بسم الله الرحمن الرحيم
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بسم الله الرحمن الرحيم. بسم الله الرحمن الرحيم. Treatment options of Genovarum , Unicompartment Arthroplasty vs High Tibial Osteotomy. H.Makhmalbaf MD. Knee surgeon Ghaem Hospital Medical School. Osteotomy about the knee.

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بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم


Treatment options of genovarum unicompartment arthroplasty vs high tibial osteotomy

Treatment options of Genovarum, UnicompartmentArthroplastyvs High TibialOsteotomy

H.Makhmalbaf MD. Knee surgeon

Ghaem Hospital Medical School


Osteotomy about the knee
Osteotomy about the knee

  • Coventry :UTO for treatment of arthritis with associated limb malalign.

  • Realignment osteotomy to transfer WB forces from the arthritic portion to a healthier location of the knee

  • Redistribution of mechanical forces to increase the life span of the knee


The goals of osteotomy
The goals of osteotomy

  • Pain relief

  • Functional improvement

  • Ability to meet heavy functional demands

  • Careful patient selection

  • Skillful surgical technique


Patient selection
Patient selection

  • The ideal candidate for osteotomy is

  • Thin active individual

  • In the 5th or 6th decade of life

  • With localized, activity-related

  • Unicompartmental knee pain

  • No PFJ OA


Patient selection1
Patient selection

  • A stable knee

  • Full extension

  • With flexion of at least 90 deg

  • No narrowing of lateral compartment

  • Medial bone loss less than 2-3mm


Patient selection historical
Patient selection: Historical

  • Age : chronological, physiological

  • Patient’s desired activity level

  • Pain: location, character, PFJ ?

  • Rhumatological status

  • Prior menisectomy

  • Infection history


Examination
Examination;

  • Malalignment: magnitude, direction

  • Prior incisions, body habitus

  • ROM: total arc, flexion contracture

  • Ligamentous deficiencies

  • PF mechanics

  • Adductor thrust


Radiological
Radiological :

  • Anatomic axis

  • Mechanical axis

  • Severity of OA

  • Magnitude of deformity

  • Tibiofemoral subluxation


Radiological1
Radiological:

  • Status of other compartments

  • Joint space opening

  • Amount of articular cartilage loss

  • CPPD, osseous defects

  • Deformities away from the joint

  • Joint line obliquity


Contraindications
Contraindications:

  • Diffuse, nonspecific knee pain

  • Patellofemoral pain primary complaint

  • Moderate or severe lig. Instability

  • Menisectomy in comp. intended for WB

  • OA in: # # # #

  • Underlying diag. Of inflammatory dis.

  • No Good ROM


Counseling
Counseling:

  • Discuss all treatment alternatives

  • No normal joint with TKA / Osteotomy

  • Long term results, rehabilitation, pain relief & durability of TKA Or Osteotomy

  • Longer post op. recovery after osteotomy

  • Results of TKA after osteotomy


Tka vs osteotomy
TKA vs Osteotomy

  • Arthroplasty provides more complete pain relief & shorter rehab. Period & is more reliable than osteotomy in most individuals older than 60 yrs. Insall JN


Long term outcome of high tibial osteotomy
Long Term Outcome of high TibialOsteotomy

A 10 to 20-year follow-up

S. Akiziki et al. Japan

JBJS 90 B May 2008

UTO is more accepted in Japan

UTO & fixation with plate no POP

94 patients (118 knees)

16.4 yr follow-up

Good result in 73.7%

Risk factors: BMI> 27.5 & ROM<100


Unicompartment arthroplasty indications
Unicompartment ArthroplastyIndications

  • Unicompartment OA

  • Good range of movement

  • Ligament stability

  • An intact ACL

  • Normal PFJ


Uka vs uto
UKA vs UTO

  • Higher initial success rate &

  • Fewer early complications

  • Could be done bilaterally at the same time

  • Full recovery within 3 months

  • With MIS techniques

  • Less blood loss, less pain &

  • Quicker recovery


Patient selection2
Patient selection

  • Osteotomy is the procedure of choice in young active male with unicomp.OA

  • Pain during rest & poor ROM is a contraindication to UTO

  • Subluxation & extreme angular deformity are contraindications to both UTO & UKR

  • Ideal candidate for UKR are middle aged patients with OA


Advantages of ukr
Advantages of UKR

  • Reliable initial result

  • Anatomic realignment

  • Retention of both ligaments

  • And easy salvage

  • Quicker surgery , less blood loss

  • Less expensive

  • Decision should be made at surgery

  • UKA or TKR


  • Unicompartment knee arthroplasty with Oxford prosthesis in patients with medial compartment arthritis

    H. Emerson Jr MD et al

    JBJS 90-A Jan 2008 / 55 patients

  • Mobile bearing Oxford UKR optimizes PE wear

  • Mechanical limb alignment without lig. Release

  • Progression of OA in the lat. Compt. , the most commen reason for final failure


Cementless oxford ukr shows reduced radiolucency at one year
Cementless patients with medial compartment arthritis Oxford UKR shows reduced radiolucency at one year

  • H. Pandit et al Nuffield Orthopaedic Centre, Oxford , England

    JBJS B Feb 2009

    61 patients / 62 knees

    32 cemented , 30 cementless

  • Radiolucency around the cementless tibial component diminishes at one year


Medial ukr in the under 50s
Medial UKR in the under 50s patients with medial compartment arthritis

  • S Parratte et al

    JBJS 91-B March 2009

    France

    35 knees , 31 patients

  • 12 year survival was 80.6%

  • The problems were PE wear

  • Consider UKR to bridge the gap between UTO & TKR


The advantages of ukr over tkr
The advantages of UKR over TKR patients with medial compartment arthritis

  • Retention of the cruciate ligaments

  • Preservation of bone stock

  • And better functional results


What is being done
What is being done? patients with medial compartment arthritis

  • In the West : UK, USA

  • In Iran

  • My experience with UKR, UTO, TKR

  • Young patients with deformity & no OA


Ukr contraindications
UKR patients with medial compartment arthritiscontraindications

  • OA in other compartments of the knee

  • Severe deformity

  • Ligament instability

  • Limitation of ROM

  • RA


Complications of ukr
Complications of UKR patients with medial compartment arthritis

  • Tibial component loosening

  • PE wear

  • OA of other compartments


Thank you patients with medial compartment arthritis


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