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Acta Orthop Belg. 2013 April ; 79(2): 191196.

Current fit of medial and lateral unicompartmental knee

arthroplasty
Wolfgang Fitz, Robin Bliss, and Elena Losina
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

Abstract
Whether failure in unicompartmental knee arthroplasty (UKA) is related to implant design
remains unclear. We hypothesize that current available UKAs fit within 2 mm. Forty-eight CTs of
cadaveric knees were compared to current available UKA brands. Overall no-fit compared to at
least one component within 2 mm is high (91.7%) and worse for males (100%) compared to
females (83.3%). Good fit was observed for the medial but not for the lateral tibia plateau. Seven
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males (29.2%) had larger dimensions of more than 2 mm. For the widest UKA brand, 12 (57%)
males and 2 females (8. 3%) had lateral femoral condyles 3 mm larger. Current UKA's in our
sample population fit less on the lateral tibia and on femoral condyles.

Keywords
knee arthroplasty; component fit; condylar dimensions; unicompartmental knee arthroplasty;
medial and lateral condyle

Introduction
Unicompartmental knee arthroplasty (UKA) has good long-term survivorship and is gaining
popularity (15,17). Despite excellent clinical results (5,13,14,17), early failure rates of UKA
remain in the 5% range (6,8,11,18). Whether this is related to surgical technique, patient
selection or implant design needs clarification. Some cohorts, such as obese patients have
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shown higher failure rates with specific, narrow implants (2).

We wonder whether femoral condyles and tibial plateaus are sufficiently covered with
current available UKA designs. We hypothesize all current available components of modern
UKA fit within 2 or 3 mm medial and lateral femoral condyles and medial and lateral tibia
plateaus.

Correspondence : Wolfgang Fitz, MD, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Brigham and
Women's Arthritis Center, 850 Boylston Street, Chestnut Hill, MA 02467, USA. [email protected].
Wolfgang Fitz, MD is member of the Scientific Advisory Board of Conformis Inc, Bedford, MA, USA, he holds stocks or stock
options of Conformis Inc., Bedford, MA and he receives royalties for intellectual property. Drs. Bliss and Losina have no related
conflict with this study.
 Fitz et al. Page 2

Materials and Methods

Height, weight, and knee dimension sizes of a sample of cadaveric subjects were easured
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(Table I). All measurements were made 5 mm below the deepest point of the articular
surface of the medial and lateral tibial plateau. The sample was composed of 24 female and
24 male cadavers, showing no significant arthritic changes. No details on age or race were
available. We computed the mean and standard deviation of sample characteristics and
performed t-tests to test for differences between male and female subjects. Using paired
ttests we also compared lateral and medial knee dimensions and tested for differences in the
whole sample, among males only, and among females only. To examine how well the
component dimensions defined two cutoffs for determining whether components would
adequately fit the subject knee, a 2 mm no-fit was defined as a UKA component dimension
at least 2 mm smaller than the measured knee dimension.

We computed the proportion of subjects with at least one knee dimension 2mm larger than
at least one brand of UKA component. We computed the proportion of the sample with knee
dimensions at least 2 mm larger and compared measurements to current available UKA
systems (Table II & III). We focused on the two largest models (DePuy HP and Zimmer
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HF). The DePuy HP have the longest and widest tibial and Zimmer HF have the widest
femoral condyle dimensions. Of the subjects whose knees are at least 2 mm larger than the
DePuy and Zimmer components we determined how often it was the medial or lateral
condyle ML width which was too wide or how often the tibial AP medial and lateral lengths
were too long, and how often the tibial ML medial and lateral widths were too wide (Table
IV).

Results
The sample was composed of 24 female and 24 male cadavers. Height, weight and
dimensions for medial, lateral femoral and tibial plateau are displayed in Table I.
Differences of each measurement are included. While AP/ML ratios were similar between
males and females on the lateral tibial plateau, there were differences for the medial tibial
plateau and lateral femoral condyle. Among the total sample, lateral femoral condyle AP
length was significantly longer than the medial condyle. The same relationship was also true
for ML condyle width. Tibial lateral AP length was significantly shorter than the medial
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length while the lateral tibia ML width was longer than medial tibia ML width. Medial and
lateral femoral condyle AP/ML ratios were similar while the medial tibia AP/ML ratio was
significantly longer than the lateral ratio. The same relationships were true among males and
females only.

Eighteen knees were measured by two observers describing observer agreement for the knee
dimensions with means for coefficient of variation between 0.01 and 0.22. Our small
coefficient of variations indicate low variability with respect to the size of the mean.

