1. Firenze, 29 Marzo 2008
ANALISI DEI RISULTATI DELLE
PROTESI A PIATTO MOBILE
ED A PIATTO FISSO
G.C. COARI - A. TRIPODO
Casa di Cura San Camillo – Forte dei Marmi (LU)

2. I PRIMI IMPIANTI DI MONO RISALGONO
AGLI ANNI ‘50 ED INIZIO ‘60
 MACINTOSH: disco protesico senza cemento
 MCKEEVER: chiglia sotto la superficie

3. ANNI ‘70
 GUNSTON e MARMOR introdussero la
protesi mono cementata
 Superficie di rivestimento femorale in
acciaio e tibiale in PE GUNSTON
Marmor

4. INIZIO ANNI ‘80
 Insall ‘80 – Mallory ‘83 – Laskin ‘86 dimostrarono una alta
percentuale di fallimenti (35%)
 Dopo questi risultati e con l’avvento di protesi totali più
evolute, diminuì fortemente l’utilizzo delle mono
 Solo MARMOR e pochi altri continuarono

5. ANNI ‘80
 LA MONO RIGUADAGNA POPOLARITA’
 VENGONO STABILITI CRITERI DI INDICAZIONE LOTUS
Soprattutto la scuola francese
(DEJOUR, MANSAT, GRUPPO
GUEPARD, CARTIER) sviluppò e
codificò la tecnica e le indicazioni
delle mono
CARTIER

6. Cartier descrisse una precisa
pianificazione preoperatoria e
teorizzò la filosofia delle mono
 Ipocorrezione dell’asse meccanico
 Rispetto dell’interlinea articolare
 Bilanciamento in flessione - estensione
della tensione dei legamenti collaterali

7. Nel 1979 OXFORD prima mono a piatto mobile

8. Nel 1989 la Mono Allegretto

9. ANNI ‘90
PFC SIGMA DURACON
MILLER-GALANTE
REPICCI NATURAL-KNEE
PCA LCS-UNI

10. STATISTICHE DI SOPRAVVIVENZA
DELL’UNICOMPARTIMENTALE
• Berger-Galante CORR 1999 10 anni 99 %
• Squire-Iowa CORR 1999 15 anni 87.5 %
• Bert-Minn J. Arthroplasty 1998 10 anni 87.4 %
• Murray-Oxford JBJS-B 1998 7.6 anni 97 %
• Tabor-Charlotte J. Arthroplasty 1998 10 anni 84 %
• Ansari-Dallas Acta Ortho Scan 1997 10 anni 87-74 %
• Robertsson-Sweden Acta Ortho Scan 1999 10 anni 88 %
• Cartier J. Artrhoplasty, 2000 10 anni 93 %
• Romagnoli - Verde JBJS 2005 13 anni 97 %

11. PROTESI MONO vs TOTALI
 SOPRAVVIVENZA A 10 ANNI SOVRAPPONIBILE
 A 15-20 ANNI
- TOTALI 90-95%
- MONO ?

12. LA PROTESI MONO: FILOSOFIA
 LA MONO DOVREBBE DURARE PIU’ DEL PAZIENTE
- NO BY-PASS ARTROSICO, NO PRE-TOTALE
- EVITARE USURA
 STRUMENTARI DEDICATI
RIPRISTINARE LA FUNZIONE LEGAMENTOSA E LA
CINEMATICA
 INDICAZIONI APPROPRIATE
 APPROCCIO MINI-INVASIVO
BREVE DEGENZA, BASSA MORBIDITA’

13. RIDURRE IL NUMERO DEGLI
INSUCCESSI DELLE MONO
 INDICAZIONI
 RIDURRE USURA DEL POLIETILENE
 TECNICA CHIRURGICA

14. INDICAZIONI
 ARTROSI MONOCOMPARTIMENTALE
 OSTEONECROSI MONOCOMPARTIMENTALE
 LCA FUNZIONALMENTE VALIDO
 VARO < 15°, CORREGGIBILE
 DEFORMITA’ IN FLESSIONE < 15°

15. INTEGRITA’ LCA
La parte posteriore delle superficie mediale tibiale e femorale
si mantiene relativamente intatta in flessione
LCM: sottoposto ad una tensione fisiologica normale

