Partial Knee Replacement for localised arthritis
Patella femoral replacement
Osteotomy – an alternative to replacement?
The knee is made up of three joints: the medial (or inner side) joint, the lateral (outer side) joint and the patellofemoral (kneecap) joint which is located at the front of the knee. Each individual compartment of the knee can wear out and cause arthritis pain. When this process becomes very severe, replacement surgery is required. It may be possible to undertake a partial knee replacement of any of these three compartments and, occasionally, more than one. Traditionally, when more than one compartment is involved your doctor will recommend total knee replacement.
This is specialist surgery for which Bristol has a national and international reputation. It is performed for isolated disease of the patellofemoral joint (where the kneecap joins the front of the thigh bone) and involves two small components being inserted into the front of your knee. It is carried out as an open surgical procedure requiring an in-patient stay. The main advantage to this type of replacement surgery is that the healthy medial and lateral joints are retained so your knee will feel ‘more normal’ and achieve an excellent range of movement after surgery compared to total knee replacement. Because of its selective nature, this surgery is sometimes performed in younger patients than those we would normally select for total knee replacement.
Medial Unicondylar knee replacement
The medial (inner) joint is the most common joint of the knee to wear out. There is a specific pattern of wear which affects the front inner aspect of your knee; it is also known as anteromedial arthritis.
- Pain made worse by activity or standing
- Reduced function
- Most people feel a very localised pain which can often be ‘pointed out’ with a finger. Sometimes the pain moves up the thigh or down the leg on the inner aspect.
When the disease becomes sufficiently severe and in certain patients after consideration of osteotomy, it may be necessary to perform a partial medial knee replacement.
Surgery is performed in a minimally invasive manner with small incisions to reduce post-operative pain and immobility. The procedure can be guided by computer navigation systems in specific cases. Most patients are in hospital for 2-4 days and are able to walk with one crutch or stick when they go home. At 4-6 weeks, the majority of patients should expect a significant improvement in function. This contrasts with total knee replacement, which often takes up to three months for patients to feel they have only just ‘broken even’.
There are two main types of partial knee replacement in the medial joint which use either a mobile or a fixed bearing device. A mobile bearing unicondylar replacement has three component parts: a femoral component made of metal to resurface the medial femoral condyle (inner aspect of your thigh bone at the knee); a tibial base plate made of metal to resurface the medial tibial plateau (inner aspect of the top of your leg bone in your knee); a meniscal bearing made of polyethylene (a type of plastic) which acts as the shock absorber between the two metal components. In a fixed bearing design, the plastic component is ‘fixed’ in the tibia (leg bone) and the femoral component slides on this. Both types work well and there is very little difference in the early outcome of both designs. Your specialist will discuss the options with you in clinic.
Lateral Unicondylar partial knee replacement
This condition is rarer than medial arthritis, but occasionally patients do have an isolated wear pattern in the lateral (outer aspect) of their knees.
- Lateral (outer) sided pain
- The pain getting worse descending stairs or going down hills
- A feeling of instability, again particularly on descending hills or stairs
Lateral unicondylar replacement is carried out using a minimally invasive surgical approach. In the majority of cases this means the incision can be smaller, in addition to reduced damage to the underlying muscles, with the overall effect of reducing patient pain and allowing an earlier return to activity. There are two basic designs – fixed or mobile – which are very similar to the medial joint as described above with just a few subtle differences.
Sometimes as a result of trauma (broken bones or previously injured ligaments), patients can experience a very early onset of arthritis often in a selective part of their knee. Occasionally, however, this is not related to any previous damage but is due to an underlying malalignment pattern which has caused an accelerated onset of wear.
- Reduced activity sometimes associated with instability (the feeling of the knee ‘giving way’) because of ligament damage
After careful discussion and examination in the clinic, you will require a full-length X-ray or possibly a scan to map the alignment of your lower limb. Your specialist will discuss the options with you before suggesting a surgical treatment plan.
One or two cuts are made in the bones around your knee – usually in the proximal tibia (upper leg bone). The leg is then carefully straightened under X-ray control and a metal plate and screws are inserted to secure the osteotomy (the ‘cut bone’) in the new position. This will allow the majority of your weight to travel through the healthy part of your knee and reduce your symptoms. After the operation, you are likely to require a period of bracing for the first few weeks. Whilst it is possible to weight bear straightaway, most patients require crutches for the first few weeks for comfort. During your subsequent visits to the hospital, X-rays will be taken and your specialist will show you how the gap is filling in with new bone to heal the osteotomy.