Current available UKA brands have different dimensions, different AP/ML ratios and vary
between sizes. Tibial components AP lengths ranged from 3.8 cm to 5.7 cm and tibia ML
width ranged from 2.3 cm to 3.4 cm, corresponding to AP/ML ratios ranging between 1.46

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and 1.78 (Table III). Femoral ML width ranged from 1.8 cm to 2.6 cm. DePuy HP had the
largest tibial component (AP length = 5.7 cm, ML width = 3.4 cm) while Zimmer HF had
the largest femoral ML width (2.6 cm). All female tibial knee dimensions fall within +/- 2
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mm of the range of UKA component dimensions for all UKA brands. Two knees exceeded
the ML width dimensional range for all brands of UKA components while one exceeded all
AP length dimensional ranges.

UKA dimensions are smaller than measured sizes and overall no-fit compared to any
component within 2 mm is high (91.7%) and worse for males (100%) compared to females
(83.3%) (Table IV). Comparing the UKA brand with the longest AP dimensions good fit
was observed for the medial tibial plateau (Table IV) : two male knees (8.3%) had longer
AP dimension of 2 mm. For the widest ML UKA brand three male knees (12.5%) had wider
ML dimensions of 2 mm. For the lateral tibial plateau, AP fit within 2 mm was good and
only 1 male knee (4.6%) exceeded 2 mm. The ML fit for the widest UKA brand showed 7
male knees (29.2%) had larger dimensions of more than 2 mm.

Coverage of the medial and lateral femoral condyle is worse. Femoral condyle ML widths
were at least 2 mm longer than the widest femoral component for 16 (66.7%) of male medial
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condyles, 21 (87.5%) of male lateral condyles, 2 (8.3%) of female medial condyles, and 5
(20.8%) of female lateral condyles.

Discussion
As more encouraging long-term results after UKA are published, indications are extended to
younger and heavier patients. Weight and activity have been discussed controversially in the
literature and some implants reported no higher failure rate in heavier patients in resurfacing
Marmor implants (4,5). Similar results were published for the Miller-Gallante UKA
(1,9,15,16,22) but not with inset all-poly tibiae or narrow implants in patients with a BMI
above 32 (2). We wondered whether, besides implant design and surgical technique, the
dimensions of femoral and tibial implants could play a role and how well current available
implants fit.

We hypothesized that all currently available components of modern UKA fit within 2 mm.

For the medial tibial plateau overall implant fit was better for females. Looking at the
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implant with the largest ML width, 12.5% had wider tibial plateaus by 2 mm. This describes
the best case scenario using the largest implant in respect to AP length and ML width. We
did not compute the coverage for smaller implants, which would result in worse coverage
and higher percentages of patients with larger medial or lateral tibial plateaus. However,
these numbers show that specifically for larger males, improvement of tibial coverage is
desirable for both tibial plateaus but even more so on the lateral side.

The poor fit of femoral components should be cautiously interpreted. Both condyles have a
different geometry with the medial femoral condyle being more curved and the lateral
condyle being more straight. Given these geometric differences the implants have to be
narrower, otherwise surgeons would not be able to rotate and place the components along
the specific curvature of both condyles. Asymmetric components fit better on the medial

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side and worse laterally. A symmetric femoral component fits better onto the lateral condyle.
No femoral component is designed for the lateral condyle with an anterior radius twice that
of the medial side and being shorter anteriorly compared to the medial condyle (12,20).
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Our measurements are comparable to other publications which studied tibial fit. Servien et
al (19) measured tibial CT after 17 medial and 18 lateral UKA's. Average AP length was
50.8 mm for the medial and 47.2 mm for lateral plateau with a ML width of 28.8 medially
and 29.3 on the lateral side. They calculated an AP/ML ratio of 1.8 medial and 1.6 lateral.
Our measurements are similar, but our ML widths are wider. We measured CTs of normal
non-arthritic knees 5 mm below the lowest point of medial and lateral tibial plateau, which
may be slightly higher compared to Servien et al (19) measurements, since they measured
the dimension just below the implant of CT. Servien et al sample was not well balanced,
since 31 of 37 subjects were females (19). Servien et al observed that some tibial
components matched the medial tibial plateau better than others and vice versa the lateral
tibial condyle. Authors felt that better coverage could be a success factor. Surgeons tend to
avoid medial overhang and therefore downsize the tibial implant by compromising
anteroposterior coverage.
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For the Korean population, smaller values are described in one publication for the medial
tibia only : 47.1 mm for AP dimension (male 49.8 mm and female 47.1 mm) and 24.8 mm
for ML dimension (26.1 mm for male and 23.5 mm for females) (21). Our measurements are
similar for the female AP lengths, but not for the rest : our male AP measurements are 6 mm
longer and our ML dimensions 6 mm wider (males 7 mm wider and females 5 mm).
Surendan et al (21) concluded that for the Korean population UKA brands tend to oversize
in the ML dimension. Fitzpatrick et al concluded that even theoretical optimized implants
could not cover more than 76% of the exposed cortical rim (7). Insufficient tibial coverage
may induce tibial plateau collapse (3,10) if forces are transmitted to cancellous bone. The
described differences of various components are important and surgeons may benefit from
knowing specific sizes in regard to AP length and ML width for medial, lateral femoral and
tibial condyles.

