Complex Approaches to The Diffuse Arthritic Knee: Including Corrective Osteotomy and Prosthetic Resurfacing

Complex Approaches to The Diffuse Arthritic Knee: Including Corrective Osteotomy and Prosthetic Resurfacing

Christian Sybrowsky

Annunziato Amendola

The treatment of active patients who develop progressive or untimely osteoarthritis of the knee remains a taxing clinical challenge for physicians. As many patients continue to participate in high-demand and rigorous physical activities well into later age, the opportunity for repetitive or traumatic chondral injury similarly increases. Consequently, an increasing number of patients present with activity-limiting knee pathology, coupled with a strong desire to remain as active as possible. The current treatments for osteoarthritis range from simple activity modification and pharmacologic therapy to more invasive surgical procedures such as total knee arthroplasty (TKA). Although TKA has been a successful procedure for the treatment of osteoarthritis in elderly patients, many physiologically young patients are hesitant to pursue this as a treatment due to activity restrictions and cautionary recommendations associated with this procedure.


The evaluation and treatment of arthritis should include a comprehensive evaluation including multiple clinical and patient-specific factors. Medical history, age, body mass index (BMI), current functional level, and patient expectations and goals must be considered when counseling patients. Prior injury, a history of surgery and radiographic appearance will also guide treatment, as the location, size, and chronicity of cartilage defects, as well as the degree of underlying degenerative joint disease, may exclude some treatments. If an osseous procedure such as high tibial osteotomy (HTO) is planned, diffuse disease is a contraindication, and bone quality must also be considered, as it may be challenging to obtain robust fixation in patients with osteoporosis and other diseases that affect bone density and quality. Consideration must also be given to other risk factors for failure, including smoking, corticosteroid dependency, chronic illness, immunosuppressants, etc.


Conservative treatment of osteoarthritis of the knee encompasses a broad spectrum of modalities and pharmaceuticals. Before considering surgical intervention, many patients are offered conservative therapies as a means to delay invasive procedures. Often, multiple modalities are used in concert to maximize benefit. These treatments can provide symptomatic relief as well as alter the knee environment to attempt to limit the progression of the disease. Conservative possibilities include nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, steroid injections, viscosupplementation, bracing and other orthoses, physical therapy and other exercise, and weight loss.

Weight Loss

Two randomized trials have demonstrated that even a modest reduction in weight (5% to 10% decrease in total body weight) can improve both pain and physical function in patients with osteoarthritis of the knee (1, 2). Although these studies did not specifically evaluate physiologically “young,” active patients, they support the notion that dietary weight loss is an important adjunct in the treatment of this disorder. More recently, the American Academy of Orthopaedic Surgeons (AAOS) has published a clinical practice guideline for the treatment of osteoarthritis of the knee, strongly recommending (grade A) that patients with a BMI >25 should be encouraged to lose a minimum of 5% of body weight (3).

Physical Therapy and Exercise

A number of randomized trials have supported regular, low-impact aerobic exercise as an effective modality for decreasing both pain and disability from knee OA (4, 5). Targeted physical therapy and home-based exercises for muscle strengthening and flexibility have also
been supported by several studies (6, 7 and 8). The beneficial effects of exercise therapy, however, may diminish over time (9, 10). The AAOS clinical practice guidelines strongly support (grade A) a low-impact fitness program, with lesser recommendations for targeted therapies (3).

Acetaminophen and NSAIDs

Acetaminophen is commonly prescribed for the analgesic treatment of arthritis due to its relative safety and efficacy. Hepatic toxicity secondary to acetaminophen overdose has been associated with dosages exceeding 4,000 mg per day. NSAIDs are also widely prescribed for degenerative joint disease. NSAIDs inhibit the enzyme cyclooxygenase, which subsequently results in decreased prostaglandin synthesis. Prostaglandins mediate the inflammatory response, which accounts for the anti-inflammatory effect of this class of drugs. However, some prostaglandins also increase protective gastric mucosal secretions and decrease gastric acid release, accounting for the nontrivial risk of gastrointestinal (GI) toxicity and bleeding associated with NSAIDs. Some studies suggest that GI toxicity is present in more than 25% of patients and treatment of GI side effects accounts for more than 30% of the total cost of arthritis care (11). Selective COX-2 inhibitors have been developed to decrease the GI toxicity and bleeding associated with conventional NSAIDs (12). COX-2 inhibitors are associated with fewer GI side effects and decreased gastroduodenal ulcers (13, 14). Topical NSAIDs have also been used in some patients to avoid systemic toxicity, but these may be effective only for a few weeks when compared with oral NSAIDs and may include side effects of rashes, burning, and itching (15). Some NSAIDs appear to stimulate collagen synthesis, which may aid in soft-tissue healing (16). However, NSAIDs and COX-2 inhibitors have also been shown to decrease bone ingrowth and may delay fracture healing (17). The AAOS clinical practice guidelines support (grade B) the use of these medications in the symptomatic treatment of osteoarthritis (3).

