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Tibial Valgus Osteotomy

The knee is composed of 3 parts: the femur, the tibia and the patella. In some cases, the axis of the lower extremity and therefore the knee is varus, or curved.

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As a result, more weight tends to pass through the medial compartment of the knee than the lateral part. This can damage the medial compartment and lead to premature wear of the cartilage and the meniscus.
In some cases, and when medical treatment is insufficient, realignment of the mechanical axis of the lower extremity may be indicated to straighten the knee.
This is a tibial valgus osteotomy.
A minimally invasive medial approach is used.
The osteotomy, which consists in cutting the top of the tibia, is performed under x-ray control. A lateral bone hinge is preserved intact so the cut can be opened up and the deformity corrected according to its magnitude.
Synthetic bone is inserted to promote consolidation.
A plate is fixed to hold the correction in place while it heals and to rapidly enable weight bearing.
The aim of the operation is to relieve the pain caused by the damage to the medial compartment of the knee and to slow down the onset of osteoarthritis.
The mechanical axis is restored and the forces redistributed.
Following the operation, crutches are used for 3 to 6 weeks to relieve the joint.

Knee ligament reconstruction

The knee is a fundamental joint connecting the femur to the tibia and the fibula. It is composed of various structures, as illustrated in this video, which can be damaged or worn: menisci, cartilage, ligaments…

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The anterior cruciate ligament is a major ligament located in the middle of the knee which connects the femur to the tibia. It prevents forward translation and stabilises the knee during rotation. Its rupture results in instability and abnormal function during flexion and extension of the knee. In this case, it must be repaired. Anterior cruciate ligament reconstruction is performed arthroscopically. The old ligament is prepared and partially cleaned. Using a drill guide, a pin is accurately positioned where the anterior cruciate ligament inserts in the femur. This pin guides the drill bit to create the femoral tunnel. The same procedure is carried out on the tibia. A tunnel is created and ends at the natural tibial insertion of the anterior cruciate ligament.
The tendons harvested beforehand are passed through these tunnels, thus recreating the anterior cruciate ligament from where it is attached to the tibia to where it is attached to the femur. The tendons are attached using interference screws, which trap the tendons in the tibia and the femur. These screws will break down over time. As much of the old anterior cruciate ligament is retained as possible to help promote cell colonization on the new ligament. The stability of the knee is thus restored.
This operation is performed arthroscopically through small incisions using a camera to visualize the joint, thus minimising scarring and enabling faster recovery.

Meniscal surgery

The meniscus acts like a shock absorber in the joint between the femur and the tibia. There are two menisci: medial and lateral, which suffer two types of trauma.

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The first is a flap with a mobile fragment in the joint between the femur and the tibia, causing pain, discomfort and cartilage damage due to rubbing of the cartilage. The meniscal bell clapper must therefore be resected using small pliers and finely rectified using a small surgical knife with a vacuum system.
The second type of lesion is peripheral, that is to say, located around the edge of a well-vascularised area where the meniscus can heal. Miniature suturing instruments are used to repair the lesion. Several stitches help the lesion to heal rapidly, thus preserving the entire meniscus.
This surgery is performed arthroscopically through small incisions using a camera to visualize the joint, thus minimising scarring and enabling faster recovery.

Patella Dysfunction

The quadriceps tendon connects the thigh muscle to the top of the patella, and the patellar tendon connects the bottom of the patella to a bump on the top of the tibia called the anterior tibial tuberosity. Two lateral bands, the lateral retinaculum and the medial retinaculum, stabilize the patella.

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– If the lateral retinaculum is too tight, the patella exerts too much external pressure on the femoral cartilage, or trochlea.

The surgical procedure is performed arthroscopically, through two small incisions using a camera to view the joint, and consists in cutting the lateral retinaculum to relieve the excessive pressure and thus reduce the rubbing between the external part of the patella and the trochlea. The retinaculum will then heal, but more loosely.

– Retraction of the lateral retinaculum is often associated with a lateral position of the patella, which is due to the off-centre insertion of the patellar tendon owing to the position of the tibial tuberosity bump, which is also in an abnormally lateral position. In addition, this situation results in excess rubbing on the lateral side of the trochlea and causes pain in the kneecap and sometimes its dislocation.

In addition to retinaculum release, the therapeutic procedure consists in repositioning the tuberosity, released beforehand by an incision of a few centimeters, in the centre of the knee and then fixing it with two screws to realign the patellar tendon in the centre of the trochlear groove.
Correct patella tracking is restored and the excessive rubbing that caused the pain in the patella and the cartilage damage is eliminated.

Any cartilage damage can be treated at the same time. Once consolidated, it is often useful to remove the screws.

Knee Cartilage Damage

Cartilage damage can be divided into three categories: Firstly, a small section of cartilage can come away from the joint with a piece of bone attached. The second possible scenario is damage to the cartilage alone, which breaks into several fragments that come away in the joint causing pain and blocking. Finally, a fragment can come away with a piece of subchondral bone. Both bone and cartilage are lost in this case and the fragment, altered and worn, cannot be reattached.

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– Firstly, a small section of cartilage can come away from the joint with a piece of bone attached.
This type of lesion can heal. The fragment can be reattached using a screw to enable stabilization and consolidation of the cartilage.
The surface of the joint is thus restored.
Once consolidated, it is often useful to envisage removing the screw.

– The second possible scenario is damage to the cartilage alone, which breaks into several fragments that come away in the joint causing pain and blocking.
The fragments are removed arthroscopically.
The damaged area where the bone is exposed is thus abraded. A technique called Pridie drilling is used to create micro-holes to induce fibrocartilaginous healing with recovery of 80% of the mechanical function of normal cartilage.
A few weeks, or even a few months, are necessary for the surface of the cartilage to heal.

– Finally, a fragment can come away with a piece of subchondral bone. Both bone and cartilage are lost in this case and the fragment, altered and worn, cannot be reattached.
It is thus necessary to reconstruct the cartilage but also the subchondral bone.
To do this, bone and cartilage plugs are harvested from a location on the surface of the knee where the cartilage is of little use. The damaged site is prepared and these samples are grafted.
Several plugs are often required; we thus talk of “Mosaicplasty”.
In this case, it is also necessary to wait several weeks for complete osteochondral consolidation and restoration of the joint surface.

These procedures are all performed arthroscopically, through two small incisions using a camera to view the joint. After the operation, it is necessary to use crutches to move around for several weeks to keep the weight off the knee, as healing is significantly improved with decreased mechanical stress due to weight.

Unicompartimental Knee Replacement

Osteoarthritis of the knee can affect just one compartment of the knee, femorotibial or femoropatellar. In this case, we talk of isolated knee osteoarthritis, which only concerns one third of the joint surface of the knee.

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As two-thirds of the surface remain intact, we can envisage a unicompartmental knee replacement, in other words only replace the area of worn cartilage.
A minimally invasive approach is thus used.

The cartilage surfaces damaged by knee osteoarthritis are resected. Specific cutting guides are placed on the tibial and femoral surfaces to ensure the correct positioning of the tibial and femoral implants.

All the other structures, ligaments, tendons and remaining knee cartilage, are conserved.

To deal with isolated knee osteoarthritis, a unicompartmental replacement helps preserve the natural sensations in the knee joint. Moreover, recovery after the operation is faster than with total knee replacement, and in over 70 % of cases the lifespan of the implant exceeds 20 years.