Las Vegas, 2014 William R. Beach, M.D. Conflict of Interest Statement • Fellowship Grants and Consultant • • • • • Share Holder Tuckahoe Surgery Center & St. Mary’s ASC • Comp Recovery AANA President and Board of Directors AAOS Coding, Coverage and Reimbursement Committee • • • Smith Nephew Arthrex Synthes Mitek Pre-op/Critical Question for Distal Realignment Is the primary problem secondary to an abnormality of the “alignment vector”? - JP Fulkerson Tibial Tuberosity Osteotomy (TTO)Techniques -Trillat – “flat cut” medialization Fulkerson – “anteriomedialization AMZ” Maquet – “steep cut’ anteriorization Preference – Fulkerson (allows infinite angle variations with a single, consistent technique) Elmslie Fulkerson Anteromedial Tibial Tubercle Transfer Fulkerson Anteromedial Tibial Tubercle Transfer (AMZ) All procedures begin with a diagnostic arthroscopy Patellar or trochlear chondroplasty (if necessary) Lateral retinacular release (rarely necessary) If the arthroscope cannot be easily passed between the patella and trochlea If the patella cannot be easily centered in the trochlea with minimal manual pressure Surgical Set-up Normal knee holder U-drape – do not attach the drape to the knee holder After the knee scope Remove the “paddles” of the knee holder Remove the well leg knee pillow Extend the leg portion of the table New ¾ sheet Knee in full extension My Surgical “Fulkerson Osteotomy” Technique Extensile Approach Not Necessary No need for a long osteotomy Minimally invasive allows fewer wound issues Faster healing Greater patient satisfaction Paratenon No longer elevate the paratenon You can incise along the medial and lateral borders of the patellar tendon and save the overlying paratenon Anterolateral Calf Musculature The exposure starts at the patellar tendon Continues inferiorly along the lateral tibia until the patella tendon fibers end Then elevate the anterior lateral calf musculature proximally along the tibial flair Drill Angle is Critical Based on the arthroscopic findings Degenerative disease = greater anteriorization Lateral tracking w/o djd = more medialization Flat cut Drill Angle is critical Steep cut osteotomy Maximize the anterior and medialization with a 60° drill angle/osteotomy (Farr) Drill Bits/Cutting Guide Must visualize the drill bits exit laterally! Requires more exposure the greater the angulation of the osteotomy = the more you want to anteriorize the tibial tubercle Drill Bits/Cutting Guides Must be Co-Planar (jig or eye-ball) Osteotomy Do not angle the saw blade proximal past the proximal drill/cutting guide Enter the tibial plateau zone Must visualize the bits/blade as they exit the lateral tibia Can Not Be Posterior! Osteotome Start the osteotome completion of the osteotomy superior medial Continue posterior to the patella tendon Extending the osteotomy Complete the osteotomy posterior to the patella tendon Then down the lateral tibia Osteotome Connect the retropatellar tendon portion of the osteotomy to the lateral cut. The lateral cut was the portion performed with the saw Complete the osteotomy Complete the cut by inserting a larger osteotome from the medial side and gentle pry up the fragment There should be only mild pressure to “crack” the distal portion which was not cut. Elevate the fragment Elevate the fragment and rotate it anteriorly and medially The co-planar osteotomy will easily translate medial and anteriorly Evaluate the Patellar Position If you have performed a lateral release palpate the patellar resting position Or palpating the femoral condyles assessing the patella in the trochlear center But Not medially Fixation Always place the distal screw first Compresses the proximal portion of the osteotomy O/w the proximal screw is often too long as it compresses the osteotomy and cause pes bursitis Screw technique Use an interfragmentary technique by overdrilling the tibial tubercle fragment and compressing the osteotomy site The proximal screw should be placed just posterior to the anterior medial tibial cortex Medial View Anteriorization & Medialization Check the anterior medial tibial offset Lateral view Anteriorization & Medialization Check the lateral tibial offset Smaller and smaller incisions Fulkerson Anteromedial Tibial Tubercle Transfer Post-operative protocol Outpatient procedure Hinge knee brace locked in full extension Toe touch to partial weight bearing – immediately advance as tolerated (2° to the short metaphyseal osteotomy) 1 week – F/U heel slides 2 weeks allow 50 degrees of motion 4 weeks allow 90 degrees of motion 6 weeks, if quad strength allows, discontinue the brace Questions? Thank You
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