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Surgical treatments for osteoarthritis
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Surgical treatments for osteoarthritis Nicolas de l’Escalopier a,*, Philippe Anract a,b,c, David Biau a,b,c a
Service de chirurgie orthope´dique et oncologique, hoˆpital Cochin, AP–HP, 75014 Paris, France Universite´ Paris-Descartes, 75000 Paris, France c Inserm U1153, 75000 France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2015 Accepted 14 April 2016
There are two main surgical treatments for osteoarthritis: conservative treatments, where the damaged cartilage is left in place, and radical treatments, where the cartilage is replaced by an artificial endoprosthesis; this latter procedure is termed joint arthroplasty. These treatments are only offered to symptomatic patients. Arthrodesis is yet another surgical intervention in cases of osteoarthritis. It will sacrifice the joint’s articular function and is performed on small osteoarthritic joints, such as wrists and ankles, for instance. Osteoarthritis symptoms are usually the consequence of an imbalance between the load applied to a joint and the surface available to support that load. Therefore, conservative treatments will either tend to decrease the load exerted on the joint, such as in a tibial valgus osteotomy for instance, or to improve the articular surface supporting that load. Sometimes, both can be provided at the same time; the peri-acetabular osteotomy for hip dysplasia is an example of such a procedure. Conservative treatments are usually offered to young patients in order to delay, if not avoid, the need for a joint prosthesis. They are usually performed before osteoarthritis appears or at an early stage. Joint arthroplasties have overwhelmingly excellent functional results and today’s research is directed towards providing rapid recovery, very long-term stability, and the assurance of a good functionality in extreme conditions. However, complications with joint arthroplasties can be serious with little, if any, reasonable salvage solution. Therefore, these procedures are offered to patients who have failed adequate medical treatment measures. ß 2016 Elsevier Masson SAS. All rights reserved.
Keywords: Osteoarthritis Joint arthroplasty Conservative surgery Hip Knee Shoulder
1. Introduction There are two main surgical treatments for osteoarthritis (OA): conservative, with the damaged cartilage left in place, and radical, with the cartilage replaced by an artificial endoprosthesis, the latter procedure termed joint arthroplasty. These treatments are offered only to symptomatic patients. Arthrodesis is another surgical intervention in cases of OA. It sacrifices the joint’s articular function and is performed on small osteoarthritic joints, such as wrists and ankles. OA symptoms usually result from an imbalance between the load applied to a joint and the surface available to support that load. Therefore, conservative treatments will tend to decrease the load exerted on the joint, such as in tibial valgus osteotomy, or improve the articular surface supporting that load. Sometimes, both solutions can be provided at the same time; peri-acetabular osteotomy for hip dysplasia is one example.
Conservative treatments are usually offered to young patients so as to delay, if not avoid, the need for joint prosthesis. They are usually performed before OA appears or at an early stage. Joint arthroplasty has overwhelmingly excellent functional results and today’s research is directed toward providing rapid recovery, very long-term stability, and the assurance of good functionality in extreme conditions. However, complications with joint arthroplasty can be serious with little, if any, reasonable salvage solution. Therefore, these procedures are offered to patients with failure of adequate medical treatment measures. In the following sections, we discuss the main surgical treatments for hip, knee, and shoulder OA. We present both conservative and radical options along with patient selection criteria, a brief description of the technique, and the expected results.
2. Hip OA 2.1. Conservative treatment
* Corresponding author. E-mail address: [email protected] (N. de l’Escalopier).
Conservative surgical treatments of hip OA have declined over the last decades after the implementation of total hip replacement
http://dx.doi.org/10.1016/j.rehab.2016.04.003 1877-0657/ß 2016 Elsevier Masson SAS. All rights reserved.
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(THR). Nonetheless, significant indications remain for young patients. These treatments will surely delay but not always avoid the need for joint replacement in the long-term [1,2]. The 3 main surgical procedures that can be performed are femoral osteotomy, pelvic osteotomy, and cartilage and labrum procedures under arthroscopy. 2.2. Femoral osteotomy This osteotomy reorients the femoral head, with one of 2 main goals: positioning an adequate portion of the femoral cartilage in front of the acetabulum, such as in rotational osteotomy of the femoral neck for osteonecrosis [3], and changing the biomechanics of the hip to reduce the load going through the joint, such as in femoral varus osteotomy. The most common osteotomies are valgus and varus femoral osteotomies; others such as flexion, extension or rotation osteotomy or a combination of these are less frequent. The varus femoral osteotomy is usually indicated for hip dysplasia, osteonecrosis, and valgus deformation. It closes the neck-shaft angle when it is superior to 1358 [4]. The long-term results for early OA are good, with 75% 10-year survival, defined as the delay before hip replacement. Second-line hip replacement will have the same prognosis as first-line replacement. The procedure is not recommended with isolated serious dysplasia [5]. Valgus femoral osteotomy is mainly performed for femoral neck non-union, slip upper-femoral epiphysis sequelae and congenital varus deformity of the femoral neck. 2.3. Pelvic osteotomy Pelvis osteotomy (including the shelf procedure) is only rarely performed today but can still provide excellent results. The common eligibility criterion is a painful, dysplastic hip in a relatively young patient (usually < 30 years old). Beyond that, we also rely on some other indications such as cartilage degeneration
stage and coxometric parameters to decide on the surgical procedure. Shelf operation consists of a bone graft addition on top of the hip where the femoral head is uncovered; although it provides support and balances the load, it does not provide cartilage (Fig. 1). The Chiari osteotomy is an augmentation osteotomy similar to the shelf procedure that decreases the contact stresses going through the joint, even though it does not provide any cartilage. The Bernese peri-acetabular osteotomy is a reorientation procedure that lets the acetabulum rotate around the femoral head to cover the uncovered anterior and lateral portion of the head. [6]. When these surgeries are performed in carefully selected patients, they provide good results and delay the need for a hip replacement in the long-term. Conversion to hip replacement occurs at 10 years in about 40% of patients for the shelf procedure and in 15 to 20% for peri-acetabular and Chiari osteotomies. [7]. 2.4. Arthroscopy Arthroscopy is indicated for femoroacetabular impingement (FAI). It occurs when anatomic variation of the hip causes impingement between the femoral head–neck junction and the acetabular rim during functional motion. This condition is mainly seen in young and active men. Open or arthroscopic osteochondroplasty of the femoral head–neck junction is the surgical treatment for symptomatic cam impingement. Depending on the surgeon, it may be performed with an anterior open approach with or without arthroscopy [8] by surgical dislocation [9] or by arthroscopy exclusively. Good to excellent results are reported in 70 to 95% of patients. 2.5. THR THR has been coined the ‘‘operation of the century’’. Millions of THRs are performed worldwide to treat OA, with more than 95% of
Fig. 1. Peri-acetabular osteotomy of the left hip (preoperative, postoperative and long-term radiographs).
