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Results of Unicompartmental Knee Arthroplasty at a Minimum of Ten Years of Follow-up
Richard A. Berger, MD1; R. Michael Meneghini, MD1; Joshua J. Jacobs, MD1; Mitchell B. Sheinkop, MD1; Craig J. Della Valle, MD1; Aaron G. Rosenberg, MD1; Jorge O. Galante, MD1
1 Department of Orthopaedic Surgery, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Suite 1063, Chicago, IL 60612. E-mail address for R.A. Berger: r.a.berger@sbcglobal.net
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Zimmer. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Zimmer). Also, a commercial entity (Zimmer) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 May 01;87(5):999-1006. doi: 10.2106/JBJS.C.00568
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Abstract

Background: There is a renewed interest in unicompartmental knee arthroplasty. The present report describes the minimum ten-year results associated with a unicompartmental knee arthroplasty design that is in current use.

Methods: Sixty-two consecutive unicompartmental knee arthroplasties that were performed with cemented modular Miller-Galante implants in fifty-one patients were studied prospectively both clinically and radiographically. All patients had isolated unicompartmental disease without patellofemoral symptoms. No patient was lost to follow-up. Thirteen patients (thirteen knees) died after less than ten years of follow-up, leaving thirty-eight patients (forty-nine knees) with a minimum of ten years of follow-up. The average duration of follow-up was twelve years.

Results: The mean Hospital for Special Surgery knee score improved from 55 points preoperatively to 92 points at the time of the final follow-up. Thirty-nine knees (80%) had an excellent result, six (12%) had a good result, and four (8%) had a fair result. At the time of the final follow-up, thirty-nine knees (80%) had flexion to at least 120°. Two patients (two knees) with well-fixed components underwent revision to total knee arthroplasty, at seven and eleven years, because of progression of patellofemoral arthritis. At the time of the final follow-up, no component was loose radiographically and there was no evidence of periprosthetic osteolysis. Radiographic evidence of progressive loss of joint space was observed in the opposite compartment of nine knees (18%) and in the patellofemoral space of seven knees (14%). Kaplan-Meier analysis revealed a survival rate of 98.0% ± 2.0% at ten years and of 95.7% ± 4.3% at thirteen years, with revision or radiographic loosening as the end point. The survival rate was 100% at thirteen years with aseptic loosening as the end point.

Conclusions: After a minimum duration of follow-up of ten years, this cemented modular unicompartmental knee design was associated with excellent clinical and radiographic results. Although the ten-year survival rate was excellent, radiographic signs of progression of osteoarthritis in the other compartments continued at a slow rate. With appropriate indications and technique, this unicompartmental knee design can yield excellent results into the beginning of the second decade of use.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James D. Heckman, M.D.
    Posted on August 30, 2006
    Concern Regarding Duplicate Publications
    The Journal of Bone and Joint Surgery, Am. Vol., Needham, MA 02492

    To The Readers:

    It has been brought to our attention by our readers that two pairs of manuscripts published in Clinical Orthopaedics and Related Research and the American volume of the Journal of Bone and Joint Surgery may represent duplicate publication. The articles in question are:

    1. “The Progression of Patellofemoral Arthrosis After Medial Unicompartmental Replacement” by Berger, et. al., Clinical Orthopaedics and Related Research, 428:92-99, November, 2004.

    “Results of Unicompartmental Knee Arthroplasty at a Minimum of Ten Years of Follow-up” by Berger, et. al., JBJS-A 87:999-1006, 2005 and:

    2. “Cementless Acetabular Reconstruction in Revision Total Hip Arthroplasty” by Della Valle et. al., Clinical Orthopaedics and Related Research, 420:96-100, March, 2004.

    “Revision of the Acetabular Component without Cement After Total Hip Arthroplasty” by Della Valle, et. al., JBJS-A 87:1795-1800, August, 2005.

