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OPEN Pain management

of unicompartmental (UKA) vs.
total knee arthroplasty (TKA)
based on a matched pair analysis
of 4144 cases
Franziska Leiss1, Julia Sabrina Götz1, Günther Maderbacher1, Florian Zeman2,
Winfried Meissner3, Joachim Grifka1, Achim Benditz1 & Felix Greimel1*

Unicompartmental knee arthroplasty and total knee arthroplasty are well established treatment
options for end-stage osteoarthritis, UKA still remains infrequently used if you take all knee
arthroplasties into account. An important factor following knee arthroplasty is pain control in the
perioperative experience, as high postoperative pain level is associated with persistent postsurgical
pain. There is little literature which describes pain values and the need for pain medication following
UKA and/or TKA. So far, no significant difference in pain has been found between UKA and TKA. The
aim of the study was to evaluate differences in the postoperative course in unicompartmental knee
arthroplasty vs. total knee arthroplasty regarding the need for pain medication and patient-reported
outcomes including pain scores and side effects. We hypothesized that unicompartmental knee
arthroplasty is superior to total knee arthroplasty in terms of postoperative pain values and the need
of pain medication. In this project, we evaluated 2117 patients who had unicompartmental knee
arthroplasty and 3798 who had total knee arthroplasty performed, from 2015 to 2018. A total of 4144
patients could be compared after performing the matched pair analysis. A professional team was used
for data collection and short patient interviews to achieve high data quality on the first postoperative
day. Parameters were compared after performing a 1:1 matched pair analysis, multicenter-wide in
14 orthopedic departments. Pain scores were significantly lower for the UKA group than those of the
TKA group (p < 0.001 respectively for activity pain, minimum and maximum pain). In the recovery unit,
there was less need for pain medication in patients with UKA (p = 0.004 for non-opioids). The opiate
consumption was similarly lower for the UKA group, but not statistically significant (p = 0.15). In the
ward, the UKA group needed less opioids (p < 0.001). Patient subjective parameters were significantly
better for UKA. After implantation of unicompartmental knee arthroplasty, patients showed lower
pain scores, a reduced need for pain medication and better patient subjective parameters in the early
postoperative course in this study.

If conservative treatment fails, total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA)
are good and well-established treatment options for end-stage arthritis, while UKA is confined to a single com-
partment of the knee. The medial compartment is associated with a higher incidence of arthritis compared to the
lateral compartment, therefore medial UKA is performed more often than lateral UKA. Because of the anatomic
and kinematic differences between the medial and lateral compartment, lateral UKA is technically more chal-
lenging than medial ­UKA1,2.
There are controversial discussions, whether a retro-patellar replacement should be performed primarily for
prosthesis implantation. A uniform recommendation has not yet been ­issued3–5.

1
Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach,
Kaiser‑Karl‑V.‑Allee 3, 93077 Bad Abbach, Germany. 2Center for Clinical Studies, University Medical Center of
Regensburg, Franz‑Josef‑Strauss‑Allee 11, 93053 Regensburg, Germany. 3Department of Anesthesiology and
Intensive Care, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. *email: [email protected]

