and

present

When is a joint replacement When is a joint replacement necessary? necessary?

Treatment of osteoarthritis

There is no etiologic treatment for osteoarthritis.

The aims of treatment are to control pain and limit functional impairment.

Before referring a patient for surgery, it is essential to prescribe physiotherapy and to achieve the best possible control of the disease by medicinal means.

Nonetheless, surgery is the "last chancesaloon" of treatment.

2 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Chevallier X. Arthrose : une maladie plus complexe qu’il n’y paraît. Rev Prat. 2012 ; 62 : 619-620.

When to refer an osteoarthritic patientfor surgery

1. "Terminal" osteoarthritis The need for surgery is dictated by the severity of the disability and/or pain

osteoarthritis causes the patient. It is these symptoms and not the condition of the joint as visualised on the

x-ray or MRI scan that indicate the need for surgery: a surgeon does not operate on pictures! In practice therefore, there are no set clinical, radiological or biological

criteria on the basis of which a joint replacement procedure is indicated. The impact of osteoarthritis on the lives of patients (their ability to use

transport, perform household chores or take part in leisure activities, etc.) can be assessed using the Lequesne index.

3 Sellam J, Berenbaum F. Quand adresser au chirurgien un patient arthrosique ? Rev. Prat. 2012 ; 62 : 644

4

According to Sellam 2012

When to refer an osteoarthritic patientfor surgery

2. "Early stage" osteoarthritis in a deformedor dysplastic joint A surgical opinion should be sought for patients with severely deformed

joints, treatment-refractory pain and moderate osteoarthritis;

Conservative surgery can be discussed for patients with early stage symptomatic osteoarthritis in a dysplastic hip or a misaligned knee (genu varum or genu valgum).

An acetabular bolt or osteotomy can be proposed for a patient aged less than 50 with a dysplastic hip (particularly subluxation with an acetabular roof defect).

These prosthetic devices have a limited life-expectancy and it is better to delay using them in younger patients.

5 Sellam J et Berenbaum F. Quand adresser au chirurgien un patient arthrosique. Rev Prat 2012 ; 62 : 644.

Surgical treatment of knee osteoarthritis

Surgery is offered for patients with treatment-resistant,painful and debilitating knee osteoarthritis.

Patients are referred for surgery on the basis of the pain and disability they experience and not the radiological findings.

The decision to replace the joint is made after a thorough assessment: clinical (age, functional requirement, comorbidities and knee range of

motion and laxity) and radiological (standard x-rays, including an axial view, leg alignment and

possibly a schuss view and images in an enforced varus or valgus positions).

The first factor taken into account is the severity of the osteoarthritis: stiffness, extent of joint-space narrowing, spread into one or more joint compartments and severity of misalignment.

Age and function-demand are also determining factors.

6 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56

In the large majority of cases, tibio-femoral osteoarthritis arises subsequent to or in combination with frontal misalignment which tilts the joint to the side: medial tibio-femoral osteoarthritis is mainly seen with the genu

varum deformity, whilst lateral osteoarthritis arises more rarely with genu valgum.

The third compartment, or patello-femoral articulation, may also be involved.

This observation is the basis for conservative surgery: correcting the misalignment results in a more even distribution of stress on the two tibio-femoral compartments and helps contain the joint degeneration.

7 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686

Knee osteoarthritis: conservative treatment (1)

8

Bilateral femorotibial knee osteoarthritis. Arthrography.

Osteotomies are particularly appropriate for patients aged less than 60-65, especially when they have an active lifestyle.

As a general rule, osteotomies are indicated for patients whose symptoms are inadequately controlled by medical treatments including viscosupplementation.

Nonetheless, it is important to perform an osteotomy in younger patients with symptomatic but tolerable osteoarthritis before the condition becomes too severe.

Carrying out an osteotomy too late reduces the chancesof a successful outcome, while the patient is still consideredto be too young for a joint replacement.

This type of procedure can delay the need for a knee replacement by 12 years.

9

Varus osteotomy for knee osteoarthritis by biomaterial implantation.

Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686

Knee osteoarthritis: conservative treatment (2)

Knee osteoarthritis: replacement surgery

This is the procedure of choice for advanced osteoarthritis which commonly affects two and even all three compartments and is particularly prevalent in the over 65 age group.

A knee replacement can involve: a single tibio-femoral compartment if only one is affected and the patient

does not present with severe misalignment or hypermobility or the whole knee, if the damage is more widespread.

Complications immediate: early dislocation, infection or thrombophlebitis. delayed: delayed onset infection with or without septic loosening,

wear and tear of the artificial joint, mechanical loosening.

Since loosening can be infectious or mechanical in origin, all cases must be screened for infection before the artificial joint is replaced.

10 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56

For dysplasia and secondary hip osteoarthritis in young patients aged less than 50 years old, conservative treatment, for instance an acetabular bolt or osteotomy, is to be preferred as artificial joints have a limited life-expectancy and are therefore to be avoided in younger patients.

Conservative treatment is therefore acetabular bolting or an osteotomy.

11

Early and congestive superior pole hip osteoarthritis. Frontal reconstruction of a right hip CT scan.

Sellam J, Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686

Hip osteoarthritis: conservativetreatment

The decision to perform a total hip replacement is taken not as a function ofradiologically-detected severity, but ofthe pain, discomfort and disability experienced by the patient.

Hip replacements have a life-expectancy of about 15 years, which explains why surgeons are reluctant to recommend them for younger patients.

Because joint implants wear out over time, younger patients often require revision hip replacement surgery which is a more complex procedure than the initial operation.

12 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686

Hip osteoarthritis: total hip replacement

Hand osteoarthritis: surgical treatment

Osteoarthritis tends to affect several finger jointswhich is why surgical treatment is to be avoided.

Although rarely required, a trapeziectomy can be proposed for thumb osteoarthritis if the joint is extremely painful.

Both arthrodesis and trapezometacarpal replacementare possible in theory but rare in practice.

13 Sellam J et Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686

Conclusion

When treating patients with debilitating osteoarthritis, surgeons have a variety of means at their disposal, to be selected depending on:

the age of the patient,

the patient's condition (physiological age, activity)

and the nature of the osteoarthritis.

14 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56