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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 -
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Arthroscopic Debridedment Cartilage Transplantation Osteotomy UKA TKA
Surgical Options for Mono-compartmental OA
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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
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Trend
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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
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• 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
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The UKA preserve Normal KinematicsPatil, JBJS(Am), 2005
Kinematics of UKA
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Patil, JBJS(Am), 2005
Kinematics of UKA
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Patil, JBJS(Am), 2005
Kinematics of UKA
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Kinematic of UKA
Variable Femoral Roll Back Dennis, JBJS(Am), 2001
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Indications & Contraindications
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• Young
• Active
• Male
• Varus DeformityMont, AAOS ICL, 2004
Ideal Indications of HTO
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•Low Demand
•Female
•Elderly
•No instability & Contracture
•Correctable DeformityMont, AAOS ICL, 2004
Ideal Indications of UKA
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Contraindications
HTO UKA
Severe Deformity +(?) +
ACL Insufficiency - +
P-F Arthritis + +
Obesity + +
Inflammatory Arthritis + +
Advanced Age + -Arthritis Opposite + +
Severe Contracture + +
Medial Plateau Depression + -Lateral Instability + +
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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
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T-F angle : Varus 14°
Mechanical Axis : Varus 20°
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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
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ACL Instability in UKA
• ACL insufficiency ; relative contraindication in UKA ICL 2005
HTO can be done in ACL DeficiencyNoyes, Am J Sports Med, 2000
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UKA in Elderly
O’Rourke, CORR, 2005
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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
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Survival
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Survival of UKA
O’Rourke, CORR, 2005
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Survival of UKA
Stukenborg, The Knee, 2001
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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
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Survival of HTO
Insall & Scott, Surger of the Knee, 4th ed.
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Survival of HTO & UKA
배대경 , 대한슬관절학회지 , 2001배대경 , 대한정형외과학회지 , 2002
UKAHTO
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과 교 정 된 HTO 나 UKA 는 결 과 가 비슷하다 .
젊은 나이에서는 UKA 는 비교적 초기에 실패한다 .
Summary of Survival
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Quality of Life
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Results of HTO vs UKA
Broughton, JBJS(Br), 1986
UKA Results were signinficantly Better than HTO
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Function of HTO vs UKA
Stukenborg, The Knee, 2001
Better Function in HTO
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Pain of HTO vs UKA
Broughton, JBJS(Br), 1986
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Activity Level of HTO vs UKA
Gillquist, CORR, 1991
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Manual Labor: 17/34
Jumping Sport: 45-60%
Nagel, JBJS(Am), 1996Odenbring, Acta Ortho Scan, 1989
Activity after HTO
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HTO is better than UKAKoshino, APKS, 2006
ROM
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HTO is better than UKAKoshino, APKS, 2006
Kneeling
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UKA 에서 동통이 적으나 ,
노동은 HTO 에서 가능하다 . HTO 에서 ROM 이 더 좋고 , Kneeling 도
가능 하다 .
Summary of Quality of Life
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Biologic Aspect
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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
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Pre-op
Medial joint space narrowing
Post-op 14 M
Restored medial joint space
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Pre-op
Post-op
Cartilage defect in tibia
Healed cartilage
Cartilage defect in femur
Regenerated cartilage
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POD 17 Months
Healed cartilage defect site
initial POD 17 Mmicrofracture post-op 2 Yr
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Complications
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early perioperative complication after HTO vs UKA
Broughton, JBJS(Br), 1986
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Early Cx after HTO
• Infection• Patella baja• Intraarticular fracture• Peroneal nerve dysfunction• Compartment syndrome• Vascular injury
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Incidence : 41%Tuner, JBJS(Br), 1993
DVT Case after HTO
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Retained Cement after UKA
Engh, J Arthroplasty, 2006
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Easy in UKA Faster Recovery
Gillquist, CORR, 1991
Rehabilitation
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UKA 가 HTO 에비해 Rehabilitation 이 쉽 고 ,, Peri- operative Complication 면에서 월등하다 .
Summary of early perioperative course
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Cosmesis
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HTO : Overcorrection
UKA : Undercorrection
Alignment
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Subcondylar Osteotomy with Blade Plate
Tibia Vara with Mild OA
Preop. POD#5Y
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Tibio-Femoral Angle : 13°
Defective Cosmesis Unbalance compared to Contralateral Side
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UKA : One Stage
HTO : Two Stage
Staged Operation in Bilateral Case
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UKA : Immediate
HTO : Delay 2-3 M
Weight Bearing
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UKA 가 HTO 에비해 Weight Bearing, Cosmesis, 면에서 월등하다 .
Summary of Short Term Results
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Long tern complication
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Long term Cx after HTO
• Loss of correction
• Arthritis opposite compartment
• Decreased function over time.• pseudoarthrosis
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Collapse after UKA
Engh, J Arthroplasty, 2006
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Wear after UKA
Vince, J Arthroplasty, 2004
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Dislocation after UKA
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Fracture after UKA
Vince, J Arthroplasty, 2004
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Technical Problems & Results of Revision
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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)
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UKA : Bone Defect
HTO : Difficult Exposure
Gillquist, CORR, 1991
Frequent Encountered Problems at Revision
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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)
Results of TKA after HTOcompared with primary TKA
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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
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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?
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Summary
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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 80 세 이후의 노인에서 아주 좋은 결과를 얻을 수 있다 .
Callahan, CORR, 2005Gillquist, CORR, 1991
Insall
UKA
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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
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J arthroplasty Oct’06
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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
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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
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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
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