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UKA has been shown to have several advantages over TKA, including reduced blood loss, shorter length
of hospitalization, improved postoperative patient-reported functional outcomes and less postoperative
­morbidity6–10. Unicompartmental knee arthroplasty allows patients a faster return to a more functional level
than TKA, but postoperative pain management still remains a challenge, since there is no significant difference
in ­pain11–16. Pain negatively affects the functional outcome, patient satisfaction and their psychological well-
being17–19. Postoperative pain management strategies include oral or intravenous analgesics, patient-controlled
analgesia (PCA), single shot or continuous peripheral nerve blocks or local infiltration analgesia (LIA). The aim
of postoperative pain management is to improve the patients’ comfort, satisfaction and functional outcome after
UKA and TKA. Insufficient pain management can be revealed by Continuous Quality Improvement (CQI) strate-
gies. The “Quality Improvement in Postoperative Pain Management (QUIPS)” project is an outstanding t­ ool20
to compare and then improve pain management. Despite the fact that the successful use of a knee arthroplasty
increases the quality of the patient’s life, 20–30% of all patients remain permanently dissatisfied with the results
of their ­operation21. Kehlet et al. reported, that 10–34% of the patients may develop chronic pain after implanta-
tion of TKA. A high postoperative pain level is associated with persistent postsurgical ­pain22,23. Previous studies
have mainly used PROM scores (WOMAC/KSS) to assess postoperative pain in the follow-up after surgery. An
investigation of early postoperative pain, the need of pain medication, side effects and functional impairments
after UKA and/or TKA has not been considered extensively so far.
The purpose of this study was to evaluate differences in the short-term perioperative course after unicom-
partmental knee arthroplasty vs. total knee arthroplasty. We also looked at the need for pain medication and
patient-reported outcomes as well as pain intensity and side effects, since total knee arthroplasty still is, by far,
the more frequently used technique. In a relevant amount of cases, UKA could have been used considering
indication ­criteria24,25.
This large-scale multicenter study evaluated the need for pain medication, subjective functional score, as well
as pain intensity scores in the immediate postoperative course of unicompartmental or total knee arthroplasty.
We assumed that unicompartmental knee arthroplasty is superior to total knee arthroplasty, in terms of post-
operative pain and the need of pain medication.

Material and methods

The QUIPS (“Quality Improvement in Postoperative Pain Management”) project is an initiative to compare
patient-reported outcomes related to perioperative pain management. With over 450,000 data records, QUIPS
is one of the largest acute pain databases in the world. In participating hospitals of the QUIPS project, data was
obtained on the first postoperative day. The QUIPS project is supported by the German Society of Surgeons
and the German Society of A ­ nesthesiologists20,26. The study was approved by the Ethics Committee, as well as,
the Data Security Board of the Jena University Hospital, Jena, Germany, and by the Ethics Committee of the
University of Regensburg. Furthermore, the project was registered in the German Register of Clinical Studies
(DRKS) with the approval number DRKS00006153 (WHO register). The study was applied in accordance with
the ethical standards of the Declaration of Helsinki 1975.
All primary unicompartmental and total knee arthroplasties included in the QUIPS data base (see below)
regardless of the anesthetic technique used, meeting the inclusion and exclusion criteria were evaluated. Inclusion
criteria were as follows: (1) patients older than 18 years of age, (2) able to communicate and (3) who had primary
unicompartmental or total knee replacement surgery performed. Information about QUIPS was supplied to all
potential patients. Participation was voluntary. Informed consent was obtained from all participants. Exclusion
criteria were: (1) absence of the patient in the ward, (2) patients who refused to participate and (3) patients who
were asleep or sedated at the time of data collection and interviews 24 h postoperative.
The QUIPS questionnaire is divided into sections dealing with pain intensity, functional impairment, side
effects of pain treatment and global assessment by the patient (compare Tables 3 and 5). Using the standardized
QUIPS questionnaire form, minimum, maximum and activity pain were rated using the numeric rating scale
“NRS” (NRS 0 = no pain, NRS 10 = worst pain imaginable). Furthermore, several side effects were monitored:
“Vomiting after surgery”, “Felt nauseous after surgery”, “Felt vertiginous after surgery” and “Tired after surgery”.
Additionally, functional outcome parameters “Pain affecting the ability to cough or to take a deep breath”, “Pain
affecting the mood”, “Pain affecting the ability to sleep” and “Pain affecting the ability to move” were evaluated.
The need for pain medication was obtained from patients’ records. The type of pain medication was classified
according to the WHO pain ladder: non-opioids (WHO ladder step 1) and opioids (summarization of WHO
ladder step 2 and step 3)27. For those patients, who needed an opioid postoperatively, the opioid equivalent was
calculated in mg by using morphine as a basis for comparing the different opioid agonists.
All patients were randomly visited to avoid selection bias and patient-interviewer interaction bias. The sur-
veyors were independent from the healthcare team. By using a standardized protocol to collect clinical data
and obtain the questionnaire parameters, standardized data assessment was guaranteed. All collected data was
anonymized.

