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Lateral Unicompartmental Knee Arthroplasty: AFrench Perspective
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. Fig. 16.8 Minimal bone resection during the tibial cut
179
16.6.2 Femoral Cuts
The distal femoral cut should also be as conservative as
possible allowing to“distalize”the femoral implant and
compensate for the congenital hypoplasia and the wear
(. Fig. 16.10). In genu valgum, OA affects preferentially the posterior part of the femoral condyle (Ollivier
etal. 2014) explaining why there may be intact cartilage
on the distal part of the condyle which has to be removed
before positioning the distal femoral cutting guide
(Scott 2005).
> If the surgeon desires to conserve a valgus deformity,
it can be adjusted for at this step depending on the
level of the cut. It should not be performed previously
during the tibial cut.
There are two ways to perform the distal femoral cut
depending on the prosthesis characteristics and the
manufacturing:
5 Dependent cut: in extension, the cutting-guide is
placed in the tibiofemoral space like a spacer. The
level of the cut corresponds to the thickness of
the component and will depend on the tibial cut
level.
16
Anatomical axis
Axis of the sagittal tibial cut
. Fig. 16.9 Direction of the sagittal tibial cut in internal rotation
Lateral Tibial Plateau Medial Tibial Plateau
Patellar Ligament
And Anterior Tibial Tuberosity
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. Fig. 16.10 Distal femoral cut
5 Independent cut: thanks to an intra-medullary guide,
the distal cut is performed according to the HKS
angle (between 4° and 6°).
Second, posterior femoral and chamfer cuts are per-
formed and reproduce the same gap in exion than in
extension (. Fig.16.11).
The rotation in the cutting-guide is crucial and will
inuence the implant rotation. Due to the divergence of
the lateral condyle compared to the medial condyle, it is
crucial to avoid excessive internal rotation in exion,
which will create an impingement in extension with the
tibial spines. The size of the component is a compromise
between the anatomical position centered on the femoral condyle and the perpendicular axis to the tibial plateau.
> It is important not to oversize the femoral implant
and preferentially to undersize it if necessary.
The anterior border of the prosthesis has to be at the
level of the landmark point contact between the femur
and tibia. This has to be 1 or 2mm under the border
between cartilage and cancellous bone created by the
bone cut. To avoid any impingement in full exion with
. Fig. 16.11 Posterior femoral and chamfer cuts performed on a
exed knee. The objective is to reproduce the same gap in exion and
extension
the polyethylene, all posterior osteophytes have to be
removed.
16.6.3 Implant Positioning
After all bone cuts are performed, the size of the
implant is chosen. It is a compromise between the best
bone coverage without any overhanging of the implant
in coronal and sagittal plans. The tibial implant should
be close to the tibial spines with 15°–20° of internal
rotation. The femoral implant is placed on a exed knee
with external rotation and as lateral as possible, and at
times it may rest on lateral condyle osteophytes
(Argenson etal. 2008). This positioning allows the ideal
contact between the two implants preventing any
impingement between the femoral condyle with the
tibial spines during extension. The knee is then placed
in full exion and internal rotation to improve exposition on the tibial plateau and nish the preparation of
the implant.
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181
16
. Fig. 16.12 Knee stability and implant positioning are tested with
trial components in exion
With trial components, the stability of the knee is
tested (. Figs.16.12 and 16.13). During exion/extension movements, the medial part of the femoral implant
should stay in front of the center of the tibial implant.
> At this step, it is important to detect any impingement
between the femoral implant and tibial spines in
extension as well as impingement between the patella
and femoral implant in extension due to the lack of
external rotation of the femoral component.
The testing in exion and extension will evaluate the
residual frontal laxity and the thickness of the polyethylene insert which is generally more important after lateral UKA than medial UKA due to femoral dysplasia.
The ligament balancing is evaluated with the trial
components. The goal is to maintain slight lateral laxity
on the unlocked knee (at 15° of exion).
> In lateral UKA, it is crucial to undercorrect the defor-
mity to avoid any excess pressure in the medial com-
partment and the development of medial OA in the
long term (Lustig etal. 2014).
