Surgery for Osteoarthritis of the Knee

Although total knee replacement is an excellent treatment of end-stage osteoarthritis of the knee in the older (>65 years) population, many patients with less severe disease are significantly impacted by their symptoms and have failed to respond to less invasive treatment alternatives. For this group, there are several less invasive surgical alternatives, including arthroscopic meniscectomy, grafting of symptomatic areas of bone marrow lesions, unloading osteotomy, and unicompartmental knee replacement. Current total knee arthroplasty designs can be expected to survive 20 years or more in the older, less active population. New materials may extend that survivorship.

Key points

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The indications for arthroscopy have narrowed.
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Orthopedic surgeons continue to explore surgical options less invasive than total knee replacement for isolated unicompartmental arthritis of the knee joint, including arthroscopic meniscectomy, grafting of symptomatic areas of bone marrow lesions, unloading osteotomy, and unicompartmental knee replacement.
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Current total knee arthroplasty designs can be expected to survive 20 years or more in the older, less active population. New materials may extend that survivorship.

When more conservative modalities of management for knee osteoarthritis (OA) are no longer or not effective, then surgery is usually indicated. Currently available surgical techniques for the treatment of OA of the knee range from arthroscopy to total joint arthroplasty. These techniques include procedures regarded as less invasive than total joint arthroplasty, including osteotomies and joint-preserving unicompartmental replacements. Total joint arthroplasty of either the hip or the knee has been demonstrated to be one of the most cost-effective medical interventions available ( Fig. 1 ). A recent study from Europe has confirmed again that total knee arthroplasty is a more cost-effective medical intervention than coronary artery bypass surgery. Total joint arthroplasty is one of the most studied treatments in OA because of the very high volume of joint replacements performed (more than 600,000 total knee replacements are performed each year in the United States, and the number is increasing annually). This high volume and the significant expense of the procedure have resulted in many well-performed studies investigating the long-term survivorship and effectiveness of this intervention in treating OA of the knee. Although total knee replacement remains an excellent procedure in the older population (>70 years of age), there are significant issues concerning the long-term durability of total knee arthroplasty in the younger population (<55 years of age). One long-term study of more than 10,000 total knees demonstrated the failure of total knee replacement at 10 years was approximately 3 times higher in the population under the age of 55 years than in the population over the age of 70 years (15% vs 6%). With this significantly higher risk of failure, multiple other alternative treatments often are recommended in this younger age group. This article reviews the alternative surgical treatments to total knee arthroplasty, including arthroscopy, a new grafting procedure for subchondral edema, osteotomy, and unicompartmental arthroplasty.