16. CARTILAGINE
PRESERVATA
PERDITA OSSEA
E CARTILAGINEA

17. LA DEFORMITA’ IN VARO
SI CORREGGE
IN FLESSIONE
IN ESTENSIONE
LA PERDITA
Preserved
OSSEA E CARTILAGINEA
Cartilage
GENERANO IL VARO
IL COLLATERALE
Lost
IL COLLATERALE
MEDIALE SI
MEDIALE E’
Cartilage
LASSO TENSIONA
& Bone (NO RETRAZIONE)

18. INSUFFICIENZA LCA
punto di contatto in estensione
si sposta posteriormente
ulteriore danno alla
cartilagine posteriore
COLLATERALE
minore spazio MEDIALE LASSO
articolare in flessione E RETRAZIONE
ed accorciamento SUCCESSIVA
LCM
DEFORMITÀ FISSA E PROGRESSIONE ARTROSICA AL COMPARTO CONTROLATERALE

19. VALUTAZIONE
INTEGRITA’ LCA OA antero-mediale
Preserved
 RX IN CARICO IN L.L. Cartilage
 EROSIONE TIBIALE NON
POSTERIORE
 CRITERIO AFFIDABILE NEL
Lost
95% DEI CASI PER LCA Cartilage
FUNZIONALE & Bone

20. CONTROINDICAZIONI
RARE SE LCA SANO
 DEFORMITA’ IN FLESSIONE > 15°
 DEFORMITA’ IN VARO > 15°
 FLESSIONE < 90°
 SEGNI DI USURA DEL COMPARTO
LATERALE
 OBESITA’

21. ALTRE “ACCETTATE”
INDICAZIONI
 ARTROSI FEMORO-ROTULEA E
DOLORE ANTERIORE
 ETA’ (< 60 E MOLTO ANZIANI)
 ATTIVITA’ ELEVATA
 OBESITA’
 CONDROCALCINOSI

22. FEMORO-ROTULEA
La Scuola di Oxford ha ignorato lo stato della F.R.
I PROBLEMI F.R. A LUNGO F.U. SONO RARI ( < 1%)
• SKAR (699 Oxford)
– 50 revisioni, una per dolore F.R.
• Risultati pubblicati > 10 aa. (Goodfellow, Svard, Smith)
– 35 revisioni nessuna per problemi F.R.
• Nessuna progressione artrosica nella F.R.
– Weale et al JBJS 1999

23. PROTESI MONO + FEMORO-ROTULEA
SERGIO ROMAGNOLI

24. RIDURRE USURA
- USURA MAGGIORE CON INSERTO FISSO
- STRESS DI CONTATTO ALTI

25. LA PROTESI CHE USIAMO
OXFORD III
 FEMORE SFERICO
 TIBIA PIATTA
 INSERTO MOBILE
- NON VINCOLATO
- CONCAVO SOPRA
- PIATTO SOTTO
- SEMPRE CONGRUENTE IN TUTTE LE POSIZIONI

26. TECNICA CHIRURGICA MINI-INVASIVA

27. RESEZIONE TIBIALE
2-3 mm. Sotto la parte più profonda del difetto

28. SEZIONE DELLA FACCETTA POSTERIORE DEL CONDILO

29. FRESATURA DEL CONDILO
FRESA SFERICA SU RIMUOVE OSSO IN MODO
SPIGOT INSERITO PROGRESSIVO PER UN
NEL FORO BILANCIAMENTO
INFERIORE DEL LEGAMENTOSO
CONDILO ACCURATO

30. BILANCIAMENTO
• INSERIRE COMPONENTI DI PROVA
• MISURARE LO SPAZIO IN FLESSIONE ED IN ESTENSIONE

31. DIFFERENZA FRA LO SPAZIO IN FLESSIONE ED IN ESTENSIONE
SPAZIO IN FLESSIONE - SPAZIO IN ESTENSIONE =
mm da fresare sul condilo

32. RIMUOVERE NUOVO OSSO DAL FEMORE CON LO
SPIGOT ADEGUATO

36. INSERIMENTO DELL’ INSERTO DEFINITIVO

37. CONTROLLO RADIOGRAFICO

38. LA PROTESI A PIATTO FISSO
ZIMMER ZUK

39. ZUK
STRUMENTARIO DEDICATO
MINIME RESEZIONI

40. ZUK

41. ZUK

42. ZUK

43. ZUK

44. NOSTRA CASISTICA OXFORD III
GENNAIO 2001- OTTOBRE 2007 192 CASI
GENNAIO 2001- DICEMBRE 2005 140 CASI
CONTROLLATI 137
- FOLLOW-UP MIN. 2 anno MAX 7 aa.
- ETA’ MEDIA 70 (51-82)
- M 57 F 80
- LATO DX 76 SIN 61

