Anterior cruciate ligament reconstruction combined to partial knee replacement in active patients with ACL deficiency and knee osteoarthritis

Unicompartmental knee replacement: controversies and technical considerations

BACKGROUND

Unicompartmental knee replacement (UKR) is one of the effective interventions for the treatment of symptomatic knee osteoarthritis. Moreover, it has multiple advantages over total knee arthroplasty (TKA), including reduced intraoperative blood loss, decreased risk of transfusion, and faster recovery. This study aimed to discuss critical technical considerations regarding UKR and some of the controversies and updates.

METHODS

We conducted a review to provide an overview of the controversies and technical considerations about UKR in several aspects. Only peer-reviewed articles were included, up to December 2023 using PubMed, Google Scholar, ERIC, and Cochrane database for systematic reviews databases.

RESULT

UKR is associated with superior patient-reported clinical and functional outcomes, as well as shorter hospital stays, fewer postoperative complications, and revealed favorable outcomes in patients' return to sport. The choice between mobile- and fixed-bearing prostheses depends, in part, on the surgeon's preference. The mobile-bearing UKR is a less constrained prosthesis and can potentially result in less wear, but it is more technically demanding. While no significant difference between mobile-bearing versus fixed-bearing prostheses, cementless is superior to cemented design. Furthermore, UKR can be a good alternative for high tibial osteotomy (HTO) and still can be considered after a failed HTO. Lastly, recent reviews have shown a revision rate comparable to that of TKA. This is probably influenced by Improved comprehension of the best indications, patient selection criteria, as well as of the design, materials, and technological advances.

CONCLUSION

UKR treatment for unicompartmental knee osteoarthritis is secure and effective. Based on clinical and functional outcomes, decreased morbidity and mortality, and cost-effectiveness, long-term studies suggest that UKR is superior to TKA. Further investigation in this area is warranted.

Unicompartmental knee replacement combined with anterior cruciate ligament reconstruction provides comparable results to total knee replacement with no increased risk of complications

INTRODUCTION

There is controversy about the management of unicompartmental knee osteoarthritis (OA) in young, active patients with anterior cruciate ligament (ACL) insufficiency. This study compares the subjective, radiological, and functional results of total knee replacement (TKR) vs. combined medial unicompartmental knee replacement (UKR) with ACL reconstruction.

METHOD

Twelve patients suffering from medial OA and ACL deficiency with varus knee deformity and/or tibial slope <10° and absence of patellofemoral-related problems were eligible for combined UKR and ACL reconstruction (Group A). Twenty-six patients matched for age, male/female ratio and body mass index who received TKR in the same time frame were included as a control group (Group B). Oxford Knee Score (OKS), WOMAC index of osteoarthritis, Knee Osteoarthritis Outcome Score (KOOS), and routine X-rays were used for assessment.

RESULTS

Ten years after surgery, the mean overall KOOS score, OKS, WOMAC index increased from preoperatively, showing a statistically significant difference (p < 0.001). In terms of KOOS, OKS, or WOMAC scores at the most recent follow-up, there was no discernible difference between the groups (p = n.s.). Three years following surgery, one female patient in group A received revision TKR due to the lateral compartment's osteoarthritis developing and the patient's pain persisting. Concerning radiographic assessment, at the most recent follow-up (average 7.9 years in group A and 8.8 years in group B), there were no radiographic indications of implant loosening or proof of pathologic radiolucent lines.

CONCLUSIONS

UKR combined with ACL restoration offers clinical and radiographic outcomes comparable to TKR 10 years following surgery with no elevated risk of complications.

Anterior cruciate ligament deficiency versus intactness for outcomes in patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis

Objective: The unicondylar knee arthroplasty (UKA) procedure is primarily indicated for osteoarthritis of the knee. Anterior cruciate ligament (ACL) defects have long been considered a contraindication to UKA. However, recent clinical studies have found that ACL defects do not affect postoperative outcomes in UKA. To elucidate whether ACL defects affect postoperative outcomes in UKA, we performed a systematic review and Meta-analysis of observational cohort studies comparing the effects of ACL defects and intactness on surgical outcomes in UKA.

Methods: In this study, we used “Anterior Cruciate Ligament”, “Anterior Cruciate Ligament Injuries” and “Arthroplasty, Replacement, Knee” as the subject terms according to PICOS principles. These subject terms and the corresponding free texts were used to conduct a systematic search in the three major databases PubMed, Embase and Cochrane on December 9, 2021. The main study variables included age, gender, region, definition of ACL defect and diagnosed diseases. The study used a random effect model to pool the effect of 95% CIs. To explore the sources of heterogeneity and to test the stability of the results, a sensitivity analysis was performed.

Results: The systematic review found no significant differences in postoperative clinical outcomes in the elderly population when unicondylar replacement was performed in the setting of multiple factors such as injury, defects, longitudinal tear, and synovial bursa injury defined as ACL deficiency. The primary clinical outcomes included postoperative revision, Tegner activity score, and Oxford Knee Score (OKS). After statistical meta-analysis, postoperative outcomes such as postoperative revision (OR, 1.174; 95% CIs, 0.758–1.817) and Tegner activity score (OR, -0.084; 95% CIs, -0.320–0.151) were not statistically different.

Conclusion: There was no difference in postoperative revision rates and functional outcomes such as Tegner activity score between the ACL-deficient group compared with the ACL-intact group. For the present results, it is not advisable to consider ACL deficiency as a contraindication of UKA.

Shift to low-impact sports and recreational activities following total knee replacement

Background:

A growing number of physically active patients undergoing total knee replacement (TKR) desires to resume their preoperative activity levels and to be able to engage in sports after surgery. The purpose of this study was to assess the sporting and physical activities of patients who had undergone TKR. It was hypothesized that the majority of patients treated by TKR would have been able to return to amateur sports and recreational activity .

Methods:

Ninety-seven patients who underwent TKR between 2014 and 2016, were retrospectively reviewed. Mean age was 70.1 years (range 64–83). Average follow-up time was 4.2 years (SD: 1.7). Assessment included Knee Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and Tegner activity level. Sporting and physical activities of all patients were reported. Wilcoxon’s signed ranks test was used for comparison between pre-operative and follow-up data. Significance was set at p < 0.05.

Results:

Both KOOS score and IKDC significantly improved after surgery (p < 0.001). No statistically significant differences were reported concerning Tegner activity level before and after surgery (p = n.s.). After surgery, a total number of 52 patients (53.6%) successfully returned to sporting and recreational activities, such as cycling, hiking, dancing and swimming. A return to activity rate of 81% of patients practicing sport before surgery was reported.

Conclusions:

TKR provides a high rate of return to sport postoperatively and confirms improved subjective results and reduced pain compared to preoperative status. However, most patients returned to low-impact activities, while a significant decrease was reported for mid- and high-impact sports.