Review Article

Management of Osteoarthritis of
the Knee in the Active Patient

Abstract
Brian T. Feeley, MD Total knee arthroplasty has been extremely successful in elderly
Robert A. Gallo, MD patients with osteoarthritis. However, there is considerable
controversy regarding how best to treat the younger, athletic
Seth Sherman, MD
patient with advanced arthritis. Treatment options range from
Riley J. Williams, MD
nonsurgical management with exercise and nonsteroidal anti-
inflammatory drugs, to joint arthroplasty with activity modification.
When properly indicated, arthroscopic débridement, high tibial
osteotomy, unicondylar knee arthroplasty, and total knee
arthroplasty allow younger patients with arthritis to maintain an
active, healthy lifestyle.

P ersons in the United States tend

From the Department of
Orthopaedic Surgery, University of
California San Francisco, San
Francisco, CA (Dr. Feeley), the
Department of Orthopedics and
Rehabilitation, Pennsylvania State
University College of Medicine,
Bone and Joint Institute, Milton S.
Hershey Medical Center, Hershey,
PA (Dr. Gallo), and the Department
of Orthopedic Surgery, Hospital for
Special Surgery, New York, NY
(Dr. Sherman and Dr. Williams).
Dr. Williams or an immediate family
member has received royalties from
Arthrex, serves as an unpaid
consultant to Histogenics, and has
received research or institutional
support from Stryker and Smith &
Nephew. None of the following
authors or any immediate family
member has received anything of
value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Feeley,
Dr. Gallo, and Dr. Sherman.
J Am Acad Orthop Surg 2010;18:
406-416
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
to remain physically active and
participate in demanding athletic
events well into their fifth, sixth, and
even seventh decades. However, with
this increase in activity comes an in-
creased risk of developing a chondral
injury that may lead to early onset of
arthritis in the knee. The recent liter-
ature on osteoarthritis (OA) in pa-
tients aged 40 to 60 years indicates
that successful outcomes can be
gained with surgical treatment. Fig-
ure 1 illustrates a recommended
treatment algorithm for early knee
OA.
Nonsurgical Management
In an effort to delay major surgery,
many younger patients with early
knee OA are offered a variety of
nonsurgical modalities, such as exer-
cise and physical therapy, bracing,
orthoses, nonsteroidal anti-inflam-
matory drugs (NSAIDs), and intra-
articular viscosupplementation or
corticosteroid injection. In general,
the goals of these therapeutic options
are to decrease pain and improve
function. Some of these modalities
may also have a disease-modifying
effect by altering the mechanical en-
vironment of the knee. Appropriate
use of specific nonsurgical modalities
requires knowledge of evidence-
based practice guidelines, careful pa-
tient selection, patient education,
and adequate long-term follow-up.
Exercise
Several large randomized controlled
trials have shown that exercise re-
duces pain and improves function in
patients with early OA.1,2 Two recent
meta-analyses also demonstrate that
muscle strengthening and aerobic ex-
ercise are important in the manage-
ment of OA.3,4 Muscle strengthening
exercises are superior for specific
impairment-related outcomes, such
as pain, but aerobic exercise contrib-
utes to better long-term functional
outcomes. An individualized, multi-
modal approach tailored to specific
symptoms and patient expectations
is recommended to maximize pain
relief and functional outcomes. Pa-
tient compliance with a regimen of
exercise or physical therapy is a sig-

406 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

nificant concern. The best available Figure 1

evidence shows that supplementation
of a home exercise program with su-
pervised exercise classes results in the
largest gains in pain relief and loco-
motion at 12-month follow-up.5 Ex-
ercise must also be sustained because
any beneficial effects are lost 6
months after an exercise program is
terminated.2

