Non-Surgical Management of End
Stage OA
"When not to Operate"
William D. Stanish, M.D.,
F.R.C.S.(C), F.A.C.S. Professor of Surgery Dalhousie University Director, Orthopaedic and
Sport Medicine Clinic of Nova Scotia Halifax, Nova Scotia The Philosophy
The Disease
Osteoarthritis is described as a generally
progressive loss of articular cartilage, accompanied by attempted repair and
remodelling. Notwithstanding the
process of ageing, hyaline cartilage becomes degenerative basically under two
conditions. (Ref: Felson DT. Epidemiology of Hip and Knee
Osteoarthritis. Epidemiology Review, 1988, 10: 1-28.) #1 Hyaline cartilage overload. In situations of disturbed joint
mechanics; e.g., genu varus, hyaline cartilage degeneration can occur depending
on the degree of external demand.
Articular cartilage possesses a very high tolerance for mechanical
loading and can tolerate stresses up to but below 25 N/m2. Most athletic physical activities, such as
running, trigger articular surface stresses in the range of 4-9 N/m2. With severe single impact loads, insult to
the chondrocyte and/or matrix will prompt initial blistering of the joint
surface. If the mechanical
disturbance is not rectified, then progressive joint surface fissuring,
followed by erosion, can occur. (Ref: Buckwalter JA, Mankin HJ. Articular
Cartilage II: Degeneration and osteoarthrosis, repair, regeneration, and
transplantation. JBJS 79A: 612-632,
1997. #2 Hyaline cartilage underload. In the clinical situation of forced immobilization
and/or underload, an unfavourable circumstance exists for hyaline
cartilage. This clinical situation
occurs far less frequently than overload but does require the same attention
to therapeutic intervention. In the
face of a significant injury to the hyaline cartilage, a period of
immobilization after such injury may prevent degeneration. Forced motion and loading may be
counterproductive in attempting to achieve hyaline cartilage restoration. (Ref: Williams JM, Brandt KD. Immobilization Ameliorates
Chemically Induced Articular Cartilage Damage. Arthritis and Rheumatism, 27: 208-216, 1984. Buckwalter JA. Activity Versus Rest in the Treatment of Bones, Soft Tissue and
Joint Injuries. Iowa Orthopaedic
Journal, 15: 29-42, 1995.) The Treatment
A successful treatment program
must address and deal effectively with: #1 Controlling
the PAIN COMPONENT (Ref: Brooks PM, Day RO. Non-steroidal Anti-inflammatory Drugs -
Differences and Similarities. New
England Journal of Medicine, 1991, 324: 1716-1725.) In most cases of early
degenerative joint disease (Grade I/Grade II) it is usually necessary to
address the intermittent exacerbations of joint pain. Invariably there is an inflammatory
component that when treated successfully, enters into remission. The treatment for the pain can be
effective with such simple techniques as activity modification, analgesia
and/or physical modalities. (Ref: Panush RS. Is Running Associated with Degenerative Joint Disease? JAMA
255: 1152-1157, 1986.) #2 Controlling
the MECHANICAL COMPONENT Invariably degenerative joint
disease within the knee is associated with a disturbed mechanical
component. If, in fact, the pain
component is not rectified with a simple medication and/or modality, then the
introduction of strategies to alter the disturbed mechanics are essential. (Ref: Articular Cartilage: Composition Structure
Response to Injury and Methods of Facilitating Repair. Buckwalter JA,
Rosenburg IC, Hunziker EB: Chapter in - Articular Cartilage in Knee joint
Function; Basic Science and Arthroscopy, (ed) J.W. Ewing, Raven Press,
New York, 1990, pp 19-56.
Fundamentals of Articular Cartilage and Meniscus Biomechanics, Now VC,
et al. Articular Cartilage in Knee Joint Function; Basic Science and
Arthroscopy; (ed) JW Ewing, Raven Press, New York, pp 1-18. Brand RA; Joint Lubrication, (ed) Albright
and Brand; The Scientific Basis of Orthopaedics, 2nd ed., Appleton &
Lang, 1987, pp 373-386. Biomechanical
Gait Analysis of Morbidly Obese Women.
El Hawary R, Stanish WD, Kozey J, Kirby RL, McLeod DA, Perey BJ.
