Long-term survivorship and failure modes of unicompartmental knee arthroplasty

The Relationship Between Age and 30-day Outcomes Following Unicompartmental versus Total Knee Arthroplasty

BACKGROUND

An enhanced understanding of the short-term complication profile following unicompartmental knee arthroplasty (UKA) versus total knee arthroplasty (TKA) can improve surgical decision-making and subsequent patient outcomes. This study aimed to determine if the difference in risk of 30-day morbidity and mortality between UKA and TKA varied as a function of patient age.

METHODS

This retrospective study of a national quality improvement database using data from 2014 to 2020 included 403,342 patients undergoing UKA (n = 12,324) or TKA (n = 391,018). A generalized additive model (GAM) evaluated non-linear relationships between primary outcome and predictors (age, procedure type, and procedure type x age interaction) using a 1:5 UKA to TKA matched sample. Probabilities and odds ratios (95% CI [confidence interval]) estimated the relative risk of complications across the age spectrum.

RESULTS

In the GAM, TKA patients relative to UKA had 1.30 higher odds (95% CI 1.19 to 1.43, P < 0.001) of 30-day morbidity and mortality. There was a significant, non-linear relationship between age and the primary outcome (P = 0.02), such that the odds were lowest at younger ages. They increased slowly until about age 65 years, at which point the slope became steeper. The interaction terms for age and procedure type were not significant (P = 0.30). The 30-day probability for short-term complications of a 65-, 75-, and 85-year-old undergoing UKA was 2.1% (95% CI, 1.8 to 2.3), 2.4% (95% CI, 2.0 to 2.8), and 3.2% (95% CI, 2.3 to 4.1), respectively. Conversely, the probability of a 65-, 75-, and 85-year-old undergoing TKA was 2.9% (95% CI, 2.7 to 3.0), 3.6% (95% CI, 3.3 to 3.8), and 5.5% (95% CI, 4.7 to 6.3).

CONCLUSIONS

Patients undergoing UKA had a quantifiable lower likelihood of morbidity or mortality than TKA at all ages. These data can provide individualized risk for UKA and TKA across the age spectrum and could be helpful in counseling patients regarding their risk for perioperative complications.

Outcomes of fixed versus mobile-bearing medial unicompartmental knee arthroplasty

Aims

The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

Methods

Prospectively collected data were reviewed for all primary cemented medial UKAs performed by seven surgeons from January 2006 to December 2022. A total of 2,999 UKAs were identified, including 2,315 FB and 684 MB cases. The primary outcome measure was implant survival. Secondary outcomes included 90-day and cumulative complications, reoperations, component revisions, conversion arthroplasties, range of motion, and patient-reported outcome measures. Overall mean age at surgery was 65.7 years (32.9 to 94.3), 53.1% (1,593/2,999) of UKAs were implanted in female patients, and demographics between groups were similar (p > 0.05). The mean follow-up for all UKAs was 3.7 years (0.0 to 15.6).

Results

Using revision for any reason as an endpoint, five-year survival for FB UKAs was 97.2% (95% CI 96.4 to 98.1) compared to 96.0% for MB (95% CI 94.1 to 97.9; p = 0.008). The FB group experienced fewer component revisions (14/2,315, 0.6% vs 12/684, 1.8%; p < 0.001) and conversion arthroplasties (38/2315, 1.6% vs 24/684, 3.5%; p < 0.001). A greater number of MB UKAs underwent revision due to osteoarthritis progression (FB = 21/2,315, 0.9% vs MB = 16/684, 2.3%; p = 0.003). In the MB group, 12 (1.8%) subjects experienced bearing dislocations which required revision surgery. There were 15 early periprosthetic tibia fractures (0.6%) in the FB group compared to 0 for MB (p = 0.035).

Conclusion

In similar patient populations, FB UKAs demonstrated slightly higher survival than a commonly used MB design. Adverse event profiles differed by bearing type, with an increased risk of bearing dislocation and OA progression with MB designs, and early periprosthetic tibia fractures for FB designs.

Associated patellofemoral osteoarthritis is not a contraindication for unicompartmental knee replacement. Report of one hundred ten prostheses with an average 6-year follow-up

INTRODUCTION

Associated patellofemoral joint osteoarthritis (APFJ-OA) has typically been considered a contraindication for unicompartmental knee arthroplasty (UKA) in the treatment of femorotibial joint osteoarthritis. However, this contraindication is being challenged. The aim of this study was to assess clinical and functional outcomes, complications, and implant survival in medial or lateral UKA, regardless of clinical symptoms or radiographic signs of APFJ-OA.

METHODS

This retrospective, comparative study included patients treated with medial or lateral UKA regardless of preoperative symptoms or signs of APFJ-OA, with a minimum 2-year follow-up. Intraoperatively, knees were subdivided based on APFJ-OA grade, according to the Outerbridge classification. Clinical and functional outcomes were analyzed using the 2011 Knee Society Score (KSS) at the last follow-up control. APFJ-OA was treated systematically, in a tailored, stepwise fashion according to its severity. Complications and implant survival rates were evaluated. Two-sided paired T-test, ANOVA, and Kruskal-Wallis tests were used with a significance level of 5%.

RESULTS

Finally, 110 UKAs were assessed 81 (73.6%) medial and 29 (26.4%) laterals. The average follow-up was 6 years (2-19.5). According to Outerbridge, 22 knees (20%) were in grade 2, 59 (53.6%) were in grade 3, and 29 (26.4%) were in grade 4. All three groups showed a statistically significant increase in KSS scores and range of motion. There were no significant differences in clinical KSS improvement and flexion contracture between Outerbridge groups (average 35.7 and -4.9, respectively). Group 3 showed statistically significant improvement in functional KSS when compared to group 2 (68.8 vs 61.2). In maximum flexion, groups 3 and 4 did significantly better than group 2 (20° vs 15°). Three prostheses (2.7%) needed revision after 7, 8.6, and 12 years due to aseptic tibial loosening. Implant survival was 100% at 5 (64 of 64), 97% at 7 (30 of 31), 93% at 9 (14 of 15), and 89% at 12 years, respectively (8 of 9).

CONCLUSION

Clinical and functional results, complications, and survival of medial or lateral UKA were not negatively affected by APFJ-OA assessed intraoperatively using the Outerbridge classification after an average follow-up of 6 years. We consider that APFJ-OA is not a contraindication for UKA when treated systematically according to its severity.

LEVEL OF EVIDENCE

IV.

Rheumatoid Arthritis Is Not a Contraindication to Unicompartmental Knee Arthroplasty

BACKGROUND

Rheumatoid arthritis (RA) has historically been considered a contraindication for unicompartmental knee arthroplasty (UKA). However, the widespread use of disease-modifying antirheumatic drugs has substantially improved the management of RA and prevented disease progression. The objective of this study was to ascertain whether RA impacts UKA revision-free survivorship.

METHODS

Patients undergoing UKA from 2010 to 2021 were identified in an administrative claims database (n = 105,937) using Current Procedural Terminology code 27446. All patients who underwent UKA who had a diagnosis of RA with a minimum of 2-year follow-up (n = 1,422) were propensity score matched based on age, sex, and Elixhauser Comorbidity Index to those who did not have RA (n = 1,422). Laterality was identified using the 10th Revision of International Classification of Diseases codes. The primary outcome was ipsilateral revision to total knee arthroplasty (TKA) within 2 years, and the secondary outcome was ipsilateral revision at any time.

RESULTS

Among the 1,422 patients who had a UKA and a diagnosis of RA, 37 patients (2.6%) underwent conversion to TKA within 2 years, and 48 patients (3.4%) underwent conversion to TKA at any point. In comparison, 28 patients (2.0%) in the propensity-matched control group underwent conversion to TKA within 2 years, and 40 patients (2.8%) underwent conversion to TKA at any point. Statistical analysis revealed no significant difference in conversion to TKA between patients who had and did not have RA, either within 2 years (P = .31) or anytime (P = .45).

CONCLUSIONS

Patients who had RA and underwent UKA did not have an increased risk of revision to TKA compared to those who did not have RA. This may indicate that modern management of RA could allow for expanded UKA indications for RA patients.

Clinical Outcomes and Survivorship of Lateral Unicompartmental Knee Arthroplasty: A Large Single Surgeon Cohort

BACKGROUND

Lateral unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated lateral compartment osteoarthritis. However, due to the rarity of the procedure, long-term outcomes and survivorship are poorly understood. We report the clinical and radiographic outcomes after lateral UKA.

METHODS

We retrospectively reviewed a consecutive series of patients who underwent lateral UKA by a single fellowship-trained arthroplasty surgeon from 2001 to 2021 with a minimum 2 year follow up. There were 161 knees in 153 patients (average age 69 years) that met inclusion criteria, with a mean follow up of 10.0 years (range 0.05 to 22.2). All patients underwent the procedure via a minimally invasive lateral parapatellar approach with a fixed-bearing implant. Patient demographics, complications, radiographic findings, patient-reported outcomes, and the need for revision surgery were evaluated. Survivorship was defined with the end point as revision of components.

RESULTS

There were 8 patients (5.0%) who underwent conversion to total knee arthroplasty for lateral UKA implant failure or progression of arthritis. There were 3 patients (1.9%) who underwent ipsilateral medial UKA due to medial compartment arthritis progression with preserved mechanical alignment and patellofemoral joint. There were 8 additional procedures that did not require implant changes, including 5 irrigation and debridements for acute periprosthetic joint infection (3.1%), 2 wound closures for dehiscence (1.3%), and one loose body removal (0.6%).

