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http://hdl.handle.net/1635/15099
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| Titre: | Les prothèses totales du genou sur grandes déviations axiales « Grand genu varum, grand venu valgum » |
| Auteur(s): | RAFA, Bachir
Hamdaoui, Tahar |
| Mots-clés: | Varus and valgus deformities
Total knee arthroplasty
soft tissue release |
| Issue Date: | 18-Jan-2021 |
| Description: | Introduction: Large axial deviations are defined as any misalignment in varus or valgus exceeding 10 °, after maximum reduction. They are not uncommon and represent 1/3 of the total knee prostheses. The good results of a total knee prosthesis in terms of longevity depend on a good alignment of the mechanical axis, and a good ligament balancing. In large deformations these two objectives are difficult to achieve, which explains the high frequency of complications: instability, rapid wear of polyethylene, and early loosening of the prosthesis.
The aim of this work is to better understand the ligamentous lesions, bone or mixed through a preoperative clinical and radiological planning to anticipate technical difficulties. The technical problems concern the choice of the approach in particular in large valgus (Keblish pathway, or anterior external pathway with or without recovery of the tibial tuberosity), the importance and chronology of ligament release for the purpose to obtain balanced spaces both in extension and flexion, and finally the place of osteotomies prior to or contemporaneous with the prosthesis when extra-articular bone deformity exceeds 10 °.
Patients and methods: This is a descriptive study that is both retrospective and prospective. It involves 67 patients totalling 77 knees reviewed. This is 54 genu varum and 23 genu valgum supported at the DOUERA CHU between 2000 and 2016 with an average age of 67 years and a mean follow-up of 7.5 years. All patients were in stadiums advanced radiology (Ahlback stages IV and V) and 16 patients had inflammatory diseases with associated coxofemoral involvement treated first. The average HKA angle was 163 ° for varus and 193 ° for valgus. Mean flexion was 98 ° for varus and 100 ° for valgus; the overall IKS score was 75 for varus and 76 for valgus
Most of the cases were classified in stage II according to Catonné (wear in the concavity associated with a laxity of the convexity). Previous tibial osteotomy was performed in 14 cases for tibia vara deformity of more than 10 °, (10 external subtractions and 4 internal additions). The average osteotomy-prosthesis time is 8 to 12 months (4 staple ablations were performed at the same time)
The recovery of TTA was associated in 9cas (7 times in the lateral lane and 2 times in the medial lane). The release of the retracted ligaments into the concavity was progressive and on demand to achieve limb retraction with an external rotation of 3 ° to 5 ° of the femoral component. The bone defect of the worn tibial plateau was filled by screws and cement without bone graft. The prosthesis used is a posterior stabilized cemented with patellar resurfacing in 53 cases (38 times in the varum and 15 times in the valgum)
Results: The clinical and radiological results are evaluated according to the International Knee Society (IKS) score and Student's "T" test is used to calculate means and significance. These results are similar to those of the literature with an HKA angle at 179 ° for varus and 181 ° for valgus. The flexion is improved at 112 ° for varus and at111 ° for valgus, the overall IKS score rose to 172 points for varus and 173 ° for valgus.
We deplore 2 septic lozenges (an early infection that has evolved badly after early revision, and a late haematogenous infection in 5 years). The recovery was performed by a prosthesis constrained after drying in 2 stages (removal of prosthesis + spacer). There are also 2 prosthetic instabilities, one by excess of ligament release (This is an old subject who refused the recovery) and the other by a poor choice of the height of the PE. (The recovery was carried out at 2 years with a thicker PE).
Discussion: The radio-clinical examination is fundamental in search of a laxity in the convexity. It must specify in the global deformation the joint part (bone wear, lesions of the ligamentous envelope) and the extra articular part (ATM angle). This requires the combination of an osteotomy to the prosthesis when it exceeds the threshold of 10 ° knowing that for the same angulation the reaxation is more difficult in case of genu valgum. The previous osteotomy puts us in the conditions of a total simple knee prosthesis
The external release can be replaced by the external condyle osteotomy of Burdin, a very attractive technique that we do not have experience in Algeria.
Conclusion: A good knowledge of the anatomopathological lesions of GDF allows the pose without apprehension of a TKA and to face the possible peroperative difficulties |
| URI: | http://hdl.handle.net/1635/15099 |
| Appears in Collections: | الطب
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