CAM 036

Unicompartmental and Bicompartmental Knee Arthroplasties

Category:Surgery   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:June 2013    

Description:
Knee joint failure often results from advanced, end stage joint disease that generally involves complete destruction of cartilage (i.e., bone-on-bone changes). Several grading systems are available to grade articular cartilage disease. The Outerbridge classification is the most widely used system of judging articular injury to the knee. This system allows delineation of varying areas of chondral pathology based on the qualitative appearance of the cartilage surface and can assist in identifying injuries that are suitable for repair techniques. The characterization of cartilage in this system is:

  • Grade 0: normal
  • Grade l: cartilage with softening and swelling
  • Grade ll: a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter
  • Grade lll: fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm
  • Grade lV: subchondral bone exposed

A second system often used for grading cartilage disease is the Kellgren-Lawrence grading scale. This scale defines injury as follows:

  • Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
  • Grade 2: definite osteophytes, definite narrowing of joint space
  • Grade 3: moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour
  • Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

The two scales are comparable, with the end point of Grade IV/4 being what is usually described as bone-on-bone. As the grade of disease increases, there is a stronger association with symptoms such as pain, stiffness and swelling.

Unicompartmental Knee Replacement (UKR) 
Unicompartmental OA can occur in any of three existing compartments of the joint: medial, lateral or patellofemoral. In comparison to TKR, UKR is typically recommended for individuals with less severe disease, and who have better knee function. During a unicompartmental knee replacement only a single compartment is replaced. Only the bony area in the single damaged compartment needs to be resurfaced. The ends of the femur and tibia are capped with metal coverings, and a plastic insert is placed between the two metal components for smooth gliding. Evidence suggests that with appropriate patient selection, UKRs are a successful option for patients with OA of the knee. UKR may be performed through standard exposure or utilizing minimally invasive surgery with modified instruments.

Medial or Lateral Compartment: Unicompartmental knee replacement has been proposed as an alternative to TKR for patients with disease limited to the medial or lateral compartment, with the proposed advantages being less pain, quicker recovery and better long-term results. A unicompartmental knee replacement requires a smaller and less invasive incision that does not interrupt the anterior and posterior cruciate ligaments, which are the main muscles controlling the knee (American Academy of Orthopaedic Surgeons [AAOS], 2006).

UKA is considered to be as safe and effective as TKA and high tibial osteotomy, although it is associated with a risk for development or progression of disease in adjacent compartments. Published scientific data confirm medium- to long-term outcomes associated with unicompartmental replacement are comparable to those of primary TKR in select patient groups (Dabov and Perez, 2003; Meek et al., 2004; Koopman and Moreland, 2005). Clinical studies have shown that patients treated with unicondylar knee replacement have better functionality and greater range of motion than patients treated with total knee replacement (Sun and Jia, 2012; Rougraff, et al., 1991; Newman, et al., 1998). Authors have also reported on the survival rate of prostheses, most of which approach at least 10 years (Murray, et al., 1998; Berger, et al., 1999). Newman et al. (2009) reported the 15-year follow-up results of the study published in 1998, and noted a 15-year survivorship rate, based on revision or failure for any reason, was 89.8 percent for UKR compared to 78.7 percent for TKR. In addition, it is possible that in later years a patient could wear out the initial knee replacement, thus requiring a revision. Research has shown that a unicondylar knee implant can be revised more easily than a total knee replacement.

Patellofemoral Replacement: Isolated OA of the patellofemoral joint occurs infrequently. Surgical treatment for isolated patellofemoral arthritis has been proposed for individuals with disabling isolated arthritis or degeneration of the patellofemoral compartment, who have failed to respond to other conservative and/or surgical treatment options, and/or is unwilling to undergo other surgical alternatives such as patellectomy or TKR. Patellectomy has been associated with poor clinical outcomes, and TKR, particularly in younger, more active individuals, is often discouraged due to complexities of the procedure, need for future revision and residual pain (Leadbetter, et al., 2008). Results of other procedures for treating patellofemoral arthritis, such as chondroplasty, lateral release, soft tissue reconstruction, realignment osteotomy and resurfacing procedures, can lead to lengthy recovery and variable outcomes. A patellofemoral knee replacement replaces only the worn articular surface underneath the patella and its articulating trochlear surface. Potential advantages of patellofemoral replacement include a less invasive approach, less bone resection and tissue destruction, decreased operative time, and blood loss, shorter rehabilitation and more normal knee kinematics.

Bicompartmental Knee Replacement/Bi-unicompartmental Knee Replacement
Bicompartmental knee replacement has been proposed for some patients with disease limited to the medial and patellofemoral compartments. With the bicompartmental knee replacement, only the diseased medial and patellofemoral compartments are replaced while sparing the lateral compartment and cruciate ligaments. In theory, retention of the cruciate ligament(s) maintains more normal knee function and mobility. It has been suggested this approach is associated with less pain and reduced tissue trauma, resulting in a more rapid recovery (Rolston, et al., 2007). Bi-unicompartmental replacement has also been reported in the published literature. This approach has been used for treating bicompartmental (i.e., medial and lateral) arthritis (Confalonieri and Manzotti, 2006). 

Policy:
Unicompartmental knee replacement (i.e., partial replacement, single compartment) is MEDICALLY NECESSARY as an alternative to total knee replacement for advanced knee joint disease due to conditions such as osteoarthritis, osteonecrosis and traumatic arthritis, when ALL of the following conditions are met:

  • Radiological evidence of articular cartilage loss and severe joint destruction with findings of bone-on-bone changes (e.g., Outerbridge Grade IV, Kellgren-Lawrence Grade 4) limited to a single compartment
  • Knee examinations demonstrate good alignment and ligamentous stability
  • Persistent knee pain despite an appropriate course of nonsurgical management (e.g., NSAIDs, analgesics, light exercise, assistive device, bracing, viscoelastic supplementation)

Bicompartmental and bi-unicompartmental knee arthroplasty is considered INVESTIGATIONAL for osteoarthritis of the knee and all other indications because their effectiveness has not been established.

