Physician’s Weekly: online CME courses, articles on hypertension, arthritis

Total knee arthroplasty (TKA) is performed in over 500,000 patients with end-stage knee arthritis each year, and a recent study projected a 673% increase in the demand for TKA by 2030. Baby boomers and the current obesity epidemic play significant roles in the predicted increase. Additionally, physicians are treating a greater number of patients in their 40s and 50s due to past athletic or trauma injuries such as meniscal and ligament tears. These injuries can predispose patients to developing severe end-stage knee arthritis at a younger age. As a result, physicians should be prepared to treat more patients with this disabling disease and learn about alternative surgical treatment options that best suit patients’ individual needs.

Although TKA often provides relief for patients with knee arthritis, the durability of knee replacements in younger patients appears to yield poorer results. A recent 5-year study evaluating TKA in patients younger than 40 found that their average flexion was just 110°. In addition, 10% of these patients required revision surgeries to address component loosening. Wear and osteolysis have been associated with replacements performed with outdated materials, including polyethylene sterilized by gamma irradiation in air. This latter material has since been replaced by gamma sterilization without oxygen, a procedure that has improved polyethylene durability.

Improved Techniques & Alternatives

My colleagues and I presented a lecture at the American Academy of Orthopaedic Surgeons annual meeting in 2008 in which we discussed choices and compromises for treatments of knee arthritis in baby boomers. We wanted to educate physicians on surgical and non-surgical treatments for tibial-femoral and patella-femoral arthritis and unicompartmental arthroplasty. We also wanted to make physicians aware of how improved techniques in TKA can lead to more durable results.

In our lecture, we emphasized that NSAIDS and exercise should always be encouraged before surgical treatment. Before considering surgery, orthopedists need to evaluate the mechanical alignment of each individual knee arthritis case. For example, in younger patients with knee arthritis, bowed legs may develop. An osteotomy can realign the tibia and femur to take the stress off of the damaged cartilage. Surgery outcomes in patients with poor mechanical alignment often fail in the long term.

Finding Alternatives

Treatment in patients with tibial-femoral arthritis should focus on exercises that improve muscular strength, endurance, joint flexibility, and range of motion. Medication or injections may also be used to provide short-term relief. Surgical options in younger patients include allograft resurfacing (performed on patients with larger lesions and bone loss), arthroscopic debridement, marrow stimulation, autologous chondrocyte transplantation, and tibial osteotomy. Pain management, physical therapy, and bracing are recommended as first-line treatment for patella-femoral arthritis. If non-surgical treatment fails, arthroscopy can be used to release lateral retinacular structure or cartilage debridement may be necessary. Autologous cartilage resurfacing has also been another alternative explored for this condition.

Unicompartmental knee arthroplasty (UKA) is typically considered at the same time as TKA. However, UKA retains the cruciate ligaments; this can provide better range of motion and function. In addition, patients who undergo UKA don’t typically require as extensive postoperative physical therapy when compared with those receiving TKA. However, the indications for unicompartmental replacements are limited. In those patients not indicated for UKA, total knee replacement is recommended.

Further research is required to evaluate the best approaches for younger patients presenting with end-stage arthritis. Individual circumstances, disease severity, and alignment should always be considered before surgical options are selected.

John J. Callaghan, MD, has indicated to Physician’s Weekly that he has received royalties from DePuy.