Journal clubUKA VS HTO

Presenter :-Dr abhishek chuadharyModerator:-Dr pavan kumar chebbi

Applied anatomy of knee complex Biomechanics of knee joint OA knee Unicondylar OA Surgical management options for

unicondylar OA Comparisons results and study conclusions

of hto vs ukr for unicondylar OA

This presentation..

Applied anatomy of knee joint

BIOMECHANICS OF KNEE

The normal anatomical load-bearing axis of the knee is viewed as ranging from 5 to 7 degrees of valgus and approximately 60% of the weight-bearing force is thought to transmit through the medial compartment and 40% through the lateral compartment

Osteoarthritis

(Degenerative arthritis/osteoarthrosis/hypertrophic

arthritis)

OSTEOARTHRITIS IS A NON-INFLAMMATORY, DEGENERATIVE CONDITION OF JOINTS CHARACTERIZED BY DEGENERATION OF ARTICULAR CARTILAGE AND FORMATION OF NEW BONE I.E. OSTEOPHYTES.

OSTEOARTHRITIS

COMMON IN WEIGHT-BEARING JOINTS SUCH AS HIP AND KNEE.

ALSO SEEN IN SPINE AND HANDS. BOTH MALE AND FEMALES ARE AFFECTED. BUT MORE COMMON IN OLDER WOMEN I.E.

ABOVE 50 YRS,PARTICULARLY IN POSTMENOPAUSAL AGE.

RISK FACTORS OBESITY ESP OA KNEE ABNORMAL MECHANICAL LOADING EG.MENISCECTOMY, INSTABILITY INHERITED TYPE II COLLAGEN DEFECTS IN PREMATURE POLYARTICULAR OAINHERITANCE IN NODAL OA OCCUPATION EG FARMERS INFECTION:NON-GONOCOCCAL SEPTIC ARTHRITISHEREDITARYPOOR POSTUREAGEING PROCESS IN JOINT CARTILAGEDEFECTIVE LUBRICATING MECHANISMINCOMPLETELY TREATED CONGENITAL DISLOCATION OF HIPPAST INJURY TO JOINT

CLASSIFICATION OF OA

MORE COMMON THAN SECONDARY OA

CAUSE –UNKNOWN

COMMON-IN ELDERS WHERE THERE IS NO PREVIOUS PATHOLOGY.

ITS MAINLY DUE TO WEAR AND TEAR CHANGES OCCURING IN OLD AGES MAINLY IN WEIGHT BEARING JOINTS.

PRIMARY OA

DUE TO A PREDISPOSING CAUSE SUCH AS:1.INJURY TO THE JOINT2.PREVIOUS INFECTION3.RA4.CDH5.DEFORMITY6.OBESITY7.HYPERTHYRIODISM

SECONDARY OA

OA IS A DEGENERATIVE CONDITION PRIMARILY AFFECTING THE ARTICULAR CARTILAGE.

1.ARTICULAR CARTILAGE2.BONE3.SYNOVIAL MEMBRANE4.CAPSULE5.LIGAMENT6.MUSCLE

PATHOLOGY

Cartilage Is The 1st Structure To Be Affected. Erosion Occurs,often Central & Frequently In Wt.

Bearing Areas. Fibrillation,which Causes Softening,splitting And

Fragmentation Of The Cartilage,occur In Both Wt. Bearing & Non-wt. Bearing Areas.

Collagen Fibres Split And There Is Disorganisation Of The Proteoglycon Collagen Relationship Such As H2o Is Attracted Into Cartilage, Which Causes Futher Softening And Flaking.These Flakes Of Cartilage Break Off And May Be Impacted B/W The Jt.Surfaces Causing Locking And Inflammation.

ARTICULAR CARTILAGE

RIGHT: EARLY OA WITH AREA OF CARTILAGE LOSS IN THE CENTER.

LEFT: MORE ADVANCED CHANGES WITH EXTENSIVE CARTILAGE LOSS AND EXPOSED UNDERLYING BONE

Arthroscopic appearances in OA of the knee joint: fibrillated surface of the cartilage on the medial femoral condyle

Bone Surface Become Hard & Polished As There Is Loss Of Protection From The Cartilage.

Cystic Cavities Form In The Subchondral Bone Because Eburnated Bone Is Brittle And Microfractures Occur.

Venous Congestion In The Subchondral Bone.

