Surgical Options Knee Nrrheum

8/18/2019 Surgical Options Knee Nrrheum

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Surgical options for patients withosteoarthritis of the kneeJörg 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 ofthese procedures is most appropriate will depend on several factors! including the location and severity of OAdamage! 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 marrowstimulation techni$ues such as microfracture are primarily used to treat focal chondral defects" the evidence forthe use of these techni$ues for knee OA remains unclear. %he goal of osteotomy for unicompartmental knee OAis 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 candidatesfor 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 kneearthroplasty and patellofemoral replacement! respectively! can be successful.

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

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

those complain of clinical symptoms. 1 musculoskeletal diseases# andespecially oa# are common causes of dis-a$ility and limitations toactivities of daily living and %ork. the direct cost of oa in the us isestimated at &'1 $illion per year# %ith a further &4 $illion inindirect costs# including lost %ages and productivity. 1 * initialtreatment of knee oa is conservative# and includes edu-cationalinformation# physical therapy# regular e+ercise# %eight reduction# theuse 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 inconsideration of patient-related factors# such as age# level of physicalactivity 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 followingcompanies4 stryker! ;immer. s. irschner declares associations with thefollowingcompanies4 Aesculap! stryker! ;immer. see the article online for full detailsof the relationships.

Arthroscopic surgeryarthroscopy is %idely usedin the treatment of oa#despite the lack of evidence sho%ing it tohave greater $enefit thanother treatments. '# the

different arthroscopictechni/ues include lavage#de$ridement# $one marro%stimulation of containedchondral lesions#osteochondraltransplantation# andautologous chondrocytetransplanta-tion. asautologousosteochondral 10 andchondrocytetransplantation 11#1 are not

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

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

compared arthroscopicsurgery %ith a nonsurgicalcontrol procedure for kneeoa. '# #14

lavage anddebridementthe rationale for arthroscopic lavage is to%ash out de$ris andinflammatory en ymes#conse/uently reducing

symptoms of synovitis and pain and improving

function. arden et al. 14

compared improvements in%oma3 score follo%ingtidal irrigation# performed%ith a 2. mm %ristarthroscope# and intra-articular corticosteroidinjec-tion. oth treatments

provided short-term painrelief ho%ever# the

$enefits lasted longer after irrigation. after " months#only ! of patients %horeceived cortico-steroidsreported continuedimprovement# compared%ith "4! of those %hounder%ent tidal i rrigation.in $oth groups# the $estoutcomes %ere reported in

patients %ith effusion andradiographic signs of mildoa at $aseline. van

oosterhout et al. 1*

compared arthroscopiclavage in

ospital8arl:ustav8arus!%echnical=niversityof


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&igure 1 | 8haracteristic appearance of advanced osteoarthritis of the knee!occurring mainly in the medial compartment. a | radiograph revealing medial jointspace narrowing and the presence of osteophytes. b | Arthroscopic view showscartilage loss at the medial femoral condyle and tibia.

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reviews

hatever techni/ueisu

sed#thefi

$r ocartilaginoustissue

pr oduced

$y

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o%stimulationdoesnot

havethe

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thetreatment

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lationisnot#

theref ore# acurativetreatmentho%ever#

many patientso$tainrelief fromsymptomsfor sever alyears.

2 theresults aregoodfor smallandfocalchondrallesions#%hichoccur

in patients%ithmoderateoa inadvancedoa#%hichisusuall

yassociated%ithlargechondraldefects# thetechni/uesarelesseffective.

unf ortunately#


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useof

$onemarro%stimulationtech-

ni/uesin

pati

ents%ithkneeoaremainsunclear. the

primaryindicationfor thissurgical

procedureremainsfocalcartilagedefects.

