INTRODUCTION — The goals of the surgical management of patients with osteoarthritis (OA) are to reduce or eliminate pain, minimize disability, and improve quality of life. Treatments should be individualized to the patient's functional status, disease severity, occupational and vocational needs, and the nature of any coexisting medical problems. The patient's expectations should be discussed to ensure they are realistic.
Surgical interventions for patients with OA are generally reserved for those who have failed less invasive modes of therapy. This topic will review the effectiveness of surgical approaches used to treat OA. Pharmacologic and nonpharmacologic approaches to the treatment of OA other than surgery are presented separately. (See "Overview of the management of osteoarthritis" and "Management of moderate to severe knee osteoarthritis", section on 'Refractory symptoms'.)
GENERAL PRINCIPLES — Total joint arthroplasty (replacement) is the definitive treatment for osteoarthritis (OA) in patients who have failed nonoperative interventions. The indications for pursuing a total knee or hip arthroplasty are discussed in detail separately (see "Total knee arthroplasty", section on 'Indications' and "Total hip arthroplasty", section on 'Indications'). In addition, a variety of other surgical procedures may be considered in selected patients with OA, including unicompartmental knee arthroplasty, hip resurfacing, and osteotomies around the knee and hip.
Surgical procedures that have been used to treat OA that are generally not recommended include joint irrigation, arthroscopic debridement, arthroscopic abrasion arthroplasty, and arthroscopic synovectomy. Cartilage restoration procedures, which may be helpful with focal cartilage defects, are also not recommended for the treatment of OA. There may be a role for arthroscopic debridement in younger patients with a labral tear or femoroacetabular impingement (FAI) of the hip without advanced OA, but additional studies are needed to establish the efficacy of this procedure for these indications. (See "Approach to hip and groin pain in the athlete and active adult", section on 'Femoroacetabular impingement'.)
SURGICAL PROCEDURES FOR KNEE AND HIP OSTEOARTHRITIS
Total joint arthroplasty (replacement) — Total joint arthroplasty (replacement) surgery is the gold standard treatment in patients with severe end-stage symptomatic osteoarthritis (OA) who have failed to respond to nonpharmacologic and pharmacologic management and who have significant impairment in their quality of life due to OA . It provides marked pain relief and functional improvement in patients with severe hip or knee OA [2-4]. As an example, a randomized trial of 100 patients with moderate to severe OA found that after 12 months, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and improvements in function and quality of life when compared with nonsurgical treatment alone (defined as a between-group difference in mean knee injury and osteoarthritis outcome score [KOOS] of at least 10 points ) . However, some patients in the nonsurgical treatment group also experienced clinically meaningful improvements, while the surgical group had a higher number of serious adverse events. Thus, some patients who appear ready for a total knee arthroplasty may still improve with focused nonoperative therapy. It is important to individualize surgical decision-making with each patient, including an informed discussion of the risks and benefits. Detailed discussions on total knee and hip arthroplasties are presented separately. (See "Total knee arthroplasty" and "Total hip arthroplasty".)
Alternatives to total knee arthroplasty
Unicompartmental knee arthroplasty — In the knee, unicompartmental arthroplasty is an alternative to total knee arthroplasty in cases of end-stage OA that are limited to a single compartment. Most unicompartmental arthroplasties involve the medial compartment, although isolated lateral and patellofemoral arthroplasties also may be performed.
Compared with patients undergoing total knee arthroplasty, patients with unicompartmental arthroplasty have a quicker recovery, lower risk of complications, and improved range of motion, but also have a higher chance of reoperation [5,6].
Historically, ideal candidates have been described as having isolated medial compartment disease, age greater than 60 years old, low levels of physical activity, weighing less than 82 kg, having a cumulative angular deformity of less than 15 degrees, both cruciate ligaments intact, a preoperative range of flexion of 90 degrees, a flexion contracture of less than 5 degrees, minimal pain at rest, and no radiographic or intraoperative evidence of chondrocalcinosis or patellofemoral OA . However, many surgeons follow more liberal criteria when considering unicompartmental arthroplasty, and many of the traditional criteria are being expanded . Methods of patient selection are not widely agreed upon but may involve history/physical examination, weightbearing and/or stress radiographs, magnetic resonance imaging (MRI), and arthroscopy .