CONCLUSIONS

Lateral UKA showed a survivorship rate of 98.0% at 5 years, 96.0% at 10 years, and 94.5% at 15 years. When including patients who underwent additional surgery for the progression of arthritis, survivorship was 97.4% at 5 years, 95.4% at 10 years, and 91.3% at 15 years. Lateral UKA should be seen as a durable treatment option for isolated lateral compartment osteoarthritis.

How Useful Is Preoperative Aspiration before Revision of Unicompartmental Knee Prostheses Because of Osteoarthritis in the Other Compartments?

AIM

Periprosthetic joint infections (PJIs) of unicompartmental knee arthroplasties (UKAs) can lead to secondary osteoarthritis of the other compartments. The objective of this study was to identify the frequency of PJIs in cases of UKA with progressed secondary osteoarthritis and the result of septic one-stage revision in these cases to verify the value of preoperative aspiration in cases of secondary osteoarthritis of UKA.

METHODS

We retrospectively reviewed 97 patients with a unicompartmental arthroplasty who underwent revision surgery to a total knee arthroplasty (TKA) between January 2013 and March 2021 because of subsequent osteoarthritis. Preoperative aspiration and sample collection during the revision surgery were employed to identify potential periprosthetic joint infections (PJIs). The post-revision period was monitored for septic complications over an average duration of 55.7 ± 25.2 months (24-113).

RESULTS

PJIs were identified in 5.2% of cases through preoperative aspiration. In all instances of PJIs, a one-stage septic revision was performed, and notably, none of these cases experienced septic complications during the follow-up period.

CONCLUSIONS

Preoperative aspiration is essential in order to exclude the presence of a PJI before performing revision surgery of UKA due to secondary osteoarthritis.

First Italian Experience with the Oxinium Metal-Backed Fixed-Bearing Medial Journey II Unicompartmental Knee System: Promising Short-Term Outcomes of 145 Cases

(1) Background: Unicompartmental knee arthroplasty (UKA) provides a viable alternative to total knee arthroplasty (TKA) in patients with isolated medial osteoarthritis (OA). From 2007 to 2021, 23% of all primary knee arthroplasties in Italy were UKAs. We retrospectively evaluated clinical outcomes and satisfaction in patients implanted with a new oxinium metal-backed fixed-bearing medial unicompartmental prosthesis at a 24-month follow-up. (2) Methods: From December 2020 to December 2021, 145 patients were treated by a single surgeon at a single institution using the hypoallergenic Journey II prosthesis. Clinical outcome measures included the Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS), Oxford Knee Society (OKS) score, University of California Los Angeles Activity Score (UCLA), the Physical Component Summary (PCS), and the Mental Component Summary (MCS), and were calculated preoperatively and at 12 and 24 months. The Forgotten Joint Score-12 (FJS-12) was calculated at 12 and 24 months. Patient satisfaction was collected at 24 months. The scores were compared using the Friedman test. (3) Results: All clinical scores improved significantly from baseline to 24 months (p < 0.0001), except for the FJS-12, which from 12 to 24 months did not improve significantly (p = 0.041). Patient satisfaction was 9.32 ± 0.74 out of 10. No patient experienced complications or required revision surgery. (4) Conclusions: The Journey II unicompartmental prosthesis is a valuable treatment option for end-stage medial OA, improving knee function, providing pain relief, and ensuring high patient satisfaction at 24 months.

What Role Does Patello-Femoral Joint Degeneration Have on Pain and Function After Unicompartmental Knee Arthroplasty? A Prospective Observational Cohort Study

BACKGROUND

Influences on anterior knee pain, stair climbing limitations, and function such as rising from sitting are poorly understood in unicompartmental knee arthroplasty (UKA). Original indications for UKA excluded patients who had patello-femoral disease, while more recent studies have expanded the indications to include these patients. This study examined the influence of the patello-femoral joint degeneration on patient-reported outcome measures relating to anterior knee pain and function after UKA.

METHODS

Between October 2017 and August 2021, Knee Injury and Osteoarthritis Outcome Score of Joint Replacement (KOOS, JR) patient-reported outcome measures were collected preoperatively and at 12 months of follow-up for 678 medial UKAs. Patello-femoral joint status was visually graded intraoperatively. Radiographic or intraoperative medial patellar facet and trochlear patello-femoral arthritis and preoperative anterior knee pain were not considered contraindications for UKA, while grade IV lateral patello-femoral arthritis was considered a contraindication for UKA. Multivariable ordinal logistic regressions were performed, using the KOOS, JR questionnaire assessing pain during stair climbing, standing upright, and function during rising from sitting. Independent regressions were performed for each targeted KOOS, JR question, with adjustments for age at surgery, sex, and baseline pain and function scores.

RESULTS

No association was observed between 12-month postoperative anterior knee pain (P = .575) and function (P = .854) with patellar osteoarthritis grading after UKA. When comparing fixed and mobile-bearing UKA designs, no association was observed between bearing type and pain (P = .663) or functional outcomes (P = .758).

CONCLUSION

Pain and function improved significantly following medial UKA and was independent of medial patellar and trochlear degenerative status.

Painful Unicompartmental Knee Arthroplasty: Etiology, Diagnosis and Management

Unicompartmental knee arthroplasty (UKA) is an increasingly common procedure. Patients with persistent or new postoperative pain can present a challenge for surgeons to accurately diagnose and treat. The purpose of this study is to provide a comprehensive review of the presentation, diagnosis, and management of the various pathologies contributing to pain after UKA. The most common causes of a painful UKA include aseptic component loosening and progression of osteoarthritis. Both of these conditions may be treated with either revision UKA or conversion to total knee arthroplasty. While technically challenging, these procedures are often associated with favorable outcomes. Other causes of pain after UKA include infection, atraumatic tibial component subsidence, periprosthetic fracture and malalignment. Careful clinical, radiographic, and laboratory evaluation is therefore critical to accurately identify the source of pain and guide appropriate management.

Unicompartimental knee arthroplasty metallosis treated with uni-on-uni revision: A case report

BACKGROUND

Metallosis is the result of metallic wear debris in the soft tissues and is associated to both local and systemic inflammatory response. Metallosis has been reported after total hip and total knee arthroplasty (TKA), but rarely after a unicompartimental knee arthroplasty (UKA). In the context of UKA metallosis, surgeons often opt for revision using a TKA. However, in this paper, the authors successfully treated UKA revising the metal back only.

CASE SUMMARY

Prior to treat our patient we conducted a literature research through which we identified eleven cases of metallosis after UKA, ten (90.9%) were treated revising using though a TKA. Only one case was managed through a uni-on-uni revision, reporting high knee function. Our patient complained worsening pain and function after a snap occurred at 16 mo after UKA implantation. At 18 mo following surgical debridment and uni-on-uni revision surgery, our patient exhibited a relevant improvement in Oxford Knee Score and a reduction of metal ion levels in the blood.

CONCLUSION

Our study highlights that in case of metallosis after UKA, the treatment may be based on surgical debridement and just revising the mobilized components.

A Case Report of Unicompartmental Knee Arthroplasty Fracture of the Femoral Component

Introduction

Unicompartmental knee arthroplasty (UKA) is performed with yearly rate of 9% in UK, and <8% in USA. It has been shown to be a successful and less invasive alternative to complete knee arthroplasty in certain patients total knee arthroplasty (TKA). Fracture of the femoral component after (UKA) has never been reported in the literature. Consequently, to investigate the major causes and mechanisms of (UKA) failure, we present a case of femoral component failure following (UKA).

Case Report

A 62-year-old patient with 2 years following an UKA presented with a right pain, stiffness, and gait abnormalities. After taking full history and careful examination and obtaining a new radiograph, a fracture of the femoral component was revealed. A revision surgery with TKA has been done, and the outcome was assessed regularly, and good results were achieved.

Conclusion

The exact reason for a femoral component fracture following UKA is yet unknown. To make an early diagnosis and avoid the need for complex knee revision surgeries, long-term follow-up is crucial for early detection of the clinical signs and symptoms of implant failure.

Septic Metallosis after Unicompartmental Knee Replacement: A Case Report and Literature Review

Introduction

Metallosis following prosthetic hip and knee replacement is a well-known complication. However, unicompartmental knee arthroplasty (UKA) metallosis is rare. In this paper, we report a case of septic metallosis after unicompartmental knee replacement and we review the literature for the available treatment options.

Case Report

A 83-year-old female patient presented with left periprosthetic knee infection on the top of unicompartmental knee prosthesis three months after septic endocarditis that was treated with anti-biotherapy. Surgical exploration showed severe infected metallosis due to chronic polyethylene wear reaction; hence, management consisted of total synovectomy and debridement of all metallic debris and two stage revision.

Conclusion

Metallosis is a well-known complication after prosthetic hip and knee replacements. However, in UKA, it remains a rare complication where only few cases were reported in the literature.

Clinical outcomes of various types of revision surgeries after unicompartmental knee arthroplasty failure

PURPOSE

The advantages of unicompartmental knee arthroplasty (UKA) have led to the procedure being increasingly performed worldwide. However, revision surgery is required after UKA failure. According to the literature review, the choice of implant in revision surgery remains a debatable concern. This study analyzed the clinical results of different types of prostheses used in treating failed UKA.

