Aims. Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery. Methods. A systematic literature search was performed of MEDLINE, Embase, and grey literature databases to include all studies which compare day-case with inpatient knee and hip replacement. Meta-analyses were performed where appropriate using a random effects model. The protocol was registered prospectively (PROSPERO CRD42023392811). Results. A total of 38 studies were included, with a total of 83,888 day-case procedures. The studies were predominantly from the USA and Canada, observational, and with a high risk of bias. Day-case patients were a mean of 2.08 years younger (95% CI 1.05 to 3.12), were more likely to be male (odds ratio (OR) 1.3 (95% CI 1.19 to 1.41)), and had a lower mean BMI and American Society of Anesthesiologists grades compared with inpatients. Overall, day-case surgery was associated with significantly lower odds of readmission (OR 0.83 (95% CI 0.73 to 0.96); p = 0.009), subsequent emergency department attendance (OR 0.62 (95% CI 0.48 to 0.79); p < 0.001), and complications (OR 0.7 (95% CI 0.55 to 0.89) p = 0.004), than inpatient surgery. There were no significant differences in the rates of reoperation or mortality. The overall rate of successful same-day discharge for day-case surgery was 85% (95% CI 81 to 88). Patient-reported outcome measures and cost-effectiveness were either equal or favoured day-case. Conclusion. Within the limitations of the literature, in particular the substantial risk of selection bias, the outcomes following day-case knee and hip replacement appear not to be inferior to those following an inpatient stay. The evidence is more robust for unicompartmental knee replacement (UKR) than for total knee replacement (TKR) or total hip replacement (THR). The rate of successful same-day discharge is highest in UKR, followed by TKR and comparatively lower in THR. Cite this article: Bone Joint J 2024;106-B(12):1385–1392

Aims. Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results. There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion. Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA. Cite this article: Bone Joint J 2024;106-B(7):680–687

Aims. Unicompartmental knee arthroplasty (UKA) has higher revision rates than total knee arthroplasty (TKA). As revision of UKA may be less technically demanding than revision TKA, UKA patients with poor functional outcomes may be more likely to be offered revision than TKA patients with similar outcomes. The aim of this study was to compare clinical thresholds for revisions between TKA and UKA using revision incidence and patient-reported outcomes, in a large, matched cohort at early, mid-, and late-term follow-up. Methods. Analyses were performed on propensity score-matched patient cohorts of TKAs and UKAs (2:1) registered in the New Zealand Joint Registry between 1 January 1999 and 31 December 2019 with an Oxford Knee Score (OKS) response at six months (n, TKA: 16,774; UKA: 8,387), five years (TKA: 6,718; UKA: 3,359), or ten years (TKA: 3,486; UKA: 1,743). Associations between OKS and revision within two years following the score were examined. Thresholds were compared using receiver operating characteristic analysis. Reasons for aseptic revision were compared using cumulative incidence with competing risk. Results. Fewer TKA patients with ‘poor’ outcomes (≤ 25) subsequently underwent revision compared with UKA at six months (5.1% vs 19.6%; p < 0.001), five years (4.3% vs 12.5%; p < 0.001), and ten years (6.4% vs 15.0%; p = 0.024). Compared with TKA, the relative risk for UKA was 2.5-times higher for ‘unknown’ reasons, bearing dislocations, and disease progression. Conclusion. Compared with TKA, more UKA patients with poor outcomes underwent revision from early to long-term follow-up, and were more likely to undergo revision for ‘unknown’ reasons, which suggest a lower clinical threshold for UKA. For UKA, revision risk was higher for bearing dislocations and disease progression. There is supporting evidence that the higher revision UKA rates are associated with lower clinical thresholds for revision and additional modes of failure. Cite this article: Bone Joint J 2023;105-B(3):269–276

Aims. Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more meaningful estimate of risk projection over a patient’s remaining lifetime, and to compare this to TKA. Methods. Incidence of revision and mortality for all primary UKAs performed from 1999 to 2019 (n = 13,481) was obtained from the New Zealand Joint Registry (NZJR). Lifetime risk of revision was calculated for patients and stratified by age, sex, and American Society of Anesthesiologists (ASA) grade. Results. The lifetime risk of revision was highest in the youngest age group (46 to 50 years; 40.4%) and decreased sequentially to the oldest (86 to 90 years; 3.7%). Across all age groups, lifetime risk of revision was higher for females (ranging from 4.3% to 43.4% vs males 2.9% to 37.4%) and patients with a higher ASA grade (ASA 3 to 4, ranging from 8.8% to 41.2% vs ASA 1 1.8% to 29.8%). The lifetime risk of revision for UKA was double that of TKA across all age groups (ranging from 3.7% to 40.4% for UKA, and 1.6% to 22.4% for TKA). The higher risk of revision in younger patients was associated with aseptic loosening in both sexes and pain in females. Periprosthetic joint infection (PJI) accounted for 4% of all UKA revisions, in contrast with 27% for TKA; the risk of PJI was higher for males than females for both procedures. Conclusion. Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods. This study highlights the higher lifetime risk of UKA revision for younger patients, females, and those with a higher ASA grade, which can aid with patient counselling prior to UKA. Cite this article: Bone Joint J 2022;104-B(6):672–679

Aims. This systematic review aims to compare the precision of component positioning, patient-reported outcome measures (PROMs), complications, survivorship, cost-effectiveness, and learning curves of MAKO robotic arm-assisted unicompartmental knee arthroplasty (RAUKA) with manual medial unicompartmental knee arthroplasty (mUKA). Methods. Searches of PubMed, MEDLINE, and Google Scholar were performed in November 2021 according to the Preferred Reporting Items for Systematic Review and Meta-­Analysis statement. Search terms included “robotic”, “unicompartmental”, “knee”, and “arthroplasty”. Published clinical research articles reporting the learning curves and cost-effectiveness of MAKO RAUKA, and those comparing the component precision, functional outcomes, survivorship, or complications with mUKA, were included for analysis. Results. A total of 179 articles were identified from initial screening, of which 14 articles satisfied the inclusion criteria and were included for analysis. The papers analyzed include one on learning curve, five on implant positioning, six on functional outcomes, five on complications, six on survivorship, and three on cost. The learning curve was six cases for operating time and zero for precision. There was consistent evidence of more precise implant positioning with MAKO RAUKA. Meta-analysis demonstrated lower overall complication rates associated with MAKO RAUKA (OR 2.18 (95% confidence interval (CI) 1.06 to 4.49); p = 0.040) but no difference in re-intervention, infection, Knee Society Score (KSS; mean difference 1.64 (95% CI -3.00 to 6.27); p = 0.490), or Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (mean difference -0.58 (95% CI -3.55 to 2.38); p = 0.700). MAKO RAUKA was shown to be a cost-effective procedure, but this was directly related to volume. Conclusion. MAKO RAUKA was associated with improved precision of component positioning but was not associated with improved PROMs using the KSS and WOMAC scores. Future longer-term studies should report functional outcomes, potentially using scores with minimal ceiling effects and survival to assess whether the improved precision of MAKO RAUKA results in better outcomes. Cite this article: Bone Joint J 2022;104-B(5):541–548

