Editors: Berry, Daniel J.; Steinmann, Scott P.
Title: Adult Reconstruction, 1st Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Section
II – Knee > Part B – Evaluation and Treatment of Knee Disorders >
18 – Osteoarthritis and Inflammatory Arthritis of the Knee
II – Knee > Part B – Evaluation and Treatment of Knee Disorders >
18 – Osteoarthritis and Inflammatory Arthritis of the Knee
18
Osteoarthritis and Inflammatory Arthritis of the Knee
Hari P. Bezwada
Jess H. Lonner
Robert E. Booth Jr.
In the presence of arthritis, pain is the leading reason
for patients to present for medical evaluation. They may have either
monoarticular or polyarticular complaints. Osteoarthritis affects
>40 million people annually, and there is an association with
advanced age. Rheumatoid arthritis, although far less prevalent,
commonly has a younger age of onset and often is more debilitating than
osteoarthritis, with polyarticular and systemic manifestations. It is
important to differentiate inflammatory from noninflammatory arthritis,
as the diagnosis has clear implications in terms of both treatment and
prognosis.
for patients to present for medical evaluation. They may have either
monoarticular or polyarticular complaints. Osteoarthritis affects
>40 million people annually, and there is an association with
advanced age. Rheumatoid arthritis, although far less prevalent,
commonly has a younger age of onset and often is more debilitating than
osteoarthritis, with polyarticular and systemic manifestations. It is
important to differentiate inflammatory from noninflammatory arthritis,
as the diagnosis has clear implications in terms of both treatment and
prognosis.
Osteoarthritis
Osteoarthritis is the end result of various disorders
that lead to structural or functional failures in one or both knees.
The knee is a diarthrodial joint with bone, cartilage, and connective
tissue. The subchondral bone is covered by hyaline cartilage, which is
made up of type II collagen, chondrocytes, and proteoglycans. The
arrangement of type II collagen along the joint surface provides
tensile strength. Proteoglycans assist with water retention and provide
a low-friction bearing surface and shock absorption. Normal synovial
fluid provides nourishment to hyaline cartilage and has viscoelastic
properties. The volume of synovial fluid increases in osteoarthritis
and is high in prostaglandins, collagenases, tumor necrosis factor 1,
and interleukins. Osteoarthritic synovial fluid is also low in
hyaluronate.
that lead to structural or functional failures in one or both knees.
The knee is a diarthrodial joint with bone, cartilage, and connective
tissue. The subchondral bone is covered by hyaline cartilage, which is
made up of type II collagen, chondrocytes, and proteoglycans. The
arrangement of type II collagen along the joint surface provides
tensile strength. Proteoglycans assist with water retention and provide
a low-friction bearing surface and shock absorption. Normal synovial
fluid provides nourishment to hyaline cartilage and has viscoelastic
properties. The volume of synovial fluid increases in osteoarthritis
and is high in prostaglandins, collagenases, tumor necrosis factor 1,
and interleukins. Osteoarthritic synovial fluid is also low in
hyaluronate.
Repetitive microtrauma is thought to create
biomechanical alterations in the cartilage matrix, which leads to
subsequent breakdown of both cartilage and subchondral bone. The water
content within the type II collagen increases and proteoglycan
synthesis increases in an attempt to promote joint repair. Chondrocytes
within the cartilage matrix eventually become overwhelmed with
attempting repair and release metalloproteinases. The
metalloproteinases cause further destruction and thinning of the
cartilage matrix. More subchondral bone becomes exposed as the
cartilage thins, leading to increased stresses and subchondral
sclerosis along with the development of osteophytes. Subchondral cysts
form as synovial fluid is forced beneath the joint surface.
biomechanical alterations in the cartilage matrix, which leads to
subsequent breakdown of both cartilage and subchondral bone. The water
content within the type II collagen increases and proteoglycan
synthesis increases in an attempt to promote joint repair. Chondrocytes
within the cartilage matrix eventually become overwhelmed with
attempting repair and release metalloproteinases. The
metalloproteinases cause further destruction and thinning of the
cartilage matrix. More subchondral bone becomes exposed as the
cartilage thins, leading to increased stresses and subchondral
sclerosis along with the development of osteophytes. Subchondral cysts
form as synovial fluid is forced beneath the joint surface.
