s. hofmann head knee training centre general orthopaedic hospital stolzalpe austria vienna vienna...
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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 UniTRANSCRIPT
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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 ?
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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
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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
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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
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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
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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
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Comparison patella Unis• Cartilage damage not main symptom• Biomechanics & clinics • Advantage
patelloplasty possibleNo sec. shortening
• DisatvantageNo lenghtening lig. patellaeNo release soft tissues
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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
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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
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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
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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
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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
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Sporting Activities Sporting Activities TKA vs UNI vs OsteoTKA vs UNI vs Osteo
Bonnin et al, KSSTA 2011
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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
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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
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Cartilage Damage prior Cartilage Damage prior SurgerySurgery
Lobenhoffer et al, ESSKA 2010
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Oxford Score Cartilage Oxford Score Cartilage DamageDamage
Lobenhoffer et al, ESSKA 2010
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Oxford Score & AgeOxford Score & Age
Lobenhoffer et al, ESSKA 2010
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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
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Summary advantages osteotomies• No artificial joint• No arthrotomy necessary• Combination with cartilage &
ligament surgery• Less expensive
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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°
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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