BONE(EBURNATION)

Gross superior view of a femoral head from a patient with radiographic stage i oa. This shows an area of complete cartilage loss, with polishing or eburnation of the underlying bone.

Osteophytes form at the margin of the articular surface,which may get projected into the jt. Or into capsule & ligament,bone of the wt.-Bearing jt.

There is alteration in the shape of the femoral head which becomes flat and mushroom shaped.

Tibial condyles become flatened.

OSTEOPHYTE AT MARGIN OF ARTICULAR SURFACE

Synovial membrane undergo hypertrophy and become oedematous (which can lead to ‘cold’ effusions).

Reduction of synovial fluid secretion results in loss of nutrition and lubricating action of articular cartilage.

CAPSULEIt undergoes fibrous degeneration and there

are low-grade chronic inflammatory changes

SYNOVIAL MEMBRANE

LIGAMENT Undergoes fibrous degernation

There is low grade chronic inflammatory changes and acc.To the aspect joint become contracted or elongated.

Muscles

Undergoes atrophy,as pt. Is not able to use the jt. Because of pain which further limits movts. And function.

Pain Stiffness Muscle spasm Restricted movement Deformity Muscle weakness or wasting Joint enlargement and instability Crepitus, Joint effusion

CLINICAL FEATURES OF OA

PAIN AND TENDERNESS◦ Usually slow onset of discomfort, with

gradual and intermittent increase

◦ Pain is more on wt. Bearing due to stress on the synovial membrane & later on due to bone surface,which r rich in nerve endings coming in contact.

-Initially relieved by rest but later on disturb sleep.

-Diffuse/ sharp and stabbing local pain

Clinical features 1

PAIN AND TENDERNESS (CONT)

◦Types of pain

Mechanical: increases with use of the joint

Inflammatory phases

Rest pain later on in 50%

Night pain in 30% later on

CLINICAL FEATURES

MOVEMENT ABNORMALITIES◦ ‘Gelling’: stiffness after periods of inactivity,

passes over within minutes (approx 15min.) Of using joint again

◦ Coarse crepitus: palpate/hear (due to flaked cartilage & eburnated bone ends)

◦ Reduced rom: capsular thickening and bony changes in joint,ms. Spasm or soft tissue contracture.

Clinical features 2

DEFORMITIES◦Soft tissue swelling: Mild synovitis Small effusions

◦Osteophytes◦Joint laxity◦Asymmetrical joint destruction leading to

angulation

Clinical features 3

OSTEOARTHRITIS OF THE DIP JOINTS. THIS PATIENT HAS THE TYPICAL CLINICAL FINDINGS OF ADVANCED OA OF THE DIP JOINTS, INCLUDING LARGE FIRM SWELLINGS (HEBERDEN’S NODES), SOME OF WHICH ARE TENDER AND RED DUE TO ASSOCIATED INFLAMMATION OF THE PERIARTICULAR TISSUES AS WELL AS THE JOINT.

Knee joint effusion

A patient with typical OA of the knees. In the normal standing posture there is a mild varus angulation of the knee joints due to symmetrical OA of the medial tibiofemoral compartments.

Pseudolaxity due to cartilage loss. The joint is not loaded in the first photograph

Unstable distal interphalangeal joints in OA. The examiner is able to push the joint from side to side due to gross instability, a common finding in late interphalangeal joint OA.

BLOOD TESTS: NORMAL

RADIOLOGICAL FEATURES:◦ CARTILAGE LOSS◦ SUBCHONDRAL SCLEROSIS◦ CYSTS◦ OSTEOPHYTES

INVESTIGATIONS

MANAGEMENT

EDUCATION PHYSIOTHERAPY

◦ EXERCISE PROGRAM◦ PAIN RELIEF MODALITIES

AIDS AND APPLIANCES MEDICAL TREATMENT SURGICAL TREATMENT

TREATMENT PRINCIPLES

NONSYSTEMIC NATURE OF DISEASE PREVENT OVERLOADING OF JOINT.

