Knee arthritis surgery: To preserve or sacrifice the joint?
Knee arthritis that cannot be addressed by nonsurgical regimens may be treated with surgery that would either preserve or sacrifice the knee joint, according to a presentation at SHBC 2018.
“Indications for [knee] surgery [are] largely symptom driven [and not] based on radiographic or biochemical markers,” said Dr Tan Tong Leng from Tan Tock Seng Hospital in Singapore. Other indications are severe deformity affecting range of ambulatory distance and failed conservative therapy resulting in persistent pain, leading to disability, restricted movement, and consequently poor quality of life, he added.
Non-extensive knee arthritis cases may merit joint preservation through arthroscopic debridement, while more extensive cases may benefit from osteotomy, which involves cutting of the bone to allow realignment of the weightbearing axis of the limb to a more neutral area, said Tan. However, osteotomy is limited to young and active individuals with less severe knee disease (ie, single compartment disease, varus or valgus deformity) who wish to continue physically demanding activities such as sports, he added.
Joint sacrificing, which could range from uni- or bicompartmental to total knee replacement, would be suitable for severe knee arthritis and deformities, he added.
“Knee replacement is a very effective surgery … that has achieved high patient satisfaction,” said Tan. Moreover, advancements in materials and techniques are being implemented to continually improve its efficacy and to achieve best outcomes, he added. “Total knee [replacement today] is in a state where cutting-edge technology [is being utilized] to try to reduce outliers so that the surgery becomes more predictable and reproducible [to benefit] all patients.”
One important consideration for knee replacement is preserving individuals’ squatting ability, noted Tan. “The best predictor of squatting would be preoperative function,” he said. “If [one is] able to squat before surgery, there is about 70–80 percent likelihood of being able to squat again while the damaged bone [is being replaced].” Implants today are designed to allow patients to have a great range of movement and should not limit one’s ability to squat, he added.
Of note is the concept of accelerated rehabilitation – which advocates either a single-night in-hospital stay postop or an outpatient procedure – that is currently gaining popularity in North America and Europe. “This is an exciting prospect for both physicians and patients, as well as for health economics … [However,] it needs to bring together various components (ie, physical therapists, physicians, etc) [to] make this a success.”
The “core” nonsurgical treatment options for knee osteoarthritis – education, exercise, and weight management – should still be offered to patients regardless of symptom severity, age, disability, or coexisting medical conditions, said Dr Mona Manghani from Tan Tock Seng Hospital, Singapore, in a separate talk. “These interventions have been shown to postpone knee surgery and provide clinically relevant improvements for most people without the associated risks of total knee replacement.”
Optimal exercise programmes for knee osteoarthritis should be geared towards improving aerobic capacity, quadriceps muscle strength, or lower extremity performance, added Manghani.