Çankaya ortopedi · gelber pe. partial meniscus substitution with a polyurethane scaffold does not...

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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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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Çankaya ortopedi · gelber pe. partial meniscus substitution with a polyurethane scaffold does not...

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