why consider partial knee...

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Andrew A. Freiberg, MD

Chief, Adult Reconstruction Service

Massachusetts General Hospital

Surgeon, Newton Wellesley Hospital

Associate Professor, Harvard Medical School

[email protected]

1

Why Consider Partial Knee Arthroplasty ?


Disclosures I have the following relevant financial relationship with a commercial

interest to disclose:

•Zimmer Biomet Royalty, Consultant

•ArthroSurface Ownership

•Orthopaedic Technology Group Ownership


•Higher patient satisfaction2

•Fewer surgical complications3

•Shorter hospitalization with PKA4

3

What Do We Know About PKA vs TKA?

3


•Functional score higher for PKA vs TKA5-7

What About Function in PKA?


•65 cement PKA implanted in 62 patients < 60, at 10 years FU

Parratte, S., et al. "Medial unicompartmental knee replacement in the under-50s." Bone & Joint Journal 91.3 (2009): 351-356.

KOOS SATISFACTION

94% satisfied or enthusiast3% no change

3% disappointed

What about QOL in PKA?

PainSymptomsADLSportQOL

86 + 12 (21 to 100)83 + 13 (27 to 100)80 + 20 (21 to 100)66 + 28 (0 to 100)78 + 26 (30 to 100)

0

10

20

30

4050

60

70

80

90

100

Douleu

r

Sympt

omes

Acitivi

tés

Sport

QD

V

Series1


•Knee kinematics which resembles normal during stair climbing8

What About Kinematics in PKA?


•Peer reviewed results◦ 90% survivorship at 20 years: M/G™ Uni fixed-bearing knee9,10,11,12

◦ 94% survivorship AUS Registry at 10 years ( ZUK )

Standing AP radiographs after 13 years

Long axis of the femoral components perpendicular to the tibia and parallel to the long axis of the tibia

No evidence of loosening

Long term results of PKA


•8% of knee replacements worldwide13,14

•Roughly 30% of US Orthopedic Surgeons reported to AJRR they perform UKA15

•Most are done by a small group of enthusiasts

8

Despite Results

UKA is Under Represented

30%

70%

Surgeons Performing Knee Arthroplasty

UKA

TKA Only


Why Do Most Orthopaedic Surgeons See These X-Rays…..


Envision this Solution?


Rather than an Ideal UKA Candidate?


What Factors Influence this Decision?


•1980’s poor results reported by influential surgeons16,17

•Led to confusion concerning the indications for and value of the procedure

•1990 UKA comprised approximately 1–2% of the knee arthroplasty cases performed in US18

•Few Orthopedists received training

Early History of UKA was Controversial

1980’s 1990’s 2000’s Now…

Poor results reported

UKS’s are <2%

1993: Stern, Becker, and Insall-”Limited

Indications”

Excellent results reported

MIS techniques

20 yr data rivals TKA

UKA’s still only 7 – 9%


I. Implant Design◦ Fixation, size, coverage, and constraint

II. Polyethylene◦ RAM extruded, terminally radiated oxygen stored and too thin

Why the Early Poor Results?


III. Poor technique◦ Inaccurate instrumentation

◦ Poor inter-component alignment

◦ Intentional overcorrection16

IV. Poor patient selection◦ Post patellectomy16

◦ Inflammatory OA19

Early Poor Results Continued


•Now we have 20 year results that rival TKA9,10,11,12

•But – majority of Orthopedists remain resistant to performing UKA’s

Excellent Results Have been Reported Since the Mid 1990s


•1989: Kozinn and Scott JBJS Current Concepts: “Ideal UKA Patient”20

•1993: Stern, Becker and Insall, UKA indicated in only 6% of patients: limited UKA to low activity, elderly, <82Kg with single compartment disease21

◦ HOWEVER on direct intra-operative visualization of 228 KA patients, 15% had isolated, single compartment arthritis

◦ Majority excluded for weight and activity21

Is There a Lack of Indications for UKA?


UKA usage = 20%!22

Usage…

Kozinn, Stuart C., Clare Marx, and Richard D. Scott. "Unicompartmental knee arthroplasty: a 4.5–6-year follow-up study with a metal-backed tibial component." The Journal of arthroplasty 4 (1989): S1-S9.


What percent of patients undergoing total knee arthroplasty are candidates for UKA?

