THE KNEE SOCIETY VIRTUAL FELLOWSHIP

Transcription

1 THE KNEE SOCIETY VIRTUAL FELLOWSHIP CHAPTER IX PARTIAL KNEE: MEDIAL, LATERAL, PFR Lateral Unicompartmental Knee Arthroplasty Presented by: Keith R. Berend, MD COPYRIGHT 2016 THE KNEE SOCIETY

2 LATERAL UKA Less than 1% of all knee arthroplasties Technically more difficult Less reproducible Complex kinematic profile Screw-home mechanism Paucity of literature Scott RD, Orthopedics 2005 Fitz, JBJS-Am 2009 Ashraf et al., JBJS-Br 2002

3 ISOLATED LATERAL OSTEOARTHRITIS Approximately 10% of OA May be more common Often missed Disease of flexion Sah & Scott, JBJS-Am 2007 Pandit et al., Knee 2009

4 RADIOGRAPHIC ANALYSIS Weight Bearing Varus Stress 45º Flexed Courtesy of Prof. David Murray Valgus Stress 45º Flexed

5 LATERAL UKR CURRENT RECOMMENDATION Fixed bearing Monoblock/DCM Same technique as medial UKA Good short results Shakespeare 05/06 50 cases

6 MATERIALS AND METHODS 132 Lateral UKA (127 patients) , 2 centers Avg. age: 69.5 years (39-97) Avg. weight: 184 lbs ( ) Avg. BMI: 30.0 kg/m 2 (19-47) Female gender: 70% Berend, Kolczun et al., CORR 2012

7 INDICATIONS Full thickness loss laterally Maintenance medially on varus stress radiograph No significant radiographic /arthroscopic patellofemoral disease Age, weight, activity, degree of deformity not used as contraindications in any case

8 VARUS STRESS VIEW 56 KNEES 15º Flexion Varus Load Correction of intra-articular deformity Preservation of medial joint space

9 DIAGNOSTIC ARTHROSCOPY 76 KNEES 2-3 weeks pre-op 5mm Interview scope Confirm isolated lateral disease

10 LATERAL UKA Metal-backed Fixed bearing Monoblock/DCM: 90 UKA Modular: 42 UKA All implants cemented

11 Patellar Tendon Split SURGICAL PEARLS Flexion Extension Preoperative arthroscopy when in doubt Hanging leg position/leg holder Mid-line skin incision Mini-LATERAL parapatellar approach Extramedullary alignment guides Patellar tendon split for vertical tibial resection Balance 2-3mm Lax 90 flexion Tight or 0mm full extension

12 PATELLAR TENDON SPLIT Trans-patellar tendon approach for vertical tibial resection Allows for proper internal rotation of tibial baseplate in relationship to femoral implant Allows for medial enough resection to reconstruct the entire lateral plateau Enlarges surface area of implant and resection to prevent subsidence and failure

13 BALANCING Laxity Flexion gap 2-3mm lax Extension gap 0mm

14 IMPINGEMENT Patellofemoral joint Tibial Implant-Femur

15 43-YEAR-OLD ACTIVE FEMALE 3 months s/p AKS lateral meniscectomy 2 years s/p lateral UKA

16 86-YEAR-OLD INACTIVE MALE >10 years pain Multiple medical comorbidities 1 year s/p UKA

17 DEVICE

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19 RESULTS 19 patients (19 knees) expired before minimum 2-year followup No revisions 13 patients (13 knees) lost before minimum 2-year follow-up Average follow-up: 12.3 months Average KSS Clinical: 92 of 100 Average KSS Pain: 44 of 50 Berend, Kolczun et al., CORR 2012

20 RESULTS 100 knees (93 living patients) Average follow-up: 39 months 99% implant survival 1 revision at 30 months 2 Reoperations: 1 medial meniscal tear 1 lateral plateau fracture (MVA) 97% free of reoperation Berend, Kolczun et al., CORR 2012