    We reviewed both pairs of manuscripts and shared the concerns raised by the reviewers with regard to the possibility of redundant publication. Therefore, we asked the authors of the four papers to review them and provide an explanation of circumstances surrounding their publication. Attached is the response letter from the authors which we do not feel, in either case, adequately justifies the publication of two separate articles because in neither case does one article provide sufficient new information beyond the information provided in the companion article. We both feel that the most important element of the authors’ response letter lies in the introductory paragraph in which the Department of Orthopaedics has decided to establish an oversight committee to vet manuscripts before submission for publication. We both endorse this concept and encourage other academic orthopaedic departments to pursue a similar review process to minimize the risk of being charged with duplicate or redundant publication.

    James D. Heckman, M.D.

    Editor-in-Chief, The Journal of Bone and Joint Surgery - American Volume

    Richard J. Brand M.D., Editor-in-Chief, Clinical Orthopaedics and Related Research.

    BELOW IS THE LETTER OF RESPONSE BY DR. BERGER, ET.AL.

    August 28,2006

    Dear Dr. Heckman:

    The editorial staff of the Journal of Bone and Joint Surgery have expressed concern that the two sets of papers discussed below represent duplicate publication as defined by the COPE (Committee on Publication Ethics) Guidelines.(1). While we acted in good faith and believed at the time that the submissions of these papers were done within the boundaries of ethical behavior, in light of our recent review of the COPE guidelines and our communications with the editor of the Journal we recognize that there exists overlap in these papers inconsistent with the COPE guidelines. In addition, in the first set of papers Figure 1 (a photograph of the prosthesis) was identical in both papers; we were in error by not obtaining permission from the publisher of the first paper prior to the publication of the second paper. We wish to express our regrets to the editorial staff of the journal, as well as to its readership. To insure that there is a clear demarcation between clinical studies submitted for publication in the future, an oversight committee in our department has been established to vet manuscripts before submission for publication. Given the circumstances presented below, we will pay particular attention to those papers that are submitted in response to an invitation to participate in a special symposium or are submitted for inclusion in proceedings from subspecialty meetings, especially if they involve a patient cohort that has been the subject of previous publications. If there is any question about potential overlap, this will be brought to the attention of the author who will address this in the cover letter to the journal. This will insure transparency for the editors and reviewers.

    In the November 2004 issue of Clinical Orthopaedics and Related Research we published a paper entitled The Progression of Patellofemoral Arthrosis After Medial Unicompartmental Replacement: Results at 11 to 15 Years and in May 2005 we published a paper in the Journal of Bone and Joint Surgery entitled Unicompartmental Knee Arthroplasty at a Minimum of Ten Years Follow-up. The JBJS paper was initiated by us and was written and submitted first. The CORR paper was requested by the Knee Society to be included in their 2004 proceedings; this paper, submitted second but published first, represents an update of the JBJS paper. There are three differences, which in our view at the time justified separate publication: 1) these two articles represent slightly different cohorts; 2) these two articles contain different data from two different follow up intervals separated by two years; and 3) the former paper reports progression of disease in the patellofemoral compartment which was discovered after the additional two years of follow-up.

    The article in JBJS entitled Unicompartmental Knee Arthroplasty at a Minimum of Ten Years Follow-up represents an unselected group of all unicompartmental knee arthroplasties done at our institution from 1987 to 1993 (n=62 unicompartmental knee replacements in 51 patients). The article in CORR entitled The Progression of Patellofemoral Arthrosis After Medial Unicompartmental Replacement: Results at 11 to 15 Years represents only the more common medial unicompartmental replacements done at our institution during the same period. The follow up interval of these two cohorts is different. For the JBJS article, the study period closed in mid 2001. This resulted in the follow up for this unselected group from 10 to 13 years, with an average follow up of 11.8 years. There were two failures in this group at 7 and 10 years. The survivorship analysis was carried out to the end of the follow up period (13 years) and the paper was finished in early 2002. It was submitted to JBJS shortly thereafter.

