Nom original: ARTICLE PTG_OTV.pdfTitre: One-stage computer-assisted total knee arthroplasty and tibial osteotomyAuteur: S. Denjean

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Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386

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Technical note

One-stage computer-assisted total knee arthroplasty and tibial
S. Denjean a , F. Chatain b,∗ , O. Tayot c

Polyclinique du Val-de-Saône, 44, rue Ambroise-Paré, 71000 Macon, France
Clinique Belledonne, pôle santé Axone, 75, avenue G.-Péri, 38400 Saint-Martin-d’Hères, France
Clinique du Parc, 155 Ter, boulevard Stalingrad, 69006 Lyon, France

a r t i c l e

i n f o

Article history:
Received 13 September 2016
Accepted 17 January 2017
Total knee arthroplasty
Computer-assisted surgery
High tibial osteotomy
One-stage surgery
Severe extra-articular bone deformities
Knee arthritis

a b s t r a c t
Same-stage tibial osteotomy may deserve consideration in candidates to total knee arthroplasty (TKA)
who have severe bone deformities, particularly at extra-articular sites. This strategy obviates the need
for either a major and technically difficult ligament release procedure, which may compromise ligament balancing, or the use of a semi-constrained prosthesis. This technical note describes a one-stage,
computer-assisted technique consisting in TKA, followed by corrective tibial osteotomy to obtain an
overall mechanical axis close to 180◦ without extensive ligament balancing. This technique provided
satisfactory outcomes in 8 patients followed-up for at least 3 years, with no specific complications or
ligament instability and with a hip-knee-ankle angle close to 180◦ . After planning, intra-operative computer assistance ensures accurate determination of both implant position and the degree of correction
achieved by the osteotomy.
© 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction
Mechanical axis alignment and ligament balancing are interdependent factors that are crucial to achieving good long-term
outcomes of total knee arthroplasty (TKA) [1,2]. In patients with
severe bone deformities, correcting the mechanical axis is technically demanding, most notably when the deformity is fixed and
extra-articular [3]. Rajgopal et al. [3], Xiao-Gang et al. [4], and
Koenig et al. [5] have stated that severe extra-articular deformities can usually be corrected during TKA by performing extensive
ligament release, although a semi-constrained prosthesis may be
required. In contrast, Zanone et al. [6], Madelaine et al. [7], and Lonner et al. [8] advocated combining the TKA with tibial osteotomy
to correct the extra-articular bone deformity, thereby avoiding
post-resection laxity, extensive ligament release, and the use of a
semi-constrained prosthesis. However, combining TKA with tibial
osteotomy is technically challenging and carries a risk of complications [7]. Two options are available: same-stage tibial osteotomy
can be performed either before or after the TKA.
This article describes a one-stage computer-assisted technique
for performing TKA followed by tibial osteotomy to obtain a

∗ Corresponding author.
E-mail address: (F. Chatain).
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.

mechanical axis of about 180◦ without extensive ligament balancing.
2. Technique
Pre-operative planning included measurement on a long-leg
radiograph of the mechanical tibial, femoral, and femoro-tibial
angles (Table 1). The reducibility of the deformity was assessed
clinically. Amplivision (Amplitude, Valence, France) [1] was used
for navigation. The prosthesis was the primary total knee implant
SCORE (Amplitude), characterised by a highly congruent rotating
platform and an elongated tibial keel. The cementless versions of
both the femoral and the tibial components were used (except in
one patient, for the tibial component).
2.1. First step: implanting the total knee prosthesis
The procedure is performed with or without a tourniquet.
An antero-medial approach is used, to allow the subsequent tibial osteotomy. A femoral rigid body is positioned through the
incision in the metaphyseal position and a tibial rigid body transcutaneously in the diaphyseal position to avoid impeding the
osteotomy. After arthrotomy and standard capsular release, the
overall deformity and its degree of reducibility are assessed by a
forced valgus or varus manoeuvre and measured using the navigation tool [9] (Fig. 1). The tibial cut is performed first, based on the


S. Denjean et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386

Table 1
Pre-operative, intra-operative, and post-operative data.
Patient #
1: B. N
2: G. AM
3: O. S
4: P. B
5: R. O
6: T. D
7: D. J
8: M. P

