A 68 yr old man came with pain and swelling of right knee. Ahlbeck grade 2 osteoahritic changes were found on investigation. What is the fuher management:
D i.e. Total knee replacement - Ahlbeck grade 2 osteoahritis (i.e. complete or almost complete obliterated joint space) with symptoms of pain and swelling in a sedentary patient (>65 years of age) is managed by knee replacementQ - Old (65 yrs) age, long standing history of pain & swelling interfering activities of daily living and grade III radiological grade of OA indicate moderately severe OA and is best managed by Total knee ahroplasty. Although it must be remembered that TKA is done only after conservative treatment measures have been exhausted. And in this case we have presumed that conservative treatment must have been tried (b/o long course) & failed. - Because ahroscopic lavage (wash out) provides symptomatic improvements in patients with normal alignment, joint space >3mmQ, stable ligaments, unicompamental OA with relevant osteophytes at the site of symptom, loose bodies, minimal Fair bank lesions, meniscal flap tear, chondral fracture/flap and outerbridge I or II lesions. And patients with bi/tri compamental OA, malalignment, irrelevant osteophytes away from symptom site, diffuse chondrosis, degenerative meniscus, significant Fair bank lesion and outbridge III or IV are poor prognostic factors for ahroscopic debridement. So obliterated joint space rules out the possibility of conservative and ahroscopic treatments. - High tibial osteotomy is indicated in physiologically young (years) and active patients with unicompamental OA of tibiofemoral jointsQ. Radiological Grading Scale of OA of Tibiofemoral Joint Ahroscopic Grading of Aicular Cailage Defect of knee joint Ahlback Kellgren Lawrence Brandt Noyes 0 No radiographic findings of osteoahritis No radiographic findings of osteoahritis No radiographic findings of osteoahritis 0 Normal aicular cailage 1 Joint space Minute osteophytes of lA Mild softening or discoloration of narrowing < 3mm doubtful clinical significance with secondary features aicular cailage 2 Joint space Definite osteophytes 50-75% joint space narrowing 1B Severe softening or discoloration of obliterated or almost obliterated with unimpaired joint space without secondary features aicular cailage 3 Minor bone attrition Definite osteophytes 50-75% joint space narrowing 2A Paial-thickness defect of ( with moderate joint space narrowing with secondary features the total thickness of aicular cailage 4 Moderate bone Definite osteophytes >75% joint space narrowing 2B Paial-thickness defect of >50% of attrition (5-15 mm) with severe joint space narrowing, subchondral sclerosis and definite deformity of bone contour. with secondary features Severe subchondral sclerosis and definite deformity of bone contour the total thickness of aicular cailage 5 Severe bone attrition (>15 mm) 3A Full-thickness aicular cailage defect with normal subchondral bone * Secondary radiological features of OA include osteophytes, subchondral 3B Full-thickness aicular cailage sclerosis & subchondral defect with erosion of subchondral bone Surgical Management Plan of Ahritis Knee - Before surgery is considered, conservative management (including anti-inflammatory medications, modification of daily activities, weight reduction for obese patients, and use of cane for ambulation) should be exhausted (adequately tried). Intra aerial injections of hyaluronic acid & steroid may be helpful in early minimal ahritis. Ahroscopic lavage (wash out) provides symptomatic improvements in patients with normal alignment, joint space >3mmQ, stable ligaments, unicompamental OA with relevant osteophytes at the site of symptom, loose bodies, minimal Fair bank lesions, meniscal flap tear, chondral fracture/flap and outerbridge I or II lesions. And patients with bi/tri compamental OA, malalignment, irrelevant osteophytes away from symptom site, diffuse chondrosis, degenerative meniscus, significant Fair bank lesion and outbridge III or IV are poor prognostic factors for ahroscopic debridement. Total (Tricompamental) Knee Replacement (TKR) : Indications - Primary indication of TKR is to relieve pain caused by severe ahritis with or without significant deformityQ. Radiological finding must correlate with clinical impression of knee ahritis. Patient who do not have complete cailage space loss before surgery tend to be less satisfied with their clinical result after TKR. - Severe pain from chondrocalcinosis & pseudogout in an elderly patient is an occasional indication of TKR in absence of complete cailage space loss. Severe patellofemoral ahritis in elderly may justify TKR because the expected outcome is better than that of patellectomy in these patients. - Osteonecrosis with subchondral collapse of femoral condyle. - Because knee replacement has a finite expected survival that is adversely affected by activity level, it generally is indicated in older patients with more sedentary life styles. It is preferable that patients undergoing TKA have a remaining normal life expectancy of between 20 & 30 years so that need for a repeat ahroplasty for a failed TKA will be minimal. It is clearly indicated in young patients who have limited function b/o systemic ahritis (eg rheumatoid ahritis) with multiple joint involvement. But the patient must understand the limitations of the procedure, be willing to modify life style to prolong the life of prosthesis and be willing to risk the lower success rate in a revision TKA. - Deformity can become the principle indication for TKR in patient with moderate ahritis & variable levels of pain when the progression of deformity begins to threaten the expected outcome of an anticipated TKR. This includes flexion contractures beyond 20deg and vurus/ valgus laxity. However, deformity without pain is not a suitable indication for surgery as it may be well tolerated by elderly. - Indications for leaving the patella unresurfaced are, a primary diagnosis of OA, satisfactory patellar cailage with no eburnated bone, congruent patello femoral tracking, a normal anatomical patellar shape and no evidence of crystalline or inflammatory ahropathy and lighter weight of patient. TKR: Contraindications - Absolute contraindications include recent or current knee infection; a remote source of ongoing infection; extensor mechanism discontinuity or severe dysfunction; recurvatum deformity secondary to muscular weakness; and presence of painless, well functioning knee ahrodesis. - Relative contraindications include fragile medical conditions, severe atherosclerotic disease of operative leg, skin conditions such as psoriasis within the operative field, venous stasis disease with recurrent cellulitis, neuropathic ahropathy, morbid obesity, recurrent UTI, and a h/o osteomyelitis in the proximity of knee.
Conservative
Ahroscopic washout
High tibial osteotomy
Total knee replacement