Bracing and Orthoses

Knee bracing and foot orthoses are
popular nonsurgical treatment op-
tions for patients with early OA.
These modalities are used primarily
by patients who wish to continue to
pursue an active lifestyle. This in-
cludes younger patients with early to
moderate disease, former athletes
with posttraumatic OA, and postmen-
iscectomy patients with isolated uni-
compartmental disease. The ideal
candidate for bracing has unicom-
partmental arthritis and wishes to
delay surgery.
The primary goal with use of a
brace or orthosis is to improve func-
tion by reducing symptoms. With the
knee brace, this is accomplished by
reducing biomechanical load in the
involved compartment or by reduc-
ing the patient’s perception of insta-
bility. Bracing should be used almost
exclusively in patients with sympto-
matic, passively correctable, unicom-
partmental varus or valgus disease
<10°. Significant medial collateral
ligament laxity and lateral collateral
ligament laxity are contraindications
for valgus and varus unloading
braces, respectively. Several clinical
trials and a recent systematic review
have demonstrated the efficacy of
this treatment modality, showing sig-
nificant improvements in pain and
function using a valgus knee brace
compared with a simple neoprene
sleeve or medical treatment alone.6-8
Clinical and gait laboratory analysis
also suggest that there is a role for
Treatment algorithm for knee arthritis in the young, active person.
NSAIDs = nonsteroidal anti-inflammatory drugs, OA = osteoarthritis
lateral wedge orthoses in persons
with medial compartment knee OA.9
Evidence suggests that pain relief and
functional improvement in these pa-
tients is achieved by a reduction in
external varus moment and medial
compartment load.9 (The AAOS
Clinical Practice Guideline on the
Treatment of Osteoarthritis of the
Knee [Nonarthroplasty] is unable to
recommend for or against the use of
a brace either with a valgus-directing
force for patients with medial uni-
compartmental OA of the knee or
with a varus-directing force for pa-
tients with lateral unicompartmental
OA of the knee. The Guideline also
suggests that lateral heel wedges not
be prescribed for patients with symp-
tomatic medial compartmental OA
of the knee. The Recommendation is
graded B, equivalent to level of evi-
dence II. The complete Clinical
Guideline is available at http://www.
aaos.org/research/guidelines/Guidelin
eOAKnee.asp.)
NSAIDs
Oral NSAIDs are often prescribed
to reduce pain and inflammation
caused by early knee OA. The au-
thors of a recent systematic review of
the use of NSAIDs for knee OA se-
lected 16 double-blind randomized
controlled trials, representing eight
different medications.10 Significant
design flaws in individual trials made
it impossible to distinguish a differ-
ence in efficacy between equivalent
recommended doses of NSAIDs. In-
stead, the authors concluded that
NSAID selection should be based on
physician preference, relative safety,
patient acceptability, and cost.
Serious gastrointestinal (GI) side

