 SPECIALTY UPDATE

Long-term results of compartmental

arthroplasties of the knee
LONG TERM RESULTS OF PARTIAL KNEE ARTHROPLASTY

S. Parratte, Partial knee arthroplasty (PKA), either medial or lateral unicompartmental knee artroplasty
M. Ollivier, (UKA) or patellofemoral arthroplasty (PFA) are a good option in suitable patients and have
A. Lunebourg, the advantages of reduced operative trauma, preservation of both cruciate ligaments and
M. P. Abdel, bone stock, and restoration of normal kinematics within the knee joint. However, questions
J-N. Argenson remain concerning long-term survival. The goal of this review article was to present the
long-term results of medial and lateral UKA, PFA and combined compartmental arthroplasty
From The Institute for multicompartmental disease. Medium- and long-term studies suggest reasonable
for Locomotion, outcomes at ten years with survival greater than 95% in UKA performed for medial
Department of osteoarthritis or osteonecrosis, and similarly for lateral UKA, particularly when fixed-bearing
Orthopedic Surgery, implants are used. Disappointing long-term outcomes have been observed with the first
Aix-Marseille generation of patellofemoral implants, as well as early Bi-Uni (ie, combined medial and
University, Marseille, lateral UKA) or Bicompartmental (combined UKA and PFA) implants due to design and
France and fixation issues. Promising short- and med-term results with the newer generations of PFAs
Department of and bicompartmental arthroplasties will require long-term confirmation.
Orthopaedic Surgery,
Cite this article: Bone Joint J 2015;97-B(10 Suppl A):9–15.
Mayo Clinic,
Minnesota, Partial knee arthroplasty (PKA) is an alterna- an independent centre using the mobile-
United States tive to total knee arthroplasty (TKA) in bearing Oxford UKA (OUKA, ZimmerBiomet,
patients with arthritis limited to one compart- Bridgend, United Kingdom) reported signifi-
ment of the knee. The benefits of PKA include cant improvements in both functional scores
the preservation of cruciate and collateral liga- and knee flexion.8 The mean Knee Society
ments and bone stock, which in turn lead to score was 90.2 (72 to 100) at ten years com-
the restoration of native knee kinematics.1-4 pared with 51.5 points (26 to 68) pre-
Improvements in implant design, materials and operatively, while mean active knee flexion
 S. Parratte, MD, PhD,
surgical technique, coupled with a greater increased from 105.5° (85° to 135°) to 130.9°
Professor understanding of the indications for PKA, have (110° to 140°; both p < 0.0001).
Aix-Marseille University, IML
Hopital Sainte Marguerite,
led to marked improvements in functional out- Argenson et al9 reported the 20-year results
13008, Marseille, France. comes and implant survival in the 40 years since of 160 medial metal-backed medial UKAs
 M. Ollivier, MD, Orthopaedic PKA was introduced.5-7 As such, PKA can now (Miller-Galante, ZimmerBiomet, Warsaw, Indi-
Surgeon be considered to be a definitive solution for ana) in 147 patients. At most recent follow-up,
 A. Lunebourg, MD,
Orthopaedic Surgeon patients with end-stage osteoarthritis (OA) lim- the 70 surviving patients had mean Knee Society
 J-N. Argenson, MD, PhD, ited to one compartment. The goal of this score (KSS) knee and function scores of 91
Professor
Aix-Marseille University, 270 review article is to present the long-term results points (50 to 100) and 88 points (45 to 100),
Boulevard Sainte Marguerite, of PKA techniques for single-compartment OA respectively.9 Mean active flexion increased
BP 29, 13274 Marseille, France.
of the knee, including medial and lateral uni- from 119° (85° to 135°) pre-operatively to 127°
 M. P. Abdel, MD, Assistant
Professor of Orthopedic
compartmental knee arthroplasty (UKA) and (80° to 145°) at most recent follow-up. Simi-
Surgery, Orthopedic Surgeon patellofemoral arthroplasty. Finally, the use of larly, a long-term series of 53 medial UKAs with
Mayo Clinic, 200 First Street
S.W., Rochester, MN 55905,
combined PKAs for multiple-compartment dis- an all-polyethylene tibial design reported mean
USA. ease will be discussed. KSS knee and function scores of 80.1 points
Correspondence should be sent (90 to 50) and 84.7 points (100 to 70), respec-
to Mr S. Parratte; e-mail: Medial UKA for degenerative arthritis tively at a mean follow-up of 14.7 years (4.2 to
sebastien@parratte.fr
Clinical outcomes. There is now good evidence 15.3), with a mean active knee flexion of 120.6°
©2015 Parratte that medial UKA (of both fixed- and mobile- (100° to 130°) at the same time point.10
doi:10.1302/0301-620X.97B10.
36426 $2.00 bearing design) provides good clinical out- There is some debate as to the relative func-
comes into the medium term. A ten-year out- tional outcomes of UKA and TKA for medial
Bone Joint J
2015;(10 Suppl A):9–15. come study of 511 knees (in 402 patients) from OA. At one year following surgery, Thienpont

