Dr Christopher Vertullo
MBBS FRACS Orth
A 52 year old male carpenter is referred by his GP after failing non-operative rehabilitation with his physio for Left medial knee osteoarthritic pain. His pain on a VAS is between 4-6/10, with a fair score on a Lysholm Knee Score of 60/100. He stopped running sports 5 years prior, due to medial pain. He stopped pivoting sports over 15 years earlier. At age 25 years he tore his Anterior Cruciate Ligament; however, this was never reconstructed, and he underwent a partial medial meniscectomy 10 years ago.
On examination, his BMI is 27, walks with a varus thrust and his alignment is in varus (bow-legged). His Anterior Cruciate Ligament is incompetent with a Grade III Lachman test and a marked Pivot shift. He indicates medial pain. He has full range of motion and intact distal pulses.
Plain radiographs show severe medial compartment osteoarthritis, and the MRI confirms a partially absent medial meniscus with extrusion. The Patellofemoral compartment and lateral compartment are normal on MRI. He is in 5 degrees of mechanical axis varus on alignment XRays.
What are his operative options ?
Always using a joint preserving approach in young patients, particularly males, is the ideal approach. An Arthroscopy is not going to help him as his problem is a combination of medial osteoarthritis and instability. Multiple randomized controlled trials suggest Arthroscopy does not help osteoarthritis symptoms. A Unicompartmental Replacement (UKR) is contraindicated due to the Anterior Cruciate Ligament deficiency and while some surgeons undertake combined ACLR and UKR, that is a very controversial procedure in any age group, particularly young males.
A Total Knee Replacement would be a possible option, but at 52 he is very young for this. The AOA National Joint Replacement Registry would suggest a male under 55 years would have a failure rate of about 8-10% by the 10th year post implantation. Given his lateral and patellofemoral compartments are well preserved, TKR would be a reasonable option if he was over 60-65, and happy to not run or jump ever again.
A combined High Tibial Osteotomy (HTO) and ACL Reconstruction would offer him the best chance of a stable high functioning knee. This is a technically demanding procedure, requiring at least 6 weeks touch weight bearing after the surgery. Full recovery can take between 6-9 months. Most patients can return to work at between 2 and 6 weeks after the procedure. The correction can be achieved by either doing an opening wedge (as seen in the photo), or a closing wedge. Closing wedge HTO was previously the most common technique; however, the opening wedge is now more common. Usually some chondral restoration is undertaken, often micro-drilling augmented with PRP.
For more information visit http://www.knee-surgeon.net.au/osteotomy-chondral-restoration/