-unionChange in patella heightInfection
8. Conversion of Tibial Osteotomy to TKATechnical concernsSkin and soft tissue statusCombined deformitiesLigamentous instability
9. Conversion of Lateral Closing WedgeSurgical ConsiderationsExposure difficulties do to patella inferaQuadriceps snipDecreased tibial slopeProximal tibial bone lossTibial component stem impingementTibial augmentationLateral soft tissue laxityPrior hardwareHan, et al: Knee Surg Sports Trauma Arthrosc: 24(8), 2016Song et al: Knee Surg Relat Res: 28(2), 2016
10. Conversion Lateral Closing WedgePosteriorTibial Slope
11. Conversion of Opening Wedge OsteotomySurgical ConsiderationsChange in tibial slopeDependent upon placement of wedgePatella inferaPrior hardwareSmith et al: Knee 18(6) 2011Sun et al: J Knee Surg 30(2), 2017ACLDeficientPCLDeficient
12. Conversion of Tibial Osteotomy to TKASurgical ApproachPrevious surgical skin incisionsTransverse scars can be ignoredLongitudinal scars approached with cautionLateral Closing Medial Opening
13. Conversion of Tibial Osteotomy to TKASurgical ApproachArthrotomyMedial arthrotomyExtensile exposuresQuadriceps snipV-Y turndownTibial tubercle osteotomy
14. Conversion of Tibial Osteotomy to TKASurgical Approach: Prior HardwareLateral closing wedgeLateral staplesLateral plate and screwsMedial opening wedgeMedial plate and screws1-stage or 2-stageWill hardware interfereWill removal compromise exposure
15. Preoperative Radiographs
16. Postoperative Radiographs
17. Conversion of Tibial Osteotomy to TKASurgical ApproachAnatomic deformitiesIntra-articular tibial correctionUnusual proximal tibial bone resectionMetaphyseal – diaphyseal mismatchLigament instabilityLateral instability with lateral closing wedgeMedial instability with medial opening wedgeVarious level of prosthetic constraint
18. Preoperative planning
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20. Implant ChoicePCL Substituting Prosthesis preferredPCL Retaining Prosthesis inferior resultsPCL contracturePCL insufficiencyDifficulty balancing the flexion and extension gap do to tibial deformityLimited motionVarus-Valgus Constraint (CCK)Unable to balance the flexion and extension gaps with ligament releases and intra-articular correctionSevere varus or valgus deformityHernigou, et al: HSS J: 9, 2013Akasaki, et al: 17, 2009
21. Clinical ResultsNo difference in clinical outcome in conversion of closing wedge osteotomy compared to primary TKANo difference in the clinical outcome in conversion of closing wedge vs opening wedge osteotomyHowever:Closing wedge osteotomy requires preoperative planning do to proximal tibial deformity and possible tibial component impingementPrior hardware with lateral closing wedge osteotomy may necessitate 2 stage procedureMore reported complication with conversion of lateral closing wedge osteotomyConversion of Tibial Osteotomy to TKABae et al: J Ortho Sci 22(3), 2017Kuwashima, et al: Knee Surg Sports Trauma Arthrscop 25(3), 2017Han, et al:Knee Surg Sports Trauma Arthrscop 24(8), 2016Ehlinger, et al: Orthop Trauma Surg 103(7), 2017
22. Final Tips and PearlsDetermine if prior hardware will interfer with componentsOne-stage vs. two-stageEvaluate prior incisionsArthrotomy may require more extensile exposurePatella inferaAssess tibial anatomyUnusual bone cuts not unusualCheck the tibial slopeMetaphyseal –diaphyseal distortionLigament instabilityImplant choice and level of constraint
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