It is often assumed that osteotomies are not effective in cases where the bone is exposed after cartilage wear. The results of osteotomies depend on preoperative planning, correct orthosis and adequate fixation. However, it has been reported that 135° of flexion with full motion for more than 10 years was obtained in patients who underwent a high tibial plateau osteotomy in a bone-to-bone situation. It is important to recognize that 30% of patients will experience persistent knee pain after knee arthroplasty, in some cases for 15-20 years. It is unfortunate that the perception is that arthroplasty is better than osteotomy. In light of this and the change from joint surgeons to sports medicine physicians has led to a diminishing acceptance of osteotomies. However, we should understand the knee surgeon and apply various surgical techniques that are beneficial to the patient. The goal of treatment is to preserve the knee joint and not to replace it. The purpose of this article is to address the need for younger surgeons to think less about replacement and more about techniques that preserve the knee, such as meniscal reconstruction, cartilage preservation and osteotomy as advocated by John Nyland.
The biomechanics of the knee joint is load-sharing through the articular cartilage and meniscus. In patients with mild valgus, osteotomies can increase the chances of healing after meniscal repair. Osteotomy after meniscectomy can reduce cartilage wear and OA. Mild internal derangement of the knee can significantly alter the pressure increase and distribution within the medial compartment of the knee. In other words, we can infer that it is more difficult to perform suture healing of medial torn meniscus in patients with internal derangement. Although there is no literature to support this idea. In patients with partial resection of the medial meniscus, any cartilage damage may become greater. Therefore, in patients with meniscal repair or replacement, cartilage injury repair can be osteotomized to recorrect the force line if the knee is being considered for preservation. A knee surgeon should know these techniques.
In a study of seven patients with internal knee rotation who underwent medial meniscus repair or re-repair with a medially supported high tibial plateau osteotomy, re-arthroscopic exploration revealed complete healing in five patients at the time of internal fixation 1 year later. Two patients did not heal completely and required a clean-up procedure. Performing a 3-4° osteotomy orthosis is critical for the decompression of the interarticular compartment involved. In addition, strong fixation such as the AO osteotomy fixation system allows for early weight bearing 3-4 weeks postoperatively. Therefore, force line correction should be considered for meniscal repair surgery in patients younger than 40 years of age with an inversion deformity.
If osteotomy is considered for patients with osteoarthritis following meniscectomy. The primary care physician should perform an MRI scan in patients with knee pain under 55 years of age, and x-ray should be done prior to arthroscopy. After clinical physical examination to confirm the force line of the knee, the physician tells the patient that the knee is in worse shape than expected and that only joint replacement will provide relief. However, a single leg standing position x-ray is more valuable than MRI and arthroscopy. Also, plain films are important.
Inadequate correction of the force line can be ineffective, and Fujisawa etal found that 30% of the force line in the lateral compartment gave the best results. Simple triangulation of the osteotomy angle is equally effective and essential, but requires proper preoperative planning. However, not all knees should be corrected to the same angle, as this may result in a non-functional increase in valgus. If partial cartilage is present medially, then the orthosis depends on the loss of medial cartilage and the status of the lateral cartilage. If there is a loss of medial interval height, the force line should be placed at the Fujisawa point according to the following guidelines.
1. 1/3 loss of medial cartilage height with 10-15% external displacement.
2. 2/3 loss of height with 20-25% external displacement.
3. Complete cartilage wear with 30-35% external displacement.
This will avoid under and over correction. If there is still 2-3° of inversion (from soft tissue laxity) this needs to be deducted from the correction angle to avoid overcorrection. Unnecessary excessive valgus may come from.
1. planning errors.
2, failure to consider laxity of the lateral ligaments.
3, orthopedic according to Fujisawa but no wear of the medial intercompartmental cartilage.
4, technical errors.
5, compression of the osteotomy site due to collapse and osteoporosis.
Intraoperative complications include.
1, fracture of the tibial plateau.
2, Displacement of the osteotomy site.
3, inadequate or excessive orthosis.
4. resulting in posterior tilt or rotational deformity.
It is important to note that femoral osteotomies heal more slowly than tibial osteotomies and should not be osteotomized in smoking patients. Unfortunately, joint surgeons and general orthopedic surgeons do not refer knee patients to knee surgery specialists in a timely manner and miss the optimal time for osteotomy. The question of how to manage combined cartilage injuries is raised here. The following four items are our approach to such problems.
A single cartilage injury can induce cartilage formation via autologous matrix.
Cartilage exfoliation reconstructs the bone defect through autologous bone and phosphate.
Subluxation leading to patellofemoral arthritis with AMIC combined with intercondylar recess coverage and force wire orthosis in the patella.
Meniscus suture. Suturing of the meniscus in the vascular area results in a healing rate of approximately 70-80%. Surface coverage and fibrous connections increase the chances of success which have been utilized in the past. Covering the suture area with a cartilage-mediated matrix helps increase the chances of healing.
In summary, many minor procedures can keep the knee joint healthy.
There are three types of surgeons.
1. These physicians have embraced the concept and do so on a daily basis. They want their patients to be able to live with their knees all the time.
2. the second type, those who find osteoarthritis and leave it to progress and replace it late.
3, This group of doctors, I hope I can at least leave them with some questions and provide them with more options in dealing with older knee disease.