Skip to main content

Advertisement

SpringerLink
Log in

Restoration or relative overcorrection of pre-arthritic coronal alignment leads to improved results following medial unicompartmental knee arthroplasty

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

A pre-arthritic alignment strategy for medial unicompartmental knee arthroplasty (UKA) aims to restore a patient’s native lower limb alignment which may translate into improved outcomes. This study aimed to assess whether patients with pre-arthritically aligned knees versus patients with non-pre-arthritically aligned knees demonstrated improved mid-term outcomes and survivorship following medial UKA. The hypothesis was that pre-arthritic alignment in medial UKA would lead to better postoperative outcomes.

Methods

A retrospective study of 537 robotic-assisted fixed-bearing medial UKA was conducted. During this procedure, the surgical goal was to restore pre-arthritic alignment guided by re-tensioning of the medial collateral ligament (MCL). For study purposes, coronal alignment was retrospectively evaluated using the mechanical hip-knee-ankle angle (mHKA). Pre-arthritic alignment was estimated through the arithmetic hip-knee-ankle (aHKA) algorithm. Knees were grouped according to the difference between postoperative mHKA and estimated pre-arthritic alignment (i.e., mHKA - aHKA) as Group 1 (pre-arthritically aligned: mHKA restored within 2.0° of the aHKA), Group 2 (mHKA > 2.0° overcorrected relative to the aHKA), or Group 3 (mHKA > 2.0° undercorrected relative to the aHKA). Outcomes included the Knee Injury and Osteoarthritic Outcome Score for Joint Replacement (KOOS, JR), Kujala, proportions of knees achieving the patient acceptable symptom state (PASS) for these scores, and survivorship. PASS thresholds for KOOS, JR and Kujala were determined using a receiver operating characteristic curve method.

Results

A total of 369 knees were categorized as Group 1, 107 as Group 2, and 61 as Group 3. At 4.4 ± 1.6 years follow-up, mean KOOS, JR was comparable among groups, while Kujala was significantly worse in Group 3. The proportion of knees achieving the PASS for Kujala (76.5 points) was lower in Group 3 (n = 32; 59%) compared to Group 1 (n = 260; 74%) (p = 0.02). 5-year survivorship was higher in Group 1 and Group 2 (99% and 100%, respectively) compared to Group 3 (91%) (p = 0.04).

Conclusion

Pre-arthritically aligned knees and knees with relative overcorrection from their pre-arthritic alignment following medial UKA demonstrated improved mid-term outcomes and survivorship compared to knees with relative under correction from their pre-arthritic alignment. These results encourage restoring or relatively overcorrecting pre-arthritic alignment to optimize outcomes following medial UKA, and caution against under correction from the pre-arthritic alignment.

Level of evidence

IV, case series.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The dataset used and analyzed for the current study can only be made available upon reasonable request through the corresponding author.

References

  1. Bayoumi T, Burger JA, Zuiderbaan HA, Ruderman LV, Nguyen JT, Pearle AD (2023) Robotic-assisted medial unicompartmental knee arthroplasty restores estimated pre-arthritic coronal limb alignment: a retrospective cohort study. Knee 41:180–189

    Article  PubMed  Google Scholar 

  2. Bayoumi T, van der List JP, Ruderman LV, Zuiderbaan HA, Kerkhoffs G, Pearle AD (2022) Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07094-01-17

  3. Bellemans J, Colyn W, Vandenneucker H, Victor J (2012) The Chitranjan Ranawat award: Is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470:45–53

    Article  PubMed  Google Scholar 

  4. Burger JA, Kleeblad LJ, Laas N, Pearle AD (2019) The influence of preoperative radiographic patellofemoral degenerative changes and malalignment on patellofemoral-specific outcome scores following fixed-bearing medial unicompartmental knee arthroplasty. JBJS 101:1662–1669

    Article  Google Scholar 

  5. Burger JA, Kleeblad LJ, Laas N, Pearle AD (2020) Mid-term survivorship and patient-reported outcomes of robotic-arm assisted partial knee arthroplasty. Bone Jt J 102-b:108–116

  6. Citak M, Suero EM, Citak M, Dunbar NJ, Branch SH, Conditt MA et al (2013) Unicompartmental knee arthroplasty: is robotic technology more accurate than conventional technique? Knee 20:268–271

    Article  PubMed  Google Scholar 

  7. Dunbar NJ, Roche MW, Park BH, Branch SH, Conditt MA, Banks SA (2012) Accuracy of dynamic tactile-guided unicompartmental knee arthroplasty. J Arthroplasty 27:803-808.e801

