Postoperative Joint Scores of Comparison between total and unicondylar knee arthroplasty：A matched comparison

doi:10.21203/rs.3.rs-5320116/v1

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Postoperative Joint Scores of Comparison between total and unicondylar knee arthroplasty：A matched comparison

https://doi.org/10.21203/rs.3.rs-5320116/v1

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Objective：To investigate the patient self-reported outcomes and clinical results of unicondylar arthroplasty versus total knee arthroplasty for osteoarthritis of the knee. To evaluate the early functional recovery of patients after both surgical modalities.

Methods：In this retrospective study, 52 patients (26 patients in the unilateral UKA group; 26 patients in the unilateral TKA group) with osteoarthritis of the knee were treated with unicondylar arthroplasty and total knee arthroplasty to compare the baseline and perioperative data of the patients in the UKA group and the TKA group, the modified Postoperative Joint Forgetting Score (MFJS), Oxford Early Recovery Score for Knee Arthroplasty (OARS) at 1, 2, 6 week and 3 month postoperatively, and Oxford Early Change Score for Knee Arthroplasty (OACS) at 1, 2, 6 week, and 3, 6 and 12 month postoperatively.

Results：The general clinical data (age, gender, body mass index) of patients in the UKA and TKA groups were not statistically significant (P>0.05) and were comparable.The operation time and intraoperative bleeding in the UKA group were lower than those in the TKA group (P<0.001). At 3, 6 and 12 month after surgery, the MFJS scores of patients in the UKA group were higher than those of patients in the TKA group (P<0.001). OARS scores at 1, 2, 6 week and 3 month postoperatively were higher in the UKA group than in the TKA group (P<0.05). There was no statistically significant difference in the comparison of OACS scores between the unilateral UKA and TKA groups at 1 week postoperatively (P>0.05), and the scores of the unilateral UKA group were higher than those of the unilateral TKA group at 2, 6 week, and 3, 6, and 12 month (P<0.05).

Conclusion：Both UKA and TKA are effective in improving functional scores in end-stage osteoarthritis of the knee.UKA has better knee proprioception and faster postoperative recovery compared to TKA.

Knee Osteoarthritis

Unicompartmental Knee Arthroplasty

Total Knee Arthroplasty

the Modified Forgotten Joint Score

Oxford Arthroplasty Early Recovery Score

Oxford Arthroplasty Early Change Score

Osteoarthritis (OA) is one of the most common joint diseases, which is mainly caused by articular cartilage damage and involves the entire joint tissue. Eventually, articular cartilage degeneration, fibrosis, fracture, defect and damage of the entire articular surface occur^[1].Knee arthroplasty is the gold standard for the treatment of end-stage knee osteoarthritis ^[2]. Knee arthroplasty has two surgical methods : UKA and TKA.UKA has the advantages of less damage and faster recovery than TKA ^[3]. The success of knee arthroplasty depends on the implant survival rate and patient-reported outcome measures (PROMs) ^[4]. The ultimate goal of knee arthroplasty is the assumption that a patient can forget the joint. It aims to quantify the degree of forgetting of the patient 's joint function before surgery, that is, the degree of recovery of joint function after surgery. The purpose is to assess the patient 's ability to forget artificial joints in daily life.Patrick G et al.proposed a modified joint forgetting score (MFJS) ^[5]. In the study, Chithartha K also found that MFJS had better discrimination ability in evaluating hip replacement and knee replacement with good performance ^[6]. With the improvement of the prognosis of patients after joint replacement, the expected value of postoperative recovery of patients is also increasing. The average score and upper limit effect of PROMs in patients show a parallel upward trend. Some PROM tools have been unable to make a suitable evaluation of higher levels of functional level and patient satisfaction ^[7].MFJS score makes up for this defect well.OARS, as a new score designed and validated to assess early recovery after arthroplasty, was used to compare recovery after UKA and TKA ^[8]. The purpose of OACS is to compare the state of patients after knee replacement intervention and the state before intervention ^[8]. Scores including the American Knee Society Score (KSS), Oxford University Knee Society Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Hospital for Special Surgery Knee Score (HSS) were also not used for early postoperative recovery after UKA or TKA, which led to a lack of effective measurement of early recovery in patients undergoing knee arthroplasty ^[9]. In this study, 52 patients with knee osteoarthritis underwent UKA and TKA respectively. The scores of each follow-up time point within 1 year after operation were compared to evaluate the joint consciousness and function of the patients after the two surgical methods.