July 2010, Vol 18, No 7 407

Management of Osteoarthritis of the Knee in the Active Patient
effects have been reported in 2% to
4% of chronic NSAID users. This
risk is halved with the use of
cyclooxygenase-2 inhibitors.11 Pa-
tients with a history of prior GI
events and concurrent corticosteroid
or anticoagulant use, or those with
cardiovascular or renal impairment,
may want to avoid NSAIDs or
strictly regulate their use.
Intra-articular
Viscosupplementation
Intra-articular viscosupplementation
is an increasingly common nonsurgi-
cal option in the management of
knee OA. The injection of hyaluronic
acid (HA) into the knee joint has the-
oretic benefits for early knee OA be-
cause of a combination of its vis-
coelastic properties as well as its
anti-inflammatory, anabolic, analge-
sic, and chondroprotective poten-
tial.12 The utility of the current litera-
ture is limited by lack of uniform
patient populations and study de-
signs, heterogeneous drug types and
delivery methods, and use of diverse
outcome measures.
A systematic review of 76 random-
ized controlled trials also demon-
strated the efficacy of HA versus
placebo.13 The 5- to 13-week postin-
jection period showed the largest
percent improvement, from a base-
line of 28% to 54% for pain and
from 9% to 32% for function. In
general, comparable efficacy was
noted with NSAIDs, and longer-term
benefits were noted in comparison
with intra-articular corticosteroids.
Few adverse events were reported in
the hyaluronan/hylan trials included
in these analyses. Of note, there were
few randomized head-to-head com-
parisons of different viscosupple-
ments. Thus, caution must be ex-
ercised in drawing conclusions
regarding the relative value of differ-
ent products from this systematic re-
view. Overall, these results support
408
the efficacy of both HA and steroids
for the temporary symptomatic man-
agement of early knee OA. Recent
studies, however, have demonstrated
that lidocaine alone and intra-
articular corticosteroids in combina-
tion with lidocaine cause consid-
erable cytotoxicity to the native
chondrocytes.14 Thus, corticosteroid
injections must be used with caution,
especially in patients with early ar-
thritis. (The AAOS Clinical Practice
Guideline on the Treatment of Os-
teoarthritis of the Knee [Nonarthro-
plasty] is unable to recommend for
or against the use of intra-articular
HA for patients with mild to moder-
ate symptomatic OA of the knee.
The Guideline suggests the use of
intra-articular corticosteroids for
short-term pain relief for patients
with symptomatic OA of the knee,
with a Grade of Recommendation of
B.)
Surgical Management
Arthroscopy
The role of arthroscopy in the treat-
ment of OA is controversial. Ap-
proximately 50% to 75% of patients
have an initial benefit following ar-
throscopic débridement; however,
15% progress to total knee arthro-
plasty (TKA) within 1 year following
surgery, and only 44% have a clini-
cally significant reduction in pain.15
Despite these modest results, arthro-
scopic débridement remains one of
the most commonly performed pro-
cedures for OA. Critical analysis of
the literature is hampered because
many of the studies are retrospective,
evaluate different patient popula-
tions, or lack generalizability to
larger patient cohorts.
Several recent studies have sug-
gested that the benefits of arthro-
scopic surgery are minimal or may
even be attributable to a placebo ef-
fect. In 2002, Moseley et al16 re-
Journal of the American Academy of Orthopaedic Surgeons
ported on a randomized controlled
trial at the Houston Veterans Affairs
Medical Center, in which patients
were subject to arthroscopic lavage,
débridement, or placebo surgery.
One hundred eighty patients were
enrolled and followed for a mean of
2 years. The average age was 53
years, and approximately 65% of the
patients in each group had moderate
to severe arthritis. During the 2-year
follow-up period, there was no bene-
fit in terms of pain scores or out-
comes measures with arthroscopic
management versus placebo surgery.
The authors concluded that the out-
comes after arthroscopic lavage or
arthroscopic débridement were no
better than those after a placebo pro-
cedure. The results of this study have
been criticized by many who believe
that the patient population—mostly
men—was not representative of the
general population. In addition, the
study used a composite scoring sys-
tem for osteoarthritic changes that
resulted in a patient with severe OA
in one compartment having the same
score as a patient with minor OA in
all three compartments.
Although the study by Moseley
et al16 is often criticized by arthro-
scopic knee surgeons, another recent
randomized trial found similar re-
sults.17 However, this more recent
study focused on a civilian popula-
tion and included an equal number
of men and women in each treatment
arm. Patients were randomly as-
signed to either surgery or physical/
medical therapy. At 2-year follow-
up, there was no difference between
the groups based on either the West-
ern Ontario and McMaster Universi-
ties Osteoarthritis Index (WOMAC)
score or the Medical Outcomes
Study 36-Item Short Form physical
component score. However, this
study excluded patients with a large
or symptomatic meniscal tear. The
authors concluded that arthroscopic
débridement was no better than an