21 2 Years s/p UKA 2 Weeks s/p MVA 1 Year s/p ORIF

22 KNEE SOCIETY PAIN AND FUNCTION Pre-op Post-op 0 Pre-op Post-op p>0.001 p<0.001

23 KNEE SOCIETY CLINICAL & RANGE OF MOTION Pre-op Post-op 0 Pre-op Post-op P< P<0.05

24 LATERAL UKA SINGLE SURGEON EXPERIENCE June 2005 Sept. 2010; 98 patients; 104 lateral UKA 102 OA; 2 PTA Mean age: 57 years; BMI: 30.0 kg/m2 Nonmodular, FB, metal backed; lateral parapatellar Mean follow-up: 2.3 years (6w 6.2 yrs) KS Pain: 10 preop to 41.6 postop KS Clinical: 48.8 preop to 89.6 postop KS Function: 53.3 preop to 73.6 postop 2 reoperations: 1 I&D non-healing wound; 1 arthroscopic repair of MMT 2 revisions: 1 to CR-TKA at 16m for femoral loosening; 1 revised elsewhere for pain Berend et al., OCNA 2015

25 IS LATERAL BETTER THAN MEDIAL?

26 JIS LATERAL COHORT 104 Lateral UKA (98 patients) Average Age: 57 years (39-97) Avg. BMI: 30.0 kg/m 2 (19-47) Female gender: 69% Minimum 24 month follow-up Cemented, metal-backed, DCM

27 INDICATIONS Full thickness loss laterally Maintenance medially on varus stress radiograph No significant radiographic/arthroscopic patellofemoral disease Age, weight, activity, degree of deformity not used as contraindications in any case

28 JIS MEDIAL COHORT 1000 Medial UKA (808 patients) Average Age: 63 years (29-91) Avg. BMI: 32.2 kg/m 2 (17-58) Female gender: 56% Minimum 24 month follow-up Cemented, mobile-bearing

29 ANTEROMEDIAL ARTHRITIS Anatomic Criteria May Expand the Percent of Ideal Candidates > 35% Full Thickness Cartilage Loss Anterior Disease, Preserved Posterior Bone Fully Correctible Full Thickness Lateral Cartilage

30 JIS: DEMOGRAPHIC & OUTCOME COMPARISON IN MEDIAL VS LATERAL UKA Characteristic Lateral UKA Medial UKA (n=104) (N=1000) P value Age (years) P<0.05 Body mass index (kg/m 2) P<0.05 Follow-up (months) NS Knee Society Pain NS Knee Society Total NS Range of Motion P<0.05 Implant Survival 98% 95% 0.040

31 FIXED LATERAL Utilized MRI imaging and cluster analysis for anatomical sizing and shape Instrumentation adapted from Mobile Bearing Medial IM Linked or EM guides

32 LATERAL TIBIAL SIZING STUDY 400+ cadavers (MRI database) Virtual resections (4 levels) Standard Horizontal: 7 º posterior, 0 º varus, 4mm below lateral plateau point Vertical: 4mm lateral to eminence point, Plane normal to Cobb Axis 1mm above standard 1mm below standard 2mm below standard

33 LATERAL TIBIAL SIZING STUDY Shape extraction 50 points around perimeter Clustering Grouped by AP size Averaging 50 points used to find average curve by RMS method 1 average cluster curve for each resection and cluster Cluster curve overlays used to create implant profile sizing rationale 8 Cluster Curves at Standard Resection Level 4 Cluster 2 Curves Overlaid (Anterior Consistent between Levels)

34 FIXED LATERAL Tibial resection Check in extension that 3-4mm shim and tibial baseplate fit or cut more tibia Femoral alignment EM guide adaptor IM Guide adaptor 0º Varus/Valgus Balance in extension Flexion will be loose Increase slope if tight

35 FIXED LATERAL Simplified technique Adapted from medial mobile bearing DCM Poly with metal backing Designed to minimize risk of impingement Anatomic size and shape Specifically designed for lateral UKA

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40 COPYRIGHT 2016 THE KNEE SOCIETY

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43 LATERAL MOBILE BEARING 100% 20mm movement Mobile bearing ideal 76% 8-year survival Contraindicated 80% 60% 40% 20% 0% All revisions Gunther, Knee 1996

44 MOBILE LATERAL High flexion Femur subluxes posteriorly Biconvex tibial insert Domed tibial baseplate Increases entrapment Clinical trial ongoing Normal movement Decreased dislocation Increased flexion Available in Canada Available in US in future