Study design

The clinical data of 102 patients (102 knees) with knee osteoarthritis admitted from September 2021 to January 2023 were retrospectively analyzed. According to the operation plan, they were divided into UKA group and TKA group, including 28 cases in UKA group and 74 cases in TKA group. Inclusion criteria : (1) Primary end-stage osteoarthritis of the knee with lesions limited to the medial compartment and narrowing of the medial compartment ; (2) Knee inversion deformity ≤ 15°, flexion contracture deformity ≤ 15°, and knee flexion > 90°; (3) The anterior and posterior cruciate ligaments of the knee were functioning normally; (4) Non-inflammatory knee osteoarthritis ; (5) Patients receiving UKA or TKA for the first time. Exclusion criteria : (1) Multicompartmental lesions in osteoarthritis of the knees ; (2) patients with severe instability of knee joint caused by medial and lateral collateral ligament injury of knee joint ; (3) Patients with inflammatory arthritis : such as rheumatoid arthritis, gouty arthritis of the knee ; (4) patients with severe cardiovascular and cerebrovascular diseases, central nervous system diseases ; (5) Patients who were lost to follow-up or with incomplete case data. According to the inclusion and exclusion criteria, 26 patients (26 knees) in the UKA group and 71 patients (71 knees) in the TKA group were included ; according to the basic characteristics of gender, age and body mass index, the UKA group and the TKA group were propensity matched. Finally, 52 cases (52 knees) were included, UKA group (n = 26) and TKA group (n = 26). This study was approved by the Medical Ethics Committee.There was no difference (P > 0.05) in baseline characteristics between the two groups (Table 1).

Table 1

Baseline data of patients in UKA group and TKA group
	TKA	UKA	P-value
Characteristics	26	26
Sex, female/male	12/14	7/19	0.150^*
Age, years	62.50(54.25, 72.75)	60.00(55.25, 69.00)	0.790⁺
Body mass index, kg/m2	24.55(23.78, 27.50)	25.00(24.20, 26.88)	0.869⁺
Left / Right	15/11	11/15
K-L Grade(%)
II	0(0)	0(0)
III	14(53.85)	17(65.38)	0.397
IV	12(46.15)	9(34.62)
*Pearson's Chi-squared Test;+ Mann-Whitney U Test

Surgical procedures

All cases were completed by the same surgeon team.

Unicompartmental knee arthroplasty : After the successful implementation of anesthesia, the patient was in a supine position, the upper and middle thighs were tied with tourniquets, and the affected limb was suspended by a special fixator at the edge of the operating table. The hip flexion was 40° and the abduction was 30°. The medial parapatellar incision of the knee joint was about 10 cm in length, separated layer by layer, and the deep fascia was opened to expose the medial compartment. It was found that the cartilage of the medial femoral condyle and the tibial plateau was severely exfoliated, the subchondral bone was leaked, the osteophyte of the medial margin of the patella was obvious, and the osteophyte of the medial femoral condyle was obvious. Clear the patella and the osteophyte of the medial femoral condyle, explore the normal cruciate ligament, the normal lateral compartment, and the location of the femoral bone marrow. After the test, the small femoral condyle prosthesis was used, the medial meniscus was removed, the medial tibial plateau osteotomy was performed, the middle line of the medial femoral condyle was marked, the posterior condyle was removed after the osteotomy mold was placed, the condyle was removed after the locator was placed, and the flexion and extension gap was balanced after the osteotomy. The stability of the joint was observed after flushing the joint cavity and placing the test model. After filling the bone cement, the prosthesis and gasket were implanted. The extension and flexion of the active joint were normal. The excess bone cement was removed, and the tourniquet was loosened to stop bleeding. Ropivacaine hydrochloride, compound betamethasone, flurbiprofen axetil injection, morphine closed the surrounding and posterior joint capsule of the incision, sutured the wound layer by layer, and fixed with elastic bandage.

