The orthopaedic approach to managing osteoarthritis of the knee
http://www.100md.com
《英国医生杂志》
1 Department of Orthopaedics, Kingston Hospital, Kingston upon Thames, Surrey KT2 7QB, 2 Department of Orthopaedics, St George's Hospital, London SW17 0QT
Correspondence to: S Gidwani samgidwani@yahoo.com
Introduction
Management of patients with mild osteoarthritis should be tailored to the individual while avoiding over-medicalisation of the condition.w1 A variety of interventions are available, including advice on changes to lifestyle and physical and pharmacological therapies. The effectiveness of many of these treatments has been reviewed elsewhere.2 3
Intra-articular steroid injections
Intra-articular steroid injections can alleviate pain in patients with moderate osteoarthritis of the knee, but this is usually short lived,2 and therefore we believe they have a limited role in treating acute exacerbations of the disease. A recent randomised double blind trial, however, has suggested that repeated injections of the steroid triamcinolone hydrochloride every three months for up to two years can lead to improved symptoms when compared with injections of saline.4 The effect was more noticeable at one year. Evidence that steroids accelerate cartilage damage is still inconclusive, but there is a small risk of septic arthritis (between 1 in 15 000 and 1 in 50 000).2 A Cochrane review of the available evidence is in preparation.
Summary points
The outcome of total knee replacement is comparable to that of total hip replacement
85% of total knee replacements are carried out for patients with osteoarthritis
Arthroscopic debridement and washout has a role as a temporising procedure in early osteoarthritis associated with mechanical symptoms
In some cases alternative surgical procedures such as unicompartmental knee replacement may be more appropriate than total knee replacement
The role and success of new techniques such as image guidance and minimally invasive surgery remain to be established
Viscosupplementation
Several hyaluronan preparations are available as intraarticular injections. Relief of symptoms is thought to result from increased viscosity of the synovial fluid—hence the term "viscosupplementation" for this type of treatment. The molecular weights of the hyaluronan derivatives vary as do the duration of courses and the numbers of injections recommended. The results of trials also differ, with some implying little benefit and others showing excellent results.5 w2 w3 A recent systematic review concluded that injections of hyaluronic acid were no more effective than nonsteroidal anti-inflammatory drugs for improving pain, physical function, and stiffness, and did not support public funding of viscosupplementation.6
Surgical intervention
w1-w13 are on bmj.com
See also p 1216
Contributors: SG and AF jointly developed the idea for this article. SG carried out the literature search and wrote the first draft. AF carried out a detailed review of the draft and further changes. AF is the guarantor.
Competing interests: None declared.
References
Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988;10: 1-28.
Dieppe P, Brandt K. What is important in treating osteoarthritis? Whom should we treat and when should we treat them? Rheum Dis Clin North Am 2003;29: 687-716.
Walker-Bone K, Javaid K, Arden N, Cooper C. Medical management of osteoarthritis. BMJ 2000;321: 936-40.
Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003;48: 370-7.
Leopold SS, Redd BB, Warme WJ, Wehrle PA, Pettis PD, Shott S. Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective, randomized trial. J Bone Joint Surg Am 2003;85-A: 1197-203.
Medical Services Advisory Committee. Intra-articular viscosupplementation for treatment of osteoarthritis of the knee. Canberra, Australia: MSAC Application 1045:88; 2003.
Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347: 81-8.
Fond J, Rodin D, Ahmad S, Nirschl RP. Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results. Arthroscopy 2002;18: 829-34.
Hanssen AD, Stuart MJ, Scott RD, Scuderi GR. Surgical options for the middle-aged patient with osteoarthritis of the knee joint. Instr Course Lect 2001;50: 499-511.
Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The install award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year follow up study. Clin Orthop 1999;367: 18-27.
Billings A, Scott DF, Camargo MP, Hofmann AA. High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am 2000;82-A: 70-9.
Murray DW, Goodfellow JW, O'Connor JJ. The Oxford medial unicompartmental arthroplasty: a ten-year survival study. J Bone Joint Surg Br 1998;80-B: 983-9.
Svard UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. A survival analysis of an independent series. J Bone Joint Surg Br 2001;83-B: 191-4.
