So this was the charge, was to talk about a 44-year-old who's active and has unit compartmental OA with various metal alignment. I need to disclose that I do get royalties from some of the implants shown in this presentation, both arthroplasty and osteotomy. So I think osteotomy should be part of your armamentarium in treating patients with osteoarthritis, particularly in the young patient with compartmental overload and you're doing some cartilage resurfacing or meniscal transplantation or has instability, I think that's a take-in and we're gonna accept that. The problem here is that you have isolated osteoarthritis, which is where the controversy exists, and so there's a number of factors to consider. The severity of the arthritis, the age of the patient, activity level, BMI, bone quality, and coexisting patella-femoral OA, and I think all these things come into play in making a decision, so there's not one way or another way to to do it. So a young patient has a medial osteochondral defect, various alignment, we do an osteochondral transfer, and osteotomy, I think that's a different question. We're talking about the older patient with arthritis. It is controversial. The indications do overlap. The reproducibility of the outcome is in question, you know, which ones do better? Arthroplasty or osteotomy patients? Survival of the procedure, particularly with osteotomy. How much activity can you do following the procedure? And then a lot of surgeons are concerned about revising an osteotomy to a total knee or even a unit compartmental arthroplasty, and so that's a problem. I think surgeons like to do one operation that works well in a reproductive fashion, and so when you look at the literature, again, the literature with osteotomies versus arthroplasty is similar to the literature that's been presented with some of the other entities here. This was a meta-analysis comparing unit compartmental to osteotomies. Again, blinding was difficult, you know, heterogeneous information and studies, but based on this review, both HTO and UNIS had comparable outcomes. UNIS had less complications, less post-operative pain, easier recovery, and less were revised to total knees. HTOs had better post-operative range of motion and function, and they did conclude that HTO may be more suitable for the higher demand patient. Here's another review. The outcomes were similar. The complication rate and conversion to total knee arthroplasty was similar comparing UNIS and HTOs. Here's another review of HTO versus arthroplasty. Again, they concluded the younger, more active patient, HTO, the older, less active patient is probably a unicompartmental arthroplasty. And again, I agree with these results, and this has generally been my experience. This is one of the studies which I think is kind of reflects what goes on, at least in my practice. This was a Mayo study comparing HTO to unicompartmental replacement. You can see the age of the UNIS are a little bit older, the average age of the HTO patients are a little bit younger, and the severity of disease was basically worse in the UNIS and was a little bit better with the HTOs, and I think that is a factor. If you have absolutely completely gone joint space, I think it'd be a little bit concerning to do an HTO. When you look at this study, early recovery is much better with the UNI, so I think that's important to consider. So if you have somebody who has bilateral metacompartmental OA, you can do bilateral UNIS and they can be walking within six weeks and back to work. I think if they have bilateral metacompartmental OA and do bilateral HTOs, that's a big, it's a big issue. But then when you look at the recovery, they tend to do well, and then the failure rate, longer term, there's a higher failure rate with HTOs versus UNIS, and this is the survival curve in this particular study. Again, this is another review looking at recovery and return to activity. UNIS were better earlier, but then they catch up a little bit later with HTO. Returned into work and sport following high tibial osteotomy. Again, it's not great literature. You can see here in six studies, 90% returned to sport within one year, all returned within two years, and 80% returned to sport at an equal or greater level, which is something to consider in some of these patients. The concern about going to total knees, and I think that is a significant concern. I think the exposure and doing the surgery is a little bit more difficult, but when you look at the results of total knee arthroplasty, the the ones that are in blue, the results are the same. The outcome of total knee following HTO and the outcome of total knee primarily are similar, and I think it's mostly to do with the exposure following an HTO. So this is the patient. I think you need to get all the information, male versus female, unilateral versus bilateral. What are the patient's expectations? It's not an easy decision, and so why would you do an HTO on this patient? I think it's ideal. It's unilateral, varus, isolated medial compartment. They want to go back to a high activity level. They have physiologic function of the knee. They have a potential for good long-term function, and you really don't burn any bridges if you do an HTO, and so here's two examples of my patients, and again there's many of these patients. There's an orthopedic surgeon here at this meeting who is 21 years following an HTO that I did 21 years ago. Anyways, this is a 55 year old, a unit compartmental, a very intelligent, researched everything, and we eventually did an HTO. You can see the medial compartment arthritis, just a very simple procedure, no cartilage surgery, and this is 15 years after an HTO. You know, he writes me an email, and this was after 12 years. He did one of the, you know, the routes in the French Alps here, as you can see here, thanking me for the HTO. This was a 51 year old neurology professor. He had bilateral disease. We did bilateral HTOs. You see here, and back to playing soccer. Again, very grateful that he's able to play with his kids and grandkids and doing well. So, how do you decide when to do an osteotomy? Well, you got to choose the right patient. It's the same as the last presentation by Armando. If you choose the right patients, I think things can work. So, they need to be educated, need to be healthy, moderate severity of arthritis, and they need to have a desire to remain active. So, HTO should be part of your armamentarium. Thank you.

osteotomy

osteoarthritis

young patients

arthroplasty

high tibial osteotomy