andpresentWhen is a joint replacementWhen is a joint replacementnecessary?necessary?
Treatment of osteoarthritisThere is no etiologic treatment for osteoarthritis. The aims of treatment are to control pain andlimit functional impairment. Before referring a patient for surgery, it isessential to prescribe physiotherapy and toachieve the best possible control of the diseaseby medicinal means. Nonetheless, surgery is the "last chancesaloon" of treatment.2 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Chevallier X. Arthrose : une maladie plus complexe qu’il n’y paraît. Rev Prat. 2012 ; 62 : 619-620.
When to refer an osteoarthritic patientfor surgery 1. "Terminal" osteoarthritis The need for surgery is dictated by the severity of the disability and/orpain osteoarthritis causes the patient. It is these symptoms and not the condition of the joint as visualised on thex-ray or MRI scan that indicate the need for surgery:a surgeon does not operate on pictures! In practice therefore, there are no set clinical, radiological or biologicalcriteria on the basis of which a joint replacement procedure is indicated. The impact of osteoarthritis on the lives of patients (their ability to usetransport, perform household chores or take part in leisure activities, etc.)can be assessed using the Lequesne index.3 Sellam J, Berenbaum F. Quand adresser au chirurgien un patient arthrosique ? Rev. Prat. 2012 ; 62 : 644
When to refer an osteoarthritic patientfor surgery 2. "Early stage" osteoarthritis in a deformedor dysplastic joint A surgical opinion should be sought for patients with severelydeformed joints, treatment-refractory pain and moderateosteoarthritis; Conservative surgery can be discussed for patients with early stagesymptomatic osteoarthritis in a dysplastic hip or a misaligned knee(genu varum or genu valgum). An acetabular bolt or osteotomy can be proposed for a patientaged less than 50 with a dysplastic hip (particularly subluxationwith an acetabular roof defect). These prosthetic devices have a limited life-expectancy and it isbetter to delay using them in younger patients.5 Sellam J et Berenbaum F. Quand adresser au chirurgien un patient arthrosique. Rev Prat 2012 ; 62 : 644.
Surgical treatment of knee osteoarthritisSurgery is offered for patients with treatment-resistant,painful and debilitating knee osteoarthritis.Patients are referred for surgery on the basis of the pain and disabilitythey experience and not the radiological findings. The decision to replace the joint is made after a thorough assessment: clinical (age, functional requirement, comorbidities and knee range ofmotion and laxity) and radiological (standard x-rays, including an axial view, leg alignment andpossibly a schuss view and images in an enforced varus or valgus positions).The first factor taken into account is the severity of the osteoarthritis:stiffness, extent of joint-space narrowing, spread into one or morejoint compartments and severity of misalignment. Age and function-demand are also determining factors.6 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56
In the large majority of cases, tibio-femoral osteoarthritis arisessubsequent to or in combination with frontal misalignmentwhich tilts the joint to the side: medial tibio-femoral osteoarthritis is mainly seen with the genuvarum deformity, whilst lateral osteoarthritis arises more rarely with genu valgum.The third compartment, or patello-femoral articulation, mayalso be involved. This observation is the basis for conservative surgery:correcting the misalignment results in a more even distributionof stress on the two tibio-femoral compartments and helpscontain the joint degeneration.7 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Knee osteoarthritis: conservativetreatment (1)
Osteotomies are particularly appropriate for patients agedless than 60-65, especially when they have an active lifestyle. As a general rule, osteotomies are indicated for patientswhose symptoms are inadequately controlled by medicaltreatments including viscosupplementation. Nonetheless, it is important to perform an osteotomy inyounger patients with symptomatic but tolerableosteoarthritis before the condition becomes too severe.Carrying out an osteotomy too late reduces the chancesof a successful outcome, while the patient is still consideredto be too young for a joint replacement. This type of procedure can delay the need for a kneereplacement by 12 years.9Varus osteotomy for knee osteoarthritis bybiomaterial implantation.Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Knee osteoarthritis: conservativetreatment (2)
Knee osteoarthritis: replacement surgeryThis is the procedure of choice for advanced osteoarthritis whichcommonly affects two and even all three compartments and isparticularly prevalent in the over 65 age group. A knee replacement can involve: a single tibio-femoral compartment if only one is affected and the patientdoes not present with severe misalignment or hypermobility or the whole knee, if the damage is more widespread. Complications immediate: early dislocation, infection or thrombophlebitis. delayed: delayed onset infection with or without septic loosening,wear and tear of the artificial joint, mechanical loosening. Since loosening can be infectious or mechanical in origin, all casesmust be screened for infection before the artificial joint is replaced.10 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56
For dysplasia and secondary hip osteoarthritis in young patients aged less than50 years old, conservative treatment, for instance an acetabular bolt orosteotomy, is to be preferred as artificial joints have a limited life-expectancyand are therefore to be avoided in younger patients. Conservative treatment is therefore acetabular bolting or an osteotomy.11Early and congestive superiorpole hip osteoarthritis. Frontalreconstruction of a right hip CTscan.Sellam J, Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686Hip osteoarthritis: conservativetreatment
The decision to perform a total hipreplacement is taken not as a function ofradiologically-detected severity, but ofthe pain, discomfort and disabilityexperienced by the patient. Hip replacements have a life-expectancyof about 15 years, which explains whysurgeons are reluctant to recommendthem for younger patients. Because joint implants wear out overtime, younger patients often requirerevision hip replacement surgery which isa more complex procedure than the initialoperation.12 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Hip osteoarthritis: total hip replacement
Hand osteoarthritis: surgical treatment Osteoarthritis tends to affect several finger jointswhich is why surgical treatment is to be avoided. Although rarely required, a trapeziectomy can beproposed for thumb osteoarthritis if the joint is extremelypainful. Both arthrodesis and trapezometacarpal replacementare possible in theory but rare in practice.13 Sellam J et Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686
Conclusion When treating patients with debilitating osteoarthritis,surgeons have a variety of means at their disposal, to beselected depending on:the age of the patient,the patients condition (physiological age, activity)and the nature of the osteoarthritis.14 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56