The severity of osteoarthritis is best determined by
reviewing weight-bearing radiographs. Typical radiographs include
weight-bearing anteroposterior and lateral views. Patellar skyline or
Merchant views are best to evaluate the patellofemoral joint, patellar
tracking, and patellar tilt. A weight-bearing 45-degree flexion or
notch view (posteroanterior) is useful in evaluating degenerative
changes mostly involving the posterior femoral condyles. Magnetic
resonance imaging, nuclear scans, and computed tomography have limited
utility.
reviewing weight-bearing radiographs. Typical radiographs include
weight-bearing anteroposterior and lateral views. Patellar skyline or
Merchant views are best to evaluate the patellofemoral joint, patellar
tracking, and patellar tilt. A weight-bearing 45-degree flexion or
notch view (posteroanterior) is useful in evaluating degenerative
changes mostly involving the posterior femoral condyles. Magnetic
resonance imaging, nuclear scans, and computed tomography have limited
utility.
Inflammatory Arthritis
Classic signs of inflammatory arthritis include warmth,
erythema, swelling, synovitis, and pain. The presentation may involve a
single or multiple joints with additional systemic complaints. The
illness may have a waxing and waning course. The level of joint
involvement may be symmetrical or asymmetrical and acute or chronic.
The keys to diagnosis include careful history and physical examination
and judicious review of appropriate laboratory and imaging studies.
erythema, swelling, synovitis, and pain. The presentation may involve a
single or multiple joints with additional systemic complaints. The
illness may have a waxing and waning course. The level of joint
involvement may be symmetrical or asymmetrical and acute or chronic.
The keys to diagnosis include careful history and physical examination
and judicious review of appropriate laboratory and imaging studies.
Rheumatoid arthritis (RA) is the most prevalent chronic, symmetrical inflammatory polyarticular arthritis. Clinical
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findings include rheumatoid nodules, symmetrical synovitis,
seropositive rheumatoid factor, synovial fluid inflammatory findings,
and radiographic changes including erosions and osteopenia. Osteophytes
and sclerosis are unusual in RA.
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TABLE 18-1 Differential Diagnosis of Inflammatory Arthritis
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Lyme disease may have either a monoarticular or
polyarticular presentation, and there is typically a history of a tick
bite and a target skin lesion (erythema chronicum migrans). However,
both the history and presence of constitutional symptoms are variable.
Serologies (Lyme titers) are useful in confirming the diagnosis;
synovial fluid analysis may show an elevated white blood cell count
with a preponderance of neutrophils.
polyarticular presentation, and there is typically a history of a tick
bite and a target skin lesion (erythema chronicum migrans). However,
both the history and presence of constitutional symptoms are variable.
Serologies (Lyme titers) are useful in confirming the diagnosis;
synovial fluid analysis may show an elevated white blood cell count
with a preponderance of neutrophils.
Other inflammatory arthropathies include Reiter disease,
psoriatic arthritis, and seronegative rheumatoid arthritis. Various
rheumatologic tests, such as rheumatoid factor, antinuclear antibody,
and HLA B-27, can help establish the diagnosis. Arthritis may also be
associated with HIV infection, hepatitis C infection, inflammatory
bowel disease, crystal deposition, and connective tissue disorders (Table 18-1).
psoriatic arthritis, and seronegative rheumatoid arthritis. Various
rheumatologic tests, such as rheumatoid factor, antinuclear antibody,
and HLA B-27, can help establish the diagnosis. Arthritis may also be
associated with HIV infection, hepatitis C infection, inflammatory
bowel disease, crystal deposition, and connective tissue disorders (Table 18-1).
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TABLE 18-2 Synovial Fluid Analysis
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Synovial Analysis
Synovial fluid analysis is a useful adjunct in
differentiating inflammatory, noninflammatory, and septic arthritis.
Aspiration should be performed with caution in patients with overlying
cellulitis or soft tissue infection because of the risk of direct
inoculation of the joint. Normal knee synovial fluid has a volume of
several milliliters and a white blood cell count <200. Synovial
fluid also contains hyaluronate (glycosaminoglycan) produced by
synoviocytes and is typically transparent with a straw color.
differentiating inflammatory, noninflammatory, and septic arthritis.
Aspiration should be performed with caution in patients with overlying
cellulitis or soft tissue infection because of the risk of direct
inoculation of the joint. Normal knee synovial fluid has a volume of
several milliliters and a white blood cell count <200. Synovial
fluid also contains hyaluronate (glycosaminoglycan) produced by
synoviocytes and is typically transparent with a straw color.