Braces and Orthoses

Knee braces and foot orthoses are commonly employed treatments for patients with early osteoarthritis who wish to maintain an active lifestyle and defer surgical treatment (18). Candidates for bracing include patients with early degenerative disease, particularly medial compartment osteoarthritis, focal posttraumatic arthritis, and meniscal deficiency resulting in unicompartmental disease. Brace design can range from simple neoprene sleeves to custom-fit hinged unloader braces, with the ultimate goal being a reduction in mechanical load in the affected compartment with a subsequent decrease in pain perception and increase in function. Unloader braces differ from traditional functional braces by the addition of an internal valgus angle (for medial compartment disease) or varus angle (for lateral compartment disease), which can, in theory, shift the weight-bearing axis toward the less affected compartment (19). Unloader bracing has been shown to be beneficial in patients with passively correctible coronal plane deformity of less than 10°, without excessive ligamentous laxity. Several studies report improvement of pain symptoms in more than 75% of patients (20, 21). with measurable reduction in both coronal moments and compartmental loads (22). Reduced muscle contractions about the knee, mediated by the stabilization of the brace, may also contribute to decreased pain in some patients (23).

Lateral wedge orthoses (both heel wedges and lateralwedge insoles) have also been shown to be beneficial in patients with symptomatic medial compartment disease (19). Pain relief and functional improvement in these patients are likely achieved by a reduction in external varus moment and medial compartment load (24). However, a recent systematic review suggests that the benefit gained from these orthoses is modest at best (25), and the AAOS clinical practice guidelines caution against their use (3).

Steroid Injections

Intra-articular corticosteroid injections are commonly used for anti-inflammatory relief in knee osteoarthritis. Although water-soluble formulations are available, depot formulations, which are less soluble and retain crystals in the injected area, are most commonly used in the treatment of osteoarthritis. Methylprednisolone and triamcinolone are the most commonly used depot preparations (26). Side effects are generally mild and can include post-injection flare, facial flushing, and skin or fat atrophy. A recent randomized, double-blind, controlled trial compared triamcinolone with saline injections in the knee repeated every 3 months for up to 2 years. Findings demonstrated improved clinical scores and range of motion in the corticosteroid group, with no progression of joint space narrowing (27). Intra-articular corticosteroid injections are supported (grade B) by the recent AAOS clinical practice guidelines for the treatment of osteoarthritis (3).


Intra-articular viscosupplementation refers to the injection of hyaluronic acid (HA) into the affected joint. With both viscous and elastic properties, HA is produced by the synovial membrane and is a major component of joint synovial fluid. HA has anti-inflammatory, anabolic, analgesic, and chondroprotective effects (28). In a recent meta-analysis of randomized controlled trials comparing HA injections with placebo, there were significant improvements in pain and functional outcomes with HA, although the effects were inversely proportional to age and the degree of joint degeneration (29). Several preparations of HA are available, including products from both avian and bacterial origins (28). The material properties of HA can be influenced by molecular weight, and cross-linking of the molecules can increase average molecular weight. Hylan G-F 20 is the only form of injectable HA in the United States that has cross-linked hyaluronan. In one study, hylan G-F 20
was shown to delay total knee replacement by 2 years or more (30). Side effects can include hypersensitivity and cutaneous anaphylaxis, and erythema (pseudo-sepsis) (31). The AAOS clinical practice guidelines could not make a recommendation for or against their use, due to inconclusive evidence (3).


The role of arthroscopy in the treatment of osteoarthritis of the knee remains controversial (18). Fifty percent or more of patients who undergo arthroscopy for osteoarthritis will report symptomatic relief (32). However, other studies have shown that only 44% of patients maintain decreased pain scores at 2-year follow-up (33), and up to 18% of patients undergo TKA within 3 years (34). Despite these findings, arthroscopic debridement remains a commonly performed procedure for osteoarthritis, and generalizability of the literature is limited by the heterogeneity of patient populations in these studies (18).

