Navigierte Korrekturosteotomien Peter Keppler Dear chairmen, ladies und gentlemen Universität Ulm Klinik für Unfallchirurgie-, Hand-, Plastische und Wiederherstellungschirurgie Univ. Prof. Dr. med. F. Gebhard

Navigare

Navigationssysteme

Intraoperative Navigation

Gewichtsbelastung im Kniegelenk ~0,5-1cm Mikulicz-Line Physiologische mechanische Beinachse (mFTA) 179° (1° Varus) Physiologische Gewichtsbelastung im Kniegelenk Medial 75% - Lateral 25% Hsu et al 1990 Clin Orthop

Ziel der Korrekturosteotomie Fujisawa-Line ~63% medial Dugdale et al 1992 Clin Orthop Beispiel 100kg Mann Ziel: mFTA 182°-184° Gewichtsbelastung im Kniegelenk Medial 55% - Lateral 45% Hsu et al 1990 Clin Orthop Fujisawa et al 1979 Orthop Clin North Am

Medivision® HTO-Modul 1/03 – 12/03 We started with navigated HTO in January 2003. This software calculates the center of the hip, knee and ankle with the help of flouroscopic pictures. At the first time you were able to check your mechanical leg axis during the operation online. You were also able to control the motion of all fragments in all direction. Zusätzliche Operationszeit ca. 30-40 Minuten

1/03 – 12/03 Medivision® HTO-Modul Ergebnisse 1/03 – 12/03 Medivision® HTO-Modul No. Patients Pre Osteotomie Post Osteotomie 2.5D Ultrasound Navigation 1 39, m left 172° 173° 181° 180° 2 55 w right 183° 3 23 w right 174° 179° 4 65 m left 171° 184° 5 46 m right 182° The results of the first 5 cases were very promising. There was nearly no difference between the ultrsound measurements and the intraoperative navigation results. The maximum postoperative difference between the 2.5D ultrasound and the Medivision software was 2°. By the way, you can see a much bigger difference between the x-ray results and the navigation. Keppler P et al, Injury 2004 (35)

Kongenitale Tibia vara Fallbeispiel Dome HTO Kongenitale Tibia vara 15 J. weiblich, mFTW=172°, mLDFW =80°

Kongenitale Tibia vara Fallbeispiel Dome HTO Kongenitale Tibia vara Postoperative Analyse: mFTW=179°

OrthoPilot® HTO-Software V 1.0 2003 Zuklappende Osteotomie

Orthopilot® HTO-Ultrasound V 1.0 4/04 – 12/05 zusätzliche Operationszeit 20 Minuten In April 2004 we started to transfer the ultrsound technology in the operation room. We developed a prototype software to determine the center of the hip joint with two ultrasound cuts. With a specially designed pointer you were able to mark the anatomical landmark during the operation under sterile conditions.

4/04 – 12/05 Orthopilot® HTO-Ultrasound Version Prospektive Studie 4/04 – 12/05 Orthopilot® HTO-Ultrasound Version Follow up: 4/2004 – 12/2005 Studien Design: prospective Patienten: n=19 (11 männlich, 8 weiblich) Alter: Mittel 42 J. (Spanne 20 to 64 J.) Osteotomie: 14 open wedge, 5 closed wedge Implantat: TOMOFIX® Between April 2004 and December 2005 we did a prospective study of 19 patients. In 14 cases we corrected the mechanical leg axis with an open wedge and in five cases with a closed wedge osteotomie.

Maximale Differenz pre-OP, intra-OPand post-OP 2° Results 4/04 – 12/05 Orthopilot® HTO-Ultrasound Version Again the maximum error between the pre-, intraoperative and postoperative results in 19 patients was only 2°. Maximale Differenz pre-OP, intra-OPand post-OP 2°

Seit 4/05 BrainLAB® VectorVision Osteotomy 1.0 Methode Seit 4/05 BrainLAB® VectorVision Osteotomy 1.0 Since April 2005 we are using the BrainLAB VectorVision Osteotomy Version 1.0. I think everybody is familiar with the registration process of this software module. It is very similar to TKA.

BrainLAB® VectorVision Osteotomy 1.0 Methode BrainLAB® VectorVision Osteotomy 1.0 With this software, you are able to plan the level of the osteotomie. You also have the possibility to check the course of the mechanical leg axis during the operation online.

Genauigkeit BrainLAB VectorVision Nabeyama et al. JBJS (2004) Kadaverstudie (n=9) BrainLAB® (Vector Vision knee 1.1.1) Ergebnisse (Genauigkeit) Femur Maximum Error 0,7° Tibia Maximum Error 2,6° Mittlerer Fehler mFTA 0,6° (Spanne -0,8° - +2,3°)

BrainLAB® VectorVision Osteotomy 1.0 Studie BrainLAB® VectorVision Osteotomy 1.0 Follow up: Seit 1/2006 Studiendesign: prospective Multicenterstudie AO/ASIF Definition des mFTA preoperativ! Patienten: n=18 (8 male, 10 female) Alter: Mittel 54 J. (Spanne 45 to 62 J.) Osteotomie: Aufklappende Osteotomie Implantat: TOMOFIX® To evalute the accuracy of this module, we started a prospective multicenter study in January this year. The outstanding feature of this study is, that you have to define your postoperative result preoperativeley and send a fax to the AO/ASIF. Up to now 8 patients were included in this study.

BrainLAB® VectorVision Osteotomy 1.0 Ergebnisse BrainLAB® VectorVision Osteotomy 1.0 Maximaler Fehler 3°!

BrainLAB® VectorVision Osteotomy 1.0 Ergebnisse BrainLAB® VectorVision Osteotomy 1.0 aPPTW Osteotomie Maximaler Fehler 3°!

Supracondyläre Valgusdeformität aLDFW = 76° mFTW= 186° Relative Außenrotation 17°

Supracondyläre Valgusdeformität Längendifferenz -1,5cm

Navigierte supracondyläre Varisation Torsion - 17°, mFTW 6° unter Navigationskontrolle

Post OP Result mFTW 180°, Torsionswinkeldifferenz 5°, Beinlängendifferenz -5mm

Zusammenfassung Das Navigationsystem ist ein digitales Lineal Das Navigationssystem ersetzt nicht die präoperative Planung 2 kommerzielle Systeme (Orthopilot, BrainLAB VectorVision) Maximaler Fehler mFTA in all Serien ≤3° Zusätzliche Operationszeit 10 Minuten!

Korrekturosteotomien Navigation als Standard?