Surgical management of osteoarthritis

Despite intensive laboratory and clinical investigation, there are no proven disease-modifying therapies for osteoarthritis (OA). Since the disease may progress inexorably to joint destruction, with attendant pain and functional loss, orthopedic surgical procedures have an important role in the management of osteoarthritis. Surgery is deployed both early in the course of disease as well as later when joint destruction occurs. Surgery may also have a preventive role prior to the onset of osteoarthritis. Accordingly, this chapter has three sections addressing current surgical treatments. The first covers arthroscopic approaches to osteoarthritis, including the management of lesions commonly associated with OA, such as meniscal tears. The advent of arthroscopic surgical approaches has permitted less invasive access to joints and the opportunity to intervene earlier in the course of joint destruction, potentially to delay and/or prevent what is otherwise a predictably progressive degenerative pathway. The second section of this chapter addresses osteotomies, which are typically done to restore a more anatomic biomechanical environment and prevent or delay the onset of OA or slow its progression. The third section discusses orthopedic procedures for advanced joint destruction including total joint replacement and arthrodesis (joint fusion). Finally, remarkable advances in tissue engineering and biologic therapies herald an era of collaborative intervention in which surgeons gain access to joints with minimally invasive approaches and apply biologic or tissue engineering therapies. Some examples of these hybrid therapies already exist including autologous cartilage implantation and meniscal allograft. The chapter closes with a brief discussion of tissue engineering and biologic therapies for OA and a glimpse of the role of orthopedic surgery in OA prevention and management over the coming decades. We recognize that the topic of surgical management of osteoarthritis is large enough to merit a full text. The goal of this review is not to summarize comprehensively all that is known about surgical management of OA but rather to provide readers with evidence and perspectives pertaining to the most salient surgical treatments for OA and to summarize the evidence base supporting the use of these surgical strategies. Arthroscopic procedures for osteoarthritis As arthroscopic surgery proliferated in the 1980s it became natural for physicians to consider arthroscopic debridement and lavage for management of osteoarthritis. However, studies of the outcome of arthroscopic procedures for osteoarthritis were methodologically weak and yielded inconsistent results. Two pivotal studies changed the outlook for arthroscopic debridement and lavage for OA. Moseley and colleagues randomized 180 subjects with symptomatic osteoarthritis to receive one of three therapies: arthroscopic debridement, arthroscopic lavage or a sham procedure. After two years of follow up, the outcomes were virtually identical in each group.1 Kirkely and colleagues randomized 170 patients with symptomatic OA to receive either arthroscopic lavage or a standard nonoperative regimen. In this study as well, there was no difference between the two randomized groups after two years of follow-up2. On the basis of these studies there is now general agreement that arthroscopic lavage and debridement are not useful for the management of osteoarthritis per se, in the absence of a superimposed structural lesion such as meniscal tear.3, 4 However, the most common indication for arthroscopic surgery in patients with osteoarthritis of the knee is, indeed, concomitant meniscal tear. The efficacy of arthroscopic partial meniscectomy (APM) in patients with concomitant OA has received relatively little study, especially given that APM is performed in over 500,000 patients with concomitant OA per year in the US.5 Effects of meniscal surgery documented in observational studies may be complicated by confounding by indication, with more active patients electing meniscal surgery and also at greater risk of OA developmet or progression on the basis of their increased activity levels and injury rates. Herrlin and colleagues performed the only RCT addressing this question, comparing the combination of APM with exercise against an exercise program alone6. The trial showed no clinically meaningful or statistically significant differences between the two strategies. A larger multicenter trial of APM with exercise vs. exercise alone, the MeTeOR Trial (Clinicaltrials.gov {type:clinical-trial,attrs:{text:NCT00597012,term_id:NCT00597012}}NCT00597012), is underway in the US, but results are not expected until 2012. Thus, the trials of Moseley and colleagues and Kirkely and colleagues provide strong evidence that patients with symptoms attributable to knee OA per se, and not meniscal tear, do not improve following arthroscopic lavage and debridement. Whether arthroscopic partial meniscectomy is useful in patients with symptomatic meniscal tear and concomitant OA is unclear and an area of active investigation. Beyond the question of symptomatic relief, there is also concern about whether arthroscopic partial meniscectomy may increase the rate of progression of osteoarthritis. Evidence from cohort studies suggests that patients who have had APM have earlier and more severe OA than age matched patients who have not had APM.7–12 In addition, patients who have not had surgery but who have a meniscal tear on MRI are known to have higher rates of incident OA and of OA progression.13 However, it remains unknown whether the increased OA incidence and progression seen in patients with APM is due to the tear or the surgery or both. Only a trial design can disentangle these potential explanations.