The 15th Medi European Sports Orthopaedic Symposium 2018 was broadcast live from Estepona. This is my talk on osteotomy.
We've learned a lot in the last decade and most of it has come from Germany where osteotomies are common. In our country it is far less common and Andreas [Imhoff] has been a real leading light in terms of developing plates and techniques which we are adopting in the UK. Thanks to my team and Rags [Raghbir KhaKha] - who is in the audience - for helping with the research and with this presentation today.
So what everyone will accept is that alignment is everything - alignment is the key - and we use it to -
This fantastic slide from Romain Seil really depicts where we want to be. We all want to be in this 'Repair' zone, and this is where the osteotomy surgery leads and keeps us, and we want to keep away from any form of 'Reconstruction' and, of course, 'Salvage', particularly since our patients are living so much longer.
In our unit, together with Chris Wilson from Cardiff and Matt Dawson from Carlisle, we combined our three datasets looking at osteotomy, and we have a good number - now close to 1000 - and we found in a very similar way to Andreas and his group and to Philipp Lobenhoffer and the other large series that we are getting very nice results with osteotomy surgery, with good reduction in knee pain, Oxford Knee Scores, and very low complication rate. And we are finding with our DFO series a very similar series of results which are very favourable for osteotomy.
So osteotomy is safe and the patients are happy. If we look at the opinion of patients - "How happy are you with your surgery?" - 87% are good or excellent.
So what about complex osteotomy? I am going to touch on some MIS (minimally-invasive) procedures that we can do -
So in terms of MIS, I think this is a very good way to go once you have become very confident with the osteotomy surgery. You can do this through small incisions in the same way as we do when we fix our plates for trauma surgery - it's all about knowing where you are, where you are going to make your cuts - and we can do this for HTO and equally we can do this for DFO. And this has been pushed most by Philipp Lobenhoffer and Kristian Kley from Hanover, but it does require a level of expertise - so this is not 'entry level' osteotomy surgery. Here this is really a very clever little trick - somebody needs to come up with a nice device as this could be used for any locking plate system. Here we have used a Passport cannula and have taken the central valve out so that we can lock the locking threads - the tower - into the plate and we can put the final two screws into the femoral osteotomy very easily through a minimally invasive stab.
So alignment is everything - it is everything to us - and it also everything to the patient. This is a young man - he is only 50-51 years of age - and he is very unhappy with his total. They have left him in extreme valgus so he wanted something different for his other knee - we went for a double osteotomy to get him into neutral and in fact I ended up doing an osteotomy to his knee replacement knee as well, from which he did very well.
Everything is about planning with osteotomy. The technique you can learn very easily, but the one step that you mustn't overlook is your pre-op planning. The key is knowing the angles, understanding how to make a plan. Now we have these very nice trauma software packages that allow us to do 'virtual' osteotomy surgery before we carry out the procedure - to calculate where the deformity is and operate in the correct bone. We can simulate the osteotomy and even simulate the plate being placed.
So 'which bone?' is crucial. Varus does not = tibia. Valgus does not = femur. It is really important that we follow the rules. We can't just simply do a MIniaci, draw the lines and always say if someone comes in to you with a varus deformity that you are going to correct that in their tibia. Twenty percent of the time it flips, and the varus is in the femur and the valgus is in the tibia. Poor planning leads to a poor outcome.
This lady was osteotomised - the plan? - there was no plan... - an osteotomy was carried out and she has been left in extreme valgus. With an appropriate it is very easy to revise that, close that, bring it back and bring her to neutral, and she ended up very happy.
The paper that gives the best results for osteotomy is this paper by Babis from the States. If you look at the bottom line here, 100% survival at 10 years! The reason why this paper is so important is because it really focuses on this crucial concept of carrying out the osteotomy in the appropriate bone, which is what they did in this series.
So if we do a deformity analysis - if the mechanical axis deviation is medial more than 15mm, you are varus. So if your MPTA is small, which it usually is 80% of the time, you are going to do a tibial correction. If the LDFA, however, is big, you are going to do a femoral varus correction. And the same applies on the lateral side for a valgus deformity - most of the time the LDFA is small or reduced and we will carry out a femoral osteotomy, but 20% of the time we will need to carry out the osteotomy in the tibia.