In appropriately selected patients, several studies have reported favorable outcomes, with a reported 10-year survival of greater than 90 percent [10-13]. A systematic review that included 8658 knees found a 10-year survival of 93 percent and a 15-year survival of 89 percent . The most common causes of revision were lateral disease progression (for medial unicondylar knee arthroplasties), aseptic loosening, bearing dislocation, and pain. The largest randomized trial to compare total versus partial knee replacement included 528 patients with medial compartment knee OA and found similar clinical outcomes, incidence of complications, and revision surgeries at 5 years . However, data from national registries report a higher revision rate for unicompartmental knee replacements compared with total knee replacements, with most estimates being approximately twice as likely for unicompartmental arthroplasties within a 7- to 10-year timeframe [8,14]. Regardless, the absolute revision rates are relatively low, and unicompartmental knee replacements can be a good choice for carefully selected patients after a complete discussion of the risks and benefits of unicompartmental versus total knee arthroplasty.
Knee osteotomy — High tibial and distal femoral osteotomies for varus and valgus knees continue to be viable surgical options for younger, more active patients with predominantly unicompartmental disease [15,16]. The basic premise of an osteotomy about the knee is to unload the diseased compartment by realigning the mechanical axis of the lower extremity . Benefits of this procedure include preservation of knee anatomy, less restriction on function, and possible delay of need for arthroplasty . Disadvantages of osteotomy include longer time to heal, possible nonunion may occur necessitating further surgery, incomplete pain relief, and increased complexity if later arthroplasty is needed [19,20].
●Varus knee – For a varus knee (more common), a high tibial osteotomy can be accomplished through several techniques including a medial opening-wedge, lateral closing-wedge, or dome osteotomy . Ideally, candidates for a high tibial osteotomy are younger than 65 years, have isolated knee arthrosis, good range of motion, and no ligamentous instability [21,22]. Contraindications to osteotomy include severe articular damage of the medial compartment joint space, tricompartmental OA, patellofemoral OA, infection or inflammatory disease, body mass index (BMI) >40, age >65, tobacco use, and markedly decreased range of motion .
A systematic review found that patients who received a high tibial osteotomy improved following the procedure, as indicated by decreased pain and by better function [17,24]. The outcomes that can be expected are illustrated by one long-term (15-year average follow-up) retrospective study of 102 high tibial osteotomies for varus knees . Excellent or good results were noted in 55 percent of patients, and fair or poor results were noted in 45 percent. Clinical results tend to deteriorate 10 to 15 years postoperatively. While there are limited data comparing different types of osteotomy techniques, different approaches can be equally successful with careful selection of patients [26,27]. Similarly, both osteotomy and unicompartmental knee replacements can have excellent clinical outcomes, but high tibial osteotomy may be preferred for younger, active patients, whereas unicompartmental knee replacement may provide better outcomes for older, less active patients.
High tibial osteotomy can be converted to a total knee arthroplasty, but the surgery is more challenging. Patients requiring subsequent conversion to a total knee arthroplasty have similar complications, clinical outcomes, and midterm implant survival rates compared with those who go directly to total knee arthroplasty. However, patients with a previous high tibial osteotomy are more likely to need an eventual revision of their total knee arthroplasty . Patients older than 60 years old, particularly women, may prefer to go directly to a total knee arthroplasty rather than undergoing an osteotomy to delay total knee arthroplasty .
●Valgus knee – For a valgus knee, either a lateral opening- or medial closing-wedge osteotomy is usually performed at the supracondylar region of the distal femur. Indications for a distal femoral osteotomy include a valgus deformity of less than 90 degrees, a preoperative motion arc of at least 90 degrees, and a less than 10-degree flexion contracture . Additionally, a medial closing-wedge high tibial osteotomy can be performed for valgus knees.
A systematic review that included data from 372 osteotomies reported a 9 percent complication rate and a 34 percent reoperation rate, of which 15 percent were converted to total knee arthroplasty . Complications from osteotomies include nonunion, failure of hardware, incomplete pain relief requiring conversion to total knee arthroplasty, neurovascular injuries, and compartment syndrome .