MATERIALS AND METHODS

This is a retrospective review of 33 failed medial UKAs between 2006 and 2017. Demographic data, failure reason, types of revision prostheses, and the severity of bone defects were analyzed. The patients were classified into three groups: primary prosthesis, primary prosthesis with a tibial stem, and revision prosthesis. The implant survival rate and medical cost of the procedures were compared.

RESULTS

A total of 17 primary prostheses, 7 primary prostheses with tibial stems, and 9 revision prostheses were used. After a mean follow-up of 30.8 months, the survival outcomes of the three groups were 88.2%, 100%, and 88.9%, respectively (P = 0.640). The common bone defect in tibia site is Anderson Orthopedic Research Institute [AORI] grade 1 and 2a (16 versus 17). In patients with tibial bone defects AORI grade 2a, the failure rates of primary prostheses and primary prostheses with tibial stems were 25% and 0%, respectively.

CONCLUSIONS

The most common cause for UKA failure was aseptic loosening. The adoption of a standardized surgical technique makes it easier to perform revision surgeries. Primary prostheses with tibial stems provided higher stability, leading to a lower failure rate due to less risk of aseptic loosening in patients with tibial AORI grade 2a. In our experience, we advise surgeons may try using primary prostheses in patients with tibial AORI grade 1 and primary prostheses with tibial stems in patients with tibial AORI grade 2a.

Safe and reliable clinical outcomes at 2 years of a fixed-bearing partial knee arthroplasty with a morphometric tibial tray in a large worldwide population

PURPOSE

The purpose of this study was to evaluate: (1) improvement of functional and quality of life scores, (2) adverse events, (3) short-term implants survivorship of a newly designed fixed-bearing partial knee replacement (PKR) with a morphometric tibial tray in a large and multicentric population at a minimum follow-up of 2 years.

METHODS

From 2017 to 2019, 479 medial PKR were implanted by 16 non-developing surgeons from United States, Europe, and Japan. Eight patients were lost to follow-up (1.8%). Standardized follow-up procedures included patient-reported outcomes (Oxford Knee Society score, Forgotten Joint Score, EQ VAS, EQ 5D), patient satisfaction, radiographic assessments, adverse event at 2 years. Comparisons between the preoperative and postoperative values were performed using Student t test. Kaplan-Meier survivorship analysis was performed with knee revision as the endpoint.

RESULTS

The mean age was 65.6 ± 9.6 years. Mean body mass index was 29.5 ± 5.1 kg/m². Oxford Knee Society score and Forgotten Joint Score, respectively, improved from 23.7 ± 8 and 16 ± 15.8 preoperatively to 42.4 ± 6.5 and 74 ± 24.9 at 2 years (p < 0.0001). Satisfaction Score was 92.3 ± 13.4 at 2 years. Ten re-operations (2.1%) were reported including seven implant removals (1.5%). No other adverse event was reported. The causes of conversion to total knee arthroplasty were: nickel allergy (n = 2), patellofemoral osteoarthritis (n = 1), pain (n = 1), deep infection (n = 3). Two re-operations were performed due to infection, and one for internal fixation for a tibial plateau fracture. The 2-year Kaplan-Meier survival estimate was 98.4%, with implant removals as the endpoint.

CONCLUSION

This prospective multicentric study reported safe and reliable clinical outcomes of a morphometric PKR, which optimized tibial coverage and femoral fit, in a large population of patients worldwide at 2 years.

LEVEL OF EVIDENCE

Prospective cohort study-therapeutic study, Level II.

Enhanced recovery after surgery (ERAS) protocol in geriatric patients underwent unicompartmental knee arthroplasty: A retrospective cohort study

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

Partial versus total knee arthroplasty for isolated antero-medial osteoarthritis - An analysis of PROMs and satisfaction

AIM

This study aimed to compare the patient-reported functional outcomes and patient satisfaction after medial Unicompartmental Knee Arthroplasty (UKA) versus Total Knee Arthroplasty (TKA), performed for anteromedial osteoarthritis (AMOA) of the knee in patients from an Indian population, at a minimum 3-year follow-up.

METHODS

This is a prospective matched cohort study (1:2 ratio). One hundred and one UKA cases were matched to 206 TKA cases by propensity score matching for age, body mass index (BMI), gender distribution, and the Charlson Comorbidity Index (CCI). The primary outcome (Oxford knee score, OKS) was assessed at a 3-year follow-up, along with secondary outcomes (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] Score, Forgotten Joint Score (FJS), Anterior Knee Pain (Kujala) score, patient satisfaction, and revision rate at the final follow-up).

RESULTS

The UKA group was superior to the TKA group in patient-reported functional outcomes based on the OKS (p = 0.004). Using the FJS score, UKA was more likely to be a forgotten joint compared to TKA (p < 0.001). However, differences in the OKS and FJS did not meet the reported minimal clinically important difference (MCID) thresholds. Quality of life (EuroQol-5D VAS scale) was found to be significantly higher in the UKA group (p < 0.001). Patients in the UKA group were more likely to be very satisfied (75.2%) versus the TKA group (62.1%, p = 0.023).

CONCLUSION

For AMOA, UKA was associated with improved patient satisfaction compared to TKA. Although patient-reported outcome measures were statistically in favour of UKA over TKA, the differences were not clinically significant. Multicenter and randomized studies comparing the two procedures are warranted.

EVIDENCE

Level-II Therapeutic.

Spacer Block Technique Was Superior to Intramedullary Guide Technique in Coronal Alignment of Femoral Component after Fixed-Bearing Medial Unicompartmental Knee Arthroplasty: A Case-Control Study

Backgrounds and Objectives: The spacer block technique in unicompartmental knee arthroplasty (UKA) has still a concern related to the precise position of the component in the coronal and sagittal planes compared to intramedullary guide technique. The purposes of this study were to explore whether the spacer block technique would improve the radiological alignment of implants and clinical outcomes compared with the outcomes of the intramedullary guide technique in fixed-bearing medial UKA. Materials and Methods: In total, 115 patients who underwent unilateral, fixed-bearing medial UKA were retrospectively reviewed and divided into group IM (intramedullary guides; n = 39) and group SB (spacer blocks; n = 76). Clinical assessment included range-of-motion and patient-reported outcomes. Radiological assessment included the mechanical femorotibial angle, coronal and sagittal alignments of the femoral and tibial components, and coronal femorotibial congruence angle. Results: All clinical outcomes showed no significant differences between groups. The coronal femoral component angle was valgus 2.4° ± 4.9° in IM group and varus 1.1° ± 3.2° (p < 0.001). In group IM, the number of outlier in coronal femoral component angle (<−10° or 10°<) was 3 cases, while in group SB, there was no outlier (p = 0.014). The coronal femorotibial congruence angle was significantly less in group SB (mean 1.9°, range, −3.2°~8.2°) than in group IM (mean 3.4°, range, −9.6°~16.5°) (p = 0.028). Conclusions: In the group SB, the coronal alignment of femoral component was closer to neutral, and outlier was less frequent than in the group IM. The spacer block technique was more beneficial in achieving proper coronal alignment of the femoral component and congruence of femorotibial components compared to the intramedullary guide technique in fixed-bearing medial UKAs.

The Performance of Diagnostic Tests for Identifying Periprosthetic Joint Infection After Failed Partial Knee Arthroplasty

BACKGROUND

Indications for unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty are expanding. Despite the lower published infection rates for UKA and patello-femoral arthroplasty than total knee arthroplasty, periprosthetic joint infection (PJI) remains a devastating complication and diagnostic thresholds for commonly utilized tests have not been investigated recently. Thus, this study evaluated if diagnostic thresholds for PJI in patients who had a failed partial knee arthroplasty (PKA) align more closely with previously reported thresholds specific to UKA or the 2018 International Consensus Meeting on Musculoskeletal Infection.

METHODS

We identified 109 knees in 100 patients that underwent PKA with eventual conversion to total knee arthroplasty within a single healthcare system from 2000 to 2021. Synovial fluid nucleated cell count and synovial polymorphonuclear percentage in addition to preoperative serum erythrocyte sedimentation rate, serum C-reactive protein, and serum white blood cell count were compared with Student's t-tests between septic and aseptic cases. Receiver operating characteristic curves and Youden's index were used to assess diagnostic performance and the optimal cutoff point of each test.

RESULTS

Synovial nucleated cell count, synovial polymorphonuclear percentage, and serum C-reactive protein demonstrated excellent discrimination for diagnosing PJI with an area under the curve of 0.97 and lower cutoff values than the previously determined UKA specific criteria. Serum erythrocyte sedimentation rateESR demonstrated good ability with an area under the curve of 0.89.

CONCLUSION

Serum and synovial fluid diagnostic thresholds for PJI in PKAs align more closely with the thresholds established by the 2018 International Consensus Meeting as compared to previously proposed thresholds specific to UKA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment patterns and failure rates associated with prosthetic joint infection in unicompartmental knee arthroplasty: A systematic review

Background

Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment.

Methods

PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed.

Results

Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all).

Conclusion

This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.

Debridement, Antibiotics, and Implant Retention for an Early Periprosthetic Infection After Unicompartmental Knee Arthroplasty: A Technical Note

Early periprosthetic joint infection in unicompartmental knee arthroplasty (UKA) is shown to have a detrimental effect on the success of UKA surgery not only because of the sequences of the infection but also due to the other healthy lateral compartment. It is well known that Oxford meniscal bearing UKA is a very precise procedure that the use of any excessive force may have an injurious effect on the future prosthesis stability with a higher risk of bearing dislocation. This technical note aims at describing how to deal with a case of early periprosthetic joint infection in a female patient who underwent debridement, wash, implant retention and change of the mobile bearing insert including the demonstration of a difficult step during this procedure.