Aims. The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and length of hospital stay influenced the relative cost per QALY. Patients and Methods. A Markov decision analysis was performed, using known parameters for costs, outcomes, implant survival, and mortality, to assess the cost-effectiveness of rUKA relative to manual TKA and UKA for patients with isolated medial compartment OA of the knee with a mean age of 65 years. The influence of case volume and shorter hospital stay were assessed. Results. Using a model with an annual case volume of 100 patients, the cost per QALY of rUKA was £1395 and £1170 relative to TKA and UKA, respectively. The cost per QALY was influenced by case volume: a low-volume centre performing ten cases per year would achieve a cost per QALY of £7170 and £8604 relative to TKA and UKA. For a high-volume centre performing 200 rUKAs per year with a mean two-day length of stay, the cost per QALY would be £648; if performed as day-cases, the cost would be reduced to £364 relative to TKA. For a high-volume centre performing 200 rUKAs per year with a shorter length of stay of one day relative to manual UKA, the cost per QALY would be £574. Conclusion . rUKA is a cost-effective alternative to manual TKA and UKA for patients with isolated medial compartment OA of the knee. The cost per QALY of rUKA decreased with reducing length of hospital stay and with increasing case volume, compared with TKA and UKA. Cite this article: Bone Joint J 2019;101-B:1063–1070

Aims. The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA. Methods. We included data from eight dedicated fast-track centres, all reporting UKAs to the same database, between 2010 and 2018. Complete ( > 99%) data on length of stay, 90-day readmission, and mortality were obtained during the study period. Specific reasons for a length of stay of > two days, length of stay > four days, and 30- and 90-day readmission were recorded. The use of UKA in the different centres was dichotomized into ≥ 20% versus < 20% of arthroplasties which were undertaken being UKAs, and ≥ 52 UKAs versus < 52 UKAs being undertaken annually. Results. A total of 3,927 procedures were included. Length of stay (mean 1.1 days (SD 1.1), median 1 (IQR 0 to 1)) was unchanged during the study period. The proportion of procedures with a length of stay > two days was also largely unchanged during this time. The percentage of patients discharged on the day of surgery varied greatly between centres (0% to 50% (0 to 481)), with centres with high UKA utilization (both usage and volume) having a larger proportion of same-day discharges. The 30- and 90-day readmissions were 166 (4.2%) and 272 (6.9%), respectively; the 90-day mortality was 0.08% (n = 3). Conclusion. Our findings suggest general underutilization of the potential for quicker recovery following UKA in a fast-track setup. Cite this article: Bone Joint J 2020;102-B(9):1167–1175

Aims. To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome. Methods. A total of 325 consecutive domed lateral UKAs undertaken for the recommended indications were included, and their functional and survival outcomes were assessed. The effects of age, weight, activity, and the presence of full-thickness erosions of cartilage in the patellofemoral joint on outcome were evaluated. Results. Median follow-up was seven years (3 to 14), and mean age at surgery was 65 years (39 to 90). Median Oxford Knee Score (OKS) was 43 (interquartile range (IQR) 37 to 47), with 260 (80%) achieving a good or excellent score (OKS > 34). Revisions occurred in 34 (10%); 14 (4%) were for dislocation, of which 12 had no recurrence following insertion of a new bearing, and 12 (4%) were revised for medial osteoarthritis (OA). Ten-year survival was 85% (95% confidence interval (CI) 79 to 90, at risk 72). Age, weight, activity, and patellofemoral erosions did not have a significant effect on the clinical outcome or survival. Conclusion. Domed lateral UKA provides a good alternative to total knee arthroplasty (TKA) in the management of lateral compartment OA. Although dislocation is relatively easy to treat successfully, the dislocation rate of 4% is high. It is recommended that the stability of the bearing is assessed intraoperatively. If the bearing can easily be displaced, the fixed rather than the mobile bearing version of the Oxford lateral tibial component should be inserted instead. Younger age, heavier weight, high activity, and patellofemoral erosions did not detrimentally affect outcome, so should not be considered contraindications. Cite this article: Bone Joint J 2020;102-B(8):1033–1040

Aims. Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs. Methods. In total, 34 patients (13 female, 21 male; mean age 62 years (41 to 79); BMI 29.7 kg/m. 2. (23.6 to 42.1)) with 38 medial Oxford partial UKAs (20 left, 18 right; 19 cementless, 14 cemented, and five hybrid) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively, and at one and two years postoperatively. Changes in mean osteoblastic activity were investigated using a tracer localization scheme with volumes of interest (VOIs), reported by normalized mean tracer values. A SPECT/CT registration platform additionally explored cortical tracer evolution in zones of interest identified by previous experimental research. Results. Significant reduction of tracer activity from the preoperative situation was found in femoral and anteromedial tibial VOIs adjacent to the UKA components. Temporarily increased osteoblastic bone activity was observed in VOIs comprising the UKA keel structure at one year postoperatively compared to the preoperative activity. Persistent higher tracer uptake was found in the posterior tibial cortex at final follow-up. Multivariate analysis showed no statistical difference in osteoblastic bone activity underneath cemented or cementless components. Conclusion. Well-functioning medial mobile-bearing UKAs showed distinct changes in patterns of normalized bone tracer activity in the different VOIs adjacent to the prosthetic components, regardless of their type of fixation. Compared to the preoperative situation, persistent high bone activity was found underneath the keel and the posterior tibial cortex at final follow-up, with significant reduced activity only being identified in femoral and anteromedial tibial VOIs. Cite this article: Bone Joint J 2022;104-B(1):34–44

Aims. Unicompartmental knee arthroplasty (UKA) provides improved early functional outcomes and less postoperative morbidity and pain compared with total knee arthroplasty (TKA). Opioid prescribing has increased in the last two decades, and recently states in the USA have developed online Prescription Drug Monitoring Programs to prevent overprescribing of controlled substances. This study evaluates differences in opioid requirements between patients undergoing TKA and UKA. Patients and Methods. We retrospectively reviewed 676 consecutive TKAs and 241 UKAs. Opioid prescriptions in morphine milligram equivalents (MMEs), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring websites six months before and nine months after the initial procedures. Bivariate and multivariate analysis were performed for patients who had a second prescription and continued use. Results. Patients undergoing UKA had a second opioid prescription filled 50.2% of the time, compared with 60.5% for TKA (p = 0.006). After controlling for potential confounders, patients undergoing UKA were still less likely to require a second prescription than those undergoing TKA (adjusted odds ratio (OR) 0.58, 95% confidence interval (CI) 0.42 to 0.81; p = 0.001). Continued opioid use requiring more than five prescriptions occurred in 13.7% of those undergoing TKA and 5.8% for those undergoing UKA (p = 0.001), and was also reduced in UKA patients compared with TKA patients (adjusted OR 0.33, 95% CI 0.16 to 0.67; p = 0.022) in multivariate analysis. The continued use of opioids after six months was 11.8% in those undergoing TKA and 8.3% in those undergoing UKA (p = 0.149). The multivariate models for second prescriptions, continued use with more than five, and continued use beyond six months yielded concordance scores of 0.70, 0.86, and 0.83, respectively. Conclusion. Compared with TKA, patients undergoing UKA are less likely to require a second opioid prescription and use significantly fewer opioid prescriptions. Thus, orthopaedic surgeons should adjust their patterns of prescription and educate patients about the reduced expected analgesic requirements after UKA compared with TKA. Cite this article: Bone Joint J 2019;101-B(7 Supple C):22–27

