The Journal of Arthroplasty 35 (2020) 2435e2438

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Primary Knee

Differences in Pain, Opioid Use, and Function Following

Unicompartmental Knee Arthroplasty compared to Total Knee
Arthroplasty
Siddharth A. Mahure, MD, MBA *, James E. Feng, MD, MS,
Ran M. Schwarzkopf, MD, MSc, William J. Long, MD, FRCSC
Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, NY

a r t i c l e i n f o a b s t r a c t

Article history: Background: We sought to determine if immediate postsurgical pain, opioid use, and clinical function
Received 25 March 2020 differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA).
Received in revised form Methods: A single-institution database was utilized to identify patients who underwent elective total
16 April 2020
joint arthroplasty between 2016 and 2019.
Accepted 20 April 2020
Results: In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients
Available online 27 April 2020
were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid
consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001)
Keywords:
unicompartmental knee arthroplasty
along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA.
total knee arthroplasty Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute
same-day discharge Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged
opioids home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably,
mobilizations when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences
outcomes regarding pain scores, opioid utilization, or mobilization were observed.
Conclusion: UKA patients are younger, have lower body mass index and American Society of Anesthe-
siologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of
stay than TKA patients and were discharged home more often than TKA patients, on both the day of
surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and
were found to require 45% lower opioid medication in the immediate postsurgical period than TKA
patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of
pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can
be successfully translated to outpatient TKAs with similar outcomes.
Level III Evidence: Retrospective Cohort Study.
© 2020 Elsevier Inc. All rights reserved.

Unicompartmental knee arthroplasty (UKA) has been demon- limited the patients deemed eligible for the procedure. Despite these
strated to be a reliable procedure in appropriately selected patients. initial guidelines, there has been significant debate regarding
Based on their early clinical experience, Kozinn and Scott [1] pro- appropriate patient selection [2,3], with some authors suggesting
vided strict contraindications to performing UKA which significantly that more lax criteria are indicated. In combination with the
expanding indications, the availability of robotic-assisted UKA con-
tinues to increase and thus there has been a renewed interest for
Investigation was performed at the New York University Langone Orthopedic performing UKA [4]. Despite this resurgence, total knee arthroplasty
Hospital, New York, NY (TKA) remains the most reliable procedure for relieving patient pain
and improving function associated with end-stage degenerative joint
No author associated with this paper has disclosed any potential or pertinent
conflicts which may be perceived to have impending conflict with this work. For disease of the knee. In an effort to provide comparative data reflective
full disclosure statements refer to https://doi.org/10.1016/j.arth.2020.04.072. of modern practice trends, we sought to determine how pain levels,
* Reprint requests: Siddharth A. Mahure, MD, MBA, Department of Orthopaedic opioid requirements, and mobilization with therapy differed in the
Surgery, New York University Langone Orthopaedic Hospital, 301 East 17th Street,
immediate postoperative period between UKA and TKA.
New York, NY 10003.

https://doi.org/10.1016/j.arth.2020.04.072
0883-5403/© 2020 Elsevier Inc. All rights reserved.
2436 S.A. Mahure et al. / The Journal of Arthroplasty 35 (2020) 2435e2438

Methods Table 1
Comparison of Baseline Demographics Between UKA and TKA Patients.