Previous surgery






Navigated tibial cut

Valgus 9
Varus 8◦
Valgus 10◦
Varus 7◦
Varus 8◦
Varus 10◦
Varus 8◦
Varus 7◦

Femoral rotation





Tibial keel size, mm






12 × 150
10 × 100
12 × 100
10 × 150
12 × 100
10 × 150
12 × 75


CWO: closing-wedge osteotomy; L: lateral; OWO: opening-wedge osteotomy; M: medial; HKA: hip-knee-ankle angle, HKA1 : pre-operative HKA angle; HKA2 : intra-operative
HKA angle during the reduction manoeuvre; HKA3 : post-operative HKA angle; MFA1 : pre-operative mechanical femoral angle; MFA3 : post-operative mechanical femoral
angle; MTA1 : pre-operative mechanical tibial angle; MTA3 : post-operative mechanical tibial angle; PT1 : pre-operative tibial slope; PT2 : navigated tibial slope; PT3 : postoperative tibial slope.

Fig. 1. Evaluation of the HKA angle and of deformity reduction by external manoeuvres, using the navigation tool. In this patient with a history of medial opening-wedge
tibial osteotomy, there is a residual varus deformity of 10◦ .

irreducible component of the deformity. For instance, if 10◦ of varus
deformity persists during the forced manoeuvre, the tibial cut is
angled 10◦ in varus (Fig. 2). Similarly, if the residual deformity is 9◦
of valgus, the tibial cut is angled 9◦ in valgus. In practice, the result is
a cut parallel to the tibial joint surface, with no attempt to replicate
an oblique joint space after the tibial osteotomy is performed. In
the sagittal plane, the tibial slope is planned perpendicularly to the
tibial mechanical axis. The femoral cuts are performed next, classically based on the ligament balance as assessed by the extension
and flexion gaps measured using the navigation tool. No specific ligament release procedure is performed, and the global mechanical
axis displayed by the navigation tool is not taken into account. The
degree of femoral rotation is based on the ligament balance in flexion. The trial implants are then inserted. Fig. 3 shows an example,
in which 10◦ of varus is allowed to persist.
2.2. Second step: corrective tibial osteotomy
The tibial osteotomy is performed to obtain an axis close to 180◦ ,
under guidance by the navigation tool and with an image amplifier.
The staples used to close the osteotomy are positioned in order to
avoid impeding the preparation of the tibial keel and the insertion
of the final implants (Figs. 4 and 5).
2.3. Third step: insertion of the final implants
The final implants are then inserted. The elongated tibial keel
bridges the tibial osteotomy. In the event of an opening-wedge

osteotomy, autologous bone grafting is performed using fragments
from the femoral resections. The two staples are left in place to
enhance stability and put pressure on the autologous bone graft
(Fig. 5). Stabilization using two staples was not required in either
of the 2 cases of closing-wedge tibial osteotomy (Fig. 6).
3. Results
This technique was used in 8 patients, 5 females and 3 males
with a mean age of 70 years (range, 56–85 years) and a mean
body mass index of 27 (range, 21–46). Primary osteoarthritis was
the reason for TKA in all 8 patients. Pre-operatively, 6 patients
had varus deformity, ranging from 15◦ to 19◦ , and 2 had valgus deformity, of 10◦ and 18◦ , respectively. Closing-wedge and
opening-wedge tibial osteotomy had been performed previously
in 3 and 2 patients, respectively. The tibial osteotomy performed
during TKA was opening-wedge in 6 of the 8 patients (Table 1).
Patellar resurfacing was not performed. Rehabilitation therapy was
started immediately, with no splinting. Contact weight bearing
was allowed with two canes, for 2 months. All patients were reevaluated by a surgeon, who determined the International Knee
Society (IKS) score and obtained radiographs including anteroposterior, lateral, axial patellar, and long-leg views. Follow-up was
3 to 11 years.
All patients were re-evaluated at least 3 years after the procedure. Knee manipulation under general anaesthesia was required
45 days post-operatively in 1 patient. Another patient experienced deep vein thrombosis. Full weight bearing was achieved

S. Denjean et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386

Fig. 2. Use of the navigation tool to plan the tibial cut at 10◦ of varus, thus correcting the residual 10◦ of valgus during passive forced varus.

Fig. 3. HKA angle measurement after insertion of the trial implants: persistence of 10◦ of varus.



S. Denjean et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386

Fig. 4. Medial opening-wedge corrective tibial osteotomy under guidance by fluoroscopy (a) and by the navigation tool (b). The final HKA angle is 180◦ .