VOL. 97-B, No. 10, OCTOBER 2015 9

10 S. PARRATTE, M. OLLIVIER, A. LUNEBOURG, M. P. ABDEL, J-N. ARGENSON

Table I. Long-term studies of medial unicompartmental knee arthroplasty

Study Implants No. of knees Duration of FU (yrs) Revised (%) (any cause)
Argenson et al9 Miller-Galante 160 20 12
Price et al15 Oxford 114 15 8
Vorlat et al16 Oxford 149 10 19
Niinimäki et al17 Registry (all) 4713 15 30
O’Rourke et al18 Marmor 136 21 14
Manzotti et al10 UC-plus 53 10 9
FU, follow-up

et al11 performed a retrospective comparison of 51 UKA On the basis of the current literature, there is no consen-
patients with 50 TKA patients, reporting equivalent results sus as to whether fixed- or mobile-bearing UKA gives better
using the forgotten joint score. In a study of 14 076 results in terms of survival or clinical outcome in the long
matched patients from the National Joint Registry for Eng- term. While mobile-bearing implants have a higher rate of
land and Wales, Liddle et al12 reported that UKA provided early bearing dislocation, polyethylene wear remains a
superior short-term clinical outcomes than TKA (in terms complication of fixed-bearing devices in the longer term
of the Oxford knee score and the EQ5D, a quality of life (although in patients with no evidence of infection or osteo-
score), higher satisfaction and lower complication rates, at lysis, liner exchange may be a successful procedure in cases
six months following surgery. In their randomised con- of polyethylene wear21). Parratte et al22 reported a retro-
trolled study, Sun et al13 demonstrated that mobile-bearing spective comparison of 79 fixed-bearing UKA with 77
UKA will results in lower complication rate, similar clinical knees with mobile-bearing UKA, reporting no significant
outcomes when compared with a fixed-bearing TKA, how- difference in the rate of revision at a minimum of 15 years’
ever, the Oxford UKA revision rate in their series was 25%. follow-up (12 of 77 knees were revised in the mobile-
However, Newman et al14 showed that the better early bearing group, compared with ten of 79 in the fixed-bear-
results with UKR are maintained at 15 years with no ing group, p = 0.44). Likewise, Confalonieri et al23 reported
greater failure rate. no difference in clinical outcomes between the two designs
Implant survival. Medium- and long-term studies suggest of UKA. Gleeson et al24 reported a prospective non-
good ten-year survival of around 95% for UKA performed randomised study of 91 patients undergoing either fixed
for medial OA in high-volume units.9,10,15-18 (Table I). A (57 knees) or mobile-bearing (47) UKA. The rate of revi-
series from the designing unit of the OUKA has reported sion was higher in the mobile-bearing group, owing to a
98% cumulative survival at ten years.19 Price et al15 number of bearing dislocations, but this difference was not
reported 92% survival at 15 years in a series from an inde- significant. Likewise, no significant difference was reported
pendent centre. In this series (as in other series of the in either the Bristol nor the Oxford knee scores between the
Oxford UKA) a high rate of radiolucent lines was noted groups, albeit that a small difference in the pain component
adjacent to the tibial component, although the significance of the Bristol score was reported in favour of the fixed-
of these lines is uncertain. bearing implant (p = 0.014).
Argenson et al9 reported 74% implant survival for the In contemporary practice, the discussion has focused on
metal-backed, fixed bearing Miller-Galante UKA at 20 comparing the results of UKA and TKA. A study of 27-year
years. They reported that the two most common reasons data from the Finnish Joint Registry compared the survival
for revision were progression of arthritis in the uninvolved of 4713 patients with UKA performed for primary OA
compartments (65%) and polyethylene wear (25%). The (mean age of 64 years; mean follow-up of six years) with
mean time for revision to TKA or addition of a PFA was that of 83 511 patients who had undergone TKA (with a
13 years (three months to 21 years). mean age of 70 years and a mean follow-up of six years).17
Similar results are reported for fixed-bearing devices Survival for UKA was 89% at five years, 81% at ten years,
with all-polyethylene tibial components.18 However, these and 70% at 15 years, compared with 96%, 93%, and 88%
results may be device-dependent: a recent randomised respectively for TKA. UKA had inferior long-term survivor-
study reported very poor survival for a UKA with an all- ship compared with cemented TKA, adjusted for age and
polythene tibial component compared with the metal- gender (hazard ratio 2.2; p < 0.001).17 The authors
backed version of the same device.20 The ten-year survival acknowledged that comparing survival directly by using
with the all polythene tibial component was 56.5% (95% arthroplasty register survival reports also may be inade-
confidence interval (CI) 31.9 to 75.2), compared with quate because of differences in indications, implant designs,
93.8% (95% CI 77.3 to 98.4) in the metal-backed group and patient demographics in patients having UKA and
(p < 0.001), although the numbers at risk were low at ten TKA. Despite these limitations, they concluded that while
years (seven and 16 for all-polythene and metal-backed UKA has advantages, the risk of revision remains higher
components, respectively). than expected with TKA.17 In 2014, Liddle et al25 reported

