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EFORT Instruction Course — Osteoarthritis: Joint Preserving Surgery of the Lower Extremity, Basel, 15 - 16 November 2013
Focus on joint preserving surgery
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An EFORT Instruction Course (IC) will be conducted in Basel in November 2013 on joint preserving surgery for the treatment of osteoarthritis (OA). This procedure continues to be widely unknown yet it allows the joint to be corrected biomechanically if the condition is diagnosed on time. This correction, in turn, postpones joint replacement by years or eliminates the need for it.
The course will be conducted by Prof. Dr. Victor Valderrabano, Director of the Orthopaedic Department at the University Hospital of Basel, who explains the importance of the topic.
Professor Valderrabano, OA sufferers have surgical options other than joint prostheses, a fact that is little known. What options are there in OA surgery today?
Prof. Valderrabano: A serious case of symptomatic OA should initially be treated conservatively. This approach can at most slow down the course of the disease because there is currently no cure for OA. When conservative treatment no longer suffices, the patient becomes a candidate for surgery. People usually think this involves replacing the joint with an endoprosthesis which is the standard therapy. There is an intermediate option, however; namely, joint preserving surgery.
Victor Valderrabano
What is the goal of joint preserving surgery as a treatment for OA?
Prof. Valderrabano: The goal of joint preserving surgery is to postpone the final stage of OA, when a prosthesis is warranted, as long as possible, preferably to the point where a prosthesis is no longer needed.
As mentioned before, this approach is not especially well known. Why is that? Is joint preserving surgery such a novel treatment for OA?
Prof. Valderrabano: This procedure has a long tradition. Before prostheses were put on the market, a large number of joint preserving surgeries were carried out. That fact has unfortunately been forgotten to a certain extent, for various reasons. One is that excellent prostheses are available today for a wide variety of possible uses. Another is that joint preserving surgery of the old classic variety was unable to do what we can do today. As a result, the possibilities of conservative surgery are less well known today. That is why many general practitioners as well as orthopaedists send patients to surgery too late. They wait as long as possible and then resort to joint replacement.
Why has joint preserving surgery become better? What can you do today that they were unable to do in the era before endoprostheses?
Prof. Valderrabano: In earlier times, there was the problem that X-raying was the only available type of medical imaging, which of course is needed for diagnosis. Indications were therefore difficult to determine. X-rays do not show very much in the stages of OA where joint preserving surgery would be advisable. Today we have magnetic resonance imaging (MRI) as well as single photon emission computed tomography combined with computed tomography, known as SPECT-CT. These technologies allow us to detect OA at an extremely early stage. We see incipient, local, asymmetric OA. And based on this information, we can conduct joint preserving surgery.
What does surgery of this kind entail?
Prof. Valderrabano: The task is to stabilize the joint biomechanically, i.e., to convert it from a pathological biomechanical state to as physiological a state as possible. This means, for example, that a joint that is askew and subject to asymmetric stresses is brought into as symmetric a state as possible by means of osteotomies and corrections of the ligaments in order to relieve the damaged area with OA. This procedure alone leads to a certain degree of recovery, which can be further supported by surgery on cartilage and which is supported in many cases. In other words, you first restore the mechanical functioning of the joint to as normal a physiological level as possible and then transplant cartilage. So, reconstructive surgery comes first, followed by cartilage surgery.
What are the advantages of these procedures? Does it really make sense to use such elaborate treatments when highly effective prostheses are available anyway?
Prof. Valderrabano: The advantage is that patients do not have any metal in their body after joint preserving surgery, which is otherwise a potential source of problems. In addition, patients preserve their proprioception and gain time. If you have a case of unilateral OA in your knee and do nothing about it, you could need a prosthesis at age 50 or 60. If you undergo joint preserving surgery, you won’t need the prosthesis until you reach the age of 70 or maybe not even at all. Studies have investigated the question of how many years you gain. However, the results were extremely divergent because the course of these conditions can vary greatly from case to case, from joint to joint and depending on the relative severity of the case. The study results indicate a gain in time of five to 15 years.
That all sounds quite complicated. Is joint preserving surgery difficult for surgeons?
Prof. Valderrabano: It requires a certain degree of biomechanical know-how; you need experience in orthopaedic surgery and you have to have learned that. That is why we are conducting our course in Basel. We cover the most important indications for joint preserving surgery, i.e., the lower extremity with hips, knee and ankle. These joints are subject to the greatest strain from gravity and are most frequently the site of mechanical damage. That is why they are well-suited for joint preserving surgery. Of course, we also operate on the upper extremity as well at our centre.
Osteoarthritis naturally has an inflammatory component as well as a mechanical one. What does this mean for surgical treatment?
Prof. Valderrabano: Basically speaking, every case of OA entails inflammation. This inflammation disappears as soon as you improve the mechanical situation, i.e., eliminate the cause of inflammation. In addition, we try to improve the situation by using chondroprotectants such as hyaluronic acid. However, in cases involving a considerably inflammatory component of OA, possibly even a systemic inflammatory component, joint preserving surgery is frequently not the procedure of choice. Its strength lies in the treatment of OA with a clearly mechanical background, for instance, for posttraumatic conditions or in cases of axis deviation. It has a certain relative though limited importance for systemic arthritis. In our population of patients about 30% to 40% are candidates for joint preserving interventions.
What do you think the future is for surgical treatment of osteoarthritis?
Prof Valderrabano: I think that in a few decades we will be in a position to cultivate artificial joints from a patient’s own tissue. I could still be around to benefit from that. If I should contract OA before that, I would want to undergo joint preserving surgery conducted by superbly trained surgeons.
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For further information about the IC in Basel: www.efort.org/ic-basel2013