The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 8

Scientific Articles | August 01, 2005

UniSpacer Arthroplasty of the Knee

Domenick J. Sisto, MD¹; Isaac L. Mitchell, MD¹

¹ Los Angeles Orthopaedic Institute, 4955 Van Nuys Boulevard, Suite 615, Sherman Oaks, CA 91403. E-mail address for D.J. Sisto: laortho1@yahoo.com

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Investigation performed at the Los Angeles Orthopaedic Institute, Sherman Oaks, California

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Aug 01;87(8):1706-1711. doi: 10.2106/JBJS.D.02339

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Abstract

Background: The operative treatment of medial compartment knee arthritis is controversial. The purpose of the present study was to report the experience of a single surgeon with the UniSpacer arthroplasty for the treatment of isolated medial compartment arthritis of the knee.

Methods: From April 2002 through November 2002, thirty-seven UniSpacer arthroplasties were performed in thirty-four patients for the treatment of arthritis that primarily involved the medial compartment of the knee. The Ahlbäck radiographic evaluation scale was used to grade the severity of arthritis; the mean preoperative score was 2.6 points for the medial compartment and 0.5 point for both the lateral and patellofemoral compartments. The study group included eighteen women (nineteen knees) and sixteen men (eighteen knees) who had a mean age of fifty-five years (range, forty-two to seventy-five years) at the time of surgery. Twelve patients had had a previous arthroscopic meniscectomy. The mean preoperative Knee Society function score was 60 points (range, 40 to 80 points), and the mean preoperative Knee Society objective score was 62 points (range, 40 to 76 points).

Results: After a mean duration of follow-up of twenty-six months (range, twenty-four to twenty-nine months), there were no excellent, ten good, fifteen fair, and twelve poor results. The mean postoperative total function score was 69 points (range, 40 to 82 points), and the mean Knee Society objective score was 72 points (range, 45 to 88 points). Six of the twelve poor results were in knees that had dislocation of the UniSpacer. All twelve knees were revised to a total knee arthroplasty.

Conclusions: On the basis of this experience, we do not recommend UniSpacer arthroplasty for the treatment of degenerative arthritis of the medial compartment of the knee.

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

Figures in this Article

The treatment of isolated medial compartment degenerative arthritis of the knee in young, active patients is controversial¹. Many patients can be managed nonoperatively with activity modification and medications, but some patients have disabling pain and require surgery. Microfracture is advocated for younger patients but is not indicated for patients with malalignment^2,3. Proximal tibial osteotomy corrects malalignment⁴, but the long-term results have not been encouraging⁵. Unicompartmental arthroplasty is reemerging as an option, but it requires bone resection and subsequent activity modification^6-8. The long-term results have been encouraging^9,10, but unicompartmental arthroplasty remains controversial¹¹. Total knee arthroplasty is a reliable procedure but typically is not recommended for younger patients who are less than fifty-five years of age, who most likely will require subsequent revision surgery¹².

The concept of a self-centering, nonfixed component that does not require osseous resection and internally realigns the varus knee is appealing. The UniSpacer implant (Centerpulse Orthopaedics, Austin, Texas) is a cobalt-chromium device that has been recommended for the surgical treatment of young, active patients with isolated medial compartment degenerative arthritis of the knee¹³.

The function of the UniSpacer implant is to restore alignment of the knee by functioning essentially as an osteotomy would. The stability of the knee is restored as the implant retensions the cruciate and collateral ligaments. The UniSpacer adapts to the kinematics of the knee. The implant has one piece, has no moving parts, and requires no bone resection and no fixation. It functions as a self-centering bearing within the knee (Figs. 1-A, 1-B, and 1-C). The normal motion of the knee, including anteroposterior translation and rotation, is maintained. The UniSpacer is available in six sizes and four thicknesses. The implant is side-specific (left or right) and requires minimal instrumentation.

The purpose of the present study was to report on our experience with use of the UniSpacer arthroplasty for the treatment of medial compartment arthritis of the knee.

Materials and Methods

Materials and Methods | Results | Discussion | References

From April 2002 through November 2002, thirty-seven UniSpacer arthroplasties were performed in thirty-four patients for the treatment of arthritis that primarily involved the medial compartment of the knee. All of the patients were evaluated with a history, a physical examination, and radiographs. All of the patients filled out a questionnaire preoperatively and postoperatively for the evaluation of activity levels, satisfaction, and the functional and objective scores of the Knee Society¹⁴. The study was approved by our institutional review board, and all patients provided informed consent to participate in the study.