45 RESULTS OF LATERAL UKA - I Study # Device (Manufacturer) F/U (yrs) Survivorship (# Rev) Scott & Santore, JBJS Brigham I & II (DePuy); all-poly tibia 3.5 (2-6) 83.3% (2) Mallory & Danyi, CORR % Polycentric (Stryker); 83% Marmor 5.6 (5-8) 50% (2) (Smith & Nephew); all-poly Marmor, CORR Marmor, cemented, all poly tibia 7.4 (3-10) 85.7% (2) Kozinn et al., J Arth Brigham Mod (DePuy), metal-backed 5.5 (5-6) 100% (0) Magnussen & Bartlett, J Arth PCA (Stryker), cementless, metal-backed (2-3) 100% (0) Christensen, CORR St. Georg Sled (Link), all-poly tibia 3.9 (1-9) 98% (1) Rougraff et al., CORR Compartmental I & II (Zimmer), all-poly 6.5 (1-14) 92.9% (1) tibia Scott et al., CORR Brigham I & II (Stryker); all-poly (8-12) 83.3% (2) Capra & Fehring, J Arth Marmor (Richards) Compartmental II 11.1 (8-14) 6.3 (4-11) 100% (0) 100% (0) Heck et al., CORR Marmor (Smith & Nephew), 6 (max 15) 97.4% (1) Compartmental I & II Swank et al., CORR Fibermesh (Zimmer); 2 Microloc (DePuy); 5.5 (4-8) 87.8% (na) cementless & cemented Witvoët et al., Rev Chir Lotus (GUEPAR) % (26) Lewold et al., J Arth Oxford (Biomet), mobile-bearing 6 (1-10) 86.1% (5) Cartier et al., J Arth Marmor, all poly tibia 12 (10-18) 85% (NA) Gunther et al., Knee Oxford, mobile-bearing 5 (3-10) 82% (11) Tabor & Tabor, J Arth Marmor-style, all-poly tibia 9.7 (5-20) 66.7% (2) Ohdera et al., J Arth different designs 8.3 (5-16) 88.9% (2) Argenson et al., JBJS Miller-Galante (Zimmer), metal-backed 5.5 (3-9) 93% (1) Ashraf et al., JBJS Br St. Georg Sled (Link), all poly tibia 9 (2-21) 74% (15)

46 RESULTS OF LATERAL UKA - II Study # Device (Manufacturer) F/U (yrs) Survivorship (# Rev) Keblish & Briard, J Arth LCS (DePuy), mobile-bearing 11 (5-19) 84.2% (3) Saxler et al., Knee AMC Uniglide (Corin), mobile-bearing 5.5 (2-13) 89% (5) O Rourke et al., CORR Marmor, all-poly tibia 24 (17-28) 72% (2) Pennington et al., J Arth Miller-Galante (Zimmer), cemented 12.4 (3-16) 100% (0) Cartier et al., Orthopedics age <60, Genesis (Smith & Nephew); 20% (5-14) 88% at 12 years uncemented Forster et al., KSSTA Preservation (DePuy), mobile-bearing Preservation, all-poly fixed bearing % (3) 100% (0) Sah et al., JBJS different designs 5.2 (2-14) 100% (0) Argenson et al., CORR different designs 12.6 (3-23) 84% (5) Bertani et al., Rev Chir different designs 9 (2-22) 85.7% (5) Lustig et al., OTSR HLS Evolution (Tornier), all-poly tibia 5.2 (2-13) 98.3% Pandit et al., Knee Oxford I&II (Biomet), mobile-bearing Oxford III flat tibia, mobile-bearing Oxford III domed tibia, mobile-bearing (3-9) 2.3 (1-4) 82% at 4 years (11) 91% at 4 years (9) 98% at 4 years (1) John et al., Int Orthop Miller-Galante, metal-backed 10.8 (2-16) 44.4% (5) Lustig et al., J Arth HLS Evolution, all-poly tibia 8.4 (5-16) 98.1% (1) Berend et al., CORR Vanguard M (Biomet), metal-backed 3.3 (2-7) 99% (1) Heyse et al., Knee Genesis (now Accuris; Smith & Nephew), (5-16) 94.0% (3) uncemented, 23 all-poly Lustig et al., CORR All post-traumatic; 6 HLS Evolution all-poly; 2 Marmor II (Richards) metal-backed; 5 Miller- Galante metal-backed 10.2 (3-22) 92.3% (1)