Osteotomyosteotomyis anesta$lished

procedurefor

thetreatment of unicompartmental kneeoathathas

$eenin usesince

the1 "0s. 4# *

osteotomyentailscuttingthrough the

$oneandfi+ingit inanother

position in


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or der tochan

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%iththeintr oduction of ne%tech-ni/ues

andmor e-sta$lefi+ationdevices#ho%ever#this

procedureis

e+periencingresurgenceinsomecountr ies. inunicompart

mental kneeoa#thegoalof osteotomyis totransf er the%eight loadfromdamagedareasto theunimpairedfemor oti$ialcompartment#andconse

/uentlyreducesymptomsanddelaytheneedfor

jointreplac

e-ment.medialcompartment oaismostoftenassoci-ated%ith avarusdefor mityof theti$ia


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ther ef or e#hi

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$ialosteotomyisthetechni/u

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of thelateralcompartmentinco

m- $ination%ithvalgusmalalignmentof thedistalfemur istreated%ithsupracondylar

femoralosteotomy.additionalarthroscopictrea

tmentisoften

perf ormedatthesametime asosteotomy#ma

king itdifficult todistinguishtheeffectof eachoperation.

earlyresultsfromosteotomyareusuallygood#%ithdeterioration over

timeo%ingto oa

progression.the

pro$a $ilityof 7osteotomysurvival9(defined asnon-conversiontototalkneearthro

plasty) after 10yearsrangesfrom*0!to

0!." 20 ameta-analysis21 of highti$ialosteotomydemonstrated anoverall 10-year


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f ailur er ateof

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et%eenhighti

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pro $a$ilityof a7good9or 7e+cellent9result%as

*

!after "0monthsand"0!after 100month

s.21s

everalstudieshavedemonstr ate

dthatthedegreeof cor rectionisthemost

im por tantfact

or for thesuccess of osteotomy.'#2

3omputer-assistednavigationimprovesthe

precision of correction#and

possi $lyimprovesthe


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%able 1 |Duantity of liter atur

e r elating to var

ious sur gicalpr oc

edur es f or knee O

A

Search terms used

Osteoarthritis and lavag

Osteoarthritis and debrid

Osteoarthritis and osteot

Osteoarthritis and unico

Osteoarthritis and patell

Osteoarthritis and (arthra Eumber ofarticle

sretr ievedfromasearchofthe9ub?eddatabaseconductedin


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tor s f or osteo

tomy f ailur e include f emale se+# o

$esity and sever e oa.

#

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medial o

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(Figur e 2)

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f the e+ten

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the develo

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s r e

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to date#

ther e is no evidence f or a

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@iven th

at u


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nicom

par tmental and tot

al k nee ar thr

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plasty ar e not ideal f or

pa

tients %ho ar e young# a

ctive and hav

e

physically demanding

jo

$s#

osteotomy should

$e con

sider ed in th

ese cases. the ideal candidat


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e f or osteo-tomy is act

ive# younger

than *0 year s old# has

a histor y of isolated m

edial com

par t

ment

pain# a malalignme

nt of less than 1*A# a

meta

physeal t

i $ial var us# f ull r ange

natur e

r e

vie%s

5 rhe

umatolo

gyvolume* 5 6une

00 5 -11


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a b +oint replacementreplacement of the entire knee joint# or total knee arthro-

plasty# is a safe and cost-effective treatment for severe oaof the knee (Figure 4). 2 ura$le alleviation of pain and

improvement of physical function can $e e+pected follo%-ing the procedure. 2 #40 in addition to physician-deriveddata# patient-centered outcome measurements have also

$ecome an essential component of any long-term analysisof the success of total knee replacement. 41 o%ing to itsirreversi$le nature# joint replacement is recom mendedonly in patients for %hom other treatment modalitieshave failed. " the procedure has a remarka$ly higher risk of failure 10 years after implantation in patients aged*0 years and younger 42 than in patients aged 0 years or older. 2 #4 #42 3omplications of joint replacement surgeryinclude prosthetic loosening# %earing of the polyethyleneinsert# infection and periprosthetic fractures. For patientsyounger than *0 years# therefore# the risks and $enefits of less-invasive surgical alternatives should $e thoroughly%eighed against those of total knee arthroplasty. 40#44