Aims. It remains controversial whether patellofemoral joint pathology is a contraindication to lateral unicompartmental knee arthroplasty (UKA). This study aimed to evaluate the effect of preoperative radiological degenerative changes and alignment on patient-reported outcome scores (PROMs) after lateral UKA. Secondarily, the influence of lateral UKA on the alignment of the patellofemoral joint was studied. Methods. A consecutive series of patients who underwent robotic arm-assisted fixed-bearing lateral UKA with at least two-year follow-up were retrospectively reviewed. Radiological evaluation was conducted to obtain a Kellgren Lawrence (KL) grade, an Altman score, and alignment measurements for each knee. Postoperative PROMs were assessed using the Kujala (Anterior Knee Pain Scale) score, Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), and satisfaction levels. Results. A total of 140 knees (130 patients) were identified for analysis. At mean 4.1 years (2.0 to 8.5) follow-up, good to excellent Kujala scores were reported. The presence of mild to moderate preoperative patellofemoral joint osteoarthritis had no impact on these scores (KL grade 0 vs 1 to 3, p = 0.203; grade 0 to 1 vs 2 to 3, p = 0.674). Comparable scores were reported by patients with osteoarthritis (Altman score of ≥ 2) evident on either the medial or lateral patellofemoral joint facet (medial, p = 0.600 and lateral, p = 0.950). Patients with abnormal patellar congruence and tilt angles (≥ 17° and ≥ 14°, respectively) reported good to excellent Kujala scores. Furthermore, lateral UKA resulted in improvements to patellofemoral alignment. Conclusion. This is the first study demonstrating that mild to moderate preoperative radiological degenerative changes and malalignment of the patellofemoral joint are not associated with poor patient-reported outcomes at mid-term follow-up after lateral fixed-bearing UKA. Our data suggest that this may be explained by realignment of the patella and thereby redistribution of loads across the patellofemoral joint. Cite this article: Bone Joint J 2020;102-B(6):727–735

Aim. There has been a significant reduction in unicompartmental knee arthroplasty (UKA) procedures recorded in Australia. This follows several national joint registry studies documenting high UKA revision rates when compared to total knee arthroplasty (TKA). With the recent introduction of robotically assisted UKA procedures, it is hoped that outcomes improve. This study examines the cumulative revision rate of UKA procedures implanted with a newly introduced robotic system and compares the results to one of the best performing non-robotically assisted UKA prostheses, as well as all other non-robotically assisted UKA procedures. Methods. Data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) for all UKA procedures performed for osteoarthritis (OA) between 2015 and 2018 were analyzed. Procedures using the Restoris MCK UKA prosthesis implanted using the Mako Robotic-Arm Assisted System were compared to non-robotically assisted Zimmer Unicompartmental High Flex Knee System (ZUK) UKA, a commonly used UKA with previously reported good outcomes and to all other non-robotically assisted UKA procedures using Cox proportional hazard ratios (HRs) and Kaplan-Meier estimates of survivorship. Results. There was no difference in the rate of revision when the Mako-assisted Restoris UKA was compared to the ZUK UKA (zero to nine months: HR 1.14 (95% CI 0.71 to 1.83; p = 0.596) vs nine months and over: HR 0.66 (95% CI 0.42 to 1.02; p = 0.058)). The Mako-assisted Restoris had a significantly lower overall revision rate compared to the other types of non-robotically assisted procedures (HR 0.58 (95% confidence interval (CI) 0.42 to 0.79); p < 0.001) at three years. Revision for aseptic loosening was lower for the Mako-assisted Restoris compared to all other non-robotically assisted UKA (entire period: HR 0.34 (95% CI 0.17 to 0.65); p = 0.001), but not the ZUK prosthesis. However, revision for infection was significantly higher for the Mako-assisted Restoris compared to the two comparator groups (ZUK: entire period: HR 2.91 (95% CI 1.22 to 6.98; p = 0.016); other non-robotically assisted UKA: zero to three months: HR 5.57 (95% CI 2.17 to 14.31; p < 0.001)). Conclusion. This study reports comparable short-term survivorship for the Mako robotically assisted UKA compared to the ZUK UKA and improved survivorship compared to all other non-robotic UKA. These results justify the continued use and investigation of this procedure. However, the higher rate of early revision for infection for robotically assisted UKA requires further investigation. Cite this article: Bone Joint J 2020;102-B(3):319–328

Aims. The aim of this study was to assess the influence of obesity on the clinical outcomes and survivorship ten years postoperatively in patients who underwent a fixed-bearing unicompartmental knee arthroplasty (UKA). Patients and Methods. We prospectively followed 184 patients who underwent UKA between 2003 and 2007 for a minimum of ten years. A total of 142 patients with preoperative body mass index (BMI) of < 30 kg/m. 2. were in the control group (32 male, 110 female) and 42 patients with BMI of ≥ 30 kg/m. 2. were in the obese group (five male, 37 female). Pre- and postoperative range of movement (ROM), Knee Society Score (KSS), Oxford Knee Score (OKS), 36-Item Short-Form Health Survey (SF-36), and survivorship were analyzed. Results. Patients in the obese group underwent UKA at a significantly younger mean age (56.5 years (. sd. 6.4)) than those in the control group (62.4 years (. sd. 7.8); p < 0.001). There was no significant difference in preoperative functional scores. However, those in the obese group had a significantly lower ROM (116° (. sd. 15°) vs 123° (. sd. 17°); p = 0.003). Both groups achieved significant improvement in outcome scores regardless of BMI, ten years postoperatively. All patients achieved the minimal clinically important difference (MCID) for OKS and KSS. Both groups also had high rates of satisfaction (96.3% in the control group and 97.5% in the obese group) and the fulfilment of expectations (94.9% in the control group and 95.0% in the obese group). Multiple linear regression showed a clear association between obesity and a lower OKS two years postoperatively and Knee Society Function Score (KSFS) ten years postoperatively. After applying propensity matching, obese patients had a significantly lower KSFS, OKS, and physical component score (PCS) ten years postoperatively. Seven patients underwent revision to total knee arthroplasty (TKA), two in the control group and five in the obese group, resulting in a mean rate of survival at ten years of 98.6% and 88.1%, respectively (p = 0.012). Conclusion. Both groups had significant improvements in functional and quality-of-life scores postoperatively. However, obesity was a significant predictor of poorer improvement in clinical outcome and an increased rate of revision ten years postoperatively