Several more recent randomized trials, however, have challenged the role of arthroscopic debridement in the treatment of osteoarthritis. In a randomized, controlled trial comparing arthroscopic lavage, debridement, or placebo surgery, Moseley et al. (32) evaluated 180 male veterans for a mean of 2 years following arthroscopy for treatment of osteoarthritis. Throughout the 2-year follow-up period, there were no statistically significant changes in pain scores among the three groups, leading the authors to conclude that the beneficial results of arthroscopy were no better than placebo in this homogenous patient population. In a subsequent study of a civilian population with moderate-to-severe osteoarthritis, Kirkley et al. (35) randomized 188 patients to either surgical debridement with medical/physical therapy or medical/physical therapy in isolation. At 2-year follow-up, there were no differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or Short Form-36 (SF-36) scores between the two groups. The authors concluded that arthroscopic debridement was no better than optimized medical/physical therapy.

These randomized studies, however, largely excluded patients with large meniscal tears or mechanical symptoms, suggesting that some subpopulations of patients, particularly those with mechanical symptoms from degenerative meniscal pathology, would benefit from arthroscopy. For example, in a study of 68 patients with Outerbridge grade IV osteoarthritis and a medial meniscal tear, up to 82% of patients reported a reduction of pain at 52 months after debridement, with 75% of patients requiring no further surgery up to 75 months after arthroscopy (36). Other authors have shown that up to 81% of patients with advanced arthritis might benefit from aggressive arthroscopic lysis of adhesions to increase joint volume and thereby decrease joint reactive forces (37). Despite these findings, however, other studies have demonstrated difficulty predicting which patients might benefit from arthroscopic debridement (33, 38). Dervin et al. (33) evaluated 126 patients with primary osteoarthritis who had failed initial medical management. Unstable chondral flaps and meniscal tears were addressed at the time of arthroscopy. Only 44% of patients maintained decreased WOMAC scores at 2 years. However, the presence of medial joint line tenderness preoperatively coupled with the debridement of a corresponding meniscal tear at the time of surgery seemed to portend better outcomes. Despite this, the authors concluded that physicians were unable to reliably predict which patients would benefit from surgery, based on preoperative clinical findings.

The role of arthroscopy in physiologically young patients with osteoarthritis is also unclear. The AAOS clinical practice guideline for treatment of osteoarthritis of the knee recommends against routine arthroscopy with debridement/lavage in patients with primary osteoarthritis (3). However, a corollary to this stipulation specifies that this recommendation does not apply to patients with a primary diagnosis of meniscal tear, loose body, or other mechanical symptoms in the setting of concomitant osteoarthritis. In the absence of specific studies targeting these subgroups, clinical judgment and proper patient selection are critical for surgical decision making. Younger patients with mechanical symptoms and less severe disease are the most likely to benefit from a trial of arthroscopy. It is important, however, to have a candid discussion regarding expectations, cautioning patients that any postoperative gains may be of limited benefit.


For more than 50 years, HTO and distal femoral osteotomy (DFO) have been used for correction of lower extremity malalignment and alleviation of unilateral compartment gonarthrosis (39, 40). Lower extremity alignment has been shown to be a significant factor in the progression of osteoarthritis of the knee (41). Coventry (42) initially defined indications for HTO and suggested that the optimal candidate was relatively active, with a stable knee, good range of motion, localized (unicompartmental) osteoarthritis, and age less than 65 years. Due to concomitant surgical procedures, contemporary indications for HTO have expanded to encompass coronal and sagittal malalignment, unicompartmental overload with prearthritic change, anteroposterior and varus/valgus instability, lateral or hyperextension thrust from posterolateral instability, and ligamentous deficiency (43, 44, 45, 46 and 47). Osteotomies are also commonly used for limb realignment in concert with meniscal transplantation or articular resurfacing procedures (48, 49, 50 and 51). The medial compartment is the most common site of deformity in both primary knee osteoarthritis and secondary arthritis resulting from osteochondral lesions, postmeniscectomy change, or chronic anterior cruciate ligament (ACL) deficiency. The lateral compartment can also be involved,
often in concert with a valgus deformity, particularly in the context of lateral meniscal deficiency, as the lateral compartment is highly reliant on meniscal integrity to avoid overload and secondary osteoarthritis. Varus deformity is usually secondary to proximal tibia vara, and is best addressed with HTO. Valgus deformity of the knee is usually secondary to deformity of the distal femur, and therefore DFO is often more appropriate.

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Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Complex Approaches to The Diffuse Arthritic Knee: Including Corrective Osteotomy and Prosthetic Resurfacing

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