treatment options of genovarum, unicompartment arthroplasty vs high tibial osteotomy h.makhmalbaf...

Treatment options of Treatment options of Genovarum, Genovarum,

Unicompartment Arthroplasty vs Unicompartment Arthroplasty vs High Tibial OsteotomyHigh Tibial Osteotomy

H.Makhmalbaf MD. H.Makhmalbaf MD. Knee surgeonKnee surgeon

Ghaem Hospital Medical SchoolGhaem Hospital Medical School

Osteotomy about the kneeOsteotomy about the knee

• Coventry :UTO for treatment of arthritis with associated limb malalign.

• Realignment osteotomy to transfer WB forces from the arthritic portion to a healthier location of the knee

• Redistribution of mechanical forces to increase the life span of the knee

The goals of osteotomyThe goals of osteotomy

• Pain relief

• Functional improvement

• Ability to meet heavy functional demands

• Careful patient selection

• Skillful surgical technique

Patient selectionPatient selection

• The ideal candidate for osteotomy is

• Thin active individual

• In the 5th or 6th decade of life

• With localized, activity-related

• Unicompartmental knee pain

• No PFJ OA

Patient selectionPatient selection

• A stable knee

• Full extension

• With flexion of at least 90 deg

• No narrowing of lateral compartment

• Medial bone loss less than 2-3mm

Patient selection: HistoricalPatient selection: Historical

• Age : chronological, physiological

• Patient’s desired activity level

• Pain: location, character, PFJ ?

• Rhumatological status

• Prior menisectomy

• Infection history

ExaminationExamination;;

• Malalignment: magnitude, direction

• Prior incisions, body habitus

• ROM: total arc, flexion contracture

• Ligamentous deficiencies

• PF mechanics

• Adductor thrust

RadiologicalRadiological: :

• Anatomic axis

• Mechanical axis

• Severity of OA

• Magnitude of deformity

• Tibiofemoral subluxation

RadiologicalRadiological::

• Status of other compartments

• Joint space opening

• Amount of articular cartilage loss

• CPPD, osseous defects

• Deformities away from the joint

• Joint line obliquity

ContraindicationsContraindications::

• Diffuse, nonspecific knee pain

• Patellofemoral pain primary complaint

• Moderate or severe lig. Instability

• Menisectomy in comp. intended for WB

• OA in: # # # #

• Underlying diag. Of inflammatory dis.

• No Good ROM

CounselingCounseling : :

• Discuss all treatment alternatives

• No normal joint with TKA / Osteotomy

• Long term results, rehabilitation, pain relief & durability of TKA Or Osteotomy

• Longer post op. recovery after osteotomy

• Results of TKA after osteotomy

TKA vs OsteotomyTKA vs Osteotomy

• Arthroplasty provides more complete pain relief & shorter rehab. Period & is more reliable than osteotomy in most individuals older than 60 yrs. Insall JN

Long Term Outcome of high Long Term Outcome of high Tibial OsteotomyTibial Osteotomy

A 10 to 20-year follow-up

S. Akiziki et al. Japan

JBJS 90 B May 2008

UTO is more accepted in Japan

UTO & fixation with plate no POP

94 patients (118 knees)

16.4 yr follow-up

Good result in 73.7%

Risk factors: BMI> 27.5 & ROM<100

Unicompartment ArthroplastyUnicompartment ArthroplastyIndicationsIndications

• Unicompartment OA

• Good range of movement

• Ligament stability

• An intact ACL

• Normal PFJ

UKA vs UTOUKA vs UTO

• Higher initial success rate &

• Fewer early complications

• Could be done bilaterally at the same time

• Full recovery within 3 months

• With MIS techniques

• Less blood loss, less pain &

• Quicker recovery

Patient selectionPatient selection• Osteotomy is the procedure of choice in

young active male with unicomp.OA

• Pain during rest & poor ROM is a contraindication to UTO

• Subluxation & extreme angular deformity are contraindications to both UTO & UKR

• Ideal candidate for UKR are middle aged patients with OA

Advantages of UKRAdvantages of UKR

• Reliable initial result• Anatomic realignment• Retention of both ligaments• And easy salvage• Quicker surgery , less blood loss• Less expensive• Decision should be made at surgery• UKA or TKR

• Unicompartment knee arthroplasty with Oxford prosthesis in patients with medial compartment arthritis

H. Emerson Jr MD et al

JBJS 90-A Jan 2008 / 55 patients

• Mobile bearing Oxford UKR optimizes PE wear

• Mechanical limb alignment without lig. Release

• Progression of OA in the lat. Compt. , the most commen reason for final failure

Cementless Oxford UKR shows Cementless Oxford UKR shows reduced radiolucency at one reduced radiolucency at one

yearyear

• H. Pandit et al Nuffield Orthopaedic Centre, Oxford , England

JBJS B Feb 2009

61 patients / 62 knees

32 cemented , 30 cementless

• Radiolucency around the cementless tibial component diminishes at one year

Medial UKR in the under 50sMedial UKR in the under 50s

• S Parratte et al

JBJS 91-B March 2009

France

35 knees , 31 patients

• 12 year survival was 80.6%

• The problems were PE wear

• Consider UKR to bridge the gap between UTO & TKR

The advantages of UKR over The advantages of UKR over TKRTKR

• Retention of the cruciate ligaments

• Preservation of bone stock

• And better functional results

What is being doneWhat is being done??

• In the West : UK, USA

• In Iran

• My experience with UKR, UTO, TKR

• Young patients with deformity & no OA

UKRUKRcontraindicationscontraindications

• OA in other compartments of the knee

• Severe deformity

• Ligament instability

• Limitation of ROM

• RA

Complications of UKRComplications of UKR

• Tibial component loosening

• PE wear

• OA of other compartments

Thank you