Aims

The mobile bearing Oxford unicompartmental knee arthroplasty (OUKA) is recommended to be performed with the leg in the hanging leg (HL) position, and the thigh placed in a stirrup. This comparative cadaveric study assesses implant positioning and intraoperative kinematics of OUKA implanted either in the HL position or in the supine leg (SL) position.

Aims. Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results. There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion. Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA. Cite this article: Bone Joint J 2024;106-B(7):680–687

Aims. Unicompartmental knee arthroplasty (UKA) has higher revision rates than total knee arthroplasty (TKA). As revision of UKA may be less technically demanding than revision TKA, UKA patients with poor functional outcomes may be more likely to be offered revision than TKA patients with similar outcomes. The aim of this study was to compare clinical thresholds for revisions between TKA and UKA using revision incidence and patient-reported outcomes, in a large, matched cohort at early, mid-, and late-term follow-up. Methods. Analyses were performed on propensity score-matched patient cohorts of TKAs and UKAs (2:1) registered in the New Zealand Joint Registry between 1 January 1999 and 31 December 2019 with an Oxford Knee Score (OKS) response at six months (n, TKA: 16,774; UKA: 8,387), five years (TKA: 6,718; UKA: 3,359), or ten years (TKA: 3,486; UKA: 1,743). Associations between OKS and revision within two years following the score were examined. Thresholds were compared using receiver operating characteristic analysis. Reasons for aseptic revision were compared using cumulative incidence with competing risk. Results. Fewer TKA patients with ‘poor’ outcomes (≤ 25) subsequently underwent revision compared with UKA at six months (5.1% vs 19.6%; p < 0.001), five years (4.3% vs 12.5%; p < 0.001), and ten years (6.4% vs 15.0%; p = 0.024). Compared with TKA, the relative risk for UKA was 2.5-times higher for ‘unknown’ reasons, bearing dislocations, and disease progression. Conclusion. Compared with TKA, more UKA patients with poor outcomes underwent revision from early to long-term follow-up, and were more likely to undergo revision for ‘unknown’ reasons, which suggest a lower clinical threshold for UKA. For UKA, revision risk was higher for bearing dislocations and disease progression. There is supporting evidence that the higher revision UKA rates are associated with lower clinical thresholds for revision and additional modes of failure. Cite this article: Bone Joint J 2023;105-B(3):269–276

Aims. Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more meaningful estimate of risk projection over a patient’s remaining lifetime, and to compare this to TKA. Methods. Incidence of revision and mortality for all primary UKAs performed from 1999 to 2019 (n = 13,481) was obtained from the New Zealand Joint Registry (NZJR). Lifetime risk of revision was calculated for patients and stratified by age, sex, and American Society of Anesthesiologists (ASA) grade. Results. The lifetime risk of revision was highest in the youngest age group (46 to 50 years; 40.4%) and decreased sequentially to the oldest (86 to 90 years; 3.7%). Across all age groups, lifetime risk of revision was higher for females (ranging from 4.3% to 43.4% vs males 2.9% to 37.4%) and patients with a higher ASA grade (ASA 3 to 4, ranging from 8.8% to 41.2% vs ASA 1 1.8% to 29.8%). The lifetime risk of revision for UKA was double that of TKA across all age groups (ranging from 3.7% to 40.4% for UKA, and 1.6% to 22.4% for TKA). The higher risk of revision in younger patients was associated with aseptic loosening in both sexes and pain in females. Periprosthetic joint infection (PJI) accounted for 4% of all UKA revisions, in contrast with 27% for TKA; the risk of PJI was higher for males than females for both procedures. Conclusion. Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods. This study highlights the higher lifetime risk of UKA revision for younger patients, females, and those with a higher ASA grade, which can aid with patient counselling prior to UKA. Cite this article: Bone Joint J 2022;104-B(6):672–679

Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes. Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty. This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice. Cite this article: Bone Jt Open 2021;2(1):48–57