OBESITY!! APPROPRIATE USE OF TREATMENT

MODALITIES◦ IMPORTANCE OF EXERCISE PROGRAM◦ AIDS, APLIANCES, BRACES◦ MEDIAL TREATMENTS◦ SURGICAL TREATMENTS

EDUCATION

WILL NOT ‘WEAR THE JOINT OUT’

IMPORTANT FOR CARTILAGE NUTRITION

SOME EVIDENCE THAT LACK OF EXERCISE LEADS TO PROGRESSION OF OA

EXERCISE

ENCOURAGE FULL RANGE LOW IMPACT MOVEMENTS EG SWIMMING, CYCLING

AVOID◦ PROLONGED LOADING◦ ACTIVITIES THAT CAUSE PAIN◦ CONTACT SPORTS◦ HIGH IMPACT SPORTS EG RUNNING

EXERCISE

Quadriceps exercises for knee oa. Quadriceps exercises are of proven value for pain relief and improving function, and everyone with knee oa should be taught the correct techniques and encouraged to make these exercises a lifetime habit. There is a weight on the ankle.

Use of transcutaneous nerve stimulation (tens) as an adjunct to other therapy for pain relief at the knee joint. The use of acupuncture, tens and other local techniques to aid pain relief in difficult cases of oa is often worthwhile.

BRACES / SPLINTS SPECIAL SHOES/INSOLES MOBILITY AIDS AIDS: DRESSING, REACHING, TAP OPENERS,

KITCHEN AIDS TAPING OF PATELLA IN PATELLO FEMORAL

OA

AIDS AND APPLIANCES

Use of a cane, stick or other walking aid. This patient, who has hip oa, has found that she can reduce the pain in her damaged left hip by leaning on the stick in the right hand as she walks. The reduction in loading can be huge, and the effect on symptoms and confidence with walking very beneficial.

The use of shoes and insoles to reduce impact loading on lower limb joints. Modern sports shoes (‘trainers’) often have appropriate insoles. Alternatively, special heel or shoe insoles of sorbithane or viscoelastic materials can be used. They may help relieve pain as well as reducing the peak impact load on the joints during walking.

SIMPLE ANALGESICS: PARACETAMOL, LOW DOSE IBUPROFEN

NSAID’S/COXIBS PRN REGULAR INTRA-ARTICULAR CORTICOSTEROIDS TOPICAL TREATMENT EG NSAID CREAMS,

CAPSAICIN ‘CHONDROPROTECTIVE AGENTS’

MEDICAL TREATMENT

A patient with oa of the carpometacarpal joint of the left thumb undergoing arthrocentesis for injection of a depot corticosteroid preparation. The doctor is distracting the patient’s thumb to open up the joint space.

Indications: pain affecting work, sleep, walking and leisure activities

Complications◦ sepsis◦ loosening◦ lifespan of materials (mechanical failure)

Joint replacement surgery

UNICOMPARTMENTAL OA

Surgical option for knee arthritis when only one compartment of the knee is involved.

Epidemiology◦ 5% of surgeries where knee arthroplasty is indicated are unicompartmental

knee replacements◦ location

fimedial compartment is most common Types of implants

◦ fixed-bearing historical standard of care

◦ mobile-bearing pros

weightbearing through the meniscus increases conformity and contact without increasing constraint

decrease in wear pattern excellent survivorship out to the second decade

cons technically demanding bearings can dislocate

ukr

INDICATIONS controversial and vary widely as an alternative to

total knee arthroplasty or osteotomy for unicompartmental disease.

classicaly reserved for older (>60), lower-demand, and thin (<82 kg) patients ◦ 6% of patient's meet the above criteria with no

contraindications

new effort to expand indications to include younger patients and patients with more moderate arthrosis.

ukr

Contraindications◦ inflammatory arthritis ◦ ACL deficiency

absolute contraindication for mobile-bearing UKA and lateral UKA  controversial for medial fixed-bearing

◦ fixed varus deformity > 10 degrees ◦ fixed valgus deformity >5 degrees

◦ restricted motion arc of motion < 90° flexion contracture of > 5-10°

◦ previous meniscectomy in other compartment◦ tricompartmental arthritis (diffuse or global pain)◦ younger high activity patients and heavy laborers◦ overweight patients (> 82 kg)◦ grade IV patellofemoral chondrosis (anterior knee pain)

Ukr

Fixed-bearing◦ 1st decade results

10-year survivorship from studies done in 1980s and 1990s ranges from 87.4% to 96%

the standard faliure rate in the first decade is 1%◦ 2nd decade results

rapid decline in survivorship ranging from 79% to 90% Mobile-bearing

◦ excellent clinical results with 15-year survivorship reported at 93%.

Long-term results◦ lateral compartment arthroplasties have equivalent

results to medial  ◦ revision rates are worse than total knee revision

rates

Outcomes

Marmor (1973) introduced the first UKA in 1973 and it subsequently became an attractive concept and an alternative procedure to HTO.

