Transcript Double Osteo_Isfahan Dr Hafman.ppt

UNI vs Osteotomy
Is there a competion ?
• Vienna
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S. Hofmann
Head Knee Training Centre
General & Orthopaedic Hospital
Stolzalpe – AUSTRIA
Stolzalpe
Therapeutic Dilemma
(active middle aged 40-60)
• Biological therapy ?
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NSAIDS, Suppl & Cartilage
Arthroscopy ?
Mechanical unloading
Braces & Distraction
Osteotomy
Joint replacement
Partial, UKA & TKA
Waller et al, KSSTA 2011
Indications for osteotomies & Unis
• Anteromedial arthrosis (AMA)
Varus 8°, ACL &
cartilage defect
• Lateral arthrosis with ACL
• ACL insufficiency &
single compartment arthrosis ?
• Patient related factors
 individual indications
ACL, osteotomy &
mosaic plasty
ACL & MIS Uni
Basic principles osteotomies
• More than 30 years
• Overcorrection of deformity
• Offloading one compartment
• Pain reduction
• Gain time before TKA
• 80 % Varus deformity
Coventry, JBJS 1987
Basic principles Unis
• More than 20 years
• Partial correction deformity
• Resurfacing one compartment
• Free of pain
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C 3
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• Timewinning or defintive solution ?
• > 90 % Varus deformities
Kennedy CORR 1987
Comparison patella osteotomy
• Cartilgage damage  not main symptom
• Biomechanics & clinics 
• Advantage
lenghtening lig. patellae (closed)
Release soft tissues
• Disatvantage
Shortening Lig. Patellae (open)
No patelloplasty
Müller EFORT 2000
Comparison patella Unis
• Cartilage damage not main symptom
• Biomechanics & clinics 
• Advantage
patelloplasty possible
No sec. shortening
• Disatvantage
No lenghtening lig. patellae
No release soft tissues
Comparison complications osteotomies
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Under- or overcorrection
Inclination joint line (3° Varus)
Loss of correction
Pseudarthrosis
Neural & vascular damage
Secoundary batella baja
 All over rate 30 - 40 %
Joint line 6° Valgus
after HTO
Comparison complications Unis
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Under- or Overcorrection
Malpositioning implants
Dislocation mobile bearings
Neural & vascular damages
Secoundary patella baja
Infection & Loosening
 Overall rate 5 -10 %
Malposition & chronic
pain with mobile bearings
Outcomes of osteotomy
• No EBM data
• Cochrane – Silver Evidence
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70% benefit 10 years
Survivalrates
5 years 73 %
10 years 52 %
Selected patients
Survival 10 y 90%
Results depend on risc factors
Feeley et al, J Am Acad Orthop Surg 2010
Hofmann et al, European IC Lectures 2011
Comparison clinical results
• Retrospective studies
• Unis
Clinical results 
Complications 
• Survival rate 10 years
HTO / Uni
76 % / 90 %
• Survival rate 15 years
HTO / Uni65 % / 88 %
Weale CORR 1994
Comparison revision to TKA
• Worser after Unis
Gill et al, CORR 1995
• Worser after osteotomies
Jackson et al, J Arthroplasty 1994
• No difference &
comparable to primary TKA
Overcorrection
Valgus 24°
McAuley et al, CORR 2001
Uni & large
bony defects
Sporting Activities
TKA vs UNI vs Osteo
Bonnin et al, KSSTA 2011
New concept of osteotomies
• Biomechanical understanding
 Alignment
 Slope & joint line
 Patellofemoral joint
• Patient selection & planning
• Safe & easy osteosynthesis
• Early functional rehabiliation
Hofmann et al, Orthopäde 2009
Hofmann et al, European IC Lectures 2011
Results New Concept
• Prospective multicenter (3)
• 369 varus knees
• FU 3.5 years (2-5)
• 3.5% Complications
• 98% Survival (3-5 years)
• Oxford Score 41 (max 48)
UKA 39 & TKA 35-40
Lobenhoffer et al, ESSKA 2010
Cartilage Damage prior
Surgery
Lobenhoffer et al, ESSKA 2010
Oxford Score Cartilage Damage
Lobenhoffer et al, ESSKA 2010
Oxford Score & Age
Lobenhoffer et al, ESSKA 2010
Patient Selections Stolzalpe
• „Golden rule age“
male < 65
female < 55
• Sporting activities
• Occupation
• Compliance &
patients expections
Adipositas per magna
Summary advantages osteotomies
• No artificial joint
• No arthrotomy necessary
• Combination with cartilage &
ligament surgery
• Less expensive
Summary advantages MIS Uni’s
• Significant shorter rehabiliation
• Less complications
• Better clinical results
• Longer survival
• Definite solution older patients
3 days post Op FL 0-100°
Summary
• New interest in Unis with MIS
• Osteotomies increasing in combination with
cartilage & ligament reconstructions
• Pre OP clearing up, planning & extensive
enlighment necessary
• Clear differential indications
• With new osteotomy concept
results are probably comparable