. Fig. 16.13 Kneestabilityandimplantpositioningaretestedwithtri-
alcomponents in extension
Lateral UKA is a resurfacing procedure of the lateral part of the knee joint and will only correct the
deformity due to the wear (intra-articular deformation)
and will respect the extra-articular deformity.
Finally, the denitive prosthesis is implanted. The
tibial implant is placed and cemented with the knee in
complete exion and internal rotation to improve exposition of the lateral compartment (. Figs. 16.14 and
16.15). Second, the femoral implant is cemented, plac-
ing the knee in full exion, impacting the posterior part
rst and then anteriorly. The knee is then moved close to
extension in order to remove all cement particles from
the back of the knee. The polyethylene insert is placed
after cleaning off the metal-back (.
Figs. 16.16 and
16.17), this can be also realized after placing temporally
a trial insert while the cement is setting in order to make
a nal check of all remaining cement particles. It is
important to place the knee at 45° of exion during the
time when the cement is curing (. Figs. 16.18 and
16.19).
Good cementation has to respect some rules to
improve implant xation (Randall et al. 2019). It is
mandatory to prepare and clean the bone surface using
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A. Schmidt et al.
. Fig. 16.14 Double cementation of the tibial component and impaction in the cancellous bone
16
. Fig. 16.15 Removal of excess cement around the implant with a specic curette to avoid any cemented foreign bodies, especially in the
posterior part of the knee
a pulsed lavage to remove all foreign bodies and dry the
blood of the trabecular bone (Schlegel et al. 2015).
Using a tourniquet or doing a double cementation
(Refsum etal. 2019)is not obligatory but is highly recommended. Several studies conrm that draining and
cleaning the cancellous bone alveolus will allow good
penetration of the cement and increase the implant xation (Scheele etal. 2017; Schlegel etal. 2014; Jaeger
etal. 2013, 2014; Clarius etal. 2009, 2012; Seeger etal.
2013).
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183
. Fig. 16.16 Cementation of the femoral component. The impaction is performed at 90° of exion and concerns all parts of the implant
(anterior, distal, and posterior)
16
. Fig. 16.17 Removal of excess cement close to the femoral
implant to avoid any impingement with soft tissues
> The objective of good cementation is to decrease the
long-term risk of aseptic loosening of the tibial component due to implant–cement–bone interface fatigue.
. Fig. 16.18 The knee is placed at 45° of exion during the curing
time of the cement
16.6.4 Common Mistakes andOperating
Diculties
Overcorrection with postoperative varus deformity
leads to increased load in the medial compartment and
the development of medial OA.A postoperative varus
deformity could be secondary to insufcient bone cut or
to a thick polyethylene insert. Conversely, undercorrection with persistence of a valgus deformity more than 7°
is associated with a higher revision rate (Perkins and
Gunckle 2002).
Concerning femoral implant positioning, the divergence axis of the condyle in exion should not be reproduced with the prosthesis to avoid any impingement in
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A. Schmidt et al.
. Fig. 16.19 Final view of the denitive prosthesis
extension with the tibial spines and with the patella in
exion.
During the tibial cut, it is important to prevent an
excessive posterior tibial slope which will increase tension on ACL and impact the ligament balancing with
laxity in exion. The tibial implant should be positioned
with an internal rotation of 15–20° and aligned with the
natural tibial slope.
16.7 Results andRevision
Outcomes of modern UKA are excellent with 90% of
survivorship at medium and long term (Greco et al.
2019; Vasso etal. 2015; Pandit etal. 2011; Walker etal.
2017). In case of failure, revision UKA with TKA is
easier with better results than revision TKA with TKA
(Lunebourg etal. 2015). Clinical and radiological results
of lateral UKA are similar to medial UKA (Argenson
etal. 2008).
Recent studies report lower revision rates with the
modern implant than previous studies on lateral
UKA.In 2002, Ashraf etal. (Ashraf etal. 2002) found
a survival rate of 83% at 10years follow-up and 74% at
15years. More recent studies reported better survivorship of lateral UKA with 90% at medium term and 80%
at long term (Deroche etal. 2019; Fornell etal. 2018).
Better patient selection criteria, surgical technique, and
implant manufacturing could explain the improvement
of the results of lateral UKA.Several studies as Deroche
etal. (Deroche etal. 2019) or Lustig etal. (Lustig etal.
