Operation of Arthritic Knee - HTO vs UKA - Beom Koo Lee, M.D. Dept. of Orthopaedic Surgery Gil Medical Center, Gachon University Surgical Options for Mono-compartmental OA Arthroscopic Debridedment Cartilage Transplantation Osteotomy UKA TKA Discussion Point to compare HTO vs UKA Trend Survival Function Kinematics Indication & contraindication Biologic aspect Perioperative morbidity Weight bearing, Rehabilitation, General Complication Problem Complication Cosmetics Technical Problem associated with TKA after Procedure Trend Trend of UKA The early reported series of unicompartmental knee replacement done by experienced surgeons did not have encouraging results, with 70% survivorship reported at 5 to 7 years, and 65% and 53% survivorships reported at 11 and 12 years, respectively. Callahan, CORR, 2005 Trend of UKA, Recently • However, more recently the reports of unicompartmental knee replacement have been more encouraging with 94% survivorship at 10 years and 90% survivorship at 18 years. Callahan, CORR, 2005 Kinematics of UKA The UKA preserve Normal Kinematics Patil, JBJS(Am), 2005 Kinematics of UKA Patil, JBJS(Am), 2005 Kinematics of UKA Patil, JBJS(Am), 2005 Kinematic of UKA Variable Femoral Roll Back Dennis, JBJS(Am), 2001 Indications & Contraindications Ideal Indications of HTO • Young • Active • Male • Varus Deformity Mont, AAOS ICL, 2004 Ideal Indications of UKA • Low Demand • Female • Elderly • No instability & Contracture • Correctable Deformity Mont, AAOS ICL, 2004 Contraindications HTO UKA +(?) + ACL Insufficiency - + P-F Arthritis + + Obesity + + Inflammatory Arthritis + + Advanced Age + - Arthritis Opposite + + Severe Contracture + + Medial Plateau Depression + - Lateral Instability + + Severe Deformity Range of Correction UKA Varus 10 - 20° Valgus < 15° Preferably 10° Pagnano, AAOS ICL, 2005 osteotomy Even Severe Deformity over 20 can be corrected by Dual Osteotomy. Hanssen Insall 3rd edit T-F angle : Varus 14° Mechanical Axis : Varus 20° Lateral Instability moderate to severe Lateral instability, and subluxation contraindicated in HTO (Insall 3rd edit) TKA is advisable in Great subluxation than UKA ( Insall 3rd edit) UKA is contraindicated for instability (ICL 2005) Management in Mild Lateral Laxity Slight Overcorrection Reefing of LCL 배대경 Spontaneous shortening 조세현 in HTO is ACL Instability in UKA • ACL insufficiency ; relative contraindication in UKA ICL 2005 HTO can be done in ACL Deficiency Noyes, Am J Sports Med, 2000 UKA in Elderly Summary of Indications UKA는 HTO에비해 비교적 Deformity 정 도가 적어야하고, Ligament가 Stable 해 야한다. UKA에서 80세 이상의 노인이나, 40대의 여성에서 유리하다. HTO는 활동이 많은 젊은 나이에 유리하다. Survival Survival of UKA O’Rourke, CORR, 2005 Survival of UKA Stukenborg, The Knee, 2001 Survival of MIS-UKA Despite an accelerated recovery and decreased hospital stay in our MISUKA, the rate of Revision due to aseptic loosening and the overall Reoperation rate compare to unfavorably with those performed with an open technique. Engh, J Arthroplasty, 2006 Survival of HTO Insall & Scott, Surger of the Knee, 4th ed. Survival of HTO & UKA HTO 배대경, 대한정형외과학회지, 2002 UKA 배대경, 대한슬관절학회지, 2001 Summary of Survival 과교정된 HTO나 UKA는 결과가 비슷하다. 젊은 나이에서는 UKA는 비교적 초기에 실 패한다. Quality of Life Results of HTO vs UKA UKA Results were signinficantly Better than HTO Broughton, JBJS(Br), 1986 Function of HTO vs UKA Better Function in HTO Stukenborg, The Knee, 2001 Pain of HTO vs UKA Broughton, JBJS(Br), 1986 Activity Level of HTO vs UKA Gillquist, CORR, 1991 Activity after HTO Manual Labor: 17/34 Jumping Sport: 45-60% Nagel, JBJS(Am), 1996 Odenbring, Acta Ortho Scan, 1989 ROM HTO is better than UKA Koshino, APKS, 2006 Kneeling HTO is better than UKA Koshino, APKS, 2006 Summary of Quality of Life UKA에서 동통이 적으나, 노동은 HTO에서 가능하다. HTO에서 ROM이 더 좋고, Kneeling도 가 능 하다. Biologic Aspect Cartilage Healing after HTO Joint Space Preop.: 1.8mm 3 Yr F-up: 2.9mm Joint Space (2Y F/U) Koshino -Joint space ;pre-op 1.1mm post-op 2.3mm -Pattern No reg;13/146 pink and yellow fibrillation 2/143 Partial coverage 50/143 Full coverrage 16/143 13,86,47/146 송은규, 