Updated HTO vs UniKnee for Postgraduate Orthopaedic Course in Newcastle March 2015

1. OA in the ‘Young” HTO & Uni Knee Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield Hospital

2. Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course Newcastle Upon Tyne 16-21 March 2015 • Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Nuffield Hospital Newcastle NGMV Charity PostGrad Orth Deiary Kader

3. HTO vs Uni?? What is the outcome of HTO and Uni? What do you require for a successful osteotomy? PLAN Varus OA in the Young

4. Must Know What is the None-operative Treatment for OA?

5. OA Nonoperative treatment Strategies may include  Weight loss  Exercise  Patient education  Analgesia, (NSAIDs)  Bracing  Intra-articular (IA) injections. Cochrane reviews  Steroids (better than placebo but not longer than 4wks  HA more prolonged effect than steroids

6. Weight loss causes a significant risk reduction of knee OA in the general population The reduction was greater in severe symptomatic OA than in asymptomatic radiographic OA Meta-analysis of 47 studies involving 446000 pts

7. m,Muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in mild to moderate OA of the knee

8. A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery  Population was older male veterans  The prevalence of mechanical symptoms was not provided  Malalignment was not reported

9. OSTEOTOMY 9

10. Osteotomy around the knee Aims of valgus osteotomy  Unload the medial compartment by slightly overcorrecting into valgus  Unloading any ligament reconstruction in patients with a varus thrust  To change the tibial slope in order to reduce translational forces and improve AP instability

11. HTO for varus Malalignment PostGrad Orth Deiary Kader

12. Lateral closed-wedge high tibial osteotomies have been the treatment of choice since 1965 (Coventry, 1965). PostGrad Orth Deiary Kader

13. OPEN Wedge HTO 1987  The open-wedge high tibial osteotomy gained recognition after the encouraging reports of (Hernigou et al., 1987).  Wedges of bone that were obtained from the iliac crest were inserted into the defect

14. Open W HTO

15. TOMOFIX

16. Proximal or High Tibial Osteotomy (HTO) The IDEAL candidate for HTO Age <60 years Isolated medial OA Good ROM Less than 5° FFD knee >120° flexion knee Patients should be able to use crutches Have no major varicose veins or peripheral vascular disease

17. The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine PostGradOrthDeiaryKader

18. Distal Femur Osteotomy for Valgus Malalignment

19. Lateral Open W DFO

20. Distal Femur Osteotomy Valgus deformity of 12º or more needs distal femoral varus producing osteotomy to address a lateral femoral condyle deficiency and to prevent joint line obliquity and gradual lateral tibial subluxation. ≈

21. Planning  Standing, long leg radiographs in neutral rotation  Measure the mechanical axis (normal = 1.2o varus)  Anatomical axis (60-70 valgus)  Measure the degree of deformity & plan the size of wedge necessary

22. Planning  62.5% across tibial plateau from medial side  Final alignment should create 10º–13 valgus. Overcorrection of 3º–5º above the 6º–7º normal valgus angle  Medial tibial cortex represents the apex of the bony wedge and should be left intact

23. PostGrad Orth Deiary Kader

24. Tibial bone varus angle (TBVA) constitutional tibia varus malalignment when the TBVA angle measured more than 5º Mid Tibia Epiphysis

25. Compensating for Abnormal AP Laxity ACL Rupture PCL Rupture PostGrad Orth Deiary Kader

26. Compensating for Abnormal AP Laxity

28. Closed wedge HTO Surgical technique  Arthroscopy  Computer-aided measurement of the wedge size or  A 10-mm wedge excision leads to  10º corrections in 57-mm-wide tibia  An angular jig is more accurate

29. Closed wedge HTO Surgical technique  Curved incision from the head of the fibula to 2 cm below the tibial tubercle. Peroneal nerve protected  Excise the bare area of the fibula head Or proximal tibiofibula joint separated using a cob elevator  A calibrated osteotomy guide must be used for the bone cut  Leave 15–20 mm of tibial plateau to avoid fracture  Fix with a plate or staples  Rigid fixation+ early mobilisation eliminates patella ligament contracture  DVT prophylaxis similar to post TKR

30. Sulzer Orthopedics, Zimmer PostGrad Orth Deiary Kader

32.  Fibular osteotomy, Separating tibiofibular joint  Contracture of the patellar tendon, patellar baja  leg shortening High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up* ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAHJ Bone Joint Surg Am, 2000 Jan Closed wedge HTO Disadvantages

