Why Consider Partial Knee Arthroplasty?

Why Consider Partial Knee Arthroplasty? Andrew A. Freiberg, MD Chief, Adult Reconstruction Service Massachusetts General Hospital Surgeon, Newton Wellesley Hospital Associate Professor, Harvard Medical School afreiberg@partners.org 1

Disclosures I have the following relevant financial relationship with a commercial interest to disclose: Zimmer Biomet Royalty, Consultant ArthroSurface Ownership Orthopaedic Technology Group Ownership

What Do We Know About PKA vs TKA? Higher patient satisfaction 2 Fewer surgical complications 3 Shorter hospitalization with PKA 4 3 3

What About Function in PKA? Functional score higher for PKA vs TKA 5-7

What about QOL 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. Pain Symptoms ADL Sport QOL KOOS 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) SATISFACTION 94% satisfied or enthusiast 3% no change 3% disappointed 100 90 80 70 60 50 40 30 20 10 0 Douleur Symptomes Acitivités Sport QDV Series1

What About Kinematics in PKA? Knee kinematics which resembles normal during stair climbing 8

Long term results of PKA Peer reviewed results 90% survivorship at 20 years: M/G Uni fixed-bearing knee 9,10,11,12 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

Despite Results UKA is Under Represented 8% of knee replacements worldwide 13,14 Roughly 30% of US Orthopedic Surgeons reported to AJRR they perform UKA 15 Most are done by a small group of enthusiasts Surgeons Performing Knee Arthroplasty 70% 30% UKA TKA Only 8

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

Envision this Solution?

Rather than an Ideal UKA Candidate?

What Factors Influence this Decision?

Early History of UKA was Controversial Excellent results reported 20 yr data rivals TKA 1980 s 1990 s 2000 s Now Poor results reported UKS s are <2% 1993: Stern, Becker, and Insall- Limited Indications MIS techniques UKA s still only 7 9% 1980 s poor results reported by influential surgeons 16,17 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 US 18 Few Orthopedists received training

Why the Early Poor Results? I. Implant Design Fixation, size, coverage, and constraint II. Polyethylene RAM extruded, terminally radiated oxygen stored and too thin

Early Poor Results Continued III. Poor technique Inaccurate instrumentation Poor inter-component alignment Intentional overcorrection 16 IV. Poor patient selection Post patellectomy 16 Inflammatory OA 19

Excellent Results Have been Reported Since the Mid 1990s Now we have 20 year results that rival TKA 9,10,11,12 But majority of Orthopedists remain resistant to performing UKA s

Is There a Lack of Indications for UKA? 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 disease 21 HOWEVER on direct intra-operative visualization of 228 KA patients, 15% had isolated, single compartment arthritis Majority excluded for weight and activity 21

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. UKA usage = 20%! 22

Stanford VA Study 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 s 23

Stanford VA Study Applied Very Conservative PKA Indications 23 : 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 UKA 23

Is There a Lack of Indications for UKA? 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 UKA 24,25,26 No! Low utilization does not appear to be related to a lack of indications

Lack of Training and Technical Expertise? 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

Risk of Progressive Arthritis? Revision for progressive arthritis is <10% at 15 20 years 10,11,12,27,28 AND, should this be considered a failure? 18 years normal knee function A Primary TKA

Why Not Just Do a TKA? UKA has lower surgical morbidity 3 Patients prefer UKA s Higher proportion of forgotten knee 29 Higher activity levels and better ROM 30,31 More normal kinematics 32 UKA is a cost effective solution 24,33,34

Summary 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

References 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) 3 rd 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 Orthopaedica Scandinavica 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. EVALUATION & TREATMENT OF 26THE INJURED ATHLETE

References 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. EVALUATION & TREATMENT OF 27THE INJURED ATHLETE

Thank You Department of Orthopaedic Surgery Massachusetts General Hospital Harvard Medical School