Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-017-4536-4

KNEE

Satisfactory outcomes following combined unicompartmental

knee replacement and anterior cruciate ligament reconstruction
Andrea Volpin1 · S. G. Kini2 · D. E. Meuffels3

Received: 30 January 2017 / Accepted: 27 March 2017

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Abstract arthroplasty and anterior cruciate ligament reconstruction;

Purpose There exist limited options for treatment of patient’s clinical and/or functional outcomes were reported;
patients with combined medial compartment arthritis and any complications intra-operatively and post-operatively
anterior cruciate ligament (ACL) deficiency. Ideal treatment were reported; and the full-text articles, written in English,
is one that offers lasting relief of symptoms not compro- German, Italian, Dutch or Spanish, were available. Quality
mising any future surgery. Unicompartmental knee replace- and risk of bias assessments were done using standardized
ment has shown consistently good results in the relatively criteria set.
young and active population, but there is a high reported Results A total of 8 studies met the inclusion criteria
incidence of failure up to 20%, if performed in ACL-defi- encompassing 186 patients who were treated with simul-
cient knees. One of the recognized treatment modality taneous ACL reconstruction and unicompartmental knee
is combined ACL reconstruction and unicompartmental arthroplasty. The mean age was 50.5 years (range from 44
arthroplasty. A systematic review was conducted looking at to 56) with a mean follow-up of 37.6 months (range from
the demographics, techniques, complications and outcome 24 to 60). There was an improvement in mean Oxford
of combined ACL reconstruction with unicompartmental Score from 27.5 to 36.8. Complications reported included
knee arthroplasty. tibial inlay dislocation (n = 3), conversion to a total knee
Methods A systematic literature search within the online arthroplasty (n = 1), infection requiring two-stage revision
Medline, PubMed Database, EMBASE, Web of Sci- (n = 2), deep-vein thrombosis (n = 1), stiffness requiring
ence, Cochrane and Google Scholar was carried out until manipulation under anaesthesia (n = 1), retropatellar pain
October 2016 to identify relevant articles. A study was requiring arthroscopic adhesiolysis (n = 1).
defined eligible if it met the following inclusion criteria: Conclusion Unicompartmental knee arthroplasty com-
the surgical procedure combined unicompartmental knee bined with ACL reconstruction can be a valid treatment
option for selected patients, with combined medial unicom-
partmental knee osteoarthritis and ACL deficiency.
Electronic supplementary material The online version of this Level of evidence Systematic Review of Level IV Studies,
article (doi:10.1007/s00167-017-4536-4) contains supplementary
material, which is available to authorized users.
Level IV.

* Andrea Volpin Keywords Unicompartmental knee replacement · Anterior

[email protected] cruciate ligament · Knee arthroplasty · Partial knee
1 replacement
Department of Trauma and Orthopaedics, University College
London Hospital, 235 Euston Road, London NW1 2BU, UK
2
Department of Trauma and Orthopaedics, Manipal Hospital,
Bangalore, India Introduction
3
Department of Orthopaedic Surgery, Erasmus MC,
University Medical Centre Rotterdam, s’ Gravendijkwal 230, Patients with a primary anterior cruciate ligament (ACL)
3000 CA Rotterdam, The Netherlands injury who develop secondary osteoarthritis (OA) are

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 Knee Surg Sports Traumatol Arthrosc