optimized medical/physical therapy
program in patients with isolated
OA.
Dervin et al15 performed a prospec-
tive evaluation of 126 patients who
failed nonsurgical treatment of OA
of the knee. Unstable chondral flaps
and degenerative meniscal pathology
were resected at the time of surgery.
In this study, 57% of patients had
grade III or IV changes according to
the classification of Dougados et al,18
and 63% had an unstable meniscal
tear. Only 44% of patients had a
clinically important reduction in
pain as determined by the WOMAC
scale at a mean follow-up of 2 years.
The only factors that predicted im-
provement at the time of surgery
were medial joint line tenderness, a
positive Steinman test, and the pres-
ence of an unstable meniscal tear at
the time of surgery. The authors
found that physicians were unable to
accurately predict who would benefit
from arthroscopic débridement.
Despite these and other studies
that have shown minimal benefit
with arthroscopic débridement, this
procedure may be beneficial in select
patients. Steadman et al19 evaluated
69 knees in 61 patients with grade 3
or 4 OA according to the Kellgren-
Lawrence radiographic scale. This
study excluded traumatic chondral
lesions, but all other patients with
advanced OA were included. Aver-
age patient age was 57 years (range,
37 to 78 years), and follow-up was
>2 years. At the time of arthroscopy,
the affected knee was insufflated to
expand the joint capsule, and partic-
ular attention was paid to perform-
ing an aggressive lysis of adhesions
to improve joint volume. At the time
of follow-up, 9 knees (13%) had
been revised to a TKA. The presence
of kissing femoral-tibial chondral le-
sions, a lower insufflation volume,
and increasing patient age resulted in
a poorer outcome. The authors con-
cluded that arthroscopic manage-
July 2010, Vol 18, No 7
ment of advanced OA could be bene-
ficial in many patients, especially
with aggressive lysis of adhesions in
the suprapatellar pouch and anterior
interval.
Most patients with advanced OA
are found to have meniscal tear on
MRI. It is unclear what role, if any,
meniscal tear has in the progression
of knee pain in these patients. Bin
et al20 evaluated 68 patients with
Outerbridge grade IV OA and a me-
dial meniscal tear at a mean
follow-up of 52 months. Following
surgery, 82% of patients reported a
reduction in pain, 14% had no
change, and 4% had an increase in
pain. At 75 months postoperatively,
75% of patients had not required
further surgery. Dervin et al15 found
that medial joint line tenderness pre-
operatively and the presence of an
unstable meniscal tear at the time of
surgery predicted a better outcome.
These studies suggest that meniscal
débridement can be beneficial in pa-
tients with mechanical symptoms
that are attributed to a degenerative
meniscal tear.
Spahn et al21 examined factors that
affected the outcome of arthroscopy
in medial compartment OA in 156
patients at a mean follow-up of 49
months. The average age was 51.6
years, and all patients had Kellgren-
Lawrence grade 2 OA. Seventy-one
percent of patients had poor out-
comes overall. Factors that were as-
sociated with worse outcome in-
cluded history of OA >24 months,
obesity, medial tibial osteophytes,
medial joint space <5 mm, smoking,
the presence of a tibial chondral
grade IV defect, and the need for
subtotal or total meniscectomy. Sig-
nificantly worse outcomes were
noted in patients with four or more
of these factors (Figure 2).
The role of arthroscopic manage-
ment of OA in the younger patient
population remains controversial,
with the literature suggesting that ar-
Brian T. Feeley, MD, et al
throscopy helps in some patients but
that others fail to improve. Success-
ful management of OA with arthros-
copy is likely the result of proper
patient selection and discussion of
the limited goals of the procedure.
Younger patients with mechanical
symptoms from a meniscal tear, with
normal knee alignment, and without
tibial chondral lesions will likely
benefit from a trial of arthroscopic
treatment. However, these patients
must be counseled that any surgical
benefits may be of brief duration and
that they may require arthroplasty in
the future (Table 1). (The AAOS
Clinical Practice Guideline on the
Treatment of Osteoarthritis of the
Knee [Nonarthroplasty] suggests
that needle lavage not be used for
patients with symptomatic OA of the
knee. The Recommendation is
graded B, equivalent to level of evi-
dence I/II. The Guideline recom-
mends against performing arthros-
copy with débridement or lavage in
patients with a primary diagnosis of
symptomatic OA of the knee. The
Recommendation is graded A, equiv-
alent to level of evidence I/II.)
High Tibial Osteotomy
High tibial osteotomy (HTO) was
popularized by Coventry and Insall
in the 1970s,22 and it remains an at-
tractive option in the attempt to pro-
long the lifespan of the native joint.
The basic premise of an HTO is to
redirect the mechanical axis from the
degenerated area of the joint to the
relatively well-preserved compart-
ment. In most instances, the weight-
bearing load is shifted from a worn
medial compartment and passed
through the healthier cartilage of the
lateral joint space.
Patients are not required to modify
their activity levels, as they would be
with arthroplasty procedures. Thus,
HTO is indicated for patients who
wish to remain active in high-load
409
Management of Osteoarthritis of the Knee in the Active Patient

Figure 2

T2-weighted fat-saturated sagittal (A) and coronal (B) magnetic resonance images of the knee demonstrating a
complex posterior horn lateral meniscus tear (arrow) with an overlying cartilage defect (arrowheads). There is
bony edema under the lesion, as well. C, Arthroscopic image of the lateral compartment with a meniscus tear.
D, Postdébridement image demonstrating softening of the lateral tibial plateau and the presence of a partial-thickness
defect on the femoral condyle.