Alternatives to total hip arthroplasty
Hemiarthroplasty — Hemiarthroplasties, a form of "partial" hip replacement, can either be unipolar (single head) or bipolar (head within a head). Hemiarthroplasty consists of a femoral stem and head ball (with no acetabular component), with the benefit of decreased dislocation risk. However, hemiarthroplasties can wear through the native acetabular bone. Hemiarthroplasties (such as a bipolar) are most often used in the setting of treating a femoral neck fracture in an older patient with minimal baseline ambulation and are generally not used for patients with hip disease from OA or other types of arthritis.
Hip resurfacing — Hip joint resurfacing, or hip resurfacing arthroplasty, has been posited as a potential alternative technique to total hip replacement. Hip resurfacing arthroplasty preserves the femoral neck and uses a small, stemmed metal prosthesis to replace the femoral head. A metal acetabular component is implanted and creates a metal-on-metal bearing surface. This metal-on-metal bearing surface has decreased wear compared with conventional polyethylene-on-metal bearing surfaces used in total hip arthroplasty and larger diameter femoral heads that decrease dislocation risk.
However, enthusiasm for hip resurfacing has diminished secondary to the potential of adverse tissue reactions associated with metal-on-metal bearings, and the concerns about the toxic effects of metal ions [30,31]. Although hip resurfacing is still used by some surgeons in highly active, young males in whom the results of total hip arthroplasty have been less predictable, there are conflicting data on the durability of joint resurfacing procedures over time [32,33]. An analysis of long-term data from several national registries found greater rates of re-revision following resurfacing compared with total hip arthroplasty . For example, the five-year cumulative revision rate in Australia was significantly greater following resurfacing (3.7 versus 2.7 percent). A systematic review comparing revision rates of metal-on-metal hip resurfacing versus total hip arthroplasty found that the average times to revision were 3 years (95% CI, 2.95-3.1) and 7.8 years (95% CI, 7.2-8.3), respectively .
Patients who require revisions of hip resurfacing procedures appear to have particularly poor outcomes . (See "Complications of total hip arthroplasty", section on 'Sequelae from metal-on-metal wear debris'.)
Patient selection and surgical technique seem to be the most important factors for success; young, active males under age 55 with OA and minimal underlying hip deformity appear to be the best candidates [31,35]. The best results in females were in women with a femoral head component diameter of 50 mm or greater . Even though in carefully selected patients, total hip resurfacing can result in similarly good functional outcomes as compared with total hip replacement, concern with increased revision rates and potential metal-on-metal toxicity limits our enthusiasm for this procedure [36-39].
Hip osteotomy — In select cases of hip developmental dysplasia, hip impingement, and other conditions with the absence of advanced OA, different types of osteotomies around the hip may be possible. While the benefits of these procedures may include pain relief and preservation of the native hip joint, the risks of nonunion, painful hardware, osteonecrosis, and progression of arthritis need to be carefully weighed. In addition, these procedures may increase risk and complexity of total hip arthroplasty when required.
Intertrochanteric osteotomy may be useful in patients with deformity or disease of the proximal femur. Indications may include early or post-collapse osteonecrosis , femoral dysplasia , fracture malunion or nonunion, and congenital deformities such as coxa vara or coxa valga. The goal of this procedure is to correct the deformity, eliminate impingement, and restore a functional range of motion.
Periacetabular osteotomy has been shown to be an effective intervention in patients with acetabular dysplasia. By rotating the acetabulum, the hip biomechanics can be improved to provide a better bearing surface for the femoral head. This has been shown to delay or prevent the progression of OA .
PROCEDURES WITH NO ROLE IN OSTEOARTHRITIS
●Knee – There is no role for joint irrigation (or lavage) in the treatment of knee osteoarthritis (OA). Joint irrigation consists of rinsing out the knee with fluid and can be done arthroscopically or nonarthroscopically. It was thought that joint irrigation relieves knee pain secondary to OA by removing cartilaginous debris and inflammatory cytokines, which may contribute to synovitis and pain [43-45].