KNEE SUPPLEMENT TO THE BONE & JOINT JOURNAL

 LONG-TERM RESULTS OF COMPARTMENTAL ARTHROPLASTIES OF THE KNEE 11

Table II. Long-term studies of lateral unicompartmental knee arthroplasty

Study Implants No. of knees Duration of FU (yrs) Revised (%) (any cause)
Argenson et al28 15 Marmor 40 16 16
20 Miller-Galante
4 Zuk
1 Alpina
Sah et al29 Brigham 49 5 0
PFC
Sigma
Preservation
Lusting et al30 HLS evolution 54 10 2
Weston-Simons et al31 Oxford Domed 265 4 8 (failure rate including 1.5 dislocation)
FU, follow-up

the rates of adverse events for matched UKA or TKA remainder they reported 94% survival at ten years and
patients extracted form England and Wales total join regis- 91% at 15 years, with no revision for wear, infection or
try, they concluded that the higher revision/re-operation patellofemoral OA. Each of these studies used fixed-
rate of UKA should be balanced against a lower occurrence bearing implants and the most common indication for revi-
of complications, re-admission, and mortality. Based on sion was progression of disease to the medial compartment
their analysis, if 100 patients receiving TKA have received (Table II).31
UKA instead, the result would be around one fewer death Given the amount of anteroposterior femoral translation
and three more re-operations in the first four years after observed in the lateral compartment, mobile-bearing lateral
surgery. UKA has been associated with a high rate of bearing dislo-
cation.3 When the standard medial Oxford UKA has been
Lateral UKA for degenerative arthritis used in the lateral compartment, bearing dislocation has
Clinical outcomes. Lateral UKA is far less common than been a serious issue with Gunther et al32 reporting a 21%
medial UKA, and accounts for only around 1% of all knee failure rate overall, and a 10% rate of bearing dislocation.
arthroplasty procedures.26 Smith et al27 reported the results This has led to the introduction of a new design of the
of 41 lateral PKAs at a minimum of five years’ follow-up. Oxford UKA with a domed tibial component and a
Functional scores showed a significant improvement biconcave mobile-bearing. This has had a positive effect on
following surgery, with the benefit maintained to five years. outcomes with Weston-Simons et al31 reporting that, at a
The mean total KSS increased from 100 points (30 to 182) mean follow-up of four years, 1.5% of knees had had a
pre-operatively, to 159 (69 to 200) at five years (p < 0.001). bearing dislocation, with an all-cause revision rate of 92%
Mean OKS was increased from 20 points (5 to 45) to 37 at eight years. With the same domed implant reported in
points (9 to 48, p < 0.001), and Western Ontario and their series of 58 lateral UKAs, Altuntas et al33 reported no
McMaster Universities Osteoarthritis Index (WOMAC) dislocation and 96.9% implant survivorship at maximal
