Name: Treating Arthritis in the Young Patient
Uploaded: 2017-03-20T00:00:00Z
Channel: Arthrex
Description: Michael Stuart, MD, (Rochester, MN) discusses his treatment algorithm for young arthritic patients.

Arthroplasty Knee

<p>Michael Stuart, MD, (Rochester, MN) discusses his treatment algorithm for young arthritic patients.</p>

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VPT1-00799-EN | A | Treating Arthritis in the Young Patient

Michael J. Stuart

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Treating Arthritis in the Young Patient

I think this is a bit of a nebulous and controversial topic. How do we define arthritis? How do we define young patient? So for the purpose of this presentation, we're talking about osteoarthritis. And often what I like to call post-traumatic degenerative arthritis. Arthritis simply means inflammation of a joint. We know it as loss of articular cartilage and meniscus. Every severely arthritic knee has a meniscus tear and absent meniscus. You can't have complete loss of your joint space on x ray and have an intact meniscus. And it's affected by a lot of different things. There's a genetic predisposition. Malalignment may be a predisposing factor injury damaging subchondral bone, articular cartilage, menisci ligaments can lead to degenerative changes. And then obesity has also been proven to be a risk factor for the development of knee arthritis. So the young patient, I guess for today will say is between the ages of 20 and 50. To me, that's a young patient. I'm soon to be 60. I don't consider myself that young. First, we start with joint preservation. We want to try to restore articular cartilage subchondral bone menisci when needed, and realign the limb accordingly. If that's not an option, we turn to arthroplasty, which is resurfacing the joint in one compartment or multiple compartments. Unicompartmental or total knee arthroplasty. We start with joint preservation. We saw some good talks this morning on ways to transplant fresh or cryopreserved articular cartilage and bone. And it really is an effective technique for the right indications. You can reestablish the joint surface contour using live hyaline articular cartilage. And hopefully this would delay arthritis progression in addition to relieving the patient's symptoms. This is just a case of a multifocal osteochondral allografts involving a condyle and a trochlea. And to show that MRI, both in the trochlea and on the femoral condyle, truly incorporates the bone, has viable articular cartilage and restores the joint surface contour. Alan Gross has a lot of experience, reported on 58 patients and had almost 70% survivorship at 20 years. Those survivors also had well functioning knees based upon HSS scores. Bill Bugbee twice as many patients followed for 13.5 year. Mean had a very similar 20 year survival. Older patients were at greater risk for failure. But two out of three success at 20 years. So osteochondral allograft transplantation should be considered in these young arthritic patients, because you can actually transplant bone and cartilage into large defects. Prior surgery is really not a contraindication, but the donor tissue has to be fresh or cryopreserved and has to be size matched. What about the meniscus? We can't forget about meniscus deficiency in these situations. Meniscus allograft transplant has been shown to relieve pain, protect articular cartilage, and decrease forces on our ligament grafts. It also hopefully will delay arthritis progression in that young patient. Here's a second look. Arthroscopy of meniscus transplant. It is remarkable how well they heal. The big question is durability. It's been reported there's an 80% success rate based upon pain relief. Peripheral healing is very reliable, but unfortunately, the long term biomechanical function and also the durability of the graft is questionable. I would say that allograft meniscus transplant is still a salvage procedure for younger patient, and it's usually done in combination with other joint preservation or restorative operations. Proximal tibial osteotomy nicely outlined by Tom. And this corrects limb alignment. Relieves pain. Decreases forces. Again not only on menisci and osteochondral grafts but also ligaments. And hopefully we'll delay arthritis progression. We use it quite commonly when we're doing ligament reconstruction, meniscus transplants and articular cartilage restoration. But there's still a role for osteotomy, in my opinion, for selected patients with unicompartmental arthritis. We measure angle of angle of correction. This is a case where we combined meniscus ACL reconstruction and osteotomy. And you can see with a little more aggressive post-operative rehabilitation these patients can actually regain motion quite quickly. This is a six week photograph. So proximal tibial osteotomy indications in my practice are actually expanding not shrinking. But you have to be very careful about patient selection. You have to be precise with your pre-operative planning. And I think we now have the techniques and instrumentation that we can be very meticulous with our surgical techniques. So this is a 31 year old woman who had medial femoral condyle osteochondritis dissecans at age 13. She developed grade four malacia of both the medial femoral condyle and medial tibial plateau. She's very symptomatic. She's got obvious genu varum and antalgic gait, medial pseudo laxity, intact cruciate ligaments. Now, I don't care what your what your definition is. To me, this is an arthritic knee in a 31 year old woman. And there are colleagues at my institution that would do a total knee arthroplasty. And maybe I can't fault them for that. In my practice, this is a joint preserving