1. UNICOMPARTMENTAL KNEE ARTHROPLASTY MINIMALLY INVASIVE TECHNIQUE

2. Frank R. Ebert, MD Assistant Chief Department of Orthopædics The Union Memorial Hospital Baltimore, Maryland

3. History Unicompartmental knee arthroplasties have been in use since the early 1970’s. UKA quickly gained popularity, but soon got a bad reputation, especially in the USA.

4. UKA Failures Improper indications Improper indications Poor surgical technique (no guides) Poor surgical technique (no guides) Inferior prosthetic designs in some cases (e.g. PCA) Inferior prosthetic designs in some cases (e.g. PCA)

5. UKA Failures cont’d. Improper Indication Improper Indication  Inflammatory Arthritis  Obesity  Severe Deformity (> 10° Varus/>15° Valgus)  Active Young Patient

6. UKA Failures cont’d. Surgical Technique Surgical Technique  Overcorrection  Undercorrection  Patellar Impingement on Femur  Component Malposition

7. UKA Failures cont’d. Prosthetic Design Prosthetic Design  6-mm Polyethylene  Cementless Fixation

8. UKA results Some prostheses like the Marmor, St George Sledge, and the M.G. have proven good long term results

9. UKA Results Swedish Registry 1975 to 1991 Swedish Registry 1975 to 1991  93% Survivorship over 16 years

10. UKA Results Swedish Registry 1975-1991 Swedish Registry 1975-1991  90% Plus Survivorship – Surgeons doing 15 or more per year.  70% to 80% Survivorship – Surgeons doing less than 15 per year.  Lesson: DO IT RIGHT! (Technique and Patient Selection) (Technique and Patient Selection)

11. Advantages UKA Less invasive surgery Less invasive surgery Shorter hospital stay Shorter hospital stay Better ROM than TKA Better ROM than TKA More ”normal knee” More ”normal knee” Easier revision Easier revision

12. ”Miniarthrotomy” John A Repicci Buffalo USA

13. Minimally invasive surgery ”Miniarthrotomy” Early mobilisation Early mobilisation No Transfusion No Transfusion Short hospital stay Short hospital stay Low Morbidity Low Morbidity Quick rehabilitation Quick rehabilitation

14. Concerns Repicci II Demanding surgical technique Demanding surgical technique No guides - ”free hand surgery” No guides - ”free hand surgery” Thin tibial component (6 - 7 mm) Thin tibial component (6 - 7 mm) Limited Sizes Limited Sizes Long term results? Long term results?

15. Why Miller - Galante uni? Proven good / excellent long term Proven good / excellent long term clinical results clinical results Excellent results (Nilsson & Dahlen, Hyldahl et. al.) Excellent results (Nilsson & Dahlen, Hyldahl et. al.) Adequate alignment and resection guides - reproducible surgical technique – Adequate alignment and resection guides - reproducible surgical technique – no ”free hand surgery” no ”free hand surgery”

16. MG-UNI 98% 10 yr. Survival (loosening or revision endpoint.) 98% Good or Excellent Results -Berger, et al. CORR, 1999

17. Clinical Results – HSS Scores Berger RA, et al. Clin Orthop Rel Res. 1999;367:50-60. Argenson JN, et al. 2001 AAOS presentation. Swienckowski, J. 2001 Poster Osteopathic Specialists Meeting 55 92 59 96 n=51 n=147 58 n=150 95

18. Clinical Results – HSS Scores Berger RA, et al. Clin Orthop Rel Res. 1999;367:50-60. Swienckowski, J. 2001 Poster Osteopathic Specialists Meeting

19. Clinical Results – Survivorship 10-year 98% 96%95% n=62 n=160 n=187

20. Clinical Results – Range of Motion n=51n=147 120º 128º

21. Randomised study comparing metal backed and all poly tibia Hyldahl, Regner, Carlsson, Kärrholm & Weidenhielm 1999 No difference in clinical results

22. Metal backed or all poly tibia?

23. Indications Medial OA grade I-III (Ahlbäck) - no inflammatory joint disease Medial OA grade I-III (Ahlbäck) - no inflammatory joint disease Mild To Moderate Deformity Mild To Moderate Deformity Intact ACL (?) Intact ACL (?) Minimal Patellofemoral Symptoms Minimal Patellofemoral Symptoms Age  55 yrs. (?) Age  55 yrs. (?)

24. Perioperative Short spinal with/without duramorph. Short spinal with/without duramorph. 1 gms.Ceflosporin I.V. prior to tourniquet inflation. 1 gms.Ceflosporin I.V. prior to tourniquet inflation.

25. Postoperative Compression dressing 24 h Compression dressing 24 h Full weight-bearing 4 - 6 h postop Full weight-bearing 4 - 6 h postop Free flexion / extension Free flexion / extension Oral pain killers Oral pain killers DVT prophylaxis for 1 month DVT prophylaxis for 1 month

26. SURGICAL TECHNIQUE

27. Miniarthrotomy Flexed knee Flexed knee Leg stabilizer Leg stabilizer 0°-120° 0°-120°

28. “Miniarthrotomy” Incision 8-10 cm, medial to patellar tendon Incision 8-10 cm, medial to patellar tendon

29. Miniarthrotomy Arthrotomy 8-10 cm Arthrotomy 8-10 cm T-incision distal to vastus medialis T-incision distal to vastus medialis Release 2 cm below joint line Release 2 cm below joint line

30. Femoral drilling i.m.

31. IM guide femur

32. Distal femoral cut

33. Distal femoral cut finished

34. Femur chamfer cuts

35. Drilling peg holes

36. Femur - posterior cut

37. Tibial resection

38. Tibial resection horizontal cut

39. Tibial resection sagittal cut

40. Resection posterior corner femur

41. Tibial sizing

42. Tibia - peg holes

43. Trial reduction, flexion

44. Trial reduction, extension

45. Cementation

46. Closure

47. UNION MEMORIAL HOSPITAL BALTIMORE, MARYLAND THANK YOU

48. MigrationPFC,Sledge& MG uni (tibial component ) Nilsson and Dahlen 1997 0 0,5 1 1,5 2 2,5 03612 PFC Sledge MG uni mm months