The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial

Abstract

Background Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and costeffectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years. Methods Our multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and ClinicalTrials.gov (NCT01352247). Findings Between Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1•04, 95% CI-0•42 to 2•50; p=0•159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0•240 additional quality-adjusted life-years, 95% CI 0•046 to 0•434) and less expensive (-£910, 95% CI-1503 to-317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR. Interpretation Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better costeffectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis.

Most unicompartmental knee replacement revisions could be avoided: a radiographic evaluation of revised Oxford knees in the National Joint Registry

“…Furthermore, the recently published 5 year results of the Total Or Partial Knee Arthroplasty Trial (TOPKAT), a pragmatic randomised controlled trial (RCT) of over 500 patients, at 27 UK sites with This work was completed at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford. 68 surgeons, has shown equivalent revision rates with TKR and UKR [1].…”

The unicompartmental knee is the preferred side in individuals with both a unicompartmental and total knee arthroplasty

“…has only found a small statistical functional difference in favour of UKA which questions the clinical relevance and continues the quest to determine if a skeleton sparing procedure with higher revision is worthwhile [2]. The clinical question which continues to be unanswered is the patientcentred complaint of gait impairment: which procedure is more likely to restore normal function?…”

Higher risk of revision for partial knee replacements in low absolute volume hospitals: data from 18,134 partial knee replacements in the Dutch Arthroplasty Register

“…Also, a lower risk of complications has been reported for PKR (Liddle et al 2014a, Beard et al 2019). Furthermore, a recent randomized trial demonstrated similar Oxford Knee Scores, a higher perceived knee improvement, higher willingness to undergo the operation again, and better cost-effectiveness after PKR compared with TKR at 5 years' follow-up (Beard et al 2019). Nevertheless, since its introduction, the PKR has been a topic of debate due to the diversity in reported long-term survival rates.…”