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Bicompartmental Knee
https://t.me/medicina_free
Arthroplasty
MichaelD.Ries
Contents
18.1 Introduction – 200
18.2 Case Example – 200
18.3 Classication – 200
18.4 Indications – 202
18.5 Implant Options andSurgical Technique – 202
199
18
18.6 Results – 204
References – 206
© 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_18
200
M. D. Ries
https://t.me/medicina_free
18
18.1 Introduction
Bicompartmental knee arthroplasty or selective replacement of the patellofemoral and either the medial or lateral tibiofemoral compartment is an alternative to total
knee arthroplasty (TKA) for treatment of osteoarthritis
involving one tibiofemoral compartment and the patellofemoral joint. Bicompartmental knee arthroplasty
preserves the anterior cruciate ligament and is associated with more favorable knee function and kinematics
than TKA.However, early failure after bicompartmental arthroplasty can develop from a number of causes
including progression of arthritis in the unreplaced tibiofemoral compartment, patellar tracking problems,
mechanical loosening, and unexplained pain.
Survivorship of bicompartmental arthroplasty is less
favorable than TKA.
18.2 Case Example
An active 61-year-old woman who had undergone successful medial right unicompartmental arthroplasty
developed medial and anterior left knee pain which
restricted her activity. She had undergone prior left knee
ACL reconstruction. Exam of the left knee demonstrated tenderness over the medial joint line and pain on
patellar compression. The knee was stable to anterior
draw and varus/valgus stress. Radiographs demonstrated good overall limb alignment and medial compartment joint space narrowing (. Fig. 18.1a, b).
Patellar views also demonstrated arthritic changes
(. Fig. 18.1c). TKA was recommended since the
arthritic involvement included both medial and patellofemoral compartments, and the patient had prior ACL
reconstruction. However, the patient requested a partial
knee replacement based on the favorable experience she
had with right knee medial UKA and preservation of
the right knee ACL.
Medial bicompartmental knee arthroplasty was per-
formed using a monolithic one-piece femoral component
(Duece, Smith and Nephew, Memphis, TN) (.
Fig.18.2).
At 2years after surgery, range of motion was 0–135° in
both knees. The patient had no knee pain and resumed
all routine and recreational activities. She considered the
clinical result of both knees to be equivalent.
a
b
c
. Fig. 18.1 a Long-standing alignment radiograph demonstrates
medial right UKA, mild left knee medial joint space narrowing, and
minimal coronal deformity. b Lateral left knee radiograph demonstrates prior ACL hardware and minimal deformity. c Axial radiographic views demonstrate patellofemoral arthritis of the left knee
partmental arthroplasty) or combined lateral
tibiofemoral unicompartmentaland patellofemoral
arthroplasty (lateral bicompartmental arthroplasty)
(Garner et al.
2019).Replacement of both medial and
lateral tibiofemoral compartments with two independent tibiofemoral unicompartmental arthroplasties
could also be considered “bicompartmental arthroplasty”, but has been termed bi-unicondylar arthroplasty (Bi-UKA) (Garner etal. 2019).
18.3 Classication
Bicompartmental knee arthroplasty is a term used to
describe combined medial tibiofemoral unicompartmental and patellofemoral arthroplasty (medial bicom-
> Since combined medial and patellofemoral OA is
more common than combined lateral and patellofemoral OA, most bicompartmental arthroplasties
replace the medial tibiofemoral and patellofemoral
compartments, while preserving the lateral tibiofemoral compartment and anterior cruciate ligament.
Bicompartmental Knee Arthroplasty
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a
201
b
18
c
. Fig. 18.2 a Long alignment radiograph after medial bicompartmen-
tal left knee arthroplasty. b Lateral radiograph after medial bicompart-
mental arthroplasty with monolithic femoral component. c Axial
radiographic views demonstrate patellofemoral replacement of left knee
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M. D. Ries
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18.4 Indications
Bicompartmental arthroplasty is an alternative to total
knee arthroplasty.It is indicated to treat medial or lateral
OA combined with patellofemoral OA in which patellofemoral OA is considered severe enough that medial
or lateral unicompartmental arthroplasty (UKA) is not
a viable option.
