UNICOMPARTMENTAL

OSTEOTOMY

FOR

A COMPARATIVE
N.

Froni

We have
unicompartmental

made

Bristol

REPLACEMENT

AND

OSTEOARTHRITIS

OF

STUDY

S.

AFTER

BROUGHTON,

Rota!

J.

Infirmary

and

a restrospective
comparison
replacement
arthroplasties

assessed
S to 10 years
after operation.
responsible
for treatment
but analysis

H.

5--b

NEWMAN.

been considerable
recent
of unicompartmental
ideal operation
provides

between
performed

and stability
unicompartmental
all achieve

over
these

a long period.
replacement
objectives.

Total
knee replacement,
and tibial osteotomy
can

but

it seems

logical

to pre-

serve normal
anticular
cartilage
and to perform
the least
destructive
operation
possible.
There
have been several
recent
reviews
of the results
of tibial
osteotomy
and of
unicompartmental
replacement
but none allowed
direct
comparison
We

between
the two procedures.
present
a retrospective
review

osteotomies

and

unicompartmental

of

knee

a series

of

replacements

performed
in Bristol
between
5 and 10 years ago for unicompartmental
arthritis.
The pre-operative
state of each
group
was similar
enough
to allow
a direct
comparison
ofthe
results.

MATERIAL
The

records

the
knee
replacement

of all
by
in

AND

patients

treated

tibial
osteotomy
Bristol
between

METHODS
for

osteoarthnitis

of

or unicompartmental
1974 and
1979

studied.
FRCS.
Hospital.

J. H. Newman,
Bristol
Royal
England.

FRCS.
Consultant
Orthopaedic
Surgeon
Infirmary.
Marlborough
Street.
Bristol

Requests
(
1986

Registrar
in Orthopaedics
Road,
Cambridge
CB2

2QQ,

620X863092

VOL..

68

B.

No.

52.00

3. MAY

BS2

8HW,

Honorary
Research
Fellow,
University
of Bristol
Orthopaedic
Surgeon)
Winford
Orthopaedic
BSI8 8AQ.
England.

for reprints
should
be sent to Mr N. S. Broughton.
British
Editorial
Society
of Bone and Joint
Surgery

0301

England.

FOLLOW-UP

J.

BAILY

Hospital,

significantly

A total

assessed.

Bristol

of the consultant
two groups
were

better

of 70 osteotomies

and that

had

this group

been

performed;

died and 10 could

not be traced,
leaving
in 45 patients
who were followed
up

All the

operations

were

performed

II
49
and

by resecting

a wedge ofbone
above
the tibial tubercie
in an attempt
to
correct
the coronal
tibiofemoral
angle.
The fibula
was
dealt with by osteotomy.
excision
of the fIbular
head or
by releasing
the tibiofihularjoint
and allowing
the fihula
to slide. No external
fixation
was used; a plaster
cylinder
was applied
and generally
removed
six weeks
after
the
operation.
In the
replacements

same five-year
period,
for osteoarthritis

of

52 unicompartmental
the knee
were

per-

formed.
traced.
ments

Six patients
had died and three
could
not be
leaving
a total of 42 unicompartmental
replacein 34 patients.
The
prosthesis
used
was the St

Geong
1976).

sledge
Any

cemented
abnormality

angle
was
deliberately
operation
most ofthe
5

a coronal
varus (Figs
Patients

in position
in the

undercorrected
medial
compartment

tibiofemoral
I, 2 and 3).
were
assessed

by interview,
was possible.

(Engelbrecht
ci
coronal
tibiofemoral

angle
at

so that
after
replacements

between
5 to

examination
An objective

a!.

valgus

10 years

and

after

the

and
radiography
assessment
of the

success
of the operation
was obtained
by using the Baily
knee score (Table
I). This scoring
system,
adapted
from
that used at the Hospital
for Special
Surgery.
New York,
has been used regularly
in Bristol
for 10 years
and has
proved
to be effective.
A score of 35 to 50 points
30 to 34 is fair, and less than 30 points
is poor.
Radiographs
Lawrence

986

KNEE

3 were poor and 3 had been revised.

