Artrosis Unicompartamental

COPYRI GHT 2003 BY THE JOURNAL OF BONE AND JOI NT SURGERY, INCORPORATED
I,,I
Cur r ent Concept s Review
Unicompar t ment al
Ar t hr it is of t he Knee
BY RICHARD IORIO, MD, AND WILLIAM L. HEALY, MD
Investigation performed at theDepartment of Orthopaedic Surgery, Lahey Clinic Medical Center,
Burlington, Massachusetts, and Boston Medical Center, Boston, Massachusetts
Unicompartmental arthritis of the knee is a degenerative condition characterized by abnormal articular cartilage
in the medial or lateral part of the tibiofemoral joint, which may be associated with meniscal disruption, ligamen-
tous instability, and limb malalignment.
Nonoperative treatments for unicompartmental degenerative arthritis of the knee include oral and injectable
medications, weight loss, exercise, physical therapy, canes, crutches, braces, and orthoses.
Arthroscopy for unicompartmental arthritis of the knee can provide a clinical benefit in terms of reduced pain
and improved function for patients with mechanical symptoms, mild degenerative disease, and minimal or no
malalignment. Meniscal tears, loose bodies, osteophytic spurs, or chondral flaps can cause mechanical symp-
toms, which can be treated successfully with arthroscopy.
Proximal tibial valgus osteotomy and distal femoral varus osteotomy for treatment of unicompartmental arthritis
of the knee can realign a deformed limb, reduce pain, and improve function for active, high-demand patients
with a projected life expectancy of twenty years or more.
As a patients life expectancy and expectations for activity decrease as a result of age and disease, unicompart-
mental and total knee arthroplasty provide predictably successful surgical options for the treatment of unicom-
partmental arthritis of the knee.
Arthritis of the knee is a common clinical problem: 2% of the
United States population older than seventeen years of age and
10% of Americans over sixty-five years of age have clinically
relevant arthritis of the knee
1
. Arthritis of the knee causes pain
and restricts activity, and patients with arthritis are twice as
likely to seek medical care as are their peers without arthritis
2
.
Unicompartmental arthritis of the knee is defined as a
condition characterized by degenerative articular cartilage in
the medial or lateral aspect of the tibiofemoral joint, which
may be associated with meniscal disruption, ligamentous in-
stability, and malalignment
1-3
. The most common symptom of
unicompartmental arthritis of the knee is pain confined to
the affected compartment, which may be associated with
swelling, effusion, instability, impingement, crepitus, stiffness,
and malalignment. Radiographic findings of unicompartmen-
tal arthritis of the knee may include joint space narrowing,
squaring of the femoral condyle, subchondral sclerosis, inter-
condylar spurring, joint line osteophytes, and varus or valgus
malalignment of the affected limb
3,4
.
We will review the natural history of unicompartmental
arthritis of the knee in adults and discuss nonoperative and
operative treatments. Isolated patellofemoral osteoarthritis
and inflammatory arthritides will not be discussed. We believe
that early diagnosis and early treatment may improve the
functional well-being and long-term outcome in patients with
unicompartmental arthritis of the knee.
Nat ural Hi st or y of Degenerat i ve
Ar t hri t i s of t he Knee
The specific cause of degenerative arthritis of the knee is not
clear, but when it occurs in an active patient, it is generally
progressive
5,6
. Trauma is frequently a cause of the degenerative
process, which results in deterioration of articular cartilage
and symptomatic degenerative arthritis
7-12
. The degenerative
process may include articular cartilage damage (chondrocytes
and matrix), meniscal damage, ligament damage, and joint in-
congruity. Angular malalignment may contribute to the devel-
opment and progression of unicompartmental arthritis of the
knee by overloading the medial or lateral aspect of a tibiofem-
oral joint with abnormal articular cartilage.
The spectrum of articular cartilage damage can range
from minimal to severe. Small, superficial, focal defects of ar-
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THE JOURNAL OF BONE & JOI NT SURGERY JBJS.ORG
VOLUME 85- A NUMBER 7 JULY 2003
UNI COMPARTMENTAL ARTHRI TI S OF THE KNEE
ticular cartilage that are not associated with symptoms should
be distinguished from extensive, full-thickness cartilage de-
fects associated with symptomatic degenerative arthritis
13-15
.
The location and size of articular cartilage defects determine
the severity of symptoms and the need for treatment
15
. When
an articular cartilage lesion is less than 2 to 3 cm
2
in area, or a
lesion has good peripheral cartilage support (shoulders), it
may take several years before degenerative arthritis develops
13-
15
(Table I). Minas and Nehrer
15
suggested that articular carti-
lage defects in which the exposed subchondral bone is not
supported by a peripheral cartilage border are often symp-
tomatic and deteriorate more quickly. Symptomatic lesions of
articular cartilage often progress with age, and treatment of
isolated chondral or osteochondral defects may decrease or
minimize the development of degenerative arthritis
13,15-18
.
Eval uat i on of Uni compar t ment al
Ar t hri t i s of t he Knee
The history and physical examination can provide useful in-
formation concerning joint line tenderness, meniscal damage,
ligamentous instability, and malalignment associated with
unicompartmental arthritis of the knee. Dynamic gait analysis
can provide additional information about ligamentous insuf-
ficiency and malalignment. Before a specific treatment is se-
lected, inflammatory arthritides should be excluded as a cause
of unicompartmental arthritis.
Radiographic evaluation is an essential component of
the diagnosis of unicompartmental arthritis of the knee. Ra-
diographs made in the anteroposterior plane with the patient
bearing weight
19
as well as lateral, tangential patellofemoral,
and tunnel views
20
allow objective evaluation of the three com-
partments of the knee (Table II). However, these radiographs
may not accurately predict the status of the articular cartilage
as seen at arthroscopy
21,22
. Radiographic sensitivity with re-
gard to showing deterioration of the articular cartilage may be
improved by making posteroanterior views with the patient
bearing weight and with the knee flexed 40to evaluate the
posterior aspects of the femoral condyles and tibial plateau,
especially in the lateral compartment
17,19
. Radiographs of the
hip, knee, and ankle made on one long film with the patient
standing allow calculation of the static mechanical axis and
identification of any angular deformity of the involved limb.