Radiographic examinations included standing anteroposterior, lateral, and Merchant¹⁵ patellofemoral views of the knee. The Ahlbäck¹⁶ radiographic evaluation scale was used to grade the severity of the arthritis in order to determine if the patient was a candidate for the procedure. With this system, the severity of the disease in each knee compartment is assigned a score between 0 and 5 points (with 5 points indicating the most severe involvement) on the basis of sclerosis, joint-space narrowing, subluxation, and the presence of osteophytes. Knees that had a lateral or patellofemoral compartment score of >1 were excluded. Knees that had a medial compartment score of >3 (indicating severe medial compartment arthritis) also were excluded. The knees in the present study had a mean score of 2.6 points (range, 2 or 3 points) for the medial compartment, 0.5 point (range, 0 or 1 point) for the lateral compartment, and 0.5 point (range, 0 or 1 point) for the patellofemoral compartment.

Patients with a fixed flexion contracture of >5°, medial femoral subluxation, subchondral bone loss on the femoral condyle or tibial plateau, osteonecrosis of the medial femoral condyle, anterior cruciate ligament or posterior cruciate ligament deficiency, or a varus deformity of >5° were excluded and were not managed with the UniSpacer arthroplasty.

The study group included eighteen women and sixteen men with a mean age of fifty-five years (range, forty-two to seventy-five years) at the time of the arthroplasty. Three patients (one woman and two men) had bilateral involvement. Twelve patients had had a previous arthroscopic medial meniscectomy of the knee. No other previous operations had been performed prior to the UniSpacer arthroplasty. All of the patients had been managed with multiple nonoperative measures (including anti-inflammatory medications, analgesics, viscosupplementation injections, bracing, physical therapy, and activity modification).

All patients were evaluated preoperatively with the use of the Knee Society functional and objective rating scales¹⁴. The scores were graded as excellent (90 points), good (80 to 89 points), fair (70 to 79 points), or poor (<70 points). The mean preoperative Knee Society function score was 60 points (range, 40 to 80 points), and the mean preoperative Knee Society objective score (Knee Society score) was 62 points (range, 40 to 76 points).

Surgical Technique

The UniSpacer was inserted as described by Hallock and Fell¹⁷. Diagnostic arthroscopy was performed to be certain that the patient had the proper indications for the procedure. The posterior and middle portions of the medial meniscus was resected to the junction of the white and red zones. The arthroscope was removed, and a 5 to 7-cm medial parapatellar incision was made. The remaining anterior horn of the medial meniscus was resected. The deep fibers of the medial collateral ligament were elevated to allow for the removal of tibial osteophytes. Femoral osteophytes were removed, and rasps were used to remove irregularities of the femoral and tibial articular surfaces.

The anteroposterior length of the medial tibial plateau was measured to ensure full anterior-to-posterior coverage with the implant. A true lateral intraoperative fluoroscopic view confirmed the ideal length. The thickness of the implant was selected on the basis of the stability of the trial implant in both flexion and extension. The trial component was removed, and the appropriately sized UniSpacer implant was inserted by holding the implant against the femoral condyle with the knee in flexion and extending the tibia over the implant. The arthrotomy was closed, and a drain was not used. A tourniquet was used for an average of fifty-five minutes (range, forty-five to seventy minutes). Intravenous antibiotics were given preoperatively. Patients typically were discharged from the hospital on the day of surgery, and prophylaxis against deep-vein thrombosis was not used because the surgical technique involved no bone resection (other than osteophyte removal) and no intramedullary dissection.

All patients were permitted to bear full weight as tolerated postoperatively. A hinged knee brace allowing a full range of motion was utilized for the first seventy-two hours and then was discontinued. A continuous-passive-motion machine was utilized for the first two weeks. Physical therapy was begun two weeks postoperatively, and a range-of-motion program combined with open chain exercises was continued for two months.

Statistical Analysis

The data were analyzed with the assistance of a clinical biostatistician. Preoperative and postoperative Knee Society scores and activity levels were compared with use of the Wilcoxon signed-rank test. Comparisons of other preoperative and postoperative variables (including the degree of arthrosis) were performed with use of the Student t test, with the level of significance set at p < 0.05.

Results

Materials and Methods | Results | Discussion | References

The average operative time was sixty-five minutes (range, forty-five to ninety minutes). Two patients stayed over-night in the hospital for pain control, and thirty-two patients were discharged on the day of surgery. The most commonly used width was 50 mm (sixteen knees), and the most commonly used thickness was 2 mm (twenty-two knees).