&igure - | >igh tibial osteotomy! often used to treat medial unicompartmental knee8atients over 0 years of age are considered the $estcandi dates for total knee replacement. 2 increasingly#

osteoarthritis. Osteotomy is carried out at the proFimal end of the tibia toolder patients %ith severe oa# as %ell as younger patients#overcorrect a varus malalignment and transfer the weight load to the intact lateral

compartment. a | %he closing wedge techni$ue involves the eFcision of a lateral' are successfully treated %ith total knee arthroplasty. 2 #4*

based bone wedge from the proFimal tibia and part of the fibula. b | %he opening registers from all over the %orld# such as the s%edishwedge techni$ue re$uires only one osteotomy and the medial'based opening of Knee arthroplasty register# 4* demonstrate a constantthe resulting gap. increase in joint replacement rates. 6oint replacement

must $e considered in patients %ith radiographic evi-a b dence of knee oa %ho have pain and disa$ility refractory

to conservative or joint-preserving therapy. 44 the indica-tion criteria for joint replacement surgery# ho%ever# mightvary $et%een countries. 4"

the demand for musculoskeletal health care servicesis e+pected to increase su$stantially in aging populationsas pu$lic e+pectations rise and diagnosis and treatmentimprove. 4 using a structured method to score pain#function# movement and deformity# the ne% Bealand

priority criteria ensure an impartial distri$ution of total joint replacement. 4' in s%eden# patients are categori edinto three groups on the $asis of pain level# serious func-tional impairment# and at least *0! reduction in radio-graphically visi$le joint space. 4 y contrast# the ontario;ip and Knee replacement 8roject team suggests a

patient-oriented approach? the need for joint replacementsurgery is indicated $y $oth the patient9s o%n perceptionsof overall symptomatic $urden and physician-derivedinformation from clinical judgments and health statusinstrument scores. *0 still# an evidence-$ased consensus

&igure | %otal knee arthroplasty replaces the femoral and tibial contact areas. on the appropriate indication for knee replacement needs Additional patellar replacement can be done optionally. a | Anteroposterior and to $e developed.b | lateral views show the metal femoral and tibial prosthetic implants. A fiFed the ideal timing of joint replacement surgery is contro-polyethylene insert is placed between the two implants. versial. 8atients %ith more-severe oa gain more from the

operation# $ut remain in %orse health postoperatively#of motion of the knee# a mi of less than 20 and radio- than patients %ith less-severe disease. *1 surgery at angraphic evidence of moderate# isolated medial compart- earlier disease stage could# therefore# $e prefera$le.ment oa. 2' ;o%ever# the $enefits of osteotomy are less age and comor$idities are su$stantial risk factors for immediate than those of knee arthroplasty# and the adverse outcomes after joint replacement. the risks of

outcome is less predicta$le. major complications# including mortality# infection# and


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reviews

pulmonary em$olism# are %ell kno%n. * in addition to a bscreening for these complications# preoperative assess-ment of mental status %ith standardi ed instruments#such as the mini mental state e+am# can help to identify

older patients at risk for delirium. 2

unicompartmental knee replacementunicompartmental knee arthroplasty could $e indicatedin cases %here oa involves only one of the three com-

partments of the knee:the medial ti$iofemoral# lateralti$iofemoral or patellofemoral compartment. the mostcommon unicompartmental knee arthroplasty replacesthe contact surfaces of only the medial ti$iofemoralcompartment %ith t%o metallic prosthetic devices andinserts a polyethylene inlay $et%een them (Figure *). For medial compartment knee arthroplasty to $e indicated#the knee ligaments (anterior and posterior cruciate liga-ments# medial and lateral collateral ligaments) should $eintact# the varus deformity should $e correcta$le# andthe lateral compartment should have full-thickness carti-

&igure , | =nicompartmental knee arthroplasty in isolated medial osteoarthritislage. *2 unicompartmental knee replacement should not $e performed in knees that have previously undergone replaces only the medial femoral and tibial contact areas. a | Anteroposterior and

b | lateral views show the metal femoral and tibial prosthetics. A mobilehigh ti$ial osteotomy. *4polyethylene meniscal insert is placed between the two implants.