47 RESULTS OF LATERAL UKA - III Study # Device (Manufacturer) F/U (yrs) Survivorship (# Revisions) Panni et al., KSSTA Zimmer High Flex (Zimmer) 4.5 (3-6) 100% (0) Schelfaut et al., KSSTA Oxford III domed mobile-bearing Min 1 96% (1) Streit et al., JBJS Br Oxford III domed mobile-bearing 3 (2-4) 94% (3) Xing et al., JKS Preservation (DePuy) 4.5 (2-6) 100% (0) Altuntas et al., Knee Oxford III domed mobile-bearing 3.2 (2-5) 96.9% (2) Sebilo et al., OTSR Implants from 30 companies 5.2 (<1-23) 84% at 10 y Thompson et al., J Arth Miller-Galante, Zimmer ZUK, Smith & Nephew Journey, Mako % Marson et al., EurJOST Oxford domed mobile-bearing; Zimmer High-flex fixed-bearing 2.9 (1-4) 2.7 (1-6) 93.3% (1) 100% (0) Smith et al., Knee AMC Uniglide fixed-bearing (Corin) % at 2 y 95.5% at 5 y Walker et al., Int Orth Oxford III domed mobile-bearing % at 2 y (1) Weston-Simons et al., Knee Oxford III domed mobile-bearing 4 ( ) 92.1% at 8 y (4) Berend et al., OCNA Vanguard M fixed-bearing 2.3 (<1-6.2) 98.1% (2) Demange et al., Int Orth iuni G1 (ConfroMIS) Miller-Galante (2-9) 97% at 3.1 y (2) 85% at 2.8 y (3)

48 SYSTEMATIC REVIEW OF MEDIAL VS. LATERAL SURVIVORSHIP IN UKA 96 eligible studies 57 cohort studies and 1 registry with medial UKA survivorship 15 cohort studies and 1 registry with lateral UKA survivorship 19 cohort studies with combined survivorship 7 registry studies with combined survivorship Van der List et al., Knee 2015

49 Medial UKA Lateral UKA Studies combining medial and lateral Registries combining medial and lateral Van der List et al., Knee 2015

50 MEAN SURVIVORSHIP OF MEDIAL AND LATERAL UKA Survivorship 5 year 10 year 15 year 20 year 25 year Medial a Lateral Combined b 72.0 a Studies combined b 72.0 a Registries combined a Medial vs. Lateral P=0.717 P=0.887 P=0.913 Cohort vs Registries P=0.133 p=0.015 a Only one study reported survivorship at this follow-up. b Only three studies reported survivorship at this follow-up. Van der List et al., Knee 2015

51 RETURN TO SPORTS AND RECREATIONAL ACTIVITY AFTER LATERAL UKA 45 patients; 45 lateral UKA, domed mobile-bearing Gender: 26 female / 19 male Mean age: 61 years (36-81) Mean BMI: 27 kg/m 2 (21-42) Mean follow-up: 3 years (2-4.3) Active in 1 sport: 42 of 45 (93%) before onset of symptoms 43 of 45 (96%) after lateral UKA with 98% returning Return to activity after surgery: 25 patients (56%) within 3 months 35 patients (78%) within 6 months 10 patients (22%) >6 months or remained inactive Walker et al., KSSTA 2015

52 INDIVIDUAL SPORTS DISCIPLINES BEFORE AND AFTER LATERAL UKA (N=45) Sport # Before # After Difference Biking % Hiking % Long walks % Nordic walking ±0% Fitness / weight-training % Swimming % Downhill skiing %* Jogging % Soccer %* Tennis %* Aqua-aerobic % Cross-country skiing % Aerobics % *Indicate statistical significant p<0.05 Walker et al., KSSTA 2015

53 SF-36 PATIENTS AFTER LATERAL UKA VS HEALTHY VS OA * * * * * * * * *Indicate statistical significant p<0.05 Walker et al., KSSTA 2015

54 SF-36 PATIENTS AFTER LATERAL UKA VS HEALTHY VS OA ** *Indicate statistical significant p<0.05 Walker et al., KSSTA 2015

55 TAKE HOME MESSAGE The lateral parapatellar approach is safe and effective No intraoperative changes in plan Indications based on anatomic criteria Stress radiographs Diagnostic arthroscopy 90% survivorship at 15 years 98% of patients return to sports and recreational activity after lateral UKA