The patient must be able to place full weight on the affected
limb for a true measurement of limb deformity to be ob-
tained. The mechanical axis is determined by a line drawn
from the center of the femoral head to the center of the knee
joint and a line drawn from the center of the knee joint
through the center of the ankle joint
19,23
. A mechanical axis of
0to 3of varus is considered to be within normal limits
19,23
.
Generally, a varus or valgus deviation of 10is associated
with symptoms of unicompartmental arthritis
19
.
Nonoperat i ve Management of
Uni compar t ment al Ost eoar t hri t i s of t he Knee
Oral Medications, Nutritional
Supplements, and Topical Analgesics
Analgesic medications without anti-inflammatory properties,
such as acetaminophen, are the initial medications used to
treat degenerative arthritis of the knee. These medications are
effective in relieving pain, they are associated with a low inci-
dence of side effects, and they are inexpensive
24-26
. Nonsteroi-
dal anti-inflammatory medications are the most commonly
used drugs for treatment of degenerative arthritis of the knee
and other joints
25-28
. These drugs, which inhibit cyclooxygenase
1 and 2, have analgesic and anti-inflammatory properties, but
they can be associated with gastrointestinal and other side ef-
fects. In a short-term clinical trial in which acetaminophen
and ibuprofen, in analgesic and anti-inflammatory doses, were
compared as treatments for symptomatic arthritis of the knee,
the efficacy of the two drugs was equivalent
24
. When nonste-
roidal anti-inflammatory drugs are used chronically, it is im-
portant for patients to have medical monitoring of hepatic,
renal, and gastrointestinal systems
28
. Specific cyclooxygenase-2
inhibitors have demonstrated clinical efficacy in the treatment
of symptomatic arthritis of the knee, with decreased gas-
trointestinal and renal side effects. However, specific cyclooxy-
genase-2 inhibitors are more expensive, and risk-benefit and
cost-benefit analyses must be completed to better define the role
of these agents
26,28
.
Nutritional supplements (so-called nutriceuticals), such
as glucosamine and chondroitin sulfate, have been touted as
chondroprotective agents. Double-blind, placebo-controlled,
randomized trials have shown that glucosamine is mildly ef-
fective for relieving pain associated with degenerative
arthritis
26,29-32
. In a study by Reginster et al.
33
, 212 patients with
osteoarthritis of the knee were randomized to a glucosamine
or a placebo treatment group. After three years of treatment,
the glucosamine group had less joint-space narrowing and
improved WOMAC (Western Ontario and McMaster Univer-
TABLE I Out erbri dge
54
Gradi ng Syst em for Car t i l agi nous
Degenerat i on
Stage I Soft discolored superficial fibrillation
Stage II Fragmentation <1.3 cm
2
Stage III Fragmentation >1.3 cm
2
Stage IV Erosion to subchondral bone (eburnation)
TABLE II Ahl bck
3
Gradi ng Syst em for Degenerat i ve
Ar t hri t i s
Stage I J oint space narrowing
Stage II J oint space obliteration
Stage III Minor bone attrition
Stage IV Moderate bone attrition
Stage V Severe bone attrition
Stage VI Subluxation
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sity Osteoarthritis Index) scores when compared with the pla-
cebo group. However, we are not aware of any long-term
studies demonstrating beneficial effects of glucosamine on the
articular cartilage of an arthritic joint
26,29
. Some patients with
unicompartmental arthritis of the knee report improvement
with use of topical analgesics (e.g., methyl salicylate, capsaicin,
and nonsteroidal creams) as either adjunctive treatment or
monotherapy
34
.
Injectable Intra-Articular Medications
Acute exacerbations of degenerative arthritis of the knee pre-
senting with pain, swelling, and effusion can be treated with as-
piration of the knee joint and intra-articular injection of a
corticosteroid preparation. Corticosteroid injections are fre-
quently combined with a local anesthetic medication, and these
injections can provide short-term symptomatic relief. How-
ever, corticosteroid injections can increase the risk of damage to
the articular cartilage of the injected knee joint, and they should
not be repeated more than three or four times a year
35
.
Intra-articular injection of hyaluronan is intended to pro-
vide so-called viscosupplementation or restoration of the rheo-
logical properties of synovial fluid in the arthritic knee. These
high-molecular-weight solutions are expected to supplement
the reduced concentration of hyaluronan in arthritic knees. It
has also been suggested that hyaluronan therapy may alter the
progression of arthritis of the knee and may decrease inflamma-
tion of the synovial membrane compared with that associated
with corticosteroid injections
17,36
. Short-term studies
17,37,38
have
suggested that there is no advantage of hyaluronic acid visco-
supplementation over nonsteroidal anti-inflammatory drugs in
the treatment of an arthritic knee. When hyaluronan injection
was compared with corticosteroid injection for treatment of ar-
thritis of the knee, the effects of hyaluronic acid viscosupple-
mentation were found to be slower in onset, the treatment was
more expensive, and it was associated with a higher risk of a
local inflammatory response
39
. However, the use of hyaluronic
acid viscosupplementation in patients who were older than the
age of sixty years and had severe disease provided longer-lasting
relief of symptoms than did intra-articular corticosteroid
injections
34,39,40
. More information on the appropriate use of this
treatment is expected from prospective, double-blind, placebo-
controlled studies.
Weight Loss
The reduction of joint reaction forces and symptoms of de-
generative arthritis by a decrease in body mass is a fundamen-
tal concept in the management of arthritic joints
34
. Obesity is
an independent risk factor for the development of osteoarthri-
tis in the knee
41
, and this association is higher for women than
for men
42
. Women over the age of fifty with malalignment
have a higher prevalence of degenerative arthritis of the knee
than do age-matched control subjects in the general, nonaf-
fected population
43
. Weight loss by obese women decreases the
risk of the development of degenerative arthritis. A weight loss
of 5.1 kg over ten years has been shown to decrease the risk of
degenerative arthritis by >50%
44
.