> The ACL should be intact and the knee should be
minimally deformed in terms of exion contracture
and coronal alignment.
The non-replaced tibiofemoral compartment should be
well preserved without arthritic changes.
18.5 Implant Options andSurgical
Technique
> Femoral implant options for bicompartmental
arthroplasty include a one-piece “off-the-shelf” femoral component, a one-piece custom femoral component, and two-piece separate conventional femoral
unicompartmental and patellofemoral implants
(Rolston et al. 2007; Rolston 2009; Palumbo et al.
2011; Tria Jr. 2013; Arnholdt et al. 2018; Steinert
etal. 2017; Tamam etal. 2015; Biazzo etal. 2019; Yeo
etal. 2015; Kanna 2017; Kamath etal. 2014).
. Fig. 18.3 The medial tibial plateau resection is made with extra-
medullary alignment used in UKA.Then the exion and extension
gaps are checked using spacer blocks at 0 and 90° of exion. (Reproduced with permission from Smith and Nephew, Memphis, TN)
18
The tibial component consists of a conventional unicompartmental implant and the patella is either unresurfaced or resurfaced with a conventional TKA patellar
component.
> The surgical technique for bicompartmental arthro-
plasty depends on the type of femoral component
used.
For a one-piece off-the-shelf femoral component, the
technique is based on a tibial cut rst to assess the exion and extension gaps prior to making the femoral
bone cuts (. Fig. 18.3). The femoral AP position is
based on an anterior referencing technique (. Fig.18.4).
The medial distal femoral condylar resection is based on
a measured resection technique (. Fig. 18.5). The AP
femoral cut block determines the amount of posterior
medial condylar resection (. Fig.18.6).
If the exion and extension gaps are asymmetric, the
gaps are balanced by upsizing or downsizing the femoral
component. The chamfer cuts and transition cut at the
junction of the intact lateral cartilage surface and femoral component are made through the femoral AP block
to complete the femoral preparation (. Fig.18.7). The
. Fig. 18.4 The femoral anterior cut block is positioned using an
intramedullary alignment rod and rotational position based on the
AP axis of the trochlear groove. (Reproduced with permission from
Smith and Nephew, Memphis, TN)
location of the femoral trochlear groove is determined
by the mediolateral position of the femoral component.
For one-piece custom component, patient-specic
instruments are used based on a pre-op CT scan and
measured resection technique (Arnholdt et al. 2018;
Steinert et al. 2017). For two-piece nonlinked femoral
unicompartmental and patellofemoral implants, each
compartment is replaced independently using techniques specic to the tibiofemoral unicompartmental
and patellofemoral implants selected. These include gap
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203
balancing, measured resection, patient-specic instrumentation, navigation, and robotics (Tamam etal. 2015;
Biazzo etal. 2019; Yeo etal. 2015; Kanna 2017; Kamath
etal. 2014).
The two independent femoral components of a mod-
ular bicompartmental knee arthroplasty can be identied on a lateral radiograph (. Fig.18.8).Revision to a
TKA may require stems and augments (. Fig.18.9).
18
. Fig. 18.5 The medial distal condylar resection is based on a mea-
sured resection technique so that the thickness of the femoral component matches the thickness of the resected distal femoral condyle.