The Oxfordmobile meniscal bearing system (Oxford UKA), designed by Goodfellow and O’Connor

(1986), addressed these problems by allowing more conformity between the femoral component and the

tibial insert in order to reduce the surface forces. This then allowed the

polyethylene to move on the underlying tibial tray, thereby avoiding the problems of increased constraint

Complications

Stress fractures ◦ always involve tibia◦ associated with high activity and patient weight◦ clinically there will be a pain free interval followed by

spontaneous pain with activity◦ blood commonly found on joint aspiration

Tibial component collapse◦ poor mechanical properties of bone

Ukr

Advantages compared to TKA  ◦ faster rehabilitation and quicker recovery◦ less blood loss◦ less morbidity◦ less expensive◦ preservation of normal kinematics

theory is that retaining ACL, PCL and other compartments leads to more normal knee kinematics

◦ smaller incision less post-operative pain leading to shorter hospital stays

compared to osteotomy◦ faster rehabilitation and quicker recovery◦ improved cosmesis◦ higher initial success rate◦ fewer short-term complications◦ lasts longer◦ easier to convert to a TKA

ukr

High tibial osteotomy is a well established procedure for the treatment of unicompartmental osteoarthritis of the knee. Most reports have shown approximately 80% satisfactory results at 5 years and 60% at 10 years after high tibial osteotomy.

The biomechanical rationale for proximal tibial osteotomy in patients with unicompartmental osteo-arthritis of the knee is “unloading” of the involved joint compartment by correcting the malalignment and redistributing the stresses on the knee joint.

HIGH TIBIAL OSTEOTOMY

(1) pain and disability resulting from osteoarthritis that significantly interfere with highdemand employment or recreation and

(2) evidence on weightbearing radiographs of degenerative arthritis that is confined to one compartment with a corresponding varus or valgus deformity. The patient must be able to use crutches or a walker and have sufficient muscle strength and motivation to carry out a rehabilitation program

Indications of proximal tibial osteotomy

(1) narrowing of lateral compartment cartilage space,

(2) lateral tibial subluxation of more than 1 cm, (3) medial compartment tibial bone loss of more

than 2 or 3 mm, (4) flexion contracture of more than 15 degrees,

(5) knee flexion of less than 90 degrees, (6) more than 20 degrees of correction needed,

(7) inflammatory arthritis, and (8) significant peripheral vascular disease.

Contraindications for proximal tibial osteotomy

Four basic types are most commonly used medial opening wedge, Wedge bone graft and rigid fixation required. lateral closing wedge, Longest track record .pop cast immobiization dome, aka ‘barrel vault’ Considered more stable ,accurate and better

adjustability of deformity correction.special jigs needed. medial opening hemicallotasis. uses an external fixator to distract the osteotomy site

gradually.

Techniques for valgus proximal osteotomy

(1) age younger than 60 years, (2) purely unicompartmental disease, (3) ligamentous stability, and (4) preoperative arc of motion of at least 90 degrees.

Normally, there is valgus alignment of 5 to 8 degrees in the tibiofemoral angle as measured on radiographs taken in the weight-bearing position. The amount of correction of the arthritic knee needed to achieve a normal angle is calculated, and an additional 3 to 5 degrees of overcorrection is added to achieve approximately 10 degrees of valgus. With a varus deformity, the only limitation in the amount of correction from a valgus osteotomy is the size of the bone wedge

that can be taken proximal to the patellar tendon.

factors associated with favorable results,

The advantage (1) it is made near the deformity, that is, the knee joint; (2) it is made through cancellous bone, which heals

rapidly; (3) it permits the fragments to be held firmly in position

by staples or a rigid fixation device, such as a plate-and-screw construct; and

(4) it permits exploration of the knee through the same incision. After this operation, the danger of delayed union or nonunion is slight and prolonged immobilization in a cast is unnecessary, especially with rigid internal fixation.

Lateral closing osteotomy

Lateral closing osteotomy

Tricortical iliac crest autograft with supplemental cancellous graft material also is recommended; however, other structural graft material, such as hydroxyapatite wedges, can be successful. Opening wedge osteotomy .

should be done if the involved extremity is 2 cm or more shorter than the contralateral extremity.

Opening wedge osteotomy also may be indicated in patients with laxity of the medial collateral ligament or combined anterior cruciate ligament deficiency.

