Review Article

Management of Osteoarthritis of
the Knee in the Active Patient

Abstract
Brian T. Feeley, MD Total knee arthroplasty has been extremely successful in elderly
Robert A. Gallo, MD patients with osteoarthritis. However, there is considerable
controversy regarding how best to treat the younger, athletic
Seth Sherman, MD
patient with advanced arthritis. Treatment options range from
Riley J. Williams, MD
nonsurgical management with exercise and nonsteroidal anti-
inflammatory drugs, to joint arthroplasty with activity modification.
When properly indicated, arthroscopic débridement, high tibial
osteotomy, unicondylar knee arthroplasty, and total knee
arthroplasty allow younger patients with arthritis to maintain an
active, healthy lifestyle.

P ersons in the United States tend

to remain physically active and
participate in demanding athletic
function. Some of these modalities
may also have a disease-modifying
effect by altering the mechanical en-
events well into their fifth, sixth, and vironment of the knee. Appropriate
From the Department of
even seventh decades. However, with use of specific nonsurgical modalities
Orthopaedic Surgery, University of
California San Francisco, San this increase in activity comes an in- requires knowledge of evidence-
Francisco, CA (Dr. Feeley), the creased risk of developing a chondral based practice guidelines, careful pa-
Department of Orthopedics and injury that may lead to early onset of tient selection, patient education,
Rehabilitation, Pennsylvania State
arthritis in the knee. The recent liter- and adequate long-term follow-up.
University College of Medicine,
Bone and Joint Institute, Milton S. ature on osteoarthritis (OA) in pa-
Hershey Medical Center, Hershey, tients aged 40 to 60 years indicates Exercise
PA (Dr. Gallo), and the Department that successful outcomes can be
of Orthopedic Surgery, Hospital for Several large randomized controlled
gained with surgical treatment. Fig-
Special Surgery, New York, NY trials have shown that exercise re-
(Dr. Sherman and Dr. Williams). ure 1 illustrates a recommended
duces pain and improves function in
treatment algorithm for early knee
Dr. Williams or an immediate family patients with early OA.1,2 Two recent
member has received royalties from OA.
meta-analyses also demonstrate that
Arthrex, serves as an unpaid
consultant to Histogenics, and has muscle strengthening and aerobic ex-
received research or institutional Nonsurgical Management ercise are important in the manage-
support from Stryker and Smith & ment of OA.3,4 Muscle strengthening
Nephew. None of the following
In an effort to delay major surgery, exercises are superior for specific
authors or any immediate family
member has received anything of many younger patients with early impairment-related outcomes, such
value from or owns stock in a knee OA are offered a variety of as pain, but aerobic exercise contrib-
commercial company or institution nonsurgical modalities, such as exer- utes to better long-term functional
related directly or indirectly to the
cise and physical therapy, bracing, outcomes. An individualized, multi-
subject of this article: Dr. Feeley,
Dr. Gallo, and Dr. Sherman. orthoses, nonsteroidal anti-inflam- modal approach tailored to specific
matory drugs (NSAIDs), and intra- symptoms and patient expectations
J Am Acad Orthop Surg 2010;18:
406-416 articular viscosupplementation or is recommended to maximize pain
corticosteroid injection. In general, relief and functional outcomes. Pa-
Copyright 2010 by the American
Academy of Orthopaedic Surgeons. the goals of these therapeutic options tient compliance with a regimen of
are to decrease pain and improve exercise or physical therapy is a sig-

406 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

nificant concern. The best available Figure 1

evidence shows that supplementation
of a home exercise program with su-
pervised exercise classes results in the
largest gains in pain relief and loco-
motion at 12-month follow-up.5 Ex-
ercise must also be sustained because
any beneficial effects are lost 6
months after an exercise program is
terminated.2