We performed a prospective, randomised controlled trial of unicompartmental knee arthroplasty comparing the performance of the Acrobot system with conventional surgery. A total of 27 patients (28 knees) awaiting unicompartmental knee arthroplasty were randomly allocated to have the operation performed conventionally or with the assistance of the Acrobot. The primary outcome measurement was the angle of tibiofemoral alignment in the coronal plane, measured by CT. Other secondary parameters were evaluated and are reported. All of the Acrobot group had tibiofemoral alignment in the coronal plane within 2° of the planned position, while only 40% of the conventional group achieved this level of accuracy. While the operations took longer, no adverse effects were noted, and there was a trend towards improvement in performance with increasing accuracy based on the Western Ontario and McMaster Universities Osteoarthritis Index and American Knee Society scores at six weeks and three months. The Acrobot device allows the surgeon to reproduce a pre-operative plan more reliably than is possible using conventional techniques which may have clinical advantages

Unicompartmental knee arthroplasty (UKA) has numerous advantages over total knee arthroplasty (TKA) and one disadvantage, the higher revision rate. The best way to minimize the revision rate is for surgeons to use UKA for at least 20% of their knee arthroplasties. To achieve this, they need to learn and apply the appropriate indications and techniques. This would decrease the revision rate and increase the number of UKAs which were implanted, which would save money and patients would benefit from improved outcomes over their lifetime. Cite this article: Bone Joint J 2018;100-B:432–5

Aims. The purpose of this study was to evaluate trends in opioid use after unicompartmental knee arthroplasty (UKA), to identify predictors of prolonged use and to compare the rates of opioid use after UKA, total knee arthroplasty (TKA) and total hip arthroplasty (THA). Materials and Methods. We identified 4205 patients who had undergone UKA between 2007 and 2015 from the Humana Inc. administrative claims database. Post-operative opioid use for one year post-operatively was assessed using the rates of monthly repeat prescription. These were then compared between patients with and without a specific variable of interest and with those of patients who had undergone TKA and THA. Results. A total of 4205 UKA patients were analysed. Of these, 1362 patients (32.4%) were users of opioids. Pre-operative opioid use was the strongest predictor of prolonged opioid use after UKA. Opioid users were 1.4 (81.6% versus 57.7%), 3.7 (49.5% versus 13.3%) and 5.5 (35.8% versus 6.5%) times more likely to be taking opioids at one, two and three months post-operatively, respectively (p < 0.05 for all). Younger age and specific comorbidities such as anxiety/depression, smoking, back pain and substance abuse were found to significantly increase the rate of repeat prescription for opioids after UKA. Overall, UKA patients required significantly less opioid prescriptions than patients who had undergone THA and TKA. Conclusion. One-third of patients who undergo UKA are given opioids in the three months pre-operatively. Pre-operative opioid use is the best predictor of increased repeat prescriptions after UKA. However, other intrinsic patient characteristics are also predictive. Cite this article: Bone Joint J 2018;100-B(1 Supple A):62–7

Aims. The purpose of this multicentre observational study was to investigate the association between intraoperative component positioning and soft-tissue balancing on short-term clinical outcomes in patients undergoing robotic-arm assisted unicompartmental knee arthroplasty (UKA). Patients and Methods. Between 2013 and 2016, 363 patients (395 knees) underwent robotic-arm assisted UKAs at two centres. Pre- and postoperatively, patients were administered Knee Injury and Osteoarthritis Score (KOOS) and Forgotten Joint Score-12 (FJS-12). Results were stratified as “good” and “bad” if KOOS/FJS-12 were more than or equal to 80. Intraoperative, post-implantation robotic data relative to CT-based components placement were collected and classified. Postoperative complications were recorded. Results. Following exclusions and losses to follow-up, 334 medial robotic-arm assisted UKAs were assessed at a mean follow-up of 30.0 months (8.0 to 54.9). None of the measured parameters were associated with overall KOOS outcome. Correlations were described between specific KOOS subscales and intraoperative, post-implantation robotic data, and between FJS-12 and femoral component sagittal alignment. Three UKAs were revised, resulting in 99.0% survival at two years (95% confidence interval (CI) 97.9 to 100.0). Conclusion. Although little correlation was found between intraoperative robotic data and overall clinical outcome, surgeons should consider information regarding 3D component placement and soft-tissue balancing to improve patient satisfaction. Reproducible and precise placement of components has been confirmed as essential for satisfactory clinical outcome. Cite this article: Bone Joint J 2019;101-B:435–442

Aims. The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA. Patients and Methods. This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers. Results. Robotic-arm assisted UKA was associated with reduced postoperative pain (p < 0.001), decreased opiate analgesia requirements (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001), and increased maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based UKA. Mean time to hospital discharge was reduced in robotic UKA compared with conventional UKA (42.5 hours (. sd 5.9). vs 71.1 hours (. sd. 14.6), respectively; p < 0.001). There was no difference in postoperative complications between the two groups within 90 days’ follow-up. Conclusion. Robotic-arm assisted UKA was associated with decreased postoperative pain, reduced opiate analgesia requirements, improved early functional rehabilitation, and shorter time to hospital discharge compared with conventional jig-based UKA

Aims. The interest in unicompartmental knee arthroplasty (UKA) for medial osteoarthritis has increased rapidly but the long-term follow-up of the Oxford UKAs has yet to be analysed in non-designer centres. We have examined our ten- to 15-year clinical and radiological follow-up data for the Oxford Phase III UKAs. Patients and Methods. Between January 1999 and January 2005 a total of 138 consecutive Oxford Phase III arthroplasties were performed by a single surgeon in 129 patients for medial compartment osteoarthritis (71 right and 67 left knees, mean age 72.0 years (47 to 91), mean body mass index 28.2 (20.7 to 52.2)). Both clinical data and radiographs were prospectively recorded and obtained at intervals. Of the 129 patients, 32 patients (32 knees) died, ten patients (12 knees) were not able to take part in the final clinical and radiological assessment due to physical and mental conditions, but via telephone interview it was confirmed that none of these ten patients (12 knees) had a revision of the knee arthroplasty. One patient (two knees) was lost to follow-up. Results. The mean follow-up was 11.7 years (10 to 15). A total of 11 knees (8%) were revised. The survival at 15 years with revision for any reason as the endpoint was 90.6% (95% confidence interval (CI) 85.2 to 96.0) and revision related to the prosthesis was 99.3% (95% CI 97.9 to 100). The mean total Knee Society Score was 47 (0 to 80) pre-operatively and 81 (30 to 100) at latest follow-up. The mean Oxford Knee Score was 19 (12 to 40) pre-operatively and 42 (28 to 55) at final follow-up. Radiolucency beneath the tibial component occurred in 22 of 81 prostheses (27.2%) without evidence of loosening. Conclusion. This study supports the use of UKA in medial compartment osteoarthritis with excellent long-term functional and radiological outcomes with an excellent 15-year survival rate. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):41–7

Many designs of unicompartmental knee replacement show early and mid-term failure due to polyethylene wear. We studied the wear rate of congruent polyethylene meniscal bearings retrieved from failed Oxford unicompartmental knee replacements. We examined 16 bearings, 0.8 to 12.8 years after implantation, measuring their thickness and comparing it with that of 14 unused bearings. The mean rate of penetration, which included the effects of wear at both upper and lower surfaces, was 0.036 mm per year (maximum 0.08). Bearings as thin as 3.5 mm wore no faster than thicker models, but ten with evidence of impingement had greater wear. The six bearings with no impingement showed a mean rate of penetration of 0.01 mm per year. In unicompartmental knee replacement, careful implantation of fully congruous meniscal bearings can avoid failure due to polyethylene wear