Aims. The aim of this study was to describe the pattern of revision indications for unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) and any change to this pattern for UKA patients over the last 20 years, and to investigate potential associations to changes in surgical practice over time. Methods. All primary knee arthroplasty surgeries performed due to primary osteoarthritis and their revisions reported to the Danish Knee Arthroplasty Register from 1997 to 2017 were included. Complex surgeries were excluded. The data was linked to the National Patient Register and the Civil Registration System for comorbidity, mortality, and emigration status. TKAs were propensity score matched 4:1 to UKAs. Revision risks were compared using competing risk Cox proportional hazard regression with a shared γ frailty component. Results. Aseptic loosening (loosening) was the most common revision indication for both UKA (26.7%) and TKA (29.5%). Pain and disease progression accounted for 54.6% of the remaining UKA revisions. Infections and instability accounted for 56.1% of the remaining TKA revision. The incidence of revision due to loosening or pain decreased over the last decade, being the second and third least common indications in 2017. There was a decrease associated with fixation method for pain (hazard ratio (HR) 0.40; 95% confidence interval (CI) 0.17 to 0.94) and loosening (HR 0.29; 95% CI 0.10 to 0.81) for cementless compared to cemented, and units UKA usage for pain (HR 0.67, 95% CI 0.50 to 0.91), and loosening (HR 0.51; 95% CI 0.37 to 0.70) for high usage. Conclusion. The overall revision patterns for UKA and TKA for the last 20 years are comparable to previous published patterns. We found large changes to UKA revision patterns in the last decade, and with the current surgical practice, revision due to pain or loosening are significantly less likely. Cite this article: Bone Jt Open 2023;4(12):923–931

Aims. The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and length of hospital stay influenced the relative cost per QALY. Patients and Methods. A Markov decision analysis was performed, using known parameters for costs, outcomes, implant survival, and mortality, to assess the cost-effectiveness of rUKA relative to manual TKA and UKA for patients with isolated medial compartment OA of the knee with a mean age of 65 years. The influence of case volume and shorter hospital stay were assessed. Results. Using a model with an annual case volume of 100 patients, the cost per QALY of rUKA was £1395 and £1170 relative to TKA and UKA, respectively. The cost per QALY was influenced by case volume: a low-volume centre performing ten cases per year would achieve a cost per QALY of £7170 and £8604 relative to TKA and UKA. For a high-volume centre performing 200 rUKAs per year with a mean two-day length of stay, the cost per QALY would be £648; if performed as day-cases, the cost would be reduced to £364 relative to TKA. For a high-volume centre performing 200 rUKAs per year with a shorter length of stay of one day relative to manual UKA, the cost per QALY would be £574. Conclusion . rUKA is a cost-effective alternative to manual TKA and UKA for patients with isolated medial compartment OA of the knee. The cost per QALY of rUKA decreased with reducing length of hospital stay and with increasing case volume, compared with TKA and UKA. Cite this article: Bone Joint J 2019;101-B:1063–1070

Aims. The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA. Methods. We included data from eight dedicated fast-track centres, all reporting UKAs to the same database, between 2010 and 2018. Complete ( > 99%) data on length of stay, 90-day readmission, and mortality were obtained during the study period. Specific reasons for a length of stay of > two days, length of stay > four days, and 30- and 90-day readmission were recorded. The use of UKA in the different centres was dichotomized into ≥ 20% versus < 20% of arthroplasties which were undertaken being UKAs, and ≥ 52 UKAs versus < 52 UKAs being undertaken annually. Results. A total of 3,927 procedures were included. Length of stay (mean 1.1 days (SD 1.1), median 1 (IQR 0 to 1)) was unchanged during the study period. The proportion of procedures with a length of stay > two days was also largely unchanged during this time. The percentage of patients discharged on the day of surgery varied greatly between centres (0% to 50% (0 to 481)), with centres with high UKA utilization (both usage and volume) having a larger proportion of same-day discharges. The 30- and 90-day readmissions were 166 (4.2%) and 272 (6.9%), respectively; the 90-day mortality was 0.08% (n = 3). Conclusion. Our findings suggest general underutilization of the potential for quicker recovery following UKA in a fast-track setup. Cite this article: Bone Joint J 2020;102-B(9):1167–1175

