The Femur-First Technique for Oxford Medial Unicompartmental Knee Arthroplasty
Authors: Alarcon Perico Diego , Lee Sheng-Hsun , Labott Josh R. , Guarin Perez Sergio F. , Sierra Rafael J. 
Published: April 2024

Background:
Unicompartmental knee arthroplasty (UKA) is a reliable procedure to treat medial compartment knee osteoarthritis (OA). The reported survivorship of UKA has varied in the literature
3–7
. In part, the higher failure rates of UKA seen in registries could be related to the caseload and experience of the reporting surgeon
8
. The introduction of techniques that make procedures more reliable, especially in the hands of inexperienced surgeons, can decrease the rate of failure. With the Oxford UKA implant (Zimmer Biomet), the recommended surgical technique involves cutting the tibia first, followed by the femoral preparation. However, a technique that allows for preparation of the femur first, as well as the use of the femoral component as a reference for the tibial cut, may reduce the common technical errors seen with the procedure. We have utilized the femur-first technique in cases of medial Oxford UKA.

Description:
The femur-first method outlined in the present article does not require any unique instruments beyond what is supplied by the manufacturer. Before beginning, the femoral positional guide needs to be decoupled from its base. To start, the intramedullary guide is introduced approximately 1 cm anterior and medial to the intercondylar notch. Once the femoral osteophytes are removed, the surgeon identifies the center of the femoral condyle and marks it. The posterior tibial cartilage is then removed with a saw to facilitate the placement of the appropriately sized femoral spherical guide. The size of the femoral component is determined by selecting the implant that aligns best with the width of the femoral condyle. The femoral drill guide is detached from its base because there is not enough space for the base, as the tibia has not yet been resected. The decoupled femoral guide is connected to the intramedullary rod, allowing the precise positioning of the femoral component in approximately 10° of flexion relative to the femoral sagittal plane and drilling of the 2 peg holes. The posterior condylar resection guide is impacted into position, and the osteotomy of the posterior condyle is made. The distal femur is then milled with use of a number-0 spigot, and the femoral component trial is positioned into place. The femoral condyle is “resurfaced” with the femoral component, which restores joint obliquity and the natural height, a critical element of the femur-first technique. Following this, the 1-mm (size-dependent) spherical gauge is placed around the femoral component trial. The tibial guide is secured with the G-clamp and a number-0 resection block, and is pinned into place. We recommend swapping the number-0 cutting guide for a +2 when making the cut in order to avoid over-resection. Recutting is advised if a minimum 3-mm feeler gauge does not adequately occupy the flexion space. The final step is to balance the flexion and extension gaps in the usual fashion.

Alternatives:
The alternative technique is a traditional tibia-first approach, in which tibial resection is performed prior to femoral resection. As described in the original manufacturer’s manual, the tibial cut is accomplished with use of a number-0 cutting guide, and the tibial rotation is based on the axis formed by the anterior superior iliac spine and knee center, irrespective of the femoral condyle.

Rationale:
The femur-first technique is advantageous in several ways. When performing the femoral cut first, the surgeon can better align the drill guide at the center of medial femoral condyle. This will result in the femoral component being positioned more in line with the coronal plane of the femoral condyle. Additionally, the tibial resection is made with the femoral trial in place; therefore, the depth of resection can be more accurate, potentially avoiding excessive bone resection. Finally, with the femoral trial in place, the surgeon can judge the rotation and medial-lateral position of the tibial component more precisely, hence lowering the possibility of bearing spin-out, impingement, and dislocation or unexplained pain.

Expected Outcomes:
The femur-first technique is a bone-preserving procedure that results in thinner bearings when compared with a tibia-first approach
1
. The femur-first approach also improves radiographic outcomes, including femoral coronal, femoral sagittal, and tibial sagittal alignments, while tibial coronal alignment does not differ. There is an early trend toward improved 5-year survivorship with the femur-first (98%) versus tibia-first (94%, p = 0.35) techniques. There has been no significant difference reported in Knee Society Scores between techniques.

Important Tips:

Perform a preliminary cut of the posterior tibial cartilage in order to allow insertion of the femoral drill guide under the femoral condyle.Make sure the femoral drill guide lies in the center of the marked medial femoral condyle.Align the tibial sagittal cut with the femoral component trial in order to avoid bearing impingement.Be conservative in the tibial cutting by utilizing a +2 cutting guide (since the coupling is performed with the intramedullary guide in place, which drives the tibial guide distally).

Acronyms and Abbreviations:

UKA = unicompartmental knee arthroplastyFF = femur-firstM-L = medial-lateralAP = anteroposteriorPA = posteroanteriorASA = acetylsalicylic acid (aspirin)BID = bis in die, twice a dayPT = physical therapyTF = tibia-firstFCA = femoral coronal angleFSA = femoral sagittal angleTSA = tibial sagittal angleIM = intramedullaryOA = osteoarthritis