Although a few initial studies had suggested a potential benefit of joint irrigation for knee OA by reducing pain and improving function [46-49], subsequent studies failed to support these findings [50,51]. The best-quality review reported no evidence of benefit with joint irrigation . In this systematic review, the efficacy of joint irrigation for the treatment of knee OA was evaluated using data from 567 patients from 7 randomized trials . Patients who underwent joint lavage were compared with a control group who received either a sham intervention mimicking joint lavage, a placebo injection, or a nonintervention control. Joint lavage was found to be no more effective in pain reduction than control interventions at three-month follow-up (standardized mean difference [SMD] -0.11, 95% CI, -0.42 to 0.21). Also, joint lavage did not show an improvement in function compared with control interventions (SMD -0.10, 95% CI, -0.3 to 0.11).
●Hip – There is no clinical evidence to support joint irrigation in the treatment of hip OA.
Knee — Arthroscopic intervention should not be used to treat isolated OA of the knee. Despite this, arthroscopic debridement has been widely used in the past as a therapeutic intervention for patients with symptomatic OA of the knee, with or without a meniscal tear. The efficacy in treating such patients with arthroscopic debridement is not supported by randomized trials [51,53-57]. Further research is needed to determine whether there is any subset of patients with OA and a meniscal tear who may be more likely to benefit from this procedure (eg, patients with mechanical symptoms such as catching or locking, or for those with only mild arthritic changes), albeit analyses to date have not been able to identify this subgroup [58,59].
Isolated osteoarthritis — Although it may seem intuitive that "cleaning out the joint" may improve clinical symptoms, this has not been borne out in clinical trials. The following studies demonstrate the lack of clinical efficacy of arthroscopic debridement in the treatment of isolated knee OA:
●A trial was conducted including 180 predominantly male and White patients under 75 years of age with knee OA . Patients were randomly assigned to arthroscopic lavage, arthroscopic debridement and lavage, or sham surgery. During the 24-month follow-up period, there were no differences in knee pain and/or function among patients who received lavage, debridement, or the sham surgery. A limitation of the study was related to the study population, which included few women, who typically have a higher prevalence of OA.
●Another randomized trial of 178 patients with moderate to severe knee OA evaluated arthroscopic debridement and lavage in combination with medical and physical therapy versus medical and physical therapy alone . At two years, there were no significant differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, which is a validated instrument for OA of the knee and hip that includes an assessment of pain, stiffness, and physical function.
Osteoarthritis plus a meniscal tear — There has been some uncertainty regarding the role of arthroscopic partial meniscectomy in the management of patients with OA and a meniscal tear. In general, in the setting of OA with a meniscal tear, nonoperative treatment with physical therapy/rehabilitation appears to be similarly efficacious to surgery without the underlying surgical risks. There may be a limited role for arthroscopy in refractory cases without advanced degeneration (ie, patients who are not yet candidates for arthroplasty).
Data from randomized trials and meta-analyses comparing arthroscopic meniscal debridement with physical therapy have reported similar outcomes in terms of pain relief and physical function [54-57,60]. Furthermore, improvements with either intervention appear to persist up to five years [55,61]. Limited data suggest that arthroscopic partial meniscectomy may be effective in those who do not respond to initial treatment with physical therapy . Also, patients with less intraarticular damage on MRI may have greater improvement with arthroscopic partial meniscectomy compared with physical therapy .
The largest meta-analysis to compare the effect of arthroscopic knee surgery with control treatments included almost 1300 patients with knee pain (with or without radiographic signs of OA) from 9 randomized trials . The arthroscopic procedures included partial meniscectomy, debridement, or both, and the control treatments included sham surgery, exercise, or medical treatment. A statistically significant but not clinically meaningful difference in pain relief was observed at three and six months in favor of arthroscopic interventions; however, this difference was not observed at later time points for up to two years. Subgroup analyses limited to patients with knee pain and radiographic OA found similar results. Deep venous thrombosis was the most frequently reported adverse event (4 per 1000 arthroscopies), followed by infection, pulmonary embolism, and death.