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patients entirely satisfied with the functional results [10]. The modern hip replacement was developed by Sir John Charnley in the 1960s and still represents the gold standard [11]. However, significant improvements have been made over the last 50 years. The operation is performed now through a 6- to 8-cm incision and the patient stays about 3 nights in hospital, and just a few days after the surgery, can expect to walk normally with no walking aids and have a painless joint. Patients should not require revision for the next decades, if ever, and are free to return to complete activity including sports. There are few technical considerations, which we briefly discuss. 2.6. Bearing surfaces The hip joint replacement is a ball-and-socket joint: it has a femoral head; the ball articulates the socket by a cup in the acetabulum. The materials in contact with each other are called bearing surfaces. Bearing surfaces are prone to wear, which may generate particulate debris and cause bone resorption and implant failure over time. Metal on polyethylene remains the most favored material among surgeons. It is cheap and easily machined in sizes and shapes. The latest developments such as highly crosslinked polyethylene have greatly decreased wear rates and almost obliterated the risk of particulate-induced osteolysis [12]. Other bearings exist. Ceramic-on-ceramic bearings [13] have been developed to avoid the wear problems with polyethylene. Indeed, there is no clinically measurable wear with this bearing. Nevertheless, this material has a risk of fracture < 1% [14]. Metal-on-metal bearings are seldom used today because of the additional risks of adverse reaction to metal debris and metal ion in blood circulation and renal excretion. 2.7. Cemented and uncemented fixation Two fixation methods exist, cemented and uncemented. Both are applicable to femoral stem and acetabular component. The results are similar and the preference for one or the other is mainly due to the surgeon or centre. In older patients, cemented fixation should be preferred because of the risk of fracture or nonintegration of uncemented implants [15]. 2.8. THR indications THR is indicated with end-stage hip arthritis, when medical treatment has become ineffective, after an observation period of several weeks to several months. The excellent results of this procedure have widened its indications. Initially used exclusively with arthritis, it is today used in multiple situations such as osteonecrosis, secondary degenerative joint disease, congenital dislocation, hip fusion, bone tumor, hereditary disorders, and fractures of the femoral neck. 2.9. THR techniques The surgery can be performed with various approaches. Each approach has relative advantages and drawbacks. The choice depends on the surgeon’s experience and choice and sometimes the anatomical characteristics of the patient. Recently, miniinvasive surgery (MIS) has permitted rapid recovery after the procedure. MIS decreases soft-tissue trauma, while allowing for adequate positioning of the prosthetic components. It contributes to dynamic stabilization of the hip [16,17]. Some patients present complex hip cases such as developmental dysplasia of the hip, post-traumatic arthritis, or Legg-Calve-Perthes disease sequelae. In these cases, surgical techniques are more elaborate, and custommade femoral implants may be necessary [18] (Fig. 2).
Fig. 2. Total hip replacement with cemented cup (polyethylene) and stem.
2.10. THR results The clinical outcomes after THR are excellent [19]. Rehabilitation after hospitalization is rarely needed, and only some patients will benefit from an additional period at a rehabilitation center before returning to independent living. Ambulatory surgery is possible for selected patients: those aged 40 to 75 years, with primary total hip arthroplasty and no history of myocardial infarction, pulmonary embolism, or anticoagulation therapy, no obesity and no important medical comorbidities. For these patients, in the Berger study, the mean time to resuming all activities of daily living was 10 days, and the mean time to walk 1/2 mile was 16 days [16]. After 3 months, patients have no limitations in everyday life activities or sports. Charnley low-friction arthroplasty remains the gold standard with the longest follow-up. Longterm results are excellent, with only 23% revision at 25 years [20]. Regarding more recent implants, mid-term results are equivalent to ceramic-on-ceramic replacements [13]. Complications are unusual after THR. The most common are infection, dislocation [17] and deep vein thrombosis and pulmonary embolism. The incidence of sepsis is 1%, on average, but is higher in patients with diabetes, rheumatoid arthritis, psoriasis, or sickle cell disease and a longer operation time [21]. Improvement in surgical techniques and implant designs has greatly reduced the rate of dislocation, from 4% with a posterior approach in the 1990s to 0.5% with an anterior approach and modern implants currently [17,22]. However, the risk of dislocation is increased in some cases such as with muscle weakness or neurological diseases, component malposition, bony impingement or previous hip surgery. Dual mobility sockets, which associates a small inner bipolar bearing that articulates with an outer true liner, are useful in reducing the risk of dislocation for these patients [23]. Deep vein thrombosis and symptomatic pulmonary embolism are rare events, about 1%, with the current prophylaxis. 2.11. THR evolution With the improvement in surgical techniques [16,24] and perioperative care [25], recovery has improved vastly over the last decade and patients usually stay in the hospital for only 2 or 3 days. However, rehabilitation programs are beneficial for some patients such as very old patients and those with neurological deficiencies [26]. However, initiatives are being developed to shorten the recovery period and hospital stay for relatively young patients without significant morbidity [16]. Furthermore, with the improvement in implants, we expect the revision rate to decrease.
