Name: Distal Femoral Osteotomy with Meniscal Allograft and Fresh Osteochondral Allograft Transplantation
Uploaded: 2017-10-06T00:00:00Z
Channel: Arthrex
Description: Jeffrey Macalena, MD, (Minneapolis, MN) presents a case study on a patient treated with distal femoral osteotomy, meniscal allograft and fresh osteochondral allograft.

<p>Jeffrey Macalena, MD, (Minneapolis, MN) presents a case study on a patient treated with distal femoral osteotomy, meniscal allograft and fresh osteochondral allograft.</p>

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VPT1-00767-EN | B | Distal Femoral Osteotomy with Meniscal Allograft and Fresh Osteochondral Allograft Transplantation

Jeffrey A. Macalena

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Distal Femoral Osteotomy with Meniscal Allograft and Fresh Osteochondral Allograft Transplantation

Hi, my name is Jeff Mikulina from the University of Minnesota. I specialize in sports medicine. Today, I'd like to talk to you about a case of mine that I think brings up a couple of different interesting topics. It's that of a 32 year old male. He underwent an ACL reconstruction about ten years previously. And at that time, a large lateral meniscectomy was performed. He's done well in regards to stability of his knee and he has not had instability symptoms. He was referred to me to see if anything else could be done for his knee, as it certainly is affecting his desired activities. Plain radiographs show prior ACL tunnel in reasonable position without significant dilation of his tunnel. Lateral joint space narrowing is subtly appreciated in these plain films. An MRI shows an intact ACL graft. However, considerable wear of his lateral femoral condyle with subchondral edema and cyst formation is noted. Where are the cartilage surfaces on the lateral department is also present. Standing alignment films demonstrate subtle genu valgus, with the weight bearing axis falling lateral to the lateral tibial spine. In patients like this. With such complex histories, I frequently offer them staging arthroscopies to fully identify and understand the intra-articular components of their knee. Further, it allows for a detailed examination under anesthesia to check for his ACL graft function. Here, arthroscopic images show an intact ACL graft and his knee was stable on examination. His lateral compartment, though, shows profound wear of the distal femur with significant change in the normal contour. Note that the tibial plateau surface is largely maintained. The lateral meniscus is certainly deficient as seen in these arthroscopic images. Given this patient's profound amount of wear to the compartment and continued pain, we ultimately offered him surgical reconstruction and cartilage reconstruction in a technique of joint preservation. Our thoughts for this were to offer him a meniscal allograft transplant to improve the transfer of forces across the knee joint. We'd also plan to resurface his lateral femoral condyle with an osteochondral allograft at the same time. At the conclusion of those intra-articular procedures, we would then perform a distal femoral osteotomy to unload the lateral compartment. The next step is how to manage the timing of it during the procedure itself. And here's this process that I follow. I first perform an arthroscopy where we prepare the intra-articular structures for the meniscus transplant. To do this we use a FlipCutter. I use a seven millimeter FlipCutter to drill both the anterior and posterior root attachments, and we make a seven millimeter socket. I do this to about 20mm in depth. We then use number two FiberStick to place through these sockets to allow for placement of our graft. After preparation of the intra-articular structures for the transplant, I then perform an open arthrotomy of the knee and complete the osteochondral allograft. After the osteochondral allograft is in place. We then return and place the meniscus transplant and suture it in place with an with an inside out technique. At that point, we can close the arthrotomy and proceed with our distal femoral osteotomy. One of the techniques that I use for the distal femoral osteotomy is to preoperatively plan the size of the correction to help determine which contour lock plate we are going to use either the small or the large. The ContourLock plate with the cloverleaf design here is low profile in nature, and I think has left soft tissue irritation on the lateral side. After isolating our surgical incision, the ContourLock plate is then placed on the bone to help determine the level of the osteotomy. Two guide pins are then placed above and below the plate, and it's very important to ensure that these guide pins are collinear with the long axis of the femur, so as not to flex or extend the osteotomy. After the guide pins are placed across, the osteotomy is completed on the lateral cortex with an oscillating saw and then further with an osteotomy after opening and then final fixation. The radiographs show good position of our osteotomy plate and screw construct. Note the position of our osteochondral allograft on the lateral femoral condyle. Restoring the normal subchondral line. A final tip is to use an alignment rod intraoperatively to confirm the amount of correction. To do this, I take an AP X-ray of the hip end of the ankle with our long alignment rod centered over both these joints. Then, by transitioning to the knee joint, we can see where the alignment rod passes the knee joint, confirming the correction of the appropriate amount. This patient was admitted to the hospital and we did put them toe touch weight bearing for the first six weeks to protect both our allografts as well as our distal femoral osteotomy. At the six week mark, we will allow weight bearing as tolerated and a slow progressive range of motion. I think that this surgical technique and treatment of both the intra articular pathology, as well as the malalignment, is a way to potentially restore his desired activity level and get him back to doing the things that he wants to do.

Distal Femoral Osteotomy with Meniscal Allograft and Fresh Osteochondral Allograft Transplantation

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