Transcript Operation of arthritic knee

Operation of Arthritic Knee
- HTO vs UKA -
Beom Koo Lee, M.D.
Dept. of Orthopaedic Surgery
Gil Medical Center, Gachon University
Surgical Options
for Mono-compartmental OA
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Arthroscopic Debridedment
Cartilage Transplantation
Osteotomy
UKA
TKA
Discussion Point
to compare HTO vs UKA
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Trend
Survival
Function
Kinematics
Indication & contraindication
Biologic aspect
Perioperative morbidity
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Weight bearing, Rehabilitation, General Complication
Problem
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Complication
Cosmetics
Technical Problem associated with TKA after Procedure
Trend
Trend of UKA
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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
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
Kinematics of UKA

The UKA preserve Normal Kinematics
Patil, JBJS(Am), 2005
Kinematics of UKA
Patil, JBJS(Am), 2005
Kinematics of UKA
Patil, JBJS(Am), 2005
Kinematic of UKA

Variable Femoral Roll Back
Dennis, JBJS(Am), 2001
Indications
& Contraindications
Ideal Indications of HTO
• Young
• Active
• Male
• Varus Deformity
Mont, AAOS ICL, 2004
Ideal Indications of UKA
• Low Demand
• Female
• Elderly
• No instability & Contracture
• Correctable Deformity
Mont, AAOS ICL, 2004
Contraindications
HTO
UKA
+(?)
+
ACL Insufficiency
-
+
P-F Arthritis
+
+
Obesity
+
+
Inflammatory Arthritis
+
+
Advanced Age
+
-
Arthritis Opposite
+
+
Severe Contracture
+
+
Medial Plateau Depression
+
-
Lateral Instability
+
+
Severe Deformity
Range of Correction

UKA
Varus 10 - 20°
 Valgus < 15°
 Preferably 10° Pagnano, AAOS ICL, 2005
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
osteotomy
Even Severe Deformity over 20 can be
corrected by Dual Osteotomy.
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Hanssen Insall 3rd edit
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T-F angle : Varus 14°
Mechanical Axis : Varus 20°
Lateral Instability
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moderate to severe Lateral instability, and subluxation
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
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Slight Overcorrection
Reefing of LCL
배대경
Spontaneous shortening 조세현
in HTO
is
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
UKA in Elderly
Summary of Indications
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UKA는 HTO에비해 비교적 Deformity 정
도가 적어야하고, Ligament가 Stable 해
야한다.
UKA에서 80세 이상의 노인이나, 40대의
여성에서 유리하다.
HTO는 활동이 많은 젊은 나이에 유리하다.
Survival
Survival of UKA
O’Rourke, CORR, 2005
Survival of UKA
Stukenborg, The Knee, 2001
Survival of MIS-UKA