45. COMPLICAZIONI
 5 REVISIONI
 INFEZIONE (2)
 LUSSAZIONE INSERTO (1)
 IPERCORREZIONE IN VALGO (1)
 DOLORE INSPIEGABILE

46. RISULTATI
VALUTATI CON SCHEDA H.S.S.
RISULTATI ECCELLENTI - BUONI NEL 97%

47. RISULTATI PUBBLICATI > 10 ANNI

48. ETA’ < 60 aa.

49. COPYRIGHT © 2003 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
UNICOMPARTMENTAL KNEE ARTHROPLASTY IN PATIENTS SIXTY YEARS OF AGE OR YOUNGER
BY DONALD W. PENNINGTON, DO, JOHN J. SWIENCKOWSKI, DO,
WILLIAM B. LUTES, DO, AND GREGORY N. DRAKE, DO
Background: …the literature is sparse regarding the use of this procedure for younger, active
patients. . . retrospective study was to evaluate the results of unicompartmental knee arthroplasty
in younger, more active patients.
Methods: 41 M-G UNI Miller-Galante system between 1988 and 1996. All of the patients were
sixty years of age or younger and all were physically active.
11ys f-up
HSS 93%
The University of California at Los Angeles activity assessment score was 6.6 ± 1.4 for the knees
in which the original prosthesis had been retained and 7.3 ± 1.5 for those in which it had been
revised.
2 RR per usura PE (1 mono – 1 solo PE) – 1 RR con PTG
9 controlateral arthrosis senza RR o peggioramento sintomatico
Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See
Instructions to Authors for a complete description of levels of evidence.

50. CURRENT CONCEPT IN JOINT REPLACEMENT
Las Vegas Maggio 2007
Oxford III
100%
80%
• 2 Chirurghi (C.D., D.M.)
Survival %
60% • 600 Mono
40% • 7 revisioni
• 6 aa. sopravvivenza 98%
20%
0%
0 2 4 6 8 10
Follow up (years)

51. Clinical Orthopaedics & Related Research: Volume 1(367) October 1999 pp 50-60
Unicompartmental Knee Arthroplasty: Clinical Experience at 6- to 10-Year Followup
Berger, Richard A. MD; Nedeff, David D. MD; Barden, Regina M. RN; Sheinkop, Mitchell M. MD; Jacobs, Joshua J. MD;
Rosenberg, Aaron G. MD; Galante, Jorge O. MD
Section Editor(s): Rand, James MD; Laskin, Richard MD; Healy, William MD
From the Department of Orthopedic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois.
Reprint requests to Richard A. Berger, MD, 1725 W. Harrison St., Suite 1063, Chicago, IL 60612.
62 mono in 51 pz with the M-G
Ave 68 aa
HSS pre 55 post 92
78% excellent 20% good
ROM 120° nel 51% oltre 120°
Finally f-up 10% controlateral e 6% patellofemoral arthrosisù
At 10 ys 98% using rx and revision survival
First, intrinsic concerns about progression of symptomatic disease in the other compartments
have not been reported in the literature.20,22,33 Second, the recovery time is shorter and the cost
is less for unicompartmental knee arthroplasty compared with total knee replacement.8,25 Finally,
patients prefer the feel of a unicompartmental knee arthroplasty compared with the feel of a total
knee replacement.8,25,27 Therefore the purpose of this study is to report the intermediate results
of cemented unicompartmental knee arthroplasty at 6 to 10 years followup.

52. CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 404, pp. 62–70
© 2002 Lippincott Williams & Wilkins, Inc.
Comparison of a Mobile With a Fixed-Bearing Unicompartmental Knee Implant
Roger H. Emerson, Jr., MD; Thomas Hansborough, BA; Richard D. Reitman, MD; Wolfgang
Rosenfeldt, BA; and Linda L. Higgins, PhD
101 mono
51 pz with the Robert Brigham unicompartmental arthroplasty system (DePuy, A Johnson &
Johnson Company, Warsaw, IN).7,7ys f-up
50 with Oxford (Biomet, Warsaw, IN) 6,8ys f-up
Survivorship analysis based on component loosening and revision showed a 99% survival for the
meniscal-bearing implant and 93% survival for the fixed-bearing implant at 11 years.
However, the fixed-bearing knee implants failed significantly more often because of tibial
component failure, in six of eight knees, at an average of 6.3 years. The mobilebearing implants
showed a trend to fail because of arthritic degeneration in the lateral compartment, at an average
of 10 years, although not statistically significant.
The mobile-bearing implants had no tibial component failures. These differences may be
attributable to implant design or surgical technique.

53. CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 428, pp. 92–99
© 2004 Lippincott Williams & Wilkins
The Progression of Patellofemoral Arthrosis after Medial Unicompartmental Replacement Results at
11 to 15 Years
Richard A. Berger, MD; R. Michael Meneghini, MD; Mitchell B. Sheinkop, MD; Craig J. Della Valle, MD; Joshua J.
Jacobs, MD; Aaron G. Rosenberg, MD; and Jorge O. Galante, MD
This study reports the 11-year to 15-year results of unicompartmental knee arthroplasty with an
emphasis on failure mechanisms and progression of patellofemoral arthrosis.
59 mono (the Miller-Galante system, Zimmer, Warsaw, IN)
HSS pre 55 post 90
Four patients (10%) had moderate or severe patellofemoral symptoms at final followup; two were
revised to a primary total knee replacement at 7 and 11 years for progressive patellofemoral
degeneration. No component was radiographically loose and no osteolysis was seen. The Kaplan-
Meier survival with loosening or revision for any reason was 98.0% ± 2.0% at 10 years and 95.7%
± 4.3% at 15 years. At up to 15 years, unicompartmental knee arthroplasty yielded good clinical
results; however, progressive patellofemoral arthritis was the primary mode of failure.

54. COPYRIGHT © 2002 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
Modern Unicompartmental Knee Arthroplasty with Cement
A THREE TO TEN-YEAR FOLLOW-UP STUDY
BY JEAN-NOËL A. ARGENSON, MD, YAMINA CHEVROL-BENKEDDACHE, MD, AND JEAN-MANUEL AUBANIAC, MD
Investigation performed at the Department of Orthopaedic Surgery, The Aix-Marseille University, Hôpital Sainte
Marguerite, Marseille, France
The purpose of the present study was to evaluate the results of a modern unicompartmental knee
arthroplasty performed with use of a cemented metal-backed prosthesis and surgical
instrumentation comparable with that used for total knee replacement
One hundred and sixty consecutive cemented metal-backed Miller-Galante prostheses in 147
patients were evaluated after a mean duration of follow-up of sixty-six months (range, thirty-six to
112 months). The mean age of the patients at the time of the index procedure was sixty-six years.
Three knees were revised because of progression of osteoarthritis in the patellofemoral joint (two
knees) or the lateral tibiofemoral compartment (one knee). Two knees had revision of the
polyethylene liner. The average Hospital for Special Surgery knee score improved from 59 points
preoperatively to 96 points at the time of the review. According to Kaplan-Meier analysis, the ten-
year survival rate (with twenty-nine knees at risk) was 94% ± 3% with revision for any reason or
radiographic loosening as the end point.

55. COPYRIGHT © 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
Medial Unicompartmental Knee Arthroplasty with the Miller-Galante Prosthesis
BY DOUGLAS NAUDIE, MD, FRCS(C), JEFF GUERIN, BMATH, DAVID A. PARKER, MBBS, FRACS,
ROBERT B. BOURNE, MD, FRCS(C), AND CECIL H. RORABECK, MD, FRCS(C)
Investigation performed at London Health Sciences Centre—University Campus, the University of Western
Ontario, London, Ontario, Canada
Background: Unicompartmental knee arthroplasty has become a popular treatment alternative for osteoarthritis
that is confined to the medial part of the knee. Excellent intermediate-term results recently have been reported in
association with the Miller-Galante unicompartmental implant. The purpose of the present study was to report on our
longer-term experience with the Miller-Galante medial unicompartmental knee implant.
Methods: 113 medial unicompartmental knee arthroplasties in eighty-four patients between 1989 and 2000.
The mean age of the patients at the time of surgery was sixty-eight years.
Forty-five patients were men, and thirty-nine were women. Were followed for a mean of ten years and were evaluated with
use of the Knee Society clinical and radiographic rating system.
Results: HSS improved from 48 and 53 points preoperatively to 93 and 80 points at the time of the most recent
evaluation. The five and ten-year rates of survival were 94% and 90%, respectively, with revision to tricompartmental knee
arthroplasty as the end point and 93% and 86%, respectively, with revision or radiographic loosening as the end point.
Conclusions: The Miller-Galante medial unicompartmental knee arthroplasty provided excellent pain relief and
restoration
of function in carefully selected patients and demonstrated durable implant survival at ten years.
Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to
Authors
for a complete description of levels of evidence.

