1. Joint Preserving Surgery of the Knee
Dr Kosta Calligeros
MBBS FRACS FAorthA

2. What do we mean by joint preservation?
Non-surgical
Surgical
Doing nothing
Arthroscopy
Pharmacotherapy
Chondral Regenerative Therapy
Physiotherapy
Orthoses
Osteotomy

3. Non-operative What is the evidence for non-surgical management?
No evidence for doing nothing
Pharmacotherapy has some evidence but also significant problems ie side effects depending on medications used and duration of therapy
Physiotherapy: Effective up to a point, very good in early disease
Orthoses, limited evidence

4. Pharmacotherapy Common Therapies
Paracetamol and NSAID’s (Selective and non-Selective)
Opioids
Steroid Injections
Glucosamine/Chondroitin

5. Pharmacotherapy Evidence Paracetamol
has very mild reduction in pain scores
Paracetamol was shown to give no clinically significant improvement compared to placebo (2016 Lancet DeCosta et al)

6. Pharmacotherapy Evidence Non-Steroidal Anti-Inflammatories
Good evidence they are effective in reducing pain in OA (Cochrane 2017)
Significant side effects depending on type of NSAID used (Selective better but still not without problems)
GI upset
Renal impairment
Cardiovascular event rate increase
Asthma

7. Pharmacotherapy Evidence Opioids
Very significant side effects ie constipation, cognitive effects, physical dependence, respiratory depression
No benefit over NSAIDS (O&C June 2016 Smith et al)

8. Pharmacotherapy Evidence Corticosteroid Injection
No benefit in pain or function when compared to placebo
Increased loss of cartilage compared to placebo over 2yrs (JAMA 2017 McAlinden et al)

9. Pharmacotherapy Evidence Glucosamine/Chondroitin
Poor quality studies show some improvement in pain and function.
The better quality studies show no difference to placebo for pain and function
Pooled studies show small benefit
No down side apart from cost

10. Surgical
Arthroscopy Vs Physiotherapy in early Osteoarthritis (June 2016 BMJ Kise et al)
Mean age participants 49.3yrs (35-60yr range)
Selection criteria included
Pre weight bearing XR changes
Minimum of 3 months knee pain
No discrete trauma or prodromal incident
At most Grade 2 (Kellgren-Lawrence) changes with medial meniscal tear on MR

11. Physiotherapy Vs Arthroscopy
Primary Outcome measures Knee Injury and Osteoarthritis Outcome Scores and Muscle Strength 3,6,12 and 24 months
Findings
No significant difference in outcome measures (KOOS) between groups
Increased muscle strength in Physiotherapy group
Decreased swelling and mechanical symptoms in physiotherapy group at 2 yrs

12. Chondral Therapy Include Microfracture (Steadman) Mosaicoplasty
Chondral Allograft
Autologous Chondrocyte implantation
Summary: NO EVIDENCE any of the above is better than doing nothing in long term (Chochrane).

13. Re-Alignment Procedures
Osteotomies about the knee
Off Loading the Medial Compartment
Options
Opening Medial Wedge Osteotomy
Closing Lateral Wedge Osteotomy

14. Re-Alignment Procedures
Osteotomies about the knee
Off Loading the Medial Compartment
Options
Opening Medial Wedge Osteotomy
Closing Lateral Wedge Osteotomy

15. Indications Isolated medial or lateral compartment osteoarthritis
Physically active younger patient (<55 yrs)
Better tolerated in the presence of physiological varus or valgus alignment
Males report better PROMS than females
Patient must be able to tolerate rehabilitation protocol
No vascular compromise, preferably a non-smoker

16. Principles
Pre-op planning from long leg Hip-Knee-Ankle Alignment Radiography
Osteotomy close to the Centre of Rotational Axis
Stable fixation of co-planar surfaces
Respect for soft tissues
Rehabilitation Protocol

17. What is the Centre of Rotational Angulation?
Use Tracing paper to do your planning with your XR’s
Drop line of axis of where you would like correction to end ie below centre of knee
Extend line up to where you would like to rotate correction
Bisector is where these two lines intersect

18. Opening Vs Closing

19. Opening Vs Closing Wedge

20. Advantages of Closing Vs Opening Wedge Osteotomies
Lateral Closing Wedge
Medial Closing Wedge
Higher Union Rate
Easy exposure
Better Soft tissue coverage
No fibular osteotomy (less risk to peroneal nerve)
Easier to reduce tibial slope (if desired)
May increase MCL tension
May weight bear immediately
Preserves bone stock

21. The Valgus Knee Distal femoral osteotomy increases power of correction
Same process, establish bisector
Measure angle
Determine size of opening or closing wedge.

22. Knee Replacement after Osteotomy
Survival of opening wedge (91%)Vs closing wedge osteotomy (85%) at 10 yrs ( Nature 2017 Kim et al)
Can make TKR difficult, must consider
Reports of worse results from TKR post HTO (JBJS 2003 Kim)
Need to plan incision of HTO
May require consideration of revision like exposure i.e. Tibial tubercle osteotomy, quads snip
Most HTO’s will result in patella-infra and joint line alteration

23. Summary Joint Preservation of the Knee throws up many options
Few have solid evidence
Must always exhaust non-operative options, physical therapy and NSAIDS have the best evidence
Arthroscopy has a very limited role
Osteotomy can be a good option in the well selected patient population