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The use of computer navigation for hip arthroplasty has increased over the last decade. Studies demonstrate substantial improvement in the accuracy of component positioning with navigation as compared with freehand alignment methods [27]. However, the benefits of this additional surgical precision has yet to translate into improved long-term clinical outcomes [28]. Resurfacing prostheses have not fulfilled their expectations and their advantages remain to be seen.
3. Knee OA 3.1. Conservative surgical treatments 3.1.1. Knee arthroscopy Arthroscopy in knee OA has limited indications. Arthroscopic lavage is the only procedure for patients with knee OA. However, a recent US multicenter randomized controlled trial showed that, even with meniscal tear, the improvements in functional status and pain at 6 months with physical therapy follow-up are similar to those with arthroscopy [29]. Guidelines for arthroscopy for nontraumatic meniscal tear in patients 40 years old are conservative [30]. 3.1.2. Femoral and tibial osteotomy The indications for femoral and tibial osteotomy have declined significantly in recent years, possibly because of improved medical treatment, decreased incidence of meniscectomy and the development of unicompartmental knee replacement (UKR). Nonetheless, high tibial osteotomy remains an attractive option for young patients with knee OA and varus deformity. It allows for a load transfer from the diseased compartment to the healthy one and is most often performed for medial isolated femorotibial OA. The 2 most common techniques are tibial valgus osteotomy by medial opening wedge or lateral closing wedge. This process postpones the indication for arthroplasty by approximately a decade [31,32]. Patients with valgus deformity may undergo a correction by femoral-shaft varisation osteotomy. However, the procedure is mechanically less beneficial and less commonly performed (Fig. 3). 3.2. Knee arthroplasty 3.2.1. Total knee replacement (TKR) Indications The primary indication is to relieve the pain caused by knee arthritis, with or without significant deformity. Before surgery, thorough medical care, including anti-inflammatory drugs, activity adaptation, physiotherapy and the use of a cane for ambulation, should be implemented. A recent randomized trial of patients with definitive knee OA ( 2 Kellgren–Lawrence score) and pain score < 60 mm on a visual analog scale, compared TKR to a rehabilitation program including exercise, education, dietary advice, use of insoles, and pain medication. Patients randomized to TKR showed a significant improvement in pain and function scores compared to controls. However, TKR patients also had more serious adverse events [33]. Knee arthroplasty is now more frequently performed than TKR in numerous developed countries. 3.2.2. TKR surgical principles and results The unconstrained knee prosthesis, which preserves the collateral ligaments, represents more than 90% of TKRs. With this design, the anterior cruciate ligament (ACL) and posterior cruciate ligament can be conserved or not. Usually these ligaments are sacrificed and the design of the implant takes over their stabilization function. Two other designs of prosthesis are the semi-constrained implants, which could overcome an average
Fig. 3. Tibial valgus osteotomy by lateral closing wedge.
frontal laxity, and constrained prosthesis, which require intramedullary stems. Knee replacements can be performed by conventional or minimal approaches and can be cemented or not. The tibial component can be mobile or fixed, with little difference in results. A patella replacement should also be considered at the time of the surgery. Imageless computer navigation, and less significantly custom cutting blocks, improve the accuracy of implant positioning during TKA [34,35]. Studies of MIS suggest that it does not confer substantial advantage after TKA [36]. Consequently, given the costs and use of surgical-room resources, these techniques have not been universally adopted (Fig. 4). Physiotherapy after knee replacement is essential to obtain a good range of motion. The clinical outcomes after TKR are not as good as those after TKR. Patients tend to show reduced activity level and only rarely return to their sporting activities. The Swedish national register and a series from large centers [37] show a survival rate of about 80% at 15 years [38]. Even if different studies show excellent long-term functional outcomes [39], stiffness and unresolved pain are common [40]. 3.2.3. Unicompartmental knee replacement (UKR) The indication for UKR is unicompartimental femorotibial OA. An anteroposterior instability of the knee is a formal contraindication. The relative contraindications are increased deformity and BMI > 35. The surgical technique is more difficult than for TKR. However, given an appropriate selection of patients and adequate surgical technique, the results are excellent. Outcomes after UKR are better than those after TKR, and patients are more prone to return to sporting activities. A literature review showed > 90% survival at 10 years [41,42] (Fig. 5).
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function with excellent longevity in multiple studies with longterm follow-up, with good results reported in 80% of patients [44,45]. The reverse shoulder prosthesis is indicated in shoulder arthritis with rotator cuff tear. With this prosthetic design, shoulder abduction is performed by the deltoid muscle and shows significant improvement [46]. Overall, 90% survival at 10 years has been reported [47]. For many authors, patients 70 years with a pseudoparalytic shoulder and irreparable rotator cuff tear are likely candidates for reverse shoulder prosthesis [48]. 5. Other joints 5.1. Elbow
Fig. 4. Total knee replacement.
