Perspectives on Modern Orthopaedics

Unicompartmental
Knee Arthroplasty
Todd Borus, MD

Abstract

Thomas Thornhill, MD

Recent increased interest in less invasive surgical techniques has

led to a concurrent resurgence in unicompartmental knee
arthroplasty. The procedure has evolved significantly over the past
three decades. Proponents of unicompartmental knee arthroplasty
cite as advantages lower perioperative morbidity and earlier
recovery. Both clinical outcome and kinematic studies have
indicated that successful unicompartmental knee arthroplasty
functions closer to a normal knee. Recent reports have
demonstrated success in expanding the classic indications of
unicompartmental knee arthroplasty to younger and heavier
patients. Both fixed- and mobile-bearing implants can yield
excellent clinical outcomes at >10 years, but with different modes
of long-term failure. Proper execution of surgical technique
remains critical to optimizing outcome. Long-term studies are
needed to appropriately define the role of less invasive
unicompartmental surgical approaches as well as the role of
computer navigation.

Dr. Borus is Orthopaedic Surgeon,

Northwest Surgical Specialists,
Vancouver, WA. Dr. Thornhill is Chair,
Department of Orthopaedic Surgery,
Brigham and Womens Hospital,
Boston, MA.
Neither Dr. Borus nor a member of his
immediate family has received anything
of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article. Dr. Thornhill or a
member of his immediate family has
received research or institutional
support from DePuy, Smith & Nephew,
and Biomet, has received royalties from
DePuy, and has stock or stock options
held in Conformis.
Reprint request: Dr. Thornhill,
Department of Ortthopaedic Surgery,
Brigham and Womens Hospital, 75
Francis Street, Boston, MA 02115.
J Am Acad Orthop Surg 2007;15:9-18
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

Volume 16, Number 1, January 2008

urgical management of unicompartmental arthrosis of the knee

continues to generate substantial
controversy. Implant design, surgical
indications and contraindications,
and techniques of modern unicompartmental knee arthroplasty (UKA)
continue to evolve since studies
were reported in the early 1970s.
The recent increase in popularity of
minimally invasive knee surgery has
spawned a resurgent interest in
UKA, which is amenable to implementation through smaller incisions
than traditional total knee arthroplasty (TKA).

Unicompartmental
Knee Arthroplasty in the
Surgical Treatment of
Osteoarthritis
In the 1970s, several studies cast
doubt on the benefit of UKA as a sur-

gical option for knee arthritis.1,2

However, advocates of UKA cite
multiple potential advantages of
UKA over TKA. Advantages of UKA
include the preservation of normal
knee kinematics, lower perioperative morbidity, less blood loss, and
accelerated patient rehabilitation
and recovery.3
Whether patient satisfaction and
overall clinical outcome after UKA
justify use of what is a technically
demanding procedure with a significant learning curve is undecided.
Several studies directly compare
patient perception and outcome
after UKA to other common surgical
alternatives, such as high tibial
osteotomy (HTO) and TKA.
Stukenborg-Colsman et al4 reported
a randomized, prospective study of
62 patients undergoing either UKA
or HTO. Kaplan-Meier survival analysis 7 to 10 years postoperatively
9

Unicompartmental Knee Arthroplasty

Figure 1

A, Intraoperative photograph of a unicompartmental knee replacement revised for

subtle loosening of the tibial component. B, Assessment of bone stock after
meticulous removal of components. Postoperative anteroposterior (C) and lateral
(D) radiographs after the revision procedure. Primary components were used with
no augments required on either the tibial or femoral side because bone loss in this
patient was minimal.

showed a survivorship of 77% for

UKA and of 60% for HTO, with a
higher rate of intraoperative and
postoperative complications in the
HTO group. However, improvements in UKA prosthetic design and
technique over those of the implant
used in the study might further magnify the clinical success rate in favor
of UKA.4
In a comparative study in patients
who underwent TKA on one side
and UKA on the contralateral side,
Laurencin et al3 demonstrated that
more patients preferred the UKA
side because it felt like a normal
knee and had better function. Moreover, in a prospective, randomized
10

