Healio
Healio
June 22, 2009
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For best results, perform osteotomies for knee OA early and in the proper patients

Young, highly active patients needing to buy time before total knee arthroplasty are ideal candidates.

Although using osteotomy as a treatment for early knee osteoarthritis is still not widely accepted by U.S. orthopedists, it is often the most rational approach to use for young, active patients, according to a physician speaking at the 25th Annual Current Concepts in Joint Replacement Winter Meeting.

Kenneth A. Krackow, MD, supported reserving total and unicompartmental knee arthroplasty for patients whose degree of knee osteoarthritis (OA) puts them beyond the indications for a knee osteotomy, during his presentation.

“The potential [osteotomy] candidate … is somebody typically 30 to 60 years of age. He or she is active, not particularly sensitive in the knee, has symptoms, but is too young, maybe too active, for a metal-and-plastic arthroplasty,” he said.

Krackow recommended doing osteotomies in a timely fashion. “Don’t wait for that bare bone or greater area of bone. Osteotomies should be done sooner rather than later,” he noted.

Bone sparing

Perform high tibial, proximal tibial and distal femoral osteotomies when indicated, but be prepared for them to be technically challenging, Krackow explained. Those challenges aside, he noted osteotomies offer such important advantages for patients and surgeons as better cosmetic appearance and a bone-sparing treatment that effectively realigns the knee.

Patients for whom knee osteotomy is indicated usually have a remaining 30- to 70-year life expectancy. Since it is conservative, Krackow encouraged first performing an osteotomy, not a total or partial knee arthroplasty, particularly in anyone younger than 60 or 70 years old.

“Consider also that an osteotomy could make a future total knee actually easier,” and will not usually interfere with it, he said.

High-level activity

Obvious deformity, coupled with the patient’s desire to resolve his or her minimal pain at night or during rest, was among the procedure’s indications Krackow discussed. He noted it is also recommended for those hoping to return to a high level of activity postoperatively.

“I fundamentally have no indication for conservative management,” Krackow said. NSAIDs and other conservative therapies are often unsuccessful in this population, he explained.

Krackow cited some success reported in predicting osteotomy outcome the literature by using short-term fiberglass off-loading casts. They work by moving the foot contact point medially or laterally based on whether the patient has a varus or valgus knee deformity.

Accurate measuring

Although knee osteotomy surgery is inherently simple, performing it well can be quite difficult. “Accuracy is paramount,” Krackow said. “The technical challenge becomes rather daunting.”

He showed how he measures the bone wedge to be removed and uses the bovie cord. For distal femoral osteotomies, “Think of the big blade plate just as if it were a staple,” Krackow said.

During the discussion period, he explained he tends to overcorrect the deformity about 2% to 4% past neutral, which is “what the literature overwhelmingly supports.”

Getting patients moving while protecting their fixation are key components of Krackow’s postoperative regimen. If he is uncertain they are healing as expected, he checks their progress with imaging.

For more information:

  • Kenneth A. Krackow, MD, can be reached at Buffalo General Hospital, Orthopaedics Department, 100 High St./B-276, Buffalo, NY 14203; 716-859-1256; e-mail: kkrackow@buffalo.edu. He is a consultant to and receives royalties from Stryker.

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