بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم بسم الله الرحمن الرحيم

2. Treatment options of Genovarum, UnicompartmentArthroplastyvs High TibialOsteotomy H.Makhmalbaf MD. Knee surgeon Ghaem Hospital Medical School

3. 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

4. The goals of osteotomy • Pain relief • Functional improvement • Ability to meet heavy functional demands • Careful patient selection • Skillful surgical technique

5. 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

6. 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

7. Patient selection: Historical • Age : chronological, physiological • Patient’s desired activity level • Pain: location, character, PFJ ? • Rhumatological status • Prior menisectomy • Infection history

8. Examination; • Malalignment: magnitude, direction • Prior incisions, body habitus • ROM: total arc, flexion contracture • Ligamentous deficiencies • PF mechanics • Adductor thrust

9. Radiological : • Anatomic axis • Mechanical axis • Severity of OA • Magnitude of deformity • Tibiofemoral subluxation

10. Radiological: • Status of other compartments • Joint space opening • Amount of articular cartilage loss • CPPD, osseous defects • Deformities away from the joint • Joint line obliquity

19. 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

20. 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

21. 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

22. 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

23. Unicompartment ArthroplastyIndications • Unicompartment OA • Good range of movement • Ligament stability • An intact ACL • Normal PFJ

24. 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

25. 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

26. 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

27. 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

28. Cementless 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

29. Medial UKR in the under 50s • 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

30. The advantages of UKR over TKR • Retention of the cruciate ligaments • Preservation of bone stock • And better functional results

31. What is being done? • In the West : UK, USA • In Iran • My experience with UKR, UTO, TKR • Young patients with deformity & no OA

32. UKRcontraindications • OA in other compartments of the knee • Severe deformity • Ligament instability • Limitation of ROM • RA

33. Complications of UKR • Tibial component loosening • PE wear • OA of other compartments

38. Thank you