So here's a patient - she's had an osteotomy carried out in her tibia for valgus - why they went in this case for tibia I am not sure as the deformity was in the femur - and it's left her with this horrible joint line obliquity. This is what the patients hate. If you create a new deformity by doing an osteotomy in the wrong bone, you will have a 100% guaranteed bad outcome. This is her plan - I ended up doing an osteotomy to take out what they had done on the tibia, and then did a standard closing wedge on the femur. And these patients do very well. This is day 1 following surgery - she has a nice straight leg raise, good function, good control of the quads and if we look at her leaving the hospital on day 2 with her double osteotomy.
So what about doing this Bilateral Simultaneous Osteotomy? Here is a case - a 47 year old - he fits into the treatment gap - he is perfect for osteotomy. He doesn't have full thickness disease. He has a failing medial compartment and varus on both sides, and he has got serious symptoms. He is struggling to walk, can't run, it is affecting his work, he has tried a brace... You can see he has this moderate disease within his knee - he is not an arthroplasty patient. We used bone wedges, which was touched on before, which I think is a fantastic adjunct to all osteotomy surgery where you are doing an opening wedge. He is leaving hospital on day 1 - weight-bearing - having had his bilateral simultaneous procedure.
This gentleman is an orthotist. He works in Birmingham and he couldn't work because his deformity had become so severe. He is 42 years of age, a large guy, and he is not a good candidate for bilateral total knee replacement. He is extremely fit and extremely active. If we look on the MRI scans the extreme varus has caused osteitis and failure of the medial compartments and there really is only one option here. So I ended up doing bilateral simultaneous double osteotomy. This is a one-off case. He pushed me into this - I would suggest it is too much. We should have staged this, but he pushed me to do both at the same time and he has ended up with a good result.
So what about changing the slope? Really we learn a lot in orthopaedics from other specialities - the dentists and also the vets. And the vets have taught us that changing the slope in dogs can sort out their cruciate issues, and we have heard some great talks already touching on this in terms of changing the sagittal plane. So we want to flatten for an ACL and create a slope for a PCL, and with this alone we often don't need to add in any further procedure.The magic figure is said to be around about 10-12 degrees in terms of where our cut-off is for doing slope-changing. We have these 'intelligent' plates - we are going to hear more about this from Andreas - this is his PEEK plate which is very clever for combined ligament surgery because of the multi-dimensional nature of the top three screws that allow you to put your screws where you want them so that you can carry out your ligament surgery in combination. This is a case where I used another plate - similar sort of concept.
So we looked at our series a while back now actually. We had close to 60 combined high tibial osteotomy with ACL, and actually these are our happiest cohort if we look at their scores and we look at our HTO cohort. We had a few complications but no failures so far, and I am very happy with the objective measures that we recorded. With the PCL, it really is - 90% of the time - enough to just change the slope. Ligament reconstruction is carried out very rarely. Here this patient had a long bone injury, PCL avulsion which I fixed and anchored down with a posterior approach. He didn't do well with that, so I ended up doing an osteotomy to var-ise and increase his slope. But we also have the ability now with these clever drilling tools - this is the 'flip-cutter' - to do combined surgery should we so wish, but this is a very rare procedure where you actually would do a PCL in combination with an osteotomy - usually the osteotomy is more than enough.
So what about this concept of just changing the slope from the front. Now this is a very interesting problem. Here you can see a 28 year old man. He has got this recurvatum - this is a reverse-slope injury. He is a construction worker - 26-27 years of age - he has huge hyperextension and he couldn't function, couldn't work. He was a roofer and he came to me from another consultant, and they always have this problem of significant recurvatum. These are on Vumedi and this full video is also available on YouTube - so you can see the recurvatum. What we did was a 'virtual' osteotomy - we planned out the hinge point, we planned out where we would do our tubercle osteotomy, how big we were going to open the osteotomy and then we used a femoral head allograft and again we are simulating that in terms of what we were going to do. And then the really clever bit is using the tubercle as the plate. So the tubercle goes on at the front and all you do is fix this with is a series of screws. So here you can see the osteotomy being carried out. I am very sad to say we came second in the ESSKA competition for this video - very sad - I will have to speak to Jan about that. And here you can see changing the slope with the cinematic effect - the fluoroscopy - and you can see us opening the osteotomy and this is really quite a simple (once you get your head around it) operation to carry out - obviously you need to be experienced with osteotomy surgery. You can see the tubercle going back and then we are placing the screws. There really is no plate for the 'opening' but for the 'closing' we use a little ancillary plate. When we look at his function - he came back - I actually had to track him down as he wasn't the greatest patient to be compliant with follow-up - but he was working on the Shard - constructing it - and climbing roofs with a completely normal knee.
