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Joint preservation remains a popular concept, but demands clear indications
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Joint preservation is an emerging field in orthopaedics that evolved primarily in response to the limitations in joint replacement technology. Orthopaedic surgeons have turned to joint preservation as a way to prevent or delay the onset of osteoarthritis or other degenerative conditions affecting the joints, particularly in young patients.
“Fifty years ago, everybody went to total hip replacement (THR) and then osteotomies and other joint preserving techniques were almost abandoned because total hips were believed to be so successful. But, we had to find out that in the young cohort of patients, severe problems can occur with THR,” Michael Leunig, MD, head of orthopaedics at Schulthess Klinik, in Zurich, said.
“If you understand what pathomorphology you have to address, joint preservation can be a very efficient procedure to prevent or at least delay osteoarthritis (OA) and make patients have much less pain,” Leunig told Orthopaedics Today Europe
If young patients with degenerative joints have unreasonable expectations from joint preserving procedures, Michael Leunig, MD, of Zurich, said it is essential to explain how limited their treatment options are.
Image: Craven J, Orthopaedics Today Europe
Leunig has worked closely with Reinhold Ganz, MD, since Ganz pioneered the periacetabular osteotomy (PAO) in 1984, a technique that has been a great asset in the field of joint preservation, according to Leunig.
Leunig explained earlier types of pelvic osteotomies tried to achieve similar goals with respect to acetabular reorientation but revealed several limitations.
“Since we now have the PAO, we have a very efficient way to optimize coverage of the femoral head,” Leunig said. The difference between Ganz’s osteotomy and previous ones is correction of the fragment can be performed with high precision and patients can weight bear and mobilize earlier due to an inherent stability of the osteotomized fragment, according to Leunig.
While a great technique for treating hip instability, and less frequently for hip impingement, PAO is a technically demanding procedure, Leunig said. After spending considerable energy performing the bone cuts that are integral to PAO, surgeons can make mistakes in the most crucial part of the procedure — the correction, he said, noting correction is the reason the PAO was originally done.
Role of hip arthroscopy
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Frequently, hip preservation can be achieved through arthroscopy. Once considered just a diagnostic tool used in conjunction with imaging, this “keyhole surgery” is now frequently employed to correct articular damage, impingement and sequelae of impingement, such as labral or chondral tears in the hip joint.
“The techniques are being refined: every passing year, the technique is getting easier and more predictable,” said Ali Bajwa, MPhil, FRCS(Orth), who works in partnership with Richard N. Villar, FRCS, a pioneer in joint preserving hip arthroscopy. “In our setting, joint replacement is a failure of our treatment, so we take hip arthroscopy very seriously and then we fight right until the end to preserve the joint,” said Bajwa, an orthopaedic consultant at Spire Cambridge Lea Hospital and the Richard Villar Practice in London and Cambridge, United Kingdom.
At Villar’s practice, hip joint preservation focuses on resolving femoroacetabular impingement, carrying out cartilage repair and regeneration, treating tendinopathies of the gluteus medius and iliopsoas tendons and performing sciatic nerve or piriformis release. Labral and chondral tears resulting from hip impingement are also treated, Bajwa said.
Young, active patients
Concerning the diagnosis, Leunig cautions that although hip arthroscopy can be effective, the problem of first diagnosing the patient’s condition remains. That, he said, requires a sharper eye and more knowledge than performing typical THR.
“If it is difficult to identify the exact problem the patient has, then the surgery is difficult and the result unpredictable. It is much more difficult than a THR, for example, where clinical and radiographic signs and symptoms are much better defined,” Leunig said. What is more, most patients with these problems are young, very active and with high demand. They often have unrealistically high expectations of the surgery, Leunig said, adding that it helps in dealing with this patient population to explain the limited options available to someone with a degenerative joint.
“If you already have cartilage damage that you cannot reverse completely, then a surgeon can only try to lessen symptoms and delay the degenerative process,” Leunig said.
Maurilio Marcacci
Conservative therapy
Not every surgeon agrees joint preservation starts with minimally invasive surgery. Maurilio Marcacci, MD, head of 3rd Orthopaedic and Traumatologic Clinic and Biomechanics Laboratory at Rizzoli Orthopaedic Institute in Bologna, said any surgical intervention using a prosthesis — such as unicompartmental knee arthroplasty — is not joint preserving. The focus should be on treating the knee joint directly, as well as managing the other factors that influence joint deterioration, he told Orthopaedics Today Europe.
“Joint preserving means to understand better, at least, the reason why a joint is going to deteriorate,” Marcacci said. “If you have malalignment, if you have a clubfoot, a malrotated hip, a neurological problem, you have to treat all of them to avoid the damage of the joint.”
To slow joint degeneration or preserve any joint, from the knee and hip to the shoulder, elbow and ankle, Marcacci recommended orthopaedic surgeons thoroughly explore conservative treatment possibilities before deciding to perform surgery. “That means prevention. That means rehabilitation. That means early surgery. But most of all, it is more comprehension of clinical biomechanics” or joint dynamics, he said.