scores increased from 36 points (15 to 53) to 22 points (12 follow-up of three years.
to 48, p < 0.001) over the same time period. Similarly,
Argenson et al28 reported favourable outcomes for lateral UKA for avascular necrosis
UKA, with mean KSS knee and function scores of 88 points Avascular necrosis (AVN) of the knee classically includes
(40 to 100) and 78 points (20 to 100), respectively at a two distinct entities: spontaneous or secondary osteo-
mean follow-up of 12.6 years. Sah et al29 reported that necrosis.34,35 Spontaneous osteonecrosis occurs most often
mean KSS knee and function scores improved from 39 and in patients older than 55, unilaterally, and in one compart-
45 points pre-operatively, to 89 and 80 points, respectively ment of the knee.34 Secondary osteonecrosis can appear
at a mean of 5.2 years. Finally, Lustig et al30 reported KSS after corticosteroid therapy, renal and systemic diseases, or
knee and function scores of 95 points (70 to 100) and 82 barotrauma, and occurs most often in younger patients
points (25 to 100), respectively, at ten years. with bilateral disease.34,35 For both types of AVN, the nat-
Implant survival. Argenson et al28 published a series of 39 ural evolution without treatment is arthritis.34,35 As the rest
lateral UKAs and demonstrated reasonable clinical and radi- of the knee is usually normal in unicompartmental osteo-
ographic results, with survival at ten and 16 years compara- necrosis, medial or lateral UKA can be used in such cases.
ble with the survival obtained for medial UKA. Sah et al29 Overall, favourable outcomes have been reported for
reported a series of 49 knees at five years with no revisions UKA in the setting of AVN, both in terms of survival and
after lateral UKA. Likewise, Lustig et al30 reported a series functional outcome, albeit that most series have been small
of 54 lateral UKAs (52 patients, mean age 72 years) at a (Table III). Bruni et al36 reported the results of 84 patients
minimum of ten years’ and a mean of 14 years’ follow-up. undergoing medial UKA for osteonecrosis, with a survival
A total of eight knees were lost to follow-up; in the of 89% at ten years. The mean Knee Society score (KSS)

VOL. 97-B, No. 10, OCTOBER 2015

12 S. PARRATTE, M. OLLIVIER, A. LUNEBOURG, M. P. ABDEL, J-N. ARGENSON

Table III. Survival studies of unicompartmental knee arthroplasty for medial osteonecrosis

Study Implants No. of knees Duration of FU (yrs) Revised (%) (any cause)
Parratte et al38 Miller-Galante 31 12 3.3
Bruni et al36 Preservation 84 10 11
Heyse et al37 Richard III 28 10 6.9
FU, follow-up

Table IV. Survival studies of patellofemoral arthroplasty

Study Implants No. of knees Duration of FU (yrs) Revised (%) (any cause)
De Winter47 1st Gen Richard II 26 11 19
Tauro48 1st Gen Lubinus 62 7.5 28
Nicol49 2nd Gen Avon 103 7.1 14
Odumenya50 2nd Gen Avon 50 5 0
FU, follow-up