33. OPEN W HTO Surgical Techineque  The MCL mobilize.  Two 2.5-mm Kirschner wires mark the oblique osteotomy  Starting proximal to the pes anserinus  4-5 cm distal to the joint line  The wires to the tip of the fibula 10-15mm  The osteotomy of the posterior two-thirds of the tibia  Leave a 10-mm lateral bone bridge intact.  Hinge on the lateral - not posterolateral - side of the tibia  The second osteotomy begins in the anterior one-third of the tibia at an angle of 135° while leaving the tibial tuberosity intac

37. Lateral Open Wedge Distal Femur  single cut  easier approach to femur  easily adjustable correction  supratrochlear area disrupted  weak medial hinge point  plate location complaints  very unstable if hinge point fractures  slowest bone healing role of grafts unclear

38. Methods of osteotomy Fixation  Cast immobilisation  Staples  Plate and screw  External fixator  Distraction osteogenesis. Correction can be adjusted after surgery. But pin tracts create a potential problem for subsequent TKA

39. Complications  Inadequate valgus correction  Overcorrection – PFJ derangement  Alteration in patella height  Intra-articular fracture  Osteonecrosis of the tibial plateau

40. Complications  Vascular injuries – anterior tibial artery, popliteal artery  Peroneal nerve palsy  Delayed or non-union  Compartment syndrome  TKR more difficult  Varus laxity (loose LCL)

41. Open wedge HTO Advantages  Easier to achieve precise angular correction  Preserves bone stock (subsequent TKR is technically easier)  Makes tightening of the MCL easier  Preserve the lateral side for LCL or posterolateral reconstruction if insufficient  No risk to peroneal nerve  Less dissection

42.  Requires a bone graft (substitute, autograft, allograft)  Increased incidence of non-union and delayed union  Large correction may affect leg lengthening  Loss of fixation and recurrence of varus deformity  Worsens patella Baja Open wedge HTO Disadvantages

43. OW-HTO  Delayed union/nonunion rates were 2.6%, 4.6%, and 4.5% for autograft, allograft bone, and synthetic bone substitutes, respectively  Non-locking plates (n = 2,148) had a rate of delayed union/nonunion of 3.7% and a mean loss of correction over time of 0.5°   Locking plates (n = 681) had a rate of delayed union/nonunion of 2.6% and a loss of correction of

44. Coventry report Outcome  5-year survival of 87%  10-year survival of 66%  However the 5-year survival was reduced down to 38% when valgus angulations at 1 year was less than 8º in a patient whose weight was more than 1.32 times the ideal weight.

45. Outcome  Obesity and inadequate correction were negative prognostic factors.  Age < 50 years to be a positive prognostic factor  Joint line preservation is key to success.

46. OW-HTO vs CW-HTO RCT 92 pts and 6 years FU More Complications in open WHTO & more conversion to TKR in closed WHTO SEPT 2014

47. Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee.

48. Principles Uni Knee  Appropriate for 25% of osteoarthritic knees needing replacement  Never release the MCL  Polyethylene dislocation rate is 1/200 after medial compartment UKR (Oxford)  Polyethylene dislocation rate is 10% after lateral compartment UKR  Dislocation rate can be reduced by using a fixed bearing UKR.

49. ? What are the Absolute contraindications for Unicompartmental knee replacement? What are the Advantages and disadvantages?

50. Uni Knee Advantages • Retains knee kinematics • Restores function and range of movement • Rapid recovery: 3X faster than TKR • Less blood loss • Cost less than TKR (all factors considered) • Quicker operation than TKR • Quicker return to work than after TKR • High flexion lifestyle.

51. Uni Knee Advantages • Lower infection rate (halved) compared with TKR • Allows minimally invasive approach • Easier to revise than HTO? • No patellar fractures or dislocations • Maximises the longevity of total knee arthroplasty • Reduced incidence of DVT • Reduced mortality from pulmonary embolism

52. Prerequisites  Intact ligaments (especially ACL and PCL)  Correctable varus deformity  Less than 10° FFD  Flexion beyond 100°  Clinically asymptomatic PFJ and contralateral compartment.

53. Contraindications  Inflammatory arthritis  Sepsis  Young age  High level of activity.

54. Relative contraindications  ACL degeneration  Chondrocalcinosis  Lateral meniscectomy  Osteonecrosis  Combined obesity and small bone size in some women.

55. Management options for medial compartment OA HTO suitable for high-demand, young patients UKA (better functional results, much better 10-year survival – 98% versus 66%)

56. THANK YOU

Updated HTO vs UniKnee for Postgraduate Orthopaedic Course in Newcastle March 2015

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