Abnormal synovial fluid has increased volume, decreased
viscosity, diminished clarity, and a change in color. Microscopic
analysis for the numbers and types of cells as well as the presence of
crystals is important. Synovial fluid culture, serologic analysis, and
immunologic evaluations should be performed as necessary (Table 18-2).
viscosity, diminished clarity, and a change in color. Microscopic
analysis for the numbers and types of cells as well as the presence of
crystals is important. Synovial fluid culture, serologic analysis, and
immunologic evaluations should be performed as necessary (Table 18-2).
Treatment
Nonoperative Treatment
The first line of treatment for arthritis of the knee
includes both physical modalities and pharmacologic interventions. The
goals are simply to decrease pain and improve function. Presently,
little can be done to reverse the degenerative process (Tables 18-3, 18-4).
includes both physical modalities and pharmacologic interventions. The
goals are simply to decrease pain and improve function. Presently,
little can be done to reverse the degenerative process (Tables 18-3, 18-4).
Physical Therapy
Physical therapy can improve and maintain the patient’s
functional level. Physical therapy programs should consist of
stretching, proprioceptive exercise, strengthening, and conditioning.
Range of motion and stretching are critical parts of a therapy program
as they help to maintain function. The quadriceps atrophy that occurs
with knee arthritis may be both rapid and dramatic. Most exercise and
strengthening programs are focused on the quadriceps mechanism,
although hamstring strengthening may be important for balancing the
quadriceps/hamstrings ratio. Patients with knee arthritis who undergo
quadriceps strengthening show
functional level. Physical therapy programs should consist of
stretching, proprioceptive exercise, strengthening, and conditioning.
Range of motion and stretching are critical parts of a therapy program
as they help to maintain function. The quadriceps atrophy that occurs
with knee arthritis may be both rapid and dramatic. Most exercise and
strengthening programs are focused on the quadriceps mechanism,
although hamstring strengthening may be important for balancing the
quadriceps/hamstrings ratio. Patients with knee arthritis who undergo
quadriceps strengthening show
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improvements
in quadriceps strength, knee pain, and function. Isometric exercises
are generally best tolerated. General aerobic conditioning from
low-impact exercises improves both patients’ overall health and
arthritic symptoms. Water therapy is especially useful in obese
patients as the force of gravity is virtually eliminated. Warm water
hydrotherapy raises body temperature, causes superficial
vasodilatation, increases peripheral circulation, has a sedative effect
on nerve endings, and causes muscle relaxation.
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TABLE 18-3 Medical Treatment of Inflammatory Arthritis
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Biomechanical Devices
Valgus-producing unloader knee braces may be helpful in
varus gonarthrosis especially when there is instability and lateral
thrust. These braces use a three-point pressure system to decrease the
deformity and off-load the affected compartment. Brace-wear compliance
is variable, as unloader braces tend to be uncomfortable and less
effective in the obese. Orthotics, namely lateral heel wedges, may also
be helpful in varus gonarthrosis. Patients with valgus knee deformities
in association with a planovalgus foot may benefit from a foot-ankle
orthosis. Assistive devices such as a cane or walker substantially
reduce forces across the affected joint.
varus gonarthrosis especially when there is instability and lateral
thrust. These braces use a three-point pressure system to decrease the
deformity and off-load the affected compartment. Brace-wear compliance
is variable, as unloader braces tend to be uncomfortable and less
effective in the obese. Orthotics, namely lateral heel wedges, may also
be helpful in varus gonarthrosis. Patients with valgus knee deformities
in association with a planovalgus foot may benefit from a foot-ankle
orthosis. Assistive devices such as a cane or walker substantially
reduce forces across the affected joint.
External Energy
Therapeutic heat may produce analgesia of the free nerve
endings and subsequent muscle relaxation. The obligatory increase in
blood flow from local heat may also wash out inflammatory mediators.
Ultrasound is a deep heat modality that may have efficacy in relieving
arthritis pain. It also has mechanical effects that create fluid
movements around cells, which in turn alters cell permeability,
promotes collagen synthesis, and alters painful nerve fibers. The use
of transcutaneous electrical neuromuscular stimulation (TENS) has been
controversial. Cryotherapy may reduce pain by reducing muscle spindle
activity and raising the pain threshold.
endings and subsequent muscle relaxation. The obligatory increase in
blood flow from local heat may also wash out inflammatory mediators.
