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  • 1. Firenze, 29 Marzo 2008 ANALISI DEI RISULTATI DELLE PROTESI A PIATTO MOBILE ED A PIATTO FISSO G.C. COARI - A. TRIPODOCasa di Cura San Camillo – Forte dei Marmi (LU)
  • 2. I PRIMI IMPIANTI DI MONO RISALGONO AGLI ANNI ‘50 ED INIZIO ‘60 MACINTOSH: disco protesico senza cemento MCKEEVER: chiglia sotto la superficie
  • 3. ANNI ‘70 GUNSTON e MARMOR introdussero la protesi mono cementata Superficie di rivestimento femorale inacciaio e tibiale in PE GUNSTON Marmor
  • 4. INIZIO ANNI ‘80 Insall ‘80 – Mallory ‘83 – Laskin ‘86 dimostrarono una alta percentuale di fallimenti (35%) Dopo questi risultati e con l’avvento di protesi totali piùevolute, diminuì fortemente l’utilizzo delle mono Solo MARMOR e pochi altri continuarono
  • 5. ANNI ‘80 LA MONO RIGUADAGNA POPOLARITA’ VENGONO STABILITI CRITERI DI INDICAZIONE LOTUSSoprattutto la scuola francese(DEJOUR, MANSAT, GRUPPOGUEPARD, CARTIER) sviluppò ecodificò la tecnica e le indicazionidelle mono CARTIER
  • 6. Cartier descrisse una precisa pianificazione preoperatoria e teorizzò la filosofia delle mono Ipocorrezione dell’asse meccanico Rispetto dell’interlinea articolare Bilanciamento in flessione - estensione della tensione dei legamenti collaterali
  • 7. Nel 1979 OXFORD prima mono a piatto mobile
  • 8. Nel 1989 la Mono Allegretto
  • 9. ANNI ‘90 PFC SIGMA DURACONMILLER-GALANTE REPICCI NATURAL-KNEE PCA LCS-UNI
  • 10. STATISTICHE DI SOPRAVVIVENZA DELL’UNICOMPARTIMENTALE• Berger-Galante CORR 1999 10 anni 99 %• Squire-Iowa CORR 1999 15 anni 87.5 %• Bert-Minn J. Arthroplasty 1998 10 anni 87.4 %• Murray-Oxford JBJS-B 1998 7.6 anni 97 %• Tabor-Charlotte J. Arthroplasty 1998 10 anni 84 %• Ansari-Dallas Acta Ortho Scan 1997 10 anni 87-74 %• Robertsson-Sweden Acta Ortho Scan 1999 10 anni 88 %• Cartier J. Artrhoplasty, 2000 10 anni 93 %• Romagnoli - Verde JBJS 2005 13 anni 97 %
  • 11. PROTESI MONO vs TOTALI SOPRAVVIVENZA A 10 ANNI SOVRAPPONIBILE A 15-20 ANNI - TOTALI 90-95% - MONO ?
  • 12. LA PROTESI MONO: FILOSOFIA LA MONO DOVREBBE DURARE PIU’ DEL PAZIENTE - NO BY-PASS ARTROSICO, NO PRE-TOTALE - EVITARE USURA STRUMENTARI DEDICATI RIPRISTINARE LA FUNZIONE LEGAMENTOSA E LA CINEMATICA INDICAZIONI APPROPRIATE APPROCCIO MINI-INVASIVO BREVE DEGENZA, BASSA MORBIDITA’
  • 13. RIDURRE IL NUMERO DEGLI INSUCCESSI DELLE MONO INDICAZIONI RIDURRE USURA DEL POLIETILENE TECNICA CHIRURGICA
  • 14. INDICAZIONI ARTROSI MONOCOMPARTIMENTALE OSTEONECROSI MONOCOMPARTIMENTALE LCA FUNZIONALMENTE VALIDO VARO < 15°, CORREGGIBILE DEFORMITA’ IN FLESSIONE < 15°
  • 15. INTEGRITA’ LCALa parte posteriore delle superficie mediale tibiale e femorale si mantiene relativamente intatta in flessione LCM: sottoposto ad una tensione fisiologica normale
  • 16. CARTILAGINE PRESERVATAPERDITA OSSEAE CARTILAGINEA
