Unicompartmental knee arthroplasty and total knee arthroplasty among medicare beneficiaries, 2000 to 2009

Michael P. Bolognesi, Melissa A. Greiner, David E. Attarian, Tyler Steven Watters, Samuel S. Wellman, Lesley H. Curtis, Keith R. Berend, Soko Setoguchi Iwata

Publication Date: 11/20/2013

Background: Unicompartmental knee arthroplasty is a less-invasive alternative to total knee arthroplasty for patients with arthritis affecting only the medial or lateral compartment. However, little is known about recent trends in the use of these procedures and the associated outcomes among older patients. Methods: With use of a nationally representative 5% sample of Medicare beneficiaries who were sixty-five years of age or older and who had undergone either unilateral unicompartmental knee arthroplasty or unilateral total knee arthroplasty from 2000 to 2009, we assessed trends in the use of unicompartmental and total knee arthroplasty, associated durations of hospital stay, and postoperative outcomes. The outcome measures were the rates of implant revision or removal within five years and the rates of periprosthetic infection, thromboembolic events, myocardial infarction, and allcause mortality within one year. We conducted Kaplan-Meier analyses to assess the cumulative incidence of unadjusted outcomes and used Cox proportional-hazards regression to understand the relative risks of the outcomes for each procedure. Results: A total of 68,603 patients underwent unilateral total knee arthroplasty (n = 65,505) or unilateral unicompartmental knee arthroplasty (n = 3098) from 2000 to 2009. The mean age was seventy-five years; 34% of the patients were men, and 92% were white. The procedure rate was twenty-one times higher for total knee arthroplasty (597 per 100,000 person-years) than unicompartmental knee arthroplasty (twenty-nine per 100,000 person-years). The use of total knee arthroplasty increased 1.7-fold, and the use of unicompartmental knee arthroplasty increased 6.2-fold. The mean length of stay (and standard deviation [SD]) was 3.9 ± 2.1 days for total knee arthroplasty and 2.4 ± 1.7 days for unicompartmental knee arthroplasty. The five-year revision rate was 3.7% for total knee arthroplasty and 8.0% for unicompartmental knee arthroplasty. After multivariable adjustment, the risk of revision remained 2.4 times higher for unicompartmental knee arthroplasty than for total knee arthroplasty (95% confidence interval [CI] = 2.03 to 2.83). After multivariable adjustment, patients who underwent unicompartmental knee arthroplasty had no significant differential oneyear risk of infection (adjusted hazard ratio [HR] = 0.74; 95% CI = 0.55 to 1.01), thromboembolic events (adjusted HR =0.86; 95% CI = 0.57 to 1.29), or mortality (adjusted HR = 0.75; 95% CI = 0.50 to 1.11). Conclusions: Although unicompartmental knee arthroplasty accounted for only 4.5% of the unilateral knee replacements among Medicare beneficiaries, the use of this procedure has increased dramatically. Compared with those who had total knee arthroplasty, patients who underwent unicompartmental knee arthroplasty had higher revision rates but shorter durations of stay and tended to have lower rates of perioperative complications. These findings need to be confirmed by studies that incorporate detailed clinical information. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.