Aims. To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome. Methods. A total of 325 consecutive domed lateral UKAs undertaken for the recommended indications were included, and their functional and survival outcomes were assessed. The effects of age, weight, activity, and the presence of full-thickness erosions of cartilage in the patellofemoral joint on outcome were evaluated. Results. Median follow-up was seven years (3 to 14), and mean age at surgery was 65 years (39 to 90). Median Oxford Knee Score (OKS) was 43 (interquartile range (IQR) 37 to 47), with 260 (80%) achieving a good or excellent score (OKS > 34). Revisions occurred in 34 (10%); 14 (4%) were for dislocation, of which 12 had no recurrence following insertion of a new bearing, and 12 (4%) were revised for medial osteoarthritis (OA). Ten-year survival was 85% (95% confidence interval (CI) 79 to 90, at risk 72). Age, weight, activity, and patellofemoral erosions did not have a significant effect on the clinical outcome or survival. Conclusion. Domed lateral UKA provides a good alternative to total knee arthroplasty (TKA) in the management of lateral compartment OA. Although dislocation is relatively easy to treat successfully, the dislocation rate of 4% is high. It is recommended that the stability of the bearing is assessed intraoperatively. If the bearing can easily be displaced, the fixed rather than the mobile bearing version of the Oxford lateral tibial component should be inserted instead. Younger age, heavier weight, high activity, and patellofemoral erosions did not detrimentally affect outcome, so should not be considered contraindications. Cite this article: Bone Joint J 2020;102-B(8):1033–1040

Aims. Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs. Methods. In total, 34 patients (13 female, 21 male; mean age 62 years (41 to 79); BMI 29.7 kg/m. 2. (23.6 to 42.1)) with 38 medial Oxford partial UKAs (20 left, 18 right; 19 cementless, 14 cemented, and five hybrid) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively, and at one and two years postoperatively. Changes in mean osteoblastic activity were investigated using a tracer localization scheme with volumes of interest (VOIs), reported by normalized mean tracer values. A SPECT/CT registration platform additionally explored cortical tracer evolution in zones of interest identified by previous experimental research. Results. Significant reduction of tracer activity from the preoperative situation was found in femoral and anteromedial tibial VOIs adjacent to the UKA components. Temporarily increased osteoblastic bone activity was observed in VOIs comprising the UKA keel structure at one year postoperatively compared to the preoperative activity. Persistent higher tracer uptake was found in the posterior tibial cortex at final follow-up. Multivariate analysis showed no statistical difference in osteoblastic bone activity underneath cemented or cementless components. Conclusion. Well-functioning medial mobile-bearing UKAs showed distinct changes in patterns of normalized bone tracer activity in the different VOIs adjacent to the prosthetic components, regardless of their type of fixation. Compared to the preoperative situation, persistent high bone activity was found underneath the keel and the posterior tibial cortex at final follow-up, with significant reduced activity only being identified in femoral and anteromedial tibial VOIs. Cite this article: Bone Joint J 2022;104-B(1):34–44

Abstract. Purpose. Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). However, its indications remain controversial. Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. Methods. The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. PubMed, Ovid, Web of Science, Google Scholar, and Cochrane library were searched in June 2021. This review was conducted in accordance with the PRISMA guidelines (PROSPERO registration number: CRD42021248322). Results. A total of 12 observational studies with 6,448 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64.32 years, with follow-up ranging from 0.2 to 15 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. Conclusion. Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that performing UKA at a younger age (< 60 years) should not be considered suboptimal. However, this finding should be applied in context, as other confounding factors need to be explored