  • 17. LA DEFORMITA’ IN VARO SI CORREGGE IN FLESSIONE IN ESTENSIONE LA PERDITA PreservedOSSEA E CARTILAGINEA Cartilage GENERANO IL VARO IL COLLATERALE Lost IL COLLATERALE MEDIALE SI MEDIALE E’ Cartilage LASSO TENSIONA & Bone (NO RETRAZIONE)
  • 18. INSUFFICIENZA LCA punto di contatto in estensione si sposta posteriormente ulteriore danno alla cartilagine posteriore COLLATERALE minore spazio MEDIALE LASSO articolare in flessione E RETRAZIONE ed accorciamento SUCCESSIVA LCMDEFORMITÀ FISSA E PROGRESSIONE ARTROSICA AL COMPARTO CONTROLATERALE
  • 19. VALUTAZIONE INTEGRITA’ LCA OA antero-mediale Preserved RX IN CARICO IN L.L. Cartilage EROSIONE TIBIALE NON POSTERIORE CRITERIO AFFIDABILE NEL Lost 95% DEI CASI PER LCA CartilageFUNZIONALE & Bone
  • 20. CONTROINDICAZIONI RARE SE LCA SANO DEFORMITA’ IN FLESSIONE > 15° DEFORMITA’ IN VARO > 15° FLESSIONE < 90° SEGNI DI USURA DEL COMPARTOLATERALE OBESITA’
  • 21. ALTRE “ACCETTATE” INDICAZIONI ARTROSI FEMORO-ROTULEA EDOLORE ANTERIORE ETA’ (< 60 E MOLTO ANZIANI) ATTIVITA’ ELEVATA OBESITA’ CONDROCALCINOSI
  • 22. FEMORO-ROTULEA La Scuola di Oxford ha ignorato lo stato della F.R. I PROBLEMI F.R. A LUNGO F.U. SONO RARI ( < 1%)• SKAR (699 Oxford) – 50 revisioni, una per dolore F.R.• Risultati pubblicati > 10 aa. (Goodfellow, Svard, Smith) – 35 revisioni nessuna per problemi F.R.• Nessuna progressione artrosica nella F.R. – Weale et al JBJS 1999
  • 23. PROTESI MONO + FEMORO-ROTULEA SERGIO ROMAGNOLI
  • 24. RIDURRE USURA- USURA MAGGIORE CON INSERTO FISSO- STRESS DI CONTATTO ALTI
  • 25. LA PROTESI CHE USIAMO OXFORD III FEMORE SFERICO TIBIA PIATTA INSERTO MOBILE - NON VINCOLATO - CONCAVO SOPRA - PIATTO SOTTO - SEMPRE CONGRUENTE IN TUTTE LE POSIZIONI
  • 26. TECNICA CHIRURGICA MINI-INVASIVA
  • 27. RESEZIONE TIBIALE2-3 mm. Sotto la parte più profonda del difetto
  • 28. SEZIONE DELLA FACCETTA POSTERIORE DEL CONDILO
  • 29. FRESATURA DEL CONDILOFRESA SFERICA SU RIMUOVE OSSO IN MODOSPIGOT INSERITO PROGRESSIVO PER UNNEL FORO BILANCIAMENTOINFERIORE DEL LEGAMENTOSOCONDILO ACCURATO
  • 30. BILANCIAMENTO• INSERIRE COMPONENTI DI PROVA• MISURARE LO SPAZIO IN FLESSIONE ED IN ESTENSIONE
  • 31. DIFFERENZA FRA LO SPAZIO IN FLESSIONE ED IN ESTENSIONESPAZIO IN FLESSIONE - SPAZIO IN ESTENSIONE = mm da fresare sul condilo
  • 32. RIMUOVERE NUOVO OSSO DAL FEMORE CON LO SPIGOT ADEGUATO
  • 33. INSERIMENTO DELL’ INSERTO DEFINITIVO
  • 34. CONTROLLO RADIOGRAFICO
  • 35. LA PROTESI A PIATTO FISSO ZIMMER ZUK
  • 36. ZUKSTRUMENTARIO DEDICATO MINIME RESEZIONI
  • 37. ZUK
  • 38. ZUK
  • 39. ZUK
  • 40. ZUK
  • 41. NOSTRA CASISTICA OXFORD IIIGENNAIO 2001- OTTOBRE 2007 192 CASIGENNAIO 2001- DICEMBRE 2005 140 CASI CONTROLLATI 137- FOLLOW-UP MIN. 2 anno MAX 7 aa.- ETA’ MEDIA 70 (51-82)- M 57 F 80- LATO DX 76 SIN 61
  • 42. COMPLICAZIONI 5 REVISIONI INFEZIONE (2) LUSSAZIONE INSERTO (1) IPERCORREZIONE IN VALGO (1) DOLORE INSPIEGABILE
  • 43. RISULTATI VALUTATI CON SCHEDA H.S.S.RISULTATI ECCELLENTI - BUONI NEL 97%
  • 44. RISULTATI PUBBLICATI > 10 ANNI
  • 45. ETA’ < 60 aa.