In the
and 10 had been revised.
It was concluded
were

operation
when
this

N. S. Broughton.
Addenbrookes

R. A. J. Baily.
FRCS.
(formerly
Consultant
Hospital,
near Bristol

Senior
Hills

fair,
poor

patients
had
osteotomies

had
were

THE

depended
on the policy
findings
showed
that the

replacement

over the
of the
mobility

TIBIAL

the results
of 49 high tibial osteotomies
and 42
for the treatment
of osteoarthritis
of the knee,

The type of operation

of the pre-operative

controversy
osteoarthnitis
pain relief,

A.

Orihopaedic

sufficiently
similar
for direct comparison
between
them.
In the replacement
group, 32 (76%)
were good, 4 were
osteotomy
group 21 (43%)
were good, 11 were fair, 7 were

There
has
treatment
knee.
The

R.

Winford

that, in this series, the results of unicompartmental

had shown no sign of late deterioration.

YEARS

HIGH

(1957)

were

assessed

grading

system

by

the

for severity

Kellgren

is good,
and

of arthritis,
447

448

N.

S.

BROUGHTON,

Fig.

J.

H.

NEWMAN,

R. A. J. RAlLY

I
Standing
radiographs
of the knees
ofa patient
who was 68 years old at
the time of operation.
Figure
1Before
operation.
Figure
2 - Six
months
after
bilateral
medial
compartment
replacement
with
St
Georg
sledge
prostheses.
No
attempt
had been made
to correct
the coronal
tibiofemoral
angle
to
physiological
valgus.
Figure
3
Five
years
after
the
operations.
There
has been no deterioration
in
the lateral
compartments
and there
is fl() evidence
of loosening.
This
figure
shows
part
of a long-leg
weight-hearing
radiograph:
the two
lines
run
from
the centre
of the
femoral
heads
to the centre
of the
ankle joints.

!.

Fig.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

UNICOMPARTMENTAL
Table
I. The Bails
maximum
for each

REPLACEMENT

knee assessment
scale.
The
fi.ature:
a completely
normal

AND

HIGH

TIBIAL

IS

P(lI1l

Severe
Moderate
Mild
None

0
6
12

The

15
.5

Ii4?l(!iOfl

Walking
distance
\Valking
aids
Stair climbing
Rising
from chair
Giving way

_0

5
5
3

12

maximum

Total
Gru/e
Good.
Fair,
Poor,

of r(suIt
35 50
30 34
under
30 pC9i)ts

Table
II. Comparison
partmental
replacement

of the pre-operative
condition
and osteotomy
groups

of

Female

:male

Pre-operative
Varus
Valgus

deformity
knees
knees

Average
deviation
tihiofemoral
angle

from the normal

of 7 valgus

68 minutes
(
The
average
unicompartmental

and for those

Most
of the

of the

believe,
similar,

consultant

therefore,
and this

tenia

as could

be determined

The

pre-operative

33

16

osteotomy

no difference

group

7.8

years

III)
showed
no
in the replacement
performed
more
results
at review.

therefore
considered
enough
before
operation

panison

of the long-term

all three
previously
We

also

showing

the effect

of length

replacements
had good

of follow-up

Replacement

and

the

that

5-61.years

7 lOyears

All

Good

24

Fair

Poor

the two
to validate

timing

of revision

operations

5-61,years

7-lOyears

All

32*

IS

21*

I(NS)

--

II

6(NS)
I0

Average
time
of revision

MAY

years).

Osteotomv

Results

3.

1.5

outcome.

Revised

No.

patients

the

similar

groups.

between

9.9

2.4

B.