The contraindications for unicompartmental knee replacement (UKR) remain controversial. The views of many surgeons are based on Kozinn and Scott’s 1989 publication which stated that patients who weighed more than 82 kg, were younger than 60 years, undertook heavy labour, had exposed bone in the patellofemoral joint or chondrocalcinosis, were not ideal candidates for UKR. Our aim was to determine whether these potential contraindications should apply to patients with a mobile-bearing UKR. In order to do this the outcome of patients with these potential contraindications was compared with that of patients without the contraindications in a prospective series of 1000 UKRs. The outcome was assessed using the Oxford knee score, the American Knee Society score, the Tegner activity score, revision rate and survival. The clinical outcome of patients with each of the potential contraindications was similar to or better than those without each contraindication. Overall, 678 UKRs (68%) were performed in patients who had at least one potential contraindication and only 322 (32%) in patients deemed to be ideal. The survival at ten years was 97.0% (95% confidence interval 93.4 to 100.0) for those with potential contraindications and 93.6% (95% confidence interval 87.2 to 100.0) in the ideal patients. We conclude that the thresholds proposed by Kozinn and Scott using weight, age, activity, the state of the patellofemoral joint and chondrocalcinosis should not be considered to be contraindications for the use of the Oxford UKR

We report the outcome of 135 knees with anteromedial osteoarthritis in which the Oxford meniscal-bearing unicompartmental arthroplasty was inserted in a district general hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had only minor osteoarthritis. The mean follow-up was 5.82 years (2 to 12). Using revision as the end-point, the outcome for every knee was established. Five knees have been revised giving a cumulative rate of survival of the prosthesis at ten years of 94.04% (95% confidence interval 84.0 to 97.8). Knee rating and patient function were assessed using the modified Knee Society scoring system. The mean knee score was 92.2 (51 to 100) and the mean functional score 76.2 (51 to 100). The survival of the implant is comparable to that reported by the designers of the prosthesis and not significantly different from that for total knee replacement. Unicompartmental knee replacement offers a viable alternative in patients with medial osteoarthritis. Appropriate selection of patients and good surgical technique are the key factors

We retrospectively studied the major complications occurring after one- and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage and 80 patients (160 UKRs) had two-stage bilateral UKRs. The bilateral UKR groups were comparable in age and American Society of Anaesthesiology grade, but more women were in the two-stage group (p = 0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep-vein thrombosis and adverse cardiac events within 30 days of surgery. No statistical differences between the groups were found regarding the operating surgeon, the tourniquet time or minor complications except for distal deep-vein thrombosis. The anaesthetic times were longer for the two-stage group (p = 0.0001). Major complications were seen in 13 patients (8.2%) with one-stage operations but none were encountered in the two-stage group (p = 0.005). Distal deep-vein thrombosis was more frequent in the two-stage group (p = 0.036). Because of the significantly higher risk of major complications associated with one-stage bilateral UKR we advocate caution before undertaking such a procedure

Aims

The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery.

A total of 10474 unicompartmental knee arthroplasties was performed for medial osteoarthritis in Sweden between 1986 and 1995. We sought to establish whether the number of operations performed in an orthopaedic unit affected the incidence of revision. Three different implants were analysed: one with a high revision rate, known to have unfavourable mechanical and design properties; a prosthesis which is technically demanding with a known increased rate of revision; and the most commonly used unicompartmental device. Most of the units performed relatively few unicompartmental knee arthroplasties per year and there was an association between the mean number carried out and the risk of later revision. The effect of the mean number of operations per year on the risk of revision varied. The technically demanding implant was most affected, that most commonly used less so, and the outcome of the unfavourable design was not influenced by the number of operations performed. For unicompartmental arthroplasty, the long-term results are related to the number performed by the unit, probably expressing the standards of management in selecting the patients and performing the operation

The outcome of high tibial osteotomy (HTO) deteriorates with time, and additional procedures may be required. The aim of this study was to compare the clinical and radiological outcomes between unicompartmental knee replacement (UKR) and total knee replacement (TKR) after HTO as well as after primary UKR. A total of 63 patients (63 knees) were studied retrospectively and divided into three groups: UKR after HTO (group A; n = 22), TKR after HTO (group B; n = 18) and primary UKR (group C; n = 22). The Oxford knee score (OKS), Knee Society score (KSS), hip–knee–ankle angles, mechanical axis and patellar height were evaluated pre- and post-operatively. At a mean of 64 months (19 to 180) post-operatively the mean OKS was 43.8 (33 to 49), 43.3 (30 to 48) and 42.5 (29 to 48) for groups A, B and C, respectively (p = 0.73). The mean KSS knee score was 88.8 (54 to 100), 88.11 (51 to 100) and 85.3 (45 to 100) for groups A, B and C, respectively (p = 0.65), and the mean KSS function score was 85.0 (50 to 100) in group A, 85.8 (20 to 100) in group B and 79.3 (50 to 100) in group C (p = 0.48). Radiologically the results were comparable for all groups except for patellar height, with a higher incidence of patella infra following a previous HTO (p = 0.02). Cite this article: Bone Joint J 2013;95-B:1348–53

Early and accurate prediction of hospital length-of-stay (LOS) in patients undergoing knee replacement is important for economic and operational reasons. Few studies have systematically developed a multivariable model to predict LOS. We performed a retrospective cohort study of 1609 patients aged ≥ 50 years who underwent elective, primary total or unicompartmental knee replacements. Pre-operative candidate predictors included patient demographics, knee function, self-reported measures, surgical factors and discharge plans. In order to develop the model, multivariable regression with bootstrap internal validation was used. The median LOS for the sample was four days (interquartile range 4 to 5). Statistically significant predictors of longer stay included older age, greater number of comorbidities, less knee flexion range of movement, frequent feelings of being down and depressed, greater walking aid support required, total (versus unicompartmental) knee replacement, bilateral surgery, low-volume surgeon, absence of carer at home, and expectation to receive step-down care. For ease of use, these ten variables were used to construct a nomogram-based prediction model which showed adequate predictive accuracy (optimism-corrected R. 2. = 0.32) and calibration. If externally validated, a prediction model using easily and routinely obtained pre-operative measures may be used to predict absolute LOS in patients following knee replacement and help to better manage these patients. . Cite this article: Bone Joint J 2013;95-B:1490–6

