Surgical Options Knee Nrrheum

  • View
    214

  • Download
    0

Embed Size (px)

Text of Surgical Options Knee Nrrheum

  • 8/18/2019 Surgical Options Knee Nrrheum

    1/45

    reviews

    Surgical options for patients with osteoarthritis of the knee Jörg Lützner, Philip Kasten, Klaus-Peter Günther and Stephan Kirschner

    abstract | Osteoarthritis (OA) of the knee is a progressive disease that ultimately damages the entire joint. nee OA should initially be treated conservatively! but surgery should be considered if symptoms persist.

    surgical treatments for knee OA include arthroscopy! osteotomy and knee arthroplasty" determining which of these procedures is most appropriate will depend on several factors! including the location and severity of OA damage! patient characteristics and risk factors. Arthroscopic lavage and debridement do not alter disease progression! and should not be used as a routine treatment for the osteoarthritic knee. #one marrow stimulation techni$ues such as microfracture are primarily used to treat focal chondral defects" the evidence for the use of these techni$ues for knee OA remains unclear. %he goal of osteotomy for unicompartmental knee OA is to transfer the weight load from the damaged compartment to undamaged areas! delaying the need for joint

    replacement. %his procedure should be considered in young and active patients who are not suitable candidates for knee arthroplasty. &or patients with severe OA! total knee arthroplasty can be a safe! rewarding and cost' effective treatment. in selected patients with isolated medial or patellofemoral OA! unicompartmental knee arthroplasty and patellofemoral replacement! respectively! can be successful.

    t*ner! +. et al. Nat. Rev. Rheumat l. ,! - /0-12 (3 /)" doi41 .1 -56nrrheum.3 /.55

    7ntroduction osteoarthritis (oa) of the knee (Figure 1) is a progres-sive disease that ultimately damages the entire joint. Knee oa is a common disease that has an increased inci-dence and prevalence in people over the age of 40 years around 10! of all people older than "0 years of age have radiological signs of knee oa# and a$out half of

    those complain of clinical symptoms. 1 musculoskeletal diseases# and especially oa# are common causes of dis-a$ility and limitations to activities of daily living and %ork. the direct cost of oa in the us is estimated at &'1 $illion per year# %ith a further &4 $illion in indirect costs# including lost %ages and productivity. 1 * initial treatment of knee oa is conservative# and includes edu-cational information# physical therapy# regular e+ercise# %eight reduction# the use of acetaminophen (paraceta-mol) and,or nsai s and intra- articular injections of corticosteroids or hyaluronate. "# if symptoms

    persist after the appropriate use of nonsurgical treatment# ho%ever# surgery can $e recommended. " this revie% outlines the surgical

    procedures availa$le to treat knee oa at various stages and in consideration of patient-related factors# such as age# level of physical activity and risk factors.

    8ompeting interests +. t*ner declares associations with the following companies4 Aesculap! stryker. 9. asten declares associations with the following companies4 #iosafe! %ornier. '9. : nther declares associations with the following companies4 stryker! ;immer. s. irschner declares associations with the following companies4 Aesculap! stryker! ;immer. see the article online for full details of the relationships.

    Arthroscopic surgery arthroscopy is %idely used in the treatment of oa# despite the lack of evidence sho%ing it to have greater $enefit than other treatments. '# the

    different arthroscopic techni/ues include lavage# de$ridement# $one marro% stimulation of contained chondral lesions# osteochondral transplantation# and autologous chondrocyte transplanta-tion. as autologous osteochondral 10 and chondrocyte transplantation 11#1 are not

    indicated for knee oa# %e %ill not discuss them in this revie%. most

    pu$lished studies of arthroscopic procedures for knee oa (ta$le 1) are of limited /uality# o%ing to lack of randomi ation# lack of a control group# short-term follo%- up# or inconsistent assessment methods. 12 only three randomi ed trials have

    compared arthroscopicsurgery %ith a nonsurgical control procedure for knee oa. '# #14

    lavage and debridement the rationale for arthroscopic lavage is to %ash out de$ris and inflammatory en ymes# conse/uently reducing

    symptoms of synovitis and pain and improving

    function. arden et al. 14

    compared improvements in %oma3 score follo%ing tidal irrigation# performed %ith a 2. mm %rist arthroscope# and intra- articular corticosteroid injec-tion. oth treatments