Rationale:
Unicompartmental knee arthroplasty is a popular treatment for unicompartmental knee arthritis. Roche and associates (2009) stated that a recently developed computer-assisted surgery/robotic system has the potential to improve alignment in and results of UKA. Pearle et al. (2009) stated that indications for UKA include mechanical axis of less than 10 degrees varus and less than five degrees valgus, intact ACL and absence of femoro-tibial subluxation. Appropriately selected patients can expect UKA to last at least 10 years. Failures in UKA are not common and involve technical errors that are thought to be corrected with use of newly developed robotic technology such as the MAKO robotic arm system (MAKOplasty). The surgeon using this technology may be able to arrive at a set target, enhance surgical precision and avoid outliers. However, whether improved precision will result in improved long-term clinical outcome remains a subject of research.

Sinha (2009) reported that the early outcomes of UKA performed with a robotically assisted navigation system have been favorable. The surgical technique enhances accuracy of bone preparation and component positioning. Technical errors of the system have been minimal. The surgeon's learning curve is not adversely affected. Early patient outcomes are excellent and complications minimal. The authors noted that further follow-up studies will help to determine whether these early outcomes are sustained over time.

Lonner (2009) noted that modular bicompartmental arthroplasty is an emerging knee-resurfacing approach that provides a conservative alternative to TKA. Isolated bicompartmental arthritis involving the medial or lateral and patello-femoral compartments, but with no significant deformity or bone deficiency, preserved motion and intact cruciate ligaments, can be effectively managed with this treatment method. For the many young and active patients with isolated bicompartmental arthritis, given the potential durability of the procedure and the prosthesis, it is appropriate to use an approach that is more conservative than TKA. Robotic arm assistance for modular bicompartmental arthroplasty optimizes component position and alignment, which may improve system performance and long-term durability. In addition, a percentage of patients who undergo isolated unicompartmental or patello-femoral arthroplasty may later develop progressive arthritis in an unresurfaced compartment. Their cases may be effectively managed with a staged modular approach to resurfacing the degenerating compartment, but additional study is needed.

In a pilot study, Lonner et al. (2010) compared the post-operative radiographical alignment of the tibial component with the pre-operatively planned position in 31 knees in 31 consecutive patients undergoing UKA using robotic arm-assisted bone preparation and in 27 consecutive patients who underwent unilateral UKA using conventional manual instrumentation to determine the error of bone preparation and variance with each technique. Radiographically, the root mean square error of the posterior tibial slope was 3.1 degrees when using manual techniques, compared with 1.9 degrees when using robotic arm assistance for bone preparation. In addition, the variance using manual instruments was 2.6 times greater than the robotically guided procedures. In the coronal plane, the average error was 2.7 degrees +/- 2.1 degrees more varus of the tibial component relative to the mechanical axis of the tibia using manual instruments, compared with 0.2 degrees +/- 1.8 degrees with robotic technology, and the varus/valgus root mean square error was 3.4 degrees manually, compared with 1.8 degrees robotically. The authors concluded that further study will be necessary to determine whether a reduction in alignment errors of these magnitudes will ultimately influence implant function or survival.

Paratte and associates (2010) stated that recent literature suggests patients achieve substantial short-term functional improvement after combined bicompartmental implants, but longer-term durability has not been documented. These investigators examined if (i) bicompartmental arthroplasty (either combined medial unicompartmental UKA and femoro-patellar arthroplasty (PFA) or medial UKA/PFA, or combined medial and lateral UKA or bicompartmental UKA) reliably improved Knee Society pain and function scores; (ii) bicompartmental arthroplasty was durable (survivorship, radiographical loosening or symptomatic disease progression); (iii) durable alignment can be achieved; and (iv) the arthritis would progress in the unresurfaced compartment. These researchers retrospectively reviewed 84 patients (100 knees) with bicompartmental UKA and 71 patients (77 knees) with medial UKA/PFA. Clinical and radiographical evaluations were performed at a minimum follow-up of five years (mean of 12 years; range of five to 23 years). Bicompartmental arthroplasty reliably alleviated pain and improved function. Prosthesis survivorship at 17 years was 78 percent in the bicompartmental UKA group and 54 percent in the medial UKA/PFA group. The high revision rate, compared with TKA, may be related to several factors such as implant design, patient selection, crude or absent instrumentation or component mal-alignment, which can all contribute to the relatively high failure rate in this series.

Literature Review: 
The reported short- and mid-term results for patellofemoral arthroplasty vary across studies but in general are good and support improvement in pain, function and mobility. Although limited, there is some recent data supporting long-term safety and efficacy (van Jonbergen, et al., 2010). Some patient populations overlap among studies, and most are in the form of retrospective and prospective case series (Meding et al., 2007; Ackroyd et al., 2007; Sisto and Sarin, 2006; Ackroyd and Chir, 2005; Leadbetter et al., 2005). Randomized controlled trials are limited. Average follow-up periods range from 3.75 years to 17 years (Argenson et al., 2005; Merchant, 2004; Kooijman et al., 2003; Smith et al., 2002; Tauro et al., 2001; de Winter et al., 2001). Various scales have been used to assess clinical outcomes, and include the ADL scale, Knee Society scores, follow-up radiographs, modified Hungerford and Kenna knee score, the Bristol Knee score and subjective questionnaires, making comparisons across studies difficult. However, good and excellent results ranged from 45 percent to 93 percent across studies. Improved survivorship has been reported with more recent implant designs (Odumenya et al., 2010; van Jonbergen et al., 2010).

