Surgical options - Others

Frequency of knee arthroscopy performed (obtained from Siemieniuk et al., 2018)

It is estimated that 25% over the age of 50 years old experience knee pain from degenerative knee disease. Some still believe that arthroscopic debridement (including washout of intra-articular debris, with or without partial menisectomy to remove damaged meniscus) may improve pain and function. A recent clinical practice guideline by Siemieniuk et al (2018) have strongly recommended the use or arthroscopy in nearly all patients with degenerative knee disease based on the systematic reviews that they have found. They also believe that further research is unlikely to alter this recommendation. This recommendation applies to individuals with to without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptoms onset.

This view is also supported by a recent systematic review and meta-analysis by Abram et al (2019). The study found that arthroscopic partial meniscectomy is not appropriate for all patients with knee pain (with or without OA) and meniscal tear.

Arthroscopy has also been found to increase the risk of requiring a TKR (Barnds et al., 2019; Rongen et al., 2017, Winter et al 2017 ). Arthroscopy within 2 years prior to a TKR increases the risk of a revision of the TKR (Gu et al 2020)

A recent study by van de Graaf et al (2019) also demonstrated that surgeons can’t predict who will respond to arthroscopy for degenerative meniscal tears. Click here to see an infographic summarising the study

In conclusion, it is clear that multiple guidelines and studies agree that arthroscopy is not recommended for OA, including degenerative meniscal tears.

An osteotomy is a procedure where bone is cut and re-aligned with the aim of altering alignment of joint, and hence where the load is being distributed.

It is typically undertaken in younger patients with the aim to delay or avoid TKR. In a recent Cochrane review (2014), the researchers found that:

• Osteotomy can improve pain and function, but this is based on changes within a treatment group.
• No studies have compared osteotomy vs. conservative management.
• There is no difference between open or closed wedge
• There is no difference with treatment failure, pain and function scores at 7.5 year follow up when comparing High Tibial Osteotomy vs. UKR.
• It is still unknown whether it does delay the need for TKR.

So far, there are no studies that directly compare surgical vs. non-surgical management. However there is on perspective study that compared the results of unloader brace vs. “usual care” (including physiotherapy). Nonetheless it did not specify what that entailed (Van Outeren et al., 2017)

A partial knee replacement is only considered when there is an isolated compartment that is affected. The most common type of partial knee replacements are:

• Unicompartmental knee replacement
• Patello-femoral replacement.

But how do they compare to TKR? 

The AAOS guidelines have found limited evidence that a partial knee replacement may reduce the risk of DVT and MUA compared to TKA (McGrory et al., 2016). There is also moderate evidence that TKS decreases the risk of revision surgery in comparison to TKA.

Uni-compartment Knee Replacement: 

A UKR is performed when only one compartment of the knee joint (medial, lateral or patellofemoral) is affected. The main advantages that has been proposed for this procedure is that it’s less invasive (in comparison to TKR),  and there is quicker recovery time. However, there is moderate evidence that the is no differences in outcomes and complications when comapring patients with medial compartment OA who underwent UKR vs. osteotomy (McGrory et al., 2016). The Australian joint replacement registry has also reported revision rate of UKR of 27.3% at 18 years.

Patello-Femoral Replacement:

Patello-femoral replacement may be considered for those individuals with patello femoral OA, with involvement of the tibiofemoral joint ruled out, and no signs of instability. Some evidence suggests that the ideal age range for a patello-femoral replacement is 40-60 years old.

Individuals with patello-femoral OA usually describe the pain to be in the anterior or retropatellar knee, and usually brought on by activities such as squatting, stairs, sit to stand, or prolonged sitting with flexed knees. Pain is usually less severe when walking on level ground and in standing position with the knee completely extended.

It is not indicated if there is a varus or valgus deformity, or a fixed flexion deformity