  • 46. COPYRIGHT © 2003 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATEDUNICOMPARTMENTAL KNEE ARTHROPLASTY IN PATIENTS SIXTY YEARS OF AGE OR YOUNGERBY DONALD W. PENNINGTON, DO, JOHN J. SWIENCKOWSKI, DO,WILLIAM B. LUTES, DO, AND GREGORY N. DRAKE, DO Background: …the literature is sparse regarding the use of this procedure for younger, active patients. . . retrospective study was to evaluate the results of unicompartmental knee arthroplasty in younger, more active patients. Methods: 41 M-G UNI Miller-Galante system between 1988 and 1996. All of the patients were sixty years of age or younger and all were physically active. 11ys f-up HSS 93% The University of California at Los Angeles activity assessment score was 6.6 ± 1.4 for the knees in which the original prosthesis had been retained and 7.3 ± 1.5 for those in which it had been revised. 2 RR per usura PE (1 mono – 1 solo PE) – 1 RR con PTG 9 controlateral arthrosis senza RR o peggioramento sintomatico Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
  • 47. CURRENT CONCEPT IN JOINT REPLACEMENT Las Vegas Maggio 2007 Oxford III 100% 80% • 2 Chirurghi (C.D., D.M.)Survival % 60% • 600 Mono 40% • 7 revisioni • 6 aa. sopravvivenza 98% 20% 0% 0 2 4 6 8 10 Follow up (years)
  • 48. Clinical Orthopaedics & Related Research: Volume 1(367) October 1999 pp 50-60Unicompartmental Knee Arthroplasty: Clinical Experience at 6- to 10-Year FollowupBerger, Richard A. MD; Nedeff, David D. MD; Barden, Regina M. RN; Sheinkop, Mitchell M. MD; Jacobs, Joshua J. MD;Rosenberg, Aaron G. MD; Galante, Jorge O. MDSection Editor(s): Rand, James MD; Laskin, Richard MD; Healy, William MDFrom the Department of Orthopedic Surgery, Rush-Presbyterian-St. Lukes Medical Center, Chicago, Illinois.Reprint requests to Richard A. Berger, MD, 1725 W. Harrison St., Suite 1063, Chicago, IL 60612. 62 mono in 51 pz with the M-G Ave 68 aa HSS pre 55 post 92 78% excellent 20% good ROM 120° nel 51% oltre 120° Finally f-up 10% controlateral e 6% patellofemoral arthrosisù At 10 ys 98% using rx and revision survival First, intrinsic concerns about progression of symptomatic disease in the other compartments have not been reported in the literature.20,22,33 Second, the recovery time is shorter and the cost is less for unicompartmental knee arthroplasty compared with total knee replacement.8,25 Finally, patients prefer the feel of a unicompartmental knee arthroplasty compared with the feel of a total knee replacement.8,25,27 Therefore the purpose of this study is to report the intermediate results of cemented unicompartmental knee arthroplasty at 6 to 10 years followup.