Aims. It is not clear whether anterior knee pain and osteoarthritis (OA) of the patellofemoral joint (PFJ) are contraindications to medial unicompartmental knee arthroplasty (UKA). Our aim was to investigate the long-term outcome of a consecutive series of patients, some of whom had anterior knee pain and PFJ OA managed with UKA. Patients and Methods. We assessed the ten-year functional outcomes and 15-year implant survival of 805 knees (677 patients) following medial mobile-bearing UKA. The intra-operative status of the PFJ was documented and, with the exception of bone loss with grooving to the lateral side, neither the clinical or radiological state of the PFJ nor the presence of anterior knee pain were considered a contraindication. The impact of radiographic findings and anterior knee pain was studied in a subgroup of 100 knees (91 patients). Results. There was no relationship between functional outcomes, at a mean of ten years, or 15-year implant survival, and pre-operative anterior knee pain, or the presence or degree of cartilage loss documented intra-operatively at the medial patella or trochlea, or radiographic evidence of OA in the medial side of the PFJ. In 6% of cases there was full thickness cartilage loss on the lateral side of the patella. In these cases, the overall ten-year function and 15-year survival was similar to those without cartilage loss; however they had slightly more difficulty with descending stairs. Radiographic signs of OA seen in the lateral part of the PFJ were not associated with a definite compromise in functional outcome or implant survival. Conclusion. Severe damage to the lateral side of the PFJ with bone loss and grooving remains a contraindication to mobile-bearing UKA. Less severe damage to the lateral side of the PFJ and damage to the medial side, however severe, does not compromise the overall function or survival, so should not be considered to be a contraindication. However, if a patient does have full thickness cartilage loss on the lateral side of the PFJ they may have a slight compromise in their ability to descend stairs. Pre-operative anterior knee pain also does not compromise the functional outcome or survival and should not be considered to be a contraindication. Cite this article: Bone Joint J 2017;99-B:632–9

Anterior knee pain and/or radiological evidence of degeneration of the patellofemoral joint are considered to be contraindications to unicompartmental knee replacement. The aim of this study was to determine whether this is the case. Between January 2000 and September 2003, in 100 knees (91 patients) in which Oxford unicompartmental knee replacements were undertaken for anteromedial osteoarthritis, pre-operative anterior knee pain and the radiological status of the patellofemoral joint were defined using the Altman and Ahlback systems. Outcome was evaluated at two years with the Oxford knee score and the American Knee Society score. Pre-operatively 54 knees (54%) had anterior knee pain. The clinical outcome was independent of the presence or absence of pre-operative anterior knee pain. Degenerative changes of the patellofemoral joint were seen in 54 patients (54%) on the skyline radiographs, including ten knees (10%) with joint space obliteration. Patients with medial patellofemoral degeneration had a similar outcome to those without. For some outcome measures patients with lateral patellofemoral degeneration had a worse score than those without, but these patients still had a good outcome, with a mean Oxford knee score of 37.6 (SD 9.5). These results show that neither anterior knee pain nor radiologically-demonstrated medial patellofemoral joint degeneration should be considered a contraindication to Oxford unicompartmental knee replacement. With lateral patellofemoral degeneration the situation is less well defined and caution should be observed

Many authors have recommended undercorrection of the deformity when carrying out unicompartmental knee arthroplasty (UKA). The isolated effect of alignment of the knee on the outcome of UKA has, however, received little attention. We reviewed 185 UKAs at a minimum of five years after surgery. They had been carried out by a single surgeon using metal-backed tibial components in the management of arthritis of the medial compartment. We measured the tibiofemoral angle (TFA) before and at four months after operation and at the most recent assessment. The amount of correction of the TFA and any subsequent loss were recorded. While adjusting for the effects of age, weight and gender of the patients and the type and thickness of the implants, the mean correction was significantly less for those with a Marmor rating of failure (6.8°) than for those rated excellent (9.2°). The mean correction was also significantly less for patients with a Marmor rating of failure (6.8°) than for those rated poor (11.1°). The mean correction for the UKAs which were revised (6.6°) was significantly less than for those not revised (9.1°). Additionally, revised UKAs had a significantly higher percentage (63%) of thinner tibial implants (< 8 mm) than the surviving UKAs (27%). These findings suggest that undercorrection of the TFA in UKA of the medial compartment should be avoided, particularly if a thin tibial polyethylene insert is used

Aims

This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA.

Failure of a unicompartmental knee replacement (UKR) may be caused by progressive osteoarthritis of the knee and/or failure of the prosthesis. Limb alignment can influence both of these factors. We have examined the fate of the other compartments and measured changes in leg alignment after UKR. A total of 50 UKRs was carried out on 45 carefully selected patients between 1989 and 1992. At operation, deliberate attempts were made to avoid overcorrection of the deformity. Four patients died, one patient was lost to follow-up and two knees were revised before review which was at a minimum of five years. Standard long-leg weight-bearing anteroposterior views of the knee and skyline views of the patellofemoral joint were taken before and at eight months and five years after operation. The radiographs of the remaining 43 knees were reviewed twice by blind and randomised assessment to measure the progression of osteoarthritis within the joints. Overcorrection of the deformity in the coronal plane was avoided in all but two knees. Only one showed evidence of progression of osteoarthritis within the patellofemoral joint, and this was only identified in one of the four assessments. Deterioration in the state of the opposite tibiofemoral compartment was not seen. Varus deformity tended to recur. Recurrent varus of 2° was observed between eight months and five years after operation. There was no correlation between the postoperative tibiofemoral angle and the extent of recurrent varus recorded at five years. Changes in alignment may be indicative of minor polyethylene wear or of subsidence of the tibial component. The incidence of progressive osteoarthritis within the knee was very low after UKR. Patients should be carefully selected and overcorrection of the deformity be avoided

There is a large amount of evidence available about the relative merits of unicompartmental and total knee arthroplasty (UKA and TKA). Based on the same evidence, different people draw different conclusions and as a result, there is great variability in the usage of UKA.

The revision rate of UKA is much higher than TKA and so some surgeons conclude that UKA should not be performed. Other surgeons believe that the main reason for the high revision rate is that UKA is easy to revise and, therefore, the threshold for revision is low. They also believe that UKA has many advantages over TKA such as a faster recovery, lower morbidity and mortality and better function. They therefore conclude that UKA should be undertaken whenever appropriate.

The solution to this argument is to minimise the revision rate of UKA, thereby addressing the main disadvantage of UKA. The evidence suggests that this will be achieved if surgeons use UKA for at least 20% of their knee arthroplasties and use implants that are appropriate for these broad indications.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):3–8.

The significance of weight in the indications for unicompartmental knee replacement (UKR) is unclear. Our hypothesis was that weight does not affect the long-term rate of survival of UKRs. We undertook a retrospective study of 212 UKRs at a mean follow-up of 12 years (7 to 22). The patients were distributed according to body mass index (BMI; < vs ≥ 30 kg/m. 2. ) and weight (< vs ≥ 82 kg). Kaplan-Meier survivorship analysis was performed and ten-year survival rates were compared between the sub-groups. Multimodal regression analysis determined the impact of the various theoretical contraindications on the long-term rate of survival of UKR. The ten-year rates of survival were similar in the two weight subgroups (≥ 82 kg: 93.5% (95% confidence interval (CI) 66.5 to 96.3); < 82 kg: 92.5% (95% CI 82.5 to 94.1)) and also in the two BMI subgroups (≥ 30 kg/m. 2. : 92% (95% CI 82.5 to 95.3); < 30 kg/m. 2. : 94% (95% CI 78.4 to 95.9)). Multimodal regression analysis revealed that weight plays a part in reducing the risk of revision with a relative risk of 0.387, although this did not reach statistical significance (p = 0.662). The results relating weight and BMI to the clinical outcome were not statistically significant. Thus, this study confirms that weight does not influence the long-term rate of survival of UKR. Cite this article: Bone Joint J 2013;95-B:1064–8

Aims

The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA.