Revision rates also vary across studies. Revision is often performed as result of progression of OA, malposition, loosening, stiffness, maltracking and/or wear and tear of the patellar component (Anderson et al., 2005; Koojman et al., 2003; Smith et al., 2002; de Winter et al., 2001). In a published review of the literature Delanois et al. (2008) reported that survival rates for patellofemoral arthroplasty ranged as follows: 95 percent to 100 percent at a mean follow-up of five years, 85 percent to 90 percent at seven to eight years, was 75 percent at 10 years and 58 percent at 16 years. Authors suggest clinical results are dependent on prosthetic design, patient selection and technical proficiency.

In 2009, van Jonbergen and colleagues evaluated whether or not patellofemoral arthroplasty compromised the results of total knee arthroplasty. The authors compared 13 subjects who underwent patellofemoral arthroplasty and required TKR with a control group of 13 subjects who underwent primary TKR. The results of the study demonstrated patellofemoral arthroplasty did not have a negative effect on the outcome of later TKR (Jonbergen et al., 2009). Lonner et al. (2006) also evaluated patients who received TKR after patellofemoral arthroplasty (n=12) to determine if results are compromised by prior arthroplasty. The mean interval to revision TKR for this study group was four years (range of one to 9.7). The results of this study suggested that TKR was not compromised when revision was performed for a failed patellofemoral replacement. Furthermore, the authors of this study noted the primary implants were able to be utilized again unless the patellar component was worn, loose or malpositioned.

The use of custom-designed patellofemoral prosthetic devices versus off-the-shelf designs has been done with the goal of improving clinical outcomes. However ,published data evaluating these methods are lacking. Patellofemoral arthroplasty has been associated with progression of OA in surrounding compartments and revision to TKR. However, it is unclear which patients are specifically at risk for development of tibiofemoral OA. Patient selection criteria have not been clearly defined, although potential candidates include individuals with severe isolated patellofemoral OA who have failed other treatments, are not candidates for or have failed other surgical options, have residual pain and/or are unwilling to undergo TKR. Although there is no general consensus, patellofemoral arthroplasty may be considered a salvage procedure prior to a TKR.

Literature Review: 
Morrison et al. (2011) reported the results of a prospective trial comparing early functional outcomes of subjects with OA of the medial and patellofemoral compartments who underwent either TKR or bicompartmental knee replacement (n=33, 21 respectively). Outcomes were assessed at three months, one year and two years postoperatively and included SF-12 and WOMAC scores, ROM and radiographs to determine loosening. At three months, the authors reported the bicompartmental group had significantly better pain scores (P=0.20) and better physical function (P=.015). However, these results did not continue beyond three months. There were no differences in scores at one or two years. The bicompartmental group also had more complications (P=.045) and a near significant trend of increased revision arthroplasty rate at two years follow-up (P=.054). The authors acknowledged that the benefits of sparing the lateral compartment and anterior cruciate ligaments in this cohort of subjects were not established.

In 2010, Heyse et al. reported the results of a retrospective case series involving nine subjects who underwent medial and patellofemoral bicompartmental arthroplasty. The average follow-up was 11.8 ± 5.4 years and included radiologic evaluations and clinical scores (KSS and WOMAC). The authors noted there were no surgical revisions, the KSS and WOMAC scores were improved and all patients were satisfied or very satisfied with the outcomes (Heyse et al., 2010). Limitations of this study include small sample population and results that cannot be generalized to larger populations.

Parratte et al. (2010) reported the results of a retrospective case series evaluating bicompartmental arthroplasty (n=155; 84 had bi-unicompartmental and 71 had medial UKA and patellofemoral). The minimum follow-up was five years, average 11.7, and ranged from five–23 years using Knee Society, function scores and radiographs. Bicompartmental arthroplasty relieved pain and improved Knee Society and function scores. Results were mixed in regard to durability. A 17-year survival to revision, radiograph loosening or disease progression was 78 percent in the group of subjects who underwent bi-unicompartmental replacement and 54 percent in the group who underwent medial unicompartmental/patellofemoral replacement. The authors reported 17 revisions in the bi-UKA group and 28 in the med-UKA/PFA group.

In 2008, Confalonieri et al. reported the results of a comparison of 22 patients who underwent bi-unicompartmental knee replacement with a similar group who underwent computer assisted TKR. The authors noted that at 48 months follow-up there were no statistical differences in surgical time, Knee Society scores, Functional and Italian Orthopaedic UKR Users Group score between groups. There was a statistically significant difference in WOMAC Function and Stiffness score in favor of the Bi-Uni group. TKR implants were statistically better aligned and positioned. As noted by the authors, these results suggest that Bi-UKR is a viable option. However, the study is flawed by its retrospective design, lack of randomization, use of different implants and different alignment systems (Confalonieri et al., 2008).

In order to estimate the utility of the Journey Deuce Knee System (Smith and Nephew Inc., Memphis, Tenn.), a bicompartmental prosthetic device, Rolston and colleagues (2007) reported the results of a series of 95 patients who were implanted with the bicompartmental device since 2003. Follow-up for this group of patients extended 33 months. The authors reported the following: 82 of 95 patients were discharged two days after surgery, the average range of motion for the group was 0° to 117°; most patients were able to walk without an assistive device two weeks post-surgery; and there was less blood loss compared to that for TKR patients. In addition, there was no lateral joint line tenderness, and the patients did not have patellofemoral pain. In 2011, Palumbo et al. reported the results of 36 subjects who received the Journey-Deuce prosthesis. Outcomes were measured using the WOMAC scores, range of motion, Knee Society functional survey and pre- and post-operative pain scores. A total of 31 percent of the subjects were unsatisfied with the surgery, and 53 percent would not repeat the procedure. The overall survival rate was 86 percent; 14 percent required conversion to TKR at a mean 19 months for persistent pain. Short-term survival of the prosthesis was unacceptably low, and the authors noted they no longer implant the device at their institution.

