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:
MEDICAL APPROPRIATENESS
Unicompartmental knee replacement is considered medically appropriate for any of the following conditions:
Osteoarthritis; or
Rheumatoid arthritis; or
Traumatic arthritis, where one or more compartments are involved; or
Varus, valgus, or posttraumatic deformity; or
Metabolic disorders resulting in refractory osteomalacia; or
Unsuccessful osteotomy, arthrodesis, or failed previous joint replacement; or
Avascular and / or aseptic necrosis (i.e., osteonecrosis and ischemic bone necrosis) of the femoral condyle.
SOURCES
American Academy of Orthopaedic Surgeons (AAOS). (2007, October). Knee implants. Retrieved December 19, 2007 from http://orthoinfo.aaos.org/topic.cfm?topic=A00221&return_link=0.
American College of Rheumatology. (1996). Guidelines for the management of rheumatoid arthritis. Retrieved April 9, 2002 from http://www.rheumatology.org/publications/guidelines/ra-mgmt/ra-mgmt.asp.
Berger, R. A., Nedeff, D. D., Barden, R. M., Sheinkop, M. M., Jacobs, J. J., Rosenberg, A. G., et al. (1999). Unicompartmental knee arthroplasty. Clinical experience at 6- to10-year follow up. Clinical Orhopaedics and Related Research, (367), 50-60. Retrieved April 8, 2002 from PubMed database.
Hayes. Medical Technology Directory. (2002, October). Unicompartmental Knee Replacement Surgery. Retrieved December 19, 2007 from https://www.hayesinc.com/subscribers/subscriberHome.do. (41 articles and/or guidelines reviewed)
Lindstrand, A., Stenstrom, A., Ryd, L., & Toksvig-Larsen, S. (2000). The introduction period of unicompartmental knee arthroplasty is critical: A clinical, clinical multicentered, and radiostereometric study of 251 Duracon unicompartmental knee arthroplasties. Journal of Arthroplasty, 15 (5), 608-816.
Newman, J. H., Ackroyd, C. E., & Shah, N. A. (1998). Unicompartmental or total knee replacement? Five-year results of a prospective, randomised trial of 102 osteoarthritic knees with unicompartmental arthritis. Journal of Bone & Joint Surgery, 80 (5), 862-865.
Price, A. J., Short, A., Kellett, C., Beard, D., Gill, H., Pandit, H., et al. (2005). Ten-year in vivo wear measurement of a fully congruent mobile bearing unicompartmental knee arthroplasty. Journal of Bone & Joint Surgery, 87 (11), 1493-1497. Abstract retrieved February 6, 2006 from PubMed database.
Quintana, J.M. (2000). Evaluation of the appropriateness of hip joint replacement techniques. International Journal of Technology Assessment in Health Care, 16 (1), 165-177. Abstract retrieved October 8, 2002 from MD Consult database.
Repicci, J. A., & Hartman, J. F. (2004). Minimally invasive unicondylar knee arthroplasty for the treatment of unicompartmental osteoarthritis: An outpatient arthritic bypass procedure. Orthopedic Clinics of North America, 35 (2), 201-206.
Tabor, O. D. Jr., Tabor, O. B., Bernard, M., & Wan, J. Y. (2005). Unicompartmental knee arthroplasty: Long-term success in middle-age and obese patients. Journal of Surgical Orthopaedic Advances, 14 (2), 59-63. Abstract retrieved February 6, 2006 from PubMed database.
U. S. Food and Drug Administration. (2002, February). Center for Devices and Radiological Health. Summary of safety and effectiveness. Retrieved April 9, 2002 from http://www.fda.gov/cdrh/pdf2/k020264.pdf.
Weale, A. E., Murray, D. W., Baines, J., & Newman, J. H. (2000). Radiological changes five years after unicompartmental knee replacement. Journal of Bone & Joint Surgery, 82 (7), 996-1000. Abstract retrieved April 10, 2002 from The Cochrane Library database.
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EFFECTIVE DATE |
2/28/2008 |
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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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