A 68 yr old man came with pain and swelling of right knee. Ahlback grade 2 osteoahritic changes were found on investigation. What is the fuher management?
Conservative [Ref: Campbell Operative Ohopaedics 11/e, p 916; Apley's Ohopaedics 9/e, p 572573; Turek's Ohopedics 6/e, p 616-621; Imaging of the knee : Techniques & application by A. Mark Davies et al 2003, p 12; Harrison 17/e, p 2163-21651 Initial management of most of the patients of knee OA is conservative or non-operative. Campbell operative ohopaedics writes ? "Osteoahritis of the knee can cause symptoms ranging from mild to disabiling. 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 compaments involved. Ahroscopic washout or debridement: - It consists of trimming of degenerate meniscal tissue and osteophytes - It may delay the need for a more definitive procedure, especially in younger, active patients with localised degenerative ahritis that causes pain at rest without malalignment or instability - It 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 unicompamental osteoahritis of the knee (medial or lateral compament osteoahritis; usually it is medial; lateral compament osteoahritis is uncommon). Medial osteoahritis is associated with varus deformity of the knee. Varus deformity causes stresses to be concentrated medially, accelerating degenerative changes in the medial pa of the joint (similarly if the deformity is of valgus position, changes are accelerated in the lateral pa). The biomechanical rationale for proximal tibial osteotomy in patients with unicompamental osteoahritis of the knee is "unloading" of the involved joint compament by correcting the malalignment and redistributing the stresses on the knee joint. Thus medial osteoahritis is treated by a varus correcting osteotomy (k/a valgus osteotomy) and the uncommon lateral osteoahritis corrected by valugus 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 Ohopaedics 1/e chapter 25) Total knee ahroplasty: - It is done for older patients with advanced OA that causes incapacitating pain and disability or young patients with tricompamental (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 fuher revision surgery. Unicompamental ahroplasty: - In carefully selected patients with either medial or lateral osteoahritis, it is becoming a ble alternative to TKA and HTO. Knee ahrodesis: - Ahrodesis is indicated less commonly than ahroplasty. If the patient is young and involved in heavy occupation, ahrodesis 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 ahrodesis results in a stiff knee which is a severe disability. Ahlback's grading of osteoahritis Ahlback's grading is radiological grading of osteoahritis. Standard textbooks of Ohopaedics (Campbell, Turek, Apley's) and of Radiology (Grainger, Sutton, Greenspan's Ohopedic Imaging) do not mention anything about it. Treatment of osteoahritis depends on symptoms and clinical profile of pt and not on radiological grading. Still we are describing the grading below. Grading of osteoahritis Apa from Ahlback grading, other commonly used grading system is by Kellgren and Lawrence. The two grading system are compared as follows: Classification of knee OA Ahlback Kellgren and Lawrence Grade Definition Grade Definition Grade 1 "doubtful" Minute osteophytes doubtful significant Grade 2 "minimal" Definite osteophytes (unimpaired air space) Grade 1 Joint space narrowing (< 3 mm) Grade 3 "moderate" Moderate diminution of joint spaces Grade 2 Joint space obliferation Grade 4 " severe " Joint space great impaired with sclerosis of subchondral bone Grade 3 Minor bone attrition (0-5 mm) Grade 4 Same as above Grade 4 Moderate bone attrition (5-10 mm) Grade 4 As above Grade 5 Severe bone attrition (> 10 mm) Grade 4 As above Note- Grade I 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)
Ahroscopic washout
High tibial osteotomy
Total knee replacement
Conservative