Statistical methods. Between 2015 and 2018, 5915 patients were included in the present cohort study after
primary unicompartmental knee arthroplasty or total knee arthroplasty. The study was conducted nationwide
in 14 orthopedic departments at the time of data evaluation. Patients were divided into two groups in question:
UKA (n = 2117) and TKA (n = 3798). The following statistical evaluation was performed according to Greimel
et al.28,29. To get comparable groups in size and distribution of the confounding variables a 1:1 match was per-
formed. Patients of the UKA group (n = 2117) and the TKA group (n = 3798) were matched according to age, sex
and ASA score. If there was more than one matching partner for one patient, one patient was randomly chosen.

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Exclusion criteria:
(1) Absence of the patient at the ward
Inclusion criteria: (2) Patients who refused to participate
(1) Patients older than 18 years of age (3) Patients who were asleep or
(2) Patients able to communicate sedated
(3) Patients receiving unicompartmental
or total knee replacement surgery , at the time of data collection and
interview on first postoperative day,
respectively

14 participating hospitals

n=5915

UKA TKA
n=2117 n=3798

Matching of age,
sex, ASA

UKA TKA
n=2072 n=2072

Figure 1.  Flowchart: study group enrollment and matching.

A total of 4144 patients were finally analyzed and compared (n = 2072, in each group, Fig. 1). After matching the
age, sex and ASA score, both groups of UKA and TKA had comparable pain intensity preoperatively (Table 2).
Continuous variables were indicated by mean (standard deviation) or median (interquartile range) depending
on the underlying distribution. Categorical data was presented as absolute numbers and/or relative frequencies.
The opioid equivalent was calculated using the Mann–Whitney-U-test. To compare the use of pain medica-
tion, side effects or functional parameters between the UKA group and the TKA group, a Pearson’s chi-squared
test was used for each pairwise comparison. The differences in the NRS values between the two study groups
were analyzed by using t-tests. Normality was assessed visually by Q-Q-Plots and by the parameters median,
mean, skewness and kurtosis. Normal distributed data were compared using students t-Test. Non-Normal data
were compared using the Mann–Whitney-U Test. All reported p-values are two-sided and a p value < 0.05 was
considered statistically significant. All analyses were performed using SPSS 25.0 (IBM SPSS Statistics, Armonk,
NY—IBM Corp.).

Results
A total of 4144 patients (n = 2072 per group, respectively) were finally statistically analyzed and compared after
performing a matching of age, sex and ASA score because of demographic inhomogeneity and to reduce con-
founding variable bias (Fig. 1). In Tables 1 and 2 demographic and general data are shown before and after the
matching. After matching, patients with UKA and TKA both showed a median pain of 6.0 (NRS) and mean pain
of 6.4 (NRS) preoperatively (Table 2). Therefore, both groups of UKA and TKA had comparable pain intensity
preoperatively. Furthermore, the choice of anesthesia before and after matching is shown in Tables 1 and 2.
In the UKA group mean activity pain was 4.1 (± 2.3) and in the TKA group 4.4 (± 2.4). Mean activity pain was
significantly lower for the UKA group (p < 0.001) (Fig. 2, Table 3). Patients with UKA had a mean minimum pain
of 1.6 (± 1.6) and mean maximum pain of 5.1 (± 2.6) whereas patients with TKA had a mean minimum pain of

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TKA UKA ALL

Patients total (%) 3798 (64.2%) 2117 (35.8%) 5915 (100%)
Age in years (median, mean ± SD) 65, 67.6 ± 9.9 65, 65.3 ± 10.5 65, 66.7 ± 10.2
Sex in % (female:male) 61.1:38.9 55.4:44.6 59.1:40.9
ASA score [median, mean ± SD] 2, 2.3 ± 0.57 2, 2.17 ± 0.55 2, 2.26 ± 0.57
Operation time in minutes (median, mean ± SD) 70, 75 ± 28 78, 81 ± 36 72, 77 ± 31
Pain before surgery NRS (median, mean ± SD) 7.0, 6.5 ± 1.9 6.0, 6.4 ± 1.8 7.0, 6.5 ± 1.9
Anesthetic technique used (general : regional : combination) (%) 12.0 : 17.7 : 57.2 10.1 : 15.3 : 63.2 11.3 : 16.8 : 59.3