(Unpublished). Interventions
to control pain in the Degenerative Athletic Knee
#1 Local Pain Control i). Cryotherapy The intermittent use of ice,
particularly on the knee joint, has proven most successful in controlling the
exacerbation (inflammatory phase) within the degenerative athletic knee. The simple process of applying a packet of
frozen vegetables for a 20/30 minute period can be as effective as the
commercially available products that are more refined. (Ref: Melzack R, Wall PD. Pain Mechanisms: A New
Theory. Science 150, pp 971-979,
1965. Waylonis GW. The Physiological
Effects of Ice Massage. Archives Physical Medicine Rehabilitation, 48: 47-52,
1967) ii) Intra-articular Cortisone Injections Although an extremely useful
technique, the intermittent use of intra-articular cortisone should be
deployed with caution. The potential risks
of provoking hyaline cartilage degeneration, the hazards as they relate to
joint infections, and the limitations of cortisone should be fully discussed
and disclosed with the patient. (Ref: Postuma P, Stanish WD. The Intra-articular
and Periarticular Use of Corticosteroid in Knee and Shoulder. The Clinical
Journal of Sport Medicine, Vol. 4, No. 3, pp 155-159, July 1994.) iii) Electrical Stimulation The intermittent use of
transcutaneous electrical stimulation (TENS) has proven to be a popular
modality for the reduction of pain.
Acupuncture, acupressure and similar type interventions could be
explored. They are uniformly non
invasive and thus extremely safe and patient friendly. (Ref:
Stanish WD, Curwin S. Special Techniques in Rehabilitation. In: The
Crucial Ligaments. (ed) JA Feagin, Jr.
Churchill Livingstone, New York, Edinburgh, London, Melbourne, pp
773-781, 1988.) #2 Systemic
Pain Control i) Analgesics ii) Non-steroidal Anti-inflammatories Very frequently the deployment
of a simple pain medication can allow the athlete to continue to participate
in the face of a degenerative knee.
The patients are usually very compliant when it comes to the
intermittent use of a medication rather than accepting drugs that must be
used over a long period of time; i.e., non-steroidal
anti-inflammatories. Currently there
is some compelling evidence that suggests that anti-inflammatory medications
used over a prolonged period of time function as an anti-metabolite and may,
in fact, disturb the normal reparative process. (Ref: Non-steroidal Anti-inflammatory Drugs in
Sports Medicine; Weiler JM, Albright JP, Buckwalter JA. in: Non-Steroidal
Anti-Inflammatory Drugs. (ed) Lewis AJ, Furst DR, New York, Publisher -
Marcel Dekker, 1987, pp 71-88.
Management of Inflammation of the Knee; Stone J, Zarins B. In: Articular Cartilage in Knee Joint
Function; Basic Science in Arthroscopy, (ed) JW Ewing, Raven Press, pp
167-189. Simon LS. Actions in
Toxicity of Non Steroidal Anti-Inflammatory Drugs. Curr. Opin. in
Rheumatology, 1995, 7: 159-166. Brooks PM, Day RO. Non-Steroidal
Anti-Inflammatory Drugs - Differences and Similarities. New England Journal of Medicine, 99: 324,
pp 1716-1725.) Interventions to Control
Mechanical Overload in the Degenerative Athletic Knee
#1 Reduction in body weight Ongoing research suggests a
significant reduction in joint reaction force with the reduction in body
weight. This is particularly true if,
in fact, the athlete suffers with disturbed joint mechanics; i.e., genu
varus. (Ref: Biomechanical Gait Analysis of Morbidly
Obese Women, El Hawary R, Stanish WD, Kozey J, Kirby RL, McLeod DA, Perey BJ.
Proceedings of the Canadian Academy of Sports Medicine, Vancouver,
19997. Newton PM et al. The Effect of
Life Long Exercise on Canine Articular Cartilage. Am. J. Sports Medicine, 25:
282-287, 1997. Felson DT, et al.
Weight Loss Reduces the Risk for Symptomatic Knee Osteoarthrosis in Women.
The Framingham Study; Annals of Internal Medicine; 116(7), pp 535-539, 1992.) #2 Activity
and footwear modification (Ref: Cooper C et al. Mechanical and
Constitutional Risk Factors for Symptomatic Knee Osteoarthritis: Differences
Between Medial, Tibial, Femoral and Patello-Femoral Disease. J. of
Rheumatology, 21: 307-313, 1994.