Patellofemoral replacement is indicated with isolated patellofemoral OA, with disabling pain and ineffective medical treatment. The results are good, with 80% good and very good results [43]. 4. Shoulder OA In shoulder arthritis, the only treatment is arthroplasty. However, the indications are fewer than for the lower limb, because shoulder arthritis is well tolerated by patients. Different types of prostheses can be used: hemiarthroplasty (replace only the humeral head), total shoulder arthroplasty and reverse shoulder arthroplasty. The evidence indicates that total shoulder arthroplasty is superior to hemiarthroplasty for pain, function, activity level, long-term survival, and revision rate and, therefore, the glenoid should be resurfaced if at all possible. Prosthetic replacement of the glenohumeral joint is now considered a successful treatment for a variety of degenerative conditions of the shoulder. Although less common than hip and knee arthroplasty, shoulder arthroplasty has shown improvements in pain and
Rheumatoid arthritis is the preferred indication for total elbow prosthesis. Post-traumatic OA of the elbow may also represent an indication for elbow prosthesis. However, patients are often younger and more active than in those with post-traumatic OA, with increased risk of mechanical failure of the implant. Various kinds of arthroplasty exist; the two most used are the semiconstrained and unconstrained. The published reports of semiconstrained and unconstrained arthroplasty show a mean of 75% satisfactory results [49]. 5.2. Ankle Ankle fusion, which may be performed open or arthroscopically, is the treatment of choice for advanced joint damage, to restore and stability. It restores a walk close to the physiological walk. The limitations are bone loss and major axis deviation. The literature reports few comparative studies, but they favor arthroscopy for early recovery [50] (Fig. 6). Ankle fusion competes with ankle prosthesis. However, indications for the latter are limited to patients with appropriate bone stock and a stable and well-aligned joint. The literature shows a satisfactory rate of 90% at 5 years [51,52]. 5.3. Wrist Degenerative arthritis in the wrist is frequently related to instability around the scaphoid (scapholunate advanced collapse wrist). The instability usually is a post-traumatic change, although primary degenerative changes are seen. The surgical treatment
Fig. 5. Unicompartmental knee replacement for medial femorotibial arthritis.
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Fig. 6. Ankle fusion.
involves limited intercarpal arthrodesis of the capitohamate and triquetrolunate joints [53]. Other motion-preserving procedures, specifically proximal row carpectomy associated or not with hemiarthroplasty [54] or capitate-hamate-triquetrum-lunate (four-corner) fusion with scaphoid excision, can be used for this troublesome problem. The wrist is most often fused for non-united or mal-united fractures of the carpal scaphoid [55] with associated radiocarpal traumatic arthritis and for severely comminuted fractures of the distal end of the radius. It is also indicated in rheumatoid arthritis [56]. 5.4. Fingers and thumb In finger and thumb arthritis, after nonsurgical treatment, many surgical options exist [57]. Soft-tissue procedures, joint replacement and arthrodesis are the main categories [58]. Only surgeons with specific training in hand surgery perform these procedures. 6. Conclusion The surgical treatment of OA requires a large array of competencies. The improvement in imaging and medical knowledge has led to better characterizing osteoarthritic pathologies. Consequently, surgical treatments can now be tailored to the joint and stage of OA to provide adequate pain relief and functional improvement in the long-term, while minimizing the associated morbidity. Subspecialization of orthopedic surgery is inevitable to meet the high demand [59,60]. Disclosure of interest The authors declare that they have no competing interest. References [1] Parvizi J, Burmeister H, Ganz R. Previous Bernese periacetabular osteotomy does not compromise the results of total hip arthroplasty. Clin Orthop Relat Res 2004;118–22. [2] Hashemi-Nejad A, Haddad FS, Tong KM, Muirhead-Allwood SK, Catterall A. Does Chiari osteotomy compromise subsequent total hip arthroplasty? J Arthroplasty 2002;17:731–9. [3] Sugioka Y, Yamamoto T. Transtrochanteric posterior rotational osteotomy for osteonecrosis. Clin Orthop Relat Res 2008;466:1104–9.
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REHAB-986; No. of Pages 7 N. de l’Escalopier et al. / Annals of Physical and Rehabilitation Medicine xxx (2016) xxx–xxx [35] Perlick L, Ba¨this H, Tingart M, Perlick C, Grifka J. Navigation in total-knee arthroplasty: CT-based implantation compared with the conventional technique. Acta Orthop Scand 2004;75:464–70. [36] Wegrzyn J, Parratte S, Coleman-Wood K, Kaufman KR, Pagnano MW. The John Insall award: no benefit of minimally invasive TKA on gait and strength outcomes: a randomized controlled trial. Clin Orthop Relat Res 2013;471: 46–55. [37] Robertsson O, Ranstam J, Sundberg M, W-Dahl A, Lidgren L. The Swedish Knee Arthroplasty Register: a review. Bone Joint Res 2014;3:217–22. [38] Rand JA, Ilstrup DM. Survivorship analysis of total knee arthroplasty. Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 1991;73:397–409. [39] Colizza WA, Insall JN, Scuderi GR. The posterior stabilized total knee prosthesis. Assessment of polyethylene damage and osteolysis after a ten-yearminimum follow-up. J Bone Joint Surg Am 1995;77:1713–20. [40] Parvizi J, Nunley RM, Berend KR, Lombardi AV, Ruh EL, Clohisy JC, et al. High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res 2014;472:133–7. [41] Cartier PSJ. Prothe`se unicompartimentale du genou Marmor : bilan clinique au recul minimal de 10 ans. Prothe`se unicompartimentale du genou. Cah SOFCOT 1998;65:177–83. [42] Hernigou PDG. Les prothe`ses unicompartimentales du genou. Symposium de la SOFCOT 70e re´union annuelle. Rev Chir Orthop 1996;82:23–60. [43] Cartier P, Sanouiller JL, Grelsamer R. Patellofemoral arthroplasty. 2-12-year follow-up study. J Arthroplasty 1990;5:49–55. [44] Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg 2002;11(2):130–5. [45] Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg 2005;14(5):471–9. [46] Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics 1993;16:65–8. [47] Gazielly D, editor. L.F. Grammont inverted shoulder arthroplasty: survivorship of 80 arthroplasties followed for 5 to 10 years, 2005.