Exercise and Physical Therapy
Exercise, as an adjunct to weight reduction, has value in the
treatment of an arthritic knee. Stretching to prevent contrac-
ture, maintain range of motion, increase muscle strength, and
increase dynamic stability of the knee can reduce symptoms
associated with an arthritic knee
17
. Quadriceps muscle weak-
ness is common among patients with degenerative arthritis of
the knee and may be a risk factor for this disease. Patient edu-
cation programs and supervised fitness and walking sessions
have been shown to improve functional status without wors-
ening the symptoms of osteoarthritis of the knee
45
. Physical
therapy modalities, such as cold treatments, hydrotherapy, ul-
trasonography, iontophoresis, and massage, can help to re-
duce swelling and stiffness during a period of exacerbation of
symptoms. Heat treatments can be used to decrease morning
stiffness, reduce start-up discomfort, and serve as a warm-up
for exercise
24,39
.
Ambulatory Support Devices
During a period of acute exacerbation of symptoms in a knee
with degenerative arthritis, ambulatory support devices can
help a patient to remain active in the presence of a painful,
swollen knee
17,26,39
. A cane in the hand contralateral to a knee
with arthritis can decrease the weight-bearing load on the de-
generated knee joint by 30% to 60%
34,46
. One or two crutches
can further decrease the load.
Braces
Three types of knee braces are commercially available for
treatment of a knee with degenerative arthritis: compression
knee sleeves, supportive knee braces, and unloading knee
braces. Polypropylene, neoprene, or elasticized knee sleeves
may minimize swelling and provide a feeling of increased sup-
port and warmth about the knee without changing limb align-
ment, joint stability, or mechanical function. Some patients
report a feeling of security with a knee sleeve, possibly because
of enhanced proprioceptive feedback
17
. Supportive knee braces
include hinged braces (for varus-valgus instability), anterior
cruciate insufficiency braces (for anteroposterior and rotatory
instability), and patellofemoral braces (for patellofemoral
malalignment or instability). Unloading braces are designed
to apply a varus or valgus force at the knee and relieve pain
during activity by distracting the joint space of the involved
compartment during weight-bearing and activity
47
. A fluoro-
scopic gait study
48
demonstrated that condylar separation of
the medial tibiofemoral joint space can be achieved with an
unloading knee brace in patients with medial unicompart-
mental arthritis. All patients (twelve of fifteen) in whom
condylar separation was achieved during gait in that study had
a decrease in symptoms. Failure of the unloading knee brace
was associated with obesity and a poor fit of the brace. Other
studies
42,49,50
have demonstrated similar efficacy of unloading
knee braces. However, patient compliance and high cost have
been mentioned as problems with unloading knee braces.
They are difficult to wear for extended periods of time because
of their size and because of the degree of force imparted to the
I,,
limb to alter alignment
51
. The use of these devices on valgus
knees with lateral compartment arthritis has not been re-
ported, to our knowledge.
Footwear Modification and Orthotics
Well-padded, energy-absorbing shoe soles or orthotic devices
can decrease the load across the knee joint during heel strike.
Deformity of the ankle, hindfoot, or midfoot leading to limb
malalignment can exacerbate tibiofemoral arthritic symp-
toms. Orthotic correction and supportive, adaptive footwear
with a medial longitudinal arch support, a calcaneal cushion,
and a rigid last can improve alignment of the foot. An ankle-
foot orthosis may be necessary for severe ankle deformity,
which can aggravate preexisting degenerative arthritis of the
knee
17,26
.
Heel and sole wedges can realign the foot 5to 10in
either the varus or the valgus plane. With a lateral wedge and
insole, the shift in alignment reduces medial joint-space
loading
52
. Keating et al.
53
evaluated 121 knees with medial uni-
compartmental arthritis in eighty-five patients who were
treated with a lateral heel and sole wedge. Sixty-one of the 121
knees had a good or excellent result after four to twenty-four
months of treatment. Knees with all grades of arthritic in-
volvement showed improvement. Patients with stage-II dis-
ease according to the modified Outerbridge classification
54
had
the most improvement. The use of heel and sole wedges for
patients with arthritis of the lateral compartment of the knee
has not been reported, to our knowledge.
Operat i ve Management of
Uni compar t ment al Ar t hri t i s of t he Knee
Arthroscopy
Arthroscopy of a painful arthritic knee permits a surgeon to
define the extent of degenerative disease, formulate a treat-
ment plan based on those findings, and correct mechanical
problems that are amenable to arthroscopic treatment
55-57
. It
has been difficult to correlate the definition of the size and
character (shape, depth, and integrity of the border) of articu-
lar cartilage lesions with the extent and degree of success of ar-
throscopic intervention by comparing studies of arthroscopic
treatment of knees with degenerative arthritis. However, sub-
optimal outcomes following arthroscopic surgery of the knee
have been associated with greater arthritic deterioration on
preoperative radiographs, limb malalignment, and calcium
pyrophosphate deposition
58,59
.
The use of arthroscopy of the knee to treat unicompart-
mental arthritis is controversial because the procedure cannot
alter the natural history of the disease
60,61
. Arthroscopic lavage
of the knee without dbridement may mitigate symptoms in
the short term by dilution of inflammatory cytokines
17,58,62
, and
there have been several retrospective studies of arthroscopic
treatment of degenerative arthritis of the knee, with both
favorable
57,58,63-66
and unfavorable
60,67-69
results. Moseley et al.
70
questioned the benefit of arthroscopic surgery as a treatment
for arthritis of the knee in a study in which they compared a
placebo group with a group treated with arthroscopic joint la-
vage and another group treated with arthroscopic dbride-
ment. All three treatment groups had a decrease in symptoms
up to two years after intervention. This study was confined to
older men in a Veterans Administration Hospital. The extent
of the arthritic involvement of the knee (in one, two, or three
compartments) was not documented. The patients were not
stratified according to the degree of malalignment, body
weight, or type of symptoms. The authors concluded that ar-
throscopy of a knee with degenerative arthritis may not be in-
dicated when there is only pain in the absence of other
symptoms (such as catching, clicking, locking, or giving-way).
