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					          Why Perform UKA?
  Making the Leap from Arthroscopy to
              Arthroplasty


• Richard Steffen, MD
• Sports Medicine Associates of San Antonio
Sports Medicine Associates of San
             Antonio


 • Team Physician- San Antonio
    Silver Stars
 • Team Physician- San Antonio
    Rampage
 • Team Physician- San Antonio
     Spurs
Tim Duncan San Antonio Spurs: SMASA patient
            DISCLOSURE
• Neither I, Richard T Steffen,nor any of my
  family members, have any relevant
  financial relationships to be discussed,
  directly or indirectly within this
  presentation.




                      V4
Making the Leap from Arthroscopy to Arthroplasty


• Non operative treatment
• Operative treatment
• Unicompartmental arthroplasty
      Non Operative Treatment
•   Activity Modification
•   Bracing
•   NSAIDS
•   Steroid Injections
•   Viscosupplementation
        NON OPERATIVE
         TREATMENT
• GOALS
 – Pain relief
 – Maintain or improve function




                      V4
    Non Operative Treatment
• Activity modification
  – Self management programs
  – Weight loss programs
  – Low impact aerobics
  – Quadriceps strenghtening




                          V4
     Non operative Treatment
• Bracing and orthotics
  – Unloader braces
     • Kirkley et al in JBJS 1999
        – Only limited effectiveness


  – Lateral heel wedges
     • Phaim et al in Osteoarthritis Cartilage 2004
        – Suggests that patients who don’t wear them may have
          fewer symptoms



                              V4
    Non Operative Treatment
• NSAIDS
  – Demonstrate significant reduction in pain
    versus placebo
  – Statistically significant increased risk of GI
    complications
• Glucosamine/ chondroitin sulfate
  – No definitive clinical improvement versus
    palcebo

                         V4
     Non Operative Treatment
• Steroid injections
  – Very effective for short term pain relief
     • 1 to 24 weeks


  – Hyaluronic acid injections
     • Generally shows positive effects




                           V4
Making the Leap from Arthroscopy to Arthroplasty
         Operative Treatment
• Needle lavage
  – Not to be shown to be significantly significant
    as a treatment option


• Arthroscopic lavage
  – Kalunian et al: osteoarthritis cartilage 2000
     • Has no significant benefit for OA of no
       undiscriminated cause


                           V4
                      Arthroscopy


• Abrasion Chondroplasty
50% of patients require TKA after 3 years (Rand ’91 Arthroscopy)


• Microfracture
Poor results in patients with lesions > 2 cm
              Osteotomy Results
• Best Results when performed early in
OA course (Lesions < grade III)

• Morrey in 1989 JBJS
   - 34 Osteotomies
   - 7.5 Yr fu
   - 73% had satisfactory results
• Holden
   - 45 Osteotomies
   - 10 Yr fu
   - 59% returned to light recreational activity
         Operative Treatment
• Free floating interpositional devices
  – Australian registry
     • Demonstrated significant revision rates ranging
       from 32% at 2 yrs to 62% at 3 yrs




                           V4
                  Why UKA?

• Treatment option for younger, active patients1
• Continuum of arthritis
  – By 2030, ~41 million persons aged ≥65 years will
    have arthritis2
  – 2nd most frequently reported chronic condition in US3
                     Why UKA?

• UKA becoming more attractive due to:
  – Higher patient satisfaction1
  – Physiologic function and kinematics, proprioception1
       • Feels more like a normal knee
       • Increased ROM
  –   Less blood loss during surgery1
  –   Accelerated rehab and recovery time1
  –   Outpatient or discharge in 1-2 days vs 3-4 days
  –   Conversion to TKA (if needed) is relatively easy
               Patient Selection
Classic Indications:
 •   Isolated compartment disease
 •   No patellofemoral pain / disease
 •   Intact ACL
 •   < 10° Varus / < 15° Valgus
 •   < 10° Flexion Contracture
 •   ROM > 5-95°
 •   Non-inflammatory arthritis
 •   Passively correctable deformity
Patient Selection
                Patient Selection

Classic Contra-
  indications:
 •   History of infection
 •   Paralysis / weak quad
     function
     –   Recurvatum
     –   Age

 •   Weight > 225 lbs
 •   High demand / activity
 •   Medial joint depression
           Patient Selection
Expanding Indications ?
   - Age
      - Activity
           - Obesity
              - ACL Deficiency
                   - PF Compartment
   “Today UKA is being considered as an option to
      treat younger and more active patients.”1
                    AAOS, 2008
Pre Operative
Post Operative
         Literature Review –
        UKA Failure Modes7-11
• Progression of OA
• Wear of poly
• Loosening of femoral and tibial
  components
• Fracture of tibial plateau
• Fractured femoral component
• Tibial subsidence
• Pain

    10 yr survivorship 80% - 92%, if successful
                          Clinical Follow-up

                 100
                  95
                  90
% Survivorship




                  85
                  80
                  75
                  70
                  65
                  60
                  55
                  50
                   1975   1980   1985   1990   1995   2000   2005
     Survivorship vs. Functionality

What have we learned?
   – UKA is a successful treatment option providing patients with
     longevity comparable to total knee arthroplasty 15


