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Osteotomy.Pdf Table of Contents About the Authors 5 Introduction 7 Basic Knee Anatomy 9 Understanding Lower Limb Malalignment 12 The Basics 12 Primary, Double, and Triple Varus 14 The Influence of Gait (How We Walk) on Forces in the Knee 18 What Happens in the Arthritis Process in the Knee Joint? 20 The Demise of Articular Cartilage 20 Types of Knee Arthritis 21 The Knee Examination 22 History 22 Where Does It Hurt? 22 Range of Knee Motion 23 Knee Ligament Tests 23 Meniscus Tests 25 Knee Joint Crepitus 25 The Patellofemoral Joint 26 Lower Limb Alignment and Gait Analysis 26 Muscle Strength and Function 26 Imaging Studies (X-rays, MRI) 26 Conservative Treatment: What You Should Have Already Tried 28 A Few Comments 28 Mild Arthritis Pain 29 Moderate Arthritis Pain 29 Severe Arthritis Pain 29 Choosing an Orthopaedic Surgeon in the United States 30 High Tibial Osteotomy for Varus (Bowed Leg) Malalignment 31 Indications 31 Contraindications 32 Timing of Knee Ligament Reconstruction if Required 33 Preoperative Planning 34 Choosing Between an Opening Wedge and Closing Wedge Procedure 35 Initial Steps for Both Osteotomy Procedures 36 Opening Wedge Osteotomy 37 Closing Wedge Osteotomy 40 Possible Complications 41 Expected Results 41 Distal Femoral Osteotomy for Valgus (Knock-Knee) Malalignment 42 Indications 42 Contraindications 43 Preoperative Planning 44 How the Operation May Be Done 44 Possible Complications 46 Expected Results 46 Limb Alignment Osteotomy Versus Partial Knee Replacement 46 Common Associated Operative Procedures 47 ACL Reconstruction 47 PCL Reconstruction 48 Posterolateral Reconstruction 49 Articular Cartilage Restoration 51 Meniscus Repair 52 Meniscus Transplantation 53 Preparing for Surgery 53 Getting Your House Ready 53 Food and Medications 55 Practice the Exercises You Will Do After Surgery 56 Mental Preparation 56 The Night Before Surgery 57 The Day of Surgery 57 Recovering From Surgery 59 Prevention of Blood Clots in Your Leg (Deep Venous Thrombosis) 59 Our Postoperative Physical Therapy Program 59 Home Exercises 67 Ankle Pumps 67 Range of Knee Motion 67 Patellar Mobilization 67 Hanging Weights 68 Rolling Stool 68 Wall Slides 68 Quadriceps Isometrics: Full Extension 69 Quadriceps Isometrics: Multi-angle 69 Straight Leg Raise: Hip Flexion 70 Straight Leg Raise: Hip Extension 70 Straight Leg Raise: Hip Abduction 70 Straight Leg Raise: Hip Adduction 70 Straight Leg Raises With Resistance Band 71 Mini-squats 72 Hamstring Curls, Active 73 Knee Extension, Active-Assisted 73 Knee Extension, Active 73 Wall Sits 73 Heel Raises 74 Toe Raises 74 Lateral Step-ups 74 Step-downs, Stable and Unstable Surface 74 Hamstring Stretch 75 Calf Stretch 75 Iliotibial Band Stretch 75 Quadriceps Stretch 76 Health, Fitness Club Exercise Machines 76 Leg Press 76 Hip Abduction/Adduction 77 Multi-Hip 77 Knee Extension 77 Hamstring Curls 78 Upper Body Weight Training 78 Core Training 78 Stationary Bicycle 78 Cross-Country Ski 79 Elliptical 79 Pool Training 79 Water Walking and Other Basic Aquatic Exercises 79 Swimming (Straight Ahead Kicking) 79 Frequently Asked Questions 80 Acronyms and References 81 Appendix 1. Gait Retraining Program for Severe, Painful Knee Hyperextension 86 5 About the Authors Dr. Frank Noyes is an internationally recognized orthopaedic surgeon and researcher who has specialized in the treatment of knee injuries and disorders for nearly 4 decades. He is the founder and chairman of the Cin- cinnati SportsMedicine and Orthopaedic Center and its nonprofit research foundation. Dr. Noyes completed his orthopaedic training at the University of Michigan Medical Center. He then received a 4-year clinical and research appointment as an orthopaedic surgeon in the United States Air Force, was commissioned as a Lieu- tenant Colonel, and began his landmark research into knee ligament injuries, the effects of immobilization, bio- mechanics of ligaments, prevention of ACL injuries in the female athlete, the diagnosis of many knee injuries and problems, and the results of treatment for a variety of knee disorders. Along with Dr. Edward Grood, Dr. Noyes established one of the first biomechanics laboratories in the United States at the University of Cincinnati College of Engineering. The laboratory was subsequently named in his honor as the Noyes Tissue Engineering and Biomechanics Laboratory. Dr. Noyes has won every conceivable award for his clinical and laboratory research from societies such as the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society of Sports Medicine, the Orthopaedic Research and Education Foundation, as well as the University of Cincinnati. He was inducted into the American Orthopaedic Society for Sports Medicine’s Hall of Fame in 2008. Dr. Noyes has been selected by his peers as one of the Best Doctors in America every year since 1992. Dr. Noyes has published over 260 clinical and scientific research studies and textbook chapters. These publica- tions detailed surgical techniques and clinical outcomes on many different types of knee injuries and disorders. He