2.6 years

3 months
significant (P<0.0I)

986

are

36

revealed

2.0

significant

groups

60 years
of age at operation
and those
under
60. The
average
period
of follow-up
for the unicompartmental
replacement
patients
was 5.8 years ( I .2 years)
and for

score

68

two

osteotomy

Average
Kellgren
in patellofenoral

\i)E..

the

38 : I I

time;
years

not

We

having
osteotomy
were
having
unicompartmental
analysis
of the results

2.0

difference

case.

3 1: I I

.-

1.9

NS.

each

63 years

--

score

Difference

for

for

Average
Kellgren
Lawrence
in unaffected
compartment

Range

were

on by the late
The osteoto-

RESULTS

3.3

27 days.
replacements

71 years

10.2

in both

I 5.4 minutes)
for osteohospital
stay
for
the
replacement
was 29

(RAJB)
registrars.

parameters

3.2

Results

uni-

( I 7.5

retrospectively.

score

Ill.

for

minutes

two groups
are essentially
by such pre-operative
en-

Average
Kellgren
Lawrence
iii affected
compartment

Table

operation
94

responsible

that
the
is supported

further
analysis
(Table
deterioration
in the results

Lawrence
Joint

the
was

having
osteotomy
unicompartment

unicom-

Osteotornv
-

age

of

is questionable,
upon
symptoms

shown
in Table
II. Patients
general
younger
than
those
replacement;
however,
further

Replacement
Average

the

duration

minutes);
it was
tomy
(P<0.05).
patients
having

policy

50
--

component
but relied

mies were performed

by other
Bristol
consultants
and
their
registrars.
There
was
little
evidence
of crossreferral,
the treatment
selected
being
dependent
on the

No fixed flexion
or lag
Varus
valgus
angle

the tibial
this feature

average

449

KNEE

angles
were measured
on
the significance
of radio-

performed
by the senior
author
Mr W. G. J. Hampson
or their

120

II3(/Ol!?litS

tibiofemonal
films. Because

replacement

5
10

I point for each

OF THE

compartmental

days

.5

.%!O5(flkflt

OSTEOARTHRITIS

lucent
lines around
we did not review
to define loosening.

Total

FOR

and the coronal

long-leg
standing

figures
shown
are the
knee scores
50 points
-

OSTEOTOMY

years

4.4 years

7months

6years

in
of
over

Again,

significant
group
with
than

eight

groups
direct

were
com-

450

N. S. BROUGHTON,

J. H. NEWMAN,

R. A. J. BAILY

Overall
assessment.
U n icom pa rtment
replacement
showed
significantly
better
results
than osteotomy
(Table
III). There
were good
results
in 43%
of the osteotomy
group.
and in 76% ofthe
replacement
group
(P<0.0l).
Revision
had been necessary
in 20%
of the osteotomy
group
but in only 7% ofthe
replacement
group.
Pain,
function
and movement.
The
I 0 osteotomy
and

Table

three replacement
tion were excluded

patients
from

who had had a revision

operathis analysis.
Of the remaining

patients.
the replacement
pain.
62%
of them
being
IV).

The

replacement

group
had
completely

group

also

significantly
pain-free

scored

better

unusual

for

the

originally

compartment

Table

after

operation
(mean
to a Sheehan
total
osteotomy

because

Table

VI.

4.4 years).
replacement

of failure

None

26*

10*

Mild

13

Moderate

14

Severe

10

Difference

V. Local

and

Local

general

MUA

( P <0.001)

complications

recorded

unite.

Five

in both

General

Urinary

other

groups.

MUA.

manipulation

subdivided

into

under

the

three

possible

No deterioration

Deterioration
2

15

to the pre-operative
postoperative

score

deformity

ofeach

(Table

I) for each

Replacement
Result

Varus

Good

26

Fair

knee,

giving

deformity

the
in each

Valgus
7

Poor

Revised

I)itiercnce

NS,

difTerence

highly
not

signifIcant

(P

Valgus

<

73*

0.00

infection

46.8

I .8*

35.8

7.0 (NS)

33.9

1
1

of knees

10.8 (NS)

significant

THE

JOURNAL

OF BONE

AND

JOINT

I
3

Osteotomy

39.6

embolus

group

14

score

thrombo3

Pulmonary

number

Varus

Mean

No deterioration

16

the mean

problems

compartments

Patellofemoral

also

anaesthesia

and

Cardiac arrest
and recovery
Diedat
l5days

related

necessary

venous

Chest

12

category.