Preoperative uncorrectable tibiofemoral subluxation can worsen clinical outcomes after fixed-bearing unicompartmental knee arthroplasty: a retrospective analysis

INTRODUCTION

The presence of tibiofemoral subluxation (TFS) in patients with unicompartmental arthritis, a potential contraindication to unicompartmental knee arthroplasty (UKA), remains controversial and is not commonly discussed. This study aimed to determine the predictability of postoperative TFS before surgery and the effect of TFS on clinical outcomes after fixed-bearing UKA.

MATERIALS AND METHODS

In total, 70 patients with anteromedial osteoarthritis and osteonecrosis of the knee who underwent fixed-bearing UKA from January 2015 to January 2017 were included. The preoperative TFS was assessed using plain anteroposterior and valgus stress radiographs. The patients were classified into three groups as follows: group A (acceptable TFS, n = 36) comprising patients with preoperative TFS less than 5.0 mm; group C (correctable TFS, n = 17) comprising patients with preoperative TFS of more than 5.0 mm but corrected to less than 5.0 mm under valgus stress; and group U (uncorrectable TFS, n = 17) comprising patients with preoperative TFS of more than 5.0 mm under valgus stress. Patient-derived clinical scores were assessed with the 2011 Knee Society Score preoperatively and 2 years postoperatively. The results were compared among the three groups using analysis of variance.

RESULTS

Group U showed significantly higher postoperative TFS than groups A and C. Improvements in "symptoms" and "patient satisfaction" scores 2 years after surgery were significantly higher in groups A and C than in group U.

CONCLUSION

Preoperative assessment of TFS under valgus stress could be a predictor of postoperative TFS. Furthermore, preoperative uncorrectable TFS could increase pain and decrease patient satisfaction 2 years after undergoing fixed-bearing UKA.

Periprosthetic Tibial Plateau Fractures After Unicompartmental Knee Arthroplasty Are Successfully Treated With Open Reduction and Internal Fixation

Periprosthetic tibial fractures after unicompartmental knee arthroplasty (UKA) are rare but devastating events. Given the relative infrequency of these injuries, treatment strategies are not well defined. The goal of this retrospective case series is to report the findings for a series of patients who underwent open reduction and internal fixation (ORIF) of periprosthetic fracture after UKA, including radiographic alignment, Knee Society Score (KSS), and failure rate. Patients were identified by the International Classification of Diseases code for periprosthetic tibial plateau fractures. Electronic medical records and radiographs were retrospectively reviewed. Fracture patterns and coronal and sagittal alignment of UKA components were measured on radiographs. Clinical outcomes, including range of motion assessment, visual analog scale pain score, and KSS, were collected at final follow-up. Eight patients satisfied the inclusion criteria for this study. Fractures occurred at a median of 14 days (range, 5-52 days) after UKA, and all showed a vertical shear pattern that exited at the meta-diaphyseal junction. Of the 8 fractures, 7 (87.5%) healed to radiographic and clinical union after the initial ORIF. One patient required reoperation for hardware failure. Mean visual analog scale pain score and KSS at final follow-up were 3 and 85±14, respectively. Periprosthetic tibial plateau fractures after UKA commonly occur as a vertical shear fracture exiting at the metadiaphyseal junction. The use of ORIF with a 3.5-mm plate in buttress mode is a reliable method for treatment of these fractures. Restoration of alignment and motion is achievable, but residual pain may affect patient-reported outcome scores. [Orthopedics. 2022;45(5):287-292.].

St Georg Sled medial unicompartmental arthroplasty: survivorship analysis and function at 20 years follow up

PURPOSE

The peri-operative and short-term benefits of unicompartmental knee arthroplasty (UKA) are well supported in the literature. However, there remains concern regarding the higher revision rate when compared with total knee replacement. This manuscript reports the functional outcome and survivorship of a large series of fixed bearing, medial unicompartmental replacements (St Georg Sled), with a minimum of 20 years follow-up.

METHODS

Between 1974 and 1994, 399 patients (496 knees) underwent a medial fixed-bearing UKA. Prospective data were collected pre-operatively and at regular intervals post-operatively using the Bristol Knee Score (BKS), Oxford Knee (OKS) and Western Ontario MacMaster (WOMAC) scores. Kaplan-Meier survival analysis was used to determine survivorship, with revision or need for revision as end point, and differences assessed using Mantel-Cox log rank test.

RESULTS

Functional knee scores improved post-operatively, but demonstrated a slight decline from 10 years of follow-up onwards. Survivorship is estimated as 86% at 10 years, 80% at 15 years, and 78% at 20 years. Sixty knees were revised, with progression of disease in another compartment the commonest reason. Eighty eight percent were revised using a primary prosthesis. For patients over the age of 65 years at the time of index procedure, 93% died with a functioning prosthesis in situ.

CONCLUSION

Medial UKA demonstrates good long-term function and survivorship, and represents an excellent surgical option for patients aged over 65 years of age, where few patients will require a revision procedure.

LEVEL OF EVIDENCE

IV.

Potential risk of medial cortex perforation due to peg position of morphometric tibial component in unicompartmental knee arthroplasty: a computer simulation study

PURPOSE

The purpose of this study is to evaluate the risk of medial tibial cortical perforation in unicompartmental knee arthroplasty (UKA) due to peg positions on the tibial tray of the Persona Partial Knee (PPK).

METHODS

Preoperative CT images of 60 patients and 60 osteoarthritic knees (30 male and 30 female patients) were used. A tibial multiplanar reconstruction (MPR) image was reconstructed in preoperative planning software, and the implant was placed in a virtual osteotomy plane. In addition to PPK, Zimmer Unicompartmental Knee (ZUK) and TRIBRID (TBD) were used for evaluation. The horizontal distances from the medial tibial cortex to the anterior and posterior pegs (APCD/PPCD, respectively) were measured under neutral, 3-degree varus, 3-degree valgus and 2 mm distal positions. The differences between implants under the same positions and between positions using the same implants were compared. The percentage of total cases with APCD/PPCD of less than 3 mm and the perforation risk rate were calculated.

RESULTS

The APCD of PPK was significantly shorter at all positions except for the varus position of TBD. The PPCD of PPK was significantly shorter at all positions compared to ZUK and TBD. There were no cases with an APCD of less than 3 mm. Except for varus positions, the perforation risk rate of PPCD was significantly higher for PPK than the other two implants.

CONCLUSION

The posterior pegs of the PPK are located more medially than the other two implants, which may result in perforation of the medial tibial cortex during implantation. Surgeons should consider the risk involved in the type of implant used.

Unicompartmental knee arthroplasty: A PearlDiver study evaluating complications rates, opioid use and utilization in the Medicare population

PURPOSE

Despite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well-reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA.

METHODS

Using PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD-9/ICD-10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA.

RESULTS

In the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8-year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p < 0.01, Δ = 41.1, 95% CI = [30.41, 52.39]). In the SAF dataset, 20,592 UKA patients and 110,562 TKA patients were identified. Survivorship was highest in patients > 80 years old and lowest in patients < 70 years old. In both datasets, postoperative complication rates were higher in TKA patients compared to UKA patients in nearly all categories.

CONCLUSIONS

UKA represents an increasingly utilized treatment for osteoarthritis in the Medicare population and may be comparatively advantageous to TKA due to reduced opioid use and complication rates after surgery.

LEVEL OF EVIDENCE

Level III.

Rapidly progressive osteoarthritis in the medial patellar facet due to lateral femoral placement after medial unicompartmental knee arthroplasty. A case report

Introduction and importance

Factors that affect patellofemoral (PF) osteoarthritis (OA) after unicompartmental knee arthroplasty (UKA) remain unclear. We report a case in which the lateral placement of the femoral component resulted in rapidly progressive OA in the medial patellar facet.

Case presentation

The patient was an 84-year-old woman who had increased pain in the left knee due to varus knee OA for 1 year and underwent medial UKA. One month after the surgery, the patient complained of limited knee flexion of 90° with anterior knee pain, and around 7-mm lateral placement of the femoral component was observed on a postoperative radiograph and computed tomography scan. Six months after the surgery, rapidly progressive OA with subchondral bone depression in the medial facet was observed and this has been ongoing till the last follow-up of 3 years. The knee flexion is limited 105° now, and the patient complains of quadriceps weakness with anterior knee pain when stair-climbing and standing up from a chair.

Clinical discussion

Lateral placement of the femoral component in medial UKA may cause progressive PF OA with limited knee flexion and anterior knee pain, which could be attributed to impingement between the femoral component and the medial patellar facet.

Conclusion

Surgeons should be careful regarding the lateral placement to prevent symptomatic PF OA from occurring after medial UKA.

•

Factors that affect patellofemoral (PF) osteoarthritis (OA) after UKA have been rarely reported.

•

An 84-year-old woman with rapidly progressive symptomatic PF OA after medial UKA is presented.

•

Impingement between the femoral component placed laterally and the medial patellar facet seems attributable to the PF OA.

•

The lateral placement would be one of risk factors for PF OA after medial UKA.

Cementless unicompartmental knee replacement achieves better ten-year clinical outcomes than cemented: a systematic review

PURPOSE

The aim of this study was to report and compare the long-term revision rate, revision indications and patient reported outcome measures of cemented and cementless unicompartmental knee replacements (UKR).