study of 102 knees treated with either TKA or UKA, Newman et al5
showed that patients in the UKA
group had less perioperative morbidity, regained knee motion more rapidly, and had a higher percentage of
excellent outcomes based on the
Bristol knee score. Kinematics of the
knee after unicompartmental replacement have provided insight
into why patients may perceive a
more nearly normal knee function
after UKA. For example, Patil et al6
studied the kinematics of stair
climbing in a dynamic cadaveric
model and found that, with regard to
tibial axial rotation and femoral rollback, UKA more closely resembles

normal knee function than does

TKA.
Whether UKA potentially compromises the feasibility of a future
revision procedure remains questionable. Barrett and Scott7 reported
a good or excellent outcome in only
13 of 29 patients (45%) at an average
of 4.6 years following revision to
TKA. Despite these results, the authors suggested that if minimal bone
is resected at the initial procedure
and implants are observed closely for
evidence of wear or lysis, primary
TKA implants can be used at the
time of revision with successful outcomes. If bone augmentation, intramedullary implant stems, or constrained implants are required, the
results deteriorate.7
In a more recent series using improved UKA implants with better
polyethelene wear characteristics
and requiring less bone resection,
Levine et al8 reported that, in 31
failed UKAs revised to TKA, clinical
results were comparable to those of
primary TKA at follow-up of similar
length. In most cases, the posterior
cruciate ligament could be spared
and bone defects corrected with simple wedges or cancellous grafts.
McAuley et al9 similarly noted in a
series of 39 consecutive UKA revisions that all tibial bone defects
were managed effectively with local
autograft or wedge augmentation; no
patient required allograft bone or
structural grafting. Femoral bone
grafting also was not required in any
patient. The data seem to indicate
that, with modern implants and
close vigilance in monitoring for
progressive wear and bone loss, UKA
may not significantly impair the results of future revision (Figure 1).
Finally, it is important to consider the cost-effectiveness of UKA as a
surgical procedure. Soohoo et al10 recently demonstrated that UKA is indeed a cost-effective alternative to
TKA when measured in units of
quality-adjusted life years. This surgical outcome is predicated on the
assumption that durability and func-

Journal of the American Academy of Orthopaedic Surgeons

Todd Borus, MD, and Thomas Thornhill, MD

tional outcomes of UKA approach

those of TKA.

Indications for
Unicompartmental
Knee Arthroplasty
Classic Indications
Several algorithms have been
proposed to identify surgical candidates for UKA. Kozinn and Scott11
provided a framework of indications
and contraindications. Their criteria include a diagnosis of unicompartmental osteoarthritis or osteonecrosis in either the medial or
lateral compartment; age >60 years
with a low demand for activity;
weight <82 kg (181 lb); minimal pain
at rest; range of motion (ROM) arc
>90 with <5 flexion contracture;
and an angular deformity <15 that
is passively correctable to neutral.
Specific contraindications to UKA
are a diagnosis of inflammatory arthritis; patient age <60 years; high
patient activity level; pain at rest
(which may indicate an inflammatory component to the arthropathy);
and patellofemoral pain or exposed
bone in the patellofemoral joint or
opposite compartment. Asymptomatic chondromalacia in the patellofemoral joint is not a contraindication.
In an analysis of the surgical pathology from 4,021 knee arthroplasties, Ritter et al12 noted that only
6.1% of knees met these anatomic
qualifications for UKA and only
4.3% also met clinical standards ideal for UKA. Recent papers have
shown that with strict adherence to
the criteria of Kozinn and Scott, gratifying results can be achieved.13
Expanding Indications
Despite these generally wellaccepted and stringent selection
guidelines, recent studies have reported excellent results even as
these traditional indications are expanded. Some of the broadened criteria relate to patient demographics
such as age and weight. Pennington
Volume 16, Number 1, January 2008

