Medical Policy

This document addresses bicompartmental knee arthroplasty.

Investigational and Not Medically Necessary:

Bicompartmental knee arthroplasty is considered investigational and not medically necessary.

Bicompartmental knee arthroplasty is offered to 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 (TKA, 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 TKA 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 TKA at 3 years for knee instability.

A study by Engh (2014) reported on the comparison of 50 bicompartmental knee replacements and TKAs. 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 TKA. Both groups had an identical surgical approach and postoperative course. At the 1-month postoperative assessment, the participants who had TKA had more difficulty climbing stairs than the participants who had bicompartmental knee arthroplasty. Eight of the TKA 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 TKA.

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 TKA. After 5 years postoperatively, 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 TKA group. In 2020 Goh and colleagues reported on the 10-year follow-up of this cohort. At 10 years, 22 participants in the bicompartmental surgery group were available for analysis and 17 participants were available for analysis in the TKA group. In the bicompartmental surgery group, median preoperative range of motion was 128.5 degrees and 120 degrees 10 years postoperatively. The TKA group had a median preoperative range of motion of 122 degrees and 124 degrees 10 years following surgery. Both groups reported 100% satisfaction 10 years postoperatively. Those in the TKA group had a 100% reporting of met expectations compared to 95% in the bicompartmental group. The authors acknowledge the potential for selection bias in this group of individuals since the study was unblinded.

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 (OKS) 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 TKA for persistent medial tibial pain.

In 2019. Biazzo and colleagues reported on a retrospective comparative study which compared 20 individuals who had received bicompartmental knee arthroplasty (group A) to a homogeneous group of 20 individuals who had TKA (group B) during the same time period. Those in the bicompartmental group were followed for a median of 34 months compared to 38 months for individuals in the TKA group. Reported complications in group A included manipulation under anesthesia for knee stiffness (n=2), patella resurfacing (n=1), scar dehiscence treated with VAC-therapy (n=1), and one failure which was treated with a TKA at another facility. Complications in group B included one superficial infection treated by surgical debridement and one revision treated by changing the thickness of polyethylene. The individuals in group A had a mean age of 67.2 years compared to 65 years in group B. The mean operating time for the bicompartmental group was longer compared to the TKA group. Those who had bicompartmental surgery had less blood loss, but a higher blood transfusion rate compared to the TKA group. The Knee Society Score was 92.3 for group A compared to 94.5 for group B. Knee Society Score function was 87.2 for group A compared to 89.2 for group B. Limitations of the study were the use of different implants between the two surgical groups and the small sample size. In terms of functional results, the bicompartmental group did not show superiority to the TKA group. Larger studies with long-term follow-up and improved clinical outcomes are necessary.

Beckmann (2020) reported the results of a prospective case series study involving 79 subjects who underwent customized, individually made (CIM) bicompartmental knee arthroplasty and were followed for 2 years. The authors reported that overall Knee Society Scoring System (KSS) score, as well as the function and satisfaction domains, significantly improved from a baseline of 69 to 94 at the 2-year post-operative time-point (p<0.001). Similarly, significant improvements from baseline were observed across all five domains of the injury and Osteoarthritis Outcome Score (KOOS). Only 2 subjects were reported to have undergone TKA procedures, resulting in a survivorship rate of 97.5% at an average follow-up of 2.6 years. This study has several important limitations, including the observational design without comparison to a control group and follow-up limited to 2 years. All the authors serve as consultants for the implant manufacturer.

Another case series study was reported by Ogura and colleagues in 2019. Their study involved 55 subjects who underwent CIM bicompartmental knee arthroplasty and were evaluated at an average follow-up of 3.8 years (range 1-6 years). They reported an overall, survival rate of 98% and 92% at 2 and 5 years, respectively. Three subjects (5%) required the conversion to TKA, and 17 subjects (29%) required other subsequent surgical procedures. Subjects with prior knee procedures had a higher rate of reoperations than those without prior procedures (14/40 [35%] vs. 3/16 [19%], no p-values provided). Several factors limit the usefulness of this study, including the single-surgeon case series design, lack of information on how subjects were selected for inclusion, and follow-up only extending to 5 years.