And here is another extreme case where we see a fourth-time-failed ACL problem. This lady we planned out to do a closing-wedge from the front and again you can see the little plate that I have used. Before we did the surgery you can see that she flicks and she actually has a pivot just flexing the knee she is so unstable. A simple slope-changing osteotomy before I did any ligament surgery was enough to abolish that. There is a really large pivot shift. This is her at 4 months. She left hospital 2-3 days after surgery and in a very quick little examination she has a very stable knee already - it wasn't quite good enough so we did go on and I did a revision ACL as a second stage with an anterolateral ligament and she was happy enough to come and have the other side done where she had a similar problem.
This is another example - this poor lady had been left with this reverse slope following a tibial plateau fracture malunited. She couldn't walk - she was in a wheelchair before the surgery. She was a model for BMW - a very active lady - did a lot of rock climbing and all I had to do was change the slope. This is a simple one because she has a problem across both sides of the slope. She worked hard - it did take her 18 months to get back to full activity but she was pretty happy with her result at the end. These patients - because they don't have intra-articular pathology - can return to normal function with this type of complex surgery.
So Rags, who is now a consultant at Guys and Tommies, was my Fellow, and has written this up and we have been given the nod from Jon Karlsson that we will have this accepted. We had it accepted a KSSTA with a few minor changes. We have been very impressed when we combined again with Matt and with Chris's patients these 10 patients have done extremely well with this procedure. Finally, I just want to touch on intra-articular issues. So here this young lady has got a more difficult problem because she has a hemi reverse-slope. She has got this injury on one side. So this osteotomy what I wanted to do - and I did before PSI - was to do a cut like for an Oxford Knee Replacement to free this section up to allow me to elevate the lateral side and to also do a var-ising osteotomy. I got a pretty good result. I didn't bring her quite as far as I would have liked - I would have liked her further over - but she did very well and was very happy. Again these patients are so incapacitated with their bony pivot shift. She was delighted that she could walk again - her only slight criticism was a small seroma that she had that she didn't like cosmetically.
I think for these patients eventually we are going to be moving to PSI solutions. This is where I think this is really going to come into its own. I have used this - I have done a nice little study with Justin Cobb at Imperial and also with Ronald van Heerwarden looking at the use of PSI. Again this a similar case hemi-plateau is down just one one side and you can see - this MRI shows most clearly how half the plateau is down. What we did, we actually combined the weight-bearing long leg X-ray with the CT so that we could get a nice plan. This is the plan that we made - so we were going to do an elevation on one side (the lateral side) and again a small correction. We had this nice cutting guide made for us - that was what it was going to look like in theatre, that is what the plate was going to look like. Then you can play with these - all of the PSI systems that are available on the market, and there are quite a few now, allow you to trial them. We had this out-rigger for a hinge pin but it was not really any use, but we had the slots for the saw to make the cuts... it all went a little bit 'hairy' at one point as I was elevating that section but I was happy that I could get a good fix and he was looking good at 6 months - united. I didn't really ask him to do this but when I asked him to show how good he was he just started jumping for joy - he was so happy!
So - osteotomy is key. Bilateral simultaneous is possible and the patients do very well - we have over 20 of those in our series now (the single bone correction, not the double that you saw). In ligament insufficiency, slope change is often enough and you won't need to add in a ligament. Manage the intra-articular defects that you see and restore the anatomy because these patients can get back to completely normal function, and think about this biological technique.