Patient reported satisfaction KOS-ADLS after Bilateral Simultaneous Unicondylar Knee Replacement compared to Total Knee Replacement in patients with early medial compartment arthritis; A Randomized Study Gp Capt V Kulshrestha, Wg Cdr Santhosh Kumar, Col B Datta Lt Col Gaurav Mittal Joint Replacement Centre, Army Hospital Research & Referral Gp Capt V Kulshrestha, Wg Cdr Santhosh Kumar, Col B Datta Lt Col Gaurav Mittal Joint Replacement Centre, Army Hospital Research & Referral

Introduction With growing surgeon and patient satisfaction younger patients opting for TKR 15 % remain dissatisfied /complication rates remain static ‘UKA’ resurgence of interest : Faster recovery, Better function, less complications However ‘steep learning curve/ more midterm failure’s Very few randomized study to show better outcomes in UKA (all in unilateral surgeries) With growing surgeon and patient satisfaction younger patients opting for TKR 15 % remain dissatisfied /complication rates remain static ‘UKA’ resurgence of interest : Faster recovery, Better function, less complications However ‘steep learning curve/ more midterm failure’s Very few randomized study to show better outcomes in UKA (all in unilateral surgeries) 1. Baker P J, JBJS Am,2013 Apr Niinimäki T, Clin Orthop Relat Res May 3. Collier MB J Arthroplasty LombardiAV Jr Clin Orthop Rlat Res.2009 Jun 5. Walton NP 2006 Apr, Jr Knee surgery

ARMY HOSPITAL RESEARCH & REFERRAL Gp Capt (Dr) Vikas Kulshrestha, MS (Orth) Col (Dr) Barun Datta, MS (Orth) Lt Col (Dr) Gaurav Mittal, MS (Orth) Gp Capt (Dr) Vikas Kulshrestha, MS (Orth) Col (Dr) Barun Datta, MS (Orth) Lt Col (Dr) Gaurav Mittal, MS (Orth)

Introduction High volume Tertiary care referral center of excellence Exclusive JRC facility Two senior Fellowships trained arthroplasty Surgeons Single arthroplasty unit with two teams performing Simultaneous Bilateral UKA / TKA in equipoise fashion Standardized institutional protocols More than 90% follow-up, being a military set up High volume Tertiary care referral center of excellence Exclusive JRC facility Two senior Fellowships trained arthroplasty Surgeons Single arthroplasty unit with two teams performing Simultaneous Bilateral UKA / TKA in equipoise fashion Standardized institutional protocols More than 90% follow-up, being a military set up

Patient recruitment 35 patients in each group Risk screening / optimization for bilateral procedure Fit patient - Informed consent for UKA or TKA (final decision as per per-op findings) / Education Randomization with sealed envelope Cross over if per-op contraindications for UKA (analyzed in same group as per ITT principle) 35 patients in each group Risk screening / optimization for bilateral procedure Fit patient - Informed consent for UKA or TKA (final decision as per per-op findings) / Education Randomization with sealed envelope Cross over if per-op contraindications for UKA (analyzed in same group as per ITT principle)

Objectives Compare patient reported outcomes (KOS-ADLS) Look at complications, LOS, ROM, readmissions revision surgery at two year. Compare patient reported outcomes (KOS-ADLS) Look at complications, LOS, ROM, readmissions revision surgery at two year. Financial Disclosures: No financial support received from any agency / company.  Ryan L. Mizner & collegues, Arthroplasty August

Inclusion criteria Bilateral Medial compartment bone on bone osteoarthritis No clinical or functional ACL laxity Radiographically normal lateral compartment / lateral PF joint Less than 15 degree and correctable varus deformity in both knee Bilateral Medial compartment bone on bone osteoarthritis No clinical or functional ACL laxity Radiographically normal lateral compartment / lateral PF joint Less than 15 degree and correctable varus deformity in both knee Exclusion criteria  More than 10 degree FFD  Fixed or More than 10 ̊varus knees or 5̊̊ valgus knees  Anterior cruciate ligament deficiency  Inflammatory / infective Bone or joint disease  Lateral Patello-femoral / lateral compartment arthritis  Inability to follow up for the study.  More than 10 degree FFD  Fixed or More than 10 ̊varus knees or 5̊̊ valgus knees  Anterior cruciate ligament deficiency  Inflammatory / infective Bone or joint disease  Lateral Patello-femoral / lateral compartment arthritis  Inability to follow up for the study.  Campbell’s operative Orthopaedics, 12th edition, chapter 7.  TOTAL KNEE ARTHROPLASTY, Richard Scott, chapter 17.

