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UNI vs Osteotomy Is there a competion ?

UNI vs Osteotomy Is there a competion ?. Vienna. S. Hofmann Head Knee Training Centre General & Orthopaedic Hospital Stolzalpe – AUSTRIA. Stolzalpe. Therapeutic Dilemma (active middle aged 40-60). Biological therapy ? NSAIDS, Suppl & Cartilage Arthroscopy ?

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UNI vs Osteotomy Is there a competion ?

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  1. UNI vs OsteotomyIs there a competion ? • Vienna S. Hofmann Head Knee Training Centre General & Orthopaedic Hospital Stolzalpe – AUSTRIA Stolzalpe

  2. Therapeutic Dilemma(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

  3. Indications for osteotomies & Unis Varus 8°, ACL & cartilage defect • Anteromedial arthrosis (AMA) • Lateral arthrosis with ACL • ACL insufficiency &single compartment arthrosis ? • Patient related factors  individual indications ACL, osteotomy & mosaic plasty ACL & MIS Uni

  4. 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

  5. Basic principles Unis • More than 20 years • Partial correction deformity • Resurfacing one compartment • Free of pain • Timewinning or defintive solution ? • > 90 % Varus deformities C 3 4 5 0 1 2 Kennedy CORR 1987

  6. 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

  7. 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

  8. 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

  9. 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

  10. Outcomes of osteotomy • No EBM data • Cochrane – Silver Evidence 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

  11. Comparison clinical results • Retrospective studies • Unis Clinical results Complications  • Survival rate 10 years HTO / Uni 76 % / 90 % • Survival rate 15 years HTO / Uni 65 % / 88 % Weale CORR 1994

  12. Comparison revision to TKA • Worser after UnisGill et al, CORR 1995 • Worser after osteotomiesJackson et al, J Arthroplasty 1994 • No difference & comparable to primary TKAMcAuley et al, CORR 2001 OvercorrectionValgus 24° Uni & largebony defects

  13. SportingActivitiesTKA vs UNI vsOsteo Bonnin et al, KSSTA 2011

  14. 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

  15. 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

  16. Cartilage Damage prior Surgery Lobenhoffer et al, ESSKA 2010

  17. Oxford Score Cartilage Damage Lobenhoffer et al, ESSKA 2010

  18. Oxford Score & Age Lobenhoffer et al, ESSKA 2010

  19. Patient SelectionsStolzalpe • „Golden rule age“ male < 65 female < 55 • Sporting activities • Occupation • Compliance & patients expections Adipositas per magna

  20. Summary advantages osteotomies • No artificial joint • No arthrotomy necessary • Combination with cartilage &ligament surgery • Less expensive

  21. 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°

  22. 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 conceptresults are probably comparable

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