2014)analyzed cemented all-polyethylene tibial implants
and found excellent results at long term with 94.4% survival at 10years, 91.4% at 15years, and 79.4% at 20years
follow-up.
The cause of main failure of lateral UKA is OA progression (87.5%), especially in the medial compartment
(Deroche et al. 2019), followed by aseptic loosening
(12.5%). Deroche etal. (Deroche etal. 2019) reported a
mean revision rate of 20.5% at 17.9years follow-up. For
patients not requiring revision surgery, the satisfaction
scores were excellent with 90.5% good results.
Concerning cemented metal-back implants, excellent
results were also reported at short (Kim etal. 2016) and
long term (Argenson etal. 2008). Argenson etal. (2008)
found these implants showed good survivorship of 92%
at 10years and 84% at 16years for lateral UKA.For
mobile-bearing UKA, Fornell et al. (2018) reported a
survival rate of 97.5% at 5years with a revision rate of
2.4% at 49months follow-up. The main cause of failure
of mobile-bearing in lateral UKA was the dislocation of
the polyethylene (Pandit etal. 2010).
Concerning the return to physical activity, Canetti
etal. (2018) found a return to sports with the low and
medium impact between 94% and 100% after a delay of
4.2 to 10.5 months in a study of cemented lateral
UKA. In a systematic literature review, Witjes et al.
(2017), reported a return to sports at high impact in 8%,
medium impact in 22%, and 70% for low impact sport.
Conclusion
z
With an appropriate surgical technique and good patient
selection criteria, lateral unicompartmental knee arthroplasty is an efcient procedure with good outcomes in
long-term follow-up similar to medial UKA (Ollivier
etal. 2014; Argenson etal. 2008). Due to the anatomical
and biomechanical differences between the lateral and
medial compartments, some technical specicities have
to be known when performing lateral UKA, which has
to be considered as a resurfacing procedure without any
correction of the frontal deformity to avoid any early
failure due to medial OA. Positioning of implants
should respect some general rules, including internal
rotation of the tibia component and positioning the
femoral component as lateral as possible with external
rotation to avoid any impingement with the tibial spines
in extension or with the patella in exion. Respecting the
importance and increased mobility of the lateral
Lateral Unicompartmental Knee Arthroplasty: AFrench Perspective
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185
16
compartment due to normal knee kinematics, it seems
to be preferential to use xed-bearing tibial components.
In order to limit the risk of aseptic loosening, it is recommended to implant cemented prostheses and have a
strict cementation technique with pulsed lavage.
Take-Home Messages
5 The anteroposterior axis of the lateral tibial pla-
teau has an internal rotational axis of 10–15°.
5 The posterior tibial slope is reduced on the lateral
side compared to the medial side (4° vs. 7°).
5 Due to the constitutional external rotation of the
lateral tibial plateau (“screw-home mechanism”
(Kim etal. 2015)), the sagittal tibial cut will be performed in internal rotation and will cross the patellar ligament.
5 The distal femoral cut should also be as conserva-
tive as possible allowing to “distalize” the femoral
implant and compensate for the congenital hypoplasia and the wear.
5 Due to the divergence of the lateral condyle com-
pared to the medial condyle, it is crucial to avoid
excessive internal rotation in exion, which will
create an impingement in extension with the tibial
spines.
5 The tibial implant should be close to the tibial
spines with 15–20° of internal rotation.
5 The femoral implant is placed on a exed knee
with external rotation and as lateral as possible,
sometimes it may rest on lateral condyle osteophytes.
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Patellofemoral Arthroplasty
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SimonGarceau, WilliamJ.Long, andRanSchwarzkopf
Contents
17.1 Introduction – 188
17.2 Clinical Evaluation – 188
17.2.1 Patient History – 188
17.2.2
Physical Examination – 188
Imaging – 189
17.2.3
17.3 Patellofemoral Arthroplasty – 190
17.3.1 Contraindications toPatellofemoral Arthroplasty
(Leadbetter etal. 2005) – 190
17.3.2 Design Features – 191
17.3.3 Surgical Technique – 192
17.3.4 Clinical Results – 193
187
17
17.4 Complications – 195
References – 196
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_17
188
S. Garceau et al.
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17.1 Introduction
Arthritis, isolated to the patellofemoral joint (PFJ), is a
well-described entity that can result in signicant disability and pain (Lonner 2007; Hofmann etal. 2013).
