Despite the fact that osteoarthritis can cause significant pain and loss of function, most patients are treated non-operatively. In patients with significant pain and loss of function who have failed conservative treatment, a careful choice of surgical treatment can achieve excellent results.
Preoperative preparation
Before planning surgery, the surgeon must weigh the risks and outcomes of each procedure. This is especially important due to the increase in younger, highly athletic patients with secondary osteoarthritis caused by trauma and sports injuries. Although there are no absolute indications or contraindications to any surgery, general treatment principles are important.
What are the indications and contraindications for surgical treatment of osteoarthritis?
Pain is one of the key determinants of treatment. If resting pain is the patient’s main problem, pain medication is often required and surgery is preferred at this time. Discomfort related to activity is also important and can affect the patient’s quality of life, but in the vast majority of cases non-surgical treatment is possible and joint replacement surgery is less often used at this stage.
Functional status is another key determinant of treatment. Walking distance often correlates with the anatomical severity of the joint disease, and the need for walking assistance with a cane is an objective indicator of functional impairment of the patient’s joints. Daily activity status is also important. Detailed questions should be asked about the patient’s ability to walk up and down stairs, reduce work hours, and engage in household and recreational activities, and this information will help evaluate the patient’s life treatment and socioeconomic status.
The mobility of the joint, the presence of deformity and the stability of the joint should also be considered. When evaluating joint stability, the knee is relatively easier than other joints, while the hip is more difficult. The evaluation of joint mobility and the presence of deformity directly affects the staging of the lesion and directly influences the choice of surgical treatment.
Other factors that should be considered include patient age and weight; joint replacement surgery has a higher failure rate in young, overweight, and active patients, which should warrant consideration of other treatments such as joint fusion. Conversely, older patients who do not have severe anatomic deformities and who need significant improvement in quality of life due to pain are better candidates for joint replacement. The patient’s ability to cooperate with treatment is also important in the choice of treatment. For example, arthroplasty requires better patient cooperation during the postoperative rehabilitation phase than does fusion. The patient should be informed about both the disease and the possible outcomes of the procedure, and the outcome the patient wants to achieve with the procedure should be a central part of the decision. Physicians often need to ask patients about their expectations for the procedure, and sometimes patients expect unrealistic results. While the correction of aesthetic problems is paramount in the patient’s mind, the patient may have adapted well to the deformity, and if function is not compromised and the integrity of other joints is not at risk, deformity correction alone is not an indication for surgery at this time.
The general health status of the patient should also be considered when assessing the risk of surgery. Severe cardiovascular and respiratory disease is a contraindication to general anesthesia and surgery, but regional block anesthesia or lumbar anesthesia can reduce the risk. Many patients requiring surgical treatment are elderly and are at relatively high risk for surgery and anesthesia, but physiologic age alone should not be considered a contraindication. Common medical conditions that require preoperative stabilization or correction include obstructive pulmonary disease, hypertension, angina pectoris, congestive heart failure, peripheral vascular disease, and diabetes mellitus, among others. Any infection should be detected and corrected prior to surgery.
There is no absolute indication for surgical treatment of osteoarthritis, but it is considered on a patient-by-patient basis, and there is no single principle that applies to all surgical procedures. Active infection and poor general condition are not suitable for surgery.
The current surgical procedures for osteoarthritis can be divided into four main categories: osteotomy, debridement, fusion, and arthroplasty. The indications and general principles of each surgical method need to be strictly controlled. How to choose the correct application of osteotomy, debridement, fusion and arthroplasty?
Osteotomy
Osteotomy is suitable for young patients with mild to moderate joint deformity. The main goal of the procedure is to relieve pain and stop the progression of osteoarthritis. It is particularly suitable for abnormal stress distribution in the joint due to poor alignment of the joint. The osteotomy restores the alignment and normal shape of the joint, redistributes the stress, corrects the abnormal stress transmission and stops the progression of the lesion.
Osteotomy is one of the first surgical methods used to treat osteoarthritis. Although it is not a curative surgery, it can provide good pain relief and improve function if the right case is selected, and the normal mobility and stability of the joint can be well maintained. It is particularly suitable for young, athletic patients, as such patients still have relatively normal articular cartilage. Deformities (e.g., knee valgus) should not be excessively severe, as they would be difficult to correct to anatomical alignment. Other important factors to consider include the strength of the muscles around the joint and the stability of the joint. The patient’s level of cooperation with treatment and awareness of the disease will also affect the outcome. Advanced instrumentation has also provided the basis for improved surgical techniques and outcomes. The use of strong internal fixation materials has allowed for less postoperative fixation in a cast and maintained postoperative joint motion. The combined use of osteotomy and arthrocentesis for severe knee osteoarthritis has also been reported in the literature to achieve better recent results and to delay total knee replacement in younger patients.
Arthrocentesis
In 1946, Magnuson introduced the concept of knee debridement, which involves smoothing irregularities in the joint surface and removing free bodies and inflammatory exudate of hyperplastic synovial tissue. This technique can also be used on the shoulder, hip, ankle, wrist, and elbow joints.
