Beom Koo Lee, M.D.Beom Koo Lee, M.D.

Dept. of Orthopaedic Surgery Dept. of Orthopaedic Surgery Gil Medical Center, Gachon UniversityGil Medical Center, Gachon University

Operation of Arthritic KneeOperation of Arthritic Knee- HTO vs UKA -- HTO vs UKA -

Arthroscopic Debridedment Cartilage Transplantation Osteotomy UKA TKA

Surgical Options for Mono-compartmental OA

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

Trend

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

• 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

Trend of UKA, Recently

The UKA preserve Normal KinematicsPatil, JBJS(Am), 2005

Kinematics of UKA

Patil, JBJS(Am), 2005

Kinematics of UKA

Patil, JBJS(Am), 2005

Kinematics of UKA

Kinematic of UKA

Variable Femoral Roll Back Dennis, JBJS(Am), 2001

Indications & Contraindications

• Young

• Active

• Male

• Varus DeformityMont, AAOS ICL, 2004

Ideal Indications of HTO

•Low Demand

•Female

•Elderly

•No instability & Contracture

•Correctable DeformityMont, AAOS ICL, 2004

Ideal Indications of UKA

Contraindications

HTO UKA

Severe Deformity +(?) +

ACL Insufficiency - +

P-F Arthritis + +

Obesity + +

Inflammatory Arthritis + +

Advanced Age + -Arthritis Opposite + +

Severe Contracture + +

Medial Plateau Depression + -Lateral Instability + +

UKA Varus 10 - 20° Valgus < 15° Preferably 10° Pagnano, AAOS ICL, 2005

osteotomy Even Severe Deformity over 20 can be

corrected by Dual Osteotomy. Hanssen Insall 3rd edit

Range of Correction

T-F angle : Varus 14°

Mechanical Axis : Varus 20°

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 배대경 Spontaneous shortening 조세현

Lateral Instability

ACL Instability in UKA

• ACL insufficiency ; relative contraindication in UKA ICL 2005

HTO can be done in ACL DeficiencyNoyes, Am J Sports Med, 2000

UKA in Elderly

O’Rourke, CORR, 2005

UKA 는 HTO 에비해 비교적 Deformity 정도가 적어야하고 , Ligament 가 Stable 해야한다 .

UKA 에서 80 세 이상의 노인이나 , 40 대의 여성에서 유리하다 .

HTO 는 활동이 많은 젊은 나이에 유리하다 .

Summary of Indications

Survival

Survival of UKA

O’Rourke, CORR, 2005

Survival of UKA

Stukenborg, The Knee, 2001

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

Survival of MIS-UKA

Survival of HTO

Insall & Scott, Surger of the Knee, 4th ed.

Survival of HTO & UKA

배대경 , 대한슬관절학회지 , 2001배대경 , 대한정형외과학회지 , 2002

UKAHTO

과 교 정 된 HTO 나 UKA 는 결 과 가 비슷하다 .

젊은 나이에서는 UKA 는 비교적 초기에 실패한다 .

Summary of Survival

Quality of Life

Results of HTO vs UKA

Broughton, JBJS(Br), 1986

UKA Results were signinficantly Better than HTO

Function of HTO vs UKA

Stukenborg, The Knee, 2001

Better Function in HTO

Pain of HTO vs UKA

Broughton, JBJS(Br), 1986

Activity Level of HTO vs UKA

Gillquist, CORR, 1991

Manual Labor: 17/34

Jumping Sport: 45-60%

Nagel, JBJS(Am), 1996Odenbring, Acta Ortho Scan, 1989

Activity after HTO

HTO is better than UKAKoshino, APKS, 2006

ROM

HTO is better than UKAKoshino, APKS, 2006

Kneeling

UKA 에서 동통이 적으나 ,

노동은 HTO 에서 가능하다 . HTO 에서 ROM 이 더 좋고 , Kneeling 도

가능 하다 .

Summary of Quality of Life

Biologic Aspect

Joint Space Preop.: 1.8mm 3 Yr F-up: 2.9mm

송은규 , 대한슬관절학회지 , 2002 Joint Space (2Y F/U)

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 16/14313,86,47/146

Cartilage Healing after HTO

Pre-op

Medial joint space narrowing

Post-op 14 M

Restored medial joint space

Pre-op

Post-op

Cartilage defect in tibia

Healed cartilage

Cartilage defect in femur

Regenerated cartilage

POD 17 Months

Healed cartilage defect site

initial POD 17 Mmicrofracture post-op 2 Yr

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

Incidence : 41%Tuner, JBJS(Br), 1993

DVT Case after HTO

Retained Cement after UKA

Engh, J Arthroplasty, 2006

Easy in UKA Faster Recovery

Gillquist, CORR, 1991

Rehabilitation

UKA 가 HTO 에비해 Rehabilitation 이 쉽 고 ,, Peri- operative Complication 면에서 월등하다 .

Summary of early perioperative course

Cosmesis

HTO : Overcorrection

UKA : Undercorrection

Alignment

Subcondylar Osteotomy with Blade Plate

Tibia Vara with Mild OA

Preop. POD#5Y

Tibio-Femoral Angle : 13°

Defective Cosmesis Unbalance compared to Contralateral Side

UKA : One Stage

HTO : Two Stage

Staged Operation in Bilateral Case

UKA : Immediate

HTO : Delay 2-3 M

Weight Bearing

UKA 가 HTO 에비해 Weight Bearing, Cosmesis, 면에서 월등하다 .

Summary of Short Term Results

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

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

Technical Problems of TKA after HTO (ICL 2004)

UKA : Bone Defect

HTO : Difficult Exposure

Gillquist, CORR, 1991

Frequent Encountered Problems at Revision

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)

Results of TKA after HTOcompared with primary TKA

HTO 는 Approach 시 조심해야 하며 , UKA 는 Bone Defect 에 대비해야 한다 .

결과는 HTO 가 UKA 후 Revision 보다 좋다 .

Summary of Problems at Revision

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

Can We expand Indication

of UKA in Young Patients?

Summary

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 세 이후의 노인에서 아주 좋은 결과를 얻을 수 있다 .

Callahan, CORR, 2005Gillquist, CORR, 1991

Insall

UKA

More Active Life Style Biologic Better Result at Revision than UKA 초기 문제가 많다 .

Weight Bearing Perioperative Complication Staging Procedure Morbidity

Iorio, JBJS(Am), 2003Gill, CORR, 1995

Chang

HTO

J arthroplasty Oct’06

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 UKA

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

Future of HTO

HTO 와 UKA 는 잘 선택될 때 좋은 결과를 얻을 수 있다 .

Indication, Cosmesis, Function, Biologic 면 에 서 완전히 다른 수술이다 .

HTO 는 초기에 문제가 많고 , UKA 는 후기에 문제가 있다 .

HTO 는 젊고 활동이 많은 환자에 유용하다 . UKA 는 활동이 적은 여성이나 , 80 대 이상에서 좋은

결과를 얻을 수 있다 .

장차 Biologic Procedure 와 결합되면 더 많은 HTO 가 시행될 것이다 .

Summary