Yunus Orthopedi & Traumatologi RSU-Dr Soetomo FK UNAIR

The treatment options for medial compartment osteoarthritis of the knee, producing symptoms sucient to warrant surgery include:

High tibial osteotomy (HTO) Unicompartmental knee replacement (UKA) Total knee replacement (TKR)

When considering which to offer one must consider

the outcome, in terms of symptomatic relief and function, the survival rate and the difficulty of revision in the event of failure of each method.

Until recently UKA has remained a procedure for the enthusiast because of three perceived problems:
1. Inferior survival rates toTKR. 2. Limited indications and therefore a technique appropriate for only small numbers of patients. 3. Technical difficulty of the procedure.

articular cartilage degeneration in the knee probably results from high impulse loading occurring at heel strike area of contact in the knee at this phase of the gait cycle is in the anteromedial tibiofemoral compartment. Radiological studies in the1960s and1970s demonstrated that about 90% of patients with osteoarthritis of the knee showed initial wear in the medial compartment and that progression to the lateral compartment was uncommon

Most arthritic knees have a varus deformity and predominantly medial tibiofemoral arthritis In 1999, it was shown that progression of osteoarthritis to the lateral compartment is usually associated with rupture of the anterior cruciate ligament (ACL), probably due to impingement of osteophytes in the intercondylar space which abrade the synovial covering of the anterior cruciate ligament

Rupture of the ACL is also associated with the development of a fixed varus deformity Before rupture occurs the posterior parts of the medial tibial and femoral articular surfaces remain intact so that in flexion the medial collateral ligament is stretched to its normal length Once the ACL has ruptured the contact point in extension moves posteriorly causing damage to hitherto normal cartilage.

The resulting loss of joint height in flexion allows the medial collateral ligament to remain shortened throughout the full range of knee movement and permanent contracture of the ligament then develops. In order to choose the best treatment for a patient with medial compartment osteoarthritis a comparison of the available options has to be made.This must compare their efficacy, longterm survival and options for revision in the event of failure.

High tibial valgus osteotomy has long been an accepted treatment for medial osteoarthritis, particularly in young activemen. few good comparisons to be found in the literature

di!erent patient groups have been studied varied outcome measures used

One comparative study did use a validated patient-based outcome measure (the Oxford knee score)

compare two cohorts One treated by Oxford UKA and the other by HTO 6 years : The 10 -year survival :
average score in the HTO group was 26.6 and in the UKA group it was 38.1

HTO with revision as the end point was 63%, and for the UKA, it was 98%.

In this comparison, the average age of the HTO group was younger than the UKA group

These differences were maintained.

Weale and Newman also reported (in their retrospective comparison of HTO with UKA)

better function and longer survival in the UKA group The functional benefits of UKA over HTO have also been shown in the gait laboratory, with more normal gait and better stair climbing

Revision of HTO toTKR is notoriously difficult

If a closing wedge osteotomy has been used the patella ligament is often short so that exposure is difficult There are problems in selecting the level of tibial resection and in soft tissue balancing.

Following failed UKA exposure, bone cuts and soft tissue balancing are no more difficult than for a primaryTKR

In terms of function and survival, HTO perform significantly worse than UKA in all patient groups that have been compared Is there still an indication for HTO?
Primary tibia vara with early secondary medial arthritis and perhaps it has a place in treating young, active men who perform heavy labour Delaying the requirement for prosthetic surgery is now the primary justification for performing HTO.

The question is, which procedure will give the longest total lifetime of the knee? At present the evidence favours UKA over HTO in most cases.

Comparisons between TKR and UKA are difficult because of the different populations undergoing each procedure Patients undergoing TKR are likely to be older and have more advanced osteoarthritis in most historical series Functional outcome following UKA is superior than TKR In an historical prospective study comparing UKA and TKR, Rugr, et al, found that therewas no statistically significant difference in aseptic loosening between two groups of patients. However, UKA was associated with a better range of movement and ambulatory function

In a bilateral study of patients undergoing a UKA on one side and a TKR on the other, it was demonstrated that in terms of pain, stability, feel and stair climbing ability, UKA performed better than the TKR In a randomized controlled trial in Bristol, it was found that UKA had less perioperative morbidity, faster rehabilitation and shorter length of stay thanTKA The retention of the ACL in UKA provides normal kinematics with normal patellofemoral joint forces.20 This results in an improved range of movement and function especially with demanding activities such as stairs

In an in vivo fluoroscopic study Price et al. have demonstrated normal kinematics by measuring the angle between the patellar tendon and the long axis of the tibia in the lateral view, they have shown that the kinematics in the sagittal plane following UKA is the same as in a normal knee. This compares dramatically with the pattern of movement seen following TKR

Inferior survival rates of UKA compared to TKR reported in the 1980s and early 1990s These failures were due to inappropriate patient selection, less refined surgical techniques compared to TKR and polyethylene wear in the original round on flat implant design. With improvement in all of these areas survival rates for both fixed and mobile bearing designs are now equal to those of the best TKR It is clear also that surgical technique plays a large part in the success of UKA Poor results for the Oxford mobile bearing design in the Swedish knee register were almost entirely due to catastrophic early failure at 1 centre

Survival rates for UKA equal to those for the best TKR can be achieved with strict criteria for patient selection, adherence to a learnt technique and the use of a design proven to have minimal polyethylene wear. Increasing numbers of groups are now demonstrating this to be the case

The revision of UKA has already been discussed. Revision of TKR is a challenging exercise with well-recognized technical difficulties

exposure, flexion and extension gap matching, soft tissue balancing and implant stability

The results of UKA revision equals those of primary TKR and are superior to those of revision TKR.