Objectives. Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty for patients who require treatment of single-compartment osteoarthritis, especially for young patients. To satisfy this requirement, new patient-specific prosthetic designs have been introduced. The patient-specific UKA is designed on the basis of data from preoperative medical images. In general, knee implant design with increased conformity has been developed to provide lower contact stress and reduced wear on the tibial insert compared with flat knee designs. The different tibiofemoral conformity may provide designers the opportunity to address both wear and kinematic design goals simultaneously. The aim of this study was to evaluate wear prediction with respect to tibiofemoral conformity design in patient-specific UKA under gait loading conditions by using a previously validated computational wear method. Methods. Three designs with different conformities were developed with the same femoral component: a flat design normally used in fixed-bearing UKA, a tibia plateau anatomy mimetic (AM) design, and an increased conforming design. We investigated the kinematics, contact stress, contact area, wear rate, and volumetric wear of the three different tibial insert designs. Results. Conforming increased design showed a lower contact stress and increased contact area. In addition, increased conformity resulted in a reduction of the wear rate and volumetric wear. However, the increased conformity design showed limited kinematics. Conclusion. Our results indicated that increased conformity provided improvements in wear but resulted in limited kinematics. Therefore, increased conformity should be avoided in fixed-bearing patient-specific UKA design. We recommend a flat or plateau AM tibial insert design in patient-specific UKA. Cite this article: Y-G. Koh, K-M. Park, H-Y. Lee, K-T. Kang. Influence of tibiofemoral congruency design on the wear of patient-specific unicompartmental knee arthroplasty using finite element analysis. Bone Joint Res 2019;8:156–164. DOI: 10.1302/2046-3758.83.BJR-2018-0193.R1

Abstract. Aims. The association between body mass index (BMI) and venous thromboembolism (VTE) is well studied, but remains unclear in the literature. We aimed to determine whether morbid obesity (BMI≥40) was associated with increased risk of VTE following total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA), compared to those of BMI<40. Methods. Between January 2016 and December 2020, our institution performed 4506 TKAs and 449 UKAs. 450 (9.1%) patients had a BMI≥40. CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) and ultrasound scan for suspected proximal deep vein thrombosis (DVT) were recorded up to 90 days post-operatively. Results. When comparing those of BMI<40 to those with BMI≥40, there was no difference in incidence of PE (1.0% vs 1.1%, p=0.803) or proximal DVT (0.4% vs 0.2%, p=0.645). There was no difference in number of ultrasound scans ordered (p=0.668), or number of CTPAs ordered for those with a BMI≥40 (p=0.176). The percentage of patients with a confirmed PE or proximal DVT were 24.2% and 3.9% respectively in the BMI<40 group, compared to 20.0% (p=0.804) and 2.3% (p=0.598) in the BMI≥40 group. Conclusion. Morbid obesity was not associated with increased risk of PE or proximal DVT within 90 days of TKA or UKA. Overall, 76.3% of CTPAs and 96.2% of ultrasound scans were negative. Increasing the threshold for VTE investigation would reduce the rate of negative investigations. Establishing more effective risk stratification protocols, to guide investigation, would likely reduce unnecessary imaging

Unicompartmental knee arthroplasty (UKA) has advantages over total knee arthroplasty but national joint registries report a significantly higher revision rate for UKA. As a result, most surgeons are highly selective, offering UKA only to a small proportion (up to 5%) of patients requiring arthroplasty of the knee, and consequently performing few each year. However, surgeons with large UKA practices have the lowest rates of revision. The overall size of the practice is often beyond the surgeon’s control, therefore case volume may only be increased by broadening the indications for surgery, and offering UKA to a greater proportion of patients requiring arthroplasty of the knee. . The aim of this study was to determine the optimal UKA usage (defined as the percentage of knee arthroplasty practice comprised by UKA) to minimise the rate of revision in a sample of 41 986 records from the for National Joint Registry for England and Wales (NJR). UKA usage has a complex, non-linear relationship with the rate of revision. Acceptable results are achieved with the use of 20% or more. Optimal results are achieved with usage between 40% and 60%. Surgeons with the lowest usage (up to 5%) have the highest rates of revision. With optimal usage, using the most commonly used implant, five-year survival is 96% (95% confidence interval (CI) 94.9 to 96.0), compared with 90% (95% CI 88.4 to 91.6) with low usage (5%) previously considered ideal. . The rate of revision of UKA is highest with low usage, implying the use of narrow, and perhaps inappropriate, indications. The widespread use of broad indications, using appropriate implants, would give patients the advantages of UKA, without the high rate of revision. Cite this article: Bone Joint J 2015;97-B:1506–11