usually young and active [27]. Recurrent episodes of giv- outcomes were reported; (3) any complications intra-oper-
ing way in which posterior femoral subluxation occurs lead atively and post-operatively were reported; (4) the full-text
progressively to posteromedial wear and OA [13, 34]. The articles were available; and (5) the articles were written in
medial collateral ligament (MCL) and the lateral compart- English, German, Italian, Dutch or Spanish.
ment are usually normal [17, 30]. The treatment options All the articles that did not meet the above criteria were
reported in the literature include arthroscopic debridement, excluded. This meant that biomechanical reports, studies
reconstruction of the ACL, high tibial osteotomy (HTO) on animals and cadavers, case reports, literature reviews,
with or without ACL reconstruction [14, 17], unicompart- technical notes, letters to editors and instructional courses
mental knee arthroplasty (UKA) with ACL reconstruction were all excluded.
[4, 10, 20] or total knee arthroplasty (TKA) [1, 32].
Due to younger age and higher activity levels seen in Search strategy
these specific patients, the goal of surgery should be to
offer a procedure that will give lasting relief of symptoms A systematic literature search (see Appendix 1) was per-
and more importantly not compromise any future surgery formed using a computer-based search within the online
with a bone-conserving option. Medline (OvidSP), PubMed Database (US National Library
In particular, high tibial osteotomy, with or without ACL of Medicine, National Institutes of Health), EMBASE, Web
reconstruction, may improve the patient’s symptoms but of Science, Cochrane and Google Scholar for articles pub-
does not completely abolish pain, and lateral compartment lished up to and including till October 2016.
osteoarthritis is a common sequel [11]. The references within any article were searched to iden-
The described advantages of unicompartmental arthro- tify further papers.
plasty over total knee replacement are preservation of bone
stock, less invasive surgery, minimal blood loss, faster
recovery, better range of movement and more physiological Identification of eligible studies
function [12].
Recent studies have shown that, with the proper patient The systematic review was performed in accordance with
selection and surgical technique, UKA can have perfor- the PRISMA guidelines, and it was registered on the
mance and survivorship comparable with total knee arthro- PROSPERO register with number CRD42016032745.
plasty or high tibial osteotomy [2]. When a UKA was Identified studies were screened, based on title and/or
placed in ACL-deficient knees, it had an unacceptably high abstract, independently by 2 reviewers (A.V. and K.S.G.)
rate of failure due to an increased anterior excursion of the Duplicates and non-relevant articles were excluded.
tibia on the femur that increases the contact forces on the Full-text versions of the selected studies were reviewed,
tibial component causing it to rock loose [7, 8]. Therefore, and if they met the eligibility criteria, the study was
UKA was considered to be contraindicated in this circum- included in the current systematic review. Disagreements
stance [7, 8]. were solved by consensus between the two reviewers or
Concomitant ACL reconstruction with UKA addresses with the third senior investigator. Initial inclusion was ini-
issues of both instability and wear. To date, no studies tially based upon the studies title and abstract, but the latter
have compared the outcomes of this combined techniques stages of the review process excluded papers based on the
and this study aims to summarize the current evidence and full-text articles.
outcomes clarifying the patient indications and the surgi-
cal techniques. A review was carried out regarding UKA in Data extraction and quality assessment
patients with isolated one-compartment osteoarthritis and
concomitant ACL deficiency with functional instability, in Two authors independently extracted and then reviewed
whom ligament reconstruction was undertaken as a com- the following details by using standardized forms: authors,
bined procedure. year of publication, geographical location of study, study
design/level of evidence, study population (knee/patients),
patient sex and age, follow-up duration, interventions, out-
Materials and methods comes and identification of any complications intra-opera-
tively and post-operatively.
Eligibility criteria The risk of bias of studies was assessed using Deeks’
quality assessment tool [3].
Studies were considered eligible if the authors described Each study was assessed using a checklist (Table 1), but
(1) the surgical procedure of combined UKA and ACL the quality score calculated was not used as an exclusion
reconstruction; (2) patient’s clinical and/or functional criterion [28].

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Knee Surg Sports Traumatol Arthrosc

Table 1  List of criteria used for methodological quality assessment

Question Response

Is there a clearly stated aim Did they have a “study question” or “main aim” or “objective”?
The question addressed should be precise and relevant in light of the
available literature
To be scored adequate the aim of the study should be coherent with the
“Introduction” of the paper
Inclusion of consecutive patients Did the authors say: “consecutive patients” or “all patients during period
from … to …” or “all patients fulfilling the inclusion criteria”?
A description of inclusion and exclusion criteria Did the authors report the inclusion and exclusion criteria?
Prospective collection of data. Data were collected according to a Did they say “prospective”, “retrospective” or “follow-up”?
protocol established before the beginning of the study The study is NOT PROSPECTIVE when: chart review, database review,
clinical guideline, practical summaries
Surgical technique description Did they report the surgical technique description?
Outcome measures Did they report outcome measures to evaluate patients after the opera-
tion?
Unbiased assessment of the study outcome and determinants To be judged as adequate the following 2 aspects had to be positive:
Outcome and determinants had to be measured independently
Both for cases and controls, the outcome and determinants had to be
assessed in the same way
Were the determinant measures used accurate (valid and reliable)? For studies where the determinant measures are shown to be valid and
reliable, the question should be answered adequate. For studies, which
refer to other work that demonstrates the determinant measures are
accurate, the question should be answered as adequate
Loss to follow-up Did they report the losses to follow-up?
Adequate statistical analyses Was an adequate statistical analyses performed?

