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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 124-127

Joint preservation in a middle-aged man with knee osteoarthritis, using novel techniques


Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission09-May-2019
Date of Acceptance11-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Abhishek Vaish
Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_21_19

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  Abstract 


The incidence of knee osteoarthritis (KOA) is on the rise and is affecting the younger population. The treatment of these younger individuals is challenging, and the treatment strategies should involve techniques to postpone or alleviate the need for joint replacement for these people. Regenerative treatment methods are useful and effective in the management of KOA at an early age. We present a case of a middle-aged man with KOA, who was managed by combined procedures of the proximal fibular osteotomy, microfracture of the cartilage lesion, and bone marrow aspirate concentrate.

Keywords: Bone marrow aspirate concentrate, cartilage injury, knee preservation, microfracture, osteoarthritis, proximal fibular osteotomy


How to cite this article:
Fooladi S, Vaish A, Nigam Y, Vaishya R. Joint preservation in a middle-aged man with knee osteoarthritis, using novel techniques. Apollo Med 2019;16:124-7

How to cite this URL:
Fooladi S, Vaish A, Nigam Y, Vaishya R. Joint preservation in a middle-aged man with knee osteoarthritis, using novel techniques. Apollo Med [serial online] 2019 [cited 2019 Dec 8];16:124-7. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/124/260684




  Introduction Top


Knee osteoarthritis (KOA) is one of the most common causes of disability in the musculoskeletal system. With changing lifestyle and increased focus on sports, knee injuries and arthritis are on the rise. In younger individuals, it is quite challenging to manage joint degeneration, and the joint preservation is considered necessary to alleviate or postpone the need for arthroplasty in younger age. Many nonoperative and operative methods are known to manage younger individuals with KOA. The nonoperative management can be useful in the initial stages and cases where there is minimal deformity of the knee. There are two common problems in the degenerative joint disease, namely change in the biomechanics of the knee and injury to the cartilage. If these two factors can be taken care of, the knee joint can be preserved. In KOA, the most common deformity is a genu varum deformity due to the involvement of the medial compartment of the knee. There is ample of published literature to show the efficacy of corrective high tibial osteotomy (HTO) to restore the knee alignment, but the HTO has some potential disadvantages after surgery.[1],[2],[3],[4] Recently, the new innovative technique of proximal fibular osteotomy (PFO) has shown promising results, as an alternative to HTO, to relieve knee pain and to correct the varus deformity in KOA. Furthermore, there are numerous techniques to repair cartilage lesions. These techniques in isolation are liable to fail early if there is an existing varus malalignment of the knee due to KOA, and otherwise, the combination of realignment surgery with cartilage repair technique is likely to provide favorable outcomes.

We present a case of a middle-aged active individual with early onset of KOA, with varus malalignment, which was successfully managed with PFO and bone marrow aspirate concentrate (BMAC).


  Case Report Top


A 47-year-old gentleman presented with progressive right knee pain for 1 year, which was gradually deteriorating so much so that he could not do many of his activities of daily living and sporting activities such as playing golf. Local examination revealed medial joint line tenderness and varus deformity of 10°. The anteroposterior plain radiograph showed medial joint space reduction [Figure 1]. Magnetic resonance imaging revealed cartilage lesion with an underlying bone marrow edema in the medial femoral condyle and trochlear region of 3 cm × 3 cm in size [Figure 2].
Figure 1: The anteroposterior plain radiograph showed medial joint space reduction

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Figure 2: Magnetic resonance imaging revealed cartilage lesion with an underlying bone marrow edema in the medial femoral condyle and trochlear region of 3 cm × 3 cm in size

