Varisation osteotomy is an established treatment for younger patient with arthritis of knee due to valgus malalignment. Since the majority of those deformities is located on the femur, supracondylar varisation osteotomy is indicated in the majority of the cases. Nevertheless, in some case in tibial deformities osteotomy of the proximal tibia can be performed. Is there an indication for double osteotomies in patients with a mixed type (femoral and tibial) deformity?
This is a difficult question. I think these rare patients who need double osteotomy around the knee (femoral and tibial) are not the common arthritis cases. They may suffer from congenital or developmental dysplasias, posttraumatic deformities, knee instability of different origin.
In the usual cases I use the old recommendation of Boitzy (In; Die Gonarthrose Hrsg. L. Nicod, Huber, Bern, 1970) when planing the osteotomy on unipedal a.p. X-rays. If the joint line is directed upwards - femoral supracondylar osteotomy is indicated, if it points out downwards - tibial osteotomy is the choice. This "iron" rule provides a horizontalization of the knee joint after the osteotomy.
Thanks for your helpful answer, which is certainly valide for the largest amount of patients. Nevertheless, the crucial questions remains: how much overcorrection of the individual bone (distal femur or proximal tibia) can be tolerated in cases of combined deformities ?
The question tackles valgus deformity. In my opinion the overall (femoral and tibial) correction should be planned so that no deviation from the normal vertical axis of the lower extremity exists after the operation. This should be the right solution if one more condition is achieved - absence of ligament instability. If knee instability exists, then the planning of single or double osteotomy around the knee must take it in additional consideration. Here the variants are several depending on the kind of instability.
In general guidelines I would recommend you to make a tibial osteotomy of substraction-Coventry in varus deformities of the knee and femoral osteotomy of addition in valgus deformities of the knee; except in post-traumatic sequels as poliomyelitis valgus that is preferable a tibial osteotomy of addition with allograft. Best regards
Dear Gustavo, by doing it in the way of your recommendation, you will probably be right in the majority in the cases, but you will certainly not perform your correction at the site of the deformity in those with a femoral varus or a tibial valgus deformity ... my questions actually yielded on those patients with a severe mixed type (combined femoral and tibial) deformity ... in order to avoid an oblique joint line double osteotomy certainly seems an interesting option
Correct Philipp. There are some cases, specially in extra-articular deformities where you can perform double osteotomies. An experimented surgeon with these procedure and correct planification and measure of the angles should be considered to achieve good outcomes, despite the surgical aggressiveness.
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