Table 1 dates for HTO. Patients should also

Predictors of Outcome Following Arthroscopic Débridement for Knee
Osteoarthritis
Variable Likely to Benefit Unlikely to Benefit
Age <40 yr >75 yr
Compartment Medial, single compartment Tricompartmental, lateral,
tibial
Joint space preservation >5 mm <5 mm
Alignment Neutral Valgus
Duration of symptoms <6 mo >1 yr
Symptom location Localized Diffuse
Weight Body mass index <30 Body mass index >30
Effusion Present Absent
activities. In such patients, HTO can tions, the clinical applicability of HTO
be performed as an isolated or a has been refined by several contraindi-
combined procedure. The most com- cations. Because HTO shifts the me-
mon indication for HTO is the treat- chanical axis away from the most se-
ment of unicompartmental varus or verely degenerated area to another, less
valgus gonarthritis; however, HTO affected area of the joint, the procedure
also can be effective in unloading is contraindicated in persons with pre-
pressure on the focal cartilage le- vious meniscectomy and/or significant
sions, such as in osteonecrosis and degeneration of the other knee com-
adult osteochondritis dissecans. Sim- partment. Persons with inflammatory
ilarly, HTO has been recently ap- diseases (eg, rheumatoid arthritis)
plied as an adjunct in chondral resur- and/or those aged >65 years are less
facing and meniscal transplantation desirable candidates because of the high
procedures in which malalignment likelihood of diseased cartilage in all
has been considered to be a contribu- compartments of the knee. Patients with
tor to the cartilage injury. symptomatic patellofemoral arthritis
Despite its potentially broad indica- are not considered to be good candi-
have range of motion of ≥90°. Because
of a frequent necessity to overcorrect
the malalignment, HTO should not be
performed in patients who are unwill-
ing to accept a valgus deformity. Some
have suggested that obesity is a relative
contraindication to HTO.23
Several techniques, including open-
ing wedge, closing wedge, oblique
plane, and ball-and-socket osteot-
omy, have been described. Because of
their relative technical ease, opening
wedge and closing wedge osteoto-
mies are the most commonly per-
formed types of HTO. They are
distinguished by two important differ-
ences. First, opening wedge HTO in-
volves incision and osteotomy on the
same side as the joint degeneration,
such as a medial incision and osteot-
omy for medial compartment disease,
whereas a closing wedge osteotomy re-
quires work on the opposite side, such
as a lateral incision and osteotomy for
medial compartment disease. Second,
opening wedge osteotomy may require
the insertion of a wedge-shaped corti-
cal bone graft between the cut bone
edges (Figure 3), whereas with closing
wedge osteotomy, angular correction
is attained by removing a wedge of
bone.

410 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

Figure 3

Medial opening wedge high tibial osteotomy (HTO). A, AP weight-bearing radiograph of the knee demonstrating loss of
joint space, predominantly on the medial side. B and C, Sequential T2-weighted fat-saturated sagittal magnetic
resonance images demonstrating loss of the medial meniscus and degeneration of the cartilage. D, Early postoperative
AP radiograph following opening wedge HTO. E, AP radiograph obtained 3 months following HTO demonstrating graft
consolidation.

Table 2
Results of Select Recent Series of High Tibial Osteotomy to Manage Varus Gonarthrosis
Mean Follow-up Mean Age
Study Number in Years (range) (yr) Technique Outcomes

Niemeyer et al28 43 pts 2 (6-24 mo) 47.3 Opening wedge, using 68% good or excellent
plate and autologous
iliac crest bone graft
Omori et al26 37 pts 17 (14-24) 59 Closing wedge using 77% good or excellent
(48 knees) threaded pins and
figure-of-8 wiring
Akizuki et al24 132 pts 16 (16-20) 63 Closing wedge using a 98% survival at 10 yr,
plate 90% survival at 15 yr
Gstöttner et al27 111 pts 12 (1-25) 54 Closing wedge using a 80% survival at 10 yr,
(134 osteotomies) staple 66% survival at 15 yr
Chiang et al29 16 pts 15 (13-16) 58 Dome-shaped, using 68% good or excellent
(19 knees) external fixation
Polyzois et al30 95 pts 8 (5-11) 69 Closing wedge using 61% good/excellent
plate
Tang and Hender- 67 knees 6.5 (1-21) 49 Closing wedge using 75% survival at 10 yr,
son25 plate or staple 67% survival at 15 yr

