S. Hofmann Head Knee Training Centre General Orthopaedic Hospital Stolzalpe AUSTRIA Vienna Vienna...
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S. HofmannS. HofmannHead Knee Training CentreHead Knee Training CentreGeneral & Orthopaedic HospitalGeneral & Orthopaedic HospitalStolzalpe – AUSTRIAStolzalpe – AUSTRIA
• ViennaVienna•
StolzalpeStolzalpe
UNI vs OsteotomyUNI vs OsteotomyIs there a competion ?Is there a competion ?
Therapeutic DilemmaTherapeutic Dilemma(active middle aged 40-60)(active middle aged 40-60)• Biological therapy ?
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)• Lateral arthrosis with ACL• ACL insufficiency &
single compartment arthrosis ?• Patient related factors
individual indications
ACL, osteotomy & mosaic plasty
Varus 8°, ACL & cartilage defect
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
Kennedy CORR 1987
0 1 5C2 3 4
• More than 20 years• Partial correction deformity • Resurfacing one compartment• Free of pain • Timewinning or defintive solution ? • > 90 % Varus deformities
Comparison patella osteotomy
Müller EFORT 2000
• Cartilgage damage not main symptom• Biomechanics & clinics • Advantage
lenghtening lig. patellae (closed) Release soft tissues
• DisatvantageShortening Lig. Patellae (open)No patelloplasty
Comparison patella Unis• Cartilage damage not main symptom• Biomechanics & clinics • Advantage
patelloplasty possibleNo sec. shortening
• DisatvantageNo lenghtening lig. patellaeNo release soft tissues
Comparison complications osteotomies• 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° Valgusafter HTO
Comparison complications Unis• 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 osteotomyOutcomes of osteotomy• No EBM data• Cochrane – Silver Evidence
70% benefit 10 years• Survivalrates
5 years 73 % 10 years 52 %
• Selected patientsSurvival 10 y 90%
• Results depend on risc factors
Hofmann et al, European IC Lectures 2011
Feeley et al, J Am Acad Orthop Surg 2010
Comparison clinical results• Retrospective studies• Unis
Clinical results Complications
• Survival rate 10 yearsHTO / Uni 76 % / 90 %
• Survival rate 15 yearsHTO / Uni65 % / 88 %
Weale CORR 1994
Comparison revision to TKA• Worser after Unis
Gill et al, CORR 1995
• Worser after osteotomiesJackson et al, J Arthroplasty 1994
• No difference & comparable to primary TKA
McAuley et al, CORR 2001 OvercorrectionValgus 24°
Uni & largebony defects
Sporting Activities Sporting Activities TKA vs UNI vs OsteoTKA vs UNI vs Osteo
Bonnin et al, KSSTA 2011
New concept of osteotomiesNew concept of osteotomies• Biomechanical understandingBiomechanical understanding
Alignment Alignment Slope & joint line Slope & joint line Patellofemoral joint Patellofemoral joint
• Patient selection & planningPatient selection & planning• Safe & easy osteosynthesisSafe & easy osteosynthesis• Early functional rehabiliationEarly functional rehabiliation
Hofmann et al, Orthopäde 2009Hofmann et al, European IC Lectures 2011
Results New Concept
• Prospective multicenter (3)Prospective multicenter (3)• 369 varus knees369 varus knees• FU 3.5 years (2-5)FU 3.5 years (2-5)• 3.5% Complications3.5% Complications
• 98% Survival (3-5 years) 98% Survival (3-5 years)
• Oxford Score 41 (max 48)Oxford Score 41 (max 48)UKA 39 & TKA 35-40UKA 39 & TKA 35-40
Lobenhoffer et al, ESSKA 2010
Cartilage Damage prior Cartilage Damage prior SurgerySurgery
Lobenhoffer et al, ESSKA 2010
Oxford Score Cartilage Oxford Score Cartilage DamageDamage
Lobenhoffer et al, ESSKA 2010
Oxford Score & AgeOxford Score & Age
Lobenhoffer et al, ESSKA 2010
Patient Selections StolzalpePatient Selections Stolzalpe
Adipositas per magna
• „„Golden rule age“Golden rule age“male < 65male < 65female < 55female < 55
• Sporting activitiesSporting activities• OccupationOccupation• Compliance & Compliance &
patients expectionspatients expections
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