Table 1.  Demographic and general data before matching. ASA—American Society of Anesthesiologists;
UKA – unicompartmental knee arthroplasty, TKA – total knee arthroplasty; NRS—numeric rating scale; SD—
standard deviation.

TKA UKA All

Patients total (%) 2072 (50%) 2072 (50%) 4144 (100%)
Age in years (median, mean ± SD) 65, 65.6 ± 10.1 65, 65.6 ± 10.1 65, 65.6 ± 10.1
Sex in % (female:male) 55.9 : 44.1 55.9 : 44.1 55.9 : 44.1
ASA score [median, mean ± SD] 2, 2.2 ± 0.5 2, 2.2 ± 0.5 2, 2.2 ± 0.5
Operation time in minutes (median, mean ± SD) 69, 75 ± 29 78, 81 ± 36 72, 78 ± 33
Pain before surgery NRS (median, mean ± SD) 6.0, 6.4 ± 1.9 6.0, 6.4 ± 1.8 6.0, 6.4 ± 1.8
Anesthetic technique used (general:regional:combination) (%) 11.2:18.7:63.9 10.1:15.3:63.2 10.7:17.0:63.5

Table 2.  Demographic and general data after matching. ASA—American Society of Anesthesiologists;
UKA—unicompartmental knee arthroplasty, TKA—total knee arthroplasty; NRS—numerous rating scale;
SD—standard deviation.

Figure 2.  Bar charts: mean numeric rating scale (NRS) values and 95% confidence intervals for activity pain,
maximum pain and minimum pain on the first postoperative day for patients with unicompartmental knee
arthroplasty (UKA) and total knee arthroplasty (TKA).

TKA UKA p values

Activity pain 4.4 ± 2.4 4.1 ± 2.3 < 0.001
Maximum pain 5.5 ± 2.6 5.1 ± 2.6 < 0.001
Minimum pain 1.8 ± 1.8 1.5 ± 1.6 < 0.001

Table 3.  Comparison of activity pain, maximum pain and minimum pain between “TKA” and “UKA” groups:
mean values, standard deviation, and their significance levels. UKA = unicompartmental knee arthroplasty,
TKA = total knee arthroplasty, p-Values < 0.05.

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TKA UKA p-Values

Recovery unit: Coanalgetics 8% 5% 0.011
Recovery unit: Nonopioids 50% 45% 0.004
Recovery unit: Opioids 57% 55% 0.152
Recovery unit: PCA 30.5% 32.9% 0.130
Ward: Coanalgetics 3.6% 4.2% 0.038
Ward: Nonopioids 94% 96% < 0.001
Ward: Opioids 84% 76% < 0.001
Ward: PCA 33.7% 34.5% 0.067
Recovery unit: Opioid equivalent (mg) (median, IQR 25%/75%) 0.0, 0.0/6.8 0.0, 0.0/7.5 0.35
Ward: Opioid equivalent (mg) (median, IQR 25%/75%) 15.0, 0.0/26.0 15.0, 0.0/30.0 0.27

Table 4.  Comparison of the need for pain medication until the first postoperative day between “UKA” and
“TKA” groups and the opioid equivalent. PCA = patient controlled analgesia.

TKA UKA p values

Pain affecting the ability to ­sleep1 43% 35% < 0.001
Pain affecting the ability to ­move1 71% 70% 0.991
Pain affecting the ability to cough or to take a deep ­breath1 3.0% 2.8% 0.78
Pain affecting the ­mood1 19% 13% < 0.001
Tired after ­surgery2 39% 31% < 0.001
Felt vertiginous after ­surgery2 24% 15% < 0.001
Felt nauseous after ­surgery2 21% 15% < 0.001

Table 5.  Questions of the QUIPS-questionnaire. Functional outcome parameters (1) and side effects (2) on
the first postoperative day.