    Article  PubMed  Google Scholar 

  8. Eijkenboom JFA, van der Heijden RA, de Kanter JLM, Oei EH, Bierma-Zeinstra SMA, van Middelkoop M (2020) Patellofemoral alignment and geometry and early signs of osteoarthritis are associated in patellofemoral pain population. Scand J Med Sci Sports 30:885–893

    Article  PubMed  PubMed Central  Google Scholar 

  9. Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191

    Article  PubMed  Google Scholar 

  10. Fleisher IT, Thompson MC, Mensah CJ, Joseph AD, McLawhorn AS, Padgett DE et al (2022) Development and validation of crosswalks between the Western Ontario & McMaster Universities Osteoarthritis Index and hip disability and osteoarthritis outcome score joint replacement/knee injury and osteoarthritis outcome score joint replacement. J Arthroplasty 37:1034–1039

    Article  PubMed  Google Scholar 

  11. Griffiths-Jones W, Chen DB, Harris IA, Bellemans J, MacDessi SJ (2021) Arithmetic hip-knee-ankle angle (aHKA): an algorithm for estimating constitutional lower limb alignment in the arthritic patient population. Bone Jt J Open 2:351–358

    Article  Google Scholar 

  12. Hernigou P, Deschamps G (2004) Alignment influences wear in the knee after medial unicompartmental arthroplasty. Clin Orthop Relat Res 423:161–165

    Article  Google Scholar 

  13. Hess S, Moser LB, Amsler F, Behrend H, Hirschmann MT (2019) Highly variable coronal tibial and femoral alignment in osteoarthritic knees: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:1368–1377

    Article  PubMed  Google Scholar 

  14. Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S (2019) Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc 27:1394–1402

    Article  PubMed  Google Scholar 

  15. Kamenaga T, Takayama K, Ishida K, Hayashi S, Kuroda R, Matsumoto T (2020) Central implantation of the femoral component relative to the tibial insert improves clinical outcomes in fixed-bearing unicompartmental knee arthroplasty. J Arthroplasty 35:3108–3116

    Article  PubMed  Google Scholar 

  16. Kort N, Stirling P, Pilot P, Müller JH (2022) Robot-assisted knee arthroplasty improves component positioning and alignment, but results are inconclusive on whether it improves clinical scores or reduces complications and revisions: a systematic overview of meta-analyses. Knee Surg Sports Traumatol Arthrosc 30:2639–2653

    Article  PubMed  Google Scholar 

  17. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163

    Article  CAS  PubMed  Google Scholar 

  18. Liddle AD, Pandit H, Judge A, Murray DW (2015) Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales. Bone Jt J 97-b:793–801

  19. Liu B, Feng C, Tu C (2022) Kinematic alignment versus mechanical alignment in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials. J Orthop Surg Res 4:171–201

    Google Scholar 

  20. Lyman S, Lee YY, Franklin PD, Li W, Cross MB, Padgett DE (2016) Validation of the KOOS, JR: a short-form knee arthroplasty outcomes survey. Clin Orthop Relat Res 474:1461–1471

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lyman S, Lee YY, McLawhorn AS, Islam W, MacLean CH (2018) What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement? Clin Orthop Relat Res 476:2432–2441

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mittal A, Meshram P, Kim WH, Kim TK (2020) Unicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA. J Orthop Trauma 2(211):15

    Article  Google Scholar 

  23. Nie Y, Yu Q, Shen B (2021) Impact of tibial component coronal alignment on knee joint biomechanics following fixed-bearing unicompartmental knee arthroplasty: a finite element analysis. Orthop Surg 13:1423–1429

    Article  PubMed  PubMed Central  Google Scholar 

  24. Pearle AD, O’Loughlin PF, Kendoff DO (2010) Robot-assisted unicompartmental knee arthroplasty. J Arthroplasty 25:230–237

    Article  PubMed  Google Scholar 

  25. Plancher KD, Brite JE, Briggs KK, Petterson SC (2022) Pre-arthritic/kinematic alignment in fixed-bearing medial unicompartmental knee arthroplasty results in return to activity at mean 10-year follow-up. J Bone Jt Surg 104:1081–1089

    Article  Google Scholar 

  26. Plate JF, Mofidi A, Mannava S, Smith BP, Lang JE, Poehling GG et al (2013) Achieving accurate ligament balancing using robotic-assisted unicompartmental knee arthroplasty. Adv Orthop 2013:837167