METHODS

Databases Medline, Embase and Cochrane Central of Controlled Trials were searched to identify all UKR studies reporting the ≥ 10 year clinical outcomes. Revision rates per 100 component years [% per annum (% pa)] were calculated by fixation type and then, subgroup analyses for fixed and mobile bearing UKRs were performed. Mechanisms of failure and patient reported outcome measures are reported.

RESULTS

25 studies were eligible for inclusion with a total of 10,736 UKRs, in which there were 8790 cemented and 1946 cementless knee replacements. The revision rate was 0.73% pa (CI 0.66-0.80) and 0.45% pa (CI 0.34-0.58) per 100 component years, respectively, with the cementless having a significantly (p < 0.001) lower overall revision rate. Therefore, based on these studies, the expected 10-year survival of cementless UKR would be 95.5% and cemented 92.7%. Subgroup analysis revealed this difference remained significant for the Oxford UKR (0.37% pa vs 0.77% pa, p < 0.001), but for non-Oxford UKRs there were no significant differences in revision rates of cemented and cementless UKRs (0.57% pa vs 0.69% pa, p = 0.41). Mobile bearing UKRs had significantly lower revision rates than fixed bearing UKRs in cementless (p = 0.001), but not cemented groups (p = 0.13). Overall the revision rates for aseptic loosening and disease progression were significantly lower (p = 0.02 and p = 0.009 respectively) in the cementless group compared to the cemented group (0.06 vs 0.13% pa and 0.10 vs 0.21% pa respectively).

CONCLUSIONS

Cementless fixation had reduced long-term revision rates compared to cemented for the Oxford UKR. For the non-Oxford UKRs, the revision rates of cementless and cemented fixation types were equivalent. Therefore, cementless UKRs offer at least equivalent if not lower revision rates compared to cemented UKRs.

LEVEL OF EVIDENCE

III.

Incidence, temporal trends and potential risk factors for aseptic loosening following primary unicompartmental knee arthroplasty: A meta-analysis of 96,294 knees

BACKGROUND

Aseptic loosening (AL) is among the major reasons for revision of failed primary unicompartmental knee arthroplasty (UKA). There is an ongoing temporal increase in the use of UKA with a resultant increase in the revision burden. We aimed to evaluate the incidence of, temporal trends and risk factors for AL.

METHODS

Longitudinal studies reporting the incidence of AL following primary UKA were sought from MEDLINE, Embase, Web of Science and Cochrane Library up to 6th April 2020. Incidence and relative risks (RR) (with 95% confidence intervals) were calculated.

RESULTS

We identified 62 studies for inclusion. Overall, 96,294 primary UKA procedures accounting for 1752 AL cases were included. AL incidence ranged from 0.00% to 22.70% over a 7.7 year weighted mean follow-up. The pooled random effects incidence (95% CI) was 1.77% (1.34-2.25) in the same follow-up period. The annual rate of AL was 0.10% (0.02-0.22). AL incidence increased with length of follow-up, but there was a temporal decrease from the 1970s onwards. Tibial loosening was more common than femoral component loosening: incidence (95% CI) of 1.63% (0.96-2.44) and 0.58% (0.20-1.09) respectively over a weighted follow-up of 6.6 years. Fixed bearing implant design and cemented fixation were both associated with increased AL risk, whereas robotic-assisted surgery was associated with decreased risk.

CONCLUSION

The overall incidence of AL following primary UKA is primarily driven by tibial component loosening and there is a temporal decline in rates. The use of mobile bearing, uncemented implants inserted with robotic assisted surgery may reduce the risk of AL.

Impact of Polyethylene Thickness on Clinical Outcomes and Survivorship in Medial Mobile-Bearing Unicondylar Knee Arthroplasty

BACKGROUND

The thickness of the polyethylene bearing in medial unicondylar knee arthroplasty (UKA) is determined by the depth of the tibial resection, degree of correctable deformity, and balance of the knee. The purpose of this study is to evaluate whether polyethylene thickness in medial mobile-bearing UKA impacts clinical outcomes and survivorship.

METHODS

A retrospective review from 2004 to 2017 identified patients who underwent a primary mobile-bearing medial UKA with 2-year minimum follow-up or revision. A total of 2305 patients (3030 knees) met inclusion criteria. Patients were divided in 2 groups: thin bearing (group 1): 3-mm or 4-mm bearing and thick bearing (group 2): ≥ 5 mm. The thin group consisted of 2640 knees (87%), whereas the thick group had 390 knees (13%). Preoperative and postoperative demographics, range of motion, Knee Society scores, complications, and reoperations were evaluated.

RESULTS

Mean follow-up was 5.2 years (range, 0.5 to 12.6). There was no significant difference between groups in postoperative range of motion or Knee Society scores (P > .05). Manipulations were performed in 1.3% of patients and not significantly different between groups. The all-cause revision rate for group 1 was 4.02% and group 2 was 4.58% (P = .6). Revision rates for tibial aseptic loosening were significantly higher in group 2 (1.8%) than those in group 1 (0.7%) (P = .04). There was no significant difference in failure rates between groups for tibial collapse or fracture, femoral aseptic loosening, arthritic progression, bearing dislocation, or other cause of revision.

CONCLUSION

This study demonstrated that thicker bearings in medial UKA increased the risk of tibial aseptic loosening, but not all-cause failures or clinical outcomes.

Prosthesis size distribution in Oxford phase III unicompartmental knee arthroplasty - Based on more than 1900 Chinese patients

Introduction

It is difficult to determine the optimal size of unicompartmental knee arthroplasty (UKA) prosthesis both pre-operatively and intra-operatively. Inappropriate femoral and tibial components are still the leading cause of failure. Several guidelines based on the Western population may not apply to the Chinese patients. We consequently try to investigate distributions of Oxford-UKA prosthesis in Chinese patients in order to provide a good reference for surgeons preoperatively.

Methods

From January 2010 to December 2019, 1909 patients (2307 knees) with primary anteromedial osteoarthritis accepted Oxford phase III UKA. Statistical analyses were performed on the distributions of the femoral, tibial, and matching of the femoral-tibial prosthesis. The possible factors affecting the sizes of femoral components, including gender, height based on gender were investigated.

Results

1. The distributions of femoral size components include extra-large (XL) 0, large (L) 1.08%, medium (M) 26.09%, small (S) 59.64%, extra-small (XS) 13.18%; the tibial sizes components were F 0, E 0.69%, D 7.80%, C 19.59%, B 24.79%, A 34.16%, AA 12.96%. 2. The matching of femur-tibia components were L-E 0.52%,L-D 0.52%,M-E 0.17%, M-D 7.28%,M - C 16.60%,M - B 1.95%,M-A 0.13%, M-AA 0.04%, S-C 2.99%, S-B 22.67%, S-A 31.12%, S-AA 2.82%, XS-B 0.17%, XS-A 2.90% and XS-AA 10.10%. The optimal matches between femoral and tibial components were: XL with F; L with E; M with C and D; S with A and B. 3. The patient's gender and height based on gender are necessary considerations for selection of femoral components (P＜0.01).

Conclusion

In Chinese patients, the size of femoral components is mainly small (S) for women, medium (M) for men. The tibial components of female patients are mainly A and B, whereas C is predominant for male patients. The more commonly used matching forms are S-A and S-B.

Prior Knee Arthroscopy Increases the Failure Rate of Subsequent Unicompartmental Knee Arthroplasty

BACKGROUND

In selected patients, knee arthroscopy is performed prior to unicompartmental knee arthroplasty (UKA) to treat symptomatic mechanical pathology, delay arthroplasty, and assess the knee compartments. The purpose of this study was to determine if knee arthroscopy prior to UKA is associated with increased rates of UKA failure or conversion to total knee arthroplasty (TKA).

METHODS

Data was collected from the Humana insurance database from 2007-2017. Patients who underwent knee arthroscopy within two years prior to UKA were identified and matched with controls based on age, gender, Charlson Comorbidity Index, smoking status, and obesity. Rates of conversion to TKA and failure for various causes were compared between cohorts.

RESULTS

Prior to propensity matching, 8353 UKA patients met inclusion criteria. Of these, 1079 patients (12.9%) underwent knee arthroscopy within two years of UKA and were matched to 1079 patients (controls) who did not undergo knee arthroscopy in the two years preceding UKA. No differences in demographics/comorbidities existed among cohorts. Compared to controls, the knee arthroscopy cohort was more likely to experience failure for aseptic loosening (2.4% vs 1.1%; OR 2.166; P = .044) and significantly more likely to require conversion to TKA (10.4% vs 4.9%; OR 2.113; P < .001) within two years of UKA.

CONCLUSION

Knee arthroscopy within two years of UKA is associated with an increased rate of UKA conversion to TKA and a higher rate of UKA failure from aseptic loosening. Although clinicians should be mindful of this association when performing knee arthroscopy in patients who may be indicated for future UKA, further research is needed to better characterize these findings.

Fixed-Bearing Medial Unicompartmental Knee Arthroplasty in Patients Younger Than 55 Years of Age at 4-19 Years of Follow-Up: A Concise Follow-Up of a Previous Report

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an effective alternative to total knee arthroplasty (TKA) in isolated unicompartmental disease; however, mid-term to long-term results in young patients are unknown. The purpose of this study is to determine the mid-term outcomes of fixed-bearing medial UKA in patients less than 55 years of age.

METHODS

Seventy-seven fixed-bearing medial UKAs in patients less than 55 years of age (mean 49.9, range 38-55) from a previously published report were retrospectively reviewed at a mean follow-up of 11.2 years (range 4.1-19.2).