Ligament reconstruction
Addressing the soft tissue also has a place in joint preservation. Experts interviewed told Orthopaedics Today Europe that ligament reconstruction in sports medicine and for traditional joint pathology is essential to combat joint degeneration. However, preserving or addressing every ligament is not always the most efficient surgical course, according to Philippe Neyret, MD, PhD, an Orthopaedics Today Europe Editorial Board member.
“To perform an ACL reconstruction is a kind of preservation of the joint because you preserve the meniscus,” Neyret, of Lyon, France, said. “The normal idea is to treat the patients in a manner to preserve as much anatomical function as possible — this is the ideal, just to replace what is torn and preserve what is healthy, but it does not work in every field.”
Sometimes preserving the PCL is unnecessary, especially since it is still not well understood how the ligament contributes to anatomical function, Neyret, second vice president elect of the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine, said. In a 2012 study, Joglekar and colleagues found no significant difference in gait between patients with cruciate-substituting or posterior stabilizing total knee arthroplasty (TKA) implants, who have the PCL sacrificed, and patients with cruciate-retaining implants where it is preserved.
The “less is more concept” in joint preservation also encompasses steroidal and hyaluronic acid (HA) injections, which surgeons like Bajwa consider part of the joint preservation options. In a 2012 systematic review of HA injections in all joints except the knee, Colen and colleagues concluded injections were useful in treating OA, but their effectiveness was unclear compared to more mainstream treatments such as corticosteroids and physiotherapy.
Bajwa said his group does not treat the hip joint with steroids because it damages cartilage, which can be counterproductive in the management of joint problems in young, active patients. But occasionally, when surgeons repair labral tears they use platelet-rich plasma (PRP), he said.
Hyaluronic acid
HA injection has been more effective than steroids or PRP, Bajwa said, adding the UK’s National Institute for Health and Clinical Excellence does not recommend HA injections for joint preservation. “We have used it in the hip joint and our results seem to indicate that our patients need fewer painkillers afterward and it supports early return to function,” he said.
According to Neyret, injections are useful in halting progression of degenerative joint disease but patients react to them differently, so it is not an effective means of managing symptoms long-term. “This is a temporary technique to allow the patient to briefly stay at his full function for a short time,” he said.
With the knowledge that a patient will eventually need an osteotomy or TKA, delaying symptoms for several months with an injection can provide a period of pain relief before an invasive procedure is necessary, Neyret said.
Evaluating results
There are a variety of methods to determine how well an intervention helped preserve a joint. In addition to MRI and radiographs, Leunig regularly assesses his joint preservation efforts with objective and subjective outcome measures, including patient-reported outcome measures or PROMs. “The satisfaction and how a patient thinks about his treatment are very much related to his subjective feelings.”
Leunig said the patient knows why we did what we did and what we expected. Therefore, whether he can resume the activities he did before, and whether he has pain or not, has a lot to do with the expectations and results. “Unfortunately, not advising they resume the activity level they had before surgery is considered a poor outcome or failure in the literature, despite a less aggressive use of the hip joint after such a procedure, which might be important for long-term survival of such a procedure,” Leunig said.
Return to sports is a doubtful measure of success, he said. “It is very important for us to understand that and also to understand what type of procedures — what type of clinical problems — can be solved in a successful way.”
For knee joint preserving procedures, Neyret uses the International Knee Documentation Committee score, but said the UCLA score measures activity well, but the Noble score is better for sports cases. To measure the extent of OA, the Knee Injury and Osteoarthritis Outcome Score is useful, but, he said, combining scores in a study is the best way to gauge results.
According to Marcacci, psychological treatment is as important as the other aspects of conservative therapy, especially in sports medicine. An athlete with a more positive outlook almost always performs better in nonoperative treatment than one who is uncooperative or does not believe a treatment will help return their function. A surgeon with a positive attitude also goes a long way toward building confidence and helping patients succeed, Marcacci added.
“If you do not have a good psychological construct, [then] you will not have a good result,” he said.
Preservation of joint cartilage
In the past 20 years imaging and the field of cartilage repair have improved considerably, but such progress still has not resulted in a much-needed breakthrough in cartilage preservation, Neyret said. Autologous chondrocyte implantation (ACI) for early OA is one of the more promising procedures available, he said.
Minas and colleagues recommend ACI to effectively delay joint replacement based on the study they published in 2010 of 153 patients prospectively followed up for 5 years, which showed significant functional improvement and pain reduction.
However, knee cartilage repair techniques that involve an implantation process were developed for very specific indications and are not good all-around cartilage repair or preservation solutions, Neyret said. Improvements and further research in this area, therefore, should be directed not at the cartilage, but at prevention of osteogenesis in subchondral bone, he said.
Future of preservation
Shoulder joint preservation efforts are starting to emerge, but there are few data to support the current procedures used to treat conditions like posterior shoulder instability. A study published in 2010 by Engelsma and colleagues concluded arthroscopic thermal capsular shrinkage, an early attempt at shoulder joint preservation meant to shrink the soft tissue in the shoulder, was abandoned due to poor results in favor of labral refixation and capsulorrhaphy techniques that were considered safe and effective.
