A patient presented with painful and swollen knee. On X-ray he was diagnosed as Osteo arthritis Ahlbeck grade II. Treatment is?
|A||High tibial osteotomy|
Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed page 241-300
A. Osteo arthritis - Womac grading.
Stage i there is softening of the cartilage if the surfaces of the knee. This may not show on Xray.
Stage ii the cartilage starts to wear away and shows as a narrowed joint space.
Stage iii osteophytes are seen. Stage 2 and 3 may merge and be difficult to separate.
Stage iv is the "bone-on-bone" with very narrow joint space, lots of osteophytes, and distortion of the joint
B. Osteo arthritis - Outerbridge Classification
Grade 0: normal cartilage;
a. Grade I: cartilage with softening and swelling;
b. Grade II: a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter;
c. Grade III: fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm;
Grade IV, exposed subchondral bone
a. Initial management of
i. Physical therapy
ii. Bracing, orthoses, ambulatory aids
iii. Nonsteroidal antiinflammatory medications, glucosamine, chondroitin, intraarticular injections of steroid or hyaluronic acid, and analgesics.
b. Arthroscopic débridement should be considered in active, older adults with mild-to-moderate osteoarthritis of the knee after conservative treatment has been exhausted. Response to treatment is unpredictable, and patients should be informed of this
c. High tibial osteotomy
High tibial osteotomy is a well-established procedure for the treatment of unicompartmental osteoarthritis of the knee.
The indications for proximal tibial osteotomy are
a. Pain and disability resulting from osteoarthritis that significantly interfere with high-demand employment or recreation,
b. Evidence on weight bearing radiographs of degenerative arthritis that is confined to one compartment with a corresponding varus or valgus deformity,
c. The ability of the patient to use crutches after the operation and the possession of sufficient muscle strength and motivation to carry out a rehabilitation program, and
d. Good vascular status without serious arterial insufficiency or large varicosities.
Contraindications to a proximal tibial osteotomy are
a. Narrowing of lateral compartment cartilage space,
b. Lateral tibial subluxation of more than 1 cm,
c. Medial compartment tibial bone loss of more than 2 or 3 mm,
d. Flexion contracture of more than 15 degrees,
e. Knee flexion of less than 90 degrees,
f. More than 20 degrees of correction needed, and
g. Rheumatoid arthritis.
d. Total knee replacement
a. The primary indication for TKA is to relieve pain caused by severe arthritis, with or without significant deformity.
b. Before surgery is considered, conservative treatment measures should be exhausted, including antiinflammatory medications, activity modifications, and the use of a cane for ambulation.
c. 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 lifestyles.
d. It also is clearly indicated in younger patients who have limited function because of systemic arthritis with multiple joint involvement.
e. Comparing all the modalities of treatment for osteoarthritis of knee for stage 2 OA arthroscopic debridement is better option than conservative method but with guarded prognosis.
f. High tibial osteotomy and total knee replacement finds its use in stage 3 and 4 OA/Advanced OA with deformity as follows
g. Unicompartmental OA High tibial osteotomy/unicondylar arthroplasty
h. Tricompartmental OA Total knee replacement