Epidemiological studies suggest that nearly 10% of
individuals over the age of 40 may have isolated PF
arthritis (Davies et al. 2002). Furthermore, females
appear to be at signicantly greater risk with one study
by McAlindon etal. suggesting a >2:1 female-to-male
predisposition in individuals over the age of 55
(McAlindon etal. 1992).
Non-surgical management represents the initial
mainstay of treatment and consists of a combination of
the following:
5 Activity modication.
5 Weight reduction.
5 Targeted physical therapy.
5 Oral anti-inammatory medication.
5 Intra-articular injections (Lonner 2018; Lonner and
Bloomeld 2013).
Physical therapy regimens should focus on optimizing patellar tracking through a low-impact quadriceps
strengthening exercise program (Witvrouw etal. 2003).
Non-operative management can reduce symptoms and
delay the need for surgical intervention. When nonoperative management fails, surgical treatment options
can be considered.
Surgical options that have been described in the
treatment of patellofemoral arthritis with varying
degrees of success, include the following:
5 Arthroscopic irrigation and debridement.
5 Tibial tubercle ofoading osteotomy (i.e., Fulkerson
anteromedialization and Maquet elevation).
5 Cartilage grafting.
5 Patellectomy.
5 Patellar resurfacing.
5 Patellofemoral arthroplasty (PFA).
5 Total knee arthroplasty (TKA) (Federico and Reider
1997; Heatley etal. 1986; Mont et al. 2002; Parvizi
et al. 2001; Hangody and Füles 2003; Minas and
Bryant 2005; Pidoriano etal. 1997).
In the short term, fair to good results have been
described in 20–75% of patients (Federico and Reider
1997; Heatley etal. 1986; Mont etal. 2002; Parvizi etal.
2001; Hangody and Füles 2003; Minas and Bryant 2005;
Pidoriano etal. 1997; Paletta and Laskin 1995). In this
chapter, a focused discussion of PFA as a treatment
modality will be conducted. To optimize surgical outcomes, careful patient selection, PFA design choice, and
meticulous surgical technique are essential.
17.2 Clinical Evaluation
17.2.1 Patient History
An attentive collection of the patient history is necessary for the identication and treatment of patients with
a painful knee secondary to PF arthritis. The clinician
should identify any history of PF dislocation which can
be indicative of PF malalignment. In such cases, realignment procedures may be required prior to surgical
intervention (Lonner 2004). Similarly, recurrent PFJ
dislocations may be associated with signicant joint dysplasia. Prior conservative and surgical treatment measures should be documented as part of a comprehensive
assessment. Characterization of the location, quality,
and onset of pain as well as aggravating and alleviating
factors is important for both accurate diagnosis and
treatment. Classically, pain associated with degenerative
changes within the PFJ is situated directly anteriorly,
within the retropatellar region, and/or in the peripatellar
region (Lonner 2007, 2018).
Furthermore, painful symptoms are typically exacerbated by activities that load the PFJ such as squatting,
ascending and descending stairs, kneeling, and prolonged sitting with the knee in a exed position (Lonner
2004, 2007). Activities that allow the knee to remain in a
more extended position such as ambulating on level
ground and being seated with the knee extended, ofoad
the PFJ and are generally better tolerated.
> Any history of pain located in the medial or lateral
compartments of the tibiofemoral articulation should
be identied as this may be indicative of more diffuse
degenerative changes which are important for indicat-
ing the appropriate treatment.
17.2.2 Physical Examination
Initial physical examination commences with having the
patient standing facing the examiner. Special attention
should be placed on the overall alignment of the lower
extremity, specically the Q-angle. This is characterized
by the angle subtended by a line drawn from the anterior
superior iliac spine (ASIS) to the center of the patella,
and a second line from the center of the patella to the
middle of the tibial tubercle.
> For Q-angles measuring greater than 15° in males and
greater than 20° in females, consideration for an
anteromedializing tibial tubercle osteotomy should
be entertained prior to PFA to ensure satisfactory PF
tracking (Lonner 2007; Lonner and Bloomeld 2013).
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