Knee Surg Sports Traumatol Arthrosc (2008) 16:1038–1042
DOI 10.1007/s00167-008-0617-8
KNEE
Medial unicompartimental knee arthroplasty
for osteonecrosis or osteoarthritis
E. Servien Æ P. C. M. Verdonk Æ S. Lustig Æ
J. L. Paillot Æ A. D. Kara Æ P. Neyret
Received: 1 February 2008 / Accepted: 25 August 2008 / Published online: 10 September 2008
Ó Springer-Verlag 2008
Abstract We report a prospective series of 33 unicom-
partmental knee arthroplasties (UKAs) operated for a
spontaneous osteonecrosis of the knee (SPONK) compared
with 35 UKAs operated for osteoarthritis (OA). The mean
follow-up was 5 years. Preoperative functional score in the
SPONK group was significantly lower than that in the OA
group. The results were comparable in terms of pain, knee
score and function. At the last follow-up, the survival rate
was 92.8% for the SPONK group and 95.4% for the OA
group. We found a higher rate of radiolucencies in the
SPONK group, however, without any clinical symptoms.
The UKA is a good option in the treatment of SPONK.
Keywords Arthroplasty
Knee
Unicompartimental

Osteonecrosis
Arthritis
Introduction
Unicompartimental knee arthroplasty (UKA) was intro-
duced into clinical practice by Marmor [12, 13] in the late
1980s and was later supported by Cartier et al. [7]. Since
then, numerous reports have been published on clinical and
E. Servien (&)
S. Lustig
J. L. Paillot
P. Neyret
Centre Albert Trillat, Groupe Hospitalier Nord, Hospices Civils
de Lyon, 8 Rue Margnolles, 69300 Lyon-Caluire, France
e-mail: elvire.servien@chu-lyon.fr
P. C. M. Verdonk
Department of Orthopaedic Surgery, Ghent University Hospital,
Ghent, Belgium
A. D. Kara
Department of Orthopaedic Surgery, Ege University Hospital,
Izmir, Turkey
123
radiological outcomes of this procedure in the medial and
lateral compartments for the treatment of osteoarthritis
(OA), while only limited data are available for spontaneous
osteonecrosis [7, 8, 11, 14–16]. Spontaneous osteonecrosis
of the knee (SPONK) is a disease that mainly affects the
medial femoral condyle. Its aetiology is poorly understood.
Besides vascular compromise of the subchondral bone,
trauma with microfracture of the subchondral bone appears
to be a possible causative factor. Intraosseous oedema
results in increased pressure within the bone marrow
compartment with subsequent oedema and necrosis.
Because of the unicompartimental nature of the knee,
unicondylar knee arthroplasty might be considered an ideal
solution for the treatment of this condition. Osteotomy [8]
or knee arthroplasty [15] are the other therapeutic options.
In comparison with total knee arthroplasty (TKA), UKA
results have been claimed to be inferior or less reproducible
mainly due to large differences in surgical techniques. The
failure rates in the different reports [3, 4] have been related
to improper selection of patients, design problems or sur-
gical technique. Nevertheless, UKA is associated with
several potential advantages.
Recently, UKA has regained interest in the orthopaedic
community due to favourable results in the Swedish registry
reports [17, 18]. The recent trend for less invasive surgical
procedures has additionally increased interest for this type of
procedure. Thus, the aim of this study is to report on the
experience with UKA for the treatment of SPONK compared
with a matched group of patients with primary medial OA.
Material and methods
Between 1988 and 2004, 1,486 TKAs and 186 unicom-
partmental knee arthroplasties (UKAs) were carried out in
Knee Surg Sports Traumatol Arthrosc (2008) 16:1038–1042 1039