RESULTS

Eleven knees were converted to TKA (14.3%) at 0.7-13.8 years postoperatively. The indications for revision included 7 for unexplained pain (9.1%), 2 for grade 4 arthritic progression (1 isolated lateral and 1 lateral and patellofemoral compartments; 2.6%), 1 for polyethylene wear (1.3%), and 1 for femoral component loosening (1.3%). Predicted survivorship free from component revision was 90.4% (95% confidence interval 86.9-93.9) at 10 years and 75.1% (95% confidence interval 66.2-84.0) at 19 years. The mean Knee Society Score improved from a mean of 51.9-88.6 points (P < .001). Of the 52 knees with 4-year minimum radiographs, 3 (5.8%) developed isolated grade 4 patellofemoral arthritis that was asymptomatic, and no knees had evidence of component loosening or osteolysis.

CONCLUSION

Fixed-bearing medial UKA is a durable option for young patients with unicompartmental arthritis, with good clinical outcomes at mid-term follow-up. Unexplained pain was the most common reason for revision to TKA.

Fixed bearing, all-polyethylene tibia, lateral unicompartmental arthroplasty - A final outcome study with up to 28 year follow-up of a single implant

BACKGROUND

Lateral unicompartmental arthroplasty (UKA) constitutes only 5-10% of all unicompartmental replacements performed. Whilst the short and medium term benefits are well documented, there remains concern regarding the higher revision rate when compared with total knee replacement. We report the long term clinical outcome and survivorship of a large series of lateral UKA.

PATIENTS AND METHODS

Between 1974 and 1994, 71 patients (82 knees) underwent a lateral fixed-bearing St Georg Sled UKA. Prospective data was collected pre-operatively and at regular intervals post-operatively using the Bristol Knee Score (BKS), with later introduction of the Oxford Knee (OKS) and Western Ontario MacMaster (WOMAC) scores. Kaplan Meier survival analysis was used, with revision, or need for revision, as end point. 85% of the patients were female. No patients were lost to follow-up.

RESULTS

Functional knee scores improved post-operatively up to 10 years, at which point they demonstrated a steady decline. Survivorship was 72% at 15 years, and 68% at 20 and 25 years. Nineteen knees were revised, with progression of disease in another compartment the commonest reason. There were two revisions due to implant fracture. In patients aged over 70 years at time of index procedure, 81% died with a functioning prosthesis in situ.

CONCLUSION

This represents the longest follow-up of a large series of lateral UKA. Results of this early design of fixed bearing UKA demonstrate satisfactory long term survivorship. In elderly patients, further intervention is rarely required. More contemporary designs or techniques may show improved long term survivorship in time.

Effects of contact stress on patellarfemoral joint and quadriceps force in fixed and mobile-bearing medial unicompartmental knee arthroplasty

Background

Unicompartmental knee arthroplasty (UKA) is an effective treatment for end-stage, symptomatic unicompartmental osteoarthritis of the knee joint. However, patellofemoral joint degeneration is a contraindication to medial UKA. Therefore, the objective of this study was to evaluate the biomechanical effect of medial UKA using fixed-bearing (FB) and mobile-bearing (MB) design prostheses on the patellofemoral joint.

Methods

A three-dimensional finite-element model of a normal knee joint was developed using medical image data. We performed statistical analysis for each model. The differences in contact stress on the patellofemoral joint and the quadriceps force between the FB and MB designs were evaluated under a deep-knee-bend condition.

Results

At an early flexion angle, the results of contact stress showed no significant difference between the FB and MB medial UKA models compared with the intact model. However, at high flexion angles, we observed a significant increase in contact stress with the FB models compared with the intact model. On the contrary, in the case of the MB models, we found no statistically significant increment compared with the intact model. A larger quadriceps force was needed to produce an identical flexion angle for both the FB and MB UKA designs than for the intact model. At high flexion angles, a significant increase quadriceps force whit the FB model compared with the intact model.

Conclusions

Our results indicate that with medial UKA, the contact stress increased and greater quadriceps force was applied to the patellofemoral joint. However, performing UKA on a patellofemoral joint with osteoarthritis should not be difficult, unless anterior knee pain is present, because the increase in contact stress is negligible.

Metallosis after knee replacement: a review

INTRODUCTION

Although metallosis is a well-known complication after total hip arthroplasty, little is known about this phenomenon after total (TKA) or unicompartmental knee arthroplasty (UKA). The aim of the present work was to review the current knowledge about the reasons and the diagnostic as well as therapeutic management of metallosis after knee arthroplasty.

MATERIALS AND METHODS

A literature search was performed through PubMed until April 2019. Search terms were "metallosis" in combination with "knee", "knee prosthesis", "knee arthroplasty" and "knee replacement", respectively. All publications were analyzed regarding publication year, level of evidence, number of knees/patients treated, type of prosthesis, metallosis cause, time period between primary implantation and metallosis emergence, laboratory examination, treatment, complications and follow up.

RESULTS

A total of 38 studies reporting on a total of 97 knees were identified. 29 studies reported on metallosis after TKA, 8 after UKA, and one study after both procedures. The time period between the primary implantation and metallosis emergence ranged between 6 weeks and 26 years. The most common reason was the failure of a metal-backed patellar component in 40%, followed by implant/structural- and PE failure (wear/dislocation) in 27% and 18% of the cases, respectively. Complete blood cell count, serum chemistry, erythrocyte sedimentation rate or C-reactive protein serum values were not indicative to diagnose metallosis. The diagnosis was confirmed by histopathological analyses and macroscopic evaluation during surgery. Depending on the particular cause various surgical procedures have been performed. Complete prosthesis exchange was the most common one showing no complications in 89.4% of the cases.

CONCLUSIONS

Metallosis after knee arthroplasty is a rare and perhaps underestimated or under published complication. A systematic diagnostic approach is necessary for the timely and correct diagnosis. A thorough debridement as well as a (sub)total synovectomy should be always performed. In cases with a damaged component, a partial/complete prosthesis exchange leads to the best results. Should a malalignment be the cause of the metallosis, then it should be corrected within the revision surgery.

Central Implantation of the Femoral Component Relative to the Tibial Insert Improves Clinical Outcomes in Fixed-Bearing Unicompartmental Knee Arthroplasty

BACKGROUND

The direct relationship between clinical outcomes and femoral component positioning relative to a tibial insert remains unknown. We determined whether the femoral component position relative to the tibial insert could affect clinical outcomes after fixed-bearing unicompartmental knee arthroplasty (UKA).

METHODS

The femoral component position relative to the tibial insert of 66 patients with anteromedial osteoarthritis and osteonecrosis of the knee who underwent fixed-bearing UKA was assessed at 2 weeks postoperatively. We classified patients according to the contact point of the femoral component with the tibial component: group M (medial), 18 knees; group C (central), 30 knees; and group L (lateral), 18 knees. Patient-derived clinical scores using the 2011 Knee Society Score were also assessed preoperatively and at 2 years postoperatively and compared among the 3 groups using the analysis of variance.

RESULTS

The average 2-year postoperative "symptom" and "patient satisfaction" scores based on the 2011 Knee Society Score were significantly higher in group C than in group M or group L.

CONCLUSION

Central implantation of the femoral component relative to the tibial insert plays an important role in decreasing pain and could result in better patient satisfaction after fixed-bearing UKA at 2 years postoperatively. Surgeons should set the femoral component at the center relative to the tibial insert for better patient satisfaction and higher active knee flexion after fixed-bearing UKA.

Unicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA

Unicompartmental knee arthroplasty (UKA) is a bone- and ligament-sparing alternative to total knee arthroplasty in the patients with end-stage single-compartment degeneration of the knee. Despite being a successful procedure, the multiple advantages of UKA do not correlate with its usage, most likely due to the concerns regarding prosthesis survivability, patient selection, ideal bearing design, and judicious use of advanced technology among many others. Therefore, the purpose of this study is to review and summarize the debated literature and discuss the controversies as “Ten Enigmas of UKA.”

Improved implant alignment accuracy with an accelerometer-based portable navigation system in medial unicompartmental knee arthroplasty

PURPOSE

This study aimed to examine the accuracy of tibial implant alignment using an accelerometer-based portable navigation system in unicompartmental knee arthroplasty (UKA).

METHODS

This retrospective matched case-control study reviewed 51 UKAs performed using an accelerometer-based portable navigation system, matched with 51 UKAs performed using conventional extramedullary rods. Coronal alignment and posterior slope of the tibial implant were measured on postoperative radiographs, and differences from preoperative planning were examined. Outliers and accuracy of tibial implant alignment were compared between the portable navigation and conventional groups using Fisher's exact test and Mann-Whitney U test, respectively.

RESULTS

In the portable navigation group, 100% of the implants were aligned within 3.0° of both target coronal and sagittal implant alignment. In the conventional group, 76.5% and 88.2% of the implants were within 3.0° of both target coronal and sagittal implant alignment. Statistical analysis revealed that outliers of coronal and sagittal alignment were significantly less in the portable navigation group than in the conventional group (P < 0.05). In addition, the absolute value difference between postoperative measurement and preoperative planning of both coronal and sagittal alignment was significantly smaller in the portable navigation group than in the conventional group (P < 0.05).

