IMUKA 2013
Masterclass in
Joint Replacement
28-29-30 November 2013
Maastricht
The Netherlands
Osteoarthritis
Nanne P. Kort, MD, PhD
Early treatment of arthritis of the knee may improve the functional well-being and long-term outcome in patients. Nonoperative treatments to reduce the pain associated with joint inflammation include weight loss, anti-inflammatory or analgesic medication, intraarticular injections, periarticular muscle strengthening and stress offloading with braces or heel wedges.1
The reduction of joint reaction forces and symptoms of degenerativearthritis by a decrease in body mass is a fundamental conceptin the management of arthritic joints.2Obesity is an independentrisk factor for the development of osteoarthritis in the knee,3and this association is higher for women than for men.4Women over the age of 50 with malalignment have a higherprevalence of degenerative arthritis of the knee than do age-matchedcontrol subjects in the general, nonaffected population.5Weight loss by obese women decreases the risk of developing degenerative arthritis. A weight loss of 5.1 kg over tenyears has been shown to decrease the risk of degenerative arthritis by >50%.6
Nonsteroidalanti-inflammatory medications are the most commonly used drugsfor treatment of degenerative arthritis of the knee and otherjoints. These drugs, which inhibit cyclooxygenase 1and 2, have analgesic and anti-inflammatory properties, butthey can be associated with gastrointestinal and other sideeffects. In a short-term clinical trial in which acetaminophenand ibuprofen, in analgesic and anti-inflammatory doses, werecompared as treatments for symptomatic arthritis of the knee,the efficacy of the two drugs was equivalent.7When nonsteroidalanti-inflammatory drugs are used chronically, it is importantfor patients to have medical monitoring of the hepatic, renal andgastrointestinal systems.8Specific cyclooxygenase-2 inhibitorshave demonstrated clinical efficacy in the treatment of symptomaticarthritis of the knee, with decreased gastrointestinal and renalside effects. However, specific cyclooxygenase-2 inhibitorsare more expensive, and risk-benefit and cost-benefit analysesmust be completed to better define the role of these agents.8Nutritional supplements (so-called nutriceuticals), such asglucosamine and chondroitin sulfate, have been touted as chondroprotectiveagents. Double-blind, placebo-controlled, randomised trialshave shown that glucosamine is mildly effective for relievingpain associated with degenerative arthritis.9-12In astudy by Reginster et al.,13212 patients with osteoarthritisof the knee were randomised to a glucosamine or a placebo treatmentgroup. After three years of treatment, the glucosamine grouphad less joint-space narrowing and improved WOMAC (Western Ontarioand McMaster University Osteoarthritis Index) scores when comparedwith the placebo group. However, we are not aware of any long-termstudies demonstrating beneficial effects of glucosamine on thearticular cartilage of an arthritic joint.9Some patientswith unicompartmental arthritis of the knee report improvementwith use of topical analgesics (e.g. methyl salicylate, capsaicinand nonsteroidal creams) as either adjunctive treatment or monotherapy.2
Acute exacerbations of degenerative arthritis of the knee presentingpain, swelling and effusion can be treated with aspirationof the knee joint and intra-articular injection of a corticosteroidpreparation. Corticosteroid injections are frequently combinedwith a local anaesthetic medication and canprovide short-term symptomatic relief. However, theseinjections can increase the risk of damage to the articularcartilage of the injected knee joint, and they should not berepeated more than three or four times a year.14
Exercise, as an adjunct to weight reduction, has value in thetreatment of an arthritic knee. Stretching to prevent contracture,maintain range of motion and increase muscle strength and dynamic stability of the knee can reduce symptoms associatedwith an arthritic knee.15Quadriceps muscle weakness is commonamong patients with degenerative arthritis of the knee and maybe a risk factor for this disease. Patient education programsand supervised fitness and walking sessions have been shownto improve functional status without worsening the symptomsof osteoarthritis of the knee.16
Three types of knee braces are commercially available for the treatmentof a knee with degenerative arthritis: compression knee sleeves,supportive knee braces and unloading knee braces. Polypropylene,neoprene or elasticised knee sleeves may minimise swellingand provide a feeling of increased support and warmth aboutthe knee without changing limb alignment, joint stability ormechanical function. Some patients report a feeling of securitywith a knee sleeve, possibly because of enhanced proprioceptivefeedback.15Supportive knee braces include hinged braces(for varus-valgus instability), anterior cruciate insufficiencybraces (for anteroposterior and rotatory instability) and patellofemoralbraces (for patellofemoral malalignment or instability). Unloadingbraces are designed to apply a varus or valgus force at theknee and relieve pain during activity by distracting the jointspace of the involved compartment during weight-bearing andactivity.17Heel and sole wedges can realign the foot 5° to 10°in either the varus or the valgus plane. With a lateral wedgeand insole, the shift in alignment reduces medial joint-spaceloading.18Keating et al.19evaluated 121 knees with medialunicompartmental arthritis in 85 patients who weretreated with a lateral heel and sole wedge. Sixty-one of the121 knees had a good or excellent result after four to 24months of treatment. Knees with all grades of arthritic involvementshowed improvement. Patients with stage-II disease accordingto the modified Outerbridge classification20improved the most.