Brown A. The Oxford unicompartmental knee replacement for osteoarthritis. Issues Emerg Health Technol 2001;23: 1-4.
Ackroyd CE, Newman JH. The Avon patellofemoral arthroplasty: two to five year results. J Bone Joint Surg Br 2003;suppl II: 162-3.
Mont MA, Haas S, Mullick T, Hungerford DS. Total knee arthroplasty for patellofemoral arthritis. J Bone Joint Surg Am 2002;84-A: 1977-81.
Dixon T, Shaw M, Ebrahim S, Dieppe P. Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need. Ann Rheum Dis 2004;63: 825-30.
Ritter MA, Berend ME, Meding JB, Keating EM, Faris PM, Crites B. Long-term follow-up of anatomic graduated components posterior cruciate-retaining total knee replacement. Clin Orthop 2001;388: 51-7.
Khaw FM, Kirk LM, Gregg PJ. Survival analysis of cemented press-fit condylar total knee arthroplasty. J Arthroplasty 2001;16: 161-7.
Robertsson O, Knutson K, Lewold S, Lidgren L. The Swedish Knee Arthroplasty Register 1975-1997. An update with special emphasis on 41,223 knees operated on in 1988-1997. Acta Orthop Scand 2001;71: 503-13.
Jacobs W, Anderson P, Limbeek J, Wymenga A. Mobile bearing vs fixed bearing prosthesis for total knee arthroplasty for post-operative functional status in patients with osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev 2004(2): CD003130.
Gidwani S, Tauro B, Whitehouse S, Newman JH. Do patients need to earn total knee arthroplasty? J Arthroplasty 2003;18: 199-203.
Kane RL, Saleh KJ, Wilt TJ, Bershadsky B, Cross WW III, MacDonald RM, et al. Total knee replacement. Rockville, MD: Agency for Healthcare Research and Quality, 2003. (Evidence report/technology assessment No 86.)
Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tricompartmental total knee replacement: a meta-analysis. JAMA 1994;271: 1349-57.
Tria AJ Jr, Coon Tm. Minimal incision total knee arthroplasty: early experience. Clin Orthop 2003;416: 185-90.
((Sam Gidwani, specialist r)
Correspondence to: S Gidwani samgidwani@yahoo.com
Introduction
Management of patients with mild osteoarthritis should be tailored to the individual while avoiding over-medicalisation of the condition.w1 A variety of interventions are available, including advice on changes to lifestyle and physical and pharmacological therapies. The effectiveness of many of these treatments has been reviewed elsewhere.2 3
Intra-articular steroid injections
Intra-articular steroid injections can alleviate pain in patients with moderate osteoarthritis of the knee, but this is usually short lived,2 and therefore we believe they have a limited role in treating acute exacerbations of the disease. A recent randomised double blind trial, however, has suggested that repeated injections of the steroid triamcinolone hydrochloride every three months for up to two years can lead to improved symptoms when compared with injections of saline.4 The effect was more noticeable at one year. Evidence that steroids accelerate cartilage damage is still inconclusive, but there is a small risk of septic arthritis (between 1 in 15 000 and 1 in 50 000).2 A Cochrane review of the available evidence is in preparation.
Summary points
The outcome of total knee replacement is comparable to that of total hip replacement
85% of total knee replacements are carried out for patients with osteoarthritis
Arthroscopic debridement and washout has a role as a temporising procedure in early osteoarthritis associated with mechanical symptoms
In some cases alternative surgical procedures such as unicompartmental knee replacement may be more appropriate than total knee replacement
The role and success of new techniques such as image guidance and minimally invasive surgery remain to be established
Viscosupplementation
Several hyaluronan preparations are available as intraarticular injections. Relief of symptoms is thought to result from increased viscosity of the synovial fluid—hence the term "viscosupplementation" for this type of treatment. The molecular weights of the hyaluronan derivatives vary as do the duration of courses and the numbers of injections recommended. The results of trials also differ, with some implying little benefit and others showing excellent results.5 w2 w3 A recent systematic review concluded that injections of hyaluronic acid were no more effective than nonsteroidal anti-inflammatory drugs for improving pain, physical function, and stiffness, and did not support public funding of viscosupplementation.6
Surgical intervention
w1-w13 are on bmj.com
See also p 1216
Contributors: SG and AF jointly developed the idea for this article. SG carried out the literature search and wrote the first draft. AF carried out a detailed review of the draft and further changes. AF is the guarantor.