    provided short-term pain relief ho%ever# the

    $enefits lasted longer after irrigation. after " months# only ! of patients %ho received cortico-steroids reported continued improvement# compared %ith "4! of those %ho under%ent tidal i rrigation. in $oth groups# the $est outcomes %ere reported in

    patients %ith effusion and radiographic signs of mild oa at $aseline. van

    oosterhout et al. 1*

    compared arthroscopic lavage in

    ospital 8arl :ustav 8arus! %echnical =niversity of

  • 8/18/2019 Surgical Options Knee Nrrheum

    2/45

    ospital 8arl :ustav 8arus! ?edical &aculty of the %echnical =niversity of

  • 8/18/2019 Surgical Options Knee Nrrheum

    3/45

    reviews

    e y p o i n t s

    1

    ■ O s

    t

    e

    o

    a

    r

    t

    h

    r

    i

    t

    i

    s

    (

    O

    A

    )

    o

    f

    t

    h

    e

    k

    n

    e

    e

    s

    h

    o

    u l

    d

    f

    i

    r

    s

    t

    b

    e

    t

    r e

    a

    t

    e

    d

    n

    o

    n

    s

    u

    r

    g

    i

    c

    a

    l

    l

    y

    "

    h

    o

    w

    e

    v

    e

    r

    !

    i

    f

    t

    h

    i

    s

    a

    p p

    r

    o

    a

    c

    h

    f

    a

    i

    l

    s

    !

    s

    e

    v

    e

    r

    a

    l

    s

    u

    r

    g

    i

    c

    a

    l

    o

    p

    t

    i

    o

    n

    s

    a

    r

    e

    a

    v

    a

    i

    l

    a

    b

    l

    e

    2 ■ A

    r t h r o s c o p i c l a v a g e a n d d e b r i d e m e n t s h o u l d n o t b

  • 8/18/2019 Surgical Options Knee Nrrheum

    4/45

    e u s e d a s a r o u t i n e t r e a t m e n

    t i n k n e e O

    A ! a

    s o n l y s e l e c t e d

    p a t i e n t s m i g h t

    b e n e

    f i t " n e i t h e r p r o c e d u r e a l t e r

    s d i s e a s e p r o g r

    e s s i o n

    3■

    evide

    nc

    e

    for

    the

    us

    e

    of

    bo

    ne

    ma

    rro

    w

    sti

    mu

    lati

    on

    tec

    hni

    $u

    es

    for

    kn

    ee

    O

    A

    i

    s

    u

    n

    c

    l

    e

    a

    r

    "

    t

    h

    e

    p

    r

    i

    m

    a

    r

    y

    i

    n

    d

    i

    c

    a

    t

    i

    o

    n

    f

    o

    r t

    h

    i

    s

    p

    r

    o

    c

    e

    d

    u

    r

    e

    r

    e

    m

    a

    i

    n

    s

    f

    o

    c

    a

    l

    c

    a

    r

  • 8/18/2019 Surgical Options Knee Nrrheum

    5/45

    til

    a

    g

    e

    d

    e

    f

    e

    ct

    s

    4

    ■ O s t e o t o m y i s r e c o m m e n d e d f o r y

    o u n g ! a c t i v e p a

    ti e n t s w i t h k n e e O

    A

    w h o a r e n o t s ui t a bl e c a n di d a t e s f o r a

    rt h r o pl a st y

    5

    ■ % o

    t

    a

    l

    k

    n

    e

    e

    a

    r

    t

    h

    r

    o

    p

    l a

    s

    t

    y

    i

    s

    a

    s

    a

    f

    e

    a

    n

    d

    c

    o

    s

    t

    '

    e

    f

    f

    e

    c

    t

    i

    v

    e

    t

    r

    e

    a

    t

    m

    e

    n

    t

    f

    o

    r

    s

    e

    v

    e

    r

    e

    k

    n e

    e

    O

    A

    !

    a

    l

    t

    h

    o

    u

    g

    h

    t

    h

    e

    r

    e

    l

    a

    t

    i

    v

    e

    r

    i

  • 8/18/2019 Surgical Options Knee Nrrheum

    6/45

    s

    k

    s

    a

    n

    d

    b

    e

    n

    e

    f

    i

    t

    s

    s

    h

    o

    u

    l

    d

    b

    e

    t

    h

    o

    r