Whether to use total or unicompartmental knee replacement (TKA/UKA) for end-stage knee osteoarthritis remains controversial. Although UKA results in a faster recovery, lower rates of morbidity and mortality and fewer complications, the long-term revision rate is substantially higher than that for TKA. The effect of each intervention on patient-reported outcome remains unclear. The aim of this study was to determine whether six-month patient-reported outcome measures (PROMs) are better in patients after TKA or UKA, using data from a large national joint registry (NJR).

We carried out a propensity score-matched cohort study which compared six-month PROMs after TKA and UKA in patients enrolled in the NJR for England and Wales, and the English national PROM collection programme. A total of 3519 UKA patients were matched to 10 557 TKAs.

The mean six-month PROMs favoured UKA: the Oxford Knee Score was 37.7 (95% confidence interval (CI) 37.4 to 38.0) for UKA and 36.1 (95% CI 35.9 to 36.3) for TKA; the mean EuroQol EQ-5D index was 0.772 (95% CI 0.764 to 0.780) for UKA and 0.751 (95% CI 0.747 to 0.756) for TKA. UKA patients were more likely to achieve excellent results (odds ratio (OR) 1.59, 95% CI 1.47 to 1.72, p < 0.001) and to be highly satisfied (OR 1.27, 95% CI 1.17 to 1.39, p <  0.001), and were less likely to report complications than those who had undergone TKA.

UKA gives better early patient-reported outcomes than TKA; these differences are most marked for the very best outcomes. Complications and readmission are more likely after TKA. Although the data presented reflect the short-term outcome, they suggest that the high revision rate for UKA may not be because of poorer clinical outcomes. These factors should inform decision-making in patients eligible for either procedure.

Cite this article: Bone Joint J 2015;97-B:793–801.

We recently published a paper comparing the incidence of adverse outcomes after unicompartmental and total knee arthroplasty (UKA and TKA). The conclusion of this study, which was in favour of UKA, was dismissed as “biased” in a review in Bone & Joint 360. Although this study is one of the least biased comparisons of UKA and TKA, this episode highlights the biases that exist both for and against UKA. In this review, we explore the different types of bias, particularly selection, reporting and measurement. We conclude that comparisons between UKA and TKA are open to bias. These biases can be so marked, particularly in comparisons based just on national registry data, that the conclusions can be misleading. For a fair comparison, data from randomised studies or well-matched, prospective observational cohort studies, which include registry data, are required, and multiple outcome measures should be used. The data of this type that already exist suggest that if UKA is used appropriately, compared with TKA, its advantages outweigh its disadvantages.

Cite this article: Bone Joint J 2017;99-B:12–15.

Radiological assessment of total and unicompartmental knee replacement remains an essential part of routine care and follow-up. Appreciation of the various measurements that can be identified radiologically is important. It is likely that routine plain radiographs will continue to be used, although there has been a trend towards using newer technologies such as CT, especially in a failing knee, where it provides more detailed information, albeit with a higher radiation exposure.

The purpose of this paper is to outline the radiological parameters used to evaluate knee replacements, describe how these are measured or classified, and review the current literature to determine their efficacy where possible.

Aims

Altered alignment and biomechanics are thought to contribute to the progression of osteoarthritis (OA) in the native compartments after medial unicompartmental knee arthroplasty (UKA). The aim of this study was to evaluate the bone activity and remodelling in the lateral tibiofemoral and patellofemoral compartment after medial mobile-bearing UKA.

This prospective study describes the outcome of the first 1000 phase 3 Oxford medial unicompartmental knee replacements (UKRs) implanted using a minimally invasive surgical approach for the recommended indications by two surgeons and followed up independently. The mean follow-up was 5.6 years (1 to 11) with 547 knees having a minimum follow-up of five years. At five years their mean Oxford knee score was 41.3 (sd 7.2), the mean American Knee Society Objective Score 86.4 (sd 13.4), mean American Knee Society Functional Score 86.1 (sd 16.6), mean Tegner activity score 2.8 (sd 1.1). For the entire cohort, the mean maximum flexion was 130° at the time of final review.

The incidence of implant-related re-operations was 2.9%; of these 29 re-operations two were revisions requiring revision knee replacement components with stems and wedges, 17 were conversions to a primary total knee replacement, six were open reductions for dislocation of the bearing, three were secondary lateral UKRs and one was revision of a tibial component. The most common reason for further surgical intervention was progression of arthritis in the lateral compartment (0.9%), followed by dislocation of the bearing (0.6%) and revision for unexplained pain (0.6%). If all implant-related re-operations are considered failures, the ten-year survival rate was 96% (95% confidence interval, 92.5 to 99.5). If only revisions requiring revision components are considered failures the ten-year survival rate is 99.8% (confidence interval 99 to 100).

This is the largest published series of UKRs implanted through a minimally invasive surgical approach and with ten-year survival data. The survival rates are similar to those obtained with a standard open approach whereas the function is better. This demonstrates the effectiveness and safety of a minimally invasive surgical approach for implanting the Oxford UKR.

Mobile-bearing unicompartmental knee replacements (UKRs) with a flat tibial plateau have not performed well in the lateral compartment, owing to a high dislocation rate. This led to the development of the Domed Lateral Oxford UKR (Domed OUKR) with a biconcave bearing. The aim of this study was to assess the survival and clinical outcomes of the Domed OUKR in a large patient cohort in the medium term.

We prospectively evaluated 265 consecutive knees with isolated disease of the lateral compartment and a mean age at surgery of 64 years (32 to 90). At a mean follow-up of four years (sd 2.2, (0.5 to 8.3)) the mean Oxford knee score was 40 out of 48 (sd 7.4). A total of 12 knees (4.5%) had re-operations, of which four (1.5%) were for dislocation. All dislocations occurred in the first two years. Two (0.8%) were secondary to significant trauma that resulted in ruptured ligaments, and two (0.8%) were spontaneous. In four patients (1.5%) the UKR was converted to a primary TKR. Survival at eight years, with failure defined as any revision, was 92.1% (95% confidence interval 81.3 to 100).

The Domed Lateral OUKR gives good clinical outcomes, low re-operation and revision rates and a low dislocation rate in patients with isolated lateral compartmental disease, in the hands of the designer surgeons.

Cite this article: Bone Joint J 2014;96-B:59–64.

The most common reasons for revision of unicompartmental knee arthroplasty (UKA) are loosening and pain. Cementless components may reduce the revision rate. The aim of this study was to compare the fixation and clinical outcome of cementless and cemented Oxford UKAs.

A total of 43 patients were randomised to receive either a cemented or a cementless Oxford UKA and were followed for two years with radiostereometric analysis (RSA), radiographs aligned with the bone–implant interfaces and clinical scores.