was 87.1 (standard deviation (SD) 13.8) with a mean Similarly, another first-generation implant, the Lubinus
WOMAC score of 12 (SD 10.3) at latest follow-up (63 to PFA, had a high rate of early revisions.42,44-46 The most
145).36 Heyse et al37 reported that the results of 28 knees common causes of failure were patellar instability (18%),
with an overall survival was 93% at ten years. The mean stiffness (18%) and tibiofemoral OA progression (12%)46
KSS was 173 (SD 27) at latest follow-up, compared with 85 (Table IV).47-50
(SD 30) pre-operatively (p < 0.0001), and the mean There are few studies which report long-term clinical
WOMAC score was 7.7 (SD 11.4) at the same time interval. outcomes following PFA, and most report on first-
Finally, Parratte et al38 reported 31 patients with either pri- generation prostheses. De Winter et al47 reported mean KSS
mary or secondary osteonecrosis. Implant survival was at of 90 points (65 to 100 ), in 21 Richards II PFAs at a mean
96% at 12 years (with a single knee undergoing revision to follow-up of 11 years. Argenson et al51 reported a series of
TKA for aseptic loosening). At seven years, the mean KSS 66 first-generation PFA implants (Autocentric; DePuy,
knee score was 95 points (75 to 100) and the mean function Warsaw, Indiana) at a mean follow-up of 16 years. In these
score was 88 (72 to 96). patients, the KSS functional score increased by 40 points
Patellofemoral arthroplasty. Overall, the reported long- from that pre-operatively, with a mean score of 81 points at
term results of patellofemoral arthroplasty (PFA) are infe- latest follow-up. Likewise, reasonable results have been
rior to those reported for medial and lateral UKA. How- reported from the first-generation Lubinus PFA (Waldemar
ever, compared with UKA, there has been much greater Link, Hamburg, Germany), with the mean Bristol knee
evolution in implant design over recent years, with first- score rising from 55 points (29 to 86) pre-operatively, to 81
generation resurfacing-type implants giving way to more (42 to 100) at latest follow-up, which was between five and
modern devices which more closely resemble the anterior ten years.48
portion of a TKA. Most long-term results for PFA relate to Outcomes of second-generation implants. Results of newer
earlier, now obsolete devices.39 implants are superior to earlier designs, but still do not
Outcomes of first-generation prostheses. Overall, first- reach the long-term levels of implant survival reported for
generation designs of PFA were associated with poor short- UKA and TKA. Nicol et al49 reported on 103 PFAs (Avon
term survival, which has been attributed to design factors PFJRs; Stryker Howmedica Osteonics, Mahwah, New Jer-
associated in particular with the deep trochlear groove in sey) implanted in patients with a mean age of 68 years.
many such designs. Lonner et al40 found that these highly- Overall survival at seven years was 86%; unlike previous
constrained designs tolerated patellar maltracking poorly, designs, the most common reason for revision was progres-
and were therefore unlikely to succeed in patients with poor sion of arthritis to the tibiofemoral joint.
pre-operative alignment without the use of re-alignment Ackroyd et al52 reported 96% survival in 109 patients
procedures during implantation. receiving the Avon PFA at five years with good functional
A series of one such design, the Richards PFA (Richards results (with a mean OKS of 39, improved from 18 pre-
prosthesis, Richards, Memphis, Tennessee), published in operatively). Odumenya et al50 reported 100% implant
1979, reported a 16% revision rate after two years of survival in 50 patients five years following implantation of
follow-up.41 In the longer-term, survival rates of 75% and the same prosthesis. One further multicentre study of 79
69% have been reported at 11 and 20 years of follow-up, knees reported 84% good and excellent results and 90% of
respectively,42,43 with satisfactory results being achieved patients reported no knee pain during activities of daily
in 86% of cases after a period of 15 years to 21 years. living at three years following Avon PFA.48

KNEE SUPPLEMENT TO THE BONE & JOINT JOURNAL

 LONG-TERM RESULTS OF COMPARTMENTAL ARTHROPLASTIES OF THE KNEE 13

Table V. Studies of combined compartmental arthroplasties

Study Implants No. of knees Duration of FU Revised (%) (any cause)

Parratte et al56 UKA: 84 Bi-UKA 17 yrs 22
Zimmer condylar 71 UKA and PFA 44
Alpina
Miller-Galante
PFA: Autocentric
Palumbo et al57 Journey Deuce 36 UKA and PFA 21 mths 14
31 clinical failure (persistent pain)
FU, follow-up; UKA, unicompartmental knee arthroplasty; PFA, patellofemoral arthroplasty

Combined compartmental arthroplasties sachusetts) with a combined monobloc femoral component