In the past 20 years, more than a
dozen articles have been published
documenting the outcomes following
HTO for unicompartmental gonar-
thritis. Comparisons are limited by
varied fixation techniques and mea-
sures used to assess outcome. Sur-
vivorship (judged as conversion to
TKA) has been reported to be
as high as 98%24 and 70%25 at 10-
and 20-year follow-up, respectively;
Omori et al26 reported good and ex-
cellent function in 77% of patients at
17 years (Table 2).
Several factors have been identified
that contribute to deterioration over
time. The most important factor, as
initially described by Insall and Agli-
etti,31 is time. HTO should not be
perceived to be the ultimate solution
to the problem of joint degeneration;
rather, it is a procedure that can de-
lay TKA, sometimes for >20 years.
Another important factor is the de-
gree of correction, which must fall
between acceptable parameters, such
as 5° to 13° of valgus for varus
gonarthrosis. Finally, increasing age
and obesity have been confirmed by
several studies to be detrimental
to the long-term effectiveness of
HTO.32,33
Patients with isolated lateral com-
partment OA can be treated with
distal femoral osteotomy. The indi-
cations and contraindications are

July 2010, Vol 18, No 7 411

Management of Osteoarthritis of the Knee in the Active Patient
Figure 4
AP (A), lateral (B), and sunrise (C) radiographs demonstrating isolated
medial compartment arthritis. Note the preservation of the patellofemoral joint
space. AP (D), lateral (E), and sunrise (F) radiographs following
unicompartmental knee arthroplasty.
largely the same as those for HTO.
The intent of the osteotomy is to
place the plane of the joint parallel
to the ground or to have a minimal
degree of obliquity relative to the
normal anatomy. Recent studies have
demonstrated results similar to the
outcomes of patients who underwent
HTO. Backstein et al34 followed 40
patients with distal femoral osteot-
omy for 10 to 15 years. The 10-year
survival rate of the distal femoral
varus osteotomy was 82%, but the
15-year survival rate was just 45%.
(The AAOS Clinical Practice Guide-
line on the Treatment of Osteoarthri-
tis of the Knee [Nonarthroplasty]
cannot recommend for or against an
osteotomy of the tibial tubercle for
patients with isolated symptomatic
patellofemoral OA.)
412
Unicondylar Knee
Arthroplasty
Early outcomes of unicompartmental
knee arthroplasty (UKA) in the
1970s and early 1980s were disap-
pointing,31 with the result that many
surgeons treated unicompartmental
OA with either HTO or TKA. How-
ever, with the growing interest in less
invasive procedures and the publica-
tion of better long-term results in
several recent series, UKA has under-
gone a resurgence.35
The indications for UKA have
changed significantly in the past 10
to 15 years. Classically, low-demand
patients aged >60 years who have a
low body mass index, intact ligamen-
tous structures, and isolated medial
compartment OA, but who have no
Journal of the American Academy of Orthopaedic Surgeons
flexion or extension contractures,
are candidates for UKA. With im-
provements in UKA prosthesis de-
sign, wear properties of the polyethy-
lene, and surgical technique, the
indications have expanded to include
younger patients, patients with mild
patellofemoral OA, and some pa-
tients with anterior cruciate ligament
(ACL) deficiency35 (Figure 4).
Recent studies have specifically ad-
dressed the outcomes of UKA in a
younger patient population. Schai
et al36 evaluated 28 UKAs in patients
aged <60 years, with patient age at the
time of surgery averaging 52 years.
Follow-up was 2 to 6 years. Good or
excellent results in terms of function
and pain relief were achieved in 90%
of patients. The average activity level
according to the Tegner and Lysholm
score improved slightly, from 2.3 points
preoperatively to 2.7 points at follow-
up. Of the 28 knees, 9 (32%) demon-
strated radiolucent lines about the tib-
ial component, and 2 had incomplete
radiolucent lines at the bone-cement in-
terface on the femoral side. The authors
found no correlation between activity
level and the presence of tibial radio-
lucent lines. Loosening of the femoral
component at the prosthesis-cement in-
terface necessitated revision in two pa-
tients; one underwent another UKA and
the other was converted to TKA.
Asymptomatic slowly progressive radi-
olucency was noted in one tibial com-
ponent. The authors concluded that
UKA in middle-aged patients was suc-
cessful but that it was not better than
TKA in terms of survival. Pennington
et al37 reviewed 41 patients aged ≤60
years who underwent UKA (average
age, 54 years). All patients who un-
derwent the procedure were de-
scribed as being physically active and
engaged in high-demand activities.
At 11-year follow-up, the Hospital
for Special Surgery score was excel-
lent in 93% of patients and good in
7%. Three patients required revi-
sion: two for extensive tibial osteoly-