When the criterion was met in the article, one point was A flow chart of the literature search is presented in
given, otherwise zero points. Zero points were also given Fig. 1.
when information concerning the specific criterion was not According to the predefined criteria, 7 studies had a total
mentioned in the article [16, 28]. score higher than six points and were considered to have
A maximum score of ten points could be obtained. a low risk of bias. One article [4] did not meet the criteria
According to the total quality score, articles were consid- and was therefore considered to have a high risk of bias.
ered of high methodological quality if a total score of six The mean quality score was 7.7 (range from 4 to 10).
points or higher had been rewarded combined with a score The quality assessment scores are shown in Table 2.
of one point each for question six, seven, eight and ten. An overview of participants’ characteristics of the 8
The materials extracted by A.V. and K.S.G. were com- studies is summarized in Table 3.
pared to each other, and conflicting data were re-checked Two studies were [20, 23] were prospective studies
from the original papers and corrected after discussion. (Level III), and the remaining six studies were retrospective
If there was a difference in opinion on quality assess- studies (Level IV) [4, 10, 25, 26, 29, 30].
ment, consensus was reached by consulting a third reviewer The included studies varied in the number of participants
(DM). from 9 to 51 patients (118 males and 68 females) treated
with ACL reconstruction and UKA.
The mean age of all patients was 50.5 years (range from
44 to 56) with a mean follow-up of 37.6 months (range
Results from 24 to 60).

The literature search identified 324 potentially relevant Pre‑operative examination and investigations
studies: 271 publications were excluded based on title and
abstract, because they did not meet the inclusion criteria. All patients included in the studies were diagnosed with
Finally, a total of 16 studies were selected for reading full medial OA; however, the OA classification used and the
text, of these 8 studies fulfilled the inclusion criteria and severity of OA were not clearly defined (Table 4).
were eligible for analysis. No randomized controlled trials ACL deficiency was evaluated clinically in all
(RCTs) were available. studies, and in three studies [20, 23, 29], magnetic

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 Knee Surg Sports Traumatol Arthrosc

resonance imaging (MRI) was used to evaluate the knee

joint pre-operatively.

Surgical techniques

In three papers [20, 25, 30], a two-stage procedure was

undertaken in some cases (a total of 46 cases), while a
simultaneous ACL reconstruction and UKA were per-
formed in all other cases.
When a simultaneous combined procedure was under-
taken, a preliminary diagnostic knee arthroscopy was per-
formed in order to confirm the diagnosis of ligament lesion
in five studies [4, 23, 25, 26, 29].
In all the papers, the ACL reconstruction was carried
out first and subsequently the arthroplasty was implanted,
except in one study [10] where the femoral and tibial sur-
faces were prepared first for UKA and then the ACL tun-
nels were drilled.
A trans-tibial technique for drilling the femur tunnel was
reported in papers [10, 20, 23, 29, 30]. A single paper [4]
reported the using of the antero-medial portal with the knee
flexed a minimum of 110° for drilling the femoral tunnel.
The graft chosen for ACL reconstruction was mainly
hamstring autograft; in three papers [10, 20, 30], bone
Fig. 1  Flow chart of the selection of articles patellar bone autograft was used.

Table 2  Quality assessment Study Criteria Total

scores
1 2 3 4 5 6 7 8 9 10

Pandit [20] 1 1 1 1 1 1 1 1 1 0 9
Tinius [25] 1 1 0 0 1 1 0 1 1 1 7
Dervin [4] 1 1 0 0 1 0 0 0 1 0 4
Krishnan [10] 1 1 1 0 1 1 0 1 1 0 7
Weston-Simons [30] 1 1 1 0 1 1 1 1 1 1 9
Tinius [26] 1 1 1 0 1 1 0 1 1 1 8
Ventura [29] 1 1 1 0 1 1 0 1 1 1 8
Tian [23] 1 1 1 1 1 1 1 1 1 1 10

Each item scored one point if it met the methodological criteria listed in Table 1. If not, or the item was not
reported, a score of zero was assigned

Table 3  Characteristics of included studies

Study Year Country Number of patients Mean age, year and range Male/female ratio Mean follow-up, months and
range