Total knee arthroplasty : After successful anesthesia, the patient was placed in a supine position, and the tourniquet was tied to the upper and middle thighs. A longitudinal incision was made in the anterior median of the knee. The length of the incision was about 16 cm, and the incision was separated and exposed in turn. The articular capsule was incised from the medial side of the patella, and its valgus was retracted to expose the articular cavity. The hyperplastic synovium, anterior and posterior cruciate ligaments, meniscus and hyperplastic osteophytes were removed. Release the soft tissue on both sides and evaluate the establishment of soft tissue balance. Tibial osteotomy : According to intramedullary positioning, tibial osteotomy ( backward 3° ) was performed. Femoral osteotomy : According to intramedullary positioning, femoral condyle osteotomy ( valgus 5°, external rotation 3° ) was performed with a template. Patella : clean up the osteophytes at the edge of the patella. Prosthesis installation : Install the femur and tibia prosthesis in turn, each component fits well, the knee joint activity is normal, and the knee joint is stable in all directions ; the test model was taken out, the prosthesis was fixed with bone cement, and the tibial prosthesis and femoral prosthesis were installed in turn. Closure of the incision : the articular cavity was cleaned with a pulse gun, the tourniquet was loosened and the bleeding was stopped. Ropivacaine hydrochloride, compound betamethasone, flurbiprofen axetil injection and morphine were used to seal the surrounding and posterior joint capsule of the incision. The wound was sutured layer by layer and fixed with elastic bandage.

Postoperative management

(1) After operation, the affected limb was raised, antibiotics were used to prevent infection, combined analgesia, subcutaneous injection of low molecular weight heparin and ankle pump function exercise were performed.(2) Postoperative rehabilitation measures : limb knee joint ice compress, lower limb limb pressure treatment. The patients were guided to perform knee flexion and extension activities and quadriceps functional exercise. On the second day after operation, the walker was used to walk. Postoperative X-ray films of the knee joint were reviewed to evaluate the position of the knee prosthesis. Blood routine, liver and kidney function, electrolytes and inflammatory indexes were reexamined at 1 day, 4 day and 7 day after operation to prevent hemorrhagic anemia, infection and electrolyte imbalance.

Statistical method

In this study, statistical software IBM SPSS, 26.0 software was used for statistical analysis. When the measurement data obeyed the normal distribution, it was expressed as mean ± standard deviation, and the independent sample t test was used for comparison between groups. When the normal distribution was not obeyed, the data were expressed as median (lower quartile-upper quartile), and the rank sum (Mann-Whitney U) test was used for comparison between groups. The count data were expressed as numbers (percentages). The comparison between the count data groups was performed by chi-square test or Fisher 's exact test. P < 0.05 was considered statistically significant.

The patients all successfully completed the surgery, the surgical incisions all healed in one stage, and the X-rays were regularly reviewed without any related complications such as knee infection and/or periprosthetic fracture.