et al14 reported on a retrospective series of UKA patients aged 60 years

(range, 35 to 60 years) with a survivorship of 92% at 11 years. Tabor et
al15 published a series noting comparable survival and clinical outcomes
of UKA in obese patients (body mass
index [BMI] >30) at up to 20 years
compared with nonobese patients.
These improved results in a heavier
and younger patient population may
reflect improvements in implant design and surgical technique; however, the data should be interpreted
with some caution because not all
studies have found similar success
in younger or heavier patients. In
their study of an obese population,
Berend et al16 found that a BMI >32
predicted failure and adversely affected survivorship in a series of 79
consecutive, minimally invasive
UKAs.
Traditionally, the presence of patellofemoral arthritis or an anterior
cruciate ligament (ACL)deficient
knee with unicompartmental arthritis has been considered a contraindication for UKA. However, Price et
al17 proposed that evidence of degenerative change of the patellofemoral
joint, either radiographically or by
direct inspection intraoperatively,
may be ignored if the patient does
not specifically have anterior knee
pain. We continue to view fullthickness chondral lesions with
eburnated bone in the patellofemoral joint as a contraindication to
UKA.
Controversy remains as to whether an ACL-deficient knee is a contraindication to medial unicompartmental replacement. Using a robotic
testing system, Suggs et al18 tested
the kinematics of anterior-posterior
tibial loads throughout the flexionextension arc of medial, fixedbearing UKA implants in ACLintact and ACL-deficient cadaveric
knee specimens. The results demonstrated markedly greater anterior
tibial translation in the specimens
with sectioned ACLs. The authors
postulate that if the ACL is deficient

in UKAs implanted in vivo, then

clinical instability may ensue, predisposing the lateral and patellofemoral compartments to continued articular damage. Moreover, Argenson
et al19 fluoroscopically studied in
vivo patients with medial fixedbearing UKAs. These authors demonstrated that patients with apparent ACL-deficiency had posterior
contact position between the femoral and tibial components in full extension, with subsequent paradoxical anterior femoral translation into
flexion. The result may increase anterior sliding of the femoral component on the tibial polyethylene, possibly accelerating the risk of
polyethylene wear.
Despite these theoretic risks of
performing UKA in patients with
ACL deficiency, Christensen20 reported equivalent results in patients
with a deficient ACL and those with
an intact ACL and suggested that an
intact ACL is not a prerequisite for a
well-functioning, durable UKA.
Hernigou and Deschamps21 also reported favorable results in UKAs in
ACL-deficient knees, provided that
the tibial component had been implanted at a slope of <7.
Lateral UKA is contraindicated in
ACL-deficient knees because the lateral compartment has inherently
more motion than does the medial
compartment and will be subjected
to even greater translation in the setting of ACL insufficiency. This can
result in an increased propensity for
sliding motion and abnormal contact positions, with a potentially
higher rate of failure.22 Increased failure rates also have been demonstrated in mobile meniscal bearing prostheses implanted in functionally
ACL-deficient knees because of instability and a propensity for meniscal bearing dislocation.23
Regarding the presence of osteonecrosis as a higher indication for
UKA, arthroplasty may be considered in the setting of primary, spontaneous osteonecrosis; however, secondary osteonecrosis (ie, secondary
11

Unicompartmental Knee Arthroplasty

to corticosteroid use) is a contraindication. In the setting of secondary

osteonecrosis, there is a higher incidence of synchronous or subsequent
osteonecrosis of the opposite compartment reported, potentially predisposing UKA to early failure. Preoperative
magnetic
resonance
imaging (MRI) is useful to evaluate
for the presence of multiple lesions
and to determine the extent of metaphyseal involvement of the lesion,
which may compromise implant fixation.

Preoperative
Assessment
Preoperative
clinical
decisionmaking in assessing a patient for
UKA includes a detailed patient history, physical examination, and radiographs. One particularly important aspect of the history is that the
patient should localize his or her
pain to either the medial or lateral
joint line, with minimal indication
of pain in the opposite compartment
or the retropatellar region. Bert24 has
labeled this concept the one-finger
test. Asked to locate his or her pain,
the patient points to the involved
compartment with one finger. This
concept is in contradistinction to
the patient who performs a knee
grab when asked to localize his or
her pain, indicating more global pain
distribution.
Routine radiographs include a
weight-bearing anteroposterior, a 45
flexed-knee posteroanterior, a lateral, and an axial patellofemoral view
to assess for degeneration of adjacent
compartments and to evaluate for tibiofemoral subluxation, which may
indicate ligamentous insufficiency.
We do not routinely use MRI or arthroscopic evaluation during the
preoperative assessment. The ultimate decision to proceed with UKA
is made intraoperatively, when the
status of the other compartments
can be directly visualized.
12

