R E S E A R C H A R T I C L E Open Access
Outcomes and early revision rate after
medial unicompartmental knee
arthroplasty: prospective results from a
non-designer single surgeon
Jonathan R. B. Hutt
, Avtar Sur
, Hartej Sur
, Aine Ringrose
and Mark S. Rickman
Background: This prospective study evaluates outcomes and reoperation rates for unicompartmental knee
arthroplasty (UKA) from a single non-designer surgeon using relatively extended criteria of degenerative changes of
grade 2 or above in either or both non-operated compartments.
Methods: 187 consecutive medial mobile bearing UKA implants were included after history, clinical assessment and
radiological evaluation. 91 patients had extended clinical outcomes. Post-operative assessment included functional
scoring with the Oxford Knee Score (OKS) and radiographic review. Survivorship curves were constructed using the
life-table method, with 95% confidence intervals calculated using Rothman’s equation. Separate endpoints were
examined: revision for any reason and revision for confirmed loosening.
Results: The mean follow-up was 3.5 years. The pre-operative OKS improved from a mean of 21.2 to 38.9 (Mann-
Whitney U Test, p = < 0.001). Twelve Patients required further operations including 9 revisions. No patients developed
deep infection and no surviving implants were loose radiographically. Survivorship at 7 years with endpoints of re-
operation, revision and aseptic loosening at surgery or radiographically was 88.4% (95% CI 79.6–93.7), 93.1% (95% CI 85.
5–96.9) and 97.3% (95% CI 91.2–99.2) respectively. The presence of pre-operative mild contralateral tibiofemoral or any
extent of patellofemoral joint degeneration was of no consequence.
Discussion: The indications for UKA are being expanded to include patients with greater deformity, more advanced
disease in the patellofemoral joint and even certain features in the lateral compartment indicative of an anteromedial
pattern of osteoarthritis (OA). However, much of the supporting literature remains available only from designer centres.
This study represents a group of patients with what we believe to be wider indications, along with decisions to treat
made on clinical grounds and radiographs alone.
Conclusion: This study shows comparable clinical outcomes of UKA for extended indications from a high volume,
high-usage non-designer unit.
Keywords: Unicompartmental, Arthroplasty, Outcomes, Survivorship, Indications
* Correspondence: email@example.com
Department of Trauma and Orthopaedics, St George’s University Hospitals
NHS Foundation Trust, London, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribut ion 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hutt et al. BMC Musculoskeletal Disorders (2018) 19:172
The Oxford unicompartmental knee arthroplasty (UKA)
(Biomet, Warsaw, Indiana) is a well-established implant
and reports from the designer centre demonstrate good
results for the medial UKA out into the second decade
 and into the midterm for its lateral counterpart .
Whilst the initial indications were relatively narrow, in-
creased experience has led to an expansion of potential
inclusion criteria, particularly with regard to the level of
deformity and disease presence elsewhere in the knee
[3–5]. The performance of the Oxford UKA in the wider
orthopaedic community has been variable, with units
reporting conflicting results, some equally favourable
[6–10], and others less so [11–14]. Much of the concern
regarding UKA in general has come from the analysis of
registry data. The Australian, the New Zealand and the
UK implant registries all report higher revision rates for
unicompartmental prostheses [15–17]. There is a debate
as to what registry data can reveal about the success of
an implant or technique, and analysis of published litera-
ture on the subject will be biased by numerous reports
from the designing centre [18–20]. As such, reports
from surgeons independent of such centres add valuable
information on outcomes from the use of implants by
the wider orthopaedic community.
Between 2005 and 2013, the senior author implanted
187 consecutive UKAs in 173 patients, a caseload of 23
per year. During the same period, the senior author per-
formed 604 TKAs, and 12 lateral UKAs. 14 bilateral
UKA procedures were performed sequentially. This cor-
responds to a usage of 30% in keeping with recommen-
dations that 30% of a surgeon’s total knee arthroplasties
should be UKAs to achieve optimum results [7,21,22].