Table 2 presents the perioperative data of UKA group and TKA group.The intraoperative blood loss in the UKA group was less than that in the TKA group, and the operation time was shorter than that in the TKA group, with statistically significant differences (P < 0.001).Table 3 presents the MFJS scores of UKA group were higher than those of TKA group at 3 months, 6 months and 12 months after operation, and the difference was statistically significant ( P < 0.001).Table 4 presents the OARS scores of UKA group were higher than those of TKA group at 1week、2 weeks、6 weeks and 3 months after operation, and the difference was statistically significant (P < 0.05).Table 5 presents the OACS scores of the UKA group were higher than those of the TKA group at 2 weeks、6 weeks and 3 months、6 months、12 months after operation, and the difference was statistically significant (P < 0.05).There was no significant difference in OACS score between UKA group and TKA group at 1 week after operation (P > 0.05).

Table 2

Comparison of perioperative data between TKA group and UKA group
	TKA	UKA	z/t	P-value
Intraoperative blood loss, ml	150.00(140.00, 150.00)	100.00(80.00, 130.00)	5.307	< 0.001^*
operation time, min	80.00(75.00, 90.00)	68.00(65.00, 76.00)	4.118	< 0.001^*
* Mann-Whitney U Test

Table 3

Postoperative MFJS scores of TKA group and UKA group
		TKA	UKA	z/t	P-value
MFJS	3 months	30.00(30.00, 32.50)	42.50(42.50, 47.50)	-6.113	< 0.001^*
	6 months	47.50 ± 4.22	65.58 ± 4.40	-14.826	< 0.001⁺
	12 months	70.00(67.50, 72.50)	85.00(80.00, 87.50)	-6.186	< 0.001^*
* Mann-Whitney U Test;+ independent sample T Test༛

Table 4

Postoperative OARS scores of TKA group and UKA group
		TKA	UKA	z/t	P-value
OARS	1 week	44.71 ± 4.50	48.21 ± 6.28	-2.266	0.028⁺
	2 weeks	65.32 ± 3.58	71.50 ± 3.69	-6.014	< 0.001⁺
	6 weeks	82.62 ± 4.45	88.53 ± 3.02	-5.50	< 0.001⁺
	3 months	94.64(94.64, 96.43)	96.43(96.43, 98.21)	-2.754	0.005^*
* Mann-Whitney U Test;+ independent sample T Test༛

Table 5

OACS scores of UKA group and TKA group
		TKA	UKA	z/t	P
OACS	1 week	-17.99 ± 8.48	-14.43 ± 8.83	-1.458	0.151⁺
	2 weeks	-10.37 ± 8.10	-3.36 ± 8.17	-3.047	0.004⁺
	6 weeks	6.99 ± 4.74	11.54 ± 4.97	-3.310	0.002⁺
	3 months	14.91 ± 5.96	25.89 ± 4.35	-7.444	< 0.001⁺
	6 months	25.21 ± 4.91	31.87 ± 5.51	-4.513	< 0.001⁺
	12 months	33.93(30.36, 41.07)	44.64(41.07, 46.43)	-4.612	< 0.001^*
* Mann-Whitney U Test;+ independent sample T Test༛

Typical case

Figure 1 Knee joint X-ray before and after UKA.

A 72-year-old female presented with pain and discomfort in the right knee. The pain was concentrated in the medial compartment.

According to the symptoms, signs and imaging examination, the initial diagnosis was : medial compartment osteoarthritis of the right knee joint, treated with UKA ;

a-b.X-ray film of the right knee joint, the results showed that the medial joint space of the knee joint narrowed with subchondral bone sclerosis ;

c-d : The anteroposterior and lateral X-ray films of the right knee joint after UKA showed that the knee prosthesis was in good position.

Figure 2 Knee joint X-ray before and after TKA.

A 73-year-old female presented with right knee pain and discomfort.

According to the symptoms, signs and imaging examination, the initial diagnosis was : right knee osteoarthritis, treated with TKA ;

e-f : X-ray of the right knee joint before operation, the results showed that the knee joint space narrowed with subchondral bone sclerosis and osteophyte formation around the joint ;

g-h : The anteroposterior and lateral X-ray films of the right knee joint after TKA showed that the knee prosthesis was in good position.