When nonoperative treatment of osteoarthritis of the knee fails to relieve pain and knee function is compromised, operative intervention is warranted. Surgical choices include arthroscopic debridement, joint reconstruction, or both. Joint reconstruction choices include osteotomy and knee replacement. Joint replacement can be unicompartmental or total.1
Arthroscopic debridement has long been considered an effective alternative in the treatment of osteoarthritis of the knee.21-23However, a recent study by Mosely and colleagues called its value into question.24They compareda placebo group with a group treated with arthroscopic jointlavage and another group treated with arthroscopic debridement.All three treatment groups had a decrease in symptoms up totwo years after intervention. This study was confined to oldermen in a Veteran's Administration Hospital. The extent of thearthritic involvement of the knee (in one, two or three compartments)was not documented. Patients were not stratified accordingto degree of malalignment, body weight or type of symptoms.The authors concluded that arthroscopy of a knee with degenerativearthritis may not be indicated when there is only pain in theabsence of other symptoms (such as catching, clicking, lockingor giving way). Furthermore, they suggested that a decreasein symptoms after arthroscopy may be associated with a placeboeffect. There have been several other retrospective studies of arthroscopictreatment of degenerative arthritis of the knee, with unfavourable results.25-27
The rationale for an osteotomy is based on the premise that excessive varus or valgus deformity leads to harmful stresses on the articular cartilage, which in turn lead to osteoarthritis. As long as overcorrection is avoided, corrective osteotomy ofthe knee is associated with biological improvement of damagedarticular cartilage with maintenance of articular cartilagein the least degenerated compartment.28-37
Unicompartmental knee arthroplasty is a potentially attractive alternativeto tibial osteotomy or total knee arthroplasty in selected osteoarthriticpatients. Traditionally, unicompartmental knee arthroplasty hasbeen reserved for patients with unicompartmental arthritis who havea sedentary lifestyle and are older than 60.However, there has been recent interest in performing this procedurein patients younger than 60 as an alternative to tibialosteotomy or total knee arthroplasty.38
Total knee replacement has been shown to have durable and predictable resultsin elderly patients, providing pain relief, improving functionand correcting deformity. The possibility ofmultiple revisions due to loosening or wear initially discouragedthe widespread use of total knee arthroplasty in young patients withdegenerative arthritis.37These concerns arose from the poorresults observed in young patients who had had a total hip arthroplasty. However,the early results of total knee arthroplasty in young patients didnot reflect the experience with total hip arthroplasty, and preliminary reports often included many patients with rheumatoid arthritisor juvenile rheumatoid arthritis. On the basisof this initial success, the indications for total knee arthroplastywere eventually expanded to younger patients with osteoarthritis. As the indications continue to expand, the decision to proceedwith total knee arthroplasty in young, active patients needsto be individualised after careful consideration of alternatives.38
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