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Beom Koo Lee, M.D.

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Operation of Arthritic Knee - HTO vs UKA - Beom Koo Lee, M.D. Dept. of Orthopaedic Surgery Gil Medical Center, Gachon University HTO Approach ... – PowerPoint PPT presentation

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Title: Beom Koo Lee, M.D.


1
Operation of Arthritic Knee- HTO vs UKA -
  • Beom Koo Lee, M.D.
  • Dept. of Orthopaedic Surgery
  • Gil Medical Center, Gachon University

2

Surgical Options for Mono-compartmental OA
  • Arthroscopic Debridedment
  • Cartilage Transplantation
  • Osteotomy
  • UKA
  • TKA

3
Discussion Point to compare HTO vs UKA
  • Trend
  • Survival
  • Function
  • Kinematics
  • Indication contraindication
  • Biologic aspect
  • Perioperative morbidity
  • Weight bearing, Rehabilitation, General
    Complication
  • Problem
  • Complication
  • Cosmetics
  • Technical Problem associated with TKA after
    Procedure

4
Trend
5

Trend of UKA
  • The early reported series of unicompartmental
    knee replacement done by experienced surgeons did
    not have encouraging results, with 70
    survivorship reported at 5 to 7 years, and 65
    and 53 survivorships reported at 11 and 12
    years, respectively.
  • Callahan, CORR, 2005

6

Trend of UKA, Recently
  • However, more recently the reports of
    unicompartmental knee replacement have been more
    encouraging with 94 survivorship at 10 years and
    90 survivorship at 18 years.
  • Callahan, CORR, 2005

7

Kinematics of UKA
  • The UKA preserve Normal Kinematics
  • Patil, JBJS(Am), 2005

8

Kinematics of UKA
  • Patil, JBJS(Am), 2005

9

Kinematics of UKA
  • Patil, JBJS(Am), 2005

10
Kinematic of UKA
  • Variable Femoral Roll Back
  • Dennis, JBJS(Am), 2001

11
Indications Contraindications
12

Ideal Indications of HTO
  • Young
  • Active
  • Male
  • Varus Deformity
  • Mont, AAOS ICL, 2004

13

Ideal Indications of UKA
  • Low Demand
  • Female
  • Elderly
  • No instability Contracture
  • Correctable Deformity
  • Mont, AAOS ICL, 2004

14

Contraindications
HTO UKA
Severe Deformity (?)
ACL Insufficiency -
P-F Arthritis
Obesity
Inflammatory Arthritis
Advanced Age -
Arthritis Opposite
Severe Contracture
Medial Plateau Depression -
Lateral Instability
15

Range of Correction
  • UKA
  • Varus 10 - 20
  • Valgus lt 15
  • Preferably 10 Pagnano, AAOS ICL, 2005
  • osteotomy
  • Even Severe Deformity over 20 can be corrected by
    Dual Osteotomy.
  • Hanssen Insall 3rd edit

16
T-F angle Varus 14 Mechanical Axis Varus 20
17

Lateral Instability
  • moderate to severe Lateral instability, and
    subluxation is contraindicated in HTO
  • (Insall 3rd edit)
  • TKA is advisable in Great subluxation than UKA
  • ( Insall 3rd edit)
  • UKA is contraindicated for instability
    (ICL 2005)
  • Management in Mild Lateral Laxity in HTO
  • Slight Overcorrection
  • Reefing of LCL ???
  • Spontaneous shortening ???

18
ACL Instability in UKA
  • ACL insufficiency
  • relative contraindication in UKA
  • ICL 2005
  • HTO can be done in ACL Deficiency
  • Noyes, Am J Sports Med, 2000

19

UKA in Elderly
  • ORourke, CORR, 2005

20

Summary of Indications
  • UKA? HTO??? ??? Deformity ??? ?????, Ligament?
    Stable ????.
  • UKA?? 80? ??? ????, 40?? ???? ????.
  • HTO? ??? ?? ?? ??? ????.