Pandit [20] 2006 UK 15 49.8 (36–60) 13/2 33.6 (30–51.6)

Tinius [25] 2007 Germany 32 46 (40–57) 25/7 31 (10–38)
Dervin [4] 2007 Canada 10 52 (47–71) 5/5 20.4 (12–46.8)
Krishnan [10] 2009 Australia 9 56 (50–64) 5/4 24 (12–60)
Weston-Simons [30] 2012 UK 51 51 (36–57) 40/11 60 (12–120)
Tinius [26] 2012 Germany 27 44 (38–53) 11/16 53 (9–71)
Ventura [29] 2015 Italy 14 55 (45–59) 9/5 26.7 (24–40)
Tian [23] 2016 China 28 50.5 (41–61) 10/18 52 (24–96)

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Knee Surg Sports Traumatol Arthrosc

Table 4  Summary of the functional score utilized in the different studies

Study Outcome measure Pre-op mean score, range and [SD] Post-op mean score, range and [SD]

Pandit [20] Oxford Knee Score 29 (17–36) 46 (37–48)

Objective Knee Society Score 55 (25–83) 99 (95–100)
Functional Knee Society Score 85 (65–90) 96 (85–1000)
Tegner 1.6 (1–3) 3.8 (3–6)
Tinius [25] Knee Society Score 83.2 (44–103) 167.6 (145–177)
Dervin [4] NR NR NR
Krishnan [10] Oxford Knee Score 23.5 (20–58) 11 (10–12)
Knee Society Score 135 (64–167) 196 (190–200)
WOMAC 45 (35–52) 24 (21–27)
Weston-Simons [30] Oxford Knee Score 28 (16–46) [9.4] 41 (17–48) [6.3]
American Knee Society Functional Score 82 (45–100) [15] 95 (45–100) [10.7]
American Knee Society Objective Score 40 (25–80) [19.3] 75 (25–95) [16.2]
Tegner 2.5 (1–5) [1.2] 3.5 (1–5) [0.7]
Tinius [26] Knee Society Score 77.1 (±11.6) 166.03 (±12.1)
Ventura [29] Oxford Knee Score 29 (10.2) 43.2 (9.5)
Knee Osteoarthritis Outcome Score 62.7 (8.4) 81 (10.2)
WOMAC 72.1 (12.5) 85.8 (8.7)
Tegner 2 (1–3) 3 (2–4)
American Knee Society Functional Score 80 (14.2) 90 (15)
American Knee Society Objective Score 45 (12.9) 77 (13)
Tian [23] Oxford Knee Score 31 (7.1) 43 (4.2)
Objective Knee Society Score 60.4 (7.1) 84.5 (6.3)
Functional Knee Society Score 63.7 (6.5) 86.9 (5.3)
Tegner 4.4 (1.2) 5.3 (0.8)

NR not reported

The graft was fixed distally with interference screws in Functional and radiological outcomes
all the papers, while the femoral graft fixation was more
heterogeneous: interference screw in three series [10, The most often used outcome scoring systems were the
20, 30] TransFix® pin (Arthrex Germany GmbH) in two Oxford Knee Score (OKS) (used by four studies [10, 20,
series [25, 26] or a EndoButton CL (Smith & Nephew, 29, 30]) and the Knee Society Score (KSS) (used by four
Memphis, Tenn) [4, 23] or Rigid-Fix device (DePuy studies [10, 20, 25, 26]).
Mitek, Raynham, MA, USA) [29]. In one study [4], no functional outcomes scores were
Post-operative rehabilitation was described as for a used; all patients except one reported satisfied with the sur-
primary UKA in two studies [20, 30] and in two studies gical procedure, and they returned to their previous sport
as for standard ACL reconstruction [4, 10]. activities level ranged from vigorous hiking to downhill
Full weight bearing post-operatively was allowed in all skiing.
except in two studies, where partial weight bearing with
the use of two crutches was prescribed for either 4 weeks Complications
[29] or 2 weeks [23].
Ventura et al. [29] reported that isometric muscle exer- Complications reported included three cases of tibial inlay
cises were started the day following the surgery, flexion dislocation occurred that required open reduction and
less 90° was allowed in the first week and as tolerated in replacement of the mobile bearing [23, 30], a single case
the following ones, and then from the fourth week after of conversion to a total knee arthroplasty due to develop-
surgery, proprioception exercises were added. ment of symptomatic lateral compartmental osteoarthritis
Tian et al. [23] reported that patients were performing [30]. Others included a deep-vein thromboses at 2 years
exercises of quadriceps with initiative and straight leg post-operatively (one case) [25], retropatellar pain due to
rising since 6 h after operations. scar adhesion that was treated arthroscopically (one case)