our department. Thirty-four of 186 patients underwent

UKA (HLS Uni, Tornier Company, Grenoble, France) due
to SPONK. Of these, 33 patients (97%) had completed
preoperative and postoperative data in our database and
were thus available for further investigation. One patient
was lost to follow-up. The diagnosis of femoral condyle
SPONK was based on plain radiographs (Fig. 1) in com-
bination with the clinical symptoms at presentation.
Magnetic resonance imaging was not performed system-
atically to evaluate possible involvement of the opposing
tibial plateau or the contralateral condyle. In all patients,
the other compartments were asymptomatic, the anterior
cruciate ligament was intact and functional, and the artic-
ular deformity was (partially) reducible. Twenty-three
female and ten male patients received 33 medial unicom-
partimental knee prostheses for SPONK. The mean age at
operation was 74 years (range 42–89 years).
All patients were operated on using the same surgical
technique. A medial parapatellar subvastus approach was
performed. Care was taken not to overcorrect the
mechanical axis. In all cases, an all-polyethylene insert was
used in combination with resurfacing of the femoral con-
dyle (Fig. 2). All implants were cemented. The patients
were followed prospectively both with standard radio- Fig. 2 UKA at 5 years of follow-up on AP view
graphs and clinical assessment using the International Knee
Society (IKS) scoring system [10]. Complications and reoperations were recorded. For the
To compare the radiographic and clinical outcome of SPONK group, the mean follow-up was 5.1 years (24–
medial UKA for SPONK, a control group of 35 patients 138 months) and for the OA group, follow-up was
operated on medial UKA for primary OA and with a 4.5 years (24–160 months).
minimal follow-up of 2 years was randomly selected.
These two populations were comparable in terms of age, Statistical method
follow-up, gender distribution and body morphological
parameters (Table 1). The Minitab Statistical Software was used for statistical
Kaplan–Meier survival analysis was applied. Revision analysis. Survival analysis of the prosthetis was performed
surgery (removal and/or conversion to TKA) and death of using the log-rank test and the Kaplan–Meier survival
the patient at the end of the year 2004 served as end-points. analysis. The Student’s t test and the chi-square test were
applied for further analysis of the different clinical and

Table 1 Demographics data for both groups

SPONK OA P value
Average SD Average SD
value value

N 33 35 n.s.
Sex (M/F) 10/23 9/26 n.s.
Age 75 6 74 8 n.s.
Follow-up (months) 62 24 54 29 n.s.
Height 163 10 160 8 n.s.
Weight 67 11 66 11 n.s.
Body mass index 25 3.6 26 3.1 n.s.

Fig. 1 Osteonecrosis of the femoral medial condyle on AP view SD standard deviation, n.s. nonsignificant

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1040 Knee Surg Sports Traumatol Arthrosc (2008) 16:1038–1042

Table 2 IKS score in both groups Table 3 Radiographic analysis

SPONK OA P value SPONK OA P value
Average value SD Average value SD Average SD Average SD
value value
Preop
Pain 20 12 17 8 n.s. Preop
Flexion 130° 13 130° 9 n.s. MFTA 176° 2 175° 2 n.s.
Knee score 63 15 56 12 n.s. Postop
Walk 26 11 27 10 n.s. MFTA 176° 4 177° 3 n.s.
Stairs 29 8 31 8 n.s. Radiolucent lines
Function 52 15 60 11 0.03 Tibia AP zone 1 8 3 n.s.
Postop Tibia AP zone 2 9 6 n.s.
Pain 43 13 44 11 n.s. Tibia PROF zone 1 3 1 n.s.
Flexion 133° 12 135° 8 n.s. Femur 3 4 n.s.
Knee score 93 7 91 9 n.s. AP antero-posterior, MFTA mechanical femoro-tibial angle, n.s.
Walk 38 17 39 16 n.s. nonsignificant, PROF profile, SD standard deviation
Stairs 38 18 38 15 n.s.
Function 84 22 85 16 n.s.
the OA group, two (5.5%) patients were also revised. Four
SD standard deviation, n.s. nonsignificant
patients (12.1%) required a reoperation in the SPONK
group and two patients (5.7%) in the OA group (Table 4).
radiological variables. A P value \0.05 was considered Kaplan–Meier analysis revealed a similar 10-year survival
significant. rate of 93 and 95%, respectively, for the SPONK group and
the OA group. At the last follow-up, three patients had died
in the SPONK group and two in the OA group.
Results