Data Source Sample Size UKA TKA P Value

119 6497
A single-institution total joint arthroplasty database was used to
Age 61.00 (11.11) 66.03 (9.58) <.0001
identify patients who underwent a primary TKA or UKA from 2016
BMI 30.67 (5.58) 32.61 (6.40) <.0001
to 2019. Both UKA and TKA were performed by multiple surgeons at % Male 51.26% 31.60% <.0001
the institution. Data were collected from our institution’s electronic Race
data warehouse, Epic Caboodle (Verona, WI). All data were White 71.43% 54.53% <.0001
Black 12.61% 20.07%
collected prospectively.
Asian 3.36% 4.34%
Other 12.61% 21.06%
Outcomes of Interest ASA status
Class 1 0.84% 1.65% <.0001
We collected information regarding surgical procedure, patient Class 2 67.23% 49.39%
Class 3 31.09% 46.54%
age, gender, American Society of Anesthesiologists (ASA) scores,
Class 4 0.84% 2.42%
discharge disposition, surgical time, and length of stay (LOS). Sur-
ASA, American Society of Anesthesiologists; BMI, body mass index; TKA, total knee
gical time was derived from the time of incision and time of closure
arthroplasty; UKA, unicompartmental knee arthroplasty.
documented in Epic and calculating the difference between the
two. Discharge disposition was stratified as home-bound or non-
home-bound. Pain score is documented in Epic during the pa- this trend with UKA patients staying nearly 1.5 days less than TKA
tients’ hospitalization using the Visual Analog Pain Scale, and this cohort (1.03 ± 1.36 vs 2.48 ± 1.52 days; P < .0001). Notably, UKA
was recorded for the 0-hour to 12-hour postoperative period and patients were discharged home at significantly higher rates than
the 12-hour to 24-hour postoperative period. Although all of our TKA patients (96.6% vs 83.0%; P < .0001) (Table 2).
TKAs and UKAs were done in the same hospital, we recognized that Postoperative pain scores for all UKA patients were found to be
often UKA patients are discharged home the same day, and thus we significantly lower at both 12 hours (1.98 vs 2.58; P < .001) and
performed subgroup analysis comparing UKA and TKA patients 24 hours postoperatively (4.60 vs 5.0; P ¼ .0500). Analysis of opioid
who had a same-day discharge and also among those who had LOS consumption mirrored pain scores, with UKA patients requiring
of at least 1 day. Inclusion criteria included patients aged 18 years less opioids during the first 24 hours (36.83 vs 56.14 MMEs; P ¼
and older who had undergone TKA or UKA for all causes. Exclusion .0218) and 48 hours (29.17 vs 43.45 MMEs; P ¼ .0207) than TKA
criteria included patients who had undergone simultaneous bilat- patients along with less aggregate opioid requirement overall
eral TKA/UKA, any revision procedures, or those for fracture-care. (75.94 vs 136.5 MMEs; P < .001).
Morphine milligram equivalents (MMEs) were calculated for each Analysis of postoperative mobilization with therapy via AMPAC
patient based on opioid consumption for 0-24 hours, 24-48 hours, scores demonstrated that UKA patients were significantly quicker
as well as for the entire hospitalization. This calculation was based to achieve higher scores than those in the TKA cohort (21.02 vs
on conversion factors described by the Centers for Disease Control 18.76; P < .001).
and Prevention and the American Pain Society [5,6]. The Activity Thirty seven percent of UKA patients were discharged home the
Measure for Post-Acute Care (AMPAC) scores were calculated for same day as compared to 2.45% of TKAs (P < .0001). Subgroup
each patient for their first 24 hours postoperatively to monitor analysis (Table 3) demonstrated that among patients discharged
physical therapy progress. This score has been previously validated home on POD 0, no differences were noted between UKA and TKA
for use in the postoperative setting [7]. Both UKA and TKA cohorts patients regarding aggregate opioid consumption (11.25 ± 11.97 vs
were part of same protocol which consisted of spinal anesthesia 11.64 ± 21.02; P ¼ .8796) or pain scores (1.52 ± 1.69 vs 1.61 ± 1.84;
intraoperatively, opioid-sparse protocol postoperatively, and initi- P ¼ .7877). Additionally, both groups had similar AMPAC mobili-
ation of physical therapy on postoperative day (POD) 0. No changes zation scores (23.24 ± 1.80 vs 23.00 ± 2.21; P ¼ .6651).
occurred during our 3-year study period. Analysis of the 63% of UKA patients and 97.55% of TKA patients
who had LOS of at least 1 day demonstrated several differences
Statistical Analysis between groups (Table 4). LOS for UKA patients was less than TKA
cohort (1.64 ± 1.40 vs 2.54 ± 1.49 days; P < .0001) and UKA patients
For categorical variables, chi-squared analysis was utilized to were discharged home at significantly higher rates than TKA pa-
determine statistically significant differences between groups tients (94.7% vs 83.0%; P < .0001). Postoperative pain scores for UKA
while the Student’s t-test was utilized for numerical variables. SAS patients in this subset were found to be significantly lower at
9.3 (Cary, NC) was utilized for all statistical analyses and P values 24 hours postoperatively (4.60 vs 5.0; P ¼ .0500). Opioid con-
<0.05 were considered statistically significant. sumption reflected pain scores, with UKA patients requiring less
opioids during the 24-hour to 48-hour period (29.17 vs 43.45 MMEs;
Results P ¼ .0207) than TKA patients along with less aggregate opioid
requirement overall (107.0 vs 149.4 MMEs; P < .001). Finally, AMPAC
A total of 6616 cases were identified: 98.20% TKA (6497) and scores demonstrated that even when having a minimum LOS of 1
1.80% (119) UKA. Analysis of baseline demographics (Table 1) day, UKA patients were still significantly quicker to achieve higher
demonstrated that UKA patients were significantly younger than scores than those in the TKA cohort (20.15 vs 18.65; P ¼ .0252).
TKA patients (61.00 vs 66.02 years; P < .001) and were more likely
to be male (51.26% vs 31.60; P < .0001). Additionally, UKA patients
had lower BMIs (30.67 vs 32.62; P < .001) and significantly lower Discussion
ASA scores than TKA patients, indicating lower comorbidity burden
(class 3: 31.09% vs 46.54%; P < .0001). This study demonstrates that compared to traditional TKA pa-
Surgical time for UKA was significantly shorter than TKA tients, UKA patients tended to be younger, healthier, and more
(102.6 ± 29.17 vs 112.0 ± 39.49; P ¼ .005) and mean LOS followed likely to be male. Additionally, UKA patients reported significantly
 S.A. Mahure et al. / The Journal of Arthroplasty 35 (2020) 2435e2438 2437