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 Knee Surg Sports Traumatol Arthrosc

[25], knee joint stiffness that required manipulation under population of 15 subjects aged 36–60 years. After an aver-
anaesthesia and an arthroscopic lysis of the adhesions (one age follow-up of 2.8 years, all patients reported high level
case) [4]. There was one reported case of pain persistence of satisfaction with increase in both occupational and phys-
and joint limitation, at 16 months after surgery, treated with ical activity.
knee arthroscopy and loose body removal with relieving of Weston-Simons et al. [30] in their case series of 52 with
the symptoms [29]. single-stage and staged ACL/UKA procedures showed an
Two patients had post-operative knee infection and overall survival of 92.7% (95% CI 83.4–100) at 5 years and
underwent a two-stage revision to a total knee arthroplasty 92.7% (95% CI 78.9–100) at 8 years. There was no signifi-
[20, 30]. cant difference between patients who underwent simulta-
neous procedures and those who underwent staged proce-
dures with respect to the mean post- operative Oxford Knee
Score.
Discussion The decision whether to combine ACL reconstruction
with unicompartmental knee arthroplasty depends partly on
According to the results of the systematic review, the con- whether the primary disorder is ACL deficiency or arthri-
comitant ACL reconstruction with UKA is an efficacious tis of the medial compartment. In primary medial arthritis
and safe technique with limited complications, suggesting with an intact ACL, the erosion is located in antero-medial
the usefulness of this surgery in selected patients. compartment [33]. This may be ideal for unicompartmen-
The combined UKA and ACL reconstruction may have tal knee arthroplasty as the rest of the knee tends to be in
some advantages in comparison with a TKA, such as bone good condition. As the degenerative process progresses, the
stock preservation, less blood loss, better knee kinematics ACL may rupture secondarily and the tibial erosion extends
and greater cost-effectiveness [21]. posteriorly. This tends to be associated with shortening of
It is important to underline that instability of the knee the medial collateral ligament and progressive lateral com-
joint represents a contraindication to the implantation of an partment arthritis. Thus, in primary medial compartment
UKA in the ACL-deficient patient [24]. A functional ACL arthritis with secondary rupture of the ACL, a combined
is believed to be integral in the success of UKA [14, 16, ligament reconstruction and unicompartmental knee arthro-
25]. plasty is not considered appropriate because of the other
With an intact ACL, the medial unicompartmental knee associated changes. These patients, who are usually elderly,
arthroplasty has achieved survival rates in excess of 90% should be considered for TKA.
at ten and 15 years in many series [5, 19]. Even in patients Concerns with a combined UKA and ACL include post-
under 60 years of age, the survival was greater than 90% at operative stiffness, graft impingement, malposition of the
10 years [19]. ACL graft tunnels, undersizing of the tibial base plate try-
Goodfellow et al. [8] found that in their 103 unicompart- ing to avoid graft impingement, the potential for a stress
mental cases, there were a significantly higher percentage raiser or delayed proximal tibia fracture, aseptic loosen-
of failures in knees with a deficient ACL (16.2%) than in ing of the tibial base plate, especially in a mobile-bearing
knees with an intact ACL (4.8%). design if ACL reconstruction fails [22].
The majority of failures were due to early tibial loos- Technical factors such as proper tensioning of either
ening, with a 21% rate of revision observed by 2 years. It collateral ligaments or ACL are key factors to successful
was proposed that this loosening may have resulted from outcomes following mobile-bearing UKA, and its implan-
eccentric or increased loading caused by posterior femo- tation relies on the integrity of both ACL and medial col-
ral subluxation or instability [8]. Kinematic studies using lateral ligament [31].
fluoroscopy showed increased femoro-tibial translation Hernigou and Deschamps [9] noticed a significant cor-
at the medial compartment and less femoro-tibial rotation relation between the anterior translation and the posterior
in the ACL-deficient knee in comparison with the normal slope of the tibial component. They also recommended
knee [28]. They also seem to present more internal rotation tibial component implantation in a slope not exceeding 7°.
during flexion [29]. Decreasing the tibial slope will reduce the force in the ante-
A recent systematic review showed that HTO with ACL rior cruciate ligament.
reconstruction, while having a comparable survival to UKA Although the combined procedure is ideally suited to the
combined to ACL reconstruction, leads to a higher compli- young and recreationally active, there is a concern that the
cation rate [17]. excellent function may result in high physical demands on
Pandit et al. [20] reported the results of combined the knee, even when the patient is advised to restrict their
ACL reconstruction and medial mobile-bearing UKA in a activities [6]. It is therefore necessary to inform the patient