Ultrasound is a deep heat modality that may have efficacy in relieving
arthritis pain. It also has mechanical effects that create fluid
movements around cells, which in turn alters cell permeability,
promotes collagen synthesis, and alters painful nerve fibers. The use
of transcutaneous electrical neuromuscular stimulation (TENS) has been
controversial. Cryotherapy may reduce pain by reducing muscle spindle
activity and raising the pain threshold.
Weight Loss and Activity Modification
Modest weight loss may have dramatic effects on
arthritis pain. Joint reactive forces may reach three to four times
body weight across the knee. This factor increases to sevenfold to
eightfold across the patellofemoral joint in deep flexion. The
increased joint forces from body weight are also affected by cyclical
loading, i.e., number of steps taken. Activity modification also may be
chondroprotective. Excessive impact loading of the knee should be
avoided as it may have a deleterious effect on knee function and
arthritis.
arthritis pain. Joint reactive forces may reach three to four times
body weight across the knee. This factor increases to sevenfold to
eightfold across the patellofemoral joint in deep flexion. The
increased joint forces from body weight are also affected by cyclical
loading, i.e., number of steps taken. Activity modification also may be
chondroprotective. Excessive impact loading of the knee should be
avoided as it may have a deleterious effect on knee function and
arthritis.
Pharmacologic Interventions
The most commonly used nonnarcotic analgesic is
acetaminophen, which can be effective, particularly in milder cases,
when used frequently as a first-line treatment for arthritis. The risks
include hepatotoxicity and interstitial nephritis in large regular
doses. Narcotic analgesics may be effective for temporary pain relief,
but have well-known side effects on the central nervous system and
gastrointestinal system.
acetaminophen, which can be effective, particularly in milder cases,
when used frequently as a first-line treatment for arthritis. The risks
include hepatotoxicity and interstitial nephritis in large regular
doses. Narcotic analgesics may be effective for temporary pain relief,
but have well-known side effects on the central nervous system and
gastrointestinal system.
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TABLE 18-4 Treatment of the Arthritic Knee
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs).
One of the first-line therapies in the medical
management of inflammatory arthritis is nonsteroidal anti-inflammatory
drugs (NSAIDs). Salicylates were among the first NSAIDs used with
typical doses of 300 to 600 mg three to four times a day. Salicylates
should not be used in gout as they have been implicated in increasing
serum uric acid levels. The main side effects are gastrointestinal,
hematologic, hepatic, and renal.
management of inflammatory arthritis is nonsteroidal anti-inflammatory
drugs (NSAIDs). Salicylates were among the first NSAIDs used with
typical doses of 300 to 600 mg three to four times a day. Salicylates
should not be used in gout as they have been implicated in increasing
serum uric acid levels. The main side effects are gastrointestinal,
hematologic, hepatic, and renal.
Most NSAIDs inhibit the cyclo-oxygenase enzymes. The
exceptions include nonacetylated salicylates such as Arthropan,
Trilisate, and Disalcid. Cyclo-oxygenase is critical in producing
prostaglandins. Prostaglandins have many effects in the body, including
vasodilation, gastrointestinal mucosal protection, and inflammation.
Prostaglandin E2 may contribute to local inflammation within the joint space. It appears that reducing the amount of prostaglandin E2
leads to less joint pain. The most common side effects of NSAIDs are on
the gastrointestinal system; the frequency ranges from 15% to 35%.
Renal toxicity also may occur as a result of interstitial nephritis or
renal hypoperfusion.
exceptions include nonacetylated salicylates such as Arthropan,
Trilisate, and Disalcid. Cyclo-oxygenase is critical in producing
prostaglandins. Prostaglandins have many effects in the body, including
vasodilation, gastrointestinal mucosal protection, and inflammation.
Prostaglandin E2 may contribute to local inflammation within the joint space. It appears that reducing the amount of prostaglandin E2
leads to less joint pain. The most common side effects of NSAIDs are on
the gastrointestinal system; the frequency ranges from 15% to 35%.
Renal toxicity also may occur as a result of interstitial nephritis or
renal hypoperfusion.
Two subgroups of cyclo-oxygenase have been discovered.