Deep
sis

18

in each

Numhsole

retention

result

Thrombocytopenia

ifiected

final

groups

Osteotomy

Deterioration

The

MUA

Wound

VII.

problems

Contralateral

Table

for both

Osteotomy

necessary

Wound

Replacement

Originally

significant

to de-

deterioration

Compartment

highly

One
knee
was
seven
months

to

Radiographic

Osteotomy

Replacement

teriorate
hut that the opposite
compartment
frequently
did so. In the unicompartmental
replacement
group
it
was unusual
to see radiographic
deterioration
of the
patellofemoral
joint
and the originally
unaffected
compartment
was seen to deteriorate
in only two of I 7 knees.
Analyses
of failures.
Ten of the osteotomies
had been
revised
between
seven
months
and seven
years after the
original
revised

groups

func-

could
be studied.
osteotomy,
it was

affected

for both

Replacement

tioli and fbr movement.

Complications.
There were more early systemic
complications
and
wound
problems
in the osteotomy
group
(Table
V).
Radiological
deterioration.
Only the 37 knees
which
had
not been revised,
and for which
pre-operative
and postoperative
radiographs
were available,
Table
VI shows
that,
after
tibial

at review

Revised

less
(Table
for

IV. Pain

SURGERY

UNI(OMPARTMENTAL

osteotomies

gave

radiographic

REPI.A(EMENT

inadequate

and

replacement.
One
after
the osteotomy.

correction

ANI)

and

HIGH

after

had

TIBIAI.

further

clinical

deterioration

total

patient.
then

who had a wound

infection
had a Sheehan
knee replace-

OSTEOTOMY

knees.

knee

that

FOR

His

results

55%

ofhis

lectomy.
The

results

ment
two years
later.
At that operation
there
was no
obvious
infection,
but two years later still an arthrodesis
was necessary
for an infected
prosthesis.
In one patient

reported.
both
(Tj#{246}rnstrand,

the

a!.

position

at

operation.

and

thesis
after
amputation

the

five
was

The

technically
symptoms

soon

after

by a Sheehan

two years
for sepsis.

at home
or they

slipped

replaced

later
an
The other

pros-

with
had

walking
declined

aids and
on been

revision
replacements.

operations
One

with
were

the supunfit for

operation.
Three

medial

patients
required
unicompantmental

Kinematic
knee prosthesis
after three months
gross
overcorrection
into
valgus
causing
terioration
revision

of the lateral
compartment.
after three
years
for deterioration

compartment
four and
lar pain.

and

the third

a halfyeans

had

because

The

a revision

after
had
a

because
rapid
second
of the

had a
lateral

operation

ofincreasingly

of
de-

after

severe

patel-

and

treated

by

lateral

replacement

did

than varus
knees
treated
by medial
number
of valgus
knees was small.
seen in the osteotomy
group.

significantly
replacement.
No similar

better

This five- to ten-year

better
results.
in terms

follow-up
ofpain

has
and

shown
function,

This

partmental
replacement
than for high tibial
similar
groups
of patients
with degenerative
the knee.
Good
partmental

early
results
have
replacement(Marmor

been

osteotomy
disease

in
of

reported
for unicom1979; Jones
ci a!. 1981;

Scott and Santore

1981; Shurley
ci a!. 1982). Our results
for this operation
are similar
to those
of Inglis
(1984)
who reported
86% satisfactory
results
in 22 operations
with a minimum
follow-up
of three years.
In our longer
follow-up

we

found

no

deterioration

with

time

in this

group.
Other
reports
have,
however,
about
longer
term
results
(Laskin
Aglietti
1980; Cameron
ci a!. 1981.
of his results
to be fain or poor
follow-up
and has consequently

been
discouraging
1978;
Insall
and
Insall
reported
64%

after a five- to seven-year

largely
abandoned
the

procedure
in favour
of total joint
replacement.
find significantly
better
results
from a small
lateral
compartment
replacement
operations
VOL..