After a mean duration of follow-up of twenty-six months (range, twenty-four to twenty-nine months), there were no excellent, ten good, fifteen fair, and twelve poor results according to the Knee Society score. The mean postoperative Knee Society objective score (72 points; range, 45 to 88 points) was better than the mean preoperative score (62 points; range, 40 to 76 points) but, with the numbers available, this difference was not significant. The mean postoperative Knee Society total function score (69 points; range, 40 to 82 points) was better than the mean preoperative score (60 points; range, 40 to 80 points) but, with the numbers available, this difference was not significant (Table I).

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TABLE I Preoperative and Postoperative Knee Society Scores

	Mean Age at Time of Surgery† (yr)	Preoperative Scores‡ (points)			Postoperative Scores‡ (points)
Gender^*		Objective	Function	Objective	Function
Female
18 (19)	56 (46 to 75)	60	59	70	67
Male
16 (18)	54 (42 to 72)	64	61	74	72

^*The data are given as the number of patients, with the number of knees in parentheses. †The values are given as the mean, with the range in parentheses. ‡The values are given as the mean.

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TABLE I Preoperative and Postoperative Knee Society Scores

	Mean Age at Time of Surgery† (yr)	Preoperative Scores‡ (points)			Postoperative Scores‡ (points)
Gender^*		Objective	Function	Objective	Function
Female
18 (19)	56 (46 to 75)	60	59	70	67
Male
16 (18)	54 (42 to 72)	64	61	74	72

^*The data are given as the number of patients, with the number of knees in parentheses. †The values are given as the mean, with the range in parentheses. ‡The values are given as the mean.

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Figs. 1-A, 1-B, and 1-C: Radiographs of the knee of a forty-five-year-old man who underwent placement of a UniSpacer. Fig. 1-A Preoperative anteroposterior and lateral radiographs demonstrating osteoarthritis of the medial component of the knee.

Six of the twelve poor results were in knees that had anterior dislocation of the implant (Fig. 1-C). All twelve knees with a poor result were revised to a total knee arthroplasty. The mean range of flexion was essentially unchanged, decreasing from 117° (range, 115° to 125°) preoperatively to 114° (range, 110° to 122°) postoperatively.

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Fig. 1-B: Anteroposterior and lateral radiographs made two months postoperatively.

Thirty-two patients (thirty-two knees) complained of pain during normal walking postoperatively. The mean preoperative pain score was 22 points (range, 10 to 30 points), and the mean postoperative pain score was 26 points (range, 0 to 40 points). Fifteen knees (41%) had a lower pain score postoperatively. Only ten patients (ten knees; 27%) had an increased activity level postoperatively, and only five patients (five knees; 14%) were able to participate in high-impact sports such as downhill skiing. Persistent postoperative swelling was present in nine patients (ten knees; 27%). Fifteen patients (fifteen knees; 41%) with a fair result were limited by pain. Ten of these fifteen patients regularly used anti-inflammatory medications.

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Fig. 1-C: Anteroposterior and lateral radiographs made three months postoperatively, demonstrating anterior dislocation of the UniSpacer implant.

The size of the implant did not appear to influence the functional outcome as the failures were not due to an excessively large or small spacer.

Discussion

Materials and Methods | Results | Discussion | References

UniSpacer arthroplasty is considered to be an alternative to proximal tibial osteotomy and knee arthroplasty for the treatment of isolated degenerative arthritis of the knee in young, active patients^13,17. The implant is designed to restore knee alignment and stability.

The concept of a metal articulation in the knee is not new. MacIntosh reported good early results in seventy-two of 103 knees after short-term follow-up¹⁸. McKeever, who introduced a fixed tibial component, reported good short-term results in thirty-nine of forty knees¹⁹.

Scott et al., in a study of forty-four McKeever metallic hemiarthroplasties, reported a 79% rate of good to excellent results after an average duration of follow-up of eight years²⁰. Thirteen patients (fourteen knees) were less than sixty-five years old (average, fifty-four years old; range, thirty-two to sixty-four years old) at the time of surgery. Thirteen of the fourteen knees in these patients were rated as good or excellent and were associated with a substantial increase in activity levels and function after five years of follow-up. Emerson and Potter, in a study of sixty-one similar implants, reported a 75% rate of good to excellent results after an average duration of follow-up of five years²¹.

