AOSSM Annual Meeting, Chicago, 2013
Isolated Medial Compartment OA of the Knee in a 50 yo
Unicompartmental Arthroplasty vs Osteotomy: Why Osteotomy?
A. Amendola, MD
Professor, Department of Orthopaedic Surgery
Director and Callaghan Chair
University of Iowa Sports Medicine
1) Introduction
a) HTO vs UNI: why is it a controversial decision in this situation?
i) No perfect solution
ii) Indications overlap?
iii) Is there a difference in activity level post surgery?
iv) Joint kinematics and function: is there a difference?
v) Revision to TKA: are you burning any bridges?
2) Indications for HTO
a) Compartment overload with cartilage resurfacing or meniscal transplantation
b) Instability with mechanical axis deviation
c) Isolated unicompartmental varus OA of the knee *
i) Considerations *
(1) Unilateral vs bilateral
(2) Patient age/activity level
(3) BMI
(4) Bone quality
(5) Coexisting Patellofemoral disease
(* overlaps with UNI)
3) Indications for UNI
a) Traditional indications
i) Unicompartmental OA and varus deformity
ii) Age> 60
iii) Low demand/activity level
iv) Weight < 100kg
v) ROM >90, FFC < 5, correctable varus < 15
vi) Stable knee
b) Expanding indications
i) Unicompartmental OA and varus deformity
ii) ROM >90, FFC or varus <15 deg
iii) Relative indications
(1) ACL intact
(2) PF disease
(3) Age > 40
(4) BMI < 32
4) Outcomes HTO vs UNI
a) In general outcomes / survival rates of HTO decline with time
i) 10 yr outcomes / survival of HTO 60-80%
b) Outcomes / survivorship of UNI more predictable over time
i) 90-98 % survivorship ( aseptic loosening) at 10 yrs, and up to 90% at 22yrs
5) Complications and revision to TKA
a) Reported operative and post operative complication rates higher with HTO vs UNI
b) Revision of HTO to TKA is more difficult vs primary TKR
i) Outcomes following revision of HTO to TKR comparable to primary TKR
c) Revision of UNI to another UNI has a high failure rate compare to revision to TKR
d) Outcomes of revision UNI to TKR not as good as primary TKR
6) Activity and patient satisfaction following HTO and UNI
a)
b)
c)
d)
e)
Patients return to the preoperative activity level following HTO
Knee feels more physiologic with HTO
Patients decrease amount and type of activity following UNI
Postoperative recovery , morbidity less with UNI
Simultaneous bilateral procedures possible with UNI
7) Patient evaluation is important
a)
b)
c)
d)
Clinical exam for isolated compartment pain, overload, ROM , stability
Radiographs skyline, standing AP, tunnel view, alignment views
MRI for ACL status, opposite compartment
Arthroscopic evaluation
8) Summary : How I decide UNI vs Osteotomy (in general )
a) Any patient requiring articular cartilage resurfacing and/or meniscal transplantation and/or
ACLR with compartment overload , by definition needs an Osteotomy
b) Any patient who desires to go back to unlimited activity , ie sports, farming, outdoor activites,
laboring work, I recommend an osteotomy
c) Heavy males and females BMI > 32 prefer an osteotomy
d) Women > men >50 who have bilateral disease, prefer to recommend UNI
e) Low demand , light, patients recommend UNI
9) Summary: This case : 50 recreational athlete isolated medial compartment OA with Varus
HTO indicated for the following reasons:
1. Ideal indication, male, unilateral, varus, isolated medial compartment
2. Return to full activity ( avoid long distance running )
3. Physiologic function of the knee
4. Potential for long term function
5. No bridges burned if subsequent arthroplasty required
10) Considerations :
a) Need to educate the patient
i) Recovery post operatively
ii) Potential complications
iii) Outcome expectations
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