DESCRIPTION
Unicompartmental knee replacement is a procedure done to replace one of the knee's three parts (thighbone, shinbone, or kneecap). The goal of the procedure is to restore knee function that has diminished due to disorders that cause chronic knee pain. An incision is made over the area of the knee that is damaged. The damaged bone is removed and replaced with a prosthetic implant. The thighbone and shinbone may be slightly sculpted to fit the implant. Once the implant is in the proper place, it is secured (e.g., with bone cement), and the wound is closed with stitches.
This procedure is also referred to as unicondylar or partial knee replacement because only part of the damaged knee is replaced.
POLICY
Unicompartmental knee replacement for the treatment of a painful and disabled knee joint is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Unicompartmental knee replacement for the treatment of other conditions/diseases is considered investigational.
Any unicompartmental knee implant device utilized for this procedure must have FDA approval specific to the indication, otherwise its use will be considered investigational.
See also: Unicondylar Interpositional Spacer for the Treatment of Osteoarthritis
MEDICAL APPROPRIATENESS
Unicompartmental knee replacement for the treatment of a painful and disabled knee joint is considered medically appropriate for ANY ONE of the following conditions:
Osteoarthritis
Rheumatoid arthritis
Traumatic arthritis, where one or more compartments are involved
Varus, valgus, or posttraumatic deformity
Metabolic disorders resulting in refractory osteomalacia
Unsuccessful osteotomy, arthrodesis, or failed previous joint replacement
Avascular and / or aseptic necrosis (i.e., osteonecrosis and ischemic bone necrosis) of the femoral condyle
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
The lack of randomized controlled trials and studies provide little evidence of the safety and efficacy for the treatment of other conditions/diseases.
SOURCES
American Academy of Orthopaedic Surgeons (AAOS). (2008, December). Treatment of osteoarthritis of the knee (non-arthroplasty). Retrieved April 18, 2011 from http://www.aaos.org/Research/guidelines/OAKguideline.pdf.
American Academy of Orthopaedic Surgeons (AAOS). (2010, September). Knee implants. Retrieved April 18, 2011 from http://orthoinfo.aaos.org/topic.cfm?topic=A00221&return_link=0.
American College of Rheumatology. (2002). Guidelines for the management of rheumatoid arthritis. 2002 update. Retrieved April 18, 2011 from http://www.rheumatology.org/practice/clinical/guidelines/raguidelines02.pdf.
Borgwardt, L., Zerahn, B., Bliddal, H., Christiansen, C., Sylvest, J., & Borgwardt, A. (2009). Similar clinical outcome after unicompartmental knee arthroplasty using a conventional or accelerated care program. A randomized, controlled study of 40 patients. Acta Orthopaedica, 80 (3), 334-337. (Level 4 Evidence - Independent study)
Dettoni, F., Bonasia, D. E., Castoldi, F., Bruzzone, M., Blonna, D., & Rossi, R. (2010). High tibial osteotomy versus unicompartmental knee arthroplasty for medial compartment arthrosis of the knee: A review of the literature. The Iowa Orthopaedic Journal, 30, 131-140.
Glass, G. (2006). Osteoarthritis. Disease-A-Month, 52 (9), 343-362.
Heller, S., Fenichel, I., Salai, M., Luria, T., & Velkes, S. (2009). The Oxford unicompartmental knee prosthesis for the treatment of medial compartment knee disease: 2 to 5 year follow-up. The Israel Medical Association Journal, 11 (5), 266-268. (Level 4 Evidence - Independent study)
Marya, S. K. S., & Thukral, R. (2009). Unicompartmental knee arthroplasty for tricompartment osteoarthritis in octogenarians. Indian Journal of Orthopaedics, 43 (4), 361-366. (Level 3 Evidence - Independent Study)
National Guideline Clearinghouse. (2010, June). The diagnosis of periprosthetic joint infections of the hip and knee. Retrieved April 18, 2011 from http://www.guidelines.gov.
Parmaksizoglu, A. S., Kabukcuoglu, Y., Ozkava, U., Bilgili, F., & Aslan, A. (2010). Short-term results of the Oxford phase 3 unicompartmental knee arthroplasty for medial arthritis. Acta Orthopaedica Traumatologica Turcica, 44 (2), 135-142. (Level 3 Evidence - Independent study)
Richmond, J. C. (2008). Surgery for osteoarthritis of the knee. Rheumatic Disease Clinics of North America, 34 (3), 815-825.
U. S. Food and Drug Administration. (2004, April). Center for Devices and Radiological Health. Oxford™ meniscal unicompartmental knee system - P010014. Retrieved April 18, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf/P010014b.pdf.
U. S. Food and Drug Administration. (2006, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K060670. Retrieved April 18, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K060670.pdf.
U. S. Food and Drug Administration. (2008, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072704. Retrieved April 18, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072704.pdf.
Volpin, G. (2009). Unicompartmental knee replacement for localized osteoarthritis of the medial or lateral compartment. The Israel Medical Association Journal, 11 (5), 308-310.
W-Dahl, A., Robertsson, O., Lidgren, L., Miller, L., Davidson, D., & Graves, S. (2010). Unicompartmental knee arthroplasty in patients aged less than 65. Acta Orthopaedica, 81 (1), 90-94.
ORIGINAL EFFECTIVE DATE: 10/1/2002
MOST RECENT REVIEW DATE: 5/12/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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