Objectives. Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty with isolated medial or lateral compartment osteoarthritis. However, polyethylene wear can significantly reduce the lifespan of UKA. Different bearing designs and materials for UKA have been developed to change the rate of polyethylene wear. Therefore, the objective of this study is to investigate the effect of insert conformity and material on the predicted wear in mobile-bearing UKA using a previously developed computational wear method. Methods. Two different designs were tested with the same femoral component under identical kinematic input: anatomy mimetic design (AMD) and conforming design inserts with different conformity levels. The insert materials were standard or crosslinked ultra-high-molecular-weight polyethylene (UHMWPE). We evaluated the contact pressure, contact area, wear rate, wear depth, and volumetric wear under gait cycle loading conditions. Results. Conforming design inserts had the lower contact pressure and larger contact area. However, they also had the higher wear rate and volumetric wear. The improved wear performance was found with AMD inserts. In addition, the computationally predicted volumetric wear of crosslinked UHMWPE inserts was less than half that of standard UHMWPE inserts. Conclusion. Our results showed that increasing conformity may not be the sole predictor of wear performance; highly crosslinked mobile-bearing polyethylene inserts can also provide improvement in wear performance. These results provide improvements in design and materials to reduce wear in mobile-bearing UKA. Cite this article: Bone Joint Res 2019;8:563–569

Abstract. Background. Daycase pathways which aim to discharge patients the same day following Unicompartmental Knee Replacement have been introduced in some centres, though most continue with Standard pathways. While Daycase pathways have cost savings, recovery data comparing pathways is limited. This study aims to compare patient-reported early recovery between Daycase and Standard pathways following UKR. Method. This study was carried out in two centres that originally used the same Standard recovery pathway for UKR. In one centre, the Standard pathway was modified into a Daycase pathway. 26 Daycase-Outpatient, 11 Daycase-Inpatient, and 18 Standard patients were recruited. Patients completed the Oxford Arthroplasty Early Recovery Score (OARS) and SF-36 (Acute) measure between Days 1–42. Results. Standard patients had significantly better Day-1 scores than Daycase patients, but this difference rapidly diminished, and from Day-3 onwards both groups had near-identical scores (OARS Day-1, 59 vs 37, p=0.002, stemming from differences in Pain, Nausea/Feeling-Unwell, Function/Mobility subscores p=0.003,0.014,0.011. OARS Day-3 48 vs 49, p=0.790). Daycase-Outpatients had a higher overall OARS (p=0.002), recovering 1–2 weeks faster than Daycase-Inpatients. OARS subscores demonstrated that Daycase-Outpatients had better Pain, Nausea/Feeling-Unwell, Fatigue/Sleep scores (p=0.020,0.0004,0.019 respectively). SF-36 scores corroborate OARS scores. Conclusion. The Standard cohort had better Day-1 scores than the Daycase cohort, likely due to later mobilisation and stronger inpatient analgesia; these differences diminished by Day-3. Daycase-Outpatients recovered substantially faster than Daycase-Inpatients – likely due to the factors that delayed their discharge. The convergence of scores at 6 weeks demonstrates that both pathways have similar early recovery outcomes