21
Survival
22

Survival of UKA
  • ORourke, CORR, 2005

23

Survival of UKA
  • Stukenborg, The Knee, 2001

24

Survival of MIS-UKA
  • Despite an accelerated recovery and decreased
    hospital stay in our MIS-UKA, the rate of
    Revision due to aseptic loosening and the overall
    Reoperation rate compare to unfavorably with
    those performed with an open technique.
  • Engh, J Arthroplasty, 2006

25

Survival of HTO
  • Insall Scott, Surger of the Knee, 4th ed.

26

Survival of HTO UKA
HTO
UKA
  • ???, ????????, 2001

???, ?????????, 2002
27

Summary of Survival
  • ???? HTO? UKA? ??? ????.
  • ?? ????? UKA? ??? ??? ????.

28
Quality of Life
29

Results of HTO vs UKA
UKA Results were signinficantly Better than HTO
  • Broughton, JBJS(Br), 1986

30

Function of HTO vs UKA
Better Function in HTO
  • Stukenborg, The Knee, 2001

31

Pain of HTO vs UKA
  • Broughton, JBJS(Br), 1986

32

Activity Level of HTO vs UKA
  • Gillquist, CORR, 1991

33

Activity after HTO
  • Manual Labor 17/34
  • Jumping Sport 45-60
  • Nagel, JBJS(Am), 1996
  • Odenbring, Acta Ortho Scan, 1989

34

ROM
  • HTO is better than UKA
  • Koshino, APKS, 2006

35

Kneeling
  • HTO is better than UKA
  • Koshino, APKS, 2006

36

Summary of Quality of Life
  • UKA?? ??? ???,
  • ??? HTO?? ????.
  • HTO?? ROM? ? ??, Kneeling? ?? ??.

37
Biologic Aspect
38

Cartilage Healing after HTO
  • Joint Space
  • Preop. 1.8mm
  • 3 Yr F-up 2.9mm
  • ???, ????????, 2002
  • Joint Space (2Y F/U)
  • Koshino
  • -Joint space pre-op 1.1mm
  • post-op 2.3mm
  • -Pattern
  • No reg13/146
  • pink and yellow fibrillation 2/143
  • Partial coverage 50/143
  • Full coverrage 16/143
  • 13,86,47/146

39
Pre-op Medial joint space narrowing
Post-op 14 M Restored medial joint space
40
Cartilage defect in tibia
Cartilage defect in femur
Pre-op
Regenerated cartilage
Healed cartilage
Post-op
41
Healed cartilage defect site
POD 17 Months
initial
microfracture
post-op 2 Yr
POD 17 M
42
Complications
43

early perioperative complication after HTO vs
UKA
  • Broughton, JBJS(Br), 1986

44
Early Cx after HTO
  • Infection
  • Patella baja
  • Intraarticular fracture
  • Peroneal nerve dysfunction
  • Compartment syndrome
  • Vascular injury

45

DVT Case after HTO
  • Incidence 41
  • Tuner, JBJS(Br), 1993

46

Retained Cement after UKA
Engh, J Arthroplasty, 2006
47

Rehabilitation
  • Easy in UKA
  • Faster Recovery
  • Gillquist, CORR, 1991

48

Summary of early perioperative course
  • UKA? HTO??? Rehabilitation? ??,, Peri- operative
    Complication ??? ????.

49
Cosmesis
50

Alignment
  • HTO Overcorrection
  • UKA Undercorrection

51

Tibia Vara with Mild OA
  • Subcondylar Osteotomy with Blade Plate

Preop.
POD5Y
52
  • Tibio-Femoral Angle 13
  • Defective Cosmesis
  • Unbalance compared to
  • Contralateral Side

53

Staged Operation in Bilateral Case
  • UKA One Stage
  • HTO Two Stage

54

Weight Bearing
  • UKA Immediate
  • HTO Delay 2-3 M

55

Summary of Short Term Results
  • UKA? HTO??? Weight Bearing, Cosmesis, ??? ????.

