Non Arthroplasty Surgery For

Knee Osteoarthritis

Dr. Wael Samir

Ass. Professor of Orthopaedic Surgery
Ain Shams University
Non Arthroplasty Surgery For Knee Osteoarthritis
1. Lavage and debridment followed by local injection
2. Meniscus surgery
- Partial meniscectomy.
- Reposition of subluxated meniscus in bankart like repair
3. Articular Cartilage Defects Treatment Modalities
I - Abrasion Arthroplasty
II- Subchondral penetration procedures
(drilling and microfracture techniques)
III- Periosteal or perichondral grafting
IV- Osteochondral autografts (mosaicplasty)
V- Osteochondral allografts
VI- Autologus Chondrocyte implantation
VII- Synthetic Cartilage Resurfacing
4. Realignment procedures : HTO
1- Lavage and Debridment followed by local injection

Theoretical Effect:
Removal of Mechanical wear Particle
Removal of Free radicals
Removal of degradative enzymes
Removing crystals in crystal synovitis
Allowing repair for local tissue and remodelling
 AAOA recommendation
(Recommendation 18)

Recommend against performing arthroscopy with

debridement or lavage in patients with a primary
diagnosis of symptomatic OA of the knee.
Levels of Evidence: I and II
Grade of Recommendation: A
 2. Meniscus surgery

1 - Partial meniscectomy.

2 - Reposition of subluxated meniscus in bankart

like repair
 Partial Meniscectomy

Arthroscopic Partial meniscectomy in osteoarthritic patients with a documented

tear and mechanical symptoms appears to be an effective procedure for the
relief of pain at short-term follow up.
 Results :

95% satisfaction rate at 3-year follow-up with traumatic

tears versus 65% with degenerative tears.

In patients with degenerative tears, the presence of

advanced osteoarthritis was associated with a less favorable
outcome.
 AAOA recommendation
(recommendation 19)

No level I or II evidence is available to suggest that

arthroscopic partial meniscectomy and/or loose body removal is
or is not appropriate for a patient with a primary diagnosis of a
torn meniscus and/or a loose body .
Level of Evidence: V
Grade of Recommendation: C
Reposition of Subluxated Meniscus in Bankart
Like Repair
(A Technique by Prof. Ezzat Kamel)
 Meniscal subluxation
The term MENISCAL
SUBLUXATION is more used in
relation to osteoarthritis, where the
joint space narrowing and osteophytes
helps to displace the meniscus out of
its place.
Meniscal subluxation is defined if the
distance between the peripheral edge
of the meniscus and the outer edge of
the tibial plateau > 3mm.

10 12/08/21
 For resotration of the lost meniscal
function :
Mechanical cushion like effect.
Stress relaxation “Hoop Stresses”.
Load transmission.
Stresses increases by 300% over the affected compartment.
Stability.

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Case presentation
3. Articular Cartilage Defects Treatment Modalities
 Abrasion Arthroplasty
A motorized cutting device is used to abrade the
cartilage defect to a depth of 1 to 2 mm into adjacent.
Creation of intracortical defect in a sclerotic lesion
without penetration of the subchondral bone uncovered small
blood vessels. The blood clot attachment to the surface
followed by fibrous metaplasia to fibrocartilage integrity.
 Drilling And Microfracture
Subchondral drilling and microfracture of the
subchondral bone stimulate the formation of cartilage by
disrupting subchondral blood vessels and allowing primitive
mesenchymal cells to migrate to the surface and differentiate
into chondroblasts and chondrocytes with production of
fibrocartilage rather than hyaline cartilage.
 Mosiacoplasty
- A mosaicplasty uses cartilage from undamaged
areas of the joint, and moves this cartilage to a
damaged area. The plugs are each a few
millimeters in diameter,
- Only useful for the treatment of focal cartilage
damage.
- Limited to 10-20 mm in size. This type of
damage is usually seen in younger patients (less
than 50 years old) who experience a trauma to
their joint.
-Not indicated in cases with widespread damage
of cartilage seen in conditions like osteoarthritis
 OATS For Chondral Defects
(osteochondral autologus transfer system)
Same principle like mosiacoplasty
The plugs of larger diameter
Used for larger defects.
 High Tibial Osteotomy
The fundamental goals of the procedure are to unload diseased
articular surfaces and to correct angular deformity at the
tibiofemoral articulation.
Berman et al stated that“...by changing alignment and
transferring weight-bearing stresses to stronger areas of the
knee joint, the degenerative process can be slowed, arrested, or
even reversed”
Jackson is credited with being the first in the English-language
literature in 1958 to report performing a proximal (high) tibial
osteotomy (HTO) to treat osteoarthritis of the knee.
Reasons to use H.T.O.:

(1) High incidence of medial compartmental osteoarthritis in

physiologically young active patients. (no TKA)
(2) Chondral resurfacing techniques are contraindicated in the presence of
tibiofemoral malalignment because they mandate concomitant
correction of significant coexistent angular deformity for better results.
(3) No permanent activity restrictions (activity modification in TKA)
(4) No need for prolonged postoperative cast immobilization and Superior
results with new fixation and postoperative management techniques.
HTO has two principle drawbacks:

1- It is not an ideal treatment option for Patients with

significant bi-compartmental or tri-compartmental disease
2-The results of the procedure progressively deteriorate.
 Contraindications to HTO

(1) Lateral compartment degenerative joint disease

(2) Loss of a significant portion of the lateral meniscus,
(3) Symptomatic patello-femoral degenerative joint disease
(4) Non-concordant pain (patello-femoral pain with medial
compartment osteoarthritis)
(5) Patient unwillingness to accept the anticipated cosmetic
appearance of the desired amount of angular correction
(6) Inflammatory arthritis.
 Results of HTO
One of the most consistent predictors of suboptimal

durability of HTO is Imprecise correction of the

preoperative angular deformity.
Moderate overcorrection is optimal

Under correction compromises the long-term success

of the operation;.
 Results of HTO

Almost all studies suggest that more 50% of HTOs remain

effective at 7 to 10years.
Long-term studies indicate that the clinical success of HTO
deteriorates with time.
TKA can be successfully postponed for at least 7 to 10years in
most appropriately selected HTO candidates.
 RESULTS
 Sprenger (LCW) : 86% survivorship 5 yrs, 56% 15 yrs

 Billings et al (LCW) 85% survivorship at 5 yrs, 53% at 10 yrs

 Naudi (94 LCW, 12 dome) 51% survivorship at 10 yrs, 30% at 20 yrs

 Coventry (LCW) 87% survivorship at 5 years, 66% at 10 years

 Yasuda (LCW) 88% satisfactory at 6 yrs, 63% at 10 yrs

 Ivarsson et al. (LCW) 50% good at 5.7 years ,43% good at 11.9 years

 Ritter(LCW) 60% survivorship at 12 years

 Hernigou et al. (MOW) 90% good or excellent at 5 yrs,45% at 10 yrs

 Insall (LCW) 85% good or excellent at 5 yrs, 63% at 9 yrs

 Vainionpää et al. (LCW) 83.5% good or fair at 6.9 years.

 Tjörnstrand et al.(LCW) 42% good at 7 years

 Cartilage Regeneration After HTO
Altering the natural history of the underlying osteoarthritis by
unloading deteriorated articular surfaces is one goal of HTO.
However,scientific data regarding this idea are limited and
controversial.
Bruce et al documented decreased medial compartment
scintigraphic uptake following valgus-producing HTO.
Improved appearance of the medial compartment articular
surfaces after HTO at the time of second-look arthroscopy also
has been reported.
Wakabayashi reported notable fibrocartilaginous repair in
unloaded eburnated bone after HTO, but there was
negligible repair of unloaded fibrillated cartilage.
 AAOA recommendation
(Recommendation 21)
Realignment osteotomy is an option in active patients

with symptomatic unicompartmental OA of the knee

with malalignment.
Levels of Evidence: IV and V

Grade of Recommendation: C
Combined HTO + intraarticular cartilage surgery

Superior outcomes (cartilage repair) rather than clinical

difference when combined open debridement, abrasion
arthroplasty, abrasion arthroplasty or drilling and HTO
compared with HTO alone.
 Bi- compartmental O.A.

Patellofemoral arthritis (PF-

OA) frequently is associated
with MC-OA.
The combination of the
conditions limits patient
selection for H.T.O. and
adversely influences long-
term outcomes.
The new“dual osteotomy”: combined open wedge
and tibial tuberosity anteriorisation osteotomies
The new“dual osteotomy”: combined open wedge
and tibial tuberosity anteriorisation osteotomies
 AAOA recommendation
(Recommendation 21)

We cannot make a recommendation for or against an

osteotomy of the tibial tubercle for patients with isolated

symptomatic patellofemoral osteoarthritis.
Level of Evidence: V

Grade of Recommendation: Inconclusive


Thank You