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Since the patient was relatively young and active, treatment options were discussed in detail, and the joint preservation was preferred. Right knee arthroscopy was done to debride the joint and stabilize the degenerated edges of the menisci. It was followed by microdrilling [Figure 3] and BMAC injection over the chondral defects [Figure 4], through a mini-open arthrotomy. The malalignment was corrected in the same sitting using PFO. BMAC injection was prepared by taking 50 ml of bone marrow from the iliac crest [Figure 5] and was then centrifuged in a commercial machine to achieve a buffy layer, containing mesenchymal cells. The postoperative radiographs [Figure 6]a and [Figure 6]b revealed opening up of the medial joint space after PFO.
Figure 3: Microdrilling at the medial femoral defect

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Figure 4: Bone marrow aspirate concentrate injection over the chondral defects through a mini-open arthrotomy

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Figure 5: Bone marrow aspirate concentrate injection was prepared by taking 50 ml of bone marrow from the iliac crest

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Figure 6: The anteroposterior (a) and lateral (b) postoperative radiographs revealed opening up of the medial joint space after proximal fibular osteotomy

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In the immediate postoperative period, the patient reported significant pain relief. He was instructed to walk nonweight-bearing with the help of a walker and a range of motion knee brace for 6 weeks to protect the newly generated cartilage tissue.

At 12-month follow-up, the patient has been doing well with a good functional outcome. Now, he seldom gets knee pain and has gone back to playing golf.


  Discussion Top


Lower-limb alignment plays an important role in the static and dynamic loading of the knee joint. Changes in the axial leg alignment can affect knee kinematics, contact forces, and overall gait.[5] Hsu et al. demonstrated that even a small change in the mechanical axis caused significant changes in the load distribution in the knee joint. Individuals with varus alignment are exposed to higher stress in the medial compartment of the knee.[6] Some individuals suffer from malalignment indirectly due to OA caused by obesity or trauma, whereas others suffer from OA due to malalignment directly. In both the situations, cartilage damage occurs as a progressive failure which subsequently results in increased malalignment.[7] Hence, the correction of malalignment is of paramount importance not only to relieve pain but also to retard the progress of KOA. HTO has been a gold standard in the treatment of varus malalignment in KOA. It has several advantages, but this procedure is complex, relatively expensive, and rehabilitation.[8],[9],[10] Some of the other disadvantages of HTO include increased risk of nonunion surgical wound infection, delay of patients undergoing full weight-bearing, peroneal nerve paralysis,[3],[4] complications related to the usage of metal plate, infection, and loss of correction angle.[10],[11]

PFO is a newer technique showing promising short-to-midterm functional outcomes in KOA. Zhang showed that PFO restored joint space on the medial side of the knee, which improved joint function, and relieving pain.[12] According to him, patients with severe varus knee deformity when treated with other modalities such as HTO had equivocal results, if not superior to PFO. Furthermore, PFO is a safe, quick, simple technique, which requires no additional implant insertion, and the patients can be mobilized full weight-bearing immediately. Therefore, PFO could be an alternative procedure for KOA and has become a popular procedure in the Eastern world (China and India, etc.).[13] Zhang et al.[12] reported the use of PFO as effective as HTO, and it has become the new choice of surgical procedure to improve joint function in patients with KOA to reduce pain and as reported by Yang et al.[14]

Total knee arthroplasty (TKA) is beneficial in patients with end-stage KOA. However, TKA is an expensive and complex procedure and is not a preferred choice in younger individuals as some patients require multiple revisions in the future.

The other problem encountered in young patients with knee pain is articular cartilage damage, which needs to be addressed preferably by a method of regenerative treatment, to avoid the need for TKA in the early part of life. The goal of surgical repair is to regenerate nearly healthy chondral tissue. Microfracture is the oldest and the simplest type of cartilage repair procedure known, but it is indicated for low-demand individuals with smaller lesions, as it produces fibrocartilage which has poor shear yield properties and tends to fail in short-to-medium term. Autologous chondrocyte implantation has an advantage that it produces better quality and durable hyaline-like cartilage. However, it is a two-stage and a costly procedure, which may not be available universally to most surgeons. Osteochondral autograft transplantation is a one-stage procedure and restores hyaline cartilage, but there is a problem of donor-site morbidity. Hence, the treatment decision should be based on the patient's activity level, age, cause, size and depth of the cartilage damages, and presence of combined defects.[15]