  • 49. CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 404, pp. 62–70© 2002 Lippincott Williams & Wilkins, Inc.Comparison of a Mobile With a Fixed-Bearing Unicompartmental Knee ImplantRoger H. Emerson, Jr., MD; Thomas Hansborough, BA; Richard D. Reitman, MD; WolfgangRosenfeldt, BA; and Linda L. Higgins, PhD 101 mono 51 pz with the Robert Brigham unicompartmental arthroplasty system (DePuy, A Johnson & Johnson Company, Warsaw, IN).7,7ys f-up 50 with Oxford (Biomet, Warsaw, IN) 6,8ys f-up Survivorship analysis based on component loosening and revision showed a 99% survival for the meniscal-bearing implant and 93% survival for the fixed-bearing implant at 11 years. However, the fixed-bearing knee implants failed significantly more often because of tibial component failure, in six of eight knees, at an average of 6.3 years. The mobilebearing implants showed a trend to fail because of arthritic degeneration in the lateral compartment, at an average of 10 years, although not statistically significant. The mobile-bearing implants had no tibial component failures. These differences may be attributable to implant design or surgical technique.
  • 50. CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 428, pp. 92–99© 2004 Lippincott Williams & WilkinsThe Progression of Patellofemoral Arthrosis after Medial Unicompartmental Replacement Results at11 to 15 YearsRichard A. Berger, MD; R. Michael Meneghini, MD; Mitchell B. Sheinkop, MD; Craig J. Della Valle, MD; Joshua J.Jacobs, MD; Aaron G. Rosenberg, MD; and Jorge O. Galante, MD This study reports the 11-year to 15-year results of unicompartmental knee arthroplasty with an emphasis on failure mechanisms and progression of patellofemoral arthrosis. 59 mono (the Miller-Galante system, Zimmer, Warsaw, IN) HSS pre 55 post 90 Four patients (10%) had moderate or severe patellofemoral symptoms at final followup; two were revised to a primary total knee replacement at 7 and 11 years for progressive patellofemoral degeneration. No component was radiographically loose and no osteolysis was seen. The Kaplan- Meier survival with loosening or revision for any reason was 98.0% ± 2.0% at 10 years and 95.7% ± 4.3% at 15 years. At up to 15 years, unicompartmental knee arthroplasty yielded good clinical results; however, progressive patellofemoral arthritis was the primary mode of failure.
  • 51. COPYRIGHT © 2002 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATEDModern Unicompartmental Knee Arthroplasty with CementA THREE TO TEN-YEAR FOLLOW-UP STUDYBY JEAN-NOËL A. ARGENSON, MD, YAMINA CHEVROL-BENKEDDACHE, MD, AND JEAN-MANUEL AUBANIAC, MDInvestigation performed at the Department of Orthopaedic Surgery, The Aix-Marseille University, Hôpital SainteMarguerite, Marseille, France The purpose of the present study was to evaluate the results of a modern unicompartmental knee arthroplasty performed with use of a cemented metal-backed prosthesis and surgical instrumentation comparable with that used for total knee replacement One hundred and sixty consecutive cemented metal-backed Miller-Galante prostheses in 147 patients were evaluated after a mean duration of follow-up of sixty-six months (range, thirty-six to 112 months). The mean age of the patients at the time of the index procedure was sixty-six years. Three knees were revised because of progression of osteoarthritis in the patellofemoral joint (two knees) or the lateral tibiofemoral compartment (one knee). Two knees had revision of the polyethylene liner. The average Hospital for Special Surgery knee score improved from 59 points preoperatively to 96 points at the time of the review. According to Kaplan-Meier analysis, the ten- year survival rate (with twenty-nine knees at risk) was 94% ± 3% with revision for any reason or radiographic loosening as the end point.