Hallock and Fell¹⁷ initially reported on sixty-six patients (seventy-one knees) who had been managed with the UniSpacer implant and had been followed for a minimum of one year. Ten knees (14%) had an exchange of the UniSpacer implant because of either pain or dislocation, and five (7%) were revised to a total knee arthroplasty. The overall rate of revision was 21% at one year¹⁷. Two-year data were reported for thirteen knees in twelve patients¹³. No additional complications or surgical procedures were reported between the first and second years¹³.

The results of the present study are not favorable. After a mean duration of follow-up of twenty-six months, there were no excellent, ten good, fifteen fair, and twelve poor results. The mean Knee Society objective and total function scores were minimally improved postoperatively. Six of the twelve poor results were associated with anterior dislocation of the implant. All twelve knees with a poor result were revised to a total knee arthroplasty. Twenty-five implants (68%) remained in place at a mean of twenty-six months.

Three mechanisms of failure were noted in association with the twelve knees that were rated as poor. The first mechanism of failure was anterior dislocation of the implant. This complication occurred in six knees, all of which were revised to a total knee arthroplasty. Hallock and Fell stated that this prosthesis is associated with a learning curve that needs to be addressed in order to prevent dislocation¹⁷. However, the implant in the thirty-fifth knee in our series dislocated two months postoperatively, despite the fact that the implant had been inserted to cover the entire anteroposterior length of the tibia in order to prevent this complication. We believe that dislocation of the implant cannot be totally avoided even with good surgical technique.

The second mechanism of failure occurred when an implant became wedged between the femur and the tibia and did not internally or externally rotate in flexion, despite the fact that all of the implants were observed to rotate properly at the time of surgery. The loss of rotation of the implant postoperatively may have been related to the development of adhesions, which prevent proper function of the UniSpacer and may cause substantial pain. This complication occurred in two knees, both of which were revised to a total knee arthroplasty.

The third mechanism of failure was persistent severe pain in the knee. This complication occurred in four knees, all of which underwent a subsequent arthroplasty. At the time of the arthroplasty, the implant was closely inspected for position, sizing, and function. All four implants appeared to be the appropriate size, and all appeared to be functioning properly. We believe that the severe postoperative pain was not secondary to a technical error or poor patient selection, but the cause remains unknown.

On the basis of this experience, we no longer recommend the UniSpacer arthroplasty to our patients. We are not certain what role, if any, it has in the treatment of isolated medial compartment degenerative arthritis of the knee. ?

References

Materials and Methods | Results | Discussion | References

Iorio R, Healy WL. Unicompartmental arthritis of the knee. J Bone Joint Surg Am.2003;85: 1351-64.851351 2003 [PubMed]

Rodrigo JJ, Steadman JR, Silliman JF, Fulstone HA. Improvement of full-thickness chondral defect healing in the human knee after débridement and microfracture using continuous passive motion. Am J Knee Surg.1994;7: 109-16.7109 1994

Blevins FT, Steadman JR, Rodrigo JJ, Silliman J. Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance. Orthopedics.1998;21: 761-8.21761 1998 [PubMed]

Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am.1993;75: 196-201.75196 1993 [PubMed]

Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am.1984;66: 1040-8.661040 1984

Insall J, Walker P. Unicondylar knee replacement. Clin Orthop Relat Res.1976;120: 83-5.12083 1976 [PubMed]

Laskin RS. Unicompartmental tibiofemoral resurfacing arthroplasty. J Bone Joint Surg Am.1978;60: 182-5.60182 1978 [PubMed]

Engh GA, McAuley JP. Unicondylar arthroplasty: an option for high-demand patients with gonarthrosis. Instr Course Lect.1999;48: 143-8.48143 1999 [PubMed]

Svard UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. A survival analysis of an independent series. J Bone Joint Surg Br.2001;83: 191-4.83191 2001 [PubMed][CrossRef]

Squire MW, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC. Unicompartmental knee replacement. A minimum 15 year followup study. Clin Orthop Relat Res.1999;367: 61-72.36761 1999 [PubMed]

Vince KG, Cyran LT. Unicompartmental knee arthroplasty: new indications, more complications? J Arthroplasty.2004;19(4 Suppl 1): 9-16.199 2004 [CrossRef]

Deshmukh RV, Scott RD. Unicompartmental knee arthroplasty for younger patients: an alternative view. Clin Orthop Relat Res.2002;404: 108-12.404108 2002 [CrossRef]

Hallock RH, Fell BM. Unicompartmental tibial hemiarthroplasty: early results of the UniSpacer knee. Clin Orthop Relat Res.2003;416: 154-63.416154 2003 [CrossRef]

Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res.1989;248: 13-4.24813 1989

Merchant AC, Mercer RL, Jacobsen RH, Cool CR. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am.1974;56: 1391-6.561391 1974

Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh).1968;Suppl 277: 7-72.7 1968

Hallock RH, Fell BM. Metallic tibial hemiarthroplasty utilizing the UniSpacer knee system: surgical technique and preliminary results. Tech Knee Surg.2003;2: 200-12.2200 2003 [CrossRef]

MacIntosh DL. Hemiarthroplasty of the knee using a space occupying prosthesis for painful varus and valgus deformities. In: Proceedings of the Joint Meeting of the Orthopaedic Associations of the English-Speaking World. J Bone Joint Surg Am.1958;40: 1431.401431 1958

McKeever DC. Tibial plateau prosthesis. Clin Orthop Relat Res.1960;18: 86-95.1886 1960

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: 203-7.67203 1985 [PubMed]

Emerson RH Jr, Potter T. The use of the McKeever metallic hemiarthroplasty for unicompartmental arthritis. J Bone Joint Surg Am.1985;67: 208-12.67208 1985

Topics

dislocations ; knee region ; knee joint ; osteoarthritis ; arthroplasty ; knee replacement arthroplasty

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Domenick J. Sisto, MD

Posted on March 19, 2011

Dr. Sisto responds to Dr. Anderson

Orthopaedic Surgeon, Los Angeles Orthopaedic Institute, Sherman Oaks, California

A patient who has had a failed unispacer due to subluxation should be revised to a unicompartment or total knee arthroplasty. The problem with revising the failed unispacer by placing a larger implant in the knee is that this increases the likelihood of pain and stiffness. The unispacer has been designed to rotate in the knee and a thicker spacer may prevent this rotation and lead to failure. This patient has already had a failed unispacer arthroplasty and I believe it would be more prudent to proceed with a unicompartment arthroplasty which has a more reliable long-term outcome.

Tom Anderson

Posted on March 19, 2011

Management of Failure of the Unispacer

Physician, Sansum Clinic, Santa Barbara, California

To the Editor:

In the authors' opinion, should a patient who had a failed unispacer due to subluxation be subjected to a second, larger unispacer after failure rather than proceed with the more invasive unicompartmental knee replacement or TKA?

Domenick J Sisto, M.D.

Posted on October 13, 2005

Dr. Sisto responds to Dr. Papavasileiou

Los Angeles Orthopaedic Institute, Sherman Oaks, CA 91403

I thank Dr. Papavasileiou for his letter.

The patients were ideal candidates to be revised to a unicompartmental arthroplasty following the failure of their Unispacer. I chose to perform a total knee arthroplasty because, in my hands, I can more reliably predict an excellent outcome with this procedure. I frequently perform unicompartmental arthroplasties but am still occasionally disappointed with their result and I must eventually perform a total knee arthroplasty a few years later. I felt that I had already subjected these patients to one failed procedure and I wanted to minimize the possibility of a second failure.

Sincerely,

Domenick J. Sisto, M.D.

Athanasios V. PAPAVASILEIOU, BSc, M.D., Ph.D.

Posted on September 21, 2005

Management of Failed UniSpacer Arthroplasty of the Knee

East Sussex Hospitals NHS Trust, Eastborne DGH, East Sussex, UK

To the Editor:

We would like to congratulate Drs. Sisto and Mitchell for their interesting article (1). However we feel that clarification is necessary regarding the management of the 12 failed UniSpacer arthroplasties.

As described in great detail in the paper the patients that had undergone the procedure had isolated unicompartmental osteoarthritis clinically, radiologically and arthroscopically. We wonder why the failed implants were revised to a Total Knee rather than Unicompartmental Knee Arthoplasty (UKA) since the patients seem to be ideal candidates for it. Did the intra-operative findings reveal any changes that would make a UKA unsuitable?

Yours truly,

Dr A. Papavasileiou BSc, MD, PhD

Mr A. Chipperfield MRCS

Mr D. Isaac MRCS

Reference:

1. Sisto DJ, Mitchell IL. UniSpacer Arthroplasty of the Knee. J Bone Joint Surg Am. 2005;87:1706-1711

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Domenick J. Sisto, Isaac L. Mitchell; UniSpacer Arthroplasty of the Knee. The Journal of Bone & Joint Surgery. 2005 Aug;87(8):1706-1711.

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