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Knee Surg Sports Traumatol Arthrosc

of the risk of failure that may require a subsequent revision 5. Deschamps G, Lapeyre B (1987) A review of 79 Lotus prosthe-
to a TKR [18] and that the revision surgery could be poten- ses with a follow-up of more than 5 years. Revue de Chirurgie
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This review has some limitations; the major drawbacks D (1997) Total knee replacement in young, active patients:
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different lengths of follow-up amongst the various studies. Surg [Am] 79-A:575–582
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In addition, the included studies used different score sys- ment in knee arthroplasty: a risk-factor with unconstrained
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grouping results. 8. Goodfellow JW, Kershaw CJ, Benson MK, O’Connor JJ
(1988) The Oxford Knee for unicompartmental osteoarthritis:
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9. Hernigou P, Deschamps G (2004) Posterior slope of the tibial
implant and the outcome of unicompartmental knee arthro-
Conclusion plasty. J Bone Joint Surg Am 86-A:506–511
10. Krishnan SRSR, Randle R (2009) ACL reconstruction with
The short-term results of ACL reconstruction combined uni-condylar replacement in knee with functional instability
with UKA are encouraging. Studies have consistently and osteoarthritis. J Orthop Surg Res 4:43
11. Latterman C, Jakob RP (1996) High tibial osteotomy alone or
reported good early clinical and radiological outcomes. A
combined with ligament reconstruction in anterior cruciate lig-
combined approach of ACL reconstruction with UKA can ament-deficient knees. Knee Surg Sports Traumatol Arthrosc
be a viable option for patients with symptomatic medial 4:32–38
compartment arthritis and ACL deficiency. However, long- 12. Laurencin CT, Zelicof SB, Scott RD, Ewald FC (1991)
Unicompartmental versus total knee arthroplasty in the
term follow-up studies are required to validate prosthesis
same patient: a comparative study. Clin Orthop Relat Res
survivorship over time and randomized clinical trials and 273:157–164
registry studies are vital to judge the decision for an ACL 13. Lee YS, Jeong YM, Sim JA, Kwak JH, Kim KH, Nam SW
reconstruction and UKA versus total knee arthroplasty or et al (2013) Specific compartmental analysis of cartilage sta-
tus in double-bundle ACL reconstruction patients: a compara-
an HTO.
tive study using pre- and postoperative MR images. Knee Surg
Sports Traumatol Arthrosc 21:702–707
14. Li Y, Zhang H, Zhang J, Li X, Song G, Feng H (2015) Clinical
Compliance with ethical standards outcome of simultaneous high tibial osteotomy and anterior
cruciate ligament reconstruction for medial compartment oste-
Conflict of interest The authors declare that they have no conflict of oarthritis in young patients with anterior cruciate ligament-
interest. deficient knees: a systematic review. Arthroscopy 31:507–519
15. Mahfouz MR, Komistek RD, Dennis DA, Hoff WA (2004)
In vivo assessment of the kinematics in normal and ante-
Funding No funding was required. rior cruciate ligament-deficient knees. J Bone Joint Surg Am
86A(Suppl 2):56–61
Ethical approval This article does not contain any studies with 16. Malmivaara A, Koes BW, Bouter LM, van Tulder MW (2006)
human participants or animals performed by any of the authors. Applicability and clinical relevance of results in randomized
controlled trials: the Cochrane review on exercise therapy for
low back pain as an example. Spine 31:1405–1409
Informed consent No informed consent. 17. Mancuso F, Hamilton TW, Kumar V, Murray DW, Pandit H
(2016) Clinical outcome after UKA and HTO in ACL defi-
ciency: a systematic review. Knee Surg Sports Traumatol
Arthrosc 24:112–122
18. Martin JG, Wallace DA, Woods DA, Carr AJ, Murray DW
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