edited a textbook entitled, “Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes” which was written for orthopaedic surgeons, physical therapists, and other sports medicine health care professionals. Dr. Noyes is also a co-editor of “ACL Injuries in the Female Athlete. Causes, Impacts, and Conditioning Programs”, a textbook written for sports medicine health care professionals, coaches, and trainers involved with female athletes. Sue Barber-Westin has directed clinical research studies for Dr. Noyes’ research Foundation for nearly 3 de- cades. In the mid 1980’s, she authored one of the first studies that measured problems during single-leg hop- ping tests in patients with ACL injuries, “Quantitative Assessment of Functional Limitations in Normal and Anterior Cruciate Ligament-Deficient Knees.” She has co-authored 140 articles in medical journals and text- books, focusing on the clinical outcome of various knee operative procedures, the methods used to determine the results of clinical investigations, differences in neuromuscular indices between male and female athletes, ef- fects of neuromuscular training in female athletes, and prevention of ACL injuries in female athletes. Sue is the associate editor of “Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes” and is the co-editor for “ACL Injuries in the Female Athlete. Causes, Impacts, and Conditioning Programs”. Sue has personally undergone 4 knee operations and played competitive junior and collegiate tennis. In 2004, Sue and Dr. Noyes were members of the clinical research team that won the Clinical Research Award from the Orthopaedic Research and Education Foundation. They are frequently invited to speak at national and international conferences and review articles for orthopaedic and sports medicine journals. Noyes and Barber-Westin have written several other eBooks for patients: 1. ACL Injury: Everything You Need to Know to Make the Right Treatment Decision 2. ACL Injury Rehabilitation: Everything You Need to Know to Restore Knee Function and Return to Activity 6 3. Knee Meniscus (Cartilage) Tears: Everything You Need to Know to Make the Right Treatment Decision 4. Patellar (Kneecap) Pain and Problems: Everything You Need to Know to Make the Right Treatment Deci- sion 5. Operations for Knee Arthritis: What To Do When All Else Has Failed To Stop Your Knee Pain 6. Knee Arthrofibrosis: Everything You Need to Know to Recognize, Treat, and Prevent Loss of Knee Motion After Injury or Surgery 7. Partial Knee Replacement: Everything You Need to Know to Make the Right Treatment Decision 8. PCL and Posterolateral Knee Ligament Injuries: Everything You Need to Know to Make the Right Treatment Decision 9. The Unstable Patella (Kneecap): Everything You Need to Know to Make the Right Treatment Decision 7 Introduction Lower limb malalignment, often referred to as bowed legs or knock-knees, can cause knee pain and limitations, especially as we grow older. In adults, a bow-legged or knock-kneed position indicates a malalignment of the lower extremity - the entire leg from the hip to the ankle. The medical terms used to describe these conditions are varus for bowed legs and valgus for knock-knees. Both varus and valgus malalignment are frequently seen in very young children and are usually corrected naturally with growth and physical maturation. In adults, lower limb malalignment may occur to one or both legs and be either a congenital disorder or happen as a result of a knee injury. The main problem with lower limb malalignment is the development of osteoarthritis in one area of the knee that causes pain, swelling, and limitations with recreational sports and eventually, with normal daily activities. Varus (bowed leg), the more common malalignment condition, may cause pain in the inner (medial) portion of the knee joint. Knee symptoms may be worsened with obesity or overuse of the knee joint, and can become a serious problem if the medial meniscus (cartilage) tears and requires partial or complete removal (called a meniscectomy). Valgus malalignment (knock-knee) may cause pain in the outer (lateral) area of the knee and can worsen upon removal of the lateral meniscus. Osteoarthritis may occur from varus or valgus malalignment because there is an abnormal amount of stress and pressure placed on just the inner (varus) or outer (valgus) part of the knee joint. A good analogy to this problem is the wearing of a portion of a tire on a car that is out of proper alignment. If the alignment is not fixed, the tire will wear out on one side, shortening its expected lifespan. Fortunately, there are operations that have gained wide acceptance as treatment options for younger active patients who have painful osteoarthritis in one portion of the knee due to varus or valgus malalignment. An operation called an osteotomy may be performed in which bone in either the femur (thigh bone) or tibia (shin bone) is cut and the leg is properly aligned by the surgeon. The operation commonly done for varus malalign- ment is called a high tibial osteotomy (HTO).
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