Medical Policy

 

Subject: Bicompartmental Knee Arthroplasty
Document #: SURG.00105 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description/Scope

This document addresses bicompartmental knee arthroplasty.

Position Statement

Investigational and Not Medically Necessary:

Bicompartmental knee arthroplasty is considered investigational and not medically necessary.

Rationale

Bicompartmental knee arthroplasty is proposed for those individuals with osteoarthritis limited to the medial and patellofemoral compartments of the knee. The bicompartmental knee arthroplasty procedure replaces only the diseased medial and patellofemoral compartments while sparing the lateral compartment and cruciate ligaments.

In 2007, Rolston and colleagues conducted a study of 100 consecutive participants older than 40 years (average age 63.7; range: 40-88 years) to estimate the utility of bicompartmental knee replacement. The individuals were observed for arthritic compartmental involvement. Radiographic interpretation found that 73 of 100 participants had involvement of both the medial and patellofemoral compartments, but no lateral involvement. Identification of this subset supports the need for a treatment option between unicondylar knee arthroplasty and total knee replacement. A total of 95 individuals were implanted by one surgeon beginning in October 2003 and followed for 33 months. Eighty-two of the 95 participants were discharged 2 days postoperatively. The average range of motion (ROM) for the group was 0° to 117°. Two weeks postoperatively, most participants were able to walk with only a minimal limp and without the aid of assistive devices. Lateral joint line tenderness was not present. No participant required a blood transfusion. Although participants reported a high level of satisfaction following the procedure, this study was not randomized, controlled or blinded.

A study by Shaw and colleagues (2013) compared the functional results of bicompartmental knee arthroplasty (n=16) to total knee arthroplasty (n=20). Using the Knee Society Score and Knee injury & Osteoarthritis Outcome Score, the participants were assessed at 6, 12, and 24 months postoperatively. The authors noted that none of the outcome scores were significantly different between the two groups. Postoperative knee ROM was reported as greater in the bicompartmental group. At the end of the 24-month period, none of the participants were revised or pending revision. While the bicompartmental group showed better ROM, the results did not necessarily indicate superior functional outcomes when compared to the total knee arthroplasty group.

A study by Kamath and colleagues (2014) reported on the 2-year results of 29 bicompartmental knee arthroplasties. The individuals were prospectively followed for 24-46 months using the Knee Society Knee and Function Scores, SF-12, Western Ontario and McMaster Universities Arthritis Index, x-rays and implant survivorship. Range of motion was improved from 122° to 133° with improvement across all functional scores. One participant required a total knee replacement at 3 years for knee instability. The study is limited by its small sample size.

A study by Engh (2014) reported on the comparison of 50 bicompartmental knee replacements and total knee replacement. All participants had osteoarthritis in the medial and patellofemoral compartments. Participants were assessed at 1, 4, 12, and 24 months following surgery with Knee Society scores, Oxford questionnaires, x-rays, and functional testing. The 50 participants were randomized to receive either a bicompartmental knee arthroplasty or a total knee arthroplasty. Both groups had an identical surgical approach and postoperative course. At the 1-month postoperative assessment, the participants who had total knee arthroplasty had more difficulty climbing stairs than the participants who had bicompartmental knee arthroplasty. Eight of the total knee participants could not step up and over an 8-inch block, but all participants in the bicompartmental group were able to complete the activity. Both groups improved over the 2-year period following surgery in terms of Average Knee Society scores, functional measurements and satisfaction survey results, but there were no significant differences between the two groups. The authors concluded that the participants who had bicompartmental knee arthroplasty did not have a better function than the participants who had a traditional total knee arthroplasty.

In a 2015 study by Yeo and colleagues, the authors reported on 26 participants who had undergone bicompartmental knee arthroplasty and 22 participants who had undergone total knee arthroplasty. After 5 years following surgery, there was improvement in functional scores in both groups. However, there was no significant difference in outcome scores when the bicompartmental group was compared to the total knee arthroplasty group.

A 2016 study by Dudhniwala and colleagues reported on 15 participants with symptomatic osteoarthritis of the knee who received bicompartmental knee arthroplasty. The participants were followed for a mean time of 54 months. The pre-operative mean Oxford knee score was 18.4 while 6 months postoperatively the mean score was 24.2 and 22.7 at 1 year. A total of 9 participants required revision to a total knee arthroplasty for persistent medial tibial pain.

Currently, the published literature is insufficient and does not adequately demonstrate clinical efficacy and safety. Studies were noted to be small group sizes or retrospective in nature (Palumbo, 2011; Parratte, 2015b). Larger, well-designed studies comparing bicompartmental arthroplasty with total knee arthroplasty, the gold standard, are warranted.

A formal position is not taken by the American Academy of Orthopedic Surgeons (AAOS) with regard to bicompartmental knee replacement as a method of treatment for osteoarthritis of the knee in their 2015 clinical practice guideline (AAOS, 2015).

Background/Overview

Osteoarthritis of the knee is an increasingly common problem due to a more active society, prior knee injuries, an increase in the elderly population and a growing percentage of the population that is overweight. Osteoarthritis of the knee should be suspected when an individual presents with knee pain that has been longstanding, increases with activity, (for example. weight bearing, stair climbing) and improves with rest. Onset of pain and dysfunction is often insidious. Deformity, fixed contracture, crepitance and effusion are common findings.

The knee has three compartments:

  1. Patellofemoral compartment: behind the kneecap riding over the end of the femur "trochlea/sulcus" groove;
  2. Medial compartment: the area of joint contact between the femur and tibia on the "inside" or medial aspect of the knee;
  3. Lateral compartment: the area of joint contact between the femur and tibia on the "outside" or lateral aspect of the knee. 