Bracing and Orthoses

Knee bracing and foot orthoses are
popular nonsurgical treatment op-
tions for patients with early OA.
These modalities are used primarily
by patients who wish to continue to
pursue an active lifestyle. This in-
cludes younger patients with early to
moderate disease, former athletes
with posttraumatic OA, and postmen-
iscectomy patients with isolated uni-
compartmental disease. The ideal
candidate for bracing has unicom-
partmental arthritis and wishes to
Treatment algorithm for knee arthritis in the young, active person.
delay surgery. NSAIDs = nonsteroidal anti-inflammatory drugs, OA = osteoarthritis
The primary goal with use of a
brace or orthosis is to improve func-
tion by reducing symptoms. With the lateral wedge orthoses in persons Guideline is available at http://www.
knee brace, this is accomplished by with medial compartment knee OA.9 aaos.org/research/guidelines/Guidelin
reducing biomechanical load in the Evidence suggests that pain relief and eOAKnee.asp.)
involved compartment or by reduc- functional improvement in these pa-
ing the patient’s perception of insta- tients is achieved by a reduction in NSAIDs
bility. Bracing should be used almost external varus moment and medial
Oral NSAIDs are often prescribed
exclusively in patients with sympto- compartment load.9 (The AAOS
to reduce pain and inflammation
matic, passively correctable, unicom- Clinical Practice Guideline on the
caused by early knee OA. The au-
partmental varus or valgus disease Treatment of Osteoarthritis of the
thors of a recent systematic review of
<10°. Significant medial collateral Knee [Nonarthroplasty] is unable to
ligament laxity and lateral collateral the use of NSAIDs for knee OA se-
recommend for or against the use of
ligament laxity are contraindications a brace either with a valgus-directing lected 16 double-blind randomized
for valgus and varus unloading force for patients with medial uni- controlled trials, representing eight
braces, respectively. Several clinical compartmental OA of the knee or different medications.10 Significant
trials and a recent systematic review with a varus-directing force for pa- design flaws in individual trials made
have demonstrated the efficacy of tients with lateral unicompartmental it impossible to distinguish a differ-
this treatment modality, showing sig- OA of the knee. The Guideline also ence in efficacy between equivalent
nificant improvements in pain and suggests that lateral heel wedges not recommended doses of NSAIDs. In-
function using a valgus knee brace be prescribed for patients with symp- stead, the authors concluded that
compared with a simple neoprene tomatic medial compartmental OA NSAID selection should be based on
sleeve or medical treatment alone.6-8 of the knee. The Recommendation is physician preference, relative safety,
Clinical and gait laboratory analysis graded B, equivalent to level of evi- patient acceptability, and cost.
also suggest that there is a role for dence II. The complete Clinical Serious gastrointestinal (GI) side