Aims. Unicompartmental knee arthroplasty (UKA) provides improved early functional outcomes and less postoperative morbidity and pain compared with total knee arthroplasty (TKA). Opioid prescribing has increased in the last two decades, and recently states in the USA have developed online Prescription Drug Monitoring Programs to prevent overprescribing of controlled substances. This study evaluates differences in opioid requirements between patients undergoing TKA and UKA. Patients and Methods. We retrospectively reviewed 676 consecutive TKAs and 241 UKAs. Opioid prescriptions in morphine milligram equivalents (MMEs), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring websites six months before and nine months after the initial procedures. Bivariate and multivariate analysis were performed for patients who had a second prescription and continued use. Results. Patients undergoing UKA had a second opioid prescription filled 50.2% of the time, compared with 60.5% for TKA (p = 0.006). After controlling for potential confounders, patients undergoing UKA were still less likely to require a second prescription than those undergoing TKA (adjusted odds ratio (OR) 0.58, 95% confidence interval (CI) 0.42 to 0.81; p = 0.001). Continued opioid use requiring more than five prescriptions occurred in 13.7% of those undergoing TKA and 5.8% for those undergoing UKA (p = 0.001), and was also reduced in UKA patients compared with TKA patients (adjusted OR 0.33, 95% CI 0.16 to 0.67; p = 0.022) in multivariate analysis. The continued use of opioids after six months was 11.8% in those undergoing TKA and 8.3% in those undergoing UKA (p = 0.149). The multivariate models for second prescriptions, continued use with more than five, and continued use beyond six months yielded concordance scores of 0.70, 0.86, and 0.83, respectively. Conclusion. Compared with TKA, patients undergoing UKA are less likely to require a second opioid prescription and use significantly fewer opioid prescriptions. Thus, orthopaedic surgeons should adjust their patterns of prescription and educate patients about the reduced expected analgesic requirements after UKA compared with TKA. Cite this article: Bone Joint J 2019;101-B(7 Supple C):22–27

Aims. It remains controversial whether patellofemoral joint pathology is a contraindication to lateral unicompartmental knee arthroplasty (UKA). This study aimed to evaluate the effect of preoperative radiological degenerative changes and alignment on patient-reported outcome scores (PROMs) after lateral UKA. Secondarily, the influence of lateral UKA on the alignment of the patellofemoral joint was studied. Methods. A consecutive series of patients who underwent robotic arm-assisted fixed-bearing lateral UKA with at least two-year follow-up were retrospectively reviewed. Radiological evaluation was conducted to obtain a Kellgren Lawrence (KL) grade, an Altman score, and alignment measurements for each knee. Postoperative PROMs were assessed using the Kujala (Anterior Knee Pain Scale) score, Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), and satisfaction levels. Results. A total of 140 knees (130 patients) were identified for analysis. At mean 4.1 years (2.0 to 8.5) follow-up, good to excellent Kujala scores were reported. The presence of mild to moderate preoperative patellofemoral joint osteoarthritis had no impact on these scores (KL grade 0 vs 1 to 3, p = 0.203; grade 0 to 1 vs 2 to 3, p = 0.674). Comparable scores were reported by patients with osteoarthritis (Altman score of ≥ 2) evident on either the medial or lateral patellofemoral joint facet (medial, p = 0.600 and lateral, p = 0.950). Patients with abnormal patellar congruence and tilt angles (≥ 17° and ≥ 14°, respectively) reported good to excellent Kujala scores. Furthermore, lateral UKA resulted in improvements to patellofemoral alignment. Conclusion. This is the first study demonstrating that mild to moderate preoperative radiological degenerative changes and malalignment of the patellofemoral joint are not associated with poor patient-reported outcomes at mid-term follow-up after lateral fixed-bearing UKA. Our data suggest that this may be explained by realignment of the patella and thereby redistribution of loads across the patellofemoral joint. Cite this article: Bone Joint J 2020;102-B(6):727–735