2 Orthopedists, one who performed UKA and another who only performed TKA reviewed 280 sequential patients who had undergone 320 TKA’s23

Stanford VA Study


•Applied Very Conservative PKA Indications23: ◦ Standard exclusions: inflammatory OA, instability, prior osteotomy, flexion

contracture > 10’

◦ Radiographic criteria: Varus > 10’, Valgus > 15’, any subluxation.

NO Patellofemoral or opposite compartment joint space narrowing or subchondral irregularities.

•Using conservative criteria up to 26% of patients undergoing TKA are likely candidates for UKA23

Stanford VA Study


•The incidence of single compartment OA appears to be 15 – 25%21,23

•AND, if mild to moderate PF OA accepted, as has been demonstrated by several authors, UKA may be indicated in up to 50%24,25,26

•It is probable that over 25% of knee arthroplasty patients would be suitable for UKA24,25,26

Low utilization does not appear to be related to a lack of indications

Is There a Lack of Indications for UKA?

No!


•Many Orthopaedic Surgeons received little to no training in PKA

•Education or Experience may have been negative

•Most will perform a TKA rather than refer for a PKA

•Concerned about Disease Progression

Lack of Training and Technical Expertise?


•Revision for progressive arthritis is <10% at 15 – 20 years10,11,12,27,28

•AND, should this be considered a failure?

Risk of Progressive Arthritis?

18 years “normal” knee function “A Primary TKA”


•UKA has lower surgical morbidity3

•Patients prefer UKA’s◦Higher proportion of “forgotten knee”29

◦Higher activity levels and better ROM30,31

◦More normal kinematics32

•UKA is a cost effective solution24,33,34

Why Not Just Do a TKA?


•The decision to proceed with a UKA is complex.

◦ Based on careful assessment of indications

◦ Surgeon training and expertise

◦ Openness to new information

◦ Willingness to do what may be best for the patient rather than what is most comfortable for the surgeon

◦ My Advice – Get trained, Go Watch, Start in Non-MIS

Summary


1. Liddle, A. D., et al. "Optimal usage of unicompartmental knee arthroplasty." Bone Joint J 97.11 (2015): 1506-1511.

2. Liddle, A. D., et al. "Patient-reported outcomes after total and unicompartmental knee arthroplasty." Bone Joint J 97.6 (2015): 793-801.

3. Brown NM, Sheth NP, Davis K, et al. Total knee arthroplasty has higher postoperative morbidity than unicompartmental knee arthroplasty: a multicenter analysis. The Journal of arthroplasty. 2012;27(8):86-90.

4. Duchman, K. R., Gao, Y., Pugely, A. J., Martin, C. T., & Callaghan, J. J. (2014). Differences in Short-Term Complications Between Unicompartmental and Total Knee Arthroplasty. The Journal of Bone and Joint Surgery-American Volume,96(16), 1387-1394. doi:10.2106/jbjs.m.01048

5. Lyons, M. C., MacDonald, S. J., Somerville, L. E., Naudie, D. D., & McCalden, R. W. (2012). Unicompartmental versus total knee arthroplasty database analysis: is there a winner?. Clinical Orthopaedics and Related Research®, 470(1), 84-90.

6. Lygre, S. H. L., Espehaug, B., Havelin, L. I., Furnes, O., & Vollset, S. E. (2010). Pain and function in patients after primary unicompartmental and total knee arthroplasty. The Journal of Bone & Joint Surgery, 92(18), 2890-2897.

7. Fisher, D. A., Dalury, D. F., Adams, M. J., Shipps, M. R., & Davis, K. (2010). Unicompartmental and total knee arthroplasty in the over 70 population. Orthopedics, 33(9).

8. Jung, M. C., Chung, J. Y., Son, K. H., Wang, H., Hwang, J., Kim, J. J., ... & Min, B. H. (2014). Difference in knee rotation between total and unicompartmental knee arthroplasties during stair climbing. Knee Surgery, Sports Traumatology, Arthroscopy, 22(8), 1879-1886.

9. Argenson, J. N. A., Chevrol-Benkeddache, Y., & Aubaniac, J. M. (2002). Modern unicompartmental knee arthroplasty with cement. J Bone Joint Surg Am, 84(12), 2235-2239.

10. Argenson, J. N. A., Blanc, G., Aubaniac, J. M., & Parratte, S. (2013). Modern unicompartmental knee arthroplasty with cement. J Bone Joint Surg Am, 95(10), 905-909.

11. Berger, R. A., Meneghini, R. M., Jacobs, J. J., Sheinkop, M. B., Della Valle, C. J., Rosenberg, A. G., & Galante, J. O. (2005). Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. The Journal of Bone & Joint Surgery, 87(5), 999-1006.