In 2006, Confalonieri and Manzotti reported the results of a retrospective analysis of bi-unicompartmental knee replacement performed on 24 knees with bicompartmental arthritis (medial and lateral). Clinical outcomes were evaluated at a minimum follow-up of 36 months and included Knee Society scores and a dedicated UKR score. The authors noted there were no revisions, and all clinical scores were improved and were similar to TKR.

Callahan et al. (1995) reported the results of a meta-analysis evaluating unicompartmental and bicompartmental knee replacement. The authors reviewed 46 studies evaluating UKR involving 2,391 patients and a mean follow-up of 4.6 years. For the bicompartmental evaluation, the total number of enrolled patients was 844, mean follow-up was 3.6 years and there were a total of 18 studies. The authors reported that outcomes for the bicompartmental knee replacement appeared worse compared to the UKR, although they noted that patients who underwent the bicompartmental approach had poorer baseline knee function. Consequently, no reliable conclusions regarding efficacy could be made.

Supporting evidence in the published scientific literature is limited and does not allow strong conclusions regarding improved patient outcomes with either a bi-unicompartmental or bicompartmental approach. There is no consensus among authors for optimal patient selection criteria and the advantages of performing bicompartmental or bi-unicompartmental knee replacement in comparison to standard treatment options such as TKR have not been clearly established in the scientific literature.

Definitions:
Three compartments of the knee:

  • Patellofemoral: Area behind the kneecap riding over the end of the femur "trochlea/sulcus" groove
  • Medial: The area of joint contact between the femur and tibia on the "inside" or medial aspect of the knee
  • Lateral: The area of joint contact between the femur and tibia on the "outside" or lateral aspect of the knee.

Total Knee Arthroplsty (also know as TKA, or Total Knee Replacement):  Performed when all three compartments of the knee are affected by advanced joint disease. TKA involves removal of a thin layer of subchondral bone and overlying articular cartilage, with anatomic resurfacing of all three compartments and insertion of the implant and bearing surface.

Unicompartmental Knee Arthroplasty (also know as UKA or Partial Knee Arthroplasty): May be performed in patients with advanced joint disease limited to a single compartment (i.e., medial, lateral or patellofemoral).

  • UKA of the Medial or Lateral Compartment  requires a smaller incision that does not interrupt the anterior and posterior cruciate ligaments, which are the main structures stabilizing the knee.
  • UKA of the Patellofemoral Compartment treats degenerative disease underneath the patella and involves implantation of a prosthesis to resurface the articulation surfaces of the patella and femur.

Bicompartmental Knee Arthroplasty: Replacement of the medial and patellofemoral compartments, with sparing of the cruciate ligaments.

Bi-unicompartmental Knee Arthroplasty: UKA performed in the contralateral compartment of a knee previously treated with a UKA.

Unicondylar Interpositional Spacers (e.g., UniSpacerTM): Metallic implants are inserted into the joint space between the affected tibial plateau and femoral condyle. Instead of being fixed, the spacers are held in place by the geometry of the curved implant, ligament tension and surrounding soft tissue structures.

References:

  1. Ackroyd CE, Chir B. Development and early results of a new patellofemoral arthroplasty. Clin Orthop Relat Res. 2005 Jul;(436):7-13.
  2. Ackroyd CE, Newman JH, Evans R, Eldridge JD, Joslin CC. The Avon patellofemoral arthroplasty: five-year survivorship and functional results. J Bone Joint Surg Br. 2007 Mar;89(3):310-5.
  3. Argenson JN, Flecher X, Parratte S, Aubaniac JM. Patellofemoral arthroplasty: an update. Clin Orthop Relat Res. 2005 Nov;440:50-3.
  4. Berend KR, Lombardi AV Jr, Adams JB. Obesity, young age, patellofemoral disease, and anterior knee pain: identifying the unicondylar arthroplasty patient in the United States. Orthopedics. 2007 May;30(5 Suppl):19-23.
  5. Berger RA, Meneghini RM, Jacobs JJ, Sheinkop MB, Della Valle CJ, Rosenberg AG, Galante JO. Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. J Bone Joint Surg Am. 2005 May;87(5):999-1006.
  6. Berger RA, Nedeff DD, Barden RM, Sheinkop MM, Jacobs JJ, Rosenberg AG, et al. Unicompartmental knee arthroplasty: clinical experience at 6- to 10-year followup. Clin Orthop Relat Res. 1999 Oct;(367):50-60.
  7. Bert JM. Unicompartmental knee replacement. Orthop Clin N Am. 2005 Oct;36(4):513-22.Orthop Clin North Am. 2009 Oct 1;40(4):537-63,x.
  8. Borus T, Thornhill T. Unicompartmental knee arthroplasty. J Am Acad Orthop Surg. 2008 Jan;16(1):9-18.
  9. Confalonieri N, Manzotti A, Cerveri P, De Momi E. Bi-unicompartmental versus total knee arthroplasty: a matched paired study with early clinical results. Arch Orthop Trauma Surg. 2008 Aug 12.
  10. Delanois RE, McGrath MS, Ulrich SD, Marker DR, Seyler TM, Bonutti PM, Mont MA. Results of total knee replacement for isolated patellofemoral arthritis: when not to perform a patellofemoral arthroplasty. Orthop Clin North Am. 2008 Jul;39(3):381-8, vii.
  11. Donell ST, Glasgow MM. Isolated patellofemoral osteoarthritis. Knee. 2007 Jun;14(3):169-76.
  12. Griffin T, Rowden N, Morgan D, Atkinson R, Woodruff P, Maddern G. Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: a systematic study. ANZ J Surg. 2007 Apr;77(4):214-21.
  13. Hamilton WG, Collier MB, Tarabee E, McAuley JP, Engh CA Jr, Engh GA. Incidence and reasons for reoperation after minimally invasive unicompartmental knee arthroplasty. J Arthroplasty. 2006 Sep;21(6 Suppl 2):98-107.
  14. Kooijman HJ, Driessen AP, van Horn JR. Long-term results of patellofemoral arthroplasty. A report of 56 arthroplasties with 17 years of follow-up. J Bone Joint Surg Br. 2003 Aug;85(6):836-40.
  15. Kort NP. Unicompartmental knee arthroplasty. eMedicine. Orthopedic surgery. Knee. Updated March 2011. Accessed April 3, 2013.
  16. Leadbetter WB, Kolisek FR, Levitt RL, Brooker AF, Zietz P, Marker DR, Bonutti PM, Mont MA. Patellofemoral arthroplasty: a multi-centre study with minimum 2-year follow-up. Int Orthop. 2008 Dec 5..
  17. Leadbetter WB, Ragland PS, Mont MA. The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures. Clin Orthop Relat Res. 2005 Jul;(436):91-9.
  18. Leadbetter WB, Seyler TM, Ragland PS, Mont MA. Indications, contraindications, and pitfalls of patellofemoral arthroplasty. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:122-37.
  19. Lonner JH. Patellofemoral arthroplasty. J Am Acad Orthop Surg. 2007 Aug;15(8):495-506.
  20. Lotke PA, Lonner JH, Nelson CL. Patellofemoral arthroplasty: the third compartment. J Arthroplasty. 2005 Jun;20(4 Suppl 2):4-6.
  21. Lyons MC, MacDonald SJ, Somerville LE, Naudie DD, McCalden RW. Unicompartmental versus total knee arthroplasty database analysis: is there a winner? Clin Orthop Relat Res. 2012 Jan;470(1):84-90.
  22. Meek RMD, Masri BA, Duncan CP. Minimally invasive unicompartmental knee replacement: rationale and correct indications. Orthop Clin North Am. 2004 Apr;35(2):191-200.
  23. Morrison TA, Nyce JD, Macaulay WB, Geller JA. Early adverse results with bicompartmental knee arthroplasty: a prospective cohort comparison to total knee arthroplasty. J Arthroplasty. 2011 Sep;26(6 Suppl):35-9.
  24. Murray DW, Goodfellow JW, O'Connor JJ. The Oxford medial unicompartmental arthroplasty: a ten-year survival study. J Bone Joint Surg Br. 1998 Nov;80(6):983-9.
  25. Newman JH, Ackroyd CE, Shah NA. Unicompartmental or total knee replacement? Five-year results of a prospective, randomised trial of 102 osteoarthritic knees with unicompartmental arthritis. J Bone Joint Surg Br. 1998 Sep;80(5):862-5.
  26. Newman J, Pydisetty RV, Ackroyd C. Unicompartmental or total knee replacement: the 15-year results of a prospective randomised controlled trial. J Bone Joint Surg Br. 2009 Jan;91(1):52-7.