CONCLUSION

The portable navigation system improved the accuracy of tibial implant alignment in UKA. We found that 100% of the implants were aligned within 3.0° of both target coronal and sagittal implant alignment. The portable navigation system decreased the outliers of tibial coronal and sagittal alignment.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

Joint Awareness after Unicompartmental Knee Arthroplasty Evaluated with the Forgotten Joint Score

Objective

To investigate the temporal relationship of medial unicompartmental knee arthroplasty (UKA) and forgotten joint score (FJS), and to analysis the predictive factors associated with FJS after medial UKA.

Methods

This is a cross‐sectional observational study. A total of 188 cases of medial UKA were included in this study, and all the prostheses used were Oxford mobile‐bearing UKA from January 2016 to January 2019. All patients have completed the questionnaire of FJS, and the relevant data were obtained for 1 month (n = 38), 6 month (n = 40), 12 month (n = 42), 24 month (n = 34), and 36 month (n = 34) patient subgroups. The score ranged from 0–100, with a higher score indicating a more natural knee joint. In addition, the associations between the potential influencing factors (body mass index [BMI], age, gender, duration of onset before surgery, Kellgren‐Lawrence grade of the medial compartment before surgery) with FJS were analyzed using Pearson correlation and multiple linear regression.

Results

Postoperative FJSs were 44.5 ± 13.5 at 1 month，63.8 ± 10.1 at 6 months, 77.1 ± 12.2 at 12 months, 78.4 ± 12.2 at 24 months, 78.9 ± 12.5 at 36 months. The postoperative FJSs were lowest at 1 month and highest at 36 month (P < 0.01). The mean value of FJS kept improving until 12 months post‐operation, which was slightly lower than that of 24 months and 36 months, but there was no statistical difference between them. Pearson correlation and multiple linear regression analysis showed that gender and Kellgren‐Lawrence grade of the medial compartment before surgery had no significant influence on FJS, while age, BMI, and duration of onset before surgery had significant associations with FJS after UKA. BMI was negatively correlated with FJS, while older patients (>60) and with longer duration of onset before surgery (>3 years) were a positive predictor of good outcome for the FJS.

Conclusion

Patients can expect marked improvement in the natural feel of the prosthesis during the first year after UKA, slight continued improvement at 2 and 3 years. Furthermore, we identified three preoperative patient‐related factors (age, BMI, and duration of onset before surgery) that may predict the FJS after medial UKA, which can be used to guide surgical decision making.

Lateral and patellofemoral compartment osteoarthritis progression after medial unicompartmental knee arthroplasty: A five- to 10-year follow-up study

BACKGROUND

The purpose of the study was to evaluate lateral and patellofemoral osteoarthritis (OA) progression after medial unicompartmental knee arthroplasty (UKA) and identify factors affecting the progression that were not identified previously.

METHODS

We evaluated 146 patients who underwent medial UKA between 2009 and 2014. Kellgren-Lawrence grading of lateral and patellofemoral OA was performed on preoperative and final follow-up knee radiographs. Radiographic and clinical characteristics, SF-36, and Oxford knee scores were compared between the OA progressed and non-progressed groups. Risk factors for lateral and patellofemoral OA progression were evaluated.

RESULTS

The lateral OA progressed and non-progressed groups significantly differed in side, preoperative flexion contracture, preoperative joint line convergence angle, postoperative tibiofemoral angle, insert size, revision status (P < 0.05), and the patellofemoral OA progressed and non-progressed groups significantly differed in age, pre- and postoperative flexion contracture, postoperative tibiofemoral angle and pre- and postoperative patellofemoral OA grade (P < 0.05). At the final follow-up, Visual Analogue Scale, Oxford Knee Scores, and SF-36 sub-scores were significantly better in the lateral OA non-progressed group (P < 0.001). Dominant leg (odds ratio (OR): 2.759), insert size (>4, OR: 2.219), revision status (+, OR: 6.692), and postoperative tibiofemoral angle (>5.5°, OR: 1.177) were independent risk factors for lateral OA progression, whereas age (>60 years, OR: 3.222), preoperative patellofemoral OA grade (>1, OR: 2.085), and postoperative flexion contracture (>10°, OR: 1.919) were those for patellofemoral OA progression.

CONCLUSIONS

Mild radiographic progression of 1 KL grade is frequently seen five to 10 years after medial UKA. Postoperative outcomes are significantly affected by lateral compartment OA progression but not by patellofemoral OA progression.

Treatment and Outcome of Periprosthetic Joint Infection in Unicompartmental Knee Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) after unicompartmental knee arthroplasty (UKA) is a devastating but poorly understood complication, with a paucity of published data regarding treatment and outcomes. This study analyzes the largest cohort of UKA PJIs to date comparing treatment outcome, septic and aseptic reoperation rates, and risk factors for treatment failure.

METHODS

Twenty-one UKAs in 21 patients treated for PJI, as defined by Musculoskeletal Infection Society criteria, were retrospectively reviewed. Minimum and mean follow-up was 1 and 3.5 years, respectively. Fourteen (67%) patients had acute postoperative PJIs. Surgical treatment included 16 debridement, antibiotics, and implant retentions (DAIRs) (76%), 4 two-stage revisions (19%), and 1 one-stage revision (5%). Twenty (95%) PJIs were culture positive with Staphylococcus species identified in 15 cases (71%).

RESULTS

Survivorship free from reoperation for infection at 1 year was 76% (95% confidence interval, 58%-93%). Overall survival from all-cause reoperation was 57% (95% confidence interval, 27%-87%) at 5 years. Two additional patients (10%) underwent aseptic revision total knee arthroplasty for lateral compartment degeneration 1 year after DAIR and tibial aseptic loosening 2.5 years after 2-stage revision. All patients who initially failed PJI UKA treatment presented with acute postoperative PJIs (5 of 14; 36%).

CONCLUSION

Survivorship free from persistent PJI at 1 year is low at 76% but is consistent with similar reports of DAIRs for total knee arthroplasties. Furthermore, there is low survivorship free from all-cause reoperation of 71% and 57% at 2 and 5 years, respectively. Surgeons should be aware of these poorer outcomes and consider treating UKA PJI early and aggressively.

Minimum 10-year outcomes of a fixed bearing all-polyethylene unicompartmental knee arthroplasty used to treat medial osteoarthritis

BACKGROUND

Unicompartmental knee arthroplasty (UKA) accounts for 8.9% of knee arthroplasty procedures in England, Wales and Northern Ireland. Fixed bearing UKA designs have shown favourable survivorship in registries when compared with mobile bearings but some studies suggest poor survival of all-polyethylene fixed tibial bearings. This study analyses long-term follow-up of patients with a medial fixed all-polyethylene tibial bearing UKA and reports survivorship and 10-year clinical outcomes.

METHODS

Data was collected prospectively for 214 medial unicompartmental all-polyethylene tibial bearing UKAs implanted in 184 patients at our tertiary referral centre between November 2002 and December 2007. The indication was osteoarthritis in all but one patient. Patient reported outcome scores were documented pre-operatively and at five, eight, 10 and 12 years of follow-up. The mean patient age was 70 years (range 41-87).

RESULTS

Outcome and survivorship data were collected for 214 medial all-polyethylene tibial bearing UKAs. There were outcomes recorded for 83 UKAs with at least 10-year follow-up. Twenty-four patients underwent revision of their UKA at an average of 5.84 years after the primary procedure. Kaplan-Meier analysis demonstrated survivorship of 89.1% at 10 years and the OKS, AKSS and WOMAC patient reported outcomes remained significantly improved in comparison to preoperatively. For those 70 years or older, 10-year survivorship was 92.4%, compared to 85.0% for those under 70 years old.

CONCLUSION

Medial fixed all-polyethylene tibial bearing UKA demonstrates acceptable long-term survivorship and patient outcomes. It appears to be a suitable option for the treatment of medial compartment OA, particularly in older patients.

Lower limb kinematics of unicompartmental knee arthroplasty individuals during stair ascent

Objective

Purpose of the study was to compare lower-limb kinematics and interlimb asymmetry during stair ascent in individuals post-medial or lateral unicompartmental knee arthroplasty (UKA).

Methods

60 patients (20 medial; 10 lateral) post-UKA and 30 matched healthy controls performed stair ascent. Spatio-temporal, lower-limb kinematics and interlimb asymmetries during stair ascent were compared.

Results

Medial-UKA group displayed 5° less knee extension of the UKA limb than controls (p = 0.005) and 2° less than the contralateral limb during stance phase. No interlimb asymmetries were found for lateral-UKA.

Conclusion

Patients post-UKA demonstrate satisfactory lower-limb kinematics and minimal interlimb asymmetry during stair ascent compared to healthy individuals.

High Failure Rates for Unicompartmental Knee Arthroplasty in Morbidly Obese Patients: A Two-Year Minimum Follow-Up Study

BACKGROUND

Several recent studies have recommended offering unicompartmental knee arthroplasty (UKA) to all patients regardless of body mass index (BMI). The aim of this investigation was to evaluate the proposition that UKA can indeed be offered to the morbidly-obese and super-obese (morbidly-obese, BMI ≥ 40 kg/m²) without compromising results or survivorship.

METHODS

We retrospectively reviewed mobile-bearing medial UKA procedures performed at our facility from January 2012 to May 2015 with a minimum of 2-year follow-up. The study cohort was divided into patients with morbid obesity (BMI ≥ 40 kg/m²) and those without morbid obesity (BMI < 40 kg/m²). A detailed medical record review was performed. Extracted outcome data included the frequency of (1) major revision procedures (components revised), (2) minor secondary procedures (components not revised), (3) infection procedures, and (4) recommendations for revision.