Cyclo-oxygenase-1 (COX-1) is found in most tissues and is important in
maintaining mucosal integrity of the gastrointestinal tract and renal
perfusion. Cyclooxygenase-2 (COX-2) is found mostly at the site of
inflammation. Selective COX-2 inhibitors are associated with improved
gastric tolerance compared with other NSAIDs. Recent evidence has
suggested that there is an increase in adverse cardiac events in
patients with cardiac disease treated with some COX-2 inhibitors, so
the indication for their use over an extended period of time is yet to
be defined.
Cyclo-oxygenase-1 (COX-1) is found in most tissues and is important in
maintaining mucosal integrity of the gastrointestinal tract and renal
perfusion. Cyclooxygenase-2 (COX-2) is found mostly at the site of
inflammation. Selective COX-2 inhibitors are associated with improved
gastric tolerance compared with other NSAIDs. Recent evidence has
suggested that there is an increase in adverse cardiac events in
patients with cardiac disease treated with some COX-2 inhibitors, so
the indication for their use over an extended period of time is yet to
be defined.
Disease-modifying antirheumatic drugs include gold
compounds, antimalarials, sulfasalazine, penicillamine, cytotoxic drugs
(azathioprine, methotrexate), cyclosporine, and flunomide. Recent
developments include tumor necrosis factor antagonists, examples of
which include etanercept, infliximab, and adalimumab (Table 18-3).
compounds, antimalarials, sulfasalazine, penicillamine, cytotoxic drugs
(azathioprine, methotrexate), cyclosporine, and flunomide. Recent
developments include tumor necrosis factor antagonists, examples of
which include etanercept, infliximab, and adalimumab (Table 18-3).
Injectable Corticosteroids.
Typical intra-articular injection combines a synthetic
corticosteroid and local anesthetic. The addition of a local anesthetic
reduces the incidence of postinjection symptom flare. Multiple studies
have supported an improvement in symptoms over placebo 1 to 2 weeks
following injection. Yet by 4 weeks, the results become very similar.
Although corticosteroids are commonly administered, there is little
literature to direct surgeons as to the optimal steroid preparation,
dosage, frequency, and length of treatment. Systemic side effects from
corticosteroid injections include allergic reactions, intra-articular
infection, and potential hyperglycemia in brittle diabetics. Frequent
injections over the long term are associated with local fat atrophy and
cartilage degeneration from decreased collagen formation. Additionally,
pain masking may lead to overuse and cartilage breakdown. Therefore
most clinicians recommend that injections be given no more frequently
than every 3 or 4 months.
corticosteroid and local anesthetic. The addition of a local anesthetic
reduces the incidence of postinjection symptom flare. Multiple studies
have supported an improvement in symptoms over placebo 1 to 2 weeks
following injection. Yet by 4 weeks, the results become very similar.
Although corticosteroids are commonly administered, there is little
literature to direct surgeons as to the optimal steroid preparation,
dosage, frequency, and length of treatment. Systemic side effects from
corticosteroid injections include allergic reactions, intra-articular
infection, and potential hyperglycemia in brittle diabetics. Frequent
injections over the long term are associated with local fat atrophy and
cartilage degeneration from decreased collagen formation. Additionally,
pain masking may lead to overuse and cartilage breakdown. Therefore
most clinicians recommend that injections be given no more frequently
than every 3 or 4 months.
Viscosupplementation.
Hyaluronic acid is a key constituent of both cartilage
and synovial fluid. Osteoarthritis is associated with a loss of
hyaluronic acid from the cartilage and the production of
low-molecular-weight hyaluronic acid by synoviocytes. The result is the
presence of a less viscous hyaluronate in the arthritic joint.
Hyaluronic acid injection may be considered for patients with
symptomatic osteoarthritis that has not responded to other conservative
measures.
and synovial fluid. Osteoarthritis is associated with a loss of
hyaluronic acid from the cartilage and the production of
low-molecular-weight hyaluronic acid by synoviocytes. The result is the
presence of a less viscous hyaluronate in the arthritic joint.
Hyaluronic acid injection may be considered for patients with
symptomatic osteoarthritis that has not responded to other conservative
measures.
Several products are available; the differences between
them are mainly based on the molecular weight of the cross-linked
hyaluronic acids. It is not clear how formulation differences impact
clinical efficacy or response. Multiple studies appear to support the
efficacy of each of these formulations, with a low-risk side effect
profile. The most common side effect is a sterile partial inflammatory
effusion, which can be difficult to distinguish from infection.