1.8 (± 1.8) and a mean maximum pain of 5.6 (± 2.6). Mean maximum pain and mean minimum pain showed a
statistically significant (each p < 0.001) advantage for the UKA group (Fig. 2, Table 3).
In the recovery unit for UKA patients the need for non-opioids was significantly lower than for the TKA
patients (p = 0.004). The opioid consumption was similarly lower for the UKA group, but not statistically sig-
nificant (p = 0.15) (Table 4).
In the ward, the percentage of patients who had taken opioids in the UKA group were statistically less than
those in the TKA group (p < 0.001). The use for non-opioids was statistically higher for UKA than for TKA
(p < 0.001). The calculation of the opioid equivalent (mg) in relation to morphine showed no statistically signifi-
cant difference between the two groups (Table 4).
Functional outcome parameters and side effects are shown in Table 5. For the parameters “woke up because
of pain”, ““felt nauseous after surgery”, “felt vertiginous after surgery”, “felt very tired after surgery” and “pain
affected the mood”, significantly better results in the UKA group were demonstrated (p < 0.001 for all 5 items
respectively). All other items did not differ significantly after comparing the two groups in question.

Discussion
In recent years many studies have been carried out on the comparison of the clinical outcomes of patients after
UKA and TKA. Among these studies, the consensus conclusion, is that patients who underwent UKA have better
function PROM scores, better range of movement, quicker recovery period and shorter ­hospitalization15,16,30,
but no difference in pain, comparing UKA to T ­ KA13,15,16. These studies in general used PROM scores (KSS/
WOMAC) for evaluation of pain intensity in the follow-up after UKA and/or TKA. Literature evaluating early
postoperative pain and pain management after UKA and TKA is emerging. In addition, possible side effects of
pain therapy and functional impairments were rarely investigated. The aim of this study was to compare the use
of pain medication, pain control and patient’s subjective parameters after having had UKA or TKA performed
as early pain control can have an impact on postoperative outcome and length of hospitalization.
Similar results to our study can be seen in the study of Melnic et al.31 in which 71 patients with UKA and 37
patients with PFA (patellofemoral arthroplasty) were matched by sex and age to 108 patients with TKA. Opioid
consumption in the first postoperative ward round was significantly lower for the UKA group than for the TKA
group or PFA. A consistent result was found in the Kalbian et al. ­study32. Patients required a significantly lower
rate of opioid prescription after UKA-implantation compared to TKA-implantation. We considered that the
reduced consumption of opioids after UKA implantation was due to lesser surgical trauma caused by a smaller
incision and a greater perseveration of native structures.
We did not expect anesthesia procedures to represent a potential confounder, as anesthesia procedures did
not differ in percentage between the two groups of UKA and TKA (Table 2).