the use of modern implants and surgical techni/ueshas improved clinical results and survival rates of medialunicompartmental knee arthroplasty. ** outcomes for relia$le and favora$le results. "* " one reason for failurethe treatment of lateral unicompartmental knee oa are of isolated patellofemoral arthroplasty is the progression of rarely reported. *" these results are less predicta$le than oa in the ti$iofemoral joint. indications for isolatedthose of medial unicompartmental oa# despite recent patellofemoral replacement include diseases of the patello-improvements in implant design. scientific de$ate a$out femoral joint leading to isolated arthritis? trochlear dys-the involvement of the patellofemoral joint in knee oa is plasia# post-traumatic arthritis and recurrent dislocationsongoing. the e+perience of the surgeon has a considera$le or su$lu+ations. "' oa of the ti$iofemoral joint should $eimpact on the outcome of unicompartmental arthroplasty? ruled out# as the treatment %ould $e unsuita$le for sucha learning curve# %ith %orse results for the surgeon9s first cases. " if the suita$ility of patellofemoral replacement is10 procedures# has $een suggested. * long-term survival uncertain# a conventional total knee replacement is recom-depends on the rate of implant failure and,or progression mended. replacement of the patellofemoral joint is likelyof oa in the lateral or patellofemoral compartment of to have a su$stantial learning curve for the surgeon# andthe knee. in general# the 10-year survival rate of medial is $est performed in speciali ed centers. 40

unicompartmental knee replacement is slightly %orsethan that of total knee arthroplasty. 4* speciali ed centers total knee replacementreport e/ual survival rates for medial unicompartmental total knee replacement is the gold standard for end-stageimplant and esta$lished total knee arthroplasty implants. *' knee oa. 2 a large num$er of %ell-designed studies havein cases of conversion from medial unicompartmental reported preoperative and postoperative results andknee replacement to total knee replacement# one-third precisely descri$ed study populations these data %ereof patients need $one grafting or %edges to augment the pooled for a us government-commissioned health tech-medial $one defect of the ti$ia. * the revision of a uni- nology assessment of total knee replacement. " most of thecompartmental knee arthroplasty# in %hich damaged patients in the report %ere a$out * years of age# t%o thirdsimplants are replaced# is considered easier# and the results %ere female and one third %ere considered o$ese 0! suf-superior# to revision of a total knee replacement. "0 fered from oa. instruments used to report improvements

isolated patellofemoral oa occurs in 10! of patients included the Knee society Knee score (KsKs)# the ;ospital%ith knee oa. "1 underlying disorders often include prior for special surgery (;ss) Knee score# the %oma3 scoretrauma to the patella# malalignment of the patellofemoral and the sF-2"# a general-purpose 2"-/uestion health

joint# trochlea dysplasia and degeneration secondary to survey. e+pressed as mean effect si es# %ith a result greater deep $ending# overuse and,or age. " Fe% patients undergo than 0.' considered a large treatment effect# increases inisolated patellofemoral replacement# "2#"4 although this these scores varied %ith the scoring instrument used.num$er is increasing. speciali ed centers report encour- %ith the ;ss score# the o$served mean effect si e rangedaging results. "2 on the other hand# these patients can also from 2. 1 ( -year follo%-up) to . (C* years9 follo%-up).

$e treated %ith conventional total knee replacement# %ith studies using the KsKs reported effect si es $et%een .2*


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reviews

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%asgenerallyreportedto

producesu$stantialimpr ovement

s#althoughtheuseof mor e-

joint-specificoutcomemeasures%asassociated%iththereportingof rema

rka$lygreater

effects. inthisreport#

poolingalltheincludedstudiesresultedin acumulativerateof adve

rseevents of *.4!.themostseverecom

plication%as

peri-

oper ativemortality(0.*!). 2

of note#0. 1! of infectionsand

0.41! of

pulmonaryem$olismoccurred%ithinthefirst

0daysafter surg


29/45

er y.*

hes%edis

hK neearthr o

plasty

r egistr y4*

sho%sthatr evisionr ateso

f totalk neearthr o

plasty

havedecr easedover time.impr ovedsurgicaltechni/uesandimpr ovedimplanttechnology%er

e $othsuggested asreasonsfor theimpr ovedoutcome

s.therateof com

plicationsinsomestudiesareinverselyrelatedtohospitalandsurgeonvolumesof oper ations

per

year .2

acom

parisonof outcomesfollo

%ingeither thereten-tionor sacrificeof the

posterior cruciateligament(83l)duringtotalkneereplacement is

providedin a3ochranereport

$ased on

eightrandomi

edstudiesatotalof * 0

patients%ithoaor rheumat


30/45

oidarthritisf o

llo%ed-u

pf or *years%er eincluded.