A 2020 prospective, randomized trial by Schrednitzki and colleagues reported on the clinical outcome bicompartmental knee arthroplasty compared to TKA. There were 80 participants enrolled, 40 in each group. The mean time for surgery was longer in the bicompartmental surgery group compared to TKA (73.5 ± 9.9 minutes compared to 58.8 ± 12.8 minutes). Calculated blood loss was lower in the bicompartmental surgery group. Participants were followed for 5 years postoperatively. While both groups showed improvement in Knee Society Scores, OKS, and University of California Los Angeles Scores from preoperatively to 5-years, there were no significant differences between the two surgical groups. Starting at 1 year postoperatively, there was a significant improvement in range of motion in the bicompartmental group (108 degrees preoperatively and 121 degrees after 5 years) compared to the TKA group (103 degrees preoperatively and 112 degrees after 5 years). The authors note due to the complexity of the bicompartmental procedure, it is questionable to justify the bicompartmental surgery over TKA with the increased surgical time (even with less blood loss and increased range of motion).

Al-Dadah and colleagues (2020) compared clinical outcomes of unicompartmental arthroplasty, bicompartmental arthroplasty and TKA in a prospective study of 133 participants. There were 30 participants in the unicompartmental group, 53 in the bicompartmental group, and 50 in the TKA group. Follow-up was 2 years postoperative. OKS and WOMAC scores improved significantly 6 months postoperatively across all 3 surgical groups. No further significant improvements were noted after 6 months among the 3 groups.

A 2021 study by Gaudiani and colleagues reported on robotic-assisted bicompartmental knee arthroplasty in 50 participants, and reported on minimum 5-year survivorship, postoperative functional outcomes, and satisfaction. At 5 years postoperative, data was available for 47 subjects and for 38 subjects at 7 years postoperative. Data was collected using the Knee Society Score Function Score (KSS-FS) with clinical follow-up taken from office visits and x-rays. The overall 5-year survivorship was 96% and 7-year survivorship was 93%. The preoperative KSS-FS was 59.4 ± 10.9. At 5 years, mean KSS-FS was 85.6 ± 15.4. Satisfaction was 91% satisfied, 5% neutral and 4% not satisfied. There were 87% of subjects who reported walking more than 10 blocks, 96% of subjects reported walking without support. All subjects were able to go up and down stairs and 47% of them required use of a rail. At 7 years, satisfaction was 76% satisfied, 13% neutral, and 11% not satisfied. Mean KSS-FS was 80.5 ± 15.8. Ability to walk more than 10 blocks was reported by 82% of subjects with 89% of subjects walking without support. All subjects were able to go up and down stairs and 61% required the use of a rail. The mean change in KSS-FS was 26.5 ± 23.0. There was no comparison to conventional bicompartmental knee arthroplasty or total knee arthroplasty.

In a 2022 retrospective cohort study by Agarwal and colleagues, the authors reported on the 1-year and 2-year rates of survival of implants, the incidence of periprosthetic joint infection and revision for aseptic loosening, and comparison of the rates of 90-day complications of bicompartmental knee arthroplasty compared to total knee arthroplasty. There were 47,942 participants who underwent unicompartmental knee arthroplasty, 758 participants who underwent bicompartmental knee arthroplasty, and 763,152 who underwent TKA. Those who had bicompartmental knee arthroplasties had increased rates of revision surgery at 1 year compared to those who had TKA (2.9% versus 1.5% respectively). The revision rates were also higher for bicompartmental knee arthroplasties at 2 years (5.7% versus 2.3% respectively). Those who had bicompartmental knee arthroplasties had a decreased risk of overall complications and major complications within 90 days of surgery. With this retrospective review, limitations include potential coding inaccuracy, inability to ascertain whether cemented or cementless implants were used, lack of differentiation whether medial or lateral procedures were done, and lack of degree of arthritis at the time of initial surgery.