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For those patients who needed an opioid, the calculation of the opioid equivalent in the recovery unit and
in the ward showed no significant difference between the two groups. One possible explanation could be an
increased individual need for opioids. In total, patients after UKA had a lower opioid consumption compared
to patients after TKA, but those who had taken an opioid may have needed a comparatively higher dose, since
significantly fewer patients required an opioid after UKA than after TKA by an equivalent opioid dose (Table 4).
On the other hand, our data showed a significantly higher percentage of non-opioid use within the UKA group
at the ward, which might have had an impact on the opioid consumption as well.
Another important parameter was the patient’s subjective pain level. A lower postoperative pain level means
increased comfort and satisfaction for the patient and consequently an improved postoperative function. Post-
operatively, there was a significant difference in pain under mobilization, measured according to the NRS-scale,
with less pain in the UKA group in comparison to the TKA group. The pain maximum and pain minimum (NRS)
were also significantly lower for the UKA group. (Fig. 2, Table 3).
To date, there are hardly any studies that have investigated early postoperative pain differences between
UKA and TKA implantation. In general, pain was investigated using PROM scores, e.g. the KS pain score or the
WOMAC score. In the systematic review and meta-analysis of Wilson et al. 15 pain specific PROM scores were
found to be equivocal after UKA compared with TKA with no significant difference between the two groups. The
matched pair analysis of Lombardi et al. 13 showed no significant difference in pain after UKA and TKA in the
KS pain score after a follow up of 6 weeks and an average of 30 months. The study by Noticewala et al. reported
a significant difference in the WOMAC pain score and the WOMAC physical function score in the follow-up
3 years after UKA or TKA with better result for ­UKA33. A recently published study by Lakra et al.34 has shown
that an improved management of early postoperative pain was associated with a better functional outcome in
the follow-up 2-years after TKA. Our results showed lower pain under mobilization and lower minimum and
maximum pain for the UKA group. Higher postoperative patient-reported functional outcomes were described
in several studies with advantages for ­UKA6,8,14,15,26.
The risk of developing chronic pain after knee surgery is reported to be even higher than in e.g. hip replace-
ment ­surgery35. A correlation between the postoperative pain level and the development of chronic pain has
been ­shown22,23. An improvement in pain management in the early postoperative course could be a contributing
factor in reducing chronic pain. This could lead to faster recovery and mobilization, psychological well-being
and to a general improvement of the outcome.
Furthermore, the group of UKA had significantly better results for side effects “very tired”, “vertiginous”,
“nausea” and functional outcome parameters: “woke up because of pain” and “pain affecting mood” (Table 5).
The patient’s quality of life and early postoperative mobilization can lead to functional improvements. In the
recovery unit, there was no statistically significant difference in opioid consumption between the UKA and TKA
group, but the parameters vertiginous and nausea could be influenced by opioid consumption.
This study shows several limitations such as the assessment of postoperative pain and pain management.
Because of organizational reasons these values have been collected on the first postoperative day and differences
in the continuing postoperative period could not be evaluated. Within the QUIPS study protocol, factors such
as indication criteria for UKA or TKA, intraoperative surgical details such as the use of tourniquets or drains
could not be investigated.
Big data studies have a general restriction in explanatory power. A huge data quantity could provide signifi-
cant results despite small differences in value. Nevertheless, in daily clinical routine big data studies are of great
interest to evaluate the efficacy of interventions.
Furthermore, selection bias cannot be barred, but the matching tries to reduce the influence of confounding
variables. One possible selection bias could have been preoperative pain intensity and anesthetic technique used,
but after matching both groups showed similar pain intensity preoperatively. We have demonstrated statistically
significant results for pain level between the both groups of UKA and TKA, but possibly they are below clinical
relevance. This big data study represents daily clinical routine and is therefore, of great interest in the clinical
decision-making process in choosing treatment options. A high percentage of patients, who are eligible for pri-
mary joint replacement with isolated unicompartmental osteoarthritis still have TKA performed.

Conclusions
In contrast to previous studies, our study has shown that patients undergoing UKA have had lower pain scores
postoperatively and less need for opioids in the ward, in a multicenter matched pair analysis in 4144 cases. Fur-
thermore, patient subjective parameters were significantly better for UKA. Although opiate consumption was less
likely for patients with UKA than for patients with TKA, there was no significant difference in opiate equivalent.

Received: 2 April 2020; Accepted: 1 October 2020

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Author contributions
F.L., W.M., J.G., A.B. and F.G. made substantial contributions to the conception and design of the study.F.L.,
J.S.G., G.M., F.Z. and F.G. participated in the acquisition of data, analysis and statistics.All authors made con-
tributions to the interpretation of data and have been involved in drafting the manuscript. All authors reviewed
and approved the final manuscript.

Funding
Open Access funding enabled and organized by Projekt DEAL. This research did not receive any specific grant
from funding agencies in the public, commercial, or non-for-profit-sectors.

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Competing interests
The authors declare no competing interests.

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