Partial Knee and ACL Replace?

[paradiddle]

I tore ACL in 1990 playing b-ball at age 35. Never had it replaced. Got a scope and some cartilage repair. In 93 tore some more got another scope.
I never got back to the level of playing B-ball again but did marching band- played a drum and did a lot of parades. etc. I felt pretty good.

The last couple of years I added some pounds. I would go for walks and noticed that inside joint would hurt a little and clunk. I saw ortho and the x-rays said - ding..... No cartlilage left on the inside. The other side looks fine.
He said because I have no ACL I can't do partial knee - otherwise I would be a good candidate. I have had 2 people I know that had TKR at a more advanced age. They were happy with the surgery but had complications with blood clots. One of my friends can't really walk all that well because of the clots.

I was thinking I would rather have a partial knee (less invasive) and have ACL repaired. I think that would work better for me. I don't know if any doctor would buy into that one unless you have heard of cases like me.

I don't have much or any pain but my function is diminshed and I can't push myself.

????

 

[beachcomber]

Sorry--- no idea about the ACL part... but I had a PKR and it is a great surgery. I have never heard of it being done unless you have healthy ligaments, tho. Mine PKR is medial and my scar is only about 4" long and has healed beautifully.

Good luck. Hope you find a good solution.

 

[npbob]

Hi There Paradiddle,
I am in pretty much the same boat. Tore medial meniscus and then the ACL 20 some years ago. Saw my ortho few years back discussed the situation and his advice was my one option is the TKR. Not sure an ACL repair and partial knee will work together well if at all. Also, there are typically degenerative changes in other parts of the knee which would preclude a succesful partial knee. I am scheduled for a TKR May 19th using computer navigation and a Stryker Triathlon implant. So it goes...
NPBOB

 

[Josephine]

In short, npbob, the two are incompatible with one another.

To start with, if you have that much damage in your knee, although one side might be worse than the other, there is no real telling how bad any of it is until the arthroscopy or MRI scan. And it is likely that even though the lateral (outside) compartment is passable, the patellar compartment won't be - that's the area behind the patella or kneecap.

Second, the surgery to repair an ACL can take every bit as long as a TKR which is also a contraindication.

Third, the intrusion into the bone to place grafts would not be compatible with a TKR.

Fourth, as a rule (and I stand to be corrected on this as regards US/UK differences) when an ACL is repaired, it requires 6-8 weeks in a plaster cast post op until the ligament has healed which again, would be contraindicated for a TKR.

Fifth, the weakness of the new ligaments would not enable good rehab for the new knee.

 

[paradiddle]

I saw this article on ACL and UKA together. Basically it says that this operation has been done but it is technically challenging. Are some OS quick to just go to TKA? The ACL rehab requires no cast and exercises are similar but with some restrictions. I think UKA and ACL (especially with allograft) might be less invasive and be a better option for a younger - more active adult.

A patient who has just one compartment (medial) damaged by accident that develops into arthritis (bone on bone) but has perfectly fine other compartments suggests that TKA may be too invasive.

broken link removed: https://proceedings.jbjs.org.uk/cgi/content/abstract/87-B/SUPP_II/151

"Introduction: Unicompartmental knee arthroplasty (UKA) is an increasingly popular procedure for young osteoarthritic patients whose age and activity levels preclude the use of a total knee arthroplasty (TKA). However, successful reconstruction using an unconstrained mobile bearing implant requires an intact and functioning ACL. Patients with isolated medial compartment OA and an absent ACL therefore provide a management dilemma for the treating surgeon. One option is to perform a combined ACL reconstruction and mobile bearing UKA. This paper presents early results of this new procedure using an Oxford UKA and ACL reconstruction using an autograft.

Materials and Methods: Eleven patients who underwent one or two-staged ACL reconstruction and Oxford UKA for treatment of symptomatic medial compartment OA were reviewed at one year after surgery. The combined procedure required specific precautions and considerations; care had to be taken to place the tibial tunnel as far laterally as possible to avoid impingement of the graft by the tibial implant. Also, the presence of a posteromedial, rather than an anteromedial cartilage defect has the potential to reduce accuracy for placement of the initial tibial cut.

Results: All patients were male with an average age of 49 years (range: 36 – 52) and mean follow up of 1.3 years. One patient needed revision to TKA due to infection. The objective and functional knee society scores improved pre to post operatively from 55 to 98, and 85 to 100, respectively.

Conclusions: ACL reconstruction and simultaneous or staged UKA is a viable treatment option for patients with symptomatic medial compartment arthritis in whom the ACL is absent. Early results of this technically demanding procedure are encouraging but longer follow-up is required. "

Even the book - Adult Reconstruction By Daniel J. Berry, Scott P Steinmann, Paul Tornetta suggests that UKA and ACL is a viable option for certain candidates.