1. S. Hofmann Head Knee Training Centre General & Orthopaedic Hospital Stolzalpe – AUSTRIA Vienna Vienna Stolzalpe UNI vs Osteotomy Is there a competion ?

2. Therapeutic Dilemma (active middle aged 40-60) Biological therapy ? NSAIDS, Suppl & Cartilage Arthroscopy ? Mechanical unloading Braces & Distraction Osteotomy Joint replacement Partial, UKA & TKA Waller et al, KSSTA 2011

3. Indications for osteotomies & Unis Anteromedial arthrosis (AMA) Lateral arthrosis with ACL ACL insufficiency & single compartment arthrosis ? Patient related factors  individual indications ACL, osteotomy & mosaic plasty Varus 8°, ACL & cartilage defect ACL & MIS Uni

4. Basic principles osteotomies More than 30 years Overcorrection of deformity Offloading one compartment Pain reduction Gain time before TKA 80 % Varus deformity Coventry, JBJS 1987

5. Basic principles Unis Kennedy CORR 1987 01 5 C 2 3 4 More than 20 years Partial correction deformity Resurfacing one compartment Free of pain Timewinning or defintive solution ? > 90 % Varus deformities

6. Comparison patella osteotomy Müller EFORT 2000 Cartilgage damage  not main symptom Biomechanics & clinics  Advantage lenghtening lig. patellae (closed) Release soft tissues Disatvantage Shortening Lig. Patellae (open) No patelloplasty

7. Comparison patella Unis Cartilage damage  not main symptom Biomechanics & clinics  Advantage patelloplasty possible No sec. shortening Disatvantage No lenghtening lig. patellae No release soft tissues

8. Comparison complications osteotomies Under- or overcorrection Inclination joint line (3° Varus) Loss of correction Pseudarthrosis Neural & vascular damage Secoundary batella baja  All over rate 30 - 40 % Joint line 6° Valgus after HTO

9. Comparison complications Unis Under- or Overcorrection Malpositioning implants Dislocation mobile bearings Neural & vascular damages Secoundary patella baja Infection & Loosening  Overall rate 5 -10 % Malposition & chronic pain with mobile bearings

10. Outcomes of osteotomy No EBM data Cochrane – Silver Evidence 70% benefit 10 years Survivalrates 5 years 73 % 10 years 52 % Selected patients Survival 10 y 90% Results depend on risc factors Hofmann et al, European IC Lectures 2011 Feeley et al, J Am Acad Orthop Surg 2010

11. Comparison clinical results Retrospective studies Unis Clinical results  Complications  Survival rate 10 years HTO / Uni 76 % / 90 % Survival rate 15 years HTO / Uni65 % / 88 % Weale CORR 1994

12. Comparison revision to TKA Worser after Unis Gill et al, CORR 1995 Worser after osteotomies Jackson et al, J Arthroplasty 1994 No difference & comparable to primary TKA McAuley et al, CORR 2001 Overcorrection Valgus 24° Uni & large bony defects

13. Sporting Activities TKA vs UNI vs Osteo Bonnin et al, KSSTA 2011

14. New concept of osteotomies Biomechanical understanding  Alignment  Slope & joint line  Patellofemoral joint Biomechanical understanding  Alignment  Slope & joint line  Patellofemoral joint Patient selection & planning Patient selection & planning Safe & easy osteosynthesis Safe & easy osteosynthesis Early functional rehabiliation Early functional rehabiliation Hofmann et al, Orthopäde 2009 Hofmann et al, European IC Lectures 2011

15. Results New Concept Prospective multicenter (3)Prospective multicenter (3) 369 varus knees369 varus knees FU 3.5 years (2-5)FU 3.5 years (2-5) 3.5% Complications 3.5% Complications 98% Survival (3-5 years) 98% Survival (3-5 years) Oxford Score 41 (max 48) UKA 39 & TKA 35-40 Oxford Score 41 (max 48) UKA 39 & TKA 35-40 Lobenhoffer et al, ESSKA 2010

16. Cartilage Damage prior Surgery Lobenhoffer et al, ESSKA 2010

17. Oxford Score Cartilage Damage Lobenhoffer et al, ESSKA 2010

18. Oxford Score & Age Lobenhoffer et al, ESSKA 2010

19. Patient Selections Stolzalpe Adipositas per magna „Golden rule age“ male < 65 female < 55 „Golden rule age“ male < 65 female < 55 Sporting activities Sporting activities Occupation Occupation Compliance & patients expections Compliance & patients expections

20. Summary advantages osteotomies No artificial joint No arthrotomy necessary Combination with cartilage & ligament surgery Less expensive

21. Summary advantages MIS Uni’s Significant shorter rehabiliation Less complications Better clinical results Longer survival Definite solution older patients 3 days post Op FL 0-100°

22. Summary New interest in Unis with MIS Osteotomies increasing in combination with cartilage & ligament reconstructions Pre OP clearing up, planning & extensive enlighment necessary Clear differential indications With new osteotomy concept results are probably comparable