68

B. No.

3. MAY

986

He did
number
of
for valgus

by the

undergone

osteotomy

appear

fact
patel-

to be less

osteotomies

Dyreby

have

varied

1983:

Insall,

been

Joseph

of assesssment
from

infer
overall
Results
have
reported

one

and

have
to

been

10 years

so

results
from
such
a
varied
dramatically
by Coventry
(1973)

paper

compares

the

results

of two

commonly
used to treat unicompartmcntal
of the knee.
Similar
groups
of patients

and

procedures
osteoarthnitis
an objective

scoring
system
used after a long follow-up
has allowed
a
useful
direct
comparison.
In total,
76% of the unicompartmental
replacement
patients
had satisfactory
results
whereas
only
43%
of the
osteotomy
patients
were

mental
connect

satisfactory.
the replacement

operations.

prostheses
were deliberately
the deformity,
with the aim
of the

relatively

the

unicompart-

positioned
of reducing

normal

to underthe risk of

contralateral

com-

partment.
After
medial
compartment
replacements
the
postoperative
coronal
tibiofemoral
angle was between
5
valgus
and 6 varus
in 85%
of the cases.
Jones
ci al.

caused
reported

significantly
for unicom-

influenced

and. more often,

retrospective
Hagstedt
1981; Vainionp#{228}#{228}
et

methods
has

451

KNEE

using
his own
assessment
after
a oneto nine-year
follow-up.
to the 56% fair or poor reported
by Harding
(1976),
using
Merle
dAubign#{233}s method
of assessment
after a five-month
to 12-year
follow-up.
Our results
fall
between
these two extremes.

(1981)
report
replacements
DISCUSSION

and

THE

previously

of

prospective
Egund
and

follow-up

deterioration

but the
trend
was

tibial
series

Several

OF

been

had

that
it is difficult
to
hetenogenous
group.
from
97%
satisfactory

equally

related
knees

have

ofhigh

Keene
1984).

At

Effect of pre-operative
deformity.
The results
are
to pre-operative
deformity
in Table
VII. Valgus

may
patients

Many

1981;

used

but
to an

total knee,
both
with poor
results

predictable.

Msika

above-knee
two osteo-

adequate
operations
one had revision

and one to a Sheehan

osteotomy
patients

either
managing
port of relatives,
further

had

was

years;
needed

tomy
patients
had
because
of continued
arthrodesis
success.

osteotomy

the knee

OSTEOARTHRITIS

a failure
which
left

mainly
by
radiological

partment
an average
contralateral
correction,

rate of over
50%
the knee in yams:

loosening.
Insall
deterioration

after
medial
failures
were

and Aglietti
in the lateral

(1980)
com-

in 50% ofcases
after correcting
vanus knees to
position
of 4 valgus.
We found
few cases of
deterioration
and, despite
deliberate
underno case
of symptomatic
loosening
of the

tibial

component.
Most
previous
studies
of osteotomy
have
shown
poor
results
after
operation
for degeneration
of the
lateral
compartment
(Shoji
and Insall
1973; Tj#{246}nnstrand
ci a!. I 98 1 ) although
this was not so in our series.
We do,
however,
agree
with
some
previous
authors
(Laskin
1978;
Insall
and
Aglietti
1980)
who
also
found
that
patients
with lateral
compartment
arthritis
had particularly good
results
after
unicompartmental
replacement;
this was impressively
shown
in the comparison
with
patients

treated
by osteotomy.
A prospective
trial is the only
prove
the superiority
of one procedure
this study
has shown
clearly
that,
group
of surgeons,
each performing
choice.

unicompartmental

replacement

conclusive
way to
oven another
but
in the care
the operation
with

of one
of his
the

St