56. Available online at www.sciencedirect.com
ScienceDirect The Knee 13 (2006) 365370
Mobile vs. fixed bearing unicondylar knee arthroplasty:
A randomized study on short term clinical outcomes and knee kinematics
Ming G. Li *, Felix Yao, Brendan Joss, James Ioppolo, Bo Nivbrant, David Wood
Perth Orthopaedic Institute, the University of Western Auslralia, Gate 3 Verdun Street, Nedlands, WA 6009, Australia
Received 23 November 2005; received in revised form 21 April 2006; accepted 9 May 2006
46 mono med 72ys main M-G and Oxford solutions
The mobile bearing knees displayed a larger and an incrementally increased tibial internal rotation (4.3", 7.6", 9.5" vs. 3.0°,
3.0°, 4.2“ respectively at 30°, 60°, 90" of knee flexion) compared to the fixed ones.
The medial femoral condyle in the mobile bearing knees remained 2 mm from the initial position vs. a 4.2 mm anterior
translation in the fixed bearing knees during knee flexion.
The contact point in the mobile bearing implant moved 2 mm postenorly vs. a 6 mm antenor movement in the other group.
The mobile bearing knees had a lower incidence of radiolucency at the bone implant interface (8% vs. 37%, p<0.05).
The incidence of lateral compartment OA and progression of OA at patello-femoral joint were equal.
No differences were found regarding Knee Society Scores, WOMAC, and SF-36 scores (p>0.05).
This study indicates that mobile bearing knees had a better kinematics, a lower incidence of radiolucency but not yet a
better knee function at 2 years.

57. CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 452, pp. 137–142
© 2006 Lippincott Williams & Wilkins
The Unicompartmental Knee
Design and Technical Considerations in Minimizing Wear
Jean-Noël A. Argenson, MD; and Sebastien Parratte, MD
Unicompartmental knee arthroplasty is an alternative to total knee arthroplasty for patients with unicompartmental
tibiofemoral noninflammatory disease. Careful patient selection and newer instrumentation has reduced the progression
of arthrosis in the other compartment and tibial loosening, leaving polyethylene wear as the predominant failure
mechanism
in more contemporary designs. Increased wear increases the debris volume at the bone-implant interface, and
wear particles will generate osteolysis leading to component loosening and unreplaced compartment degeneration.
The design-related factors that minimize wear include a polyethylene thickness of greater than 6 mm, a limited shelf age,
and a design allowing large areas of contact mediolaterally and anteroposteriorly.
Congruous mobile-bearing implants could play a substantial role in reducing wear if they are not associated with
dislocation and nonreproducible surgical techniques.
Important technical factors include accurate instrumentation avoiding component-to-component malposition
and edge loading, allowing slight under-correction of the preoperative deformity.
The patient-related factors include a weight limit, a functional anterior cruciate ligament, and a correctable frontal
deformity. Continued research including that related to cross-linking and sterilization methods is mandatory to improve
polyethylene strength. A better understanding of kinematics and contact forces may provide long-term survival and patient
satisfaction after unicompartmental arthroplasty.
Level of Evidence: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of
evidence.

58. LE TECNICHE ED I DISEGNI PROTESICI
POSSONO ESSERE DIFFERENTI…
 Corrette indicazioni
 Ipocorrezione dell’asse meccanico
 Rispetto dell’interlinea articolare
 Bilanciamento in flessione – estensione della tensione dei
legamenti collaterali
 Tecnica M.I.S.
… POSSIAMO GARANTIRE ECCELLENTI
RISULTATI CON COMPLICAZIONI CONTENUTE

59. GRAZIE