Ankle joint preservation options are also limited. “The ankle is very often traumatized where you have lesions of the bone or the cartilage because of previous trauma,” Marcacci said. “The best prevention for this is a good foot with dynamic and muscular control of the movements, or proprioception; this is very important for preservation of the ankle.”
In the literature, ankle distraction arthroplasty showed promising results as an alternative to fusion. The joint space-extending procedure maintains motion and has been successful for ankle arthritis. Tellisi and colleagues found in a 2009 study that 91% of patients treated with distraction arthroplasty for this indication had improved pain and those with the longest follow-up demonstrated the best results.
Although joint preservation courses are being held more regularly, Leunig cautioned that surgeons eager to use these newer techniques need proper instruction in joint mechanics and how to execute such complicated procedures. “We deal with a very young, highly active population who has still many years to go … so when you do something in this group you have to be really sure you did the right thing,” he said. “That is a big challenge.” – by Jeff Craven
References:
- Colen S, Haverkamp D, Mulier M, van den Bekerom MP. Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: What is the current evidence? BioDrugs. 2012;26:101-112.
- Engelsma Y, Willems WJ. Arthroscopic stabilization of posterior shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2010; 18:1762-1766.
- Joglekar S, Gioe TJ, Yoon P, Schwartz MH. Gait analysis comparison of cruciate retaining and substituting TKA following PCL sacrifice. Knee. 2012;19:279-285.
- Minas T, Gomoll AH, Solhpour S, et al. Autologous chondrocyte implantation for joint preservation in patients with early osteoarthritis. Clin Orthop Relat Res. 2010;468:147-157.
- Tellisi N, Fragomen AT, Kleinman D, et al. Joint preservation of the osteoarthritic ankle using distraction arthroplasty. Foot Ankle Int. 2009;30:318-325.
For more information:
- Ali Bajwa, MPhil, FRCS(Orth), can be reached at Richard Villar Practice, Spire Cambridge Lea Hospital, 30 New Rd., Impington, Cambridge, UK; email: alibajwa@doctors.org.uk.
- Michael Leunig, MD,can be reached at Lengghalde 2, CH-8008 Zurich, Switzerland; email: michael.leunig@kws.ch.
- Maurillio Marcacci, MD, can be reached at Via di Barbiano, 1/10, Bologna, Italy; email: m.marcacci@biomec.ior.it.
- Philippe Neyret, MD, PhD, can be reached at the Hospital of the Croix-Rousse, 8 Rue de Margnolles, Lyon, France; email: philippe.neyret@chu-lyon.fr.
Disclosures:
- Bajwa teaches hip arthroscopy courses for Smith & Nephew, for which he is uncompensated. Marcacci receives royalties and funding from Finceramica, SPA. Leunig and Neyret have no relevant financial disclosures.
What results do you expect from a successful joint preservation procedure? Why?
Objective assessment of the joint
Norimasa Nakamura
I expect a successful joint preservation procedure to prevent the development of osteoarthritis. This can be evaluated through imaging, such as X-ray and MRI. This is one way to assess a successful joint preservation procedure in patients, but such an assessment should also be accompanied by determining the patient’s satisfaction with the procedure as measured by high self-assessment scores, such as with the Knee Injury and Osteoarthritis Outcome Score, and the International Knee Documentation Committee scoring systems.
However, joint preservation can only be assessed after years of long-term follow-up. Furthermore, it can most clearly be evaluated not by subjective scoring alone but by the objective assessment of the condition of the joint.
Norimasa Nakamura, MD, PhD, is an orthopaedic surgeon at Osaka University Graduate School of Medicine, Osaka, Japan.
Disclosure: Nakamura has no relevant financial disclosures.
Balancing patient, surgeon outcomes
Oliver Marin-Peña
The term “successful” in joint preservation surgery should be considered from the patient’s point of view and from the orthopaedic surgeon’s point of view. As hip preserving surgeons, we are focused on keeping a joint pain-free to avoid implanting a total hip arthroplasty prosthesis as long as possible. By contrast, young active patients’ expectations are higher than surgeons realize. The huge amount of information collected by these patients before surgery contributes to their increased expectations regarding quick recovery and sport practice after joint preserving surgery. These high expectations are not actually supported by the published mid-term results.
The mismatch between surgeon and patient expectations should be minimized through an accurate physical exam that rules out other sources of pain separate from the hip joint. Pain from the lumbar spine, trochanteric region, pubalgia and sciatic compression syndrome are commonly associated with pain from the hip joint.
Patient preoperative information should be an important factor to approximate the expectations between patients and surgeons. An in-depth conversation with the patient could clarify possible misunderstandings on the source of pain that mainly could improve after hip preserving surgery and what pain is likely not able to improve.
Oliver Marin-Peña, MD, is an orthopaedic surgeon at University Hospital Infanta Leonor in Madrid.
Disclosure: Marin-Peña has no relevant financial disclosures.