Surgical procedure Part preparation/ Reconfirmation of patient optimization DVT prophylaxis as per risk screening/ implement risk orders for systemic ailments Pre-emptive analgesia / Single shot spinal anaesthesia Inj Tranexamic acid (induction and repaeat after 3 hr) Dexamethasone for PONV and Pain control Part preparation/ Reconfirmation of patient optimization DVT prophylaxis as per risk screening/ implement risk orders for systemic ailments Pre-emptive analgesia / Single shot spinal anaesthesia Inj Tranexamic acid (induction and repaeat after 3 hr) Dexamethasone for PONV and Pain control  J Arthroplasty Dec Kulshrestha V, Kumar S. DVT prophylaxis after TKA  J Arthroplasty Sep;28, Backes JR: Dexamethasone reduces LOS and improves PONV after TKA

Salient Surgical Details Total Knee Replacement TKR : Medial Para-patellar Arthrotomy. Intramedullary guide for femur and extra medullary guide for Tibial cut. Posterior Stabilized implant without patella resurfacing TKR : Medial Para-patellar Arthrotomy. Intramedullary guide for femur and extra medullary guide for Tibial cut. Posterior Stabilized implant without patella resurfacing Unicondylar Knee Arthroplasty UKR : Moderately invasive Arthrotomy Extra-medullary guide for Tibial cut and Tibial block technique for distal Femur UKR was performed using fixed bearing design. UKR : Moderately invasive Arthrotomy Extra-medullary guide for Tibial cut and Tibial block technique for distal Femur UKR was performed using fixed bearing design.

Post-Operatively Post-Op nursing In Bohler-Brawn Position (24 h) Multimodal analgesia Chemo / Mechanical means for DVT prophylaxis No transfusion trigger/ based on symptom and rehab Radiographic analysis Discharged to home by 3-7 days Prompt Patient and care-takers education on rehab Post-Op nursing In Bohler-Brawn Position (24 h) Multimodal analgesia Chemo / Mechanical means for DVT prophylaxis No transfusion trigger/ based on symptom and rehab Radiographic analysis Discharged to home by 3-7 days Prompt Patient and care-takers education on rehab

Statistics Stata Version 12 (StataCorp LP, Texas, USA) Intention To Treat (ITT) principle. Two-sample independent t-test or the nonparametric Mann-Whitney–Wilcoxon test Stata Version 12 (StataCorp LP, Texas, USA) Intention To Treat (ITT) principle. Two-sample independent t-test or the nonparametric Mann-Whitney–Wilcoxon test

Demographics ArthroplastyTKAUKA Mean age Gender 72% F83% F BMI FCI Average operative time 56 min (30 – 83 min). 65 min ( min) Intra-Op complicationsNil02 Chemoprophylaxis for DVT1105 Length of hospital stay6.6 days5.4 days Surgical details

KOS – ADLS & Patient satisfaction TKAUKA

At two year KOS - ADLS Post operatively patient satisfaction85.7 %89 % Knee Flexion115.8 (SD7.7)116.9(SD 7.1) Gain in KOS-ADLS47 (SD 13)50 (SD 9.8) KOS – ADLS & Patient satisfaction. Baseline KOS ADLS Preoperative patient satisfaction 40.4 % 37.4% Knee Flexion110 (SD 11.1)116 (SD 8.9)

Complications and Reoperation / Readmission TKAUKA Respiratory failure01Nil Blood transfusion02Nil Peri-prosthetic fracture Readmission 01Nil Stiff knees01Nil Wound Dehiscence02Nil Anterior knee pain02Nil

Steep learning curve Complex Procedure Questionable longevity Midterm failures Implant Design Careful patient selection Improved technology and surgical techniques Pre-Op Counseling Accelerated Rehabilitation RESURGENCE OF UKA  Joint Registries, Reviews by Ninmaki / Liddle n colleagues  Clin Sports Med 2014 Jan; Riff AJ: Outcomes and complications  Nehrus n colleagues, Lombardi n colleagues, Lim n colleagues, Mathew’s n colleagues

Discussion Management of Bone to Bone medial compartment OA remains to be contentious. Shifting equilibrium amongst HTO / UKA / TKA in such patients with no proven advantages. Steep learning curve and Midterm failures demands further insight and discussions Management of Bone to Bone medial compartment OA remains to be contentious. Shifting equilibrium amongst HTO / UKA / TKA in such patients with no proven advantages. Steep learning curve and Midterm failures demands further insight and discussions  Ronn K : Current surgical treatment of knee osteoarthritis

Strengths Randomized study, conducted in an Equipoise fashion Single Arthroplasty unit with uniform technique, implants and postoperative protocols Simultaneous Bilateral cases : Avoids bias of well leg. Consistent follow-up more than 90% Randomized study, conducted in an Equipoise fashion Single Arthroplasty unit with uniform technique, implants and postoperative protocols Simultaneous Bilateral cases : Avoids bias of well leg. Consistent follow-up more than 90%

Limitations The patients could not be blinded. Did not use any objective outcome assessment Or high demand physical activities performance tool Predetermined Implant designs Radiological outcome of surgery in terms of alignment and implant fixation not assessed Could not look at midterm failures of UKR The patients could not be blinded. Did not use any objective outcome assessment Or high demand physical activities performance tool Predetermined Implant designs Radiological outcome of surgery in terms of alignment and implant fixation not assessed Could not look at midterm failures of UKR

Summary Management of Bone to Bone medial compartment OA remains to be contentious. Either UKA/TKA at two year follow up give similar outcomes when performing activities of daily living UKR patients have decreased length of stay and reduced early post-op complications. Can UKR provide enhanced physical ability to perform high demand activities including sports as compared to TKR ???

Acknowledgements Mr Balwant & Mr Kamalnath (Research cum Physician Assistants) Miss Hemlata (Physiotherapist cum Physician Assistant)

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