situation. So we elected to do a medial femoral condyle osteochondral allograft transplant combined with a valgus producing proximal medial tibial osteotomy. You can see complete loss of articular cartilage intralesional osteophytes from the previous microfracture. She does have some tibial changes, but fortunately they're not horrible and luckily has an intact medial meniscus. I can't bring myself to take out that meniscus. Take out the viable articular cartilage in a 31 year old. So instead, we did this combined procedure that you're all familiar with. We can restore hyaline articular cartilage, a very large graft. We realign the limb at five year follow up. Has no pain. Granted, her joint space is narrow but much better than pre-op five years earlier. Has symmetric knee range of motion and no tenderness, and it won't be difficult to convert this to an arthroplasty. Hopefully when she's older. What about uni? Actually, my practice now incorporates many more units than it did before. There's a lot of advantages to a total knee. There's less complications. It's very bone preserving. Kinematics of the knee are quite honestly improved. And patients like units better than total knee arthroplasty. Is it cost effective? Well, it certainly is in the short term, but the ultimate result depends upon the rate of conversion of total knee arthroplasty. So if you have a highly selected patient that has severe pain, they failed a non-operative program. They have arthritis in one compartment. You don't think they're a candidate or they're not interested in joint preservation procedures, I would do a uni. Not everybody is the ideal candidate. Localized medial knee pain. No night pain. Minimal anterior knee pain. Intact cruciate ligaments. Good motion. Realistic. Realistic expectations. I think they're awesome. However, I would caution you that the durability in very young active patients is unknown. So I still make a plea for joint preservation surgery in that situation. The SOS results with primary iBalance UK looking at visual analog pain scores are very favorable, as are junior scores looking at six months and three years. We just published last week a series of unicompartmental knee arthroplasty compared to valgus producing proximal tibial osteotomy in an 18 to 55 year old patient group with painful medial compartment arthritis. Is, we compared 182 units to 57 Osteotomies and looked at activity level, function, durability. And we found to our surprise that the activity level across the board, and even those performing heavy labor before surgery was actually better in the uni group at three months, two years and final follow up, we also found that survival of the uni, although the follow up was different, was 92% at almost six year mean the osteotomy was only 77% at seven year mean. So the unicompartmental arthroplasty was more durable. But those that failed failed earlier than the uni group. So we concluded, which was against our hypothesis that uni patients have a higher activity level. Earlier after surgery, which persisted at midterm follow up they had earlier, but actually less frequent conversion to a total knee and the current proximal tibial osteotomy techniques, however, may have less complications and increased survival. But at least it does challenge the perception that we had the young patients regain a higher activity level after an osteotomy with medial compartment arthritis and varus malalignment. So I think these are very reliable for pain relief. The prosthetic designs and instrumentation have evolved, so it's a much simpler procedure. I do them all as outpatients. They have very little pain. They're on crutches typically for about two weeks, then a cane for another couple of weeks. The results would show 90% survival more than ten years and 75% more than 20 years. This is the ideal situation. Very painful knee. Just like the hip, it's focal osteonecrosis, probably related to an untreated meniscal tear. In this situation, the patellofemoral joint looked good. This is a tough problem to solve with bipolar osteochondral allografts or osteotomy. So in this case we do this unicompartmental arthroplasty. Patient goes home the same day very satisfied with the results. Now there is a role for total knee arthroplasty in the young adult. Again, in highly selected patients with severe pain who have failed the Non-operative program and their arthritis involves multiple compartments. And in my practice, they often have associated problems like collateral ligament insufficiency that simply do not allow us to proceed with unicompartmental arthroplasty. And here's a case from recently where you can see this patient's had ligament surgery and meniscal surgery. They have lateral tibial subluxation, compartmental arthritis, varus malalignment. And this case in my opinion is best treated with a total knee arthroplasty. So treating arthritis in the young patient is very challenging. I think we have more tools in our toolbox than we've ever had before. We should try to strive, when possible to preserve the joint, restore limb alignment, replace menisci articular cartilage when possible. And if you can't perform a unicompartmental arthroplasty for those patients with disabling pain due to isolated mono compartmental arthritis and a total knee arthroplasty, at least in my opinion, is a last resort when there are simply no other alternatives. And the results are very good. You'll have happy patients. You have to warn them that with the average age now of females in the United States living into their 90s, it might not last forever. If you give a 31 year old a total knee, but still, it's their only option if they're willing to go through it. It is a very successful procedure.