Buckwalter JA, Lane NE.
Athletics and Osteoarthritis. AJSM 25(6), 1997, pp. 873-881.) #3 Knee
Bracing The unloader brace has proven
to be most popular and readily accepted by patients. The science may be soft, however ongoing
research provides convincing evidence of the ability to normalize joint
mechanics with the use of knee and foot orthoses. (Ref: Application of a Lateral Heel Wedge as a
Non Surgical Treatment for Varus Gonarthrosis; Giffin JR, Stanish WD,
MacKinnon S, MacLeod DA, J. of Prosthetics and Orthotics, Vol 7, No. 1,
Winter/1995. Effective Axial
Alignment of the Lower Extremity on Articular Cartilage of the Knee; Coventry
M. In: Articular Cartilage and Knee Joint Function, Basic Science in
Arthroscopy; (ed) JW and Raven Press, pp 311-317. Valgus Knee Bracing for Medial Gonarthrosis; Horlick SJ, Loomar
RL. Clinical Journal of Sports
Medicine, 1993, pp 251-255. Use of
Lateral Heel Wedges in the Treatment of Medial Osteoarthritis of the Knee;
Keating EM, et al. Orthopaedic
Review, 1993, 12: 921-924. Functional
Knee Braces and Dynamic Performance:
A Review. Kramer JF, et
al. Clinical Journal of Sports
Medicine; 7: 32-39, 1997.) The
Role of Surgery
#1. Arthroscopic excision of damaged cartilage
with penetration of subchondral bone. (Ref: Ewing JW. Arthroscopic Treatment of
Degenerative meniscal Lesions and Early Degenerative Arthritis of the Knee.
In: Articular cartilage and Knee Joint Function; Basic Science and
Arthroscopy, pp 137-145, (ed) JW Ewing, New York, Raven Press 1990. Johnson LL. Arthroscopic Abrasion
Arthroplasty. In: Operative
Arthroscopy. (ed) JB McGinty, Raven Press, Philadelphia 1996, pp.
427-446.) #2. Perichondral
Grafts (Ref: Hommings GN et al. Perichondral Grafting
for Cartilage Lesions of the Knee. JBJS 72B: 1003-1007, 1990.) #3. Autologous
Chondrocyte Transplantation (Ref: Brittberg et al. Treatment of Deep
Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation.
New England Journal of Medicine; 331: 889-895, 1994.) #4. Allograft (Ref: Gross AE. Fresh Small Fragment
Osteochondral Allografts Used for Post Traumatic Defects in the Knee Joint.
In: Biology and Biomechanics of the Traumatized Synovial Joint: The knee
as a model. pp. 123-141, American Academy of Orthopaedic Surgeons, 1992,
Rosemont, Illinois.) #5 Osteotomy (Ref: Insall et al. High Tibial Osteotomy for
Varus Gonarthrosis - A Long Term Follow-Up Study. JBJS 66A, pp. 1040-1048,
Sept. 1984. Proximal Tibial Osteotomy: A subjective outcome study; Nagel et
al, JBJS 1996, Sept. 78:1353-1358; Proximal Tibial Osteotomy: A critical
long-term study of 87 cases. Coventry MB, et al. JBJS 1993, Feb. 75:
196-201.) #6 Total Knee
Arthroplasty (Ref: Campbell's Operative Orthopaedics, 9th
Ed., 1998) Conclusions:
The potential disasters
#1 Treating the
pain component without adjusting the disturbed knee mechanics. #2 Performing
surgery without exhausting all non surgical measures. The presence of medial compartment
gonarthrosis does not justify a surgical intervention until the patient has
been fitted with a proper knee orthosis, has altered their activity, and has
been placed on a program of NSAID/analgesics prior to their athletic event. #3 Under
estimating the nature of the disease and/or the severity of the arthritic
process. it is disastrous to consider
a surgical procedure designed to unload a compartment of the knee when, in
fact, the joint surface facing new stresses is not healthy, thus unable to
accept the new load. (Ref: Oxford Textbook of Sports Medicine, 2nd
Ed. (ed) Mark Harries, Clyde Williams, William D. Stanish, Lyle J. Micheli;
Oxford Medical Publications, 1998.
The articular Cartilage and Knee Joint Function; Basic Science and
Arthroscopy, (ed) J. Ewing, Raven Press, 1990.)  Previous Lecture |