There is little doubt that UKA has significant advantages over TKR in the short and medium term Using data from the Swedish register, Robertsson estimated that the cost of UKA was 57% of that of TKR with lower complication rates and length of hospital stay. Revising UKA provides results similar to primary TKR.

The success of medial unicompartmental knee replacements is dependent upon strict adherence to the indications extending these indications is likely to lead to inferior results.

The accepted indications formedial compartment UKA are:

1. Medial compartment arthritiswith symptoms sufficient to warrant TKR. 2. An intact ACL. 3. An intact lateral tibiofemoral compartment. 4. Correctable varus deformity. 5. Less than101 of fixed flexion deformity. 6. Flexion beyond 100

If these indications are accepted then asmany as 1 in 4 osteoarthritic knees will be appropriate for UKA

The absolute contraindications are:

1. Inflammatory arthropathy. 2. Previous high tibial osteotomy. 3. Sepsis.

However, suggested contraindications have included :

patellofemoral joint osteoarthritis, chondrocalcinosis, obesity, young age and high levels of activity

If these suggested CI are accepted as restrictions to the use of UKA then less than 1 in 20 knees would be suitable It is important to have good evidence to refute these contraindications.

Patellofemoral joint osteoarthritis

It is very common in knees with symptomatic osteoarthritis The arguments against its inclusion as a contraindication are similar to those against resurfacing in TKR Correct mechanical alignment, good quadriceps function and normal knee kinematics are probably more important in eliminating pain from the patellofemoral joint than the quality of the articular surface UKA corrects the mechanical axis and allows normal kinematics and rapid quadriceps rehabilitation

Progression of osteoarthritis in the patellofemoral joint is very rare following UKA and, in the Swedish register there have been no revisions of UKA for patellofemoral joint osteoarthritis. The state of the patellofemoral joint, therefore, does not seem to influence the outcome following UKA and should not be considered a contraindication

Age Older patients do very well with TKR with excellent long-term implant survival. Interestingly, function is usually considered a requirement reserved for young patients. Elderly patients, particularly those with underlying medical pathology, run the risk of significant morbidity and mortality following TKR. With the opportunity for minimally invasive surgery and the reduction of this risk these patients are ideal for UKA.

Young patients with UKA have the same survival as the older patients there is no evidence that in the age groups currently undergoing TKR there should be any restrictions to the use of UKA because of age

Obesity Obesepatients present three potential difficulties :

technical, increased risk of complications and theoretical risk of early failure

exposure in the obese knee for a total knee replacement can be awkward The minimally invasive technique for UKA allows Straight forward exposure because there is no requirement to dislocate the patella There is also no correlation between obesity and wear in UKA

Chondrocalcinosis Chondrocalcinosis falls into two clinical groups There are patients with generalized chondrocalcinosis with synovitis and effectively an inflammatory condition within the knee These should be treated as any other inflammatory condition Chondrocalcinosis seen on the X-ray with some calcification in themeniscus butwith no generalized inflammatory signs should not be considered a contraindication for UKA

Lateral compartment UKA is a more demanding procedure and has produced a smaller quantity of less reliable data than the medial compartment UKA. Bicompartmental UKA should not be used in place of TKR.

Radiographic confirmation of the indications is important but straightforward.Three films are required:

1. AP standing 2. Lateral 3. Valgus stress view

The standing view demonstrates the typical medial compartment arthritis (Ahlbach grades 2 and 3 are usually suitable for unicompartmental replacement) The lateral X-ray demonstrates that the tibial bone erosion is confined to the anterior and mid parts of the medial tibial plateau and does not extend to the posterior margins correlates with an intact ACL

UKA has been demonstrated that the small implants may be inserted through a short parapatellar incision without dislocation of the patella. The minimally invasive technique has the potential further to reduce the morbidity, complications and length of hospital stay in UKA Early functional recovery has been assessed by the time taken to achieve independence on stairs, a straight leg raise and flexion to 70 Patients undergoing a minimally invasive technique achieved these in approximately half the time taken for those undergoing an open procedure and a third of the time for patients receiving a total knee replacement

In bilateral procedures this effect was maintained. The medium-term results have shown no difference in the final range of movement and knee score between the minimally invasive and the open techniques Patients are now able to return home within 2-3 days and in some centres the surgery is now performed as a day case.

UKA is a good alternative for most knees currently treated by HTO and for 25-30% of osteoarthritic knees currently receiving a TKR UKA gives better results in terms of function, pain relief, morbidity and patient satisfaction than HTO or TKR and its long-term survival is significantly better than HTO and as good as TKR The use of a minimally invasive approach with specifically designed instruments offers further benefit to the patient from decreased morbidity, faster rehabilitation and reduced length of hospital stay UKA should be the preferred procedure for patients fulfilling the indications if the appropriate surgical expertise is available