56
Long tern complication
57
Long term Cx after HTO
  • Loss of correction
  • Arthritis opposite compartment
  • Decreased function over time.
  • pseudoarthrosis

58

Collapse after UKA
  • Engh, J Arthroplasty, 2006

59

Wear after UKA
Vince, J Arthroplasty, 2004
60

Dislocation after UKA
61

Fracture after UKA
Vince, J Arthroplasty, 2004
62
Technical Problems Results of Revision
63

Technical Problems of TKA after HTO (ICL 2004)
  • Difficult Exposure
  • Bone Defect
  • Difficult Ligament Balance
  • Prolonged Operative Time
  • Increased Blood Loss
  • Offset Stem Sometimes
  • But, No Problem after Open Wedge HTO
  • (Kitson) Injury 200132

64

Frequent Encountered Problems at Revision
  • UKA Bone Defect
  • HTO Difficult Exposure
  • Gillquist, CORR, 1991

65

Results of TKA after HTOcompared with primary
TKA
  • Less Successful
  • (windsor 1988 JBJS)
    (Cameroon1996 orthopedic
  • (Katz 1987 JBJS)
  • More infection (Jackson J arthroplasty 1994)
  • difficult exposure , mild decreased flexion but
  • No difference
  • (Haddad 2000 J arthroplasty)
  • (Windsor)

66

Summary of Problems at Revision
  • HTO? Approach? ???? ??, UKA? Bone Defect? ????
    ??.
  • ??? HTO? UKA ? Revision?? ??.

67

Can We expand Indication of UKA in Young
Patients?
  • We may rightfully expect Higher Failure Rates,
    perhaps Greater Damage in the Younger, More
    Active Patient. New, expanded Indications for UKA
    may lead to More Complications and perhaps More
    Severe Failures.
  • Vince, J Arthroplasty, 2004

68
Summary
69

UKA
  • Faster Recovery
  • Immediate Weight Bearing
  • High Initial Success Rate
  • Fewer Early Complications
  • Simultaneous Bilateral Procedure
  • Better Cosmesis
  • Less Infection
  • Less Blood Loss
  • Less Function and Activity
  • 80? ??? ???? ?? ?? ??? ?? ? ??.
  • Callahan, CORR, 2005
  • Gillquist, CORR, 1991
  • Insall

70

HTO
  • More Active Life Style
  • Biologic
  • Better Result at Revision than UKA
  • ?? ??? ??.
  • Weight Bearing
  • Perioperative Complication
  • Staging Procedure
  • Morbidity
  • Iorio, JBJS(Am), 2003
  • Gill, CORR, 1995
  • Chang

71
J arthroplasty Oct06
72

Future of UKA
  • Although the unicompartmental prosthesis used in
    this series has not shown promising results and
    does not match the results of some other
    prosthesis, and the introduction of guide
    instruments for precise surgical techniques has
    currently improved the survival of UKAs to over
    90 at 10 years. Therefore, we think that in
    patients over 60 years of age, unicompartmental
    osteoarthritis UKA offers Better Long-term
    Results than HTO.
  • Stukenborg, The Knee, 2001

73

Future of HTO
  • It is proposed that Future Biologic Resurfacing,
    together with Computer- and even Robotic-Methods,
    as well as other advances in Biology and
    Technology, will combine to resurrect the
    performance of knee osteotomies
  • Krackow, J Arthroplasty, 2004

74

Summary
  • HTO? UKA? ? ??? ? ?? ??? ?? ? ??.
  • Indication, Cosmesis, Function, Biologic??? ???
    ?? ????.
  • HTO? ??? ??? ??, UKA? ??? ??? ??.
  • HTO? ?? ??? ?? ??? ????.
  • UKA? ??? ?? ????, 80? ???? ?? ??? ?? ? ??.
  • ?? Biologic Procedure? ???? ? ?? HTO? ??? ???.

75
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