    As a direct result of an invitation by the Knee Society to participate in the scientific program of the 2004 Open Meeting in San Francisco, a study was undertaken to update the results out to fifteen years of follow up on a group of selected unicompartmental replacements, including just the more common medial unicompartmental replacements (n=59 of the 62 unicompartmental knee replacements in 48 of the 51 patients reported in the JBJS paper); the less common lateral replacements (n=3 unicompartmental knee replacements in three patients) were excluded. The study period closed in mid 2003, 2 years after the study period for the JBJS paper. All patients who were still alive and were able to travel were seen for follow up, examined, and had new radiographs taken. The average increase in follow up for this group of patients was 2 more years than the previous paper on the entire population of medial and lateral unicompartmental replacements. However, due to the fact that some patients had died, the average follow up only increased by 1.5 years to 13.3 years; all patients had between 11 to 15 year follow up. This analysis was completed and the paper was submitted to CORR in early 2004 as requested by the Knee Society to be included in their proceedings. The survivorship analysis was redone and was carried out to the end of the follow up period, 15 years. Since there were no new failures since year 7 and 10, the survivorship was unchanged past 10 years to 15 years. In addition, the failures reported in this cohort were the same as those reported in the JBJS paper. Figure 4 in the JBJS paper and Figure 5 in the CORR paper are different since the x-axis in the JBJS paper is carried out to 13 years, while the x-axis in the CORR paper is carried out to 15 years.

    In addition, the CORR paper focuses on the progression of patellofemoral disease which was discovered after the two-year additional follow up. In the JBJS paper, the prevalence of radiographic changes was 34%, with nearly two-thirds of these having Grade 1 changes. In contrast, the CORR paper reported a prevalence of radiographic changes in the patellofemoral joint of 54%, with less than one-third having Grade 1 changes and over half of these having Grade 2 changes. We believe this is a clinically relevant finding.

    It is unfortunate that the paper with longer follow up was published prior to the paper with shorter follow up; this can occur with the vagaries of the review process. We did not cite the JBJS paper in our CORR paper, because it was not yet published.

    In the March 2004 issue of Clinical Orthopaedics and Related Research we published an article entitled "Cementless acetabular reconstruction in revision total hip arthroplasty" as part of the symposium on "Revision Total Hip Arthroplasty" sponsored by the Hip Society. This invited article presented detailed descriptions of the surgical technique we presently use, a review of the published literature on the topic and clinical results of a cohort of 138 patients who underwent cementless acetabular reconstruction at the time of a revision total hip arthroplasty who were followed for a minimum of ten years.

    Subsequently, we submitted an original scientific article to the Journal of Bone and Joint Surgery entitled "Revision of the acetabular component without cement after total hip arthroplasty" which was published in August of 2005. This was a follow up note updating previous reports in the Journal of Bone and Joint Surgery now at a minimum of 15 years; the same cohort of 138 hips was studied. This report included information regarding periacetabular osteolysis and the fate of the femoral components; two important facets of this report that were not investigated in the CORR publication. Further, at this later time point (minimum 15 as opposed to 10 years), there were 2 reoperations for wear and osteolysis that were not previously recognized as well as an additional acetabular component failure. The article published in the Journal of Bone and Joint Surgery did not reference the work in Clinical Orthopaedics and Related Research as it had not been published at the time of submission.

    We believed at the time of submission that the publication of these two separate articles was justified as they had a different scope and intent (an invited review article with a review of the literature and a detailed description of the surgical technique as compared to an original scientific article), reported different clinical information (e.g. periacetabular osteolysis and the outcomes of the femoral components) and despite studying the same cohort of patients had differing criteria for entrance into the study (10 as compared to 15 year minimum follow up) and a mean follow up that differed by more than two years.

    We appreciate this opportunity to clarify the nature and intent of these two sets of papers and will be vigilant in future submissions regarding adherence to the COPE guidelines.

    Sincerely,

    Richard A. Berger, M.D.

    Craig Della Valle, M.D.

    Joshua J. Jacobs, M.D.

    Mitchell B. Sheinkop, M.D.

    Aaron G. Rosenberg, M.D.

    Jorge 0. Galante, M.D.

    Reference:

    1. The COPE Report 1999 City, Committee of Publication Ethics, 2003. http://www.publicationethics.org.uk

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