MEDIAL OPENING WEDGE OSTEOTOMY

roughly 1 degree of correction for each 1 mm of length at the base of the wedge (e.g., 20 degrees of correction =a 20-mm base of the wedge). This is true only if the tibia is 57 mm wide, however, and we prefer using exact measurements for the width of the base of the osteotomy, with a right triangle con-structed from a preoperative drawing or the

formula W =diameter ×0.02 ×angle or tangent tables.

Alternately, full-length, near actual size, standing anteroposterior radiographs can be used to determine the size of the wedge needed. The desired alignment, based on the mechanical axis from the center of the femoral head through the knee to the center of the ankle, can be achieved by cutting the appropriate-sized wedge from the proximal tibia.

How much to cut…

recurrence of deformity (loss of correction) most commen,

peroneal nerve palsy, nonunion, infection, knee stiffness or instability, intraarticular fracture, deep vein thrombosis, compartment syndrome, patella infra, and

osteonecrosis of the proximal fragment. Inadequate correction and recurrent varus

deformity have been reported to occur in 5% to 30% of patients with proximal tibial osteotomy.

GENERAL COMPLICATIONS OF HIGH TIBIAL OSTEOTOMY

ABSTRACT BACKGROUND:the choice of surgical treatments

for unicompartmental osteoarthritis (oa) of the knee is still somewhat controversial. midterm results from cases treated using unicompartmental knee arthroplasty (uka) or open wedge high tibial osteotomy (owhto) were evaluated retrospectively.

METHODS:twenty-seven knees of 24 patients with varus deformities underwent owhto and 30 knees of 18 patients underwent uka surgeries for the treatment of medial compartmental osteoarthritis (oa). the kss score,fta, range of motion and complications were evaluated before and after surgery.

RESULTS:

the preoperative mean kss scores were 49 points in the owhto group and 62 in the uka group which improved postoperatively to 89 (excellent; 19 knees, good; 8 knees), and 88 (excellent; 25, good; 4, fair; 1), respectively. there was no significant difference between the owhto and uka scores. seventeen patients in the owhto group could sit comfortably in the formal japanese style after surgery. the preoperative mean fta values for the owhto and uka groups were 182 degrees and 184, and at follow-up measured 169 and 170, respectively. in the uka group, the femoral component and the polyethylene insertion in one patient was exchanged at 5 years post-surgery and revision tkas were performed in 2 cases. in the owhto group, one tibial plateau fracture and one subcutaneous tissue infection were noted.

Treatment options should be carefully considered for each OA patient in accordance with their activity levels, grade of advanced OA, age, and range of motion of the knee. OWHTO shows an improved indication for active patients with a good range of motion of the knee.

Conclusions

The Iowa Orthopaedic Journal volume 30

This review examined the literature regarding high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA), focusing on indications,survivorship and functional outcomes of the two procedures, as well as revision to total knee arthro-plasty (TKA) after failed HTO or UKA.

The aim of this review is to identify the correct in-dications for HTO and UKA, analyze the results from both treatments, and report on the comparison studies in the literature.

AbstrAct

HTO and UKA share the same indications in selected cases of medial unicompartmental knee arthrosis. These indications include patients who are:

1) 55 to 65 years old; 2) moderately active; 3) non-obese; 4) have mild varus malalignment; 5) no joint instability; 6) good range of motion; and 7) moderate unicompartmental arthrosis

Few studies are available in the literature comparing the outcomes of HTO and UKA. those few studies show slightly better results for UKA in terms of survivorship and functional outcome. Nevertheless, the differences are not remarkable, the study methods are not homogeneous and most of the papers report on closing wedge HTOs. For these reasons, no definitive conclusions can be drawn.

TKA represents the revision option for both treatments and yields satisfactory functional outcomes and survivorship. Whether revision HTO and UKA-to-TKA perform any worse than primary TKA is still controversial. With the correct indications, both treatments produce durable and predictable outcomes in the treatment of medial unicompartmental arthrosis of the knee. there is no evidence of superior results of one treatment over the other.

High tibial osteotomy and unicompartmental knee arthroplasty represent a “strange couple” in the treat-ment of medial compartment arthrosis of the knee.

HTO has long been considered a successful and widely performed procedure to address malalignment and subsequent unicompartmental arthrosis of the knee. UKA has gained popularity in the management of uni-compartmental arthrosis, when total knee arthroplasty and HTO are the only alternative treatments available.