Furthermore, they suggested that a decrease in symptoms af-
ter arthroscopy may be associated with a placebo effect.
Arthroscopic dbridement for isolated unicompartmen-
tal arthritis of the knee has been reported to be beneficial for
patients with mild degenerative disease, normal alignment,
and an unstable meniscal tear
59,66,71-73
. Varus malalignment is a
more negative prognostic factor than is valgus malalignment
when predicting whether arthroscopic dbridement will be
successful for the treatment of unicompartmental arthritis of
the knee
66
.
Operative Treatment of Damaged Articular Cartilage
Focal defects of articular cartilage secondary to trauma or os-
teochondritis dissecans have limited capacity for repair and
often progress to osteoarthritis with symptoms of pain, swell-
ing, and stiffness
13,15,74
. The Pridie operationwhich involves
an arthrotomy; dbridement of osteophytes, loose bodies, me-
niscal fragments, and ligamentous debris; and drilling of ex-
posed subchondral bone to encourage a fibrocartilaginous
repairhas a success rate similar to that of other fibrocartilag-
inous stimulation techniques
75
. In one series
75
, forty-six of
sixty patients were satisfied with the result of this operation
and thought that it was a success and five patients believed
that they were worse off than they had been preoperatively.
With the arthroscopic microfracture technique, an awl is
used to crack exposed or eburnated condylar bone, create sub-
chondral bleeding, and stimulate development of fibrocar-
tilage
76,77
. Arthroscopic abrasion arthroplasty
78
is an arthroscopic
modification of open dbridement
75,79-81
. With that procedure,
arthroscopic tools are used to dbride the joint and a rotatory
instrument is employed to abrade sclerotic bone and stimulate
fibrocartilage formation. Lesions >2 cm
2
are more likely to
progress to arthritis because of the inability of fibrocartilage to
effectively replace hyaline cartilage in these defects
13-15
.
In patients with focal defects of articular cartilage in
whom arthroscopic dbridement is not successful and micro-
fracture or abrasion arthroplasty is not likely to succeed, im-
plantation or transplantation of articular cartilage may be a
reasonable treatment option. Three methods of implantation
of articular cartilage are available at this time: (1) autologous
osteochondral plug transfer, (2) autologous chondrocyte im-
plantation, and (3) osteochondral allograft transplanta-
tion
13,15,82-98
. To our knowledge, a comparison of the long-term
results of these procedures has not been published. We are also
not aware of any studies on the use of these techniques in the
I,,,
treatment of unicompartmental arthritis; their role remains to
be defined.
For cartilage implantation or transplantation to be suc-
cessful, as defined by reduced pain, improved function, and a
satisfied patient, the limb must be well aligned and the knee
must be stable. If the mechanical axis of the limb passes through
the compartment with the damaged articular cartilage, align-
ment must be shifted to relieve the stress on that compartment.
Realignment can be achieved with osteotomy
99,100
. Instability
secondary to ligamentous or meniscal pathology can be associ-
ated with progression of chondral damage, and instability must
be corrected to minimize force transmission to the surgically al-
tered articular cartilage
16,17,101
.
Patients with low-grade unicompartmental arthritis of
the knee (Outerbridge stage II or lower) and a previous menis-
cectomy have been reported to have had good results at a maxi-
mum of five years after meniscal transplantation
17,102-105
. Meniscal
allografts may not be useful in patients with advanced osteoar-
thritis, instability, or deformity. Short-term follow-up of pa-
tients treated with meniscal allograft transplantation combined
with osteotomy and/or anterior cruciate ligament reconstruc-
tion has shown promising results
106
.
Osteotomy
Limb malalignment can accentuate stress on damaged articular
cartilage, leading to pain, progressive loss of articular cartilage,
and increasing angular deformity of the knee. The goal of os-
teotomy in the treatment of unicompartmental arthritis of the
knee is to realign the limb and shift weight-bearing force from
the degenerated tibiofemoral compartment to the healthier
compartment. As long as overcorrection is avoided, corrective
osteotomy of the knee is associated with biological improve-
ment of damaged articular cartilage with maintenance of artic-
ular cartilage in the less degenerated compartment
107-109
.
Patient selection is critical to the success of knee
osteotomy
100
, which may be considered for patients with a
high-demand, active lifestyle whose life expectancy exceeds
the expected survival of a knee prosthesis. Stability of the knee
and a functional range of motion are generally required for a
successful osteotomy, and inflammatory arthritis and knee
stiffness are generally contraindications
17,19
. Instability due to
anterior cruciate ligament insufficiency can be corrected with
reconstruction of that ligament. The reconstruction can be
combined with osteotomy, as staged or simultaneous proce-
dures, in order to unload an arthritic compartment and re-
store stability of the knee
101
.
Correction of deformity is critical to the success of a
knee osteotomy. The normal mechanical axis of the limb, de-
fined as a line from the center of the hip joint to the center of
the ankle joint, should pass through or just medial to the cen-
ter of the knee joint. Angular deformity of the limb can be
measured as the angle subtended at the knee by a line through
the center of the femoral head and the center of the knee, and
extended to the floor, and a line from the center of the knee to
the center of the ankle. An angle of 0to 3of varus is consid-
ered normal
19,23
. The angle of correction of an osteotomy is
determined by adding to the deformity of the limb an overcor-
rection of 2to 4to ensure a shift of the weight-bearing force
to the uninvolved compartment
110
.
Varus Unicompartmental Arthritis
A stable knee with arthritis of the medial compartment associ-
ated with a varus deformity, without subluxation or lateral
thrust, and with an arc of motion of 90may be treated with a
proximal tibial valgus osteotomy
17,19,110,111
. Mild-to-moderate
patellofemoral arthritis is not a contraindication to a success-
ful outcome of a high tibial osteotomy
112
. Several surgical tech-
niques to correct varus deformities at the knee, including
lateral closing-wedge osteotomy, medial opening-wedge os-
teotomy, and dome osteotomy of the proximal part of the
tibia, have been described.