Design Considerations
for Successful
Unicompartmental
Knee Arthroplasty
General Principles
Design of UKA implants continues to evolve in terms of geometry,
materials, fixation techniques, and
bearing surfaces. Generally, successful implant design relies on the following principles. First, implant design should permit stable, long-term
fixation to host bone. Second, the
sagittal and coronal plane geometry
between the femoral and tibial components should strike a balance between optimizing contact area and
limiting constraint. Limiting contact area can minimize polyethylene
contact stresses and wear; overconstraint can lead to accelerated loosening. Both Schai et al25 and Hodge
and Chandler26 reported an increased
rate of prosthetic loosening in UKA
designs with more constrained topography. Because knee kinematics
are driven by the cruciate ligaments
and the unresurfaced compartment,
a fixed bearing UKA cannot be fully
conforming.
Fixed-bearing Versus
Mobile-bearing Design
Fixed-bearing tibial components
can be either all polyethylene or
metal backed. One of the earliest
fixed-bearing designs was the Marmor prosthesis (Smith & Nephew,
Memphis, TN), introduced for clinical use in the early 1970s.27 The
original Marmor prosthesis was designed with a tibial component that
was cemented on cancellous bone
within the cortical rim as an inlay
prosthesis. As design modification
progressed, metal backing was introduced in the 1980s in an attempt to
more evenly distribute weightbearing stress to the underlying tibial bone. The modularity of metalbacked components also facilitates
easier femoral component insertion
during the cementing process and allows the possibility of isolated poly-

ethylene exchange, when required.

The disadvantage of this design is
that either a thinner polyethylene
liner or a larger tibial cut is needed
to accommodate the metal backing.
Many modern UKA systems allow
for implantation of either allpolyethylene or metal-backed components; good clinical results have
been reported with both. Hyldahl et
al28 used radiostereometric analysis
to follow tibial component fixation
in 45 patients randomized to allpolyethylene tibial components or
metal-backed components of the
same design. At 2-year follow-up,
there was no statistically significant
difference in clinical results or migration of the tibial component.
However, the long-term results of
this trial remain undetermined.
An alternative implant design
philosophy is a tibial component
with a mobile meniscal bearing. Mobile polyethylene bearings have been
used in both the United States and
Europe. Whereas the most successful fixed-bearing designs incorporate
round-on-flat or slightly dished geometries, mobile-bearing UKA components such as the Oxford (Biomet,
Warsaw, IN) are fully congruent (ie,
constant radius) with an uncaptured
straight track. Other mobile-bearing
designs, such as the LCS (Low Contact Stress) component (DePuy, Warsaw, IN), capture the mobile polyethylene -bearing in a dovetail radial
track, theoretically reducing the risk
of bearing dislocation. The purpose
of both of these mobile-bearing designs is to optimize congruency of
the femoral and tibial components
throughout ROM, thereby minimizing point tibial contact forces and
stress at the implant fixation interface.

Clinical Results: Fixed

Versus Mobile Bearing
Several published studies indicate
the potential long-term success of
both fixed- and meniscal-bearing
UKA implants. Berger et al13 recent-

Journal of the American Academy of Orthopaedic Surgeons

Todd Borus, MD, and Thomas Thornhill, MD

ly reported results of a modular

fixed-bearing, metal-backed tibial
component. The thinnest polyethylene in this series was 5.7 mm, used
in more than half of the patients.
These authors reported an overall
survival of the implant of 96% at a
minimum 10-year follow-up (average, 12 years). At final follow-up,
92% of patients had an excellent or
good outcome. The authors attribute
their success, in part, to strict patient selection criteria and proper
surgical technique.
Similarly, excellent long-term results have recently been published
on the Oxford meniscal-bearing
UKA. Price et al17 reported a 15-year
survival of 93% in 439 knees, with
91% good or excellent clinical results. Of interest, thickness of the
polyethylene insert was as thin as
3.5 mm, with no degradation in clinical outcome or increased rate of failure reported in patients treated with
thinner polyethylene. The authors
suggest that the congruency of the
mobile-bearing design and the resulting decrease in polyethylene
contact stresses may obviate the
need for thicker (>6 mm) inserts.
This fact is clinically important because it supports the surgical principle of minimizing the thickness of
the tibial bone cut.
Several studies directly compare
the clinical results of mobile- and
fixed-bearing UKAs. In a retrospective review, Emerson et al29 noted a
survivorship, based on component
loosening and revision, of 99% for
the Oxford meniscal-bearing design
and of 93% for the Robert Brigham
fixed-bearing design (Johnson &
Johnson Orthopaedics, Raynham,
MA). The results of this study may
be difficult to extrapolate, however,
because the authors choice of implant occurred during two different
time periods and thus may not account for such issues as advances in
polyethylene quality or surgeon experience over time. The only prospective, randomized controlled
study to date comparing meniscalVolume 16, Number 1, January 2008