Hyaluronic acid appears better than placebo, and the effect is similar
to that of nonsteroidal anti-inflammatories. The analgesic effect
appears to last for several months. A course of viscosupplementation
may be repeated every 6 months, although the efficacy may be reduced
and the risk of allergic reaction may increase.
them are mainly based on the molecular weight of the cross-linked
hyaluronic acids. It is not clear how formulation differences impact
clinical efficacy or response. Multiple studies appear to support the
efficacy of each of these formulations, with a low-risk side effect
profile. The most common side effect is a sterile partial inflammatory
effusion, which can be difficult to distinguish from infection.
Hyaluronic acid appears better than placebo, and the effect is similar
to that of nonsteroidal anti-inflammatories. The analgesic effect
appears to last for several months. A course of viscosupplementation
may be repeated every 6 months, although the efficacy may be reduced
and the risk of allergic reaction may increase.
Nutraceuticals/Dietary Supplements
Although studies are scant and poorly controlled, there
has been some suggestion that certain naturally occurring dietary
supplements, herbal remedies, and so-called nutraceuticals may be
helpful in the management of knee arthritis. Omega-3 fatty acids may
reduce the production of inflammatory mediators in the body and have
been shown to reduce stiffness in patients with rheumatoid arthritis.
Methylsulfonylmethane (MSM), glucosamine, and chondroitin sulphate are
popular supplements that have been touted for their virtues in slowing
down the progression of arthritis. Glucosamine ostensibly enhances
cartilage production and reduces pain to a level similar to that of
NSAIDS, although conflicting reports have suggested this to be a
placebo effect. Chondroitin sulfate may inhibit proteases and thereby
slow the progression of arthritis and reduce inflammation.
Antioxidants, namely vitamins C, D, E, may be beneficial in cartilage
formation, but further study is necessary.
has been some suggestion that certain naturally occurring dietary
supplements, herbal remedies, and so-called nutraceuticals may be
helpful in the management of knee arthritis. Omega-3 fatty acids may
reduce the production of inflammatory mediators in the body and have
been shown to reduce stiffness in patients with rheumatoid arthritis.
Methylsulfonylmethane (MSM), glucosamine, and chondroitin sulphate are
popular supplements that have been touted for their virtues in slowing
down the progression of arthritis. Glucosamine ostensibly enhances
cartilage production and reduces pain to a level similar to that of
NSAIDS, although conflicting reports have suggested this to be a
placebo effect. Chondroitin sulfate may inhibit proteases and thereby
slow the progression of arthritis and reduce inflammation.
Antioxidants, namely vitamins C, D, E, may be beneficial in cartilage
formation, but further study is necessary.
Topical Agents
Aspercreme (10% trolamine salicylate cream) is absorbed
percutaneously and hydrolyzed into salicylic acid. Topical application
of capsaicin affects the A, delta, and C nerve fibers and secondarily
leads to depletion of substance P.
percutaneously and hydrolyzed into salicylic acid. Topical application
of capsaicin affects the A, delta, and C nerve fibers and secondarily
leads to depletion of substance P.
Surgical Management
Arthroscopy
Arthroscopy has a limited role in the management of the
osteoarthritic knee. The presence of mechanical symptoms is the main
indication for arthroscopic intervention in the presence of
degenerative joint disease (DJD), usually when arthritis is mild and
associated with a meniscus tear. Severe or end-stage arthritis should
be excluded with weight-bearing radiographs prior to arthroscopy as the
likelihood of success is dependent on the degree of arthritic changes.
Arthroscopic debridement in osteoarthritis has not been better than
placebo. An additional role of arthroscopy may be in the case of
isolated cartilage lesions or defects in which
osteoarthritic knee. The presence of mechanical symptoms is the main
indication for arthroscopic intervention in the presence of
degenerative joint disease (DJD), usually when arthritis is mild and
associated with a meniscus tear. Severe or end-stage arthritis should
be excluded with weight-bearing radiographs prior to arthroscopy as the
likelihood of success is dependent on the degree of arthritic changes.
