s. hofmann head knee training centre general orthopaedic hospital stolzalpe austria vienna vienna...

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