The most common technique for proximal tibial valgus
osteotomy is creation of a lateral closing wedge, which can be
stabilized with internal fixation (staples, plate, screws, or ten-
sion band), external fixation, or a cast. Billings et al.
113
de-
scribed a technique involving plate-and-screw fixation that
provided reproducible angular correction, created stability at
the osteotomy site, allowed early motion of the knee, and pro-
vided predictably successful results. Other methods of per-
forming proximal tibial valgus osteotomy include a dome cut
(which permits greater angular correction without shortening
the limb
114
), an interlocking-wedge osteotomy (which can ad-
vance the tibial tubercle anteriorly
115
), and proximal tibial val-
gus osteotomy combined with tibial tubercle elevation
osteotomy (which permits a more distal wedge cut)
110
.
Proximal tibial valgus osteotomy can also be performed
with a medial opening-wedge osteotomy in the proximal part
of the tibia. Methods of fixation for medial opening-wedge
osteotomy include plate-and-screw fixation with or without
autogenous or allogeneic bone graft
116
, a hemicallotasis tech-
nique with external fixation
117
, and small-wire external fixa-
tion. The potential advantages of medial opening-wedge
osteotomies fixed with plates and screws include a simple re-
producible bone cut, no disruption of the proximal tibiofibu-
lar joint, minimized risk of peroneal nerve injury, avoidance
of patella infera, and prevention of contracture of the patellar
tendon due to its resultant redundancy
116
.
Medial opening-wedge osteotomy of the proximal part
of the tibia with use of porous hydroxyapatite to treat osteoar-
thritis of the medial compartment of the knee was successful
in a series of twenty-one knees in eighteen patients followed
for an average of 78.6 months (range, thirty-eight to 114
months)
118
. All patients had pain relief and improvement in
walking ability. No patient required conversion to total knee
arthroplasty or had graft collapse. External fixation methods
can be associated with pin track infection, nonunion, and
deep venous thrombosis. In addition, an external frame is re-
quired for an average of seven weeks.
A nine-year survivorship analysis of 113 knees treated
with proximal tibial valgus osteotomy demonstrated a ten-
dency for recurrence of varus alignment of >5(in 18% of the
knees), progression of lateral compartment arthritis (in 60%),
I,,o
and progression of medial compartment arthritis (in 93%)
119
.
The probability of progression of the arthritis was much higher
than was the probability of recurrence of varus malalignment.
The Mayo Clinic has a forty-year experience with proxi-
mal tibial osteotomy for treatment of medial tibiofemoral
arthritis and varus deformity of the knee. Prior to the popu-
larization of total and unicompartmental knee arthroplasty,
Coventry et al.
120
reported the results of eighty-seven osteoto-
mies in seventy-three patients followed for a median of ten
years. With failure defined as the performance of a total knee
arthroplasty after the osteotomy, the survivorship was 89% at
five years and 75% at ten years. If, at one year after the opera-
tion, the valgus angulation of the anatomic axis (femorotibial
angle) was <8or if the patients weight was more than 1.32
times the ideal body weight, the survivorship decreased to
38% at five years and to 19% at ten years.
Insall et al.
112
reported on ninety-five knees followed for
an average of 8.9 years (range, five to fifteen years) after a
proximal tibial valgus osteotomy. Eighty-one knees had a
good or excellent result at five years, and sixty had a good or
excellent result at nine years. Twenty-two knees underwent
conversion to a total knee arthroplasty. Although varus defor-
mity recurred after the osteotomy in twenty-nine knees, the
lack of ideal alignment (10of femorotibial valgus) was not
necessarily associated with an unsatisfactory result. The au-
thors concluded that total knee arthroplasty is a more suitable
operation for patients who are more than sixty years old and
that high tibial osteotomy should be reserved for more active
patients. In a subsequent outcome study by the same group,
proximal tibial valgus osteotomy met the expectations of
twenty-eight of thirty-four men with high demands (average
age, forty-nine years)
121
.
Noyes et al.
101
evaluated the results of proximal tibial val-
gus osteotomy and anterior cruciate ligament reconstruction in
forty-one patients (mean age, thirty-two years; range, sixteen to
forty-seven years) with symptomatic varus malalignment and
chronic anterior cruciate ligament insufficiency. At a mean of
fifty-eight months (range, twenty-three to eighty-six months),
ten of fifteen patients with severe arthritis of the medial com-
partment had a significant decrease in symptoms (p < 0.05).
The authors recommended anterior cruciate ligament recon-
struction and proximal tibial osteotomy for patients with me-
dial unicompartmental arthritis and functional instability who
plan to return to high-demand athletic activities.
Holden et al.
122
studied fifty-one knees in forty-five pa-
tients who had undergone proximal tibial valgus osteotomy
before the age of fifty (average age, forty-one years; range,
twenty-three to fifty years). At an average of ten years, 70% of
the knees were rated good or excellent. Deficiency of the an-
terior cruciate ligament at the time of the osteotomy did not
prevent a good result. In a study of 106 high tibial valgus oste-
otomies in eighty-five patients followed for a minimum of ten
years, Naudie et al.
123
reported a survivorship of 73% at five
years, 51% at ten years, 39% at fifteen years, and 30% at twenty
years. An age of more than fifty years, previous arthroscopic
dbridement, a lateral thrust, preoperative knee flexion of <120,
insufficient valgus correction, and delayed union or nonunion
were significantly associated with early failure (p 0.05). A sub-
set of patients who were younger than fifty years of age and
who had had preoperative knee flexion of >120had a proba-
bility of survival (no need for conversion of the high tibial os-
teotomy to a total knee arthroplasty) approaching 95% at five
years, 80% at ten years, and 60% at fifteen years
123
. Numerous
studies
124,125
have demonstrated similar results.