0

nodif f er ences

in painor str ength%er e

found

$et%een

patients%hose83l%as

sacrificedandthose in%hom it%asretained.8atients%hose83l%assacrificedandin%hom a

posterior sta$i

li edinlay%asusedsho%edan'Agreater incr

easeinrange of motioncom

pared%iththose%hose83l%asretained.

theclinicalscor es(usingthe;ssscor e)

demonstrated astatisticallysignificantadvantage of intraoper ative83lsacrificeover retention#although

theclinicalrelevance of thisadvantage is/uestiona$le

. aseparate3ochranereportcom

paredtheclinicaloutcomesand


31/45

posto

per ative

r angeof motionf ollo%ingtheuseo

f either mo

$ileor

fi+edti

$ialinsertsinto

talkneearthr oplasty?onlyt%ostudiesmetthe

inclusioncriteria#andtheoutcomesdidnotdiffer

$et%eenthet%otreatmentmodalities. 1

t%one%technologiesintroducedintototalkneearthr oplasty

surgeryareminimallyinvasivesurgery(mis)and

navigatedtotal

kneearthr oplasty.agreatnum

$er of reports

deal%ithminimallyinva

sive 2

totalkneearthr oplasty

: althoughnoacce

pteddefinition of mise+ists. incont

rasttothenumerousavaila$ledescriptionsof mis

techni/ues#onlyafe%randomiedcontrolledtrials

haveinvestigated


32/45

the

potential

$en

ef itsof mis.sometr

ialssho%a

$enef icia

lshort-ter mef fectof mis#%her easother sdonot

. ameta-analysisof short-termoutcome

ssho%ed

asmalladvantage for misover conventionalsurgery#

$utmainly instudiesthatcom

$inedmis

%iththeuseof anavigationsystem.3om

puter navigationimpr ovesthe

precisionof

postoper ativealignmentfollo

%ingtotalkneearthr oplasty#assho%ninlong-legradiogra

phs.2 noaddi-


33/45

tionalef fectof com

puter navigationhas

$eensho%noncom

ponentalignmentor

ear lyclinicaloutcomes.

%heth

er thisimpr oved

precision%illleadto

$etter long-termresultsandlo%er revisionratesisunkno%n.

3om puter navigationre/uireslonger oper atingtimesthanconven-tionalsurgery#andhasareportedlearn

ingcurve of a$out 20

procedur es. 4

thesefactsmighthaveinfluenced themajo

rityof surgeons%honotdonavigateeachtotalkneearthr oplasty#eventhoughthee/ui

pment isavaila$le.

* in

summar y# noclear evidencee+ists torecommendthe%idespreaduseof either misor com

puter navigation in

totalkneearthr oplasty.

8onclusionsinitially#treatmentof kneeoa


34/45

should

$enons

urgical.if thisther a

pyfails#ho%ever #surgicaltr eatmentcan

$ere

commended."#

ina

dvan

cedstages of kneeoa%ithcom

pletelossof artic

ular cartilage#totalkneearthr oplastyrelia

$lyrelieves

painandimpr ovesfunc-tion.if oaislimited tothemedialcom

partment#uni-com

partmentalkneearthr oplastyis

e/uallyeffectiveastotalkneereplacement.osteotomy

should $econsidere

d for young#active

patients%ithunicompartm

entaloa.

onemarr o%stimulationtechni/uescan

$eusedtotreatfull-thick nesschondrallesions

patients%ithmoderateoa%ithsmallchondraldefects

$enefitmost

fromthisappr oach.arthr oscopiclavageandde$r

idementshould


35/45

not

$eusedasr

outinetr eatmentsf or k neeoaho%ever #

patients%ithsym

pto

maticmeniscaltear sa

ndloo

se $odies%ithlockingsym

ptomsmight

$enefitfromthese

proce-dures. insummary# allavaila$lesurgicaltreatmentsshould $econsidered#andtheappr opriatetreatmentselectedonthe

$asisof the

patient9s

char acter istics# as%ellasthe

presentationandseverity

of thedisease.

