Total versus partial knee replacement in patients with medial compartment knee osteoarthritis: the TOPKAT RCT

Abstract

Background Late-stage medial compartment knee osteoarthritis can be treated using total knee replacement or partial (unicompartmental) knee replacement. There is high variation in treatment choice and insufficient evidence to guide selection. Objective To assess the clinical effectiveness and cost-effectiveness of partial knee replacement compared with total knee replacement in patients with medial compartment knee osteoarthritis. The findings are intended to guide surgical decision-making for patients, surgeons and health-care providers. Design This was a randomised, multicentre, pragmatic comparative effectiveness trial that included an expertise component. The target sample size was 500 patients. A web-based randomisation system was used to allocate treatments. Setting Twenty-seven NHS hospitals (68 surgeons). Participants Patients with medial compartment knee osteoarthritis. Interventions The trial compared the overall management strategy of partial knee replacement treatment with total knee replacement treatment. No specified brand or subtype of implant was investigated. Main outcome measures The Oxford Knee Score at 5 years was the primary end point. Secondary outcomes included activity scores, global health measures, transition items, patient satisfaction (Lund Score) and complications (including reoperation, revision and composite ‘failure’ – defined by minimal Oxford Knee Score improvement and/or reoperation). Cost-effectiveness was also assessed. Results A total of 528 patients were randomised (partial knee replacement, n = 264; total knee replacement, n = 264). The follow-up primary outcome response rate at 5 years was 88% and both operations had good outcomes. There was no significant difference between groups in mean Oxford Knee Score at 5 years (difference 1.04, 95% confidence interval –0.42 to 2.50). An area under the curve analysis of the Oxford Knee Score at 5 years showed benefit in favour of partial knee replacement over total knee replacement, but the difference was within the minimal clinically important difference [mean 36.6 (standard deviation 8.3) (n = 233), mean 35.1 (standard deviation 9.1) (n = 231), respectively]. Secondary outcome measures showed consistent patterns of benefit in the direction of partial knee replacement compared with total knee replacement although most differences were small and non-significant. Patient-reported improvement (transition) and reflection (would you have the operation again?) showed statistically significant superiority for partial knee replacement only, but both of these variables could be influenced by the lack of blinding. The frequency of reoperation (including revision) by treatment received was similar for both groups: 22 out of 245 for partial knee replacement and 28 out of 269 for total knee replacement patients. Revision rates at 5 years were 10 out of 245 for partial knee replacement and 8 out of 269 for total knee replacement. There were 28 ‘failures’ of partial knee replacement and 38 ‘failures’ of total knee replacement (as defined by composite outcome). Beyond 1 year, partial knee replacement was cost-effective compared with total knee replacement, being associated with greater health benefits (measured using quality-adjusted life-years) and lower health-care costs, reflecting lower costs of the index surgery and subsequent health-care use. Limitations It was not possible to blind patients in this study and there was some non-compliance with the allocated treatment interventions. Surgeons providing partial knee replacement were relatively experienced with the procedure. Conclusions Both total knee replacement and partial knee replacement are effective, offer similar clinical outcomes and have similar reoperation and complication rates. Some patient-reported measures of treatment approval were significantly higher for partial knee replacement than for total knee replacement. Partial knee replacement was more cost-effective (more effective and cost saving) than total knee replacement at 5 years. Future work Further (10-year) follow-up is in progress to assess the longer-term stability of these findings. Trial registration Current Controlled Trials ISRCTN03013488 and ClinicalTrials.gov NCT01352247. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 20. See the NIHR Journals Library website for further project information.

Functional results and survivorship after medial unicompartmental knee arthroplasty: a single center experience from Saudi Arabia

“…Numerous reports have shown that in isolated degeneration of the medial compartment of the knee, UKA achieves functional results and survivorship that are comparable to results for total knee arthroplasty (TKA). 4 – 8 HTO also has comparable results with UKA in the younger patients. 9 – 11 For older patients UKA has the advantage of earlier weight-bearing mobilization.…”

“…Advocates of medial UKA stress the advantages of medial UKA over TKA, including quicker recovery, shorter hospital stay, fewer morbidities and mortalities, preservation of bone stock, an easier revision to TKA, and lower costs. 4 , 13 , 16 – 19 Patilet al 20 examined knee kinematics on cadaveric knees and concluded that tricompartmental knee replacement significantly changed knee kinematics while medial UKA preserved knee kinematics, which might benefit the patient's rehabilitation and implant survival and wear. In a clinical context, research has shown that the gait pattern of patients undergoing UKA is closer to the physiological pattern.…”

A retrospective analysis of trends in primary knee arthroplasty in Germany from 2008 to 2018

“…Especially unicompartimental knee arthroplasty (UKA) has gained interested in the last decade. Reasons are suspected benefits such as less tissue trauma, reduced blood loss during surgery and better functionality due to faster rehabilitation, recovery and improved range of motion 9 .…”

Comparison of Functional Outcome of Total and Unicompartmental Knee Arthroplasty Using Computer-Assisted Patient-Specific Templating

“…The current operative treatment modalities of advanced osteoarthritis are total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). However, replacing all the affected and nonaffected surfaces is considered the gold standard procedure [ 2 , 3 ]. On the other hand, many surgeons argue the superiority of UKA in unicompartmental cases to spare the undamaged compartments, despite having higher revision rates when compared to TKA [ 2 , 4 ].…”

“…However, replacing all the affected and nonaffected surfaces is considered the gold standard procedure [ 2 , 3 ]. On the other hand, many surgeons argue the superiority of UKA in unicompartmental cases to spare the undamaged compartments, despite having higher revision rates when compared to TKA [ 2 , 4 ].…”