Aim. There has been a significant reduction in unicompartmental knee arthroplasty (UKA) procedures recorded in Australia. This follows several national joint registry studies documenting high UKA revision rates when compared to total knee arthroplasty (TKA). With the recent introduction of robotically assisted UKA procedures, it is hoped that outcomes improve. This study examines the cumulative revision rate of UKA procedures implanted with a newly introduced robotic system and compares the results to one of the best performing non-robotically assisted UKA prostheses, as well as all other non-robotically assisted UKA procedures. Methods. Data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) for all UKA procedures performed for osteoarthritis (OA) between 2015 and 2018 were analyzed. Procedures using the Restoris MCK UKA prosthesis implanted using the Mako Robotic-Arm Assisted System were compared to non-robotically assisted Zimmer Unicompartmental High Flex Knee System (ZUK) UKA, a commonly used UKA with previously reported good outcomes and to all other non-robotically assisted UKA procedures using Cox proportional hazard ratios (HRs) and Kaplan-Meier estimates of survivorship. Results. There was no difference in the rate of revision when the Mako-assisted Restoris UKA was compared to the ZUK UKA (zero to nine months: HR 1.14 (95% CI 0.71 to 1.83; p = 0.596) vs nine months and over: HR 0.66 (95% CI 0.42 to 1.02; p = 0.058)). The Mako-assisted Restoris had a significantly lower overall revision rate compared to the other types of non-robotically assisted procedures (HR 0.58 (95% confidence interval (CI) 0.42 to 0.79); p < 0.001) at three years. Revision for aseptic loosening was lower for the Mako-assisted Restoris compared to all other non-robotically assisted UKA (entire period: HR 0.34 (95% CI 0.17 to 0.65); p = 0.001), but not the ZUK prosthesis. However, revision for infection was significantly higher for the Mako-assisted Restoris compared to the two comparator groups (ZUK: entire period: HR 2.91 (95% CI 1.22 to 6.98; p = 0.016); other non-robotically assisted UKA: zero to three months: HR 5.57 (95% CI 2.17 to 14.31; p < 0.001)). Conclusion. This study reports comparable short-term survivorship for the Mako robotically assisted UKA compared to the ZUK UKA and improved survivorship compared to all other non-robotic UKA. These results justify the continued use and investigation of this procedure. However, the higher rate of early revision for infection for robotically assisted UKA requires further investigation. Cite this article: Bone Joint J 2020;102-B(3):319–328

Aims. The aim of this study was to assess the influence of obesity on the clinical outcomes and survivorship ten years postoperatively in patients who underwent a fixed-bearing unicompartmental knee arthroplasty (UKA). Patients and Methods. We prospectively followed 184 patients who underwent UKA between 2003 and 2007 for a minimum of ten years. A total of 142 patients with preoperative body mass index (BMI) of < 30 kg/m. 2. were in the control group (32 male, 110 female) and 42 patients with BMI of ≥ 30 kg/m. 2. were in the obese group (five male, 37 female). Pre- and postoperative range of movement (ROM), Knee Society Score (KSS), Oxford Knee Score (OKS), 36-Item Short-Form Health Survey (SF-36), and survivorship were analyzed. Results. Patients in the obese group underwent UKA at a significantly younger mean age (56.5 years (. sd. 6.4)) than those in the control group (62.4 years (. sd. 7.8); p < 0.001). There was no significant difference in preoperative functional scores. However, those in the obese group had a significantly lower ROM (116° (. sd. 15°) vs 123° (. sd. 17°); p = 0.003). Both groups achieved significant improvement in outcome scores regardless of BMI, ten years postoperatively. All patients achieved the minimal clinically important difference (MCID) for OKS and KSS. Both groups also had high rates of satisfaction (96.3% in the control group and 97.5% in the obese group) and the fulfilment of expectations (94.9% in the control group and 95.0% in the obese group). Multiple linear regression showed a clear association between obesity and a lower OKS two years postoperatively and Knee Society Function Score (KSFS) ten years postoperatively. After applying propensity matching, obese patients had a significantly lower KSFS, OKS, and physical component score (PCS) ten years postoperatively. Seven patients underwent revision to total knee arthroplasty (TKA), two in the control group and five in the obese group, resulting in a mean rate of survival at ten years of 98.6% and 88.1%, respectively (p = 0.012). Conclusion. Both groups had significant improvements in functional and quality-of-life scores postoperatively. However, obesity was a significant predictor of poorer improvement in clinical outcome and an increased rate of revision ten years postoperatively