  27. Odumenya M, Costa ML, Parsons N, Achten J, Dhillon M, Krikler SJ. The Avon patellofemoral joint replacement: Five-year results from an independent centre. J Bone Joint Surg Br. 2010 Jan;92(1):56-60.
  28. Palumbo BT, Henderson ER, Edwards PK, Burris RB, Gutiérrez S, Raterman SJ. Initial experience of the Journey-Deuce bicompartmental knee prosthesis: a review of 36 cases. J. Arthroplasty. 2011 Sep;26(6 Suppl):40-5.
  29. Pandit H, Jenkins C, Gill HS, Barker K, Dodd CA, Murray DW. Minimally invasive Oxford phase three unicompartmental knee replacement: results of 1000 cases. J Bone Joint Surg Br. 2011 Feb;93(2):198-204.
  30. Parratte S, Pauly V, Aubaniac JM, Argenson JN. Survival of bicompartmental knee arthroplasty at five to 23 years. Clin Orthop Relat Res. 2010 Jan;468(1):64-72.
  31. Pearle AD, O'Loughlin PF, Kendoff DO. Pearle AD, O'Loughlin PF, Kendoff DO. Robot-assisted unicompartmental knee arthroplasty. J Arthroplasty. 2010 Feb;25(2):230-7.
  32. Rolston L, Bresch J, Engh G, Franz A, Kreuzer S, Nadaud M, Puri L, Wood D. Bicompartmental knee arthroplasty: a bone-sparing, ligament-sparing, and minimally invasive alternative for active patients. Orthopedics. 2007 Aug;30(8 Suppl):70-3.
  33. Romanowski MR, Repicci JA. Minimally invasive unicondylar arthroplasty: eight-year follow-up. J Knee Surg. 2002 Winter;15(1):17-22.
  34. Satku K. Unicompartmental knee arthroplasty: is it a step in the right direction?—surgical options for osteoarthritis of the knee. Singapore Med J. 2003;44(11):554-6.
  35. Tauro B, Ackroyd CE, Newman JH, Shah NA. The Lubinus patellofemoral arthroplasty. A five- to ten-year prospective study. J Bone Joint Surg Br. 2001 Jul;83(5):696-701.
  36. Thienpont E, Price A. Bicompartmental knee arthroplasty of the patellofemoral and medial compartments. ee Surg Sports Traumatol Arthrosc. 2012 Nov 25.
  37. Thompson SA, Liabaud B, Nellans KW, Geller JA. Factors Associated With Poor Outcomes Following Unicompartmental Knee Arthroplasty: Redefining the "Classic" Indications for Surgery. J Arthroplasty. 2013 Mar 21. pii: S0883-5403(13)00205-2.
  38. van Jonbergen HP, Poolman RW, van Kampen A. Isolated patellofemoral osteoarthritis. Acta Orthop. 2010 Apr;81(2):199-205.
  39. van Jonbergen HP, Werkman DM, Barnaart LF, van Kampen A. Long-term outcomes of patellofemoral arthroplasty. Arthroplasty. 2010 Oct;25(7):1066-71.
  40. Walker T, Perkinson B, Mihalko WM. Patellofemoral arthroplasty: the other unicompartmental knee replacement. J Bone Joint Surg Am. 2012 Sep 19;94(18):1712-20.
  41. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43(9):1905-1915.
  42. Emerson RH Jr, Potter T. The use of the McKeever metallic hemiarthroplasty for unicompartmental arthritis. J Bone Joint Surg Am. 1985;67(2):208-212.
  43. Scott RD, Joyce MJ, Ewald FC, Thomas WH. McKeever metallic hemiarthroplasty of the knee in unicompartmental degenerative arthritis. Long-term clinical follow-up and current indications. J Bone Joint Surg Am. 1985;67(2):203-207.
  44. Brown A. The Oxford unicompartmental knee replacement for osteoarthritis. Issues in Emerging Health Technologies Issue 23. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2001.
  45. Griffen T, Maddern G, Rowden N, et al. Unicompartmental knee arthroplasty for unicompartmental osteoarthritis: A systematic review. ASERNIP-S Report; 44. North Adelaide, SA: Royal Australasian College of Surgeons, Australian Safety and Efficacy Register of New Interventional Procedures (ASERNIP) - Surgical; 2005.
  46. Mont MA, Stuchin SA, Paley D, et al. Different surgical options for monocompartmental osteoarthritis of the knee: High tibial osteotomy versus unicompartmental knee arthroplasty versus total knee arthroplasty: Indications, techniques, results, and controversies. Instr Course Lect. 2004;53:265-283.
  47. Gesell MW, Tria AJ Jr. MIS unicondylar knee arthroplasty: Surgical approach and early results. Clin Orthop Relat Res. 2004;(428):53-60.
  48. Rees JL, Price AJ, Beard DJ, et al. Minimally invasive Oxford unicompartmental knee arthroplasty: Functional results at one year and the effect of surgical inexperience. Knee. 2004;11(5):363-367.
  49. Fuchs S, Rolauffs B, Plaumann T, et al. Clinical and functional results after the rehabilitation period in minimally-invasive unicondylar knee arthroplasty patients. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):179-186.
  50. Yang KY, Wang MC, Yeo SJ, Lo NN. Minimally invasive unicondylar versus total condylar knee arthroplasty -- early results of a matched-pair comparison. Singapore Med J. 2003;44(11):559-562.