Geviewcriteria

Article

spublishedinenglisha

nd:er manwer eident

ifiedbysearching9ub?edin<ecember3

5usin


36/45

g the f ollowing sear ch ter ms4 Hosteoar thr itis and lavageI! Hosteoar thr it

is an

ddebridementI!Hosteoarthritisand osteotomy and kneeI! Hosteoar thr itis and unicom

par tm

ental and kneeI! Hosteoar thr itis

and patellof emor al and kneeI! and Hosteoa

r thr i


37/45

tis and (ar thr op

lasty or r eplace

ment) and kneeI.

-1


38/45

reviews

@. ;hang! w. et al. OArsi recommendations for the 3- . ? iller! #. s.! steadman! +. r.! #riggs! . .! 1. wright! r. +. et al. 9atient'reported outcome andmanagement of hip and knee osteoarthritis! rodrigo! +. +. J rodkey! w. :. 9atient satisfaction survivorship after inemaF total knee

9art ii4 OArsi evidence'based! eFpert consensus and outcome after microfracture of the arthroplasty. J. ! ne J int Surg. "m. 52'a!guidelines. #ste arthritis $artilage 12! 1-@0123 degenerative knee. J. Knee Surg. 1@! 1-01@ 3 2 03 @ (3 ).(3 5). (3 ). 3. rand! +. A.! %rousdale! r. %.! ilstrup! armsen! w. s. &actors affecting the durabi li tyarthroscopic surgery for osteoarthritis of the of the tibia for degenerative arthritis of the knee. of primary total knee prostheses. J. ! ne J int knee. N. %ngl. J. &ed. - @! 51055 (3 3). A preliminary report. J. ! ne J int Surg. "m. @! Surg. "m. 5,'a! 3,/032, (3 -).

/. irkley! A. et al. A randomi*ed trial of /5 0// (1/2,). -. >ofmann! A. A.! >eithoff! s. ?. J 8amargo! ?.arthroscopic surgery for osteoarthritis of the 3,. +ackson! +. 9. J waugh! w. %ibial osteotomy for 8ementless total knee arthroplasty in patientsknee. N. %ngl. J. &ed. -,/! 1 /@011 @ (3 5). osteoarthritis of the knee. J. ! ne J int Surg !r. , years or younger. $lin. #rth p. Relat. Res.

1 . >angody! . et al. ?osaicplasty for the treatment -'#! @ 20@,1 (1/21). ! 1 301 @ (3 3).of articular cartilage defects4 application in clinical 32. Aki*uki! s.! shibakawa! A.! %aki*awa! %.! . :unther! . 9. surgical approaches for practice. #rth pedics 31! @,10@,2 (1//5). Kama*aki! i. J >oriuchi! >. %he long'term osteoarthritis. !est Pract. Res. $lin. Rheumat l.

11. #rittberg! ?. et al. %reatment of deep cartilage outcome of high tibial osteotomy4 a ten' to 1,! 23@02 - (3 1).defects in the knee with autologous chondrocyte 3 'year follow'up. J. ! ne J int Surg. !r. / ! ,. %he swedish nee Arthroplasty register.

transplantation. N. %ngl. J. &ed. --1! 55/05/, ,/30,/2 (3 5). Annual report 3 @. http466www.knee.nko.se6

(1// ). 3@. van raaij! %.! reijman! ?.! #rouwer! r. w.! english6online6uploaded&iles611 L

13. #ehrens! 9. et al. indications and implementation +akma! %. s. J verhaar! +. E. survival of closing' s Ar3 @Lengl1.3.pdf .of recommendations of the working group wedge high tibial osteotomy4 good outcome in 2. ?e rF! >. et al. international variation in hipH%issue regeneration and %issue substitutesI men with low'grade osteoarthritis after replacement rates. "nn. Rheum. 'is. 23!for autologous chondrocyte transplantation 1 012 years. "cta #rth p. @/! 3- 0- (3 5). 3330332 (3 -).(A8%) M:ermanN. (. #rth p. )hre. Grenzge*. 1 3! 35. 8oventry! ?. #.! ilstrup! . %. >igh tibial osteotomy , . lewellyn'%homas! >. A.! Arshinoff! r.! #ell! ?.!administration of corticosteroids! arthroscopic for the treatment of osteoarthritis of the knee4 williams! +. i. J Eaylor! 8. .! Ackroyd! 8. e. Jaupattarakasem! 9. J sumananont! 8 . knee. An arthroscopic study of , knee joints. ubbard! ?. +. Articular debridement versus Sp rts +raumat l. "rthr sc. 1@! 13501- (3 /). ,-. ?urray!