Total knee arthroplasty after a failed proximal tibial
closing-wedge osteotomy can be more difficult to perform
than a primary knee replacement because of a shift of the
proximal tibial articular surface in relation to the medullary
canal, osseous insufficiency of the lateral aspect of the proxi-
mal part of the tibia, and altered patellofemoral mechanics
caused by patella infera and contraction of the patellar ten-
don. The clinical results of total knee arthroplasty after high
tibial osteotomy vary. Windsor et al.
126
reported that they were
not as satisfactory as those after primary total knee arthro-
plasty, with thirty-two of forty-five knees having a good or ex-
cellent result at a minimum of two years. Katz et al.
127
compared the results of twenty-one total knee arthroplasties
after high tibial osteotomy with those of twenty-one primary
total knee arthroplasties. Seventeen of the arthroplasties done
after an osteotomy had a good or excellent result, whereas all
twenty-one of the primary total knee arthroplasties had a
good or excellent result. In contrast, Staheli et al.
128
reported
that thirty-one of thirty-five patients treated with total knee
arthroplasty after an osteotomy of the proximal part of the
tibia had a good or excellent result. Meding et al.
129
evaluated
the results of ninety-five consecutive total knee replacements
performed in eighty-two patients at an average of ten years
and four months after high tibial osteotomy. While the num-
ber of previous operative procedures and the severity of pre-
operative flexion contracture were related to diminished
postoperative motion, the previous high tibial osteotomy had
no adverse effect on the eventual results of the posterior cruci-
ate ligament-retaining total knee arthroplasty performed with
cement fixation.
Valgus Unicompartmental Arthritis
Lateral tibiofemoral unicompartmental arthritis associated with
valgus deformity is less common than is medial unicompart-
mental arthritis associated with varus deformity
17,72
, and valgus
deformities are more common in women than in men
72
. Valgus
deformity may include contraction of the lateral soft-tissue
structures, laxity of the medial collateral ligament, and distal
lateral femoral hypoplasia or bone loss. External rotation or re-
curvatum of the knee can also develop in these patients
9,17,72,130,131
.
Joint line obliquity can be associated with lateral unicompart-
mental arthritis and is a consideration in the choice of correc-
tive osteotomy. Large valgus deformities can be associated with
increased valgus tilt of the joint line. A proximal tibial varus os-
teotomy cannot correct the tilt of the joint line because the os-
teotomy is performed distal to the joint line. Distal femoral
varus osteotomy may correct valgus tilt in more severely valgus
knees. Associated insufficiency of the medial collateral ligament
I,,,
and medial thrust (low adductor moment) can cause dynamic
deformity and failure of an osteotomy unless it is corrected at
the time of the osteotomy
132,133
.
Proximal tibial varus osteotomy can be used to treat
lateral unicompartmental arthritis in patients with a tibiofem-
oral angular deformity of 12of valgus and a predicted joint-
line obliquity of 10
17,72,100,132
. Coventry
132
performed a closing-
wedge varus osteotomy of the medial aspect of the proximal
part of the tibia in thirty-one knees in twenty-eight patients
who had painful unicompartmental arthritis of the lateral
compartment. The patients were followed for an average of
9.4 years (range, two to seventeen years). Six knees required
total knee arthroplasty at an average of 9.8 years after the os-
teotomy. Twenty-four knees had either no pain or mild pain at
the last evaluation. Marti et al.
134
performed an opening-wedge
varus osteotomy of the lateral aspect of the proximal part of
the tibia in thirty-six patients with an average valgus defor-
mity of 11.6. They reported thirty good or excellent results at
an average of eleven years, with the best results obtained in pa-
tients with isolated lateral arthritis who had undergone a
Fig. 1-A
Posteroanterior standing radiograph
made with the knee in 40 of flexion of
a thirty-eight-year-old woman with de-
generative arthritis of the lateral com-
partment and valgus malalignment of
the right knee.
Fig. 1-B
Fi g. 1-B Anteroposterior standing radiograph made after distal femoral varus osteotomy. Fi g. 1-C Eight-year follow-up anteroposterior stand-
ing radiograph made after implant removal, showing maintenance of the lateral joint space.
Fig. 1-C
I,,8
proximal lateral opening-wedge varus osteotomy.
Distal femoral varus osteotomy can be used to treat lat-
eral tibiofemoral arthritis in patients with a preoperative ti-
biofemoral angle of >12or a predicted joint-line obliquity of
>10after osteotomy
72,99,135-137
(Figs. 1-A, 1-B, and 1-C). Healy
et al.
99
reported the results of twenty-three distal femoral varus
osteotomies in twenty-one patients followed for an average of
four years (range, two to nine years). Nineteen of the twenty-
three knees had a good or excellent result as rated with The
Hospital for Special Surgery knee score. Fifteen of sixteen
knees with lateral tibiofemoral arthritis and valgus deformity
had a good or excellent result. Rheumatoid arthritis and inad-
equate preoperative motion were associated with poor results.
Intermediate-term results reported by other authors
135-137
con-
firmed these findings. In a long-term evaluation of twenty-
one patients treated with distal femoral varus osteotomy for
lateral unicompartmental arthritis, Finkelstein et al.
138
found a
ten-year survivorship of 64%, with conversion to total knee
arthroplasty as the end point. In patients with severe valgus
deformity in whom a single osteotomy will result in excessive
bone loss or joint line obliquity, a distal femoral varus osteot-
omy can be combined with a proximal tibial medial osteot-
omy to obtain correction
72
.
Unicompartmental Knee Arthroplasty
Arthroplasty is considered for treatment of painful unicompart-
mental arthritis when restoration of the articular cartilage and os-
teotomy are not indicated. The choice of unicompartmental or
total knee arthroplasty depends on the patient, the knee, and the
surgeon. The ideal candidate for unicompartmental knee arthro-
plasty has low activity demands, a stable knee with <15of flexion
contracture, no varus or valgus malalignment or minimal mala-
lignment that can be passively corrected on examination, and
unicompartmental osteoarthritis with no or minimal degenera-
tion of the articular cartilage of the contralateral compartment or
patellofemoral joint
139,140
(Figs. 2-A through 2-D). In general, pa-
tients with unicompartmental osteoarthritis and osteonecrosis
are suitable candidates for unicompartmental knee arthro-
plasty
19,141
, while patients with inflammatory arthritis are not
140
.