  • 52. COPYRIGHT © 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Medial Unicompartmental Knee Arthroplasty with the Miller-Galante Prosthesis BY DOUGLAS NAUDIE, MD, FRCS(C), JEFF GUERIN, BMATH, DAVID A. PARKER, MBBS, FRACS, ROBERT B. BOURNE, MD, FRCS(C), AND CECIL H. RORABECK, MD, FRCS(C) Investigation performed at London Health Sciences Centre—University Campus, the University of Western Ontario, London, Ontario, Canada Background: Unicompartmental knee arthroplasty has become a popular treatment alternative for osteoarthritis that is confined to the medial part of the knee. Excellent intermediate-term results recently have been reported in association with the Miller-Galante unicompartmental implant. The purpose of the present study was to report on our longer-term experience with the Miller-Galante medial unicompartmental knee implant. Methods: 113 medial unicompartmental knee arthroplasties in eighty-four patients between 1989 and 2000. The mean age of the patients at the time of surgery was sixty-eight years. Forty-five patients were men, and thirty-nine were women. Were followed for a mean of ten years and were evaluated with use of the Knee Society clinical and radiographic rating system. Results: HSS improved from 48 and 53 points preoperatively to 93 and 80 points at the time of the most recent evaluation. The five and ten-year rates of survival were 94% and 90%, respectively, with revision to tricompartmental knee arthroplasty as the end point and 93% and 86%, respectively, with revision or radiographic loosening as the end point. Conclusions: The Miller-Galante medial unicompartmental knee arthroplasty provided excellent pain relief and restoration of function in carefully selected patients and demonstrated durable implant survival at ten years. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
  • 53. Available online at www.sciencedirect.comScienceDirect The Knee 13 (2006) 365370 Mobile vs. fixed bearing unicondylar knee arthroplasty: A randomized study on short term clinical outcomes and knee kinematics Ming G. Li *, Felix Yao, Brendan Joss, James Ioppolo, Bo Nivbrant, David Wood Perth Orthopaedic Institute, the University of Western Auslralia, Gate 3 Verdun Street, Nedlands, WA 6009, Australia Received 23 November 2005; received in revised form 21 April 2006; accepted 9 May 2006 46 mono med 72ys main M-G and Oxford solutions The mobile bearing knees displayed a larger and an incrementally increased tibial internal rotation (4.3", 7.6", 9.5" vs. 3.0°, 3.0°, 4.2“ respectively at 30°, 60°, 90" of knee flexion) compared to the fixed ones. The medial femoral condyle in the mobile bearing knees remained 2 mm from the initial position vs. a 4.2 mm anterior translation in the fixed bearing knees during knee flexion. The contact point in the mobile bearing implant moved 2 mm postenorly vs. a 6 mm antenor movement in the other group. The mobile bearing knees had a lower incidence of radiolucency at the bone implant interface (8% vs. 37%, p<0.05). The incidence of lateral compartment OA and progression of OA at patello-femoral joint were equal. No differences were found regarding Knee Society Scores, WOMAC, and SF-36 scores (p>0.05). This study indicates that mobile bearing knees had a better kinematics, a lower incidence of radiolucency but not yet a better knee function at 2 years.
  • 54. CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 452, pp. 137–142© 2006 Lippincott Williams & Wilkins The Unicompartmental Knee Design and Technical Considerations in Minimizing Wear Jean-Noël A. Argenson, MD; and Sebastien Parratte, MD Unicompartmental knee arthroplasty is an alternative to total knee arthroplasty for patients with unicompartmental tibiofemoral noninflammatory disease. Careful patient selection and newer instrumentation has reduced the progression of arthrosis in the other compartment and tibial loosening, leaving polyethylene wear as the predominant failure mechanism in more contemporary designs. Increased wear increases the debris volume at the bone-implant interface, and wear particles will generate osteolysis leading to component loosening and unreplaced compartment degeneration. The design-related factors that minimize wear include a polyethylene thickness of greater than 6 mm, a limited shelf age, and a design allowing large areas of contact mediolaterally and anteroposteriorly. Congruous mobile-bearing implants could play a substantial role in reducing wear if they are not associated with dislocation and nonreproducible surgical techniques. Important technical factors include accurate instrumentation avoiding component-to-component malposition and edge loading, allowing slight under-correction of the preoperative deformity. The patient-related factors include a weight limit, a functional anterior cruciate ligament, and a correctable frontal deformity. Continued research including that related to cross-linking and sterilization methods is mandatory to improve polyethylene strength. A better understanding of kinematics and contact forces may provide long-term survival and patient satisfaction after unicompartmental arthroplasty. Level of Evidence: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
  • 55. LE TECNICHE ED I DISEGNI PROTESICIPOSSONO ESSERE DIFFERENTI… Corrette indicazioni Ipocorrezione dell’asse meccanico Rispetto dell’interlinea articolare Bilanciamento in flessione – estensione della tensione dei legamenti collaterali Tecnica M.I.S. … POSSIAMO GARANTIRE ECCELLENTI RISULTATI CON COMPLICAZIONI CONTENUTE
  • 56. GRAZIE