The aim of this study was to prospectively evaluate the
early outcomes and revision rate from a single high vol-
ume non-designer practice of unicompartmental knee
replacement as well as the effect of using relatively ex-
tended criteria with regards to other compartments in
Patients presenting to the senior author with symptom-
atic knee arthritis are evaluated for their suitability for
UKA as follows: The history and clinical examination fo-
cuses on presence of isolated unicompartmental knee
pain severe enough to justify joint replacement and an-
terior cruciate ligament (ACL) integrity. Clinical evi-
dence of sagittal instability and the presence of
inflammatory disease remain absolute contraindications
to UKA. Maximum acceptable pre-operative deformity
is 15 degrees of varus that is correctable to neutral and
10 degrees of fixed flexion. No patients have been re-
fused UKA based on BMI. Radiographic evaluation is
with standing AP and Rosenberg views along with
standard lateral and skyline views. The presence of
bone-on-bone contact was considered an indication to
proceed with UKA. Stress radiographs and MRI scans
are not used. Evidence of mild disease of the contralat-
eral compartment, for example marginal osteophytes, is
not considered a contra-indication in the setting of min-
imal joint space narrowing. Degeneration of the patello-
femoral joint (PFJ) is considered irrelevant unless pain is
wholly anterior, and specifically worse on stairs than
with simple walking. No arthroscopic examinations are
performed solely to evaluate the knee for
decision-making purposes. For this study, both the patel-
lofemoral and contralateral tibiofemoral compartment
were evaluated on pre-operative radiographs according
to the Kellgren-Lawrence grading. We considered pa-
tients with evidence of degenerative change of grade 2
or above in either or both non-operated compartments
to have relatively extended indications for UKA. At sur-
gery, ACL integrity is assessed clinically with examin-
ation under anaesthesia (EUA) and direct inspection and
the lateral compartment is also directly inspected. Intra-
operative findings of patellofemoral joint degeneration,
whatever the severity, are not considered a contraindica-
tion to UKA. Within the time frame of the study, no pa-
tients were converted to TKR based on concerns with
ACL integrity at operation. Three patients scheduled for
a UKA received a TKA due to significant lateral disease
that was not identified on pre-operative radiographs.
Surgical technique was per manufacturer guidelines
using a tourniquet and thigh support with free draping
of the limb using the described minimally invasive ap-
proach . All patients underwent a standardized
post-operative recovery physiotherapy programme of im-
mediate full weight bearing, range of motion and
strengthening exercises without restrictions.
Post-operative review was at 6 weeks, 6 months and
then annually, including functional scoring with the Ox-
ford Knee Score (OKS) and radiographs with standard
AP standing and lateral views. All patients were followed
prospectively and reviewed by independent examiners.
For this study, patients undergoing combined UKA and
ACL reconstruction have been excluded.
Data was tested for normality using D’Agostino’sK
Pre-and post-operative OKS were thus compared using
the Mann-Whitney U-test with significance set at p<
0.05. Correlations for age and BMI used Spearman’s rank
test. Complication rates for extended indications were
compared using Fisher’s exact test. Survivorship curves
were constructed using the life-table method, with 95%
confidence intervals calculated using Rothman’s equa-
tion [24,25]. Separate endpoints were examined: revi-
sion for any reason and revision for confirmed
Hutt et al. BMC Musculoskeletal Disorders (2018) 19:172 Page 2 of 6
loosening. Patients who died or were lost to follow-up
were treated as censored data.
All procedures performed in studies involving human
participants were in accordance with the ethical standards
of the Clinical Research Facility of St George’s Hospital.
All patients provided written informed consent to their
data being part of this study as part of their surgical consent.
Between 2005 and 2013, the senior author implanted
187 consecutive UKAs in 173 patients. During the same
period, the senior author performed 604 TKAs, and 12
lateral UKAs. 14 bilateral UKA procedures were per-
formed sequentially. Patient demographics are shown in
Table 1. The mean overall follow-up was 3.5 years. 5 pa-
tients died from unrelated causes, all with
well-functioning implants. 7 patients (3.7%) were lost to
follow-up and proved untraceable. 2 had data at
6 months, whilst 5 had no follow-up data available. The
pre-operative OKS improved from a mean of 21.2 to
38.9 (Fig. 1, p = < 0.001). There was no correlation be-
tween the post-op OKS and either age (p= 0.88) or BMI
Twelve patients required 13 further operations. Two
required bearing revision after dislocation within
6 months. One of these was later revised at 7 yrs. for
progression of osteoarthritis (OA) in the lateral compart-
ment, whilst the other had no further problems. Four
patients had revision to total knee arthroplasty (TKA)
for pain alone, without evidence of component loosening
at surgery. Three patients had revision for femoral com-
ponent loosening, all with single peg components. Two
were converted to TKA and 1 had a revision of the UKA
femoral component alone to a twin peg design. One pa-
tient was revised to a TKA for progression of arthritis
following multiple haemarthroses for a familial bleeding
disorder. Two further patients had additional lateral
compartment and patellofemoral arthroplasty respect-
ively without revision of the original UKA. No patients
developed deep infection and no surviving implants were
Survivorship at 7 years with endpoints of re-operation,
revision and aseptic loosening at surgery or radiograph-
ically was 88.1% (95% CI 79.1–93.5), 92.9% (95% CI
85.1–96.8) and 97.3% (95% CI 90.9–99.2) respectively.