Osteoarthritis can affect any or all of the compartments of the knee. Primary total knee replacement is most commonly performed for knee joint failure caused by osteoarthritis. The success of primary total knee replacement is strongly supported by more than 20 years of follow-up data. Bicompartmental research is focused on replacing the medial and patellofemoral compartments of the knee most often affected by osteoarthritis, via minimally invasive surgery. Using this approach, it is expected that the lateral compartment, anterior cruciate ligament and posterior cruciate ligament will be preserved. These structures would provide increased stability during physical activity, such as walking, climbing stairs or simply standing up from a seated position.

Definitions

Arthroplasty: Surgical replacement of all or part of a joint.

Femur: A bone of the leg situated between the pelvis and knee in humans.

Osteoarthritis: A progressive disorder of the joints caused by gradual loss of cartilage. Also known as osteoarthrosis or degenerative joint disease.

Range of motion: Measurement of the extent to which a joint can go through all its normal spectrum of movements.

Tibia: Larger of the two bones of the lower leg and is the weight-bearing bone of the shin.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When Services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT

 

27599

Unlisted procedure, femur or knee [when specified as bicompartmental knee arthroplasty]

 

 

ICD-10 Procedure

 

 

For the following codes when specified as bicompartmental knee arthroplasty:

0SRT0J9-0SRU0JZ

Replacement of knee joint, femoral surface with synthetic substitute, open approach [right or left, cemented or unspecified; includes codes 0SRT0J9, 0SRT0JZ, 0SRU0J9, 0SRU0JZ]

0SRV0J9-0SRW0JZ

Replacement of knee joint, tibial surface with synthetic substitute, open approach [right or left, cemented or unspecified; includes codes 0SRV0J9, 0SRV0JZ, 0SRW0J9, 0SRW0JZ]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

References

Peer Reviewed Publications:

  1. Dudhniwala AG, Rath NK, Joshy S, et al. Early failure with the Journey-Deuce bicompartmental knee arthroplasty. Eur J Orthop Surg Traumatol. 2016; 26(5):517-521.
  2. Engh GA, Parks NL, Whitney CE. A prospective randomized study of bicompartmental vs. total knee arthroplasty with functional testing and short term outcome. J Arthroplasty. 2014; 29(9):1790-1794.
  3. Kamath AF, Levack A, John T, et al. Minimum two-year outcomes of modular bicompartmental knee arthroplasty. J Arthroplasty. 2014; 29(1):75-79.
  4. Morrison TA, Nyce JD, Macaulay WB, Geller JA. Early adverse results with bicompartmental knee arthroplasty: a prospective cohort comparison to total knee arthroplasty. J Arthroplasty. 2011; 26(6 Suppl):35-39.
  5. Palumbo BT, Henderson ER, Edwards PK, et al. Initial experience of the Journey-Deuce bicompartmental knee prosthesis: a review of 36 cases. J Arthroplasty. 2011; 26(6 Suppl):40-45.
  6. Parratte S, Ollivier M, Lunebourg A, et al. Long-term results of compartmental arthroplasties of the knee: Long term results of partial knee arthroplasty. Bone Joint J. 2015a; 97-B(10 Suppl A):9-15.
  7. Parratte S, Ollivier M, Opsomer G, et al. Is knee function better with contemporary modular bicompartmental arthroplasty compared to total knee arthroplasty? Short-term outcomes of a prospective matched study including 68 cases. Orthop Traumatol Surg Res. 2015b; 101(5):547-552.
  8. Rolston L, Bresch J, Engh G, et al. Bicompartmental knee arthroplasty: a bone-sparing, ligament-sparing and minimally invasive alternative for active patients. Orthopedics. 2007; 30(8 Suppl):70-73.
  9. Shah SM, Dutton AQ, Liang S, Dasde S. Bicompartmental versus total knee arthroplasty for medio-patellofemoral osteoarthritis: a comparison of early clinical and functional outcomes. J Knee Surg. 2013; 26(6):411-416.
  10. Yeo NE, Chen JY, Yew A, et al. Prospective randomised trial comparing unlinked, modular bicompartmental knee arthroplasty and total knee arthroplasty: a five years follow-up. Knee. 2015; 22(4):321-327.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Orthopaedic Surgeons (AAOS). Surgical management of osteoarthritis of the knee. Evidence-based clinical practice guideline. 2015. Available at: http://www.orthoguidelines.org/topic?id=1019. Accessed on April 20, 2018.
Websites for Additional Information
  1. Arthritis Foundation. Available at: http://www.arthritis.org/. Accessed on April 20, 2018. 
Index

Arthroplasty
Bicompartmental

Document History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section.

Reviewed

08/03/2017

MPTAC review. Updated Description/Scope, Rationale, Definitions, and References sections.

Reviewed

08/04/2016

MPTAC review. Updated Rationale and Reference sections. Removed ICD-9 codes from Coding section.

Reviewed

08/06/2015

MPTAC review. Updated Rationale and References sections.

Reviewed

08/14/2014

MPTAC review. Updated Rationale and References sections.

Reviewed

08/08/2013

MPTAC review. Updated Rationale and References.

Reviewed

08/09/2012

MPTAC review. Rationale and References updated.

Reviewed

08/18/2011

MPTAC review. References updated.

Reviewed

08/19/2010

MPTAC review. References updated.

Reviewed

08/27/2009

MPTAC review. References updated.

New

08/28/2008

MPTAC initial document development.