Studie über die arthroskopische Chirurgie

Seit 1985 führen wir in unserer Spezialklinik für Gelenkchirurgie und arthroskopische Chirurgie sowie Sporttraumatologie bei der medialen und lateralen Gonarthrose als alternative Behandlungsmaßnahme zur prothetischen Versorgung die Arbrasions-Chondroplastik in Verbindung mit Kniegelenks naher valgisierender bzw. varisierender Umstellungsosteotomie durch.

Diese spezielle kombinierte Technik ist der Prothese (die ca. 9 - 10 Jahre überdauert) schlechthin überlegen und schonender, wobei das Kniegelenk erhalten wird. Wie aus der nachfolgenden Studie - die z. Zt. nur in englischer Sprache für die internationale Veröffentlichung vorgesehen ist - hervorgeht, haben bisher nur 2,5 % der Patienten nach Ablauf von 10 Jahren sich einer prothetischen Versorgung unterzogen. Wir werden demnächst die Studie auch in deutscher Sprache veröffentlichen.

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Abrasion Arthroplasty with High Tibial Osteotomy for treatment of sever osteoarthritis - a follow up subjective study.

Since 1980 we have started treatment of advanced osteoarthritis knee by abrasion under arthroscopic guidance. But since 1985 we have started the combination of Arthroscopic Abrasion Arthroplasty (AAA) and High Tibial Osteotomy (HTO).

Aim of the study

To present the follow up results of AAA and HTO performed to patients with advanced varus osteoarthritis knee; who are candidates for Total Knee Replacement (TKR) or Unicompartmental Knee Replacement (UKR)

Materials and methods

All patients in this study were those suffering from advanced (severe) knee joint varus osteoarthritis. The patients were of any age, any gender, and the most important point is that the patient must accept the 6-8 weeks non-weight bearing rehabilitation program. The patient also my be obese (mild) but not morbid obesity. All our patient were candidate for artificial prosthesis (they mentioned they had already date for TKR & UTKR), they search about an alternative to prosthesis.

Since 1985 till 2006 more than 1.500 patients with advanced osteoarthritis of medial knee compartment; underwent AAA with HTO at the clinic of Dr Witwity, and Oxford score was sent to 946 patients till 2003 as we are concerning with patients more than three years follow up-also some patient come for metal removal and second look also was included. The Oxford 12 points questionnaire is reliable and used by many surgeons to evaluate the patients with TKR &UKR.509 patients sent their answers, 246 females and 263 males, 260 Lt knee, 249 Rt knee and 19 were bilateral. Average age 60 years (29 – 84 year).

Technique of the operation

Arthroscopic Abrasion Arthroplasty with High Tibial Osteotomy done for all patients with grade IV chodromalacia and sclerotic lesion   medial compartmental knee osteoarthritis (bare bone).

AAA is multiple tissue debridement procedure and it is consisted of Abrasion, which must be strictly intra-cortical, preserving the tide mark as a vital bearing zone for the expected newly formed fibrocartlige. Only 1-3 mm is abraded till the appearance of the superficial blood vessels which take the salt and pepper appearance (minute dark red tinny vessels against pale white background of abraded bone). In few number patients Micro-fracture technique is done using special sharp knife to reach the deep cortical layers without disturbing the tide-mark line.

Arthroplasty indicates multiple tissue debridement (cleaning house) and includes:

1. partial synovectomy.
2. partial meniscectomy.
3. Articular cartilage debridement by electric shaver and YAG laser.
4. Loose body removal and also osteopytes producing symptoms asmechanical block

We consider the crystal deposition of calcium pyrophosphate is not a contra indication for AAA&HTO.

Postoperative

The patient usually needs no narcotics for pain relieve, the drain is removed after 4-6 hours, Continuous Passive Movement (CPM) machine is started immediately in the early post-operative time 20-30 min./3 times a day; this helps absorption of the hemarthrosis, and stimulate granulation tissue formation which is then transformed into fibrocartlige like tissue covering the bare bone. The patient is allowed to ambulate as early as possible non weight bearing using elbow crutches for 2 weeks then returns in second sitting for HTO.

NB: Because of pain temporary immobilization needed after HTO but immediate mobilization is needed after abrasion; so we cannot do both in one sitting.