The femoral components migrated significantly during the first year (mean 0.2 mm) but not during the second. There was no significant difference in the extent of migration between cemented and cementless femoral components in either the first or the second year. In the first year the cementless tibial components subsided significantly more than the cemented components (mean 0.28 mm (sd 0.17) vs. 0.09 mm (sd 0.19 mm)). In the second year, although there was a small amount of subsidence (mean 0.05 mm) there was no significant difference (p = 0.92) between cemented and cementless tibial components. There were no femoral radiolucencies. Tibial radiolucencies were narrow (< 1 mm) and were significantly (p = 0.02) less common with cementless (6 of 21) than cemented (13 of 21) components at two years. There were no complete radiolucencies with cementless components, whereas five of 21 (24%) cemented components had complete radiolucencies. The clinical scores at two years were not significantly different (p = 0.20).

As second-year migration is predictive of subsequent loosening, and as radiolucency is suggestive of reduced implant–bone contact, these data suggest that fixation of the cementless components is at least as good as, if not better than, that of cemented devices.

Cite this article: Bone Joint J 2015; 97-B:185–91.

Symptomatic and asymptomatic deep-vein thrombosis (DVT) is a common complication of knee replacement, with an incidence of up to 85% in the absence of prophylaxis. National guidelines for thromboprophylaxis in knee replacement are derived from total knee replacement (TKR) data. No guidelines exist specific to unicompartmental knee replacement (UKR). We investigated whether the type of knee arthroplasty (TKR or UKR) was related to the incidence of DVT and discuss the applicability of existing national guidelines for prophylaxis following UKR.

Data were collected prospectively on 3449 knee replacements, including procedure type, tourniquet time, surgeon, patient age, use of drains and gender. These variables were related to the incidence of symptomatic DVT.

The overall DVT rate was 1.6%. The only variable that had an association with DVT was operation type, with TKR having a higher incidence than UKR (2.2% versus 0.3%, p < 0.001). These data show that the incidence of DVT after UKR is both clinically and statistically significantly lower than that after TKR.

TKR and UKR patients have different risk profiles for symptomatic DVT. The risk-benefit ratio for TKR that has been used to produce national guidelines may not be applicable to UKR. Further research is required to establish the most appropriate form of prophylaxis for UKR.

The Oxford unicompartmental knee replacement (UKR) was designed to minimise wear utilising a fully-congruent, mobile, polyethylene bearing. Wear of polyethylene is a significant cause of revision surgery in UKR in the first decade, and the incidence increases in the second decade. Our study used model-based radiostereometric analysis to measure the combined wear of the upper and lower bearing surfaces in 13 medial-compartment Oxford UKRs at a mean of 20.9 years (17.2 to 25.9) post-operatively.

The mean linear penetration of the polyethylene bearing was 1.04 mm (0.307 to 2.15), with a mean annual wear rate of 0.045 mm/year (0.016 to 0.099). The annual wear rate of the phase-2 bearings (mean 0.022 mm/year) was significantly less (p = 0.01) than that of phase-1 bearings (mean 0.07 mm/year).

The linear wear rate of the Oxford UKR remains very low into the third decade. We believe that phase-2 bearings had lower wear rates than phase-1 implants because of the improved bearing design and surgical technique which decreased the incidence of impingement. We conclude that the design of the Oxford UKR gives low rates of wear in the long term.

We describe 88 knees (79 patients) with lateral unicompartmental osteoarthritis which had been treated by the St Georg Sled prosthesis.

At a mean follow-up of nine years (2 to 21) 15 knees had revision surgery, nine for progression of arthritis, six for loosening, four for breakage of a component and four for more than one reason. Six patients complained of moderate or severe pain at the final follow-up. Only five knees were lost to follow-up in the 21-year period.

We performed survivorship analysis on the group using revision for any cause as the endpoint. At ten years the cumulative survival rate was 83%, and at 15 years, when ten knees were still at risk, it was 74%.

Based on our clinical results and survival rate the St Georg Sled may be considered to be a suitable unicompartmental replacement for isolated lateral compartment osteoarthritis.

Osteoarthritis of the medial compartment of the knee often shows a specific pattern of anterior wear. Review of our revisions from a series of medial metal-backed Brigham unicondylar knee replacements performed between 1983 and 1989 showed that this wear pattern was common on the tibial polyethylene surface. We reviewed these cases retrospectively to compare the pattern of preoperative erosion with the wear of the prosthesis. In all 14 knees with severe anterior wear in a unicompartmental replacement, the prearthroplasty radiographs showed similar patterns, suggesting that the implanted tibial component may continue to be subjected to the same localised stresses that precipitated the failure of the original articular cartilage. Many tibial components implanted during the 1980s had an unacceptably thin anterior rim of polyethylene and it seems that greater thickness is essential at the anterior and peripheral margins of the tibial plateau.

Varus malalignment after total knee replacement is associated with a poor outcome. Our aim was to determine whether the same was true for medial unicompartmental knee replacement (UKR). The anatomical leg alignment was measured prospectively using a long-arm goniometer in 160 knees with an Oxford UKR. Patients were then grouped according to their mechanical leg alignment as neutral (5° to 10° of valgus), mild varus (0° to 4° of valgus) and marked varus (> 0° of varus). The groups were compared at five years in terms of absolute and change in the Oxford Knee score, American Knee Society score and the incidence of radiolucent lines.

Post-operatively, 29 (18%) patients had mild varus and 13 (8%) had marked varus. The mean American Knee Society score worsened significantly (p < 0.001) with increasing varus. This difference disappeared if a three-point deduction for each degree of malalignment was removed. No other score deteriorated with increasing varus, and the frequency of occurrence of radiolucent lines was the same in each group.

We therefore conclude that after Oxford UKR, about 25% of patients have varus alignment, but that this does not compromise their clinical or radiological outcome. Following UKR the deductions for malalignment in the American Knee Society score are not justified.

We describe a technique for the diagnosis of loosening of the femoral component of the Oxford Unicompartmental Knee Replacement using accurately aligned lateral radiographs in extension and flexion. If gaps are present between the component and cement on one radiograph and not on the other, the component is loose.

Twenty patients underwent simultaneous bilateral medial unicompartmental knee arthroplasty. Pre-operative hip-knee-ankle alignment and valgus stress radiographs were used to plan the desired post-operative alignment of the limb in accordance with established principles for unicompartmental arthroplasty. In each patient the planned alignment was the same for both knees. Overall, the mean planned post-operative alignment was to 2.3° of varus (0° to 5°).

The side and starting order of surgery were randomised, using conventional instrumentation for one knee and computer-assisted surgery for the opposite side.

The mean variation between the pre-operative plan and the achieved correction in the navigated and the non-navigated limb was 0.9° (sd 1.1; 0° to 4°) and 2.8° (sd 1.4; 1° to 7°), respectively. Using the Wilcoxon signed rank test, we found the difference in variation statistically significant (p < 0.001).

Assessment of lower limb alignment in the non-navigated group revealed that 12 (60%) were within ± 2° of the pre-operative plan, compared to 17 (87%) of the navigated cases.

Computer-assisted surgery significantly improves the post-operative alignment of medial unicompartmental knee arthroplasty compared to conventional techniques in patients undergoing bilateral simultaneous arthroplasty. Improved alignment after arthroplasty is associated with better function and increased longevity.