A 68 yr. old man came with pain and swelling of right knee. Ahlback grade 2 osteoarthritic changes were found on investigation. What is the further management?
Ans. is 'd' i.e. Conservative Initial management of most of the patients of knee OA is conservative or non-operative.Campbell operative orthopaedics writes - "Osteoarthritis of the knee can cause symptoms ranging from mild to disabling. Initial management of most patients should be nonoperative".Surgical management is needed when the conservative management fails.Surgical management in brief:The choice of surgical procedure depends on the patient's age and activity demand, severity of the disease and the number of knee compartments involved.Arthroscopic washout or debridement:It consists of trimming of degenerate meniscal tissue and osteophytesIt may delay the need for a more definitive procedure, especially in younger, active patients with localised degenerative arthritis that causes pain at rest without malalignment or instabilityIt may also be considered in active, older adults with mild to moderate OA Realignment osteotomy:High or proximal tibial osteotomy (HTO)-High tibial osteotomy is a procedure for the treatment of unicompartmental osteoarthritis of the knee (medial or lateral compartment osteoarthritis; usually it is medial; lateral compartment osteoarthritis is uncommon).Medial osteoarthritis is associated with varus deformity of the knee. Varus deformity causes stresses to be concentrated medially, accelerating degenerative changes in the medial part of the joint (similarly if the deformity is of valgus position, changes are accelerated in the lateral part).The biomechanical rationale for proximal tibial osteotomy in patients with unicompartmental osteoarthritis of the knee is "unloading" of the involved joint compartment by correcting the malalignment and redistributing the stresses on the knee joint.Thus medial osteoarthritis is treated by a varus correcting osteotomy (k/a valgus osteotomy) and the uncommon lateral osteoarthritis corrected by valgus correcting osteotomy (k/a varus osteotomy).According to Ebnezar (3/e p547) High tibial osteotomy is done for varus deformity less than 15deg and valgus deformity less than 12deg.Supracondylar or distal femoral osteotomy- - distal femoral osteotomy is done for correction of valgus deformity more than 12 to 15deg (Ref: Campbell's Orthopaedics 11/e chapter 25)Total knee arthroplasty:It is done for older patients with advanced OA that causes incapacitating pain and disability or young patients with tricompartmental (medial and lateral tibio femoral and patellofemoral) disease. But it should be delayed in young patients as long as possible as prostheses may wear out over time and may need further revision surgery.Unicompartmental arthroplasty:In carefully selected patients with either medial or lateral osteoarthritis, it is becoming a viable alternative to TKA and HTO.Knee arthrodesis:Arthrodesis is indicated less commonly than arthroplasty. If the patient is young and involved in heavy occupation, arthrodesis is indicated to give him a stable and strong knee.This procedure provides permanent pain relief and allows the patient to return to durable, active work. However arthrodesis results in a stiff knee which is a severe disability.Ahlback's grading of osteoarthritisAhlback's grading is radiological grading of osteoarthritis. Standard textbooks of Orthopaedics (Campbell, Turek, Apley's) and of Radiology (Grainger, Sutton, Greenspan's Orthopedic Imaging) do not mention anything about it. Treatment of osteoarthritis depends on symptoms and clinical profile of pt and not on radiological grading.Still we are describing the grading below.Grading of osteoarthritisApart from Ahlback grading, other commonly used grading system is by Kellgren and Lawrence. The two grading system are compared as follows:Classification of knee OAAhlbackKellgren and LawrenceGradeDefinitionGradeDefinition Grade 1 "doubtful"Minute osteophytes doubtful significant Grade 2 "minimal"Definite osteophytes (unimpaired air space)Grade 1Joint space narrowing (<3 mm)Grade 3 "moderate"Moderate diminution of joint spacesGrade 2Joint space obliterationGrade 4 "severe"Joint space great impaired with sclerosis of subchondral boneGrade 3Minor bone attrition (0-5 mm)Grade 4Same as aboveGrade 4Moderate bone attrition (5-10 mm)Grade 4As aboveGrade 5Severe bone attrition (> 10 mm)Grade 4As aboveNote- Grade 1 of Ahlback is equivalent to grade 3 of Kellgren and Lawrence& grade 2, 3, 4&5 of Ahlback is equivalent to grade 4 of Kellgren and Lawrence.It must be noted that the radiological grading may not correlate with clinical symptomology of the patients. The treatment is based on the symptoms of patient (and not merely on radiographic appearances)
Arthroscopic washout
High tibial osteotomy
Total knee replacement
Conservative
Arthritis