sis, and one for continuing knee pain
and a progressive tibial radiolucent
line. Nine knees showed progression
of OA in the unresurfaced compart-
ment, but none required conversion
to TKA, and none of these patients
had a worsening Hospital for Special
Surgery score. The overall survival
rate was 92% at 11 years.
Chronic ACL deficiency leads to
medial meniscal tears and medial
compartment OA; treatment options
for these patients are limited. Tradi-
tionally, ACL deficiency was a con-
traindication to UKA for the man-
agement of medial compartment OA
because eccentric loading and exces-
sive wear occurred on the tibial poly-
ethylene component. However, this
has not always been borne out in
the literature. Hernigou and Des-
champs38 retrospectively reviewed
the results of 99 UKAs at a mean
follow-up of 16 years. At the time of
the arthroplasty, the ACL was con-
sidered to be normal in 50 knees,
damaged in 31, and absent in 18. Of
the 18 knees with ACL deficiency at
the time of surgery, 11 had not failed
at final follow-up. The mean poste-
rior tibial slope in these 11 knees
was <5°. Seven knees in which the
ACL was absent at the time of the
arthroplasty were revised. In these
knees, the tibial prosthesis was im-
planted with a posterior slope of
>8°. The authors concluded that re-
sults in the ACL-intact and ACL-
deficient groups were similar when
the tibial component had a slope of
<7°.
Another option for persons with
ACL deficiency is to reconstruct the
ACL in conjunction with the UKA.
Pandit et al39 performed ACL recon-
struction in conjunction with UKA in
15 patients and matched these results
to a group of 15 patients with intact
ACL. At 2.5 years after the proce-
dure, no difference was found be-
tween the groups with regard to Ox-
ford Knee Scores and Knee Society
July 2010, Vol 18, No 7
scores. Both groups had an average
functional Knee Society score of 96
(out of 100). Although there was
only short-term follow-up, it is
worth noting that no patient in ei-
ther group had radiologic evidence
of loosening. In vivo kinematics of
the knees that underwent ACL re-
construction and UKA in a step-up
exercise and in deep knee flexion
have been shown to be equal, as
well.39 Thus, combined management
of ACL deficiency with medial com-
partment OA with ACL reconstruc-
tion and UKA warrants further in-
vestigation and long-term follow-up
studies because the early results are
quite promising.
Total Knee Arthroplasty
Results of knee replacement have con-
tinued to get better with improvements
in polyethylene durability and prosthe-
sis design. Advances in design have led
to survivorship rates of 90% at 10 to
15 years, as well as better pain relief and
functional improvement.40 Despite
good clinical results with long-term
follow-up in older persons, TKA is
usually reserved as a final treatment
option, especially in younger, active
patients.
Few studies have specifically evalu-
ated the results of TKA in patients
aged <60 years. This is likely be-
cause, until recently, most surgeons
believed that age <60 years was a
contraindication to TKA. Dalury
et al41 reviewed 103 cemented TKAs
in patients aged <45 years, most of
whom were diagnosed with rheuma-
toid arthritis or juvenile rheumatoid
arthritis. At 7-year follow-up, there
were no revisions for aseptic loosen-
ing or wear; however, this popula-
tion is likely not as high-demand as a
similar cohort with posttraumatic or
primary OA. Similarly, Spahn et al21
reported no revisions in 57 patients
aged <50 years at 9 years following
surgery. Duffy et al42 recently re-
Brian T. Feeley, MD, et al
viewed the results of 52 cemented
TKAs in patients aged ≤55 years (av-
erage age, 53 years; range, 29 to 55).
Average time to follow-up was 12
years (range, 10 to 15 years). Only
two patients required revision at <10
years, one for sepsis at 1 year and
one for instability at 8 years. Six pa-
tients required revision at >10 years,
all for osteolysis and loosening. The
overall survival rate was 96% at 10
years and 85% at 15 years.
Although these studies document ac-
ceptable survival rates, a significant
limitation is that activity level before
and after surgery is not documented in
any of them. In an earlier study, Duffy
et al43 found that although objective