Introduction

The original intent of HTO is correction of a knee angular deformity or metaphyseal tibial malalignment, which determines a medial symptomatic overload or initial arthrosis.

The ideal candidate for an HTO is 1. a young (less than 60 years old), 2. active patient affected by symptomatic mild-to-moderate

varus knee (5 to 15 degrees) with mild medial compartment involvement (less than grade III, Ahlback classification), intact lateral and patellofemoral compartments,

3. good knee range of motion (knee flexion >120 degrees), and

4. no joint laxity or instability.

INDICATIONS FOR HTO

However, the indications for HTO have been recently expanded to include posterolateral laxity and varus hyperextension thrust, anterior cruciate liga-ment (ACL) deficiency and varus thrust or alignment, and combined ligamentous laxity with varus or posterolateral thrust.

UKA is the partial surface replacement of the knee joint. Its increasing popularity is due to:

1) the possibility of replacing a severely damaged compartment;

2) the preservation of bone stock; together with 3) a faster recovery time and minimal invasiveness

compared to TKA.

With recent technical improvements, UKA is consistently less invasive, and newer designs with arthroscopic techniques will soon be introduced into the marketplace.

INDICATIONS FOR UKA

1) unicompartmental osteoarthritis or femoral condyle avascular necrosis, with intact lateral and patellofemoral compartments;

2) age over 60 years; 3) low demands; 4) no obesity; 5) minimal pain at rest; 6) range of motion (ROM) arc over 90 degrees with less

than 5 degrees flexion contracture; and 7) within 10 degrees of axial malalignment, which can be passively corrected almost to neutral.

Anterior cruciate ligament (ACL) deficiency has been considered a contraindication??

The ideal indications for UKA include:

SUMMARY OF INDICATIONS OF HTO AND UKA OR BOTH

Many papers in the literature described the outcomes of HTO and UKA.

These mainly focused on survivorship analyses, technical features (such as closed versus open HTO, or all polyethylene versus metal-backed tibial UKA),

complications and adverse effects of the procedures, as well as

outcomes of revisions to TKA.

Only a few papers reported a direct comparison of the two procedures

OUTCOMES OF HTO AND UKA

Survivorship analyses- the 10-year sur vivorship increased from around 50% to 80%

Patient satisfaction and clinical results were reported to be good as well, with 50 to 80% achieving good to excellent results at five-to-seven years follow-up, and 30 to 60% good to excellent results at 10-to-15 years follow-up.

RESULTS OF HTO

unfavorable factors.1. Advanced age, 2. over- or under-correction, 3. instability and severe arthrosis 4. The goal to be achieved in alignment

assessment is a slight valgus overcorrection (2 to 5 degrees)

RESULTS OF HTO CONT..

Controversies still exist regarding three topics and these include:

1) the most reliable HTO technique (closing, opening, or dome),

2) the clinical implications of patellar height changes, and

3) the technical difficulties related to surgical technique/means of synthesis.

RESULTS OF HTO CONT..

The complications-1. fibular osteotomy or proximal tibiofibular joint disruption, 2. peroneal nerve dissection, 3. more demanding subsequent TKA,4. loss of bone stock, and 5. more difficulty controlling tibial slope (with a tendency to

decrease it).

For all these reasons, the opening wedge HTO gained popularity and became a widely used alternative. This technique however is not itself free from drawbacks including the necessity for bone grafting and possible collapse or loss of correction.

RESULTS OF HTO CONT..

UKA was introduced in the 1970s but did not gain wide acceptance due to poor early results, high failure rates, and high technical demands .

10 -15 years survival rate ranges from 82 to 95 %

Aspects which most likely affect the outcome of UKA are prosthetic design, alignment, and stability and experience of surgeon.

RESULTS OF UKA

COMPARISONS BETWEEN HTO AND UKA

JANUARY 2014

High tibial osteotomies (HTO) and unicompartmental knee arthroplasties (UKA) are performed for the treatment of isolated unicompartmental osteoarthritis (OA) of the knee.

Before the development ofknee arthroplasties, HTO was the most common operative treatment option for knee OA.

Over the past two decades, the incidence of osteotomies has decreased, but symptomatic, radiologically mild or moderate knee OA is still commonly regarded as an indication of HTO in young and active patients

After development and popularisation of total knee arthroplasty (TKA), the overall proportion of UKAs has decreased in the treatment of knee OA . However, UKA is provided as an option for TKA in cases of isolated unicompartmental knee OA, and significant numbers of UKAs are still performed worldwide.