Longevity is no longer an issue
   – Shift focus to functionality of implants
      • ROM
      • Return to activity
   – UKA Performance


                    Patient Selection!
            My Experience

• 296 Procedures
    2007- present
    • 5 Lateral
    • 291 Medial
Be a Champion to your Patients!
                                  References
1.    Insall, Walker -Unicondylar knee replacement Clin Orthop Relat Res. 1976 Oct;(120):83-5.
2.    Laskin -Unicompartmental tibiofemoral resurfacing arthroplasty J Bone Joint Surg Am. 1978
      Mar;60(2):182-5
3.    Marmor - J Bone Joint Surg Am. 1979 Apr;61(3):347-53. - Marmor modular knee in
      unicompartmental disease. Minimum four-year follow-up.
4.    Jones -Unicompartmental knee arthroplasty using polycentric and geometric hemicomponents. J
      Bone Joint Surg Am. 1981 Jul;63(6):946-54.
5.    Thornhill - Unicompartmental knee arthroplasty. - Clin Orthop Relat Res. 1986 Apr;(205):121-31.
6.    Kozinin, Marx, Scott - Unicompartmental knee arthroplasty. A 4.5-6-year follow-up study with a
      metal-backed tibial component - J Arthroplasty. 1989;4 Suppl:S1-10
7.    Heck DA, Marmor L, Gibson A, Rougraff BT Unicompartmental knee arthroplasty. A multicenter
      investigation with long-term follow-up evaluation - Clin Orthop Relat Res. 1993 Jan;(286):154-9.
8.    Klemme - Unicompartmental knee arthroplasty. Sequential radiographic and scintigraphic
      imaging with an average five-year follow-up - Clin Orthop Relat Res. 1993 Jan;(286):154-9.
9.    Lewold - The Swedish knee arthroplasty register. A nation-wide study of 30,003 knees 1976-
      1992 - Acta Orthop Scand. 1994 Aug;65(4):375-86
10.   Berger - Unicompartmental knee arthroplasty. Clinical experience at 6- to 10-year followup - Clin
      Orthop Relat Res. 1999 Oct;(367):50-60
11.   Squire - Unicompartmental knee replacement. A minimum 15 year followup study - Clin Orthop
      Relat Res. 1999 Oct;(367):61-72
12.   Tabor, Tabor - Unicompartmental knee arthroplasty: long-term success in middle-age and obese
      patients - J Surg Orthop Adv. 2005 Summer;14(2):59-63
13.   Murray, Goodfellow - The Oxford medial unicompartmental arthroplasty: a ten-year survival study
      - J Bone Joint Surg Br. 1998 Nov;80(6):983-9
14.   Svard, Price - Long-term clinical results of the medial Oxford unicompartmental knee arthroplasty
      - Clin Orthop Relat Res. 2005 Jun;(435):171-80
                                    References
1.    American Academy of Orthopaedic Surgeons (AAOS). Knee Replacement Options Expanding. Available at:
      http://www6.aaos.org/news/Pemr/releases/release.cfm?releasenum=643. Accessed January 25, 2010.

2.    Center for Disease Control (CDC). Public Health and Aging.: Projected Prevalence of Self-Reported Arthritis or
      Chronic Joint Symptoms Among Persons ≥65 Years - United States, 2005-2030. MMWR, 52, 489-491.
      Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5221a1.htm. Accessed January 25, 2010.

3.    Benson, V. & Marano, M. (1998). Current Estimates from the National Health Interview Survey, 1995. Vital &
      Health Statistics 10, 199, 1-428.

4.    Romagnoli, Sergio. The Adventures of Unicondylar Knee Replacement. Proceedings from Current Concepts
      in Joint Replacement. Spring 2001, Paper33.

5.    Murray, David. Unicondylar Knee Replacement: Now or Never? Orthopedics. September 2000, Vol 23, page
      980.

6.    Keene GCR, Forster MC. Modern Unicompartmental Knee Replacement. Current Orthopaedics. 2005; 19:428-
      445.

7.    Unicompartmental Knee Arthroplasty: Clinical Experience at 6 to 10 Years Follow up, Berger, 1999.

8.    Modern Cemented Metal-Backed Unicompartmental Knee Arthroplasty: A 3 to 10- Year Follow up Study.
      Presented at he 68th A AOS, Argenson, 2001.

9.    Unicompartmental Knee Arthroplasty: Ten-year Follow up. Swienckowski, 2001.

10.   Oxford Medial Unicompartmental Knee Arthroplasty A SURVIVAL ANALYSIS OF AN INDEPENDENT SERIES,
      Svard 2005.
                                       References
11. The Oxford Medial Unicompartmental Arthroplasty: A Ten Year Survival Study, Goodfellow.


12. Reoperation of Minimally Invasive UKA, Hamilton 2006.

13. Failure Mechanisms After Unicompartmental and Tricompartmental Primary Knee Replacement. Furnes, 2007.

14. Medial Unicompartmental Knee Arthroplasty with the Miller Galante Prosthesis, Naudie 2004.

15. Svard, U. & Price, A. AAOS 2006.

				
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