bearing and fixed-bearing UKAs is

that of Confalonieri et al,30 in which
the authors compared the AMC
mobile-bearing component (Alphanorm, Quiershied, Germany) with
the Allegretto fixed-bearing component (Centerpulse, Baar, Switzerland). At a mean 5.7-year follow-up,
there was no statistically significant
difference between the groups in
terms of clinical outcome scores or
revision rates.
Lewold et al31 compared the 699
mobile-bearing Oxford UKAs of the
patients in the Swedish registry data
set with a matched cohort of fixedbearing Marmor UKAs. The 6-year
revision rate of the Oxford group was
more than twice that of the Marmor
group. The most common cause of
revision in the mobile-bearing group
was dislocation of the polyethylene,
a complication unique to this group,
especially early in the learning
curve.
Overall comparative data between fixed- and mobile-bearing
components remain mixed. Larger,
long-term follow-up studies may be
needed to determine any true clinical or survivorship difference between fixed- and meniscal-bearing
UKAs.

Failure Mechanisms:
Implications for Surgical
Technique
Although good long-term survivorship has been reported in recent studies, important causes of long-term
failure of UKAs include wear, loosening, and adjacent compartment degeneration.32,33 The relative incidence
of each of these factors varies. In an
analysis of UKA in a communitybased registry of 516 UKAs implanted by 23 different surgeons,
Gioe et al32 found an overall survivorship of several different fixed-bearing
designs of 88.6% at 10 years. Mean
time to revision surgery was 3.62
years (range, 5 months to 8.4 years).32
Progression of arthritis in uninvolved
compartments was the most com-

mon cause for revision (51%), followed by aseptic loosening, polyethylene wear or osteolysis, and
unexplained pain. The authors did
not indicate whether adjacent compartment degeneration requiring revision occurred in the contralateral
tibiofemoral compartment, the patellofemoral compartment, or a combination of the two. In contradistinction, an outcome analysis of 1,135
revised UKAs from the Swedish registry indicated that the primary reason for revision was component loosening (43% of cases), followed by
progression of adjacent compartment
arthrosis (26%) and other mechanical
problems (15%).33
Review of the literature indicates
that surgical technique at the time
of the index procedure can minimize
each of the modes of failure, potentially improving the results of
present and future procedures. As
with any arthroplasty procedure,
once adequate implant fixation has
been achieved, component positioning and alignment and soft-tissue
balancing are essential to obtaining
success (Figure 2).
Patellofemoral and
Opposite Compartment
Degeneration
The patellofemoral joint may be
subject to progressive deterioration
after either medial or lateral UKA.
Hernigou and Deschamps34 analyzed
the patellofemoral complications
following 99 UKAs at a mean
follow-up of 14 years. They noted
two distinct entities responsible for
patellofemoral symptoms that affected clinical outcome: progressive
osteoarthritis and component impingement on the patella. Progression of osteoarthritis occurred in
38% of knees when referenced to
preoperative radiographs. Incongruity on the preoperative axial skyline
radiograph was an important predictor of the joint-space narrowing seen
at final follow-up. Femoral component impingement on the patella occurred in a distinct subset of 28% of
13

Unicompartmental Knee Arthroplasty

Figure 2

Anteroposterior (A), lateral (B), and

Merchant view (C) radiographs of a
patient 1 year after all-polyethylene,
fixed-bearing unicompartmental
arthroplasty. In the coronal plane (panel
A), the components are congruent in
extension, with appropriate medial/
lateral positioning to optimize contact
area and prevent edge loading. Minimal
tibial bone has been resected, and a
6-mm tibial polyethylene component
has been placed. In the sagittal plane
(panel B), the tibial component
matches the slope of the native tibial
articular surface, and the femoral
component meets the contour of the
medial femoral condyle without
overstuffing the flexion space or the
patellofemoral joint. The Merchant view
(panel C) further verifies that placement
and sizing of the femoral component
have avoided patellar impingement.