(Reproduced with permission from Smith and Nephew, Memphis,
TN)
a b
. Fig. 18.6 The posterior medial condylar resection is determined
by the size of the AP cutting block. (Reproduced with permission
from Smith and Nephew, Memphis, TN)
. Fig. 18.7 a The chamfer cuts and transition cut at the junction
of the intact lateral cartilage are made through the AP block to complete the femoral bone cuts. (Reproduced with permission from
Smith and Nephew, Memphis, TN). b The measured distal reception
technique is intended to provide a smooth transition between the
femoral component articular surface and intact lateral cartilage
204
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M. D. Ries
ab
18
. Fig. 18.8 a A 63-year-old male 4years after modular bicompart-
mental knee arthroplasty developed pain limiting activity. AP radiograph demonstrates the progression of arthritis into the lateral
tibiofemoral compartment. b Lateral radiograph shows that the two-
18.6 Results
The clinical outcome of partial and total knee arthroplasties can be assessed in terms of functional results
and durability. Function is usually measured using knee
scoring systems (e.g., Knee Society Score, KOOS Jr)
while durability is represented by implant survivorship
studies. Comparisons of unicompartmental and total
knee arthroplasty have generally demonstrated equivalent or more favorable function after UKA, but better
durability after TKA (Wilson et al. 2019).More favorable function after partial knee replacement in comparison to total knee replacement has been attributed to the
preservation of the ACL.
> Meta-analyses of prior studies comparing bicompart-
mental and TKA have found more favorable knee
part modular femoral component results in four independently
cemented components (trochlear femoral component, medial femoral component, medial tibial component, and patellar component)
function scores and range of motion after bicompartmental compared to TKA, but more complications
and less survivorship than TKA (Amit etal. 2020; Ma
etal. 2017) (.
Tabl e 18.1).
More favorable knee function after partial knee
replacement in comparison to total knee replacement
has been attributed to preservation of the ACL.Bicompartmental arthroplasty is also associated with better
comfort during everyday activities than TKA (Parratte
etal. 2015a).
> Comparative uoroscopic invivo kinematics appear
more normal after bicompartmental knee arthro-
plasty than TKA which is consistent with the pro-
prioception and stability provided by an intact ACL
(Park etal. 2015; Lefer etal. 2012).
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18
. Fig. 18.9 a The patient was treated with revision TKA. AP
radiograph demonstrates revision of the femoral and tibial components with a medial tibial augment and stemmed implants to accom-
> However, an unacceptably high revision rate after
bicompartmental knee arthroplasty using a monolithic design has been identied (Kooner etal. 2017;
Dudhniwala etal. 2016; Morrison etal. 2011).
The reasons for the failure of monolithic designs are
not clear, but may be related to the link between the formal condylar and trochlear parts of the implant which
restricts independent positioning and sizing of the tibiofemoral and patellofemoral components. Modular
bicompartmental knee arthroplasty requires implantation of four independent components (medial or lateral
femoral, trochlear femoral, patellar, and tibial components), each of which may result in mechanical failure.
modate bone loss. b Lateral radiograph demonstrates revision of the
bicompartmental arthroplasty with retention of the original patellar
component
Long-term studies with modular two-piece designs have
also demonstrated less favorable survivorship than TKA
(Parratte etal. 2010, 2015b).
> The relatively high failure and complication rate after
modular bicompartmental knee arthroplasty has
been attributed to the technical difculty of the procedure, use of mechanical instrumentation, and various implant design factors (Parratte etal. 2010).
Use of more modern techniques such as robotics,
navigation, and custom implants may mitigate the risk
of mechanical failure.
18
M. D. Ries
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206
. Table 18.1 Published results of bicompartmental knee
arthroplasty
Publication
Amit
etal.
2020)
(
Ma etal.
(
2017)
Parratte
etal.
(
2015a)
Park
etal.
2015)
(
Lefer
etal.
(2012)
Kooner
etal.
2017)
(
Dudhniwala
etal.
(2016)
Morrison etal.
(
2011)
Parratte
etal.
2010)
(
Parratte
etal.