PKAs can be used in combination when more than one have been disappointing, and the implant has since been
compartment is affected by disease. This can either be a recalled because of its high failure rate.57,61 In terms of
combination of a medial and lateral UKA (Bi-Uni) or a functional results, a study comparing 50 bicompartmental
combination of UKA and PFA (bicompartmental arthro- arthroplasties with 50 TKAs demonstrated no difference in
plasty, which can either be achieved with two implants or terms of KSS or OKS at two years.62
with one combined bicompartmental prosthesis). Com- Modern combined compartmental arthroplasty is still in
bined compartmental arthroplasties can be an alternative its infancy, but shows promise. From the early studies of
to TKA with the advantages of preserving bone stock and this technique, it seems important to select patients with
restoring more normal kinematics.53-55 Owing to these intact cruciate ligaments and only moderate frontal and
potential advantages over TKA, there is a renewed interest sagittal deformities. We recommend the use of fixed-bear-
in combined compartmental implants.53,54 ing implants in the medial compartment, and use of sepa-
Implant survival and functional outcomes following combined rate implants for the bi-compartimental arthroplasties with
compartmental arthroplasties. Parratte et al56 reported a ret- a cemented second generation of patellofemoral implant.58
rospective analysis of 177 knees (155 patients) receiving Medial and lateral UKAs have demonstrated good mid- to
either bi-uni (100 knees) or bicompartmental arthroplasty long-term implant survival with excellent functional outcomes
(77 knees). At 17 years, implant survival was 78% in the bi- when performed in centres with expertise in performing such
uni group and 54% in the bicompartmental group. Clinical cases. There appears to be little difference on the basis of cur-
outcomes, reported at a minimum of five, and a mean of 12 rent data between fixed- and mobile-bearing devices in the
years, were more encouraging, with a mean KSS knee and medial compartment, but we prefer fixed-bearings in the lat-
function score of 88 (65 to 100) and 88 (58 to 100), respec- eral compartment as there is a significant incidence of bearing
tively in the bi-uni group, up from 44 (25 to 64) and 42 (17 dislocation with mobile bearings. UKA offers tempting advan-
to 59); results were almost as good in the bicompartmental tages regarding morbidity and function, but has a higher risk
group, with the mean KSS knee score rising from 38 (14 to of revision in the longer term; therefore, it may be that the
65) to 84 (59 to 100) and the mean function score rising choice of TKA or UKA represents the choice between superior
from 35 (10 to 57) to 79 (58 to 100). The authors explained revision rates and superior functional outcomes. Disap-
the poor survival as being due to factors related to design pointing long-term outcomes have been observed with the
and instrumentation of the prostheses used, and the use of first generation of PFAs, and in early series of combined
cementless PFA (Table V).57 compartmental arthroplasties owing to factors related to
Data examining current implants are limited, however, implant design and fixation. Promising short- and mid-
short-term results with modern bi-uni or with bicompart- term results with the new generation of PFAs and bicom-
mental arthroplasties using combinations of currently partmental arthroplasties should now be confirmed at
used implants appear promising.40,58,59 One recent study, longer follow-up.
where 34 patients receiving bicompartmental arthroplasty
This is an open-access article distributed under the terms of the Creative Com-
were matched to similar patients receiving TKA demon- mons Attributions licence CC-BY-NC, which permits unrestricted use, distribu-
strated benefits in terms of knee flexion and forgotten tion, and reproduction in any medium, but not for commercial gain, provided
the original author and source are credited.
knee score.58 However, a second study of the same combi-
nation of implants, a randomised controlled trial of 48 Author contributions:
S. Parratte: writing the paper.
patients at five years, demonstrated no benefit of bicom- M. Ollivier: writing the paper.
partmental arthroplasty over TKA in terms of functional A. Lunebourg: writing the paper.
M. P. Abdel: writing the paper.
scores, albeit with less blood loss reported in the bicom- J-N. Argenson: writing the paper
partmental group.60 No benefits in any form have been received or will be received from a commer-
The early results of a specially designed bicompartmental cial party related directly or indirectly to the subject of this article.

implant Journey Deuce (Smith & Nephew, Andover, Mas- This article was primary edited by A. D. Liddle.

VOL. 97-B, No. 10, OCTOBER 2015

14 S. PARRATTE, M. OLLIVIER, A. LUNEBOURG, M. P. ABDEL, J-N. ARGENSON

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