Well, I was going to say, this is the easiest debate I've ever had because you already presented the data showing that UNI does better, but we'll still do it anyway. So I have no disclosures. So first of all, let's just review what the task at hand was for me. This is a 44-year-old attorney, enjoys hiking and cycling, no medial joint space. This is the information I was given. So what are the things we have to think about? They're 44, they're young, hiking and cycling. So they're active, we want to preserve motion, but it's mostly lower impact sports, no medial joint space, so advanced grade four arthritis, and they throw in he's attorney, which means basically if he doesn't do well, he's going to sue your ass. So what are your options? You can continue non-operative care, all the biologic stuff we heard about. There's arthroscopic debridement, and again, this is a grade four case, so we know that's probably not a good option. And then we have osteotomy, and we have replacement, both UNI and total knee replacement that we have to really discuss. And you know, what are going to be the goals of this treatment? We want pain relief, we want some functional return, including sports, and we want longevity and survival, and then we're really, you know, this whole framework is around the fact that we have a young, active patient. And so what are going to be the pros and cons of things we need to think about? And this is going to kind of be the summary. I mean, the advantage of an HTO is you've got joint preservation, but really when we think about replacement, the pain relief is going to be better. I think most of us will agree to that. The longevity and survival, as I'll show and we've already heard, is likely better. And then the real question is, well, what about this issue of functional return in sports? And that's where it's a little more controversial. So I also think we have to talk about what are we dealing with? And actually, Dr. Amendola really, really stated this. I mean, these are two of my patients, both 44, this is true, who came in to see me with medial compartment OA, but you can see that the one is grade 4 and the other is really much more, you know, in sort of the mild to moderate category. And I think that the mild to moderate category certainly may do better with an HTO, but when we're really thinking about grade 4 arthritis that's bone on bone, it's less likely to be successful. And if you look at the literature on who does poorly with osteotomy, it's really, you know, those Kellogg and Loire grade 4 patients that seem to do worse. So that's where we really have to think twice about osteotomy. So what about the results you saw? You saw some of this when we look at UNI versus HTO. And I'm going to point out that this isn't really specified to the young patient, although many of these are indicated for this. So, you know, WOMAX is better with UNI compartmental. Many of the other outcomes showed no differences, but the survival with UNI is definitely better, especially at 10 years, about 96% for a UNI, about 88% for an HTO. And then this other study, again, when you look at long-term, they're both around 90% for 10 years, and then HTO really deteriorates while UNI continues to have a good survival rate. This is the study that you really saw referred to in the previous lecture, showing, you know, higher activity scores, better survivorship for a UNI. It did, however, show that if you failed with a UNI, it was going to occur early, even though you had a lower overall failure rate. So then the question comes up, you know, how does knee arthroplasty do, particularly in the young patient? So since I was kind of assigned, like, the session of death, the last session on the last day, I was like, well, I got to make something positive out of this. So I assigned my research team to do a systematic review on UNI in total, specifically in the young patient. And we're, you know, submitting this now. It's already submitted for publication. So this really looked just at UNI in totals in patients 55 and younger. And there were 21 studies with totals and five studies with UNI specifically in this population. So first of all, when it comes to pain relief, I mean, this is nothing unexpected. You know, good knee society scores and knee society function scores in these young patients, both at 5 to 10 and at 10 to 20 years. So really relatively well sustained, even in young patients. What about range of motion? So this is one of the things that we think about, especially when we're comparing HTO to arthroplasty. So you know, with total knees, the range was really about 100 to 120. So again, not perfect. And especially when you're thinking about higher level activities, UNI's definitely better range of motion when you look at these studies, you know, about 125 to 130. When you think about survival and longevity, this is our forest plot. And you can see they really center around that about 95% number. But with totals, it was 90 to 98% at basically at 10 years. And then it goes down some, and you know, the studies have different long-term outcomes. But it was still about 85% at 10 to 20 years in these young patients. And pretty similar with UNI, a little lower when you looked at the studies that went out to 20 years. So what about what's shown for return to sports? Now this is not specific to young patients. This is what's in the literature. And there's really not a lot after arthroplasty when you look at this. About 71% or so return to sports after total. Most of this is low-impact stuff, walking, cycling, swimming. It does, however, state, when you just look at return to sport, that the studies that had younger patients, they were typically the ones that did a better job of returning to sports than the older patients. And this is another study specifically looking at UNI. And again, somewhere around 87% to 98% following UNI, again, low-impact activity. But it does seem to be a little better in terms of activity for UNIs. So in the systematic review we did, it was really very limited data when you look at the arthroplasty literature in young patients and whether or not they return to sports. Somewhere around 60% to 72%. And there's actually a lot of studies that show that although we think we tell our patients, oh, you're going to return to sports after we do your arthroplasty. If you really look at it carefully, a lot of people lose the ability to play sports in these studies in terms of activity with arthroplasty. So you know, there's certainly one of the downsides to doing arthroplasties in potentially young patients. What about UNI versus total? Again, this is not specific to the young patient. But just to mention it, several recent studies that have looked at this, because it seems obvious that UNI would be a better choice in this patient, and that would certainly be the one for me. But when you look carefully at UNI versus total, there's actually been a lot of recent data that shows nearly equivalent outcome with the isolated medial compartment OA in these patients. And really, you know, this is a match study, UNI versus total. Basically one showed higher function and less pain and higher satisfaction with UNI. But the other studies really at 10 years showed similar functional outcome, quality of life, and satisfaction. And again, a randomized control trial recently published showing similar five-year outcomes between UNI and total for isolated medial compartment OA. So you know, final considerations on what you're going to do with these patients. I think you have to think about their functional demands, obviously the status of the other compartments. And we really have to think about whether or not the return to sports and their functional goals are realistic. But in conclusion, I'd say for most patients, arthroplasty is the way to go if you're grade four when you look at pain relief, return to lower impact sports, and survival. Thank you.

treatment options

advanced grade four arthritis

knee replacement

UNI

pain relief