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[48] Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole´ D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br 2004;86:388–95. [49] Aldridge JM, Lightdale NR, Mallon WJ, Coonrad RW. Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesis. A 10- to 31-year survival analysis. J Bone Joint Surg Br 2006;88:509–14. [50] Nielsen KK, Linde F, Jensen NC. The outcome of arthroscopic and open surgery ankle arthrodesis: a comparative retrospective study on 107 patients. Foot Ankle Surg 2008;14:153–7. [51] Easley ME, Adams SB, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am 2011;93:1455–68. [52] Karantana A, Hobson S, Dhar S. The scandinavian total ankle replacement: survivorship at 5 and 8 years comparable to other series. Clin Orthop Relat Res 2010;468:951–7. [53] Bain GI, McGuire DT. Decision making for partial carpal fusions. J Wrist Surg 2012;1:103–14. [54] Culp RW, Bachoura A, Gelman SE, Jacoby SM. Proximal row carpectomy combined with wrist hemiarthroplasty. J Wrist Surg 2012;1:39–46. [55] Tambe AD, Trail IA, Stanley JK. Wrist fusion versus limited carpal fusion in advanced Kienbock’s disease. Int Orthop 2005;29:355–8. [56] Trieb K. Arthrodesis of the wrist in rheumatoid arthritis. World J Orthop 2014;5:512–5. [57] Shuler MS, Luria S, Trumble TE. Basal joint arthritis of the thumb. J Am Acad Orthop Surg 2008;16:418–23. [58] Shin EK, Osterman AL. Treatment of thumb metacarpophalangeal and interphalangeal joint arthritis. Hand Clin 2008;24:239–50 [v]. [59] Spaans AJ, van den Hout JAAM, Bolder SBT. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop 2012;83:342–6. [60] Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am 2001;83-A:1622–9.
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Update article
Surgical treatments for osteoarthritis Nicolas de l’Escalopier a,*, Philippe Anract a,b,c, David Biau a,b,c a
Service de chirurgie orthope´dique et oncologique, hoˆpital Cochin, AP–HP, 75014 Paris, France Universite´ Paris-Descartes, 75000 Paris, France c Inserm U1153, 75000 France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2015 Accepted 14 April 2016
There are two main surgical treatments for osteoarthritis: conservative treatments, where the damaged cartilage is left in place, and radical treatments, where the cartilage is replaced by an artificial endoprosthesis; this latter procedure is termed joint arthroplasty. These treatments are only offered to symptomatic patients. Arthrodesis is yet another surgical intervention in cases of osteoarthritis. It will sacrifice the joint’s articular function and is performed on small osteoarthritic joints, such as wrists and ankles, for instance. Osteoarthritis symptoms are usually the consequence of an imbalance between the load applied to a joint and the surface available to support that load. Therefore, conservative treatments will either tend to decrease the load exerted on the joint, such as in a tibial valgus osteotomy for instance, or to improve the articular surface supporting that load. Sometimes, both can be provided at the same time; the peri-acetabular osteotomy for hip dysplasia is an example of such a procedure. Conservative treatments are usually offered to young patients in order to delay, if not avoid, the need for a joint prosthesis. They are usually performed before osteoarthritis appears or at an early stage. Joint arthroplasties have overwhelmingly excellent functional results and today’s research is directed towards providing rapid recovery, very long-term stability, and the assurance of a good functionality in extreme conditions. However, complications with joint arthroplasties can be serious with little, if any, reasonable salvage solution. Therefore, these procedures are offered to patients who have failed adequate medical treatment measures. ß 2016 Elsevier Masson SAS. All rights reserved.
Keywords: Osteoarthritis Joint arthroplasty Conservative surgery Hip Knee Shoulder
1. Introduction There are two main surgical treatments for osteoarthritis (OA): conservative, with the damaged cartilage left in place, and radical, with the cartilage replaced by an artificial endoprosthesis, the latter procedure termed joint arthroplasty. These treatments are offered only to symptomatic patients. Arthrodesis is another surgical intervention in cases of OA. It sacrifices the joint’s articular function and is performed on small osteoarthritic joints, such as wrists and ankles. OA symptoms usually result from an imbalance between the load applied to a joint and the surface available to support that load. Therefore, conservative treatments will tend to decrease the load exerted on the joint, such as in tibial valgus osteotomy, or improve the articular surface supporting that load. Sometimes, both solutions can be provided at the same time; peri-acetabular osteotomy for hip dysplasia is one example.
Conservative treatments are usually offered to young patients so as to delay, if not avoid, the need for joint prosthesis. They are usually performed before OA appears or at an early stage. Joint arthroplasty has overwhelmingly excellent functional results and today’s research is directed toward providing rapid recovery, very long-term stability, and the assurance of good functionality in extreme conditions. However, complications with joint arthroplasty can be serious with little, if any, reasonable salvage solution. Therefore, these procedures are offered to patients with failure of adequate medical treatment measures. In the following sections, we discuss the main surgical treatments for hip, knee, and shoulder OA. We present both conservative and radical options along with patient selection criteria, a brief description of the technique, and the expected results.
2. Hip OA 2.1. Conservative treatment
* Corresponding author. E-mail address: [email protected] (N. de l’Escalopier).
Conservative surgical treatments of hip OA have declined over the last decades after the implementation of total hip replacement
http://dx.doi.org/10.1016/j.rehab.2016.04.003 1877-0657/ß 2016 Elsevier Masson SAS. All rights reserved.