The success of knee arthroplasty depends on the implant survival rate and Patient-Reported Outcome Measures ( PROMs )^[4]. Many PROMs scoring tools are widely used in clinical practice and research after knee arthroplasty to evaluate the postoperative rehabilitation and surgical results of patients. The most widely used include the American Knee Society Score ( KSS ), Oxford University Knee Score ( OKS ), Knee Injury and Osteoarthritis Outcome Score ( KOOS ), Western Ontario and McMaster University Arthritis Index ( WOMAC ), Hospital for Special Surgery Knee Score ( HSS ), etc.With the improvement of the prognosis of patients after joint replacement, the expectations of patients are also increasing. The average score and upper limit effect of PROMs in patients are increasing in parallel^[7]. Some PROM tools cannot fully distinguish between higher levels of function and patient satisfaction. Therefore, Behrend^[10] et al.proposed a new PROM tool in 2012. The Joint Forgetting Score ( FJS ) is a PROM with a lower upper and lower limit effect, which means that it has a good ability to distinguish between patients with good results and patients with excellent results^[7][11]. The FJS score has been validated in knee arthroplasty and has been translated into many languages for use worldwide^{[7][12][13][14][15]}. Patrick G^[5] et al.found that the repeated missing data in FJS limited the reliability of FJS. According to the conclusion of Jenkinson et al.in a computer research method that 'if three or more questions are not answered, the patient 's score should be omitted', they solved the problem of repeated missing FJS data by slightly modifying some questions to improve understanding and eliminate unnecessary problems. Patrick G et al.finally proposed the Modified Joint Forgetting Score ( MFJS ) by modifying and verifying the FJS problem. Compared with FJS, MFJS is a more relevant measurement tool for patient-reported outcomes^[5]. The development and application of OARS score and OACS score also make up for the vacancy of quantitative indicators of early functional recovery after knee arthroplasty^[8][9].The results of this study showed that there was no significant difference in baseline data of gender, age and BMI between UKA and TKA (Table 1), which reduced the error caused by heterogeneity between the two groups. Compared with TKA, UKA has significant advantages in reducing the operation time and intraoperative blood loss (Table 2), which has a positive effect on accelerating the recovery of patients after joint replacement and reducing the incidence of complications^[16]. Through a study on the blood loss of UKA and TKA patients, Schwab^[17] et al. found that the blood loss of patients undergoing UKA was lower than that of patients undergoing TKA. Wang^[18] et al. also found that the UKA group was lower than the TKA group in terms of operation time and blood loss. This conclusion is the same as the conclusion of this study, which may be related to the fact that UKA retained the anterior cruciate ligament of the knee joint, retained the bone mass of the femur and tibia, and retained the normal biomechanical function of the knee joint. Schwab^[17] et al. found that UKA treatment is feasible even for patients with mild anemia before surgery, and postoperative review found that it does not increase the rate of anemia and blood transfusion after surgery.The retention of the cruciate ligament in knee arthroplasty makes the patient 's limb feel greatly retained, and the patient will feel that the knee joint is more natural, so as to forget that he has undergone knee arthroplasty to a greater extent, and the activity is closer to the normal knee joint^[16]. The results of this study showed that the MFJS of the UKA group and the TKA group continued to improve at 3 months, 6 months and 1 year after surgery, indicating that the MFJS of the UKA was better than that of the TKA at each follow-up stage compared with the TKA (Table 3). The results show that UKA can better preserve the function and integrity of the fork ligament, better preserve the patient 's knee joint proprioception, and patients have lower joint awareness. In the study of Gill^[19] et al., whether it is TKA or UKA, the FJS at 1 year after joint replacement is the lowest. In TKA, the FJS value of the 5-year group after joint replacement was the highest, and the FJS value decreased slightly during the 10-year follow-up period, but it was not significant. Therefore, we need to do a long-term follow-up on the MFJS score of patients after UKA and TKA to study the long-term clinical effect after UKA and TKA.At each follow-up time point after OARS, the scores of UKA patients and TKA patients showed a trend of change, and were affected by the follow-up time. The total scores of UKA and TKA patients at 1 week、 2 weeks、6 weeks and 3 months of OARS were increased, and the OARS score of UKA was significantly higher than that of TKA patients, which also indicated that the early recovery of UKA was faster than that of TKA. In a two-year prospective, randomized, multi-center, blinded study, Jani et al.found that unicompartmental knee arthroplasty had a faster recovery than total knee arthroplasty^[20]. This may also be related to UKA 's smaller surgical incision, less soft tissue operation, more bone mass retention, smaller implants, and less bone cement.The purpose of OACS is to compare the status of patients after knee replacement intervention and the status before intervention. The OACS value of 0 indicates the preoperative functional status^[8]. The OACS of UKA and TKA patients increased from 1 week to 1 year. In the early postoperative period, the patient 's condition was significantly worse than that before surgery. In the first and second weeks, UKA and TKA patients showed worse functional status than before surgery. At the 6th week, there was a significant difference between UKA and TKA patients (Table 5). The OACS score of patients only reported the same status as before surgery, and UKA patients were better than TKA patients, indicating that more patients in UKA achieved preoperative functional status. With the passage of follow-up time, the status of UKA and TKA patients tended to improve. UKA patients were different from TKA patients and recovered better than TKA. As the number of knee replacements continues to increase in younger and more active patients, they are more expected to return to physical activity (RTS) after surgery. Moreover, studies have shown that the incidence of RTS increases over time, and about 87.9% of patients return to exercise 14 months after TKA^[21]. At 1 week to 1 year after surgery, both UKA group and TKA group gradually developed better, and patients with UKA were significantly better than those with TKA, which may be related to the smaller invasion of UKA and the presence of proprioception brought by the retention of the cruciate ligament, so that patients have better evaluation on PROMs.