    Article  PubMed  PubMed Central  Google Scholar 

  27. Rivière C, Harman C, Leong A, Cobb J, Maillot C (2019) Kinematic alignment technique for medial OXFORD UKA: An in-silico study. Orthop Traumatol Surg Res 105:63–70

    Article  PubMed  Google Scholar 

  28. Rivière C, Sivaloganathan S, Villet L, Cartier P, Lustig S, Vendittoli PA et al (2022) Kinematic alignment of medial UKA is safe: a systematic review. Knee Surg Sports Traumatol Arthrosc 30:1082–1094

    Article  PubMed  Google Scholar 

  29. Roche M, O’Loughlin PF, Kendoff D, Musahl V, Pearle AD (2009) Robotic arm-assisted unicompartmental knee arthroplasty: preoperative planning and surgical technique. Am J Orthop (Belle Mead NJ) 38:10–15

    PubMed  Google Scholar 

  30. Sekiguchi K, Nakamura S, Kuriyama S, Nishitani K, Ito H, Tanaka Y et al (2019) Effect of tibial component alignment on knee kinematics and ligament tension in medial unicompartmental knee arthroplasty. Bone Jt Res 8:126–135

    Article  CAS  Google Scholar 

  31. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J et al (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–42

    Article  PubMed  Google Scholar 

  32. Thein R, Zuiderbaan HA, Khamaisy S, Nawabi DH, Poultsides LA, Pearle AD (2015) Medial unicondylar knee arthroplasty improves patellofemoral congruence: a possible mechanistic explanation for poor association between patellofemoral degeneration and clinical outcome. J Arthroplasty 30:1917–1922

    Article  PubMed  Google Scholar 

  33. Walsh JM, Huddleston HP, Alzein MM, Wong SE, Forsythe B, Verma NN et al (2022) The minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptomatic state after medial patellofemoral ligament reconstruction. Arthrosc Sports Med Rehabil 4:e661–e678

    Article  PubMed  PubMed Central  Google Scholar 

  34. Whiteside LA (2005) Making your next unicompartmental knee arthroplasty last: three keys to success. J Arthroplasty 20:2–3

    Article  PubMed  Google Scholar 

  35. Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35

    Article  CAS  PubMed  Google Scholar 

  36. Zhu GD, Guo WS, Zhang QD, Liu ZH, Cheng LM (2015) Finite element analysis of mobile-bearing unicompartmental knee arthroplasty: the influence of tibial component coronal alignment. Chin Med J 128:2873–2878

    Article  PubMed  PubMed Central  Google Scholar 

  37. Zuiderbaan HA, van der List JP, Kleeblad LJ, Appelboom P, Kort NP, Pearle AD et al (2016) Modern indications, results, and global trends in the use of unicompartmental knee arthroplasty and high tibial osteotomy in the treatment of isolated medial compartment osteoarthritis. Am J Orthop (Belle Mead NJ) 45:E355-e361

    PubMed  Google Scholar 

Download references

Funding

This study received no funding.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Computer Assisted Surgery Center, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA

    Tarik Bayoumi, Lindsey V. Ruderman & Andrew D. Pearle

  2. Department of Orthopaedic Surgery, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität, Berlin, Germany

    Joost A. Burger

  3. Department of Orthopaedic Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands

    Jelle P. van der List & Gino M. M. J. Kerkhoffs

  4. Amsterdam Movement Sciences, Sports, Amsterdam, The Netherlands

    Jelle P. van der List & Gino M. M. J. Kerkhoffs

  5. Department of Orthopaedic Surgery, Medische Kliniek Velsen, Velsen, The Netherlands

    Hendrik A. Zuiderbaan

Authors
  1. Tarik Bayoumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joost A. Burger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lindsey V. Ruderman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jelle P. van der List
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hendrik A. Zuiderbaan
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gino M. M. J. Kerkhoffs
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Andrew D. Pearle
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tarik Bayoumi.

Ethics declarations

Conflict of interest

Dr. Andrew D. Pearle is a consultant for Smith & Nephew and DePuy Synthes. Dr. Hendrik A. Zuiderbaan is a consultant for Smith & Nephew. The other authors declare to have no potential conflict of interest.

Ethical approval

Approval from the Internal Review Board of the Hospital for Special Surgery was obtained prior to the start of the study (IRB #2021-2004).

Informed consent

Informed consent was not applicable to this study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bayoumi, T., Burger, J.A., Ruderman, L.V. et al. Restoration or relative overcorrection of pre-arthritic coronal alignment leads to improved results following medial unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 31, 3981–3991 (2023). https://doi.org/10.1007/s00167-023-07441-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-023-07441-9

Keywords

Search

Navigation