RESULTS

We found 152 patients (190 knees) who met criteria for inclusion. Mean follow-up duration was 3.4 years (range: 2.0-6.8 years). Major revision surgery occurred more frequently in the morbid-obesity UKA group (15.7% vs 3.0%, P < .01). Rates of minor secondary surgery and infection were comparable for both groups. Most failures in the morbid-obesity UKA group (85.7%) were due to disease progression involving other compartments or mobile-bearing instability.

CONCLUSION

We found the rate of early major revision surgery in morbidly-obese patients undergoing UKA to be over 5-times greater than that of other patients. Failure was predominantly due to disease progression in other compartments or mobile-bearing instability. Further study is warranted and needed before expanding UKA indications to the morbidly-obese population.

Reduction in tibiofemoral conformity in lateral unicompartmental knee arthroplasty is more representative of normal knee kinematics

AIMS

Commonly performed unicompartmental knee arthroplasty (UKA) is not designed for the lateral compartment. Additionally, the anatomical medial and lateral tibial plateaus have asymmetrical geometries, with a slightly dished medial plateau and a convex lateral plateau. Therefore, this study aims to investigate the native knee kinematics with respect to the tibial insert design corresponding to the lateral femoral component.

METHODS

Subject-specific finite element models were developed with tibiofemoral (TF) and patellofemoral joints for one female and four male subjects. Three different TF conformity designs were applied. Flat, convex, and conforming tibial insert designs were applied to the identical femoral component. A deep knee bend was considered as the loading condition, and the kinematic preservation in the native knee was investigated.

RESULTS

The convex design, the femoral rollback, and internal rotation were similar to those of the native knee. However, the conforming design showed a significantly decreased femoral rollback and internal rotation compared with that of the native knee (p < 0.05). The flat design showed a significant difference in the femoral rollback; however, there was no difference in the tibial internal rotation compared with that of the native knee.

CONCLUSION

The geometry of the surface of the lateral tibial plateau determined the ability to restore the rotational kinematics of the native knee. Surgeons and implant designers should consider the geometry of the anatomical lateral tibial plateau as an important factor in the restoration of native knee kinematics after lateral UKA.Cite this article: Bone Joint Res 2019;8:593-600.

Long-term outcomes of unicompartmental knee arthroplasty in patients requiring high flexion: an average 10-year follow-up study

INTRODUCTION

To evaluate the long-term survival of unicompartmental knee arthroplasty (UKA) in the Asian population and assess differences in clinical outcomes between mobile- and fixed-bearing UKA.

MATERIALS AND METHODS

Among 111 cases of UKA that were performed by 1 surgeon from January 2002 to December 2009, we retrospectively reviewed 96 cases (36 mobile-bearing, 62 fixed-bearing) for this study. We examined cause of revision or failure, type of reoperation/revision, and duration from the surgery date to the revision upon reviewing the medical record. Survival analysis was conducted using the Kaplan-Meier method. Functional outcomes were evaluated based on range of motion and patient-reported outcome (PRO) measures (Knee Injury and Osteoarthritis Outcome Score) for cases with at least 8 years of follow-up (average, 10.2 years).

RESULTS

Overall, the 10-year survival was 88% [95% confidence interval (CI) 0.81-0.95], and the estimated mean survival time was 13.4 years (95% CI 12.5-14.2). In a comparison of survival between the mobile- and fixed-bearing groups, the former had a 10-year survival of 85% (95% CI, 0.72-0.97) and an estimated mean survival time of 13.5 years (95% CI 12.2-14.7) and the latter had a 10-year survival of 90% (95% CI 0.82-0.99) and an estimated mean survival time of 13.4 years (95% CI 12.3-14.4). Thus, there was no significant difference in survival between the two groups (log-rank test, p = 0.718). In addition, no significant difference in functional outcomes was observed between the two groups (p > 0.05 for all).

CONCLUSIONS

UKA performed in the Asian population showed a relatively good functional outcome and survival rate at an average 10-year follow-up. No difference in survival and PROs was observed according to the bearing type. Although the present study demonstrated a good survival rate, similar to that in other Western studies, further studies investigating the impact of the Asian lifestyle on the long-term survival of UKA is necessary.

Patellar complications following total knee arthroplasty: a review of the current literature

Total knee arthroplasty is a common operation for treating patients with end-stage knee osteoarthritis and generally has a good outcome. There are several complications that may necessitate revision of the implants. Patella-related complications are difficult to treat, and their consequences impact the longevity of the implanted joint and functional outcomes. In this review, we explore the current literature on patellar complications in total knee arthroplasty and identify risk factors as well as strategies that can help in preventing these complications. We present pertinent findings relating to patellar complications. They can be classified into bony or soft tissue complications and include bone loss, aseptic loosening, periprosthetic fractures, patella fracture, patellar clunk syndrome, patellofemoral instability, extensor mechanism complications, maltracking, patella baja and malrotation. We conclude that patellar complications in total knee arthroplasty are common and have significant implications for the functional outcome of total knee arthroplasty. A high index of suspicion should be maintained in order to avoid them. Implant malpositioning and other forms of intraoperative technical error are the main cause of these complications, and therefore, primary prevention is crucial. When dealing with these established problems, a clear plan of action should be formulated in advance to allow appropriate management as well as anticipation of adverse outcomes.

Analysis of Retrieved Unicompartmental Knee Implants and Tissue: Third-Body Wear as a Potential Contributor to Progression of Arthritis to Adjacent Compartments

Unicompartmental knee arthroplasty (UKA) for the treatment of single-compartment osteoarthritis has been associated with polyethylene wear and progression of osteoarthritis into adjacent compartments, leading to revision. In this study, damage and clinical failure modes of retrieved UKA implants were investigated and protein expression profiles between articular cartilage adjacent to UKA and primary osteoarthritic cartilage were compared. Fifty retrieved UKA implants were analyzed for various damage. Records review and radiographic analysis were performed to collect clinical data and implant characteristics. Cartilage harvested from revision UKA and primary total knee arthroplasty surgeries was characterized with a proteome profiling array detecting levels of 36 different cytokines, chemokines, and acute phase inflammatory proteins. Progression of osteoarthritis (n=18, 36%) and component loosening (n=17, 34%) were the most common reasons for revision. Liners exhibited the highest frequency of damage modes. Progression of arthritis positively correlated with radiographic presence of extruded bone cement and burnishing of liner components. A protein-level profile between revision UKA and primary total knee arthroplasty cartilage showed 12 differentially expressed cytokines. Failure of UKA may be secondary to the effects of wear debris particulate migration into the adjacent compartment, suggesting an additional pathway of cartilage damage manifesting as traditional clinical symptoms. [Orthopedics. 2019; 42(3):149-157.].

Medial Unicompartmental Arthroplasty of the Knee

Indications for medial unicompartmental knee arthroplasty (UKA) have expanded over the past two decades. Proposed advantages include faster recovery, improved kinematics, and better functional outcomes compared with total knee arthroplasty (TKA) in age-matched control subjects. A focused preoperative examination and imaging is essential to identify appropriate surgical candidates. No difference has been demonstrated between fixed- and mobile-bearing implants for implant survivorship or patient-reported outcomes. The most common reasons for conversion to a TKA are aseptic loosening and progression of osteoarthritis. Ten-year survival for UKA in cohort studies has shown to be >90% with outcomes after conversion to TKA being similar to outcomes for revision TKA. Registries have consistently shown lower implant survival for UKA compared with that for TKA, which is likely secondary to use of several different implants by surgeons of varying levels of experience. UKA has the potential to be a cost-effective alternative to TKA in certain patient populations when performed at high-volume centers with advanced surgical techniques.

How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up

BACKGROUND

Knee replacements are the mainstay of treatment for end-stage osteoarthritis and are effective. Given time, all knee replacements will fail and knowing when this failure might happen is important. We aimed to establish how long a knee replacement lasts.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE and Embase for case series and cohort studies published from database inception until July 21, 2018. Articles reporting 15 year or greater survival of primary total knee replacement (TKR), unicondylar knee replacement (UKR), and patellofemoral replacements in patients with osteoarthritis were included. Articles that reviewed specifically complex primary surgeries or revisions were excluded. Survival and implant data were extracted, with all-cause survival of the knee replacement construct being the primary outcome. We also reviewed national joint replacement registry reports and extracted the data to be analysed separately. In the meta-analysis, we weighted each series and calculated a pooled survival estimate for each data source at 15 years, 20 years, and 25 years, using a fixed-effects model. This study is registered with PROSPERO, number CRD42018105188.

FINDINGS

From 4363 references found by our initial search, we identified 33 case series in 30 eligible articles, which reported all-cause survival for 6490 TKRs (26 case series) and 742 UKRs (seven case series). No case series reporting on patellofemoral replacements met our inclusion criteria, and no case series reported 25 year survival for TKR. The estimated 25 year survival for UKR (based on one case series) was 72·0% (95% CI 58·0-95·0). Registries contributed 299 291 TKRs (47 series) and 7714 UKRs (five series). The pooled registry 25 year survival of TKRs (14 registries) was 82·3% (95% CI 81·3-83·2) and of UKRs (four registries) was 69·8% (67·6-72·1).

INTERPRETATION

Our pooled registry data, which we believe to be more accurate than the case series data, shows that approximately 82% of TKRs last 25 years and 70% of UKRs last 25 years. These findings will be of use to patients and health-care providers; further information is required to predict exactly how long specific knee replacements will last.

FUNDING

The National Joint Registry for England, Wales, Northern Ireland, and Isle of Man and the Royal College of Surgeons of England.