Is there a surgical alternative for the arthritic knee

Total Knee ReplacementIs there a surgical alternative for the
arthritic knee that works?
Richard Carrington FRCS(Orth)
Royal National Orthopaedic Hospital
NHS Trust
YES
• Joint Repair
• Joint Replacement, Unicompartmental
Surgery
Repair ,
Replacement
Joint Preservation • Unicompartment
– Medial, Lateral ,
• Articular Cartilage
regeneration
– Bone Marrow Stimulation
– Chondrocyte
transplantation
– Stem Cells
– Allograft
• Osteotomy
Patellofemoral
Arthroscopy with
Lavage and Debridement
• NO BENEFIT for unselected OA
Moseley JB et al. A controlled trial of
arthroscopic surgery for osteoarthritis of
the knee. N Engl J Med 2002 Jul 11;
347(2):81-8.
– Kirkley A et al. A randomized trial of
arthroscopic surgery for osteoarthritis
of the knee. NEJM Sep 2008;359:1097.
– Two other RCTs
NO!
Articular Cartilage Repair
Bone Marrow Stimulation
Release of Bone marrow stem cells
Into defect, differentiate into fibroblasts /
? Chondrocytes.
Fibrocartilage repair
1. DILLING
2. MICROFRACTURE
3. CHONDROPLASTY
Drilling
Pridie 1959 – concept of drilling eburnated bone
– stimulate inflammatory and reparative response
Pridie 1959
• 0.25in drill holes
• 62 knees, 60 patients,
– Av age 52 (40-60yrs)
– 75% successful – would have operation again
• Pain relief ? Due to repair / drilling
• Arnoldi 1972 Intra-osseous bone pressure
– > 40 mmHg pain
– < 35 mmHg no pain
Microfracture
Microfracture
• Steadman - 3-5 year follow-up for full-thickness lesions – 75% better,
20% same, 5% worse.
• Recent paper 80% rated themselves as better ( smaller group selected
retrosp, smaller lesions, no histology )
• Hunziker 2002 reported that results decline after 5 years
• Durability of Fibrocartilage repair remains a concern
• No good evidence for OA
Abrasion Chondroplasty
• Same principles as osteochondral drilling
• For incomplete lesions – create full-thickness lesion using burr. Reparative
response through release of pleuripotential stem cells
• No studies demonstrate predictable or consistent good results
• Fibrocartilage repair
Abrasion Chondroplasty
• Friedman 1984, 73 pts 60% improved, 6%
worse
• Several series show no difference in results
between simple debridement and
chondroplasty
Autologous Chondrocyte Implantation
• Prevention / Postponement of OA
• Inferior results with advancing age
• ? Biological joint replacement
ACI- Biopsy and Cell Culture
• Harvest 200-300mg of full thickness cartilage from non-load
bearing region of trochlea
• Cells grown on monolayer with patients serum
• Number of cells multiplied by X10-12
ACI- Implantation Technique
• ACI-P;
– Periosteal membraneHarvested from distal
femur
• ACI-C
– Porcine derived type
I/III collagen
Membrane
Adverse Prognostic indicator
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Age >35
Duration of symptoms >1 year
Poor preoperative level of functioning
Multiple lesions
Lesion size
Lesion site (patella)
Revision surgery
• Clin Orthop Relat Res. 2001 Oct;(391
Suppl):S349-61. Autologous chondrocyte
implantation for focal chondral defects of the
knee. Minas T.
• Patient satisfaction at 24 months for Simple,
Complex, and Salvage categories was 60%,
70%, and 90%,
STEM CELLS
Mesenchymal stem cells
Rizzoli Orthopaedic Institute
University of Bologna
Chairman: Prof. Sandro Giannini
Prof Buda
Bone Marrow Derived
CellsTransplantation
MSC
ONE-STEP SURGICAL TECHNIQUE
1) Platelet gel production
2) Bone marrow harvesting and concentration
3) Biomaterial preparation
4) Arthroscopic (or arthrotomic)
implantation
ACI vs BMDCT
CLINICAL RESULTS: AOFAS SCORE
Higher outcomes for BMDCT
Osteochondral Allografts
• Rare
• Usually for Posttraumatic OA
Knee Osteotomy
The basis of osteotomy about the knee is to
transfer weight bearing forces from the
arthritic portion of the knee to a healthier
location of the knee joint.
Principles of Osteotomy
• Realignment of the mechanical axis
Ideal Candidate for Osteotomy
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Thin
Active
Middle aged
Localised compartment pain
No patellofemoral symptoms
Knee stable
ROM 0-90 flexion
Patient counselling
• Patients expectations
• Cons
– Rehab longer
– Less pain relief
• Pros
– More ‘normal knee’
– High impact activity allowed
– ‘buying time with osteotomy
Surgical techniques
• Tibial osteotomy
– Varus knee to valgus
– Closing lateral wedge
– Opening medial wedge
• Valgus knee
– Closing wedge supracondylar femoral osteotomy
Opening wedge
Survival
Study
10 yr survival %
Cass and Bryan (1988)
69
Coventry ( 1993)
66
Healy and Riley (1986)
80
Ritter and Fechtman (1988)
58
Rudan and Simurda (1991)
80
Insall’s 3 decades of results
• Following HTO pain recurrs in most knees >
TKA
• Younger patients with moderate varus best
results
• Overall preoperative status of knee most
important determinator of outcome
Influence of High Tibial Osteotomy on Bone Marrow oedema in the
Knee. Kroner AH, Berger CE, Kluger R, Oberhauser G, Bock P, Engel A.
From the, Vienna, Austria
Clin Orthop Relat Res. 2006 Aug 24;
• To determine the influence of high tibial
osteotomy on subchondral bone marrow
oedema in medial osteoarthritis of the varus
knee
• ‘early lateral closing wedge osteotomy should
be considered in patients with varus
malalignment and bone marrow oedema even
in mild cases of medial osteoarthritis.’
Unicompartmental knee replacement
• 1955 Mckeever hemiarthroplasty
• 1970s Goodfellow UKR
Fixed bearing or
meniscal bearing
Patello-femoral replacement
Advantages of UKR
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Quicker recovery
Fewer complications compared to osteotomy
Cruciate retained, normal feeling knee
Retention of bone stock
UKR patient selection
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Single compartment disease
Stable Knee
Varus less than 10 degrees,
OA,
Results UKR
• Oxford 98% survival at
10 yrs
• Literature review 80%
survival at 10 yrs
UKR survival
NJR 2013
Failed UKR
Revision to TKR
Conclusions
• There are surgical alternatives to TKR for the arthritic
knee which are successful.
• Correct Patient Selection and Technique Selection are
key to good outcomes.
Thank you