knee scores and survival were good
in a group of patients aged ≤55 years
who underwent TKA, the functional
score improved from 45 points to 60
points (range, 0 to 100). It will be
important to determine functional
outcome and ability to return to an
active lifestyle in younger, higher-
demand patients with tricompart-
mental OA who require TKA.
The types of acceptable activity
following TKA are of considerable
debate as well. Bradbury et al44
found that 49% of patients partici-
pated in sports at least once a week
before TKA, and 65% returned to
sports after TKA. Most of these pa-
tients returned to activities such as
bowling, but 20% retuned to higher-
demand activities such as biking and
tennis. Healy et al45 reviewed athletic
activity after joint arthroplasty. They
included responses from 58 members
of The Knee Society who were sur-
veyed to determine recommenda-
tions for sports participation for pa-
tients following knee replacement
surgery (Table 3).
Return to Sports
Traditionally, most outcome data
following knee procedures have been
413
Management of Osteoarthritis of the Knee in the Active Patient
Table 3
Activity Recommendations Following Total Knee Arthroplasty: 1999 Knee Society Survey
Recommended/Allowed Allowed With Experience
Low-impact aerobics
Stationary cycling
Bowling
Golf
Dancing
Horseback riding
Croquet
Walking
Swimming
Shooting
Shuffleboard
Horseshoes
a
NordicTrack
Adapted with permission from Healy WL, Iorio R, Lemos MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29(3):377-388.
used to define success or failure
based on return to activities of daily
living. Recently, however, because of
changing attitudes and technological
advances, treatment goals for OA
have advanced beyond performance
of basic activities. Within the past
few years, there has been an increas-
ing interest in defining acceptable
athletic activity and expectations fol-
lowing surgical intervention for knee
OA. Little information is currently
available to guide athletes following
HTO. The assumption is that HTO
is performed to allow the patient to
return to her or his desired level of
sporting activities.
Several articles have addressed the
topic of athletic activity in persons
undergoing UKA and TKA; the
guidelines for activity following ar-
throplasty are summarized in Table
3. Although the recommended list of
activities does not differ between
UKA and TKA, the expected athletic
activity does. Separate studies have
reported that >90% of athletically
active patients who undergo UKA
can expect to return to their desired
414
Not Recommended No Conclusion
Road cycling Racquetball Fencing
Canoeing Squash Inline skating
Hiking Rock climbing Downhill skiing
Rowing Soccer Weight lifting
Cross-country skiing Singles tennis
Stationary skiinga Volleyball
Speed walking Football
Tennis Gymnastics
Weight machines Lacrosse
Ice skating Hockey
Basketball
Jogging
Handball
sporting and recreational activi-
ties.46,47 In contrast, only 63.6% of Summary
patients were able to return to sports
The treatment of OA of the knee in the
following TKA.46 Even among those
young, active patient remains a chal-
who are able to return to sport after
lenge to the orthopaedic surgeon. Ini-
TKA, most return to a lower level of
tial nonsurgical management with ex-
activity and at a decreased frequen-
ercise, activity modification, NSAIDs,
cy.48,49 The reasons for such a low re-
and viscosupplementation may improve
turn to sport after TKA are varied,
symptoms but will not dramatically al-
but >40% curtail athletic activity as
ter the natural history of the disease
a precaution.45 Despite concerns of both
process. Surgical treatments, when used
surgeons and patients, no evidence ex-
for the proper indications, offer patients
ists correlating increased nonimpact
a good potential solution for their ar-
athletic activity with aseptic loosening.
thritis and allow for a return to athletic
Dahm et al50 found that 12% of pa-
activities. Treatment should be guided
tients who underwent TKA partici-
based on the patients’ symptoms and
pated in activities that were not rec-
expectations.
ommended by their physician;
however, this group did not have a
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