However, if the cartilage damage is associated with any malalignment, it should be tackled by both techniques of correction of malalignment and the repair of the chondral defect, as it was done in this case, using PFO and BMAC. These simultaneous procedures have not been described adequately in the literature, and hence, we have presented this newer innovative and less invasive technique of PFO instead of the conventional HTO, with cartilage repair using BMAC, to achieve similar results. Our technique is less invasive, economical, and patient-friendly. We believe that joint preservation is the way forward in a younger patient with cartilage damage and KOA, provided that the patient selection is correct.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Duivenvoorden T, Brouwer RW, Baan A, Bos PK, Reijman M, Bierma-Zeinstra SM, et al. Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: A randomized controlled trial with a six-year follow-up. J Bone Joint Surg Am 2014;96:1425-32.  Back to cited text no. 1
    
2.
Laprade RF, Spiridonov SI, Nystrom LM, Jansson KS. Prospective outcomes of young and middle-aged adults with medial compartment osteoarthritis treated with a proximal tibial opening wedge osteotomy. Arthroscopy 2012;28:354-64.  Back to cited text no. 2
    
3.
Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint Surg Am 2003;85-A: 469-74.  Back to cited text no. 3
    
4.
Dahl AW, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthop 2010;81:161-4.  Back to cited text no. 4
    
5.
Kendoff D, Board TN, Citak M, Gardner MJ, Hankemeier S, Ostermeier S, et al. Navigated lower limb axis measurements: Influence of mechanical weight-bearing simulation. J Orthopaed Res 2008;26:553-61.  Back to cited text no. 5
    
6.
Hsu RW, Himeno S, Coventry MB, Chao EY. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clin Orthop Relat Res 1990;255:215-27.  Back to cited text no. 6
    
7.
Chantarapanich N, Nanakorn P, Chernchujit B, Sitthiseripratip K. A finite element study of stress distributions in normal and osteoarthritic knee joints. J Med Assoc Thai 2009;92 Suppl 6:S97-103.  Back to cited text no. 7
    
8.
Sabzevari S, Ebrahimpour A, Roudi MK, Kachooei AR. High tibial osteotomy: A systematic review and current concept. Arch Bone Jt Surg 2016;4:204-12.  Back to cited text no. 8
    
9.
Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 1987;69:745-9.  Back to cited text no. 9
    
10.
Woodacre T, Ricketts M, Evans JT, Pavlou G, Schranz P, Hockings M, et al. Complications associated with opening wedge high tibial osteotomy – A review of the literature and of 15 years of experience. Knee 2016;23:276-82.  Back to cited text no. 10
    
11.
Kyung HS, Lee BJ, Kim JW, Yoon SD. Biplanar open wedge high tibial osteotomy in the medial compartment osteoarthritis of the knee joint: Comparison between the aescula and tomoFix plate. Clin Orthop Surg 2015;7:185-90.  Back to cited text no. 11
    
12.
Zhang YZ. Innovations in orthopedics and traumatology in China. Chin Med J (Engl) 2015;128:2841-2.  Back to cited text no. 12
    
13.
Wang X, Wei L, Lv Z, Zhao B, Duan Z, Wu W, et al. Proximal fibular osteotomy: A new surgery for pain relief and improvement of joint function in patients with knee osteoarthritis. J Int Med Res 2017;45:282-9.  Back to cited text no. 13
    
14.
Yang ZY, Chen W, Li CX, Wang J, Shao DC, Hou ZY, et al. Medial compartment decompression by fibular osteotomy to treat medial compartment knee osteoarthritis: A pilot study. Orthopedics 2015;38:e1110-4.  Back to cited text no. 14
    
15.
Seo SS, Kim CW, Jung DW. Management of focal chondral lesion in the knee joint. Knee Surg Relat Res 2011;23:185-96.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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