Our study describes limitations of current available unicompartmental implants for both,
medial and lateral, femoral and tibial condyles. The worst fit was observed for the lateral
tibial plateau and for both femoral condyles. A different tibial implant, rounder with a lower
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AP/ML ratio would improve lateral tibial plateau fit. Design improvements for medial and
lateral femoral condyles are difficult and limited due to the different geometry of medial and
lateral femoral condyles. Surgeons should be aware of the consequences of using an
asymmetric versus a symmetric femoral component for either medial or lateral femoral
condyle and the consequences of poor fit. Surgeons should use implant sizes and their
potential to improve implant fit for their different patients.

References
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2. Berend KR, Lombardi AV Jr, Mallory TH, Adams JB, Groseth KL. Early failure of minimally
invasive unicompartmental knee arthroplasty is associated with obesity. Clin Orthop Relat Res.
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11. McGovern TF, Ammeen DJ, Collier JP, Currier BH, Engh GA. Rapid polyethylene failure of
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results of a prospective randomised controlled trial. J Bone Joint Surg. 2009; 91-B:5257.
14. Patil S, Colwell CW Jr, Ezzet KA, D'Lima DD. Can normal knee kinematics be restored with
unicompartmental knee replacement ? J Bone Joint Surg. 2005; 87-A:332338. [PubMed:
15687156]
15. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental knee arthroplasty in
patients sixty years of age or younger. J Bone Joint Surg. 2003; 85-A:19681973. [PubMed:
14563806]
16. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Lateral unicompartmental knee
arthroplasty : survivorship and technical considerations at an average follow-up of 12.4 years. J
Arthroplasty. 2006; 21:1317. [PubMed: 16446180]
17. Price AJ, Dodd CA, Svard UG, Murray DW. Oxford medial unicompartmental knee arthroplasty in
patients younger and older than 60 years of age. J Bone Joint Surg. 2005; 87-B:14881492.
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18. Robertsson O, Knutson K, Lewold S, Lidgren L. The Swedish Knee Arthroplasty Register
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Orthop Scand. 2001; 72:503513. [PubMed: 11728079]
19. Servien E, Saffarini M, Lustig S, Chomel S, Neyret P. Lateral versus medial tibial plateau :
morphometric analysis and adaptability with current tibial component design. Knee Surg Sports
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menisci in the movement of the knee. Tokushima J Exp Med. 1961; 8:189202. [PubMed:
13912036]
21. Surendran S, Kwak DS, Lee UY, et al. Anthropometry of the medial tibial condyle to design the
tibial component for unicondylar knee arthroplasty for the Korean population. Knee Surg Sports
Traumatol Arthrosc. 2007; 15:436442. [PubMed: 16964513]
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Table I
Sample description and comparison of male to female measures

Total Males Females P-Value Comparing Males to Females

Fitz et al.

Height (cm) 168.7(10.3) 173.6(9.1) 163.4(8.9) p<0.001

Weight (kg) 73.8(21.9) 74.9(22.2) 72.6(20.6) p=0.715

Medial Tibia AP Length 5.06(0.46) 5.37(0.38) 4.75(0.29) p<0.001

Medial Tibia ML Width 3.04(0.32) 3.27(0.25) 2.82(0.19) p<0.001

Lateral Tibia AP Length 4.74(0.46) 5.03(0.34) 4.45(0.38) p<0.001

Lateral Tibia ML Width 3.21(0.32) 3.41(0.26) 3.01(0.23) p<0.001

Medial Condyle AP Length 5.73(0.45) 6.01(0.33) 5.45(0.37) p<0.001

Medial Condylar ML Width 2.61(0.29) 2.80(0.23) 2.43(0.22) p<0.001

Lateral Condyle AP Length 6.23(0.51) 6.55(0.35) 5.92(0.45) p<0.001

Lateral Condylar ML Width 2.85(0.33) 3.09(0.25) 2.61(0.19) p<0.001

Med/Fem Art. Surface AP Length 4.84(0.41) 5.04(0.35) 4.65(0.38) p=0.001

Lat/Fem Art. Surface AP Length 4.46(0.47) 4.71(0.41) 4.22(0.41) p<0.001

Lateral Tibia AP/ML Ratio 1.48(0.09) 1.48(0.11) 1.48(0.08) p=0.869

Medial Tibia AP/ML Ratio 1.67(0.09) 1.64(0.10) 1.69(0.08) p=0.093

Lateral Condyle AP/ML Ratio 2.2(0.17) 2.13(0.17) 2.27(0.12) p=0.002

Medial Condyle AP/ML Ratio 2.21(0.18) 2.16(0.19) 2.25(0.18) p=0.080

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Table II

a: Tibial implant dimensions (cm) of available UKAs

Fitz et al.