대한슬관절학회지, 2002 Pre-op Post-op 14 M Medial joint space narrowing Restored medial joint space Pre-op Cartilage defect in tibia Cartilage defect in femur Regenerated cartilage Healed cartilage Post-op Healed cartilage defect site POD 17 Months initial microfracture post-op 2 Yr POD 17 M Complications early perioperative complication after HTO vs UKA Broughton, JBJS(Br), 1986 Early Cx after HTO • Infection • Patella baja • Intraarticular fracture • Peroneal nerve dysfunction • Compartment syndrome • Vascular injury DVT Case after HTO Incidence : 41% Tuner, JBJS(Br), 1993 Retained Cement after UKA Engh, J Arthroplasty, 2006 Rehabilitation Easy in UKA Faster Recovery Gillquist, CORR, 1991 Summary of early perioperative course UKA가 HTO에비해 Rehabilitation이 쉽 고,, Peri- operative Complication 면에 서 월등하다. Cosmesis Alignment HTO : Overcorrection UKA : Undercorrection Tibia Vara with Mild OA Subcondylar Osteotomy with Blade Plate Preop. POD#5Y Tibio-Femoral Angle : 13° Defective Cosmesis Unbalance compared to Contralateral Side Staged Operation in Bilateral Case UKA : One Stage HTO : Two Stage Weight Bearing UKA : Immediate HTO : Delay 2-3 M Summary of Short Term Results UKA 가 HTO 에 비 해 Weight Bearing, Cosmesis, 면에서 월등하다. Long tern complication Long term Cx after HTO • Loss of correction • Arthritis opposite compartment • Decreased function over time. • pseudoarthrosis Collapse after UKA Engh, J Arthroplasty, 2006 Wear after UKA Vince, J Arthroplasty, 2004 Dislocation after UKA Fracture after UKA Vince, J Arthroplasty, 2004 Technical Problems & Results of Revision Technical Problems of TKA after HTO (ICL 2004) Difficult Exposure Bone Defect Difficult Ligament Balance Prolonged Operative Time Increased Blood Loss Offset Stem Sometimes But, No Problem after Open Wedge HTO (Kitson) Injury 2001;32 Frequent Encountered Problems at Revision UKA : Bone Defect HTO : Difficult Exposure Gillquist, CORR, 1991 Results of TKA after HTO compared with primary TKA Less Successful (windsor 1988 JBJS) (Cameroon1996 orthopedic (Katz 1987 JBJS) More infection (Jackson J arthroplasty 1994) difficult exposure , mild decreased flexion but No difference (Haddad 2000 J arthroplasty) (Windsor) Summary of Problems at Revision HTO는 Approach시 조심해야 하며, UKA 는 Bone Defect에 대비해야 한다. 결과는 HTO가 UKA 후 Revision보다 좋 다. Can We expand Indication of UKA in Young Patients? We may rightfully expect Higher Failure Rates, perhaps Greater Damage in the Younger, More Active Patient. New, expanded Indications for UKA may lead to More Complications and perhaps More Severe Failures. Vince, J Arthroplasty, 2004 Summary UKA Faster Recovery Immediate Weight Bearing High Initial Success Rate Fewer Early Complications Simultaneous Bilateral Procedure Better Cosmesis Less Infection Less Blood Loss Less Function and Activity 80세 이후의 노인에서 아주 좋은 결과를 얻을 수 있다. Callahan, CORR, 2005 Gillquist, CORR, 1991 Insall HTO More Active Life Style Biologic Better Result at Revision than UKA 초기 문제가 많다. Weight Bearing Perioperative Complication Staging Procedure Morbidity Iorio, JBJS(Am), 2003 Gill, CORR, 1995 Chang J arthroplasty Oct’06 Future of UKA Although the unicompartmental prosthesis used in this series has not shown promising results and does not match the results of some other prosthesis, and the introduction of guide instruments for precise surgical techniques has currently improved the survival of UKAs to over 90% at 10 years. Therefore, we think that in patients over 60 years of age, unicompartmental osteoarthritis UKA offers Better Long-term Results than HTO. Stukenborg, The Knee, 2001 Future of HTO It is proposed that Future Biologic Resurfacing, together with Computerand even RoboticMethods, as well as other advances in Biology and Technology, will combine to resurrect the performance of knee osteotomies Krackow, J Arthroplasty, 2004 Summary HTO와 UKA는 잘 선택될 때 좋은 결과를 얻을 수 있다. Indication, Cosmesis, Function, Biologic면에서 완 전히 다른 수술이다. HTO는 초기에 문제가 많고, UKA는 후기에 문제가 있다. HTO는 젊고 활동이 많은 환자에 유용하다. UKA는 활동이 적은 여성이나, 80대 이상에서 좋은 결과 를 얻을 수 있다. 장차 Biologic Procedure와 결합되면 더 많은 HTO가 시행될 것이다.