Modifications de la cinématique du genou et des bras de levier du quadriceps et des ischio-jambiers après ostéotomie tibiale haute « curviplane » de valgisation ou de varisation: Étude in vitro

RésuméLes modifications de cinématique du genou, des bras de levier des muscles quadriceps et des ischio-jambiers induites par une déviation en valgus ou en varus du tibia ont été étudiées sur cinq préparations anatomiques de membres inférieurs non fixés. Une ostéotomie tibiale haute « curviplane » a permis d’appliquer des déviations frontales. Deux électrogoniomètres à six degrés de liberté ont été utilisés pour l’étude des cinématiques. Les excursions tendineuses des muscles étudiés ont été mesurées par des LVDT (linear variable differential transformer) et ont permis en combinaison avec les données de l’électrogoniomètre de calculer les bras de levier musculaires. Nos résultats ont démontré que l’ostéotomie « curviplane » engendre une déformation tridimensionnelle du tibia et des modifications significatives des bras de levier du quadriceps et du semi-tendineux. La déviation en varus induit une rotation interne du tibia et de la rotule, inversement pour la valgisation. La déformation en varus ne modifie pas la valeur maximale du bras de levier du quadriceps mais celle-ci survient pour un angle de flexion du genou plus élevé. En outre, la valeur moyenne du bras de levier du muscle semitendinosus est réduite. La déviation en valgus accroît la valeur maximale du bras de levier du quadriceps. La valeur moyenne du bras de levier du muscle semitendinosus est également accrue. Les modifications induites par la valgisation seraient donc favorables à la physiologie articulaire du genou.

Purpose of the studyAnalysis of the correction or over-correction of high valgus and varus tibial osteotomies is generally limited to the frontal plane. Most likely however, the deformation observed radiographically in the frontal plane is simply a one-dimensional expression of a more complex three-dimensional deformation. This might be one of the causes for certain failures after surgery and recurrent problems which are difficult to solve. We proposed using 3D electrogoniometric to measure of the effect of a “dome” osteotomy on patellar and femoro-tibial kinematics and the changes in the moment arms of the knee muscles.Material and methodsWe used five lower limbs harvested from non-fixed cadavers. A “dome” osteotomy was stabilized by external fixation. Three-dimensional analysis of the femoro-tibial and femoro-patellar kinematics was performed using two electrogoniometers with six degrees of freedom. Changes in the lengths of the hamstrings and quadriceps was measured using four LVDT linear variable differential transformers. The muscles lever arms were measured with the tendon excursion method.ResultsAt 90° flexion, varus osteotomy induced internal rotation while valgus osteotomy induced the opposite effect. Beyond 40° flexion, there was a clear internal rotation of the patella for varus and neutral corrections. Valgus corrections however induced external rotation. The peak lever arm of the quadriceps increased with valgus, while the angle of the peak was higher for varus correction. Valgus appeared to increase the lever arm of the semitendinous.DiscussionOur study demonstrated that the effect of tibial osteotomy is not limited to the frontal plane. Tibial rotations are observed systematically for all corrections in the frontal plane. Varus correction tends to create internal rotation while valgus correction tends to have the opposite effect. Axial correction also affects patellar kinematics. Interanal rotation is induced by varus correction and external rotation by valgus correction. This patellar rotation could result from tibial rotations induced by the different corrections. The loss of the parallelism between the patellar crest and the trochlear groove could produce changes in femoropatellar surface contact and pressure, potentially leading to pain or cartilage degeneration. The maximal value of the quadriceps moment arm appears to increase with valgus. The efficacy of the quadriceps could thus be improved with valgus, potentially increasing extension force. Valgus increases the moment arm, improving limb flexion, while varus correction has the opposite effect. This could explain a loss in flexion amplitude in patients with varus or who underwent varus osteotomy. Tibial osteotomy is designed to correct the deviation solely in the frontal plane but also has effects in all three planes. Further 3D analyses of the morphology and physiology of the knee joint would be needed to better understand the physiological and pathological processes involved.