Objectives

Because there have been no standard methods to determine pre-operatively the thickness of resection of the proximal tibia in unicompartmental knee arthroplasty (UKA), information about the relationship between the change of limb alignment and the joint line elevation would be useful for pre-operative planning. The purpose of this study was to clarify the correlation between the change of limb alignment and the change of joint line height at the medial compartment after UKA.

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.

Although it has been suggested that the outcome after revision of a unicondylar knee replacement (UKR) to total knee replacement (TKR) is better when the mechanism of failure is understood, a comparative study on this subject has not been undertaken.

A total of 30 patients (30 knees) who underwent revision of their unsatisfactory UKR to TKR were included in the study: 15 patients with unexplained pain comprised group A and 15 patients with a defined cause for pain formed group B. The Oxford knee score (OKS), visual analogue scale for pain (VAS) and patient satisfaction were assessed before revision and at one year after revision, and compared between the groups.

The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically significant difference between the mean improvements in each group for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis in group A, performed in order to define a patient factor that predicts outcome of revision surgery in patients with unexplained pain, showed no pre-operative differences between both subgroups.

These results may be used to inform patients about what to expect from revision surgery, highlighting that revision of UKR to TKR for unexplained pain generally results in a less favourable outcome than revision for a known cause of pain.

Cite this article: Bone Joint J 2013;95-B:1204–8.

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.

The Oxford unicompartmental knee replacement (UKR) is an established treatment option in the management of symptomatic end-stage medial compartmental osteoarthritis (MCOA), which works well in the young and active patient. However, previous studies have shown that it is reliable only in the presence of a functionally intact anterior cruciate ligament (ACL). This review reports the outcomes, at a mean of five years and a maximum of ten years, of 52 consecutive patients with a mean age of 51 years (36 to 57) who underwent staged or simultaneous ACL reconstruction and Oxford UKR. At the last follow-up (with one patient lost to follow-up), the mean Oxford knee score was 41 (sd 6.3; 17 to 48). Two patients required conversion to TKR: one for progression of lateral compartment osteoarthritis and one for infection. Implant survival at five years was 93% (95% CI 83 to 100). All but one patient reported being satisfied with the procedure. The outcome was not significantly influenced by age, gender, femoral or tibial tunnel placement, or whether the procedure was undertaken at one- or two-stages.

In summary, ACL reconstruction and Oxford UKR gives good results in patients with end-stage MCOA secondary to ACL deficiency.

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.

Polyethylene particulate wear debris continues to be implicated in the aetiology of aseptic loosening following knee arthroplasty. The Oxford unicompartmental knee arthroplasty employs a spherical femoral component and a fully congruous meniscal bearing to increase contact area and theoretically reduce the potential for polyethylene wear. This study measures the in vivo ten-year linear wear of the device, using a roentgenstereophotogrammetric technique.

In this in vivo study, seven medial Oxford unicompartmental prostheses, which had been implanted ten years previously were studied. Stereo pairs of radiographs were acquired for each patient and the films were analysed using a roentgen stereophotogrammetric analysis calibration and a computer-aided design model silhouette-fitting technique. Penetration of the femoral component into the original volume of the bearing was our estimate of linear wear. In addition, eight control patients were examined less than three weeks post-insertion of an Oxford prosthesis, where no wear would be expected. The control group showed no measured wear and suggested a system accuracy of 0.1 mm. At ten years, the mean linear wear rate was 0.02 mm/year.

The results from this in vivo study confirm that the device has low ten-year linear wear in clinical practice. This may offer the device a survival advantage in the long term.

The December 2024 Knee Roundup. 360. looks at: Unicompartmental knee arthroplasty and total knee arthroplasty in the same patient?; Lateral unicompartmental knee arthroplasty: is it a good option?; The fate of the unresurfaced patellae in contemporary total knee arthroplasty: early- to mid-term results; Tibial baseplate migration is not associated with change in PROMs and clinical scores after total knee arthroplasty; Unexpected positive intraoperative cultures in aseptic revision knee arthroplasty: what effect does this have?; Kinematic or mechanical alignment in total knee arthroplasty surgery?; Revision total knee arthroplasty achieves minimal clinically important difference faster than primary total knee arthroplasty; Outcomes after successful DAIR for periprosthetic joint infection in total knee arthroplasty

The April 2024 Knee Roundup. 360. looks at: Challenging the status quo: re-evaluating the impact of obesity on unicompartmental knee arthroplasty outcomes; Timing matters: the link between ACL reconstruction delays and cartilage damage; Custom fit or off the shelf: evaluating patient outcomes in tailored versus standard knee replacements; Revolutionizing knee replacement: a comparative study on robotic-assisted and computer-navigated techniques; Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years; Modern digital therapies?; A matched study on fracture rates following knee replacement surgeries;

The August 2024 Knee Roundup. 360. looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford

The June 2023 Knee Roundup. 360. looks at: Cementless total knee arthroplasty is associated with early aseptic loosening in a large national database; Is cementless total knee arthroplasty safe in females aged over 75 years?; Could novel radiological findings help identify aseptic tibial loosening?; The Attune cementless versus LCS arthroplasty at introduction; Return to work following total knee arthroplasty and unicompartmental knee arthroplasty; Complications and downsides of the robotic total knee arthroplasty; Mid-flexion instability in kinematic alignment better with posterior-stabilized and medial-stabilized implants?; Patellar resurfacing does not improve outcomes in modern knees

Aims. Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods. A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results. Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion. Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908

The August 2023 Knee Roundup. 360. looks at: Curettage and cementation of giant cell tumour of bone: is arthritis a given?; Anterior knee pain following total knee arthroplasty: does the patellar cement-bone interface affect postoperative anterior knee pain?; Nickel allergy and total knee arthroplasty; The use of artificial intelligence for the prediction of periprosthetic joint infection following aseptic revision total knee arthroplasty; Ambulatory unicompartmental knee arthroplasty: development of a patient selection tool using machine learning; Femoral asymmetry: a missing piece in knee alignment; Needle arthroscopy – a benefit to patients in the outpatient setting; Can lateral unicompartmental knees be done in a day-case setting?

Aims. To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). Methods. This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated. Results. rUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of £13,078 for a unit undertaking 400 cases per year. A cost per QALY of less than £20,000 was achieved when ≥ 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than £38,000, which was in part due to the increased intraoperative consumable costs associated with rUKA (£626 per patient). When the absolute cost difference (operative and revision costs) was less than £240, a cost per QALY of less than £20,000 was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero. Conclusion. rUKA was a cost-effective intervention with an incremental cost per QALY of £13,078 at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than £240 to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow-up. Cite this article: Bone Jt Open 2023;4(11):889–898

Aims. The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). Methods. In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. Results. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). Conclusion. OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data. Cite this article: Bone Jt Open 2023;4(3):138–145