Abstract
Symptomatic osteoarthritis (OA) of the knee develops often in association with anterior cruciate ligament (ACL) deficiency. Two distinct pathologies should be recognised while considering treatment options in patients with end-stage medial compartment OA and ACL deficiency. Patients with primary ACL deficiency (usually traumatic ACL rupture) can develop secondary OA (typically presenting with symptoms of instability and pain) and these patients are typically young and active. Patients with primary end stage medial compartment OA can develop secondary ACL deficiency (usually degenerate ACL rupture) and these patients tend to be older. Treatment options in either of these patient groups include arthroscopic debridement, reconstruction of the ACL, high tibial osteotomy (HTO) with or without ACL reconstruction, unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). General opinion is that a functionally intact ACL is a fundamental prerequisite to perform a UKA. This is because previous reports showed higher failure rates when ACL was deficient, probably secondary to wear and tibial loosening. Nevertheless in some cases of ACL deficiency with end-stage medial compartment OA, UKA has been performed in isolation and recent papers confirm good short- to mid-term outcome without increased risk of implant failure. Shorter hospital stay, fewer blood transfusions, faster recovery and significantly lower risk of developing major complications like death, myocardial infarction, stroke, deep vein thrombosis (as compared to TKA) make the UKA an attractive option, especially in the older patients. On the other hand, younger patients with higher functional demands are likely to benefit from a simultaneous or staged ACL reconstruction in addition to UKA to regain knee stability. These procedures tend to be technically demanding. The main aim of this review was to provide a synopsis of the existing literature and outline an evidence-based treatment algorithm.
Highlights
Few rules are known in medicine, but one of these assumes that unicompartmental knee arthroplasty (UKA) for medial osteoarthritis (MOA) is contraindicated if anterior cruciate ligament (ACL) is functionally deficient.This has been generally accepted since the first reports highlighted a higher incidence of complications, in terms of tibial loosening and higher revision rate, when UKA were performed in ACL-deficient knees [9, 11].Primary MOA in an ACL-intact knee usually involves the antero-medial aspect of the inner compartment and is called antero-medial osteoarthritis
In some cases of ACL deficiency with end-stage medial compartment OA, UKA has been performed in isolation and recent papers confirm good short- to mid-term outcome without increased risk of implant failure
The kinematics of the ACL-deficient knees seemed to be more physiological than data reported for total knee arthroplasty (TKA), but not as close to healthy knees as ACL-reconstructed UKA knees
Summary
Few rules are known in medicine, but one of these assumes that unicompartmental knee arthroplasty (UKA) for medial osteoarthritis (MOA) is contraindicated if anterior cruciate ligament (ACL) is functionally deficient.This has been generally accepted since the first reports highlighted a higher incidence of complications, in terms of tibial loosening and higher revision rate, when UKA were performed in ACL-deficient knees [9, 11].Primary MOA in an ACL-intact knee usually involves the antero-medial aspect of the inner compartment and is called antero-medial osteoarthritis. The preserved postero-medial compartment maintains a functional medial collateral ligament (MCL) [25] as every time the knee flexes, the femur rides out of the tibial defect allowing the MCL to regain its normal length. J Orthopaed Traumatol (2016) 17:267–275 wear patch on the medial tibial plateau extends posteriorly, the ACL progressively becomes damaged, typically from notch osteophytes, and eventually ruptures. These patients typically exhibit a more extensive wear pattern involving the posterior aspect of the medial compartment [27]. Every time the patient moves his/her knee, the femur rides free of the defect and corrects the varus deformity, thereby maintaining the normal length and functionality of the MCL
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