12. Foran, J. R., Brown, N. M., Della Valle, C. J., Berger, R. A., & Galante, J. O. (2013). Long-term survivorship and failure modes of unicompartmental knee arthroplasty. Clinical Orthopaedics and Related Research®, 471(1), 102-108.

13. European Millennium Report Study 2013.

14. US Millennium Study 2014.

15. AJRR (American Joint Replacement Registry) 3rd annual report. 2016

16. Insall, John, and Paolo Aglietti. "A five to seven-year follow-up of unicondylar arthroplasty." JBJS 62.8 (1980): 1329-1337.

17. Laskin, Richard S. "Unicompartmental tibiofemoral resurfacing arthroplasty." JBJS 60.2 (1978): 182-185.

18. Mannava, M. D., Cara M. Lorentzen, and Beth P. Smith. "Unicompartmental Knee Arthroplasty: Past, Present, Future.“

19. Robertsson, Otto, et al. "The Swedish Knee Arthroplasty Register 1975-1997: an update with special emphasis on 41,223 knees operated on in 1988-1997." Acta OrthopaedicaScandinavica 72.5 (2001): 503-513.

20. Kozinn, Stuart C., and R. I. C. H. A. R. D. Scott. "Unicondylar knee arthroplasty." JBJS 71.1 (1989): 145-150.

21. Stern, Steven H., Michael W. Becker, and John N. Insall. "Unicondylar Knee Arthroplasty: An Evaluation of Selection Criteria." Clinical orthopaedics and related research 286 (1993): 143-148.

References

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22. Kozinn, Stuart C., Clare Marx, and Richard D. Scott. "Unicompartmental knee arthroplasty: a 4.5–6-year follow-up study with a metal-backed tibial component." The Journal of arthroplasty 4 (1989): S1-S9.

23. Woolson, Steven T., Beatrice Shu, and Nicholas J. Giori. "Incidence of radiographic unicompartmental arthritis in patients undergoing knee arthroplasty." Orthopedics 33.11 (2010).

24. Willis-Owen, Charles A., et al. "Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy." The Knee 16.6 (2009): 473-478.

25. Goodfellow, J. W., et al. "The Oxford Knee for unicompartmental osteoarthritis. The first 103 cases." Bone & Joint Journal 70.5 (1988): 692-701.

26. Beard, D. J., et al. "The influence of the presence and severity of pre-existing patellofemoral degenerative changes on the outcome of the Oxford medial unicompartmental knee replacement." Bone & Joint Journal 89.12 (2007): 1597-1601.

27. Pandit, H., et al. "The clinical outcome of minimally invasive Phase 3 Oxford unicompartmental knee arthroplasty." Bone Joint J 97.11 (2015): 1493-1500.

28. Price, Andrew J., and Ulf Svard. "A second decade lifetable survival analysis of the Oxford unicompartmental knee arthroplasty." Clinical Orthopaedics and Related Research® 469.1 (2011): 174-179.

29. Zuiderbaan, Hendrik A., et al. "Unicompartmental knee arthroplasty versus total knee arthroplasty: which type of artificial joint do patients forget?." Knee Surgery, Sports Traumatology, Arthroscopy 25.3 (2017): 681-686.

30. Hopper, Graeme Philip, and William Joseph Leach. "Participation in sporting activities following knee replacement: total versus unicompartmental." Knee Surgery, Sports Traumatology, Arthroscopy 16.10 (2008): 973.

31. John, Joby, Cyril Mauffrey, and Peter May. "Unicompartmental knee replacements with Miller-Galante prosthesis: two to 16-year follow-up of a single surgeon series." International orthopaedics 35.4 (2011): 507-513.

32. Argenson, Jean-Noël A., et al. "In vivo determination of knee kinematics for subjects implanted with a unicompartmental arthroplasty." The Journal of arthroplasty 17.8 (2002): 1049-1054.

33. Slover, James, et al. "Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients: a Markov decision analysis." JBJS 88.11 (2006): 2348-2355.

34. Soohoo, Nelson F., et al. "Cost-effectiveness analysis of unicompartmental knee arthroplasty as an alternative to total knee arthroplasty for unicompartmental osteoarthritis." JBJS 88.9 (2006): 1975-1982.

References

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Department of Orthopaedic SurgeryMassachusetts General HospitalHarvard Medical School

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