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(THR). Nonetheless, significant indications remain for young patients. These treatments will surely delay but not always avoid the need for joint replacement in the long-term [1,2]. The 3 main surgical procedures that can be performed are femoral osteotomy, pelvic osteotomy, and cartilage and labrum procedures under arthroscopy. 2.2. Femoral osteotomy This osteotomy reorients the femoral head, with one of 2 main goals: positioning an adequate portion of the femoral cartilage in front of the acetabulum, such as in rotational osteotomy of the femoral neck for osteonecrosis [3], and changing the biomechanics of the hip to reduce the load going through the joint, such as in femoral varus osteotomy. The most common osteotomies are valgus and varus femoral osteotomies; others such as flexion, extension or rotation osteotomy or a combination of these are less frequent. The varus femoral osteotomy is usually indicated for hip dysplasia, osteonecrosis, and valgus deformation. It closes the neck-shaft angle when it is superior to 1358 [4]. The long-term results for early OA are good, with 75% 10-year survival, defined as the delay before hip replacement. Second-line hip replacement will have the same prognosis as first-line replacement. The procedure is not recommended with isolated serious dysplasia [5]. Valgus femoral osteotomy is mainly performed for femoral neck non-union, slip upper-femoral epiphysis sequelae and congenital varus deformity of the femoral neck. 2.3. Pelvic osteotomy Pelvis osteotomy (including the shelf procedure) is only rarely performed today but can still provide excellent results. The common eligibility criterion is a painful, dysplastic hip in a relatively young patient (usually < 30 years old). Beyond that, we also rely on some other indications such as cartilage degeneration
stage and coxometric parameters to decide on the surgical procedure. Shelf operation consists of a bone graft addition on top of the hip where the femoral head is uncovered; although it provides support and balances the load, it does not provide cartilage (Fig. 1). The Chiari osteotomy is an augmentation osteotomy similar to the shelf procedure that decreases the contact stresses going through the joint, even though it does not provide any cartilage. The Bernese peri-acetabular osteotomy is a reorientation procedure that lets the acetabulum rotate around the femoral head to cover the uncovered anterior and lateral portion of the head. [6]. When these surgeries are performed in carefully selected patients, they provide good results and delay the need for a hip replacement in the long-term. Conversion to hip replacement occurs at 10 years in about 40% of patients for the shelf procedure and in 15 to 20% for peri-acetabular and Chiari osteotomies. [7]. 2.4. Arthroscopy Arthroscopy is indicated for femoroacetabular impingement (FAI). It occurs when anatomic variation of the hip causes impingement between the femoral head–neck junction and the acetabular rim during functional motion. This condition is mainly seen in young and active men. Open or arthroscopic osteochondroplasty of the femoral head–neck junction is the surgical treatment for symptomatic cam impingement. Depending on the surgeon, it may be performed with an anterior open approach with or without arthroscopy [8] by surgical dislocation [9] or by arthroscopy exclusively. Good to excellent results are reported in 70 to 95% of patients. 2.5. THR THR has been coined the ‘‘operation of the century’’. Millions of THRs are performed worldwide to treat OA, with more than 95% of
Fig. 1. Peri-acetabular osteotomy of the left hip (preoperative, postoperative and long-term radiographs).
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patients entirely satisfied with the functional results [10]. The modern hip replacement was developed by Sir John Charnley in the 1960s and still represents the gold standard [11]. However, significant improvements have been made over the last 50 years. The operation is performed now through a 6- to 8-cm incision and the patient stays about 3 nights in hospital, and just a few days after the surgery, can expect to walk normally with no walking aids and have a painless joint. Patients should not require revision for the next decades, if ever, and are free to return to complete activity including sports. There are few technical considerations, which we briefly discuss. 2.6. Bearing surfaces The hip joint replacement is a ball-and-socket joint: it has a femoral head; the ball articulates the socket by a cup in the acetabulum. The materials in contact with each other are called bearing surfaces. Bearing surfaces are prone to wear, which may generate particulate debris and cause bone resorption and implant failure over time. Metal on polyethylene remains the most favored material among surgeons. It is cheap and easily machined in sizes and shapes. The latest developments such as highly crosslinked polyethylene have greatly decreased wear rates and almost obliterated the risk of particulate-induced osteolysis [12]. Other bearings exist. Ceramic-on-ceramic bearings [13] have been developed to avoid the wear problems with polyethylene. Indeed, there is no clinically measurable wear with this bearing. Nevertheless, this material has a risk of fracture < 1% [14]. Metal-on-metal bearings are seldom used today because of the additional risks of adverse reaction to metal debris and metal ion in blood circulation and renal excretion. 2.7. Cemented and uncemented fixation Two fixation methods exist, cemented and uncemented. Both are applicable to femoral stem and acetabular component. The results are similar and the preference for one or the other is mainly due to the surgeon or centre. In older patients, cemented fixation should be preferred because of the risk of fracture or nonintegration of uncemented implants [15]. 2.8. THR indications THR is indicated with end-stage hip arthritis, when medical treatment has become ineffective, after an observation period of several weeks to several months. The excellent results of this procedure have widened its indications. Initially used exclusively with arthritis, it is today used in multiple situations such as osteonecrosis, secondary degenerative joint disease, congenital dislocation, hip fusion, bone tumor, hereditary disorders, and fractures of the femoral neck. 2.9. THR techniques The surgery can be performed with various approaches. Each approach has relative advantages and drawbacks. The choice depends on the surgeon’s experience and choice and sometimes the anatomical characteristics of the patient. Recently, miniinvasive surgery (MIS) has permitted rapid recovery after the procedure. MIS decreases soft-tissue trauma, while allowing for adequate positioning of the prosthetic components. It contributes to dynamic stabilization of the hip [16,17]. Some patients present complex hip cases such as developmental dysplasia of the hip, post-traumatic arthritis, or Legg-Calve-Perthes disease sequelae. In these cases, surgical techniques are more elaborate, and custommade femoral implants may be necessary [18] (Fig. 2).