Aujla and colleagues (2022) reported on the 10-year outcomes of 41 participants who underwent bicompartmental knee arthroplasty. There were 10 participants who underwent bilateral surgery. Postoperatively, assessment was done at 1, 2, 5, and 10 years using x-rays, OKS, EuroQol Group 5-Dimension self-reported questionnaire (EQ-5D), and maximal ROM. At 10 years postoperatively, 11 participants were lost to follow-up (8 deceased and 3 could not be located for review). There were 7/22 (32%) tibial components and 10/22 (45%) femoral components which showed progressive radiolucencies starting at year 2 and continuing until the 10-year follow-up. OKS preoperatively was 25.4 and 43.5 at 10 years. Initial knee flexion was 116.4° and 127.3° after 10 years. EQ-5D preoperatively was 70.5 and 77.4 after 10 years. OKS and ROM improved from preoperatively to 1 year postoperatively, without further significant changes thereafter. Postoperative complications included 1 wound infection, a fall which resulted in further surgery due to trauma, and 3 participants required secondary surgeries for patellar re-surfacing due to crepitus and/or pain. The authors note:

due to the technical challenges and high rate of radiolucent lines in our series, as well as unacceptably high revision rates in other published reports, further design and implant evolution is required before a subsequent bicompartmental prosthesis becomes an effective option for the treatment of medial and patellofemoral arthritis.

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 2022 clinical practice guideline (AAOS, 2022).

Currently, the published literature does not demonstrate bicompartmental knee arthroplasty to be as beneficial over TKA.

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 TKA is most commonly performed for knee joint failure caused by osteoarthritis. The success of primary TKA 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.

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.

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.

Peer Reviewed Publications:

1. Agarwal AR, Cohen JS, Fuller SI, et al. Analysis of revision rates and complication rates among patients undergoing unicompartmental and bicompartmental knee Arthroplasties when compared to total knee arthroplasty. The Knee. 2023; 40:166-173.
2. Al-Dadah O, Hawes G, Chapman-Sheath PJ, et al. Unicompartmental vs. segmental bicompartmental vs. total knee replacement: comparison of clinical outcomes. Knee Surg Relat Res. 2020; 32(1):47.
3. Aujla RS, Woodhouse J, Ebert JR, et al. Journey-Deuce bicompartmental knee arthroplasty with the addition of computer navigation achieves good clinical outcomes and implant survival at 10 years. Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA. 2022; 30(9):3168-3175.
4. Beckmann J, Steinert AF, Huber B, et al. Customised bi-compartmental knee arthroplasty shows encouraging 3-year results: findings of a prospective, multicenter study. Knee Surg Sports Traumatol Arthrosc. 2020; 28(6):1742-1749.
5. Biazzo A, Silvestrini F, Manzotti A, Confalonieri N. Bicompartmental (uni plus patellofemoral) versus total knee arthroplasty: a match-paired study. Musculoskelet Surg. 2019; 103:63-68.
6. 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.
7. 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.
8. Gaudiani MA, Samuel LT, Diana JN, et al. Robotic-arm assisted bicompartmental knee arthroplasty: durable results up to 7-year follow-up. Int J Med Robot. 2022; 18(1):e2338.
9. Goh JKM, Chen JY, Yeo NEM, et al. Ten year outcomes for the prospective randomised trial comparing unlinked, modular bicompartmental knee arthroplasty and total knee arthroplasty. Knee. 2020;27(6):1914-1922.
10. Kamath AF, Levack A, John T, et al. Minimum two-year outcomes of modular bicompartmental knee arthroplasty. J Arthroplasty. 2014; 29(1):75-79.
11. 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.
12. Ogura T, Le K, Merkely G, et al. A high level of satisfaction after bicompartmental individualized knee arthroplasty with patient-specific implants and instruments. Knee Surg Sports Traumatol Arthrosc. 2019; 27(5):1487-1496.
13. 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.
14. 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.
15. 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.
16. 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.
17. Schrednitzki D, Beier A, Marx A, Halder AM. No major functional benefit after bicompartmental knee arthroplasty compared to total knee arthroplasty at 5-year follow-up. J Arthroplasty. 2020; 35(12):3587-3593.
18. 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.
19. 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. 2022. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/surgical-management-knee/smoak2cpg.pdf. Accessed on March 14, 2023.

1. Arthritis Foundation. Available at: http://www.arthritis.org/. Accessed on March 14, 2023. 

Arthroplasty
Bicompartmental