This clinical study has certain limitations: First, the sample size is small, and can be verified by a multi-center, large sample size; second, the follow-up time is short, and the follow-up time is extended to observe the long-term clinical functional recovery of patients after surgery.

In summary, through this study, it can be seen that unicompartmental knee arthroplasty and total knee arthroplasty for end-stage knee osteoarthritis can improve the quality of life of patients, relieve knee symptoms and improve knee function ; from the overall efficacy analysis, unicompartmental knee arthroplasty has lower joint consciousness than total knee arthroplasty. It has the advantages of better joint amnesia, faster recovery of knee function after operation, and less trauma to soft tissue. For patients with medial unicompartmental osteoarthritis of the knee, it can help patients choose between UKA and TKA.

Ethics approval and consent to participate

This retrospective cohort study received approval from the institutional review board (ethical approval number: KJX-2022-083-02).

Consent for publication

We agreed to publish this paper in the journal.

Competing interests

The authors declare no competing interests.

Author details

¹Shihezi University of Medicine,Xinjiang Shihezi,832002,China; ²Department of Arthrosurgery,the First Affiliated Hospital of Shihezi University,Xinjiang Shihezi,832008,China.

Funding

The National Natural Science Foundation of China(82160423)

Author Contribution

C.L.,C.S., Z.Z. Study design and supervision; C.L. investigation; C.L. writing—original draft preparation and formal analysis ; C.L., C.S., Z.Z. writing—review and editing. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

Not applicable.

Availability of data and materials

Data can be obtained by contacting the corresponding author upon request.

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Postoperative Joint Scores of Comparison between total and unicondylar knee arthroplasty：A matched comparison

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Abstract

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Introduction

Methods

Study design

Surgical procedures

Postoperative management

Statistical method

Results

Typical case

Discussion

Conclusions

Declarations

Author details

Funding

Author Contribution

Acknowledgements

Availability of data and materials

References

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