The early results of unicompartmental knee arthroplasty
were discouraging
142-144
, but evolution of patient selection, surgi-
cal technique, and implant design over the past thirty years has
refined the indications and improved the clinical outcome. The
optimal age for unicompartmental knee arthroplasty is not
clear, and there is controversy about its use in active younger
patients (less than sixty years old). Youth and high activity de-
Fig. 2-A
Anteroposterior standing radiograph of a forty-five-year-old woman
with symptoms in the lateral compartment of the left knee and a
normal mechanical axis.
Fig. 2-B
Lateral radiograph showing minimal patellofemoral degenerative
arthritis.
I,,,
mand have been associated with poorer results
141,145
. In patients
with medial unicompartmental arthritis, the best results are ob-
tained when the postoperative mechanical axis is in the center
or slightly medial to the center of the knee. Overcorrection and
severe undercorrection have been associated with early failure
146
.
In patients with lateral unicompartmental arthritis, the cor-
rected mechanical axis should be in the lateral compartment,
medial to the preoperative mechanical axis
143,147,148
. Poor results
have been reported as a result of technical problems such as in-
adequate implant fixation, poorly designed articulating surfaces
(nonconforming articulations), and insufficient polyethylene
thickness
143,145,148-154
.
Unicompartmental knee arthroplasty has several poten-
tial advantages over total knee arthroplasty. The surgical ap-
proach and surgical dissection can be considerably less extensive
for unicompartmental knee arthroplasty
155
. Patellar resurfacing
is avoided. Requirements for perioperative blood transfusion
are diminished
156
. The range of motion following unicompart-
mental knee arthroplasty is generally greater
156-158
. Properly se-
lected patients have a shorter postoperative recovery time, and
they return to work or to preoperative activities faster. Further-
more, revision of a unicompartmental arthroplasty is less diffi-
cult than is revision of a total knee arthroplasty
156
.
More recent intermediate and long-term follow-up
studies of unicompartmental knee arthroplasty performed
with a well-designed implant in properly selected patients
have demonstrated predictably good results comparable with
those of total knee arthroplasty during the first postoperative
decade
145,147
. In a study of 100 unicompartmental arthroplasties
followed for eight to twelve years, in patients with a mean age
of seventy-one years at the time of the operation, Scott et al.
147
reported an 85% survivorship at ten years, with the end point
defined as revision arthroplasty. Thirteen patients underwent
revision. Stockelman and Pohl
159
reported forty-three satisfac-
tory results and four revision operations at an average of 7.4
years (range, five to twelve years) after forty-seven unicom-
partmental knee arthroplasties. In a study of sixty-two uni-
compartmental knee arthroplasties in patients with an average
Fig. 2-C
Posteroanterior standing radiograph made with the knee in
40 of flexion, demonstrating osteoarthritis in the lateral
compartment.
Fig. 2-D
Postoperative anteroposterior standing radiograph made
five years after a unicompartmental knee arthroplasty. The
mechanical axis is now in the center of the knee joint.
I,oo
age of sixty-eight years (range, fifty-one to eighty-four years),
Berger et al.
160
reported a 98% survivorship at ten years, with
revision to total knee arthroplasty as the end point. One
patient required revision to a total knee arthroplasty at eighty-
seven months. Christensen
161
reported that seven of 575 uni-
compartmental prostheses required revision to a total knee
arthroplasty at two to eleven years. Squire et al.
162
reported that
fourteen of 140 cemented unicompartmental knee prostheses
in patients with an average age of seventy years required revi-
sion to a total knee arthroplasty after fifteen to twenty-two
years of follow-up. In a study of 143 medial Oxford unicom-
partmental knee arthroplasties followed for a mean of 7.6
years, the survivorship was 98% at ten years
163
. Five knees re-
quired revision to a total knee arthroplasty.
Revision of a failed unicompartmental knee arthroplasty
to a total knee arthroplasty can be accomplished successfully
but may be associated with technical difficulties. Barrett and
Scott
164
reported a good or excellent result in thirteen of twenty-
nine patients at an average of 4.6 years after they had undergone
a revision to a total knee arthroplasty. Treatment of osseous in-
sufficiency requiring augmentation with bone graft or bone ce-
ment and use of long-stem implants was necessary in 50% of
these revision operations. The authors suggested that the tech-
nique of the original operation determines the technical diffi-
culty of the revision surgery. When minimal bone was resected
during the unicompartmental knee arthroplasty, and primary
total knee arthroplasty implants can be used during the revision
surgery without bone augmentation, stems, or constrained im-
plants, revision to a total knee arthroplasty following unicom-
partmental knee arthroplasty can be as successful as primary
total knee arthroplasty
164
.
Unicompartmental knee arthroplasty and high tibial os-
teotomy have been used to treat unicompartmental arthritis in
similar patients. Broughton et al.
165
compared the results of
forty-two unicompartmental knee arthroplasties with those of
forty-nine high tibial osteotomies after an intermediate five to
ten-year follow-up. A good result was reported after thirty-two
of the forty-two unicompartmental knee arthroplasties at an
average of 5.8 years and after twenty-one of the forty-nine high
tibial osteotomies at an average of 7.8 years. The authors con-
cluded that the results of unicompartmental knee arthroplasty
were better than those of osteotomy, and the knees had less late
deterioration. Ivarsson and Gillquist
166
reported that patients
who had had unicompartmental knee arthroplasty demon-
strated better gait velocity and superior muscle strength com-
pared with those who had had an osteotomy.
Schai et al.