All revisions were included for the re-operation end-
point. Only operations where the UKA implant was re-
moved or replaced were included for the revision
endpoint. The full survivorship curves and confidence
intervals for the three outcomes are shown in Fig. 2a-c.
The complete life tables for each outcome including
confidence intervals and effective number at risk each
year are provided in Additional file 1.
Effect of degeneration in other compartments
96 patients (51%) had no pre-operative extended indica-
tions, compared with 91 (49%) who did. The outcomes
for patients with extended indications in various combi-
nations are set out in Table 2. The extended indications
group had a significantly higher OKS (p= 0.01), a differ-
ence which remained significant for any case with PFJ de-
generation (p = 0.01) or with isolated PFJ degeneration (p
= 0.05). However, as the differences are less than 5 points,
an accepted minimally important clinical difference for
the OKS, this may not translate into clinical significance.
No other comparisons reached statistical significance; im-
portantly, patients without extended indications did not
demonstrate superior post-operative outcomes when com-
pared with any subgroups of patients with extended indi-
cations including those with a PFJ grade of 3 or 4 (p=
0.15). Only one patient with extended indications had a
revision to a TKA for arthritis progression –this was the
patient with a familial bleeding disorder. Overall, patients
with extended indications had significantly lower rates of
re-operation and revision (p=0.003).
The indications for UKA are being expanded to include
patients with greater deformity, more advanced disease
in the patellofemoral joint and even certain features in
the lateral compartment indicative of an anteromedial
pattern of OA [3–5]. However, much of the supporting
literature remains available only from designer centres.
Table 1 Cohort Demographics
Mean BMI, Range 29.7 (17.9–45.1)
Mean Age at Surgery / Years, Range 64.2 (49–84)
Mean Follow-up / Years, Range 3.6 (0.5–8)
Fig. 1 Pre-and post-operative OKS
Hutt et al. BMC Musculoskeletal Disorders (2018) 19:172 Page 3 of 6
This study represents a group of patients with what we
believe to be wider indications, along with decisions to
treat made on clinical grounds and radiographs alone.
Only very rarely was the procedure changed based on
The senior author implanted 187 consecutive UKAs in
173 patients, a caseload of 23 per year. During the same
period, the senior author performed 604 TKAs, and 12
lateral UKAs. 14 bilateral UKA procedures were per-
formed sequentially. This corresponds to a usage of 30%
in keeping with recommendations that 30% of a sur-
geon’s total knee arthroplasties should be UKAs to
achieve optimum results Despite the broad criteria and
the fact that the senior author receives patients from
other consultants in the hospital for consideration of
UKA, the ratio of UKA:TKA for patients presenting with
symptomatic knee arthrosis in the period of this study
was approximately 1:3.
Nine UKA implants have been revised so far, and we
are not aware of any currently at risk. Four revisions
were for unexplained but persistent medial pain. All
were uncomplicated revisions to a TKA using simple
primary implants and no obvious cause for pain was
identified in any case. Whilst 3 patients have gone on to
a reasonable result, one continues to have unexplained
pain. None of these patients had extended indications as
we have defined. Three femoral components were re-
vised for aseptic loosening. All were of the single peg de-
sign, which has been noted in the past to be associated
with an incidence of early loosening . One was re-
vised to a twin peg design and continues to function well
(recent OKS 47), whilst the other 2 cases were revised to
total knee arthroplasty, with satisfactory outcomes. Dur-
ing this series of patients, the twin-peg design for the
femoral component became available. Within the litera-
ture there are no reports of femoral loosening issues for
this iteration. Similarly, there were no failures of the
twin peg femoral component in this series. It is possible
therefore that these 3 revisions could have been avoided
with the use of the newer design implants.
There were 2 bearing dislocations; one undoubtedly due
to surgical error, with residual cement at the back of the tib-
ial component leading to anterior dislocation in full flexion.