Longer-term follow-up data of patients from randomized trials demonstrate that improvements in pain for patients with OA and meniscal tear treated with either partial meniscectomy or physical therapy may persist for up to five years [55,61]. A longitudinal study of 351 patients from a randomized trial comparing physical therapy with partial meniscectomy found that pain scores improved similarly in both groups after 5 years of follow-up [56,61]. Pain scores improved substantially after the first 3 months and continued to improve through the next 24 months, and then remained stable thereafter.
The management of chronic degenerative meniscal injuries in the absence of OA is discussed elsewhere. (See "Meniscal injury of the knee", section on 'Chronic degenerative meniscal injury'.)
Hip — There is no established role for the use of hip arthroscopy in the treatment of advanced OA of the hip, and no randomized studies have been performed. Arthroscopic surgery is being performed more commonly in the hip joint to debride or repair tears of the acetabular labrum and also address femoroacetabular impingement (FAI) (see "Imaging evaluation of the painful hip in adults", section on 'Femoroacetabular impingement'). However, more studies are needed to clarify whether addressing labral tears and/or FAI arthroscopically can delay the onset or prevent the progression of hip OA . There is preliminary evidence that arthroscopic debridement of the labrum in patients older than 45 years old has minimal benefit for pain and function and should only be considered with caution . (See "Imaging evaluation of the painful hip in adults", section on 'Acetabular labral tears' and "Imaging evaluation of the painful hip in adults", section on 'Femoroacetabular impingement'.)
Arthroscopic abrasion arthroplasty — Arthroscopic abrasion arthroplasty, involving burring and drilling of sclerotic bone, has not been shown to be beneficial in the management of OA. The results are unpredictable, and the process often leads to a worsening of symptoms including pain and functional issues. In one study, 50 percent of those undergoing abrasion arthroplasty required total knee replacement within three years .
Arthroscopic synovectomy — No clinical trials have been performed that study the efficacy of arthroscopic synovectomy in patients with OA, and it is generally not recommended. It is sometimes used in patients with inflammatory arthritis and is discussed in detail separately. (See "Synovectomy for inflammatory arthritis of the knee".)
Autologous chondrocyte implantation — Autologous chondrocyte implantation is not recommended for OA. It is unlikely that this technique, in which localized regions of degenerated cartilage are replaced with chondrocyte grafts, will be helpful in patients with advanced OA because of the large surface area that needs grafting in this setting.
Chondrocyte grafts may be beneficial for selected patients with severe but limited focal articular cartilage defects. MRI suggests that such chondrocyte grafts achieve a more uniform fill of the chondral defect and are less likely to produce osteophytes than microfracture techniques for promoting cartilage formation . Carefully selected patients may benefit in the short to medium term, but more research is needed to establish long-term effectiveness including preventing progression to OA [67,68].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteoarthritis" and "Society guideline links: Total knee arthroplasty" and "Society guideline links: Total hip arthroplasty".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Total knee replacement (Beyond the Basics)" and "Patient education: Total hip replacement (Beyond the Basics)")
PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Knee osteoarthritis".)
SUMMARY AND RECOMMENDATIONS
●Total joint arthroplasty (replacement) is reserved for patients with severe symptomatic osteoarthritis (OA) who have failed to respond to nonpharmacologic and pharmacologic management and who have clinically important impairment in their quality of life due to OA. (See 'Total joint arthroplasty (replacement)' above.)
●Alternatives to total knee arthroplasty for selected patients with knee OA include unicompartmental knee arthroplasty and knee osteotomy. (See 'Alternatives to total knee arthroplasty' above.)
●Alternatives to total hip arthroplasty for selected patients with hip OA include hemiarthroplasty, hip osteotomy, and perhaps, for a very specific group, hip resurfacing. (See 'Alternatives to total hip arthroplasty' above.)
●Procedures that have no role for the treatment of knee or hip OA include joint irrigation/lavage, arthroscopic debridement, arthroscopic abrasion arthroplasty, arthroscopic synovectomy, or autologous chondrocyte implantation. (See 'Procedures with no role in osteoarthritis' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Kenneth Kalunian, MD, who contributed to an earlier version of this topic review.
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