Introduction

HTO alters the anatomy and biomechanics of the knee. The most common changes are ligamental imbalance, patellar tendon length alteration, scar formation and possible rotational deformities.

All these factors may make a subsequent TKA procedure more difficult, but most of the previous studies show no adverse effects on the results of subsequent TKA.

Results of UKA operations are controversial. Most single centre studies report UKA results that are comparable with those of TKA However, these studies are not supported by available arthroplasty register data from Australia, Finland, New Zealand, Norway, Sweden and the United Kingdom, which report repeatedly inferior survivorship of UKA compared with TKA patients.

Results..Incidedence of HTO

Results ..incidence age gp

Results…

Results ...

Results ..

Results..

Marmor (1973) introduced the first UKA in 1973 and it subsequently became an attractive concept and an alternative procedure to HTO.

The Oxfordmobile meniscal bearing system (Oxford UKA), designed by Goodfellow and O’Connor (1986), addressed these problems by allowing more conformity between the femoral component and the tibial insert in order to reduce the surface forces. This then allowed the polyethylene to move on the underlying tibial tray, thereby avoiding the problems of increased constraint

Ukr

Results ..ukr incidence

Results…ukr

Ukr results

following conclusion can be made based on the results of this study. 1. The overall incidence of osteotomies in the treatment of knee OA has decreased steadily over the last two decades, but in the age group less than 50 years, the incidence has slightly increased. The decline in incidence has been steeper in female patients.

2. The short term survivorship of HTO at a nationwide level is comparable with that regularly reported in single hospital or surgeon series, but the midterm survivorship is worse. Females and patients aged more than 50 years have poorer results.

3. The survivorship of TKAs after previous HTO is satisfactory when compared

with that following routine primary TKAs.

4. The survivorship of UKA cases is poorer compared that of TKA. Critical patient screening for indications and adequate surgical techniques are crucial to provide satisfactory UKA results for selected patients with isolated knee osteoarthritis. In addition, UKA patients have a high revision rate, especially because of aseptic loosening.

conclusions

JBJS 1986 RETROSPECTIVE STUDY COMPARISON AFTER 5-10 YEARS

Methods…Study groups

Results ..complications

Results…

Results…

This five to ten year study has shown significantly better results in terms of pain and function ,in similar group of patients for unicompartmental degenerative disease of the knee.

However the age group (mean age 63 years) for tibial osteotomy is not favorable as we know now may have resulted in outright better outcome for ukr.

Conclusions…

Isolated medial joint line pain, age 40 to 60 years, body mass index (BMI) < 30, high demand activity but no running or jumping, varus malalignment < 15 degrees, metaphyseal varus of tibia> 5 degrees, full range of movement, normal lateral and patellofemoral compartments, no defect of the posteromedial tibia, normal ligament balance, nonsmoker and some level of pain tolerance.

Presenter conc…Hto can be done if ideal candidate is available..

Thank you…

Improvements in surgical techniques and instruments have given the UKA procedure potential advantages over TKA in properly selected patients. These includeless bone resection, preservation of the cruciate ligaments, quicker recovery, decreased perioperative complications and a subjective preference as feeling “more normal”, returning to sports, improved walking ability, and lower cost

Only two prospective RCTs have compared UKA and TKA procedures. In the first, 15-year follow-up study, UKA produced similar or slightly better results compared with TKA. The survivorship of the implant in both groups, with revision or a Bristol Knee Score < 60 as the endpoint, was 89.8% in the UKA group and 78.7% in the TKA group. The Bristol Knee Scores of the UKA group was better throughout the study period and at 15 years 15 of the surviving UKAs (71.4%) and 10 of the surviving TKAs (52.6%) achieved an excellent outcome. In the second RCT study, including 56 knees(mean follow-up 52 months, range 70– 100), mobile bearing UKA achieved similar clinical effects to those of TKA, but had a higher first year revision rate because of the learning curve. According to the scale of the Knee Society, at the latest follow-up, the mean Knee Society score was 80.6 (range 70–100) and 78.9 (range 70–87) for UKA and TKA, respectively. Seven UKAs were converted to TKA due to component loosing – all of them within the first two years of starting the procedure and all of them in relatively young patients. None of the TKAs was revised (Sun & Jia 2012).

Uka vs tka