For the SPONK group, the mean preoperative IKS knee Discussion
and function score improved significantly from 63 to 93
and from 52 to 84 postoperatively, respectively. For the The clinical outcome of UKA for primary unicomparti-
OA group, the preoperative IKS mean knee and function mental OA has been frequently reported in the literature [1,
score improved significantly from 56 to 91 and from 60 to 2, 6]. Data on UKA for SPONK, on the other hand, are
85 postoperatively, respectively. scarce. The limited number of patients in this series and
Preoperatively, the IKS function score was significantly previously published series probably reflects the low inci-
better in the OA group than in the SPONK group dence of this disease in the general population. In the
(P = 0.03). Postoperatively, no significant differences present series, only patients with radiographically diag-
were found between groups. For the SPONK and OA nosed medial femoral SPONK were included.
groups, the mean preoperative flexion was 130° and To analyze the clinical and radiological results, a com-
remained unchanged at final follow-up (Table 2). parable and prospective series of UKA patients treated for
No significant differences were found in the preopera-
tive and postoperative axial alignment between groups.
However, a higher number of radiolucent lines were
Table 4 Distribution of reoperation for both groups
observed in the SPONK group. These lines were most
frequently on the tibial side but were considered stable and SPONK (n = 4) OA (n = 2)
nonevolutional in all cases (Table 3). None of these
Patient no. 1 Posterior cyst
patients underwent reoperation.
Patient no. 2 Patellar fracture
In both groups, contralateral (i.e. lateral) compartment
Patient no. 3 Lateral meniscalteara
degenerative changes were noticed in a total of six patients
Patient no. 4 Synovectomya
at final follow-up (three in each group). So far, none of
Patient no. 5 Synovectomya
these patients had to be revised.
Patient no. 6 Synovectomya
In the SPONK group, two knees underwent conversion
to TKA: one for pain and one for infection within the All P values are nonsignificant
a
2 years following the unicompartmental arthroplasty. In Arthroscopy

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Knee Surg Sports Traumatol Arthrosc (2008) 16:1038–1042
unicompartimental medial OA and operated on using the
same surgical technique and prosthetic device was selected.
The results were comparable in term of pain, knee score
and function. Preoperative functional score in the SPONK
group was significantly lower than that in the OA group.
This observation could be explained by the more sudden
onset of SPONK. In both groups, flexion at follow-up
averaged 130°, which is comparable to other published
series [13]. In general, the obtained flexion after a UKA is
higher than that after a TKA, and UKA might be consid-
ered a high-flexion prosthetic design. It is tempting to state
that a well-functioning UKA guarantees a nearly normal
function and kinematic behavior in a higher percentage of
patients compared to modern designed TKA patients [19].
The fact that both cruciate ligaments are retained, no soft
tissue releases are performed, the original axial alignment
is restored but not corrected and that only the affected
compartment is resurfaced contributes probably to this high
success ratio.
With regard to revision and survival rate, a recent meta-
analysis by Myers et al. [15] reports better results with
TKA. In that study, the revision rate after TKA for SPONK
is lower when compared to UKA with a mean revision rate
of 3 versus 13%, respectively. Nevertheless, recent data
suggest that UKA for SPONK has the lowest revision rates
when compared to unicompartimental diseases [11, 16].
However, our study is a prospective continuous study with
an anonymous and independent database and with a match-
paired group. There were no statistical differences in terms
of reoperation rate (excluding revision) between both
groups.
The SPONK group showed a higher frequency of
radiolucencies. All radiolucencies were evaluated as stable;
however, this phenomenon is also observed in other
modern UKA prosthetic designs and is most frequently
observed around the tibial component. The higher fre-
quency of radiolucencies in the SPONK group could reflect
lower quality of bone–cement integration. The authors
hypothesise that the tibial cut was probably thicker in the
SPONK patients when compared with the OA population,
consequently cementing the tibial component on a more
cancellous, but less stable metaphyseal bone. The thicker
tibial cut in SPONK is a direct consequence of the surgical
technique, in which the distal femur serves as a reference
for the tibial cut. In this series, the radiolucencies did not
lead to revision of the prosthesis for loosening.
On the contrary, radiolucent lines are infrequently
observed on the femoral side in both SPONK and OA,
indicating adequate stability of the femoral component. No
fixation problems have been documented using the surgical
technique described in the present study.
Recently, progression of patello-femoral OA has been
reported after UKA [5, 9]. In the present series, no
1041
progression of patello-femoral OA was observed in either
group at the final follow-up.
Conclusion
End-stage SPONK is a sound indication of UKA with
excellent clinical and radiological results. A high postop-
erative flexion can be guaranteed using modern prosthetic
design. Stable radiolucent lines around the tibial compo-
nent are more frequently observed in the SPONK
population than the OA population.
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