cases and was associated more frequently with lateral UKA and anterior placement of the femoral component.
Others have stressed the importance of avoiding component oversizing and placing the femoral component in congruity with the
anterior femur in the sagittal plane
14

to prevent patellar impingement.13

Intraoperatively, one can mark the
sulcus terminalis, or the leading
edge of the weight-bearing portion of
the femoral condyle, as a reference
point for sizing the femoral component. It is important not to size or
implant the component beyond this
landmark (Figure 3).

Some have postulated that overcorrection of joint alignment transfers increased weight-bearing force
to the opposite tibiofemoral compartment, thereby accelerating degeneration. Squire et al35 reported
progression of contralateral compartment degeneration in 46% of
136 knees at 11 years in their series.
However, Berger et al13 reported that,
at a 10- to 13-year follow-up, only
18% of knees had progressive loss of
joint space in the contralateral tibiofemoral compartment, none of
which caused symptoms requiring
revision. The authors postulated
that an overall undercorrection of
deformity in this patient series
might have been responsible for the
low rate of degeneration of the opposite compartment. The average preoperative deformity in this series
was 8 of varus from the mechanical
axis, and the average postoperative
alignment remained in 2 of mechanical varus. To prevent overcorrection, the authors recommend not
performing a formal medial collateral ligament release and inserting a
polyethylene insert that allows
2 mm of joint laxity in full extension
and flexion.
The primary concern regarding
undercorrection of deformity has
traditionally been that the prosthesis
would be vulnerable to accelerated
wear and/or tibial component loosening. Despite these concerns, no revisions in the series by Berger et al13
were performed for tibial component
loosening, wear, or subsidence.
Component Wear and
Loosening
The cause of wear in UKA is multifactorial. At the manufacturing
level, wear has been correlated with
the shelf age of the polyethylene tibial component sterilized by gamma
irradiation in air. Collier et al36
found that, with revision as an end
point, the 6-year survival in a series
of 100 UKAs was 96% when the
shelf age of the insert was <1.7 years
but only 71% when the shelf age

Journal of the American Academy of Orthopaedic Surgeons

Todd Borus, MD, and Thomas Thornhill, MD

Figure 3

Figure 4

A, Intraoperative photograph demonstrating demarcation of the sulcus terminalis,

or edge of the weight-bearing portion of the femoral condyle. B, To avoid patellar
impingement when sizing the femoral component, it is important not to violate the
leading edge of this landmark.

was >1.7 years.36 These authors postulated that discrepancies in polyethylene quality and shelf age may
partially account for the wide range
of wear rates and survivorship of implants between studies, even when
the same modular tibial component
was used. Surgeons are encouraged
to obtain the sterilization date from
manufacturers to better guide implant choices and to understand the
potential effect of shelf age on outcomes.
A comparative study by Emerson
et al29 demonstrated that the longterm primary mode of failure differs
between fixed and mobile bearing
UKAs depending on surgical technique. In 51 fixed-bearing UKAs, the
primary reason for revision was tibial component failure (eg, polyethylene wear, aseptic loosening, subsidence of the tibial component).
However, because of concern for
mobile-bearing instability, the 50
mobile-bearing implants were implanted with a tendency to stuff the
involved compartment, with a resultant overcorrection of deformity.
Volume 16, Number 1, January 2008

The primary reason for failure of the

mobile-bearing design was progressive arthritis of the lateral compartment. Price et al17 further confirmed
this observation in a series of 439
medial Oxford UKAs, in which the
primary cause for revision was progression of arthritis in the lateral
compartment.
Minimizing Failure:
Component Positioning
and Alignment
Several additional principles of
component positioning at the time
of surgery have been shown to affect
the long-term outcome of UKA. To
facilitate
implant
congruence
throughout the flexion/extension
arc, the tibial component should be
implanted perpendicular to the long
axis of the tibia in the coronal plane.
In a three-dimensional finite element analysis of tibial component
inclination in UKA, Sawatari et al37
demonstrated increased cancellous
bone stresses when the tibial component was placed in varus. With regard to the sagittal plane placement