Joint debridement is appropriate for young patients with mild to moderate osteoarthritis who have no or mild joint deformity and should not have poor alignment of the joint. Due to the popularity of arthroscopic techniques, arthroscopic debridement is now done in the vast majority of cases. Arthroscopic debridement has the advantages of minimal surgical trauma, thorough debridement, and few complications, and provides significant pain relief, but postoperative joint swelling can be prolonged but will gradually subside.
Insall reported an average follow-up of 6.5 years after knee debridement, with an excellent rate of about 75%. Arthrocentesis does not reverse the pathological process of arthritis, but only tries to prevent its further development and delay the arrival of joint replacement. Joint cleanup is very effective in treating mechanical factors of arthritis such as free body locking, while it has very limited efficacy in severe osteoarthritis with extensive cartilage breakdown, and is more effective in early osteoarthritis, so cases need to be carefully selected.
Joint fusion
Although joint replacement has become the mainstay of treatment for severe osteoarthritis, joint fusion still has its applications in the treatment of osteoarthritis. If arthroplasty fails, joint fusion may be the only option or the ultimate treatment. In some specific cases, fusion may be the initial treatment. In cervical or lumbar osteoarthritis where conservative treatment has failed, decompression of the compression and fusion of the involved stages are required. Localized fusion between the carpal bones can be effective in managing pain and instability without complete loss of wrist motion.
In young patients with single lower extremity osteoarthritis who are overweight and active, joint fusion may be an option if the joint destruction is too severe for other surgical approaches. As long as the adjacent joint has good mobility, function can be maintained and long-term pain relief can be obtained. However, if arthritis is also present in other joints, joint fusion is contraindicated and the possible results of arthroplasty should be carefully considered. Anatomy is also a preoperative consideration. For example, insufficient bone mass or power may be a contraindication to other treatments, at which point joint fusion may be considered. For example, if the shoulder joint lacks adequate rotator cuff and deltoid dynamics, but the muscles stabilizing the scapula are good, fusion can be effective in relieving pain and improving function of the upper extremity. The development of internal fixation devices has increased the success rate of fusion while eliminating the need to rely on long-term cast immobilization. Care should also be taken to preserve the soft tissues surrounding the joint during fusion to allow for a better anatomic relationship in the event of future arthroplasty.
Arthroplasty
The concept of contemporary arthroplasty originated with the Smith-Peterson malleolar cupplasty, but arthroplasty took a great leap forward in the 1970s with the application of sophisticated engineering principles to the field of orthopedics. Charnley’s use of bone cement (polymethylmethacrylate) to fix metal and plastic implants and the interface between the bones played a huge role in the development of artificial joints.
Arthroplasty can be considered when there is severe pain and dysfunction in the joint, but it is important to ensure adequate bone and muscle strength to meet the requirements for a satisfactory outcome. Failed arthroplasty often results in suboptimal functional recovery, so other surgical salvage, such as arthrofusion, should be considered if possible. Arthroplasty includes arthroplasty, partial replacement, and total arthroplasty.
Arthroplasty was first introduced by Girdlestone as a procedure for the hip in which the femoral head and neck are removed to create a fibrous prosthetic joint. Excellent results are rarely seen after arthroplasty, and most patients have residual partial pain, dysfunction, and limb shortening, requiring external support such as a cane or crutches for mobility.
Partial arthroplasty consists mainly of femoral head replacement and unicondylar knee replacement. Femoral head replacements are more commonly used for femoral neck fractures in older patients, while total hip replacements are more commonly used for osteoarthritis. The indications for unicondylar replacement of the knee are very limited and only apply to unicondylar lesions of the knee. Moreover, the extent of the lesion involving the unicondyle is difficult to define, and in most cases the relatively normal side of the articular cartilage is already pathologically damaged to a significant degree. Although excellent results have been reported with unicondylar replacements for osteoarthritis, more people have opted for total knee replacements.
After decades of development, total arthroplasty has become a more established treatment for severe osteoarthritis. Depending on the design of the prosthesis and the fixation method, there are mainly cemented, biologic and hybrid fixation methods. Long-term follow-up of cemented total hip replacements has shown an excellent rate of about 90%, with a slight increase in acetabular loosening at 20 years. non-cemented methods of fixation of hip and knee prostheses were introduced in the 1980s, and hydroxyapatite coating technology has improved the strength of the prosthesis. Due to the long reported increase in acetabular prosthesis loosening, a hybrid fixation approach, where the acetabular side is fixed with uncemented fixation and the femoral prosthesis stem is fixed with cement, has emerged, with initial clinical reports of high success rates.
Infection is an early complication of joint replacement and can be prevented by prophylactic application of antibiotics and operating room laminar flow equipment and strict aseptic technique. Once postoperative infection occurs, it is quite troublesome to manage and has a long cycle time, but is not untreatable. Wear and loosening of the joint is a long-term complication of joint replacement, and with the gradual increase in active young patients, wear becomes a major factor affecting the long-term outcome, and studies of ceramic-ceramic and metal-metal joint surfaces minimize the occurrence of wear particles and osteolysis.
In conclusion, the treatment of osteoarthritis needs to be based on the patient’s symptoms, the degree of deformity, the degree of imaging lesions, and the patient’s own expectations and requirements for treatment, so as to develop a comprehensive surgical plan, clarify the indications and risks of each procedure, minimize the risks of surgery, and obtain better treatment results.