154
evaluated the results two to six years after
twenty-eight unicompartmental knee arthroplasties performed
in patients with an average age of fifty-two years. Twenty-five
patients had satisfactory pain relief, and two patients required
revision to a total knee arthroplasty. The conclusion of the study
was that, at two to six years, unicompartmental knee arthro-
plasty in middle-aged patients yields results (with revision con-
sidered the end point) that are competitive with those of
osteotomy but inferior to those of total knee arthroplasty.
Long-term survivorship analysis comparing the results of
unicompartmental knee arthroplasty in well-selected patients
with those of total knee arthroplasty are not available, to our
knowledge. In a short-term (six-month to four-year) study
comparing the results of thirty-one unicompartmental knee ar-
throplasties with those of 133 total knee arthroplasties, Weale et
al.
167
reported that the patient-perceived outcomes, pain scores,
and functional results were equivalent in the two groups. Lau-
rencin et al.
168
compared the results in twenty-three patients
who had had a unicompartmental knee arthroplasty on one
side and a total knee arthroplasty on the other; ten patients pre-
ferred the side with the unicompartmental procedure, three
preferred the side with the total knee arthroplasty, and ten
found no difference. Comparison studies
157,158
have shown that
patients with unicompartmental knee arthroplasty have a better
range of motion (flexion of >120) and walk faster than do
those treated with total knee arthroplasty.
Recently developed minimally invasive techniques for
unicompartmental knee arthroplasty have emphasized smaller
skin and capsular incisions, limited quadriceps disruption, and
decreased rehabilitation time. Long-term follow-up studies on
these techniques are not available, to our knowledge. Peer-
reviewed results have been reported for only 136 elderly patients
(average age, sixty-six years) followed for an average of eight
years; eleven patients required revision to a total knee arthro-
plasty
155
. Minimally invasive unicompartmental knee arthro-
plasty is an attractive surgical treatment option for elderly
patients with unicompartmental arthritis, and it may be pre-
ferred over osteotomy or total knee arthroplasty in these pa-
tients. Minimally invasive unicompartmental knee arthroplasty
has been described as a so-called pre-total knee arthroplasty op-
eration for patients of all ages
155
; however, this recommendation
requires further investigation and scientific support.
Total Knee Arthroplasty
Total knee arthroplasty is an accepted surgical treatment for
painful unicompartmental osteoarthritis of the knee in older
patients, and the prevalence of total knee arthroplasty is
increasing
169-173
. Total knee arthroplasty has also performed well
in younger patients
174-178
. When patients of any age with uni-
compartmental osteoarthritis and with any diagnosis are poor
candidates for other types of nonoperative and operative treat-
ment, total knee arthroplasty is an option. To our knowledge,
the results of total knee arthroplasty in patients with unicom-
partmental arthritis of the knee are no different than those in
patients with bicompartmental or tricompartmental degenera-
tive arthritis.
Aut hors Opi ni on and Concl usi ons
At the beginning of the twenty-first century, unicompartmen-
tal arthritis of the knee is a common clinical problem in the
United States, and many diverse nonoperative and operative
treatments are available. Oral and injectable medications,
weight loss, exercise, physical therapy, canes, crutches, braces,
orthotics, arthroscopy, cartilage resurfacing, osteotomy, and
arthroplasty offer patients and surgeons a wide spectrum of
successful treatment options.
I,oI
Arthroscopic surgery for unicompartmental arthritis of
the knee should be reserved for patients with mechanical
symptoms (catching, clicking, locking, instability, or giving-
way) that are consistent with loose meniscal fragments, chon-
dral articular flaps, loose bodies, and/or impinging intercon-
dylar spurs. When arthroscopy of the knee is performed for
mechanical symptoms, the outcome is predictably successful.
However, in sharp contrast, arthroscopic surgery performed
merely for a painful arthritic knee without mechanical symp-
toms may not have a lasting benefit
63
. Future studies are war-
ranted to determine whether arthroscopic surgery can benefit
patients who have primary mechanical symptoms with con-
comitant arthritic symptoms
179
.
When unicompartmental arthritis has developed in a
knee, consideration should be given to an attempt to delay or
ameliorate the degenerative process with biological treat-
ments. Historically, this advice was proposed for younger,
high-demand patients. However, as patients with arthritic
knees now live longer and desire active lifestyles, treatment
options for unicompartmental osteoarthritis should be con-
sidered in light of life expectancy and a patients desire for ac-
tivity. Osteotomy is an attractive surgical option for active
patients with unicompartmental arthritis and limb deformity
who are expected to live twenty years or more.
As a patients life expectancy and expectations for activ-
ity decrease as a result of age or disease, unicompartmental
knee arthroplasty and total knee arthroplasty become more
attractive options for the surgical treatment of unicompart-
mental arthritis of the knee. Unicompartmental knee arthro-
plasty can be a successful option, with enduring results, for
unicompartmental, noninflammatory arthritis. When patient
selection, surgical technique, and implant utilization are opti-
mized, unicompartmental knee arthroplasty can offer patients
a knee that is functionally superior to a total knee prosthesis,
and conversion to total knee arthroplasty can be performed
without substantial surgical difficulty. Minimally invasive uni-
compartmental knee arthroplasty may offer advantages with
regard to short-term rehabilitation over traditional arthro-
plasty approaches.
Total knee arthroplasty is a predictably successful treat-
ment for unicompartmental arthritis in the older population.
The surgical technique of total knee arthroplasty is more com-
monly mastered by general orthopaedic surgeons than are
alternative operations such as osteotomy and unicompart-
mental knee arthroplasty. Wear of bearing surfaces and im-
plant loosening are concerns in young active patients treated
with total knee arthroplasty; however, a well-performed total
knee arthroplasty in this population will provide an excellent
functional outcome for many years. Surgeons must consider
surgical skill and patient demands when choosing a surgical
treatment for unicompartmental arthritis of the knee.
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Artrosis Unicompartamental

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COPYRI GHT 2003 BY THE JOURNAL OF BONE AND JOI NT SURGERY, INCORPORATED

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