Fig. 2. Total hip replacement with cemented cup (polyethylene) and stem.
2.10. THR results The clinical outcomes after THR are excellent [19]. Rehabilitation after hospitalization is rarely needed, and only some patients will benefit from an additional period at a rehabilitation center before returning to independent living. Ambulatory surgery is possible for selected patients: those aged 40 to 75 years, with primary total hip arthroplasty and no history of myocardial infarction, pulmonary embolism, or anticoagulation therapy, no obesity and no important medical comorbidities. For these patients, in the Berger study, the mean time to resuming all activities of daily living was 10 days, and the mean time to walk 1/2 mile was 16 days [16]. After 3 months, patients have no limitations in everyday life activities or sports. Charnley low-friction arthroplasty remains the gold standard with the longest follow-up. Longterm results are excellent, with only 23% revision at 25 years [20]. Regarding more recent implants, mid-term results are equivalent to ceramic-on-ceramic replacements [13]. Complications are unusual after THR. The most common are infection, dislocation [17] and deep vein thrombosis and pulmonary embolism. The incidence of sepsis is 1%, on average, but is higher in patients with diabetes, rheumatoid arthritis, psoriasis, or sickle cell disease and a longer operation time [21]. Improvement in surgical techniques and implant designs has greatly reduced the rate of dislocation, from 4% with a posterior approach in the 1990s to 0.5% with an anterior approach and modern implants currently [17,22]. However, the risk of dislocation is increased in some cases such as with muscle weakness or neurological diseases, component malposition, bony impingement or previous hip surgery. Dual mobility sockets, which associates a small inner bipolar bearing that articulates with an outer true liner, are useful in reducing the risk of dislocation for these patients [23]. Deep vein thrombosis and symptomatic pulmonary embolism are rare events, about 1%, with the current prophylaxis. 2.11. THR evolution With the improvement in surgical techniques [16,24] and perioperative care [25], recovery has improved vastly over the last decade and patients usually stay in the hospital for only 2 or 3 days. However, rehabilitation programs are beneficial for some patients such as very old patients and those with neurological deficiencies [26]. However, initiatives are being developed to shorten the recovery period and hospital stay for relatively young patients without significant morbidity [16]. Furthermore, with the improvement in implants, we expect the revision rate to decrease.
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The use of computer navigation for hip arthroplasty has increased over the last decade. Studies demonstrate substantial improvement in the accuracy of component positioning with navigation as compared with freehand alignment methods [27]. However, the benefits of this additional surgical precision has yet to translate into improved long-term clinical outcomes [28]. Resurfacing prostheses have not fulfilled their expectations and their advantages remain to be seen.
3. Knee OA 3.1. Conservative surgical treatments 3.1.1. Knee arthroscopy Arthroscopy in knee OA has limited indications. Arthroscopic lavage is the only procedure for patients with knee OA. However, a recent US multicenter randomized controlled trial showed that, even with meniscal tear, the improvements in functional status and pain at 6 months with physical therapy follow-up are similar to those with arthroscopy [29]. Guidelines for arthroscopy for nontraumatic meniscal tear in patients 40 years old are conservative [30]. 3.1.2. Femoral and tibial osteotomy The indications for femoral and tibial osteotomy have declined significantly in recent years, possibly because of improved medical treatment, decreased incidence of meniscectomy and the development of unicompartmental knee replacement (UKR). Nonetheless, high tibial osteotomy remains an attractive option for young patients with knee OA and varus deformity. It allows for a load transfer from the diseased compartment to the healthy one and is most often performed for medial isolated femorotibial OA. The 2 most common techniques are tibial valgus osteotomy by medial opening wedge or lateral closing wedge. This process postpones the indication for arthroplasty by approximately a decade [31,32]. Patients with valgus deformity may undergo a correction by femoral-shaft varisation osteotomy. However, the procedure is mechanically less beneficial and less commonly performed (Fig. 3). 3.2. Knee arthroplasty 3.2.1. Total knee replacement (TKR) Indications The primary indication is to relieve the pain caused by knee arthritis, with or without significant deformity. Before surgery, thorough medical care, including anti-inflammatory drugs, activity adaptation, physiotherapy and the use of a cane for ambulation, should be implemented. A recent randomized trial of patients with definitive knee OA ( 2 Kellgren–Lawrence score) and pain score < 60 mm on a visual analog scale, compared TKR to a rehabilitation program including exercise, education, dietary advice, use of insoles, and pain medication. Patients randomized to TKR showed a significant improvement in pain and function scores compared to controls. However, TKR patients also had more serious adverse events [33]. Knee arthroplasty is now more frequently performed than TKR in numerous developed countries. 3.2.2. TKR surgical principles and results The unconstrained knee prosthesis, which preserves the collateral ligaments, represents more than 90% of TKRs. With this design, the anterior cruciate ligament (ACL) and posterior cruciate ligament can be conserved or not. Usually these ligaments are sacrificed and the design of the implant takes over their stabilization function. Two other designs of prosthesis are the semi-constrained implants, which could overcome an average
Fig. 3. Tibial valgus osteotomy by lateral closing wedge.