39/45


40/45

reviews

60. saldanh

a!

. A.!

eys!:.w.!sv

ar d!=.8.!white!s.>.

J r ao!8.r evisionofOFf or dmedialunicompar t

mentalkneearthr oplastyto

totalkneearthr oplastyRresultsofamulti

centr estudy.K nee 1!3@,03@/(3

@).61. ?

c Alindon! %. e.! snow! s.! 8ooper ! 8.

J <ieppe!

9.

A. r adiogr aphi

c patter ns of

osteoarthriti

s oftheknee

jointinthecommunity4theimportanceofthepat

ellof emoral

joint.

"nn. Rheum.'is.,1!5

05 /(1//3).

62. :r els

amer!r.9.Jstein!


41/45

ty4five'year sur vivor shipandf unctionalr esults.J .!

ne J

i nt Sur g .!r .5/!-

1

0-1,(3

@).

64. 8ar tier !9

.!sanouiller!+.

.J

hef acha!

A.

ong'ter mresultswiththefir stpatellof emor alpr osthe

sis.$ li n.#rt h

p.R el at .R es.

-2!

@ 0,

(3

,).

65.as

kin!

r . s. J van stei

jn! ?. %otal knee r eplacement

f or patients wi

th patellof emor a

l

ar thritis.$ li n.#rt h

p.R el at .R es.-2@!5/

0/,(1///).

66. ?ont!?.

A.!>aa

s!s.!?ullick!%.J >

unger f or d!<.s.%ot

alkne


42/45

e ar thr oplasty f or patellof emor al ar thr itis. J . !

ne J

i nt Sur g .

"

m. 5

'a! 1/@@

01/5

1 (3

3).

67. 9ar vi*i!+.!stuar t!?.+.!9agn

ano!?.w.J >anssen

! A.<.%otalknee ar

thr oplasty in pat

ients

with isolated patellof emor al ar thr itis.

$li n.#rt h p.Rel at.Re

s.-/3!1 @

01,3(3

1).

68. <elanois!r.e.

etal. r esultsoftotalkn

eer epl

acementforisolatedpatellofemoralarthritis4whennottoper for mapatellofemoralarthroplasty.#rt h

p.$li n.Nrth

"m. -/!-510-55(3

5).

69.ane!r.

.et al.%ota

lkneer eplacement.%

v i d .R


43/45

e p. + ec hn

l .

"ssess. / Summ.

0 1

05 (3

-).

70. +acobs!

w. 8.! 8lement!

<. +. J wymenga!

A. #.

r etention ver sus r emovalof the poster ior cr uciate ligamentin totalknee r eplacement4

asystem

aticliter atur ereviewwithinthe8ochraneframewor k.

"ct a#rt h p.@2!@,@

0@25(3

,).

71. +acobs! w.!

Ander son! 9. :.! van

i

mbeek! +. J wyme

nga!

A.

A. #. ?obile bear ing vs f iFed


44/45

bearingprosthesesfortotalkneearth

roplastyforpost'operativefunctionalstatusinpatients

withosteoarthritisandrheumatoidarthritis.$ c hrane'at a*ase#S stematic Rev ie s31!issue 3.

Art.Eo.48<

-1-doi41 .1361

2,15,5.8<

-1-.pub3(3

).

72. vav

ken!

9.!:r uber !?.J <or otka!r .Outcomes af ter minimally invasive totalknee r eplacementRa meta'a

nalysis M:er manN.

(.#rt h p.1n all.1 2!@25

0@@3(3

5).

73. #auwens!

.etal. Eaviga

tedtotalkneer eplace

ment.

Ameta'analysis.J

.!

ne

J i ntSurg.

"m.5/!321032/(3

@).

74. +enny! +. K.! ?ie

hlke! r .

. J :iu

r ea!

A.

ear ning

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l knee r eplacement.

A multi'centr e study compar in

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b

eginner centr es. K nee 1,! 5

05

(3

5).

75. &r ieder ich!E.J

ver donk!r.%heuseof com

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'assisted or thopedic sur ger y f or totalknee r eplac

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*www.nature.com6nrrhe

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