  51. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Lateral unicompartmental knee arthroplasty: Survivorship and technical considerations at an average follow-up of 12.4 years. J Arthroplasty. 2006;21(1):13-17.
  52. Walton NP, Jahromi I, Lewis PL, et al. Patient-perceived outcomes and return to sport and work: TKA versus mini-incision unicompartmental knee arthroplasty. J Knee Surg. 2006;19(2):112-116.
  53. Pandit H, Beard DJ, Jenkins C, et al. Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty. J Bone Joint Surg Br. 2006;88(7):887-892.
  54. Griffin T, Rowden N, Morgan D, et al. Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: A systematic study. ANZ J Surg. 2007;77(4):214-221.
  55. Khanna G, Levy BA. Oxford unicompartmental knee replacement: Literature review. Orthopedics. 2007;30(5 Suppl):11-14.
  56. Callahan CM, Drake BG, Heck DA, et al. Patient outcomes following unicompartmental or bicompartmental knee arthroplasty: A meta-analysis. J Arthroplasty. 1995;10(2):141-150.
  57. American Academy of Orthopaedic Surgeons (AAOS). AAOS clinical guideline on osteoarthritis of the knee (phase II). Rosemount, IL: AAOS; 2003.
  58. Rolston L, Bresch J, Engh G, et al. Bicompartmental knee arthroplasty: A bone-sparing, ligament-sparing, and minimally invasive alternative for active patients. Orthopedics. 2007;30(8 Suppl):70-73.
  59. Saldanha KA, Keys GW, Svard UC, et al. Revision of Oxford medial unicompartmental knee arthroplasty to total knee arthroplasty - results of a multicentre study. Knee. 2007;14(4):275-279.
  60. Argenson JN, Parratte S, Flecher X, Aubaniac JM. Unicompartmental knee arthroplasty: Technique through a mini-incision. Clin Orthop Relat Res. 2007;464:32-36.
  61. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137-162.
  62. Geller JA, Yoon RS, Macaulay W. Unicompartmental knee arthroplasty: A controversial history and a rationale for contemporary resurgence. J Knee Surg. 2008;21(1):7-14.
  63. Borus T, Thornhill T. Unicompartmental knee arthroplasty. J Am Acad Orthop Surg. 2008;16(1):9-18.
  64. Asakawa K, Spry C. Unicompartmental knee arthroplasty (UKA): A review of the clinical and cost- effectiveness and guidelines for use. Health Technology Inquiry Service (HTIS). Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (CADTH); August 8, 2008. 
  65. Confalonieri N, Manzotti A, Cerveri P, De Momi E. Bi-unicompartmental versus total knee arthroplasty: A matched paired study with early clinical results. Arch Orthop Trauma Surg. 2009;129(9):1157-1163.
  66. Roche M, O'Loughlin PF, Kendoff D, Robotic arm-assisted unicompartmental knee arthroplasty: Preoperative planning and surgical technique. Am J Orthop. 2009;38(2 Suppl):10-15.
  67. Pearle AD, Kendoff D, Stueber V, et al. Perioperative management of unicompartmental knee arthroplasty using the MAKO robotic arm system (MAKOplasty). Am J Orthop. 2009;38(2 Suppl):16-19.
  68. Sinha RK. Outcomes of robotic arm-assisted unicompartmental knee arthroplasty. Am J Orthop. 2009;38(2 Suppl):20-22.
  69. Lonner JH. Modular bicompartmental knee arthroplasty with robotic arm assistance. Am J Orthop. 2009;38(2 Suppl):28-31.
  70. Newman J, Pydisetty RV, Ackroyd C. Unicompartmental or total knee replacement: The 15-year results of a prospective randomised controlled trial. J Bone Joint Surg Br. 2009;91(1):52-57.
  71. Parratte S, Pauly V, Aubaniac JM, Argenson JN. Survival of bicompartmental knee arthroplasty at five to 23 years. Clin Orthop Relat Res. 2010;468(1):64-72.
  72. Lonner JH, John TK, Conditt MA. Robotic arm-assisted UKA improves tibial component alignment: A pilot study. Clin Orthop Relat Res. 2010;468(1):141-146.
  73. Kock FX, Weingartner D, Beckmann J, et al. Operative treatment of the unicompartmental knee arthritis - results of a nationwide survey in 2008. Z Orthop Unfall. 2011;149(2):153-159.
  74. Palumbo BT, Henderson ER, Edwards PK, et al. Initial experience of the Journey-Deuce bicompartmental knee prosthesis. A review of 36 Cases. J Arthroplasty. 2011;26(6 Suppl):40-45.
  75. Morrison TA, Nyce JD, Macaulay WB, Geller JA. Early adverse results with bicompartmental knee arthroplasty. A prospective cohort comparison to total knee arthroplasty. J Arthroplasty. 2011;26(6 Suppl):35-39.
  76. Johnson TC, Tatman PJ, Mehle S, Gioe TJ. Revision surgery for patellofemoral problems: Should we always resurface? Clin Orthop Relat Res. 2012;470(1):211-219.
  77. Lyons MC, MacDonald SJ, Somerville LE, et al. Unicompartmental versus total knee arthroplasty database analysis: Is there a winner? Clin Orthop Relat Res. 2012;470(1):84-90.