2015b)
(
TKA total knee arthroplasty, BKA bicompartmental knee
arthroplasty, UKA unicompartmental knee arthroplasty
Methods Number of
Patients
Systematic
review
Metaanalysis
Comparative
cohort
study
Kinematic
uoroscopic
Kinematic
gait
analysis
Systematic
review
Retrospective
review
Comparative
cohort
Retrospective
review
Review
article
9 studies,
331 patients
(341 knees)
5 studies,
261 patients
34 BKA, 34
TKA
10 BKA BKA motion
10 BKA BKA kinematics
6 studies,
274 patients
(277 knees)
15 BKA BKA revision rate of
21 BKA, 33
TKA
71 patients,
(77 medial
UKA/PFJ
knees)
5325 medial
UKA, 408
lateral
UKA, 107
BKA
Results
BKA comparable
function to TKA, but
poor long-term
survivorship
BKA has better knee
function and life
quality, but higher
complication rate
than TKA
BKA greater
forgotten knee score
and functional
outcomes than TKA
patterns consistent
with retained ACL
function
similar to contralateral normal knee
No signicant
differences in knee
function, length of
stay, complication
rate, or revision rate
between BKA and
TKA
60% at follow-up of
54months
BKA had higher
complication rate
than TKA
BKA survivorship at
17years 54%
BKA less favorable
survivorship than
UKA
Conclusion
z
Bicompartmental knee arthroplasty may offer more
favorable knee function than TKA as a result of preservation of the ACL and the non-arthritic tibiofemoral
compartment. However, the limited durability of bicompartmental knee arthroplasty in comparison to TKA
and risk of mechanical failure may not outweigh the
potential benet of better knee function than TKA.
Take-Home Messages
5 Bicompartmental knee arthroplasty is an alterna-
tive to TKA when arthritis is limited to either the
medial or lateral tibiofemoral compartment and
the patellofemoral joint.
5 Bicompartmental knee arthroplasty retains the
ACL. Kinematics and knee function have been
found to be more favorable after bicompartmental
knee arthroplasty than TKA.
5 A high rate of failure of bicompartmental knee
arthroplasty has been reported at mid-term fol-
up.
low-
5 Monolithic (one-piece) bicompartmental femoral
component designs are associated with a higher
failure rate than modular (two-part) trochlear and
femoral condylar component designs.
5 The limited durability of bicompartmental knee
arthroplasty in comparison to TKA may not outweigh the potential benet of ACL retention and
better knee function than TKA.
References
Amit P, Singh N, Soni A, Bowman NK, Maden M (2020) Systematic
review of modular bicompartmental knee arthroplasty for
Medio-patellofemoral osteoarthritis. J Arthroplast 35:893–899
Arnholdt J, Kamawal Y, Holzapfel BM, Ripp A, Rudert M, Steinert
AF (2018) Evaluation of implant t and frontal plane alignment
after bi-compartmental knee arthroplasty using patient-specic
instruments and implants. Arch Med Sci 14:1424–1431
Biazzo A, Silvestrini F, Manzotti A, Confalonieri N (2019)
Bicompartmental (uni plus patellofemoral) versus total knee
arthroplasty: a match-paired study. Musculoskelet Surg 103:63–
68
Dudhniwala AG, Rath NK, Joshy S, Forster MC, White SP (2016)
Early failure with the Journey-Deuce bicompartmental knee
arthroplasty. Eur J Orthop Surg Traumatol 26:517–521
Garner A, van Arkel RJ, Cobb J (2019) Classication of combined
partial knee arthroplasty. Bone Joint J 101-B:922–928
Kamath AF, Levack A, John T, Thomas BS, Lonner JH (2014)
Minimum two-year outcomes of modular bicompartmental
knee arthroplasty. J Arthroplast 29:75–79
Bicompartmental Knee Arthroplasty
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207
18
Kanna R (2017) Modular bicompartmental knee arthroplasty: indi-
cations, technique, prosthetic design, and results. Acta Orthop
Belg 83:124–131
Kooner S, Johal H, Clark M (2017) Bicompartmental knee arthro-
plasty vs total knee arthroplasty for the treatment of medial
compartment and patellofemoral osteoarthritis. Arthroplasty
Today 29:309–314
Lefer J, Scheys L, Planté-Bordeneuve T, Callewaert B, Labey L,
Bellemans J, Franz A (2012) Joint kinematics following bicompartmental knee replacement during daily life motor tasks.