Table 2 is our opinion that the decreased pain scores for UKA is multifactorial
Comparison of Immediate Outcomes for All Patients. and may be due to smaller incision sizes, diminished stress to soft
Sample Size UKA TKA P Value tissues intraoperatively, decreased requirement for bone cuts, and
119 6497
possibly higher pain tolerance associated with younger patients.
However, this commonly held believe conflicts with the findings of
Surgical time 102.6 ± 29.17 112.0 ± 39.49 .005
our subgroup analysis demonstrating similar pain scores and opioid
LOS (d) 1.03 ± 1.36 2.48 ± 1.52 <.0001
Home discharge (%) 96.64% 83.04% <.0001 consumption when comparing outpatient TKAs to UKAs, thus sug-
Total MME 75.94 ± 135.5 136.5 ± 232.8 <.0001 gesting that the distinction between the groups that has previously
MME 0-24 h 36.83 ± 37.33 56.14 ± 91.71 .0218 been published may be a result of patient-related factors and ex-
MME 24-48 h 29.17 ± 40.01 43.45 ± 46.00 .0207
pectations, rather than the surgical procedure.
Pain score 0-12 h 1.98 ± 1.93 2.58 ± 1.90 <.0001
Pain score 12-24 h 4.60 ± 1.93 5.0 ± 1.70 .0500 Although prior authors have commented upon lower UKA pain
AMPAC raw score 21.02 ± 3.54 18.76 ± 3.44 <.0001 scores, to our knowledge we are the first to report upon decreased
AMPAC, Activity Measure for Post-Acute Care; LOS, length of stay; MME, morphine
opioid requirements of UKA patients compared to TKA patients. Our
milligram equivalent; TKA, total knee arthroplasty; UKA, unicompartmental knee data demonstrated that at 24 hours UKA patients required 36% less
arthroplasty. opioids than TKA patients, a difference that remained consistent at
48 hours with UKA patients requiring 33% less opioids. Notably,
lower postoperative pain scores that were associated with less aggregate opioid consumption for UKA patients was 45% less than
opioid consumption. UKA patients mobilized significantly quicker those who underwent TKA. The significance of UKA patients
with therapy and had an overall LOS in days that was only 41% of requiring nearly 50% of opioids compared to TKA patients is
total LOS for TKA patients. Finally, UKA patients were able to be particularly relevant during preoperative counseling patients,
discharged home on POD 0 at significantly higher rates than TKA especially in light of the opioid epidemic and the responsibility of
patients (37% vs 2.45%; P < .0001) and analysis found that even orthopedic surgeons in minimizing abuse [16e18]. Rhon et al [19]
when admission was required, UKA patients had superior metrics found that younger age was an independent risk factor for chronic
than TKA patients in all categories. prescription opioid abuse after orthopedic surgery, data that
Our results reporting demographics and immediate periopera- become particularly relevant given the younger age of UKA patients
tive results for UKA are in line with the literature. UKA patients in at the time of surgery. We feel that our data regarding reduced
our series were on average 5 years younger than TKA patients, opioid utilization in UKA patients provide the impetus to aggres-
similar to a study of 2243 patients by Ko et al [8] that reported age sively develop more multimodal protocols in TKA patients along
of UKA patients significantly younger than TKA patients (62.9 vs with an understanding of how patient perception of procedure and
67.1; P < .0001). The reason for this is likely due to a combination of expectations can be leveraged to reduce opioid consumption.
surgeon preference and younger patients opting for what they Indeed, the fact that UKA and TKA patients discharged the same day
perceive as “less invasive” surgery compared to TKA. Moorman et al as procedure were similar in terms of opioid consumption and pain
[9] surveyed patients and reported that the “procedure that re- scores (Table 3) lends credence to the idea that patient selection
quires the least amount of bone cutting or removal would be ex- and setting of expectations can have a significant impact on out-
pected to be the most preferred surgical alternative,” thus comes, and that UKA protocols can be successfully translated to
corroborating patient perspective that UKA is “less surgery” than selected TKA patients.
TKA. Additionally, various authors have reported that patients Our data demonstrate that UKA patients had higher AMPAC
correlate smaller incisions for UKA as indicating a less invasive scores indicating quicker mobilization with physical therapy than
procedure [10], and it is possible that younger patients may care TKA patients. A prior systematic review also found that UKA pa-
more for cosmesis than an elderly cohort. Similar to other studies, tients had greater postoperative knee range of motion than TKA
we found that UKA patients were more likely to be male than fe- patients (125 vs 114 ; P ¼ .004) [20]. We believe that the quicker
male [8,11,12]dtrends that are possibly reflective of occupational- mobilization of UKA patients is multifactorial and due to a combi-
related demands of younger male UKA cohort. Finally, the nation of higher preoperative functional status along with a shorter,
decreased comorbidity burden that we noted at the time of UKA as less invasive procedure resulting in less pain and opioid related side
compared to TKA is likely multifactorial and correlated with effects (such as nausea, vomiting, and sedation) than those in the
younger patient age and higher preoperative functional status TKA group. We believe that combination of all of these factors is
[8,13] resulting in improved cardiopulmonary health. why UKA patients had an overall LOS that was 1.5 days shorter than
The shorter surgical time reported for UKA in our series has been TKA patients and allowed nearly 96% of them to be discharged
corroborated by prior authors [13,14]. Postoperatively, we found that home as compared to only 83% of TKA cohort, along with 37% (vs
UKA patients reported significantly less pain than their TKA coun-
terparts at 24 hours postoperatively, findings that have been previ- Table 4
Subgroup Analysis for UKAs and TKAs With LOS Greater Than Zero.
ously confirmed in both the immediate postoperative period [3,8,15]
and also 10-year follow-up data for 599 propensity-matched UKAs. It UKA TKA P Value