Coding Section

Codes Number Description
CPT 27438 Arthroplasty, patella; with prosthesis
  27440 Arthroplasty, knee, tibial plateau;
  27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
  27442 Arthroplasty, femoral condyles or tibial plateau(s), knee;
  27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy
  27445 Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)
  27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
  27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
  27486 Revision of total knee arthroplasty, with or without allograft; one component
  27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component
  27599  Unlisted procedure, femur or knee  
ICD-9 Diagnosis 715.16

Ostoarthrosis, Localized, Primary, Lower Leg

  715.26

Ostoarthrosis, Localized, Secondary, Lower Leg

  715.36

Ostoarthrosis, Localized, Not Specified Whether Primary or Secondary, Lower Leg

  715.96

Ostoarthrosis,Unspecified Whether Generalized or Localized, Lower Leg

ICD-9 Procedure 00.80 Revision of knee replacement, total (all components)
  00.81 Revision of knee replacement, tibial component
  00.82 Revision of knee replacement, femoral component
  00.83 Revision of knee replacement, patellar component
  81.54 Total knee replacement
  81.55 Revision of knee replacement, not otherwise specified
ICD-10-CM (effective 10/01/15) M17.10 Unilateral primary osteoarthritis, unspecified knee
  M17.5 Other unilateral secondary osteoarthritis of knee
  M17.9 Osteoarthritis of knee, unspecified
ICD-10-PCS (effective 10/01/15) 0SRC0JZ  Replacement of Right Knee Joint with Synthetic Substitute, Open Approach 
  0SPC0JZ Removal of Synthetic Substitute from Right Knee Joint, Open Approach 
  0SPC4JZ Removal of Synthetic Substitute from Right Knee Joint, Percutaneous Endoscopic Approach 
  0SRD0JZ Replacement of Left Knee Joint with Synthetic Substitute, Open Approach 
  0SPD0JZ Removal of Synthetic Substitute from Left Knee Joint, Open Approach 
  0SPD4JZ Removal of Synthetic Substitute from Left Knee Joint, Percutaneous Endoscopic Approach
  0SRV0JZ  Replacement of Right Knee Joint, Tibial Surface with Synthetic Substitute, Open Approach 
  0SRW0JZ  Replacement of Left Knee Joint, Tibial Surface with Synthetic Substitute, Open Approach
  0SRT0JZ  Replacement of Right Knee Joint, Femoral Surface with Synthetic Substitute, Open Approach
  0SUC0JZ Supplement Right Knee Joint with Synthetic Substitute, Open Approach 
  0SUC4JZ Supplement Right Knee Joint with Synthetic Substitute, Percutaneous Endoscopic Approach 
  0SUT09Z Supplement Right Knee Joint, Femoral Surface with Liner, Open Approach 
  0SPC09Z  Removal of Liner from Right Knee Joint, Open Approach 
  0SRU0JZ Replacement of Left Knee Joint, Femoral Surface with Synthetic Substitute, Open Approach
  0SUD0JZ Supplement Left Knee Joint with Synthetic Substitute, Open Approach
  0SUD4JZ  Supplement Left Knee Joint with Synthetic Substitute, Percutaneous Endoscopic Approach
  0SUU09Z  Supplement Left Knee Joint, Femoral Surface with Liner, Open Approach 
  0SPD09Z  Removal of Liner from Left Knee Joint, Open Approach 
  0QRD0JZ Replacement of Right Patella with Synthetic Substitute, Open Approach
  0QRD3JZ  Replacement of Right Patella with Synthetic Substitute, Percutaneous Approach 
  0QRD4JZ Replacement of Right Patella with Synthetic Substitute, Percutaneous Endoscopic Approach 
  0QUD0JZ Supplement Right Patella with Synthetic Substitute, Open Approach
  0QUD3JZ Supplement Right Patella with Synthetic Substitute, Percutaneous Approach
  0QUD4JZ Supplement Right Patella with Synthetic Substitute, Percutaneous Endoscopic Approach
  0SUC09C Supplement Right Knee Joint with Liner, Patellar Surface, Open Approach
  0QPD0JZ Removal of Synthetic Substitute from Right Patella, Open Approach
  0QPD3JZ Removal of Synthetic Substitute from Right Patella, Percutaneous Approach
  0QPD4JZ Removal of Synthetic Substitute from Right Patella, Percutaneous Endoscopic Approach
  0QRF0JZ Replacement of Left Patella with Synthetic Substitute, Open Approach
  0QRF3JZ Replacement of Left Patella with Synthetic Substitute, Percutaneous Approach
  0QRF4JZ Replacement of Left Patella with Synthetic Substitute, Percutaneous Endoscopic Approach
  0QUF0JZ Supplement Left Patella with Synthetic Substitute, Open Approach
  0QUF3JZ Supplement Left Patella with Synthetic Substitute, Percutaneous Approach
  0QUF4JZ Supplement Left Patella with Synthetic Substitute, Percutaneous Endoscopic Approach
  0SUD09C Supplement Left Knee Joint with Liner, Patellar Surface, Open Approach
  0QPF0JZ Removal of Synthetic Substitute from Left Patella, Open Approach
  0QPF3JZ Removal of Synthetic Substitute from Left Patella, Percutaneous Approach
  0QPF4JZ Removal of Synthetic Substitute from Left Patella, Percutaneous Endoscopic Approach
  0SRC07Z Replacement of Right Knee Joint with Autologous Tissue Substitute, Open Approach
  0SRC0JZ Replacement of Right Knee Joint with Synthetic Substitute, Open Approach
  0SRD0KZ  Replacement of Right Knee Joint with Nonautologous Tissue Substitute, Open Approach
  0SRD07Z Replacement of Left Knee Joint with Autologous Tissue Substitute, Open Approach
  0SRD0JZ Replacement of Left Knee Joint with Synthetic Substitute, Open Approach
  0SRD0KZ Replacement of Left Knee Joint with Nonautologous Tissue Substitute, Open Approach
  0SRT07Z  Replacement of Right Knee Joint, Femoral Surface with Autologous Tissue Substitute, Open Approach
  0SRT0JZ  Replacement of Right Knee Joint, Femoral Surface with Synthetic Substitute, Open Approach
  0SRT0KZ  Replacement of Right Knee Joint, Femoral Surface with Nonautologous Tissue Substitute, Open Approach
  0SRU07Z  Replacement of Left Knee Joint, Femoral Surface with Autologous Tissue Substitute, Open Approach
  0SRU0JZ Replacement of Left Knee Joint, Femoral Surface with Synthetic Substitute, Open Approach
  0SRU0KZ Replacement of Left Knee Joint, Femoral Surface with Nonautologous Tissue Substitute, Open Approach
  0SRV07Z Replacement of Right Knee Joint, Tibial Surface with Autologous Tissue Substitute, Open Approach
  0SRV0JZ Replacement of Right Knee Joint, Tibial Surface with Synthetic Substitute, Open Approach
  0SRV0KZ Replacement of Right Knee Joint, Tibial Surface with Nonautologous Tissue Substitute, Open Approach
  0SRW07Z Replacement of Left Knee Joint, Tibial Surface with Autologous Tissue Substitute, Open Approach
  0SRW0JZ   Replacement of Left Knee Joint, Tibial Surface with Synthetic Substitute, Open Approach
  0SRW0KZ Replacement of Left Knee Joint, Tibial Surface with Nonautologous Tissue Substitute, Open Approach
  0SWC0JZ  Revision of Synthetic Substitute in Right Knee Joint, Open Approach 
  0SWC3JZ Revision of Synthetic Substitute in Right Knee Joint, Percutaneous Approach
  0SWC4JZ Revision of Synthetic Substitute in Right Knee Joint, Percutaneous Endoscopic Approach 
  0SWD0JZ Revision of Synthetic Substitute in Left Knee Joint, Open Approach 
  0SWD3JZ Revision of Synthetic Substitute in Left Knee Joint, Percutaneous Approach 
  0SWD4JZ Revision of Synthetic Substitute in Left Knee Joint, Percutaneous Endoscopic Approach 
  0SRT0J9-0SRU0JZ  Replacement of knee joint, femoral surface with synthetic substitute, open approach [right or left, cemented or unspecified; includes codes 0SRT0J9, 0SRT0JZ, 0SRU0J9, 0SRU0JZ] 
  0SRV0J9-0SRW0JZ  Replacement of knee joint, tibial surface with synthetic substitute, open approach [right or left, cemented or unspecified; includes codes 0SRV0J9, 0SRV0JZ, 0SRW0J9, 0SRW0JZ] 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

06/01/2019 

Annual review, no change to policy intent. 

06/07/2018 

Annual review, no change to policy intent. 

06/07/2017 

Annual review, no change to policy intent. 

05/12/2017 

Corrected review date. No other changes made. 

06/02/2016 

Annual review, no change to policy intent. 

06/18/2015 

Annual review, no change to policy, added coding. 

06/11/2014

Annual review, no changes made.

 


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