At revision, an identical bearing was replaced after removal
Table 2 Outcomes for Extended Indications
Re-operation, Revision or
96 37.6 12
91 40.3 1
grade > 2
93 40.2 0
grade > 2
27 40.8 0
grade > 2
64 40.1 0
grade > 2
3 44.0 1
PFJ Grade III/IV 39 39.5 0
Fig. 2 aSurvivorship curve with 95% Confidence Intervals for Re-
operation. bSurvivorship curve with 95% Confidence Intervals for
Revision. cSurvivorship curve with 95% Confidence Intervals for
Hutt et al. BMC Musculoskeletal Disorders (2018) 19:172 Page 4 of 6
of the errant cement. The second dislocation occurred for
no clear reason and was revised to a bearing 1 mm thicker;
this patient is currently functioning extremely well (2-year
OKS 48). The dislocation rate of 1% is in line with other
published rates in the literature and remains a potential
complication of any mobile bearing UKA design.
Two cases went on to have further compartments re-
placed –one patellofemoral at 40 months and one lat-
eral at 32 months after UKA. If anything, this represents
a failure of patient selection, necessitating a further op-
eration a moderate time after the primary surgery with a
rate of 1%. Patient selection and indeed implant selec-
tion in any orthopaedic surgery is complex and often dif-
ficult, and no selection process will be perfect. By
narrowing the inclusion criteria for UKA this 1% failure
rate could be lowered, but perhaps not eradicated due to
natural variances. There were no deep infections in this
series, and this is consistent with other reports of low in-
fection rates for UKA in comparison with TKA [27–29].
For any new orthopaedic implant, favourable results
would be expected from developing centres, and whilst
it might be rational to assume that similar outcomes will
not be achieved by the wider surgical community, our
series forms part of a growing number of independent
reports of good results and favourable revision rates [6,
7,9,10]. There are also reports from other units with
less success [11–14], but the main contrast comes from
concerns raised primarily by registry data . Inevitably
the performance of an implant is dependent on the tech-
nique used to implant it, and studies have demonstrated
the effect of a significant learning curve for UKA [31–
34] with some authors advocating minimum numbers to
be undertaken in order to maintain competence .
Strengths of the study that should be noted are the
series does not include the learning curve of the senior
author, with more than 50 procedures being carried out
as a registrar and fellow, but all cases carried out as a
consultant are included with a usage of 30% as recom-
mended for optimal results.
Limitations include the difficulty to quantify the effect
of a single surgeon’s ability to master a new technique.
Undoubtedly many surgeons never get over this learning
curve before abandoning the technique in favour of ei-
ther osteotomy or total knee arthroplasty, which will
affect global outcomes. Ultimately, the fate of UKA may
depend on whether there is any clinical benefit for the
patients. Level one evidence on this issue is on the way
In conclusion, we have shown comparable clinical out-
comes and survivorship of the medial Oxford UKA
when used with wider indications in a large cohort of
patients. Our all cause revision survivorship rate of 93%
at 7 years is similar to figures reported from systematic
reviews of registry data which show an all cause revision
rate for total knee replacement of 6% at 5 years and 12%
at 10 years . In addition, the use of extended indica-
tions in this series has not had a detrimental effect on
post-operative outcomes or re-operation or revision
rates. We believe this data justifies the continued use of
UKA at our institution within our current indications
and serves to highlight the importance of practice ana-
lysis by individual surgeons of techniques that might be
controversial in the wider orthopaedic literature.
Additional file 1: Outcome life tables. (TIFF 3853 kb)
No funding was received for this study.
Availability of data and materials
The datasets generated and/or analysed during the current study are
available in the figshare repository, https://figshare.com/s/
JH was involved in data analysis and drafting the manuscript. AR and HS
were involved in data acquisition. AS was involved in data acquisition and
preparation for submission. MR was the operating surgeon and was involved
in the acquisition and interpretation of the data. All authors read and
approved the final manuscript.
Ethics approval and consent to participate
As the manuscript contains outcome data collected as part of standard
routine care, the ethics department at St George’s Hospital determined that
formal ethics approval was not required. However, all procedures performed
in studies involving human participants were in accordance with the ethical
standards of the Clinical Research Facility of St George’s Hospital. All patients
provided written informed consent to their data being part of this study as
part of their surgical consent.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Department of Trauma and Orthopaedics, St George’s University Hospitals
NHS Foundation Trust, London, UK.
Department of Orthopaedics and
Trauma, The University of Adelaide and Royal Adelaide Hospital, Adelaide,
Received: 15 July 2017 Accepted: 17 May 2018
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