N ¼ 75 (63% of N ¼ 6338 (97.55%

Table 3 All UKAs) of All TKAs)
Subgroup Analysis for UKAs and TKAs With Same-Day Discharge.
Surgical time 102.1 ± 28.8 108.7 ± 39.1 .0507
UKA TKA P Value LOS (d) 1.64 ± 1.40 2.54 ± 1.49 <.0001
Home discharge (%) 94.67% 82.64% <.0001
N ¼ 44 (37% of All UKAs) N ¼ 159 (2.45% of All TKAs) Total MME 107.7 ± 162.3 149.4 ± 235 <.0001
Surgical time 117.6 ± 39.8 122.7 ± 30.1 .3542 MME 0-24 h 51.6 ± 36.2 57.26 ± 92.91 .5954
Total MME 11.25 ± 11.97 11.64 ± 21.02 .8796 MME 24-48 h 29.17 ± 40.01 43.45 ± 46.00 .0207
Pain score 0-12 h 1.52 ± 1.69 1.61 ± 1.84 .7877 Pain score 12-24 h 4.60 ± 1.93 5.0 ± 1.70 .0500
AMPAC raw 23.24 ± 1.80 23.00 ± 2.21 .6651 AMPAC raw score 20.15 ± 3.68 18.65 ± 3.41 .0252
score AMPAC, Activity Measure for Post-Acute Care; LOS, length of stay; MME, morphine
AMPAC, Activity Measure for Post-Acute Care; MME, morphine milligram equiva- milligram equivalent; TKA, total knee arthroplasty; UKA, unicompartmental knee
lent; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty. arthroplasty.
2438 S.A. Mahure et al. / The Journal of Arthroplasty 35 (2020) 2435e2438

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