Size 1 Size 2 Size 3 Size 4 Size 5 Size 6

AP - ML (Ratio) AP - ML (Ratio) AP - ML (Ratio) AP - ML (Ratio) AP - ML (Ratio) AP - ML (Ratio)

[1] Stryker Triathlon 4.1-2.3(1.78) 4.4-2.5(1.76) 4.7-2.7(1.74) 5.0-2.9(1.72) 5.3-3.1(1.71) 5.6-3.3(1.70)

[2] Depuy Sigma High Performance Partial Knee System 4.2-2.4(1.75) 4.5-2.6(1.73) 4.8-2.8(1.71) 5.1-3.0(1.70) 5.4-3.2(1.69) 5.7-3.4(1.68)

[3] Zimmer Unicompartmental High Flex Knee System 4.1-2.3(1.78) 4.4-2.5(1.76) 4.7-2.7(1.74) 5.0-2.9(1.72) 5.3-3.1(1.71) 5.6-3.3(1.70)

[4] Smith and Nephew Journey 3.8-2.4(1.58) 4.2-2.5(1.68) 4.6-2.7(1.70) 4.9-2.9(1.69) 5.2-3.0(1.73) 5.5-3.2(1.72)

[5] Biomet Oxford 3.8-2.6(1.46) 4.1-2.6(1.58) 4.4-2.8(1.57) 4.7-3.0(1.57) 5-3.2(1.56) 5.3-3.4(1.56)

[6] Wright Advance 4.0-2.4(1.67) 4.4-2.6(1.69) 4.9-2.9(1.69) 5.4-3.3(1.64)

b: Femoral implant dimensions of available UKAs

Femoral ML Width

Min (cm) Max (cm)

[1] Stryker Triathlon 1.9 2.4

[2] Depuy Sigma High Performance Partial Knee System 1.8 2.5

[3] Zimmer Unicompartmental High Flex Knee System 2.1 2.6

[4] Smith and Nephew Journey 1.8 2.5

[5] Biomet Oxford 1.9 2.3

[6] Wright Advance 1.9 2.2

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Table III
Proportion of sample with 2 mm-fits of components1 to knee dimensions
Fitz et al.

Total Males Females

2mm-Fit N(%) 2mm-No Fit N(%) 2mm-Fit N(%) 2mm-No Fit N(%) 2mm-Fit N(%) 2mm-No Fit N(%)

Any component2 4 (8.3) 44 (91.7) 0 (0.0) 24 (100) 4 (16.7) 20 (83.3)

Depuy3 13 (27.1) 35 (72.9) 0 (0.0) 24 (100) 13 (54.2) 11 (45.8)

Zimmer4 20 (41.7) 28 (58.3) 2 (8.3) 22 (91.7) 18 (75.0) 6 (25.0)

1
2mm-Fit defined as subject knee dimension lies within +/- 2mm of component dimension, 2mm-No Fit defined as subject knee dimension larger than component dimension +2mm.
2
Any component displays number and proportion of sample with at least one knee dimension larger than at least one of the available component sizes.
3
Depuy has longest Tibial AP Length and Tibial ML Width.
4
Zimmer has widest Femoral condylar ML Width.

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Table IV
Dimensions where Depuy and Zimmer components are 2mm smaller than subject
measures
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Depuy Dimensions 2 mm smaller than subject Zimmer Dimensions 2 mm larger than subject
measure1 measure 2

Males N(%) Females N(%) Males N(%) Females N(%)

Total 22 (100.0) 11 (45.8) 22 (91.7) 6 (25.0)

Femoral condyle3 ML
Width

Medial 17 (70.8) 4 (16.7) 16 (66.7) 2 (8.3)

Lateral 23 (95.8) 10 (41.7) 21 (87.5) 5 (20.8)

Tibia AP Length

Medial 2 (8.3) 0 (0.0) 3 (12.5) 0 (0.0)

Lateral 0 (0.0) 0 (0.0) 1 (4.2) 0 (0.0)

Tibia ML Width

Medial 3 (12.5) 0(0.0) 6 (25.0) 0 (0.0)

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Lateral 7 (29.2) 0(0.0) 12 (50.0) 1 (4.2)

1
Depuy has longest Tibial AP Length and Tibial ML Width
2
Zimmer has widest Condylar ML Width
3
AP length of condylar component part not published sole comparison for this part of the UKA component is the ML width
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