Despite an accelerated recovery and
decreased hospital stay in our MISUKA, 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
Survival of HTO
Insall & Scott, Surger of the Knee, 4th ed.
Survival of HTO & UKA
HTO
배대경, 대한정형외과학회지, 2002
UKA
배대경, 대한슬관절학회지, 2001
Summary of Survival
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과교정된 HTO나 UKA는 결과가 비슷하다.
젊은 나이에서는 UKA는 비교적 초기에 실
패한다.
Quality of Life
Results of HTO vs UKA
UKA Results were signinficantly Better than HTO
Broughton, JBJS(Br), 1986
Function of HTO vs UKA
Better Function in HTO
Stukenborg, The Knee, 2001
Pain of HTO vs UKA
Broughton, JBJS(Br), 1986
Activity Level
of HTO vs UKA
Gillquist, CORR, 1991
Activity after HTO
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Manual Labor: 17/34
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Jumping Sport: 45-60%
Nagel, JBJS(Am), 1996
Odenbring, Acta Ortho Scan, 1989
ROM
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HTO is better than UKA
Koshino, APKS, 2006
Kneeling
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HTO is better than UKA
Koshino, APKS, 2006
Summary of Quality of Life
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UKA에서 동통이 적으나,
노동은 HTO에서 가능하다.
HTO에서 ROM이 더 좋고, Kneeling도 가
능 하다.
Biologic Aspect
Cartilage Healing
after HTO
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Joint Space
Preop.: 1.8mm
 3 Yr F-up: 2.9mm
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Joint Space (2Y F/U)
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Koshino
-Joint space ;pre-op 1.1mm
post-op 2.3mm
-Pattern
No reg;13/146
pink and yellow fibrillation 2/143
Partial coverage 50/143
Full coverrage 16/143
13,86,47/146
송은규, 대한슬관절학회지, 2002
Pre-op
Post-op 14 M
Medial joint space
narrowing
Restored medial joint space
Pre-op
Cartilage
defect in tibia
Cartilage
defect in
femur
Regenerated
cartilage
Healed cartilage
Post-op
Healed cartilage
defect site
POD 17 Months
initial
microfracture
post-op
2 Yr
POD 17 M
Complications
early perioperative
complication after HTO vs UKA
Broughton, JBJS(Br), 1986
Early Cx after HTO
• Infection
• Patella baja
• Intraarticular fracture
• Peroneal nerve dysfunction
• Compartment syndrome
• Vascular injury
DVT Case after HTO
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Incidence : 41%
Tuner, JBJS(Br), 1993
Retained Cement
after UKA
Engh, J Arthroplasty, 2006
Rehabilitation
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Easy in UKA
Faster Recovery
Gillquist, CORR, 1991
Summary
of early perioperative
course
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UKA가 HTO에비해 Rehabilitation이 쉽
고,, Peri- operative Complication 면에
서 월등하다.
Cosmesis
Alignment
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HTO : Overcorrection
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UKA : Undercorrection
Tibia Vara with Mild OA
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Subcondylar Osteotomy with Blade
Plate
Preop.
POD#5Y
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Tibio-Femoral Angle : 13°
Defective Cosmesis
Unbalance compared to
Contralateral Side
Staged Operation
in Bilateral Case
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UKA : One Stage
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HTO : Two Stage
Weight Bearing
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UKA : Immediate
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HTO : Delay 2-3 M
Summary
of Short Term Results
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UKA 가 HTO 에 비 해 Weight Bearing,
Cosmesis, 면에서 월등하다.
Long tern complication
Long term Cx after HTO
• Loss of correction
• Arthritis opposite compartment
• Decreased function over time.
• pseudoarthrosis
Collapse after UKA
Engh, J Arthroplasty, 2006
Wear after UKA
Vince, J Arthroplasty, 2004
Dislocation after UKA
Fracture after UKA
Vince, J Arthroplasty, 2004
Technical Problems
& Results of Revision
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 2001;32
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Frequent Encountered
Problems at Revision
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UKA : Bone Defect
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HTO : Difficult Exposure
Gillquist, CORR, 1991
Results of TKA after HTO
compared with primary TKA
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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)
Summary
of Problems at Revision
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HTO는 Approach시 조심해야 하며, UKA
는 Bone Defect에 대비해야 한다.
결과는 HTO가 UKA 후 Revision보다 좋
다.
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
Summary
UKA
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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
80세 이후의 노인에서 아주 좋은 결과를 얻을 수 있다.
Callahan, CORR, 2005
Gillquist, CORR, 1991
Insall
HTO
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More Active Life Style
Biologic
Better Result at Revision than UKA
초기 문제가 많다.
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Weight Bearing
Perioperative Complication
Staging Procedure
Morbidity
Iorio, JBJS(Am), 2003
Gill, CORR, 1995
Chang
J arthroplasty Oct’06
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
Future of HTO

It is proposed that Future Biologic
Resurfacing,
together
with
Computerand
even
RoboticMethods, as well as other advances
in Biology and Technology, will
combine
to
resurrect
the
performance of knee osteotomies
Krackow, J Arthroplasty, 2004
Summary

HTO와 UKA는 잘 선택될 때 좋은 결과를 얻을 수 있다.
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Indication, Cosmesis, Function, Biologic면에서 완
전히 다른 수술이다.
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HTO는 초기에 문제가 많고, UKA는 후기에 문제가 있다.
HTO는 젊고 활동이 많은 환자에 유용하다.
UKA는 활동이 적은 여성이나, 80대 이상에서 좋은 결과
를 얻을 수 있다.
장차 Biologic Procedure와 결합되면 더 많은 HTO가
시행될 것이다.