Competing interests: None declared.
References
Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988;10: 1-28.
Dieppe P, Brandt K. What is important in treating osteoarthritis? Whom should we treat and when should we treat them? Rheum Dis Clin North Am 2003;29: 687-716.
Walker-Bone K, Javaid K, Arden N, Cooper C. Medical management of osteoarthritis. BMJ 2000;321: 936-40.
Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003;48: 370-7.
Leopold SS, Redd BB, Warme WJ, Wehrle PA, Pettis PD, Shott S. Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective, randomized trial. J Bone Joint Surg Am 2003;85-A: 1197-203.
Medical Services Advisory Committee. Intra-articular viscosupplementation for treatment of osteoarthritis of the knee. Canberra, Australia: MSAC Application 1045:88; 2003.
Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347: 81-8.
Fond J, Rodin D, Ahmad S, Nirschl RP. Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results. Arthroscopy 2002;18: 829-34.
Hanssen AD, Stuart MJ, Scott RD, Scuderi GR. Surgical options for the middle-aged patient with osteoarthritis of the knee joint. Instr Course Lect 2001;50: 499-511.
Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The install award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year follow up study. Clin Orthop 1999;367: 18-27.
Billings A, Scott DF, Camargo MP, Hofmann AA. High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am 2000;82-A: 70-9.
Murray DW, Goodfellow JW, O'Connor JJ. The Oxford medial unicompartmental arthroplasty: a ten-year survival study. J Bone Joint Surg Br 1998;80-B: 983-9.
Svard UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. A survival analysis of an independent series. J Bone Joint Surg Br 2001;83-B: 191-4.
Brown A. The Oxford unicompartmental knee replacement for osteoarthritis. Issues Emerg Health Technol 2001;23: 1-4.
Ackroyd CE, Newman JH. The Avon patellofemoral arthroplasty: two to five year results. J Bone Joint Surg Br 2003;suppl II: 162-3.
Mont MA, Haas S, Mullick T, Hungerford DS. Total knee arthroplasty for patellofemoral arthritis. J Bone Joint Surg Am 2002;84-A: 1977-81.
Dixon T, Shaw M, Ebrahim S, Dieppe P. Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need. Ann Rheum Dis 2004;63: 825-30.
Ritter MA, Berend ME, Meding JB, Keating EM, Faris PM, Crites B. Long-term follow-up of anatomic graduated components posterior cruciate-retaining total knee replacement. Clin Orthop 2001;388: 51-7.
Khaw FM, Kirk LM, Gregg PJ. Survival analysis of cemented press-fit condylar total knee arthroplasty. J Arthroplasty 2001;16: 161-7.
Robertsson O, Knutson K, Lewold S, Lidgren L. The Swedish Knee Arthroplasty Register 1975-1997. An update with special emphasis on 41,223 knees operated on in 1988-1997. Acta Orthop Scand 2001;71: 503-13.
Jacobs W, Anderson P, Limbeek J, Wymenga A. Mobile bearing vs fixed bearing prosthesis for total knee arthroplasty for post-operative functional status in patients with osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev 2004(2): CD003130.
Gidwani S, Tauro B, Whitehouse S, Newman JH. Do patients need to earn total knee arthroplasty? J Arthroplasty 2003;18: 199-203.
Kane RL, Saleh KJ, Wilt TJ, Bershadsky B, Cross WW III, MacDonald RM, et al. Total knee replacement. Rockville, MD: Agency for Healthcare Research and Quality, 2003. (Evidence report/technology assessment No 86.)
Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tricompartmental total knee replacement: a meta-analysis. JAMA 1994;271: 1349-57.
Tria AJ Jr, Coon Tm. Minimal incision total knee arthroplasty: early experience. Clin Orthop 2003;416: 185-90.
((Sam Gidwani, specialist r)