Arthroscopic debridement in osteoarthritis has not been better than
placebo. An additional role of arthroscopy may be in the case of
isolated cartilage lesions or defects in which
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microfracture,
subchondral drilling, or abrasion techniques can be used. The clinical
data to support these techniques remain limited. Mosaicplasty or
autologous chondrocyte transplantation can be performed in young
patients with small lesions but are not presently advocated for more
diffuse and advanced degenerative disease. Arthroscopic synovectomy
with or without biopsy may have a role in inflammatory synovitis.
Osteotomy
Valgus-producing high tibial osteotomy is indicated in
patients with varus gonarthrosis and isolated medial compartment
arthritis. Varus-producing distal femoral osteotomy is indicated in
patients with valgus gonarthrosis and isolated lateral compartment
arthritis. Other general requirements include age younger than 50
years, intact anterior cruciate ligament, minimal flexion contracture,
good motion, noninflammatory arthritis, and no dynamic thrust. Because
of the apparent short-term superiority of unicompartmental
arthroplasty, periarticular osteotomies are not being performed as
frequently as a decade ago, except perhaps in young laborers with
unicompartmental disease.
patients with varus gonarthrosis and isolated medial compartment
arthritis. Varus-producing distal femoral osteotomy is indicated in
patients with valgus gonarthrosis and isolated lateral compartment
arthritis. Other general requirements include age younger than 50
years, intact anterior cruciate ligament, minimal flexion contracture,
good motion, noninflammatory arthritis, and no dynamic thrust. Because
of the apparent short-term superiority of unicompartmental
arthroplasty, periarticular osteotomies are not being performed as
frequently as a decade ago, except perhaps in young laborers with
unicompartmental disease.
Unicompartmental Arthroplasty
The role of unicompartmental arthroplasty in the
arthritic patient continues to evolve. Minimally invasive techniques
are enhancing the popularity of this procedure, particularly as an
alternative to periarticular osteotomy. In the past, the ideal patient
was older than 60 years of age and led a sedentary lifestyle. More
current indications might include active middle-aged patients
undergoing a first arthroplasty as a staged procedure before total knee
arthroplasty (TKA). Benefits might include less invasive surgery, less
blood loss, more natural knee kinematics (retaining both cruciate
ligaments), a faster recovery than with TKA, and more pronounced pain
relief than osteotomy. Isolated monocompartmental arthritis of the
tibiofemoral joint or patellofemoral joint remain true indications for
unicompartmental arthroplasty. Degenerative changes in other
compartments and inflammatory arthritis are contraindications.
arthritic patient continues to evolve. Minimally invasive techniques
are enhancing the popularity of this procedure, particularly as an
alternative to periarticular osteotomy. In the past, the ideal patient
was older than 60 years of age and led a sedentary lifestyle. More
current indications might include active middle-aged patients
undergoing a first arthroplasty as a staged procedure before total knee
arthroplasty (TKA). Benefits might include less invasive surgery, less
blood loss, more natural knee kinematics (retaining both cruciate
ligaments), a faster recovery than with TKA, and more pronounced pain
relief than osteotomy. Isolated monocompartmental arthritis of the
tibiofemoral joint or patellofemoral joint remain true indications for
unicompartmental arthroplasty. Degenerative changes in other
compartments and inflammatory arthritis are contraindications.
Total Knee Arthroplasty
Total knee arthroplasty is the procedure of choice for
most patients with severe tricompartmental arthritis and provides
reliable and durable results. Inflammatory arthritis, deformity,
contractures, and instability are best managed with total knee
arthroplasty rather than the other surgical procedures.
most patients with severe tricompartmental arthritis and provides
reliable and durable results. Inflammatory arthritis, deformity,
contractures, and instability are best managed with total knee
arthroplasty rather than the other surgical procedures.
Suggested Readings
Argensen
JN, Chevrol-Benkeddache Y, Aubaniac JM. Modern unicompartmental knee
arthroplasty with cement: a three to ten year follow-up. J Bone Joint Surg Am. 2002; 84:2235-2239.
JN, Chevrol-Benkeddache Y, Aubaniac JM. Modern unicompartmental knee
arthroplasty with cement: a three to ten year follow-up. J Bone Joint Surg Am. 2002; 84:2235-2239.
Behrens F, Shepard N, Mitchell N. Metabolic recovery of articular cartilage after intra-articular injections of glucocorticoid. J Bone Joint Surg Am. 1976; 58:1157-1160.
Bradley
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