HTO: valgus Osteotomy is done by removing a bone wedge with the base directed laterally , about 1mm for each 1 degree to realign the tibia but we usually intend to produce over correction by adding 3degrees more to the angle measured is standing x-ray position, fixation by a stable and keep the patient immobilized for 5 days post operative.

The rehabilitation program starts, CPM and non weight bearing for 4-6 weeks. After that the patient starts to bear weight as he can, and starts the extensive rehabilitation program to regain full muscle power.

The patient returns back after 6-12 moths for implant removal and second look arthroscopy.

Results

The patient can sleep the first night after the operation with no pain, no analgesic. The total patients who sent answers are 509, with average follow up period 7 years (1 – 18 years), 48 patients had prosthesis i.e. 9,4% of all the responding patients this means that 90,6% of our patient along the follow up period; lead a good life without a prosthesis.

It was also noticed that from those patients who had a prosthesis, 8 patients had a prosthesis after more than 10 years, 10 patients after 7 years (7-10), and only 17 patients has prosthesis before 5 years i.e. 3.3%only of our patient decide to do prosthesis before 5 years which consider a high success of this operation and we can consider it Bio-prosthesis.

The operation can be repeated without any significant danger on the knee or the patient.

The operation AAA and HTO also success in deferring the prosthesis many years later.

Case presentation

Here are some patients arthroscopic photos taken during 2^nd look arthroscopy during metal removal and the corresponding x-ray

Case no. one

(A) pre op

(B) post op

Fig (1) Shows the bare bone and after one year covered by fibro-cartilage


Fig (2) shows x-ray of the same patient in fig (1) pre and post operative and show the joint space and method of fixation.

(A) pre op

(B) post op

Fig (2) shows the x-ray pre and post operative, note the realignment and joint space
NB. The joint space widening has no relation to clinical improvement

Case no. two

(A) pre op

(B) post op

Fig (3) shows other patient pre and post operative after one year

Here is the corresponding x-ray pre and post operative

(A) pre op

(B) post op

Fig (4) shows the same patient in fig (3) x-ray


Fig (5) shows patient before and after 4 years follow up come complaining of another symptom 

(A) pre op

(B) post op

In this pictures fig (5) we can notice the new fibro-cartilage, it looks like hyaline cartilage.

Also we notice that there is no correlation between the joint space and patient satisfaction.

Statistical analysis and data

Table (1) shows the results  for each question of the Oxford 12 questionnaire the mean knee score was 37.7 many patients(50patients) have the score of 48 which is the maximal score .


Diagram (1) shows the statistical analysis of the answers for each of the 12 question. It must be noticed that the maximum answer of any question is 4.ie it shows the average answer for each question. It noticed that the average answer for all questions is 3

Diagram (2) shows the average score for each follow up period as we divide the patients according the years of follow up into 9 groups the results are satisfied even after 10 years.



Diagram (3) shows the comparison between the results of TKR & UKR and the current study. We can show that our results still more better than joint replacement.

Conclusion

Arthroscopic Abrasion Arthroplasty with high tibial Osteotomy is an efficient and sufficient operation to those patient suffering from advanced osteoarthritis knee and seeking an alternative to prosthesis and improve the life quality if compared to the knee prosthesis.

Abrasion alone can relieve the symptoms but it will return again after sometime so it is considered palliative treatment so it must be combined with HTO if there is any malalignment present.

This operation can be repeated another time even after 15 years with no danger on the patient not like the prosthesis which is considered internal amputation of the joint as described by some patients.

In about 3% of patients return to do lateral release to the lateral patellar retinaculum, due to lateral shifting of patellar pathway after HTO.

The key of success of the combination AAA and HTO is collected mainly in the following points:

1. Intact lateral compartment.
   
2. Average weight of the patient, avoid morbid obesity.
   
3. No sever mal-alignment, avoid sever varus.
4. Only uni-compartmental knee osteoarthritis +/- PFOA
5. Patient compliance is of great importance i.e. the patient who select himself for this procedure and refuse the prostheses has the great liability for success and get benefit from the operation.
6. Don’t ignore ligamentous instability.

The author

Dr med. T. Witwity

Chief of clinic Dr Witwity for arthroscopic surgery and sport medicine

Stade Germany