frontal laxity, and constrained prosthesis, which require intramedullary stems. Knee replacements can be performed by conventional or minimal approaches and can be cemented or not. The tibial component can be mobile or fixed, with little difference in results. A patella replacement should also be considered at the time of the surgery. Imageless computer navigation, and less significantly custom cutting blocks, improve the accuracy of implant positioning during TKA [34,35]. Studies of MIS suggest that it does not confer substantial advantage after TKA [36]. Consequently, given the costs and use of surgical-room resources, these techniques have not been universally adopted (Fig. 4). Physiotherapy after knee replacement is essential to obtain a good range of motion. The clinical outcomes after TKR are not as good as those after TKR. Patients tend to show reduced activity level and only rarely return to their sporting activities. The Swedish national register and a series from large centers [37] show a survival rate of about 80% at 15 years [38]. Even if different studies show excellent long-term functional outcomes [39], stiffness and unresolved pain are common [40]. 3.2.3. Unicompartmental knee replacement (UKR) The indication for UKR is unicompartimental femorotibial OA. An anteroposterior instability of the knee is a formal contraindication. The relative contraindications are increased deformity and BMI > 35. The surgical technique is more difficult than for TKR. However, given an appropriate selection of patients and adequate surgical technique, the results are excellent. Outcomes after UKR are better than those after TKR, and patients are more prone to return to sporting activities. A literature review showed > 90% survival at 10 years [41,42] (Fig. 5).
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function with excellent longevity in multiple studies with longterm follow-up, with good results reported in 80% of patients [44,45]. The reverse shoulder prosthesis is indicated in shoulder arthritis with rotator cuff tear. With this prosthetic design, shoulder abduction is performed by the deltoid muscle and shows significant improvement [46]. Overall, 90% survival at 10 years has been reported [47]. For many authors, patients 70 years with a pseudoparalytic shoulder and irreparable rotator cuff tear are likely candidates for reverse shoulder prosthesis [48]. 5. Other joints 5.1. Elbow
Fig. 4. Total knee replacement.
Patellofemoral replacement is indicated with isolated patellofemoral OA, with disabling pain and ineffective medical treatment. The results are good, with 80% good and very good results [43]. 4. Shoulder OA In shoulder arthritis, the only treatment is arthroplasty. However, the indications are fewer than for the lower limb, because shoulder arthritis is well tolerated by patients. Different types of prostheses can be used: hemiarthroplasty (replace only the humeral head), total shoulder arthroplasty and reverse shoulder arthroplasty. The evidence indicates that total shoulder arthroplasty is superior to hemiarthroplasty for pain, function, activity level, long-term survival, and revision rate and, therefore, the glenoid should be resurfaced if at all possible. Prosthetic replacement of the glenohumeral joint is now considered a successful treatment for a variety of degenerative conditions of the shoulder. Although less common than hip and knee arthroplasty, shoulder arthroplasty has shown improvements in pain and
Rheumatoid arthritis is the preferred indication for total elbow prosthesis. Post-traumatic OA of the elbow may also represent an indication for elbow prosthesis. However, patients are often younger and more active than in those with post-traumatic OA, with increased risk of mechanical failure of the implant. Various kinds of arthroplasty exist; the two most used are the semiconstrained and unconstrained. The published reports of semiconstrained and unconstrained arthroplasty show a mean of 75% satisfactory results [49]. 5.2. Ankle Ankle fusion, which may be performed open or arthroscopically, is the treatment of choice for advanced joint damage, to restore and stability. It restores a walk close to the physiological walk. The limitations are bone loss and major axis deviation. The literature reports few comparative studies, but they favor arthroscopy for early recovery [50] (Fig. 6). Ankle fusion competes with ankle prosthesis. However, indications for the latter are limited to patients with appropriate bone stock and a stable and well-aligned joint. The literature shows a satisfactory rate of 90% at 5 years [51,52]. 5.3. Wrist Degenerative arthritis in the wrist is frequently related to instability around the scaphoid (scapholunate advanced collapse wrist). The instability usually is a post-traumatic change, although primary degenerative changes are seen. The surgical treatment
Fig. 5. Unicompartmental knee replacement for medial femorotibial arthritis.
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Fig. 6. Ankle fusion.
involves limited intercarpal arthrodesis of the capitohamate and triquetrolunate joints [53]. Other motion-preserving procedures, specifically proximal row carpectomy associated or not with hemiarthroplasty [54] or capitate-hamate-triquetrum-lunate (four-corner) fusion with scaphoid excision, can be used for this troublesome problem. The wrist is most often fused for non-united or mal-united fractures of the carpal scaphoid [55] with associated radiocarpal traumatic arthritis and for severely comminuted fractures of the distal end of the radius. It is also indicated in rheumatoid arthritis [56]. 5.4. Fingers and thumb In finger and thumb arthritis, after nonsurgical treatment, many surgical options exist [57]. Soft-tissue procedures, joint replacement and arthrodesis are the main categories [58]. Only surgeons with specific training in hand surgery perform these procedures. 6. Conclusion The surgical treatment of OA requires a large array of competencies. The improvement in imaging and medical knowledge has led to better characterizing osteoarthritic pathologies. Consequently, surgical treatments can now be tailored to the joint and stage of OA to provide adequate pain relief and functional improvement in the long-term, while minimizing the associated morbidity. Subspecialization of orthopedic surgery is inevitable to meet the high demand [59,60]. Disclosure of interest The authors declare that they have no competing interest. References [1] Parvizi J, Burmeister H, Ganz R. Previous Bernese periacetabular osteotomy does not compromise the results of total hip arthroplasty. Clin Orthop Relat Res 2004;118–22. [2] Hashemi-Nejad A, Haddad FS, Tong KM, Muirhead-Allwood SK, Catterall A. Does Chiari osteotomy compromise subsequent total hip arthroplasty? J Arthroplasty 2002;17:731–9. [3] Sugioka Y, Yamamoto T. Transtrochanteric posterior rotational osteotomy for osteonecrosis. Clin Orthop Relat Res 2008;466:1104–9.
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