Fig. 5. Final result after navigated TKA and medial opening-wedge tibialosteotomy.

by all patients after 2 months. The mean knee and function IKS
scores were 91 and 87, respectively. Mean flexion was 110◦ (range,
90–130) and the mean HKA angle was 180◦ (range, 176◦ –181◦ ).
The patella was aligned in all 8 patients. There were no cases of
rotational ligament instability, inadequate implant fixation, or specific complications of osteotomy (fracture, non-union, discomfort,
or hardware breakage).

4. Discussion
Same-stage TKA and tibial osteotomy is regarded as technically challenging [4,7,8]. A navigation tool benefits both reliability
and reproducibility by determining the optimal orientation of the
cuts – most notably at the tibia (the site of the deformities in
our population) – according to the irreducible component of the

S. Denjean et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386


Fig. 6. Final result after navigated TKA and medial closing-wedge tibial osteotomy.

deformity during reduction manoeuvres. Thus, the size of the bone
wedge can be planned, and correction of the HKA angle by the
osteotomy after insertion of the trial implants can be monitored
in real time.
Navigation has been proven to increase the accuracy and reproducibility of TKA [10–15], thereby improving long-term implant
survival [2]. Navigated TKA combined with tibial osteotomy has
been recommended by Rhee et al. [16] for patients with severe
extra-articular deformities and by Catani et al. [17] for those with
extra-articular mal-union. Of our 8 patients, 5 had a history of tibial
osteotomy, which had caused metaphyseal mal-union. Correcting
the deformity within the prosthesis via extensive soft-tissue release
can raise technical challenges and can induce instability requiring
the use of a semi-constrained prosthesis. Achieving correction by
an osteotomy within the deformity, without damaging the ligaments, therefore holds appeal as a more rational and conservative
Nevertheless, navigating complex surgical procedures requires
thorough familiarity with the software, which can be achieved only
by using the navigation tool routinely for all primary arthroplasties, particularly in simple cases. This strategy is followed in our
department. Navigation should not be reserved for complex cases.
The surgical sequence described here consists in inserting the
trial TKA implants then performing the tibial osteotomy, which is
maintained by two staples, and inserting the final implants, including a tibial implant equipped with a long keel. Madelaine et al. [7],
in contrast, have advocated performing the tibial osteotomy before
the TKA. However, bone healing was delayed in their population
and they consequently recommended rigid internal plate fixation.
Furthermore, with their sequence, concern about loading and compromising the primary osteotomy may impede a reliable evaluation
of ligament balance.
In contrast, starting by preparing the TKA allows ligament
balancing in flexion and extension within the intact ligament envelope, without considering the mechanical axis or having to protect

the tibial osteotomy. Furthermore, rigid internal fixation is unnecessary. Stability is ensured by the long tibial keel, two staples to
maintain the osteotomy, and autologous bone grafting if openingwedge osteotomy was performed. Thus, immediate weight bearing
can be allowed. However, as a precaution, our patients were asked
to use two canes to minimise weight bearing. Complete bone healing was achieved consistently. Tibial plate fixation requires a more
extensive approach, with detachment of the medial ligament plane,
and also increases the risk of specific complications (plate breakage,
delayed healing, and discomfort due to the hardware located under
the skin). The use of a long tibial keel precludes adjustment of the
tibial slope, but this is probably a smaller disadvantage compared to
those associated with tibial plate fixation. The recommended keel
length is 100 mm. In our study, of the 2 patients with the poorest
outcomes, 1 received a 75 mm keel and the other no keel (material
unavailable in the operating theatre), which may have contributed
to loss of angle correction in the coronal plane. In our patients,
tibial slope was planned perpendicularly to the tibial mechanical
axis, both because the tibial implant had 4◦ of slope within the
insert and to avoid impeding the implantation of the long tibial
keel. Tibial slope measurement by the navigation tool after the tibial osteotomy was not feasible in our patients but would be possible
with the currently available software. We assessed tibial slope clinically based on absence of extension lag before and after the tibial
5. Conclusion
The technique described herein produced satisfactory clinical
and radiographic outcomes. For patients with severe, irreducible
bone deformities, we recommend the use of a navigation tool for
performing an accurate tibial osteotomy in combination with primary TKA. We advocate performing the TKA first then correcting
the mechanical axis by a tibial osteotomy, to avoid extensive softtissue release or the use of a semi-constrained prosthesis.


S. Denjean et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 381–386

Disclosure of interest
SD, OT, and FC receive royalties from Amplitude.

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