Anteroposterior radiograph of a knee

demonstrating misalignment after
unicompartmental knee arthroplasty,
with obvious malrotation of the tibial
and femoral components. This
radiograph emphasizes the importance
of placing the tibial component
perpendicular to the long axis of the
tibia, thereby subsequently ensuring
that the femoral component is
positioned perpendicular to the tibial
component throughout the flexion/
extension arc. Doing so will maintain
implant congruency and avoid
edge-loading of the polyethylene.

of the tibial component, Hernigou

and Deschamps21 recommend ensuring a tibial slope of <7 to protect the
ACL from degeneration and rupture,
mitigating against late anteroposterior instability of the knee. We generally recommend attempting to
match the slope of the native tibial
slope.
Equally important are guidelines
for placement of the femoral implant. In general, the femoral component should be placed perpendicular
to the tibial component in the coronal plane. Doing so underscores the
importance of correct tibial component placement, to avoid obligatory
femoral malrotation (Figure 4). Importantly, most UKA instrumenta15

Unicompartmental Knee Arthroplasty

Figure 5

Most implant systems provide a mechanism for ensuring balanced flexion and extension gaps. Intraoperative photographs
demonstrate spacer blocks placed in the (A) flexion and extension (B) spaces, thereby confirming equality.

tion systems provide techniques for

ensuring that the flexion/extension
gaps between the femoral and tibial
components are balanced (Figure 5).

The Role of Minimally

Invasive
Surgery/Computer
Navigation
Techniques for minimally invasive
knee surgery have gained increasing
attention. Among the first to propose minimally invasive applications to UKA were Repicci and
Eberle,38 who cited the potential advantages of decreased blood loss, tissue trauma, and morbidity as well as
earlier recovery and easier rehabilitation. Although the exact criteria
for minimally invasive UKA have
16

yet to be defined, Repicci and

Eberle38 have described the procedure through a 3-inch incision, compared with a 6- to 8-inch length for a
standard incision. The minimally invasive approach also deviates with
respect to the technique of arthrotomy and exposure. Most advocates of
minimally invasive knee surgery
champion an arthrotomy that does
not invade the quadriceps femoris
tendon. Also, eversion of the patella
is avoided. To gain adequate exposure, some authors describe making
a transverse incision in the capsule,
halfway between the vastus medialis
and the joint line.39
Despite encouraging results, to
date there have been no randomized,
controlled trials to confirm whether
there is any actual patient benefit

from a less invasive approach. Rees et

al40 reported decreased functional
outcomes and ROM in patients early
in the learning curve for minimally
invasive implantation of the Oxford
UKA. Fisher et al41 demonstrated
that minimally invasive UKA was
not as accurate as open UKA in anteroposterior tibial placement or
postoperative limb alignment. Although the results of minimally invasive UKA remain to be determined
in the long term, a greater emphasis
on postoperative analgesia and accelerated rehabilitation has improved
patient satisfaction.42
The use of computer-assisted surgical navigation has been applied to
UKA surgical technique, especially
with concurrent minimally invasive
knee surgery techniques. Using long

Journal of the American Academy of Orthopaedic Surgeons

Todd Borus, MD, and Thomas Thornhill, MD

leg weight-bearing radiographs and

nonweight-bearing leg-alignment
computer tomography, Cossey and
Spriggins43 demonstrated that UKA
performed with computer-assisted
surgical navigation resulted in a
more accurate and reproducible limb
alignment than did UKA performed
without surgical navigation. However, the study was conducted using
two separate UKA systems with different instrumentation and design,
thus making the results difficult to
compare.

Summary
Unicompartmental knee arthroplasty continues to evolve, and studies
show that the procedure can result
in excellent outcomes. Satisfying
clinical results have been reported
over three decades; however, debate
continues regarding the intricacies
of the surgical technique, fixation
methods, and optimal implant design. Adherence to strict surgical indications and appropriate patient selection, combined with meticulous
surgical execution, are important
factors in optimizing outcome. The
role of minimally invasive surgery
and computer navigation should be
subject to further study to more directly define the role of this procedure.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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Volume 16, Number 1, January 2008

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Journal of the American Academy of Orthopaedic Surgeons