Gait Posture 36:454–460
Ma JX, He WW, Kuang MJ, Sun L, Lu B, Wang Y, Ma XL (2017)
Efcacy of bicompartmental knee arthroplasty (BKA) for
bicompartmental knee osteoarthritis: a metaanalysis. Int J Surg
46:53–60
Morrison TA, Nyce JD, Macaulay WB, Geller JA (2011) Early
adverse results with bicompartmental knee arthroplasty: a prospective cohort comparison to total knee arthroplasty. J
Arthroplast 26(6 Suppl):35–39
Palumbo BT, Henderson ER, Edwards PK, Burris RB, Gutiérrez S,
Raterman SJ (2011) Initial experience of the Journey-Deuce
bicompartmental knee prosthesis: are view of 36 cases. J
Arthroplast 26(6 Suppl):40–45
Park BH, Lefer J, Franz A, Dunbar NJ, Banks SA (2015) Kinematics
of mono block bicompartmental knee arthroplasty during
weight-bearing activities. Knee Surg Sports Traumatol Arthrosc
23:1756–1762
Parratte S, Pauly V, Aubaniac JM, Argenson JN (2010) Survival of
bicompartmental knee arthroplasty at 5 to 23 years. Clin Orthop
Relat Res 468:64–72
Parratte S, Ollivier M, Opsomer G, Lunebourg A, Argenson JN,
Thienpont E (2015a) Iskneefunctionbetterwithcontemporarymodularbicompartmentalarthroplastycomparedto total knee
arthroplasty? Short-term outcomes of a prospective matched
study including 68 cases. Orthop Traumatol Surg Res 101:547–
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Parratte S, Ollivier M, Lunebourg A, Abdel MP, Argenson JN
(2015b) Long-term results of compartmental arthroplasties of
the knee: long term results of partial knee arthroplasty. Bone
Joint J 97-B(10 Suppl A):9–15
Rolston L (2009) Bicompartmental knee arthroplasty using a mono-
lithic implant design. Sem Arthroplasty 20:161–163
Rolston L, Bresch J, Engh G, Franz A, Kreuzer S, Nadaud M, Puri
L, Wood D (2007) Bicompartmental knee arthroplasty: a bone-
sparing, ligament-sparing, and minimally invasive alternative for
active patients. Orthopedics 30(8 Suppl):70–73
Steinert AF, Beckmann J, Holzapfel BM, Rudert M, Arnholdt J
(2017) Bicompartmental individualized knee replacement : use
of patient-specic implants and instruments (iDuo™). Oper
Orthop Traumatol 29:51–58
Tamam C, Plate JF, Augart M, Poehling GG, Jinnah RH (2015) Ret-
rospective clinical and radiological outcomes after robotic
assisted bicompartmental knee arthroplasty. Adv Orthop
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Tria AJ Jr (2013) Bicompartmental knee arthroplasty: the clinical
outcomes. Orthop Clin North Am 44:281–286
Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson
WF, Bottomley N, Hopewell S, Price AJ (2019) Patient relevant
outcomes of unicompartmental versus total knee replacement:
systematic review and meta-analysis. BMJ 364:l352
Yeo NE, Chen JY, Yew A, Chia SL, Lo NN, Yeo SJ (2015) Prospec-
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Total Knee Arthroplasty
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AlexLencioni andCraigA.Hogan
Contents
19.1 Introduction – 210
19.2 Case Example – 210
19.3 Surgical Technique – 210
19.4 Gap Balancing Versus Measured Resection – 213
19.4.1 Gap Balancing – 213
19.4.2
Measured Resection – 215
Comparison ofOutcomes – 216
19.4.3
19.5 Mechanical Versus Kinematic Alignment – 216
19.5.1 Mechanical Alignment – 216
19.5.2 Kinematic Alignment – 216
19.5.3 Comparison ofOutcomes – 216
209
19
19.6 Unicompartmental, Bicompartmental,
andTricompartmental Knee Arthroplasty – 217
References – 218
© 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_19
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