July 2010, Vol 18, No 7 407

Management of Osteoarthritis of the Knee in the Active Patient

effects have been reported in 2% to the efficacy of both HA and steroids ported on a randomized controlled
4% of chronic NSAID users. This for the temporary symptomatic man- trial at the Houston Veterans Affairs
risk is halved with the use of agement of early knee OA. Recent Medical Center, in which patients
cyclooxygenase-2 inhibitors.11 Pa- studies, however, have demonstrated were subject to arthroscopic lavage,
tients with a history of prior GI that lidocaine alone and intra- débridement, or placebo surgery.
events and concurrent corticosteroid articular corticosteroids in combina- One hundred eighty patients were
or anticoagulant use, or those with tion with lidocaine cause consid- enrolled and followed for a mean of
cardiovascular or renal impairment, erable cytotoxicity to the native 2 years. The average age was 53
may want to avoid NSAIDs or chondrocytes.14 Thus, corticosteroid years, and approximately 65% of the
strictly regulate their use. injections must be used with caution, patients in each group had moderate
especially in patients with early ar- to severe arthritis. During the 2-year
thritis. (The AAOS Clinical Practice follow-up period, there was no bene-
Intra-articular
Guideline on the Treatment of Os- fit in terms of pain scores or out-
Viscosupplementation
teoarthritis of the Knee [Nonarthro- comes measures with arthroscopic
Intra-articular viscosupplementation plasty] is unable to recommend for management versus placebo surgery.
is an increasingly common nonsurgi- or against the use of intra-articular The authors concluded that the out-
cal option in the management of HA for patients with mild to moder- comes after arthroscopic lavage or
knee OA. The injection of hyaluronic ate symptomatic OA of the knee. arthroscopic débridement were no
acid (HA) into the knee joint has the- The Guideline suggests the use of better than those after a placebo pro-
oretic benefits for early knee OA be- intra-articular corticosteroids for cedure. The results of this study have
cause of a combination of its vis- short-term pain relief for patients been criticized by many who believe
coelastic properties as well as its with symptomatic OA of the knee, that the patient population—mostly
anti-inflammatory, anabolic, analge- with a Grade of Recommendation of men—was not representative of the
sic, and chondroprotective poten- B.) general population. In addition, the
tial.12 The utility of the current litera- study used a composite scoring sys-
ture is limited by lack of uniform tem for osteoarthritic changes that
patient populations and study de- Surgical Management resulted in a patient with severe OA
signs, heterogeneous drug types and in one compartment having the same
delivery methods, and use of diverse Arthroscopy score as a patient with minor OA in
outcome measures. The role of arthroscopy in the treat- all three compartments.
A systematic review of 76 random- ment of OA is controversial. Ap- Although the study by Moseley
ized controlled trials also demon- proximately 50% to 75% of patients et al16 is often criticized by arthro-
strated the efficacy of HA versus have an initial benefit following ar- scopic knee surgeons, another recent
placebo.13 The 5- to 13-week postin- throscopic débridement; however, randomized trial found similar re-
jection period showed the largest 15% progress to total knee arthro- sults.17 However, this more recent
percent improvement, from a base- plasty (TKA) within 1 year following study focused on a civilian popula-
line of 28% to 54% for pain and surgery, and only 44% have a clini- tion and included an equal number
from 9% to 32% for function. In cally significant reduction in pain.15 of men and women in each treatment
general, comparable efficacy was Despite these modest results, arthro- arm. Patients were randomly as-
noted with NSAIDs, and longer-term scopic débridement remains one of signed to either surgery or physical/
benefits were noted in comparison the most commonly performed pro- medical therapy. At 2-year follow-
with intra-articular corticosteroids. cedures for OA. Critical analysis of up, there was no difference between
Few adverse events were reported in the literature is hampered because the groups based on either the West-
the hyaluronan/hylan trials included many of the studies are retrospective, ern Ontario and McMaster Universi-
in these analyses. Of note, there were evaluate different patient popula- ties Osteoarthritis Index (WOMAC)
few randomized head-to-head com- tions, or lack generalizability to score or the Medical Outcomes
parisons of different viscosupple- larger patient cohorts. Study 36-Item Short Form physical
ments. Thus, caution must be ex- Several recent studies have sug- component score. However, this
ercised in drawing conclusions gested that the benefits of arthro- study excluded patients with a large
regarding the relative value of differ- scopic surgery are minimal or may or symptomatic meniscal tear. The
ent products from this systematic re- even be attributable to a placebo ef- authors concluded that arthroscopic
view. Overall, these results support fect. In 2002, Moseley et al16 re- débridement was no better than an

408 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

optimized medical/physical therapy ment of advanced OA could be bene- throscopy helps in some patients but
program in patients with isolated ficial in many patients, especially that others fail to improve. Success-
OA. with aggressive lysis of adhesions in ful management of OA with arthros-
Dervin et al15 performed a prospec- the suprapatellar pouch and anterior copy is likely the result of proper
tive evaluation of 126 patients who interval. patient selection and discussion of
failed nonsurgical treatment of OA Most patients with advanced OA the limited goals of the procedure.
of the knee. Unstable chondral flaps are found to have meniscal tear on Younger patients with mechanical
and degenerative meniscal pathology MRI. It is unclear what role, if any, symptoms from a meniscal tear, with
were resected at the time of surgery. meniscal tear has in the progression normal knee alignment, and without
In this study, 57% of patients had of knee pain in these patients. Bin tibial chondral lesions will likely
grade III or IV changes according to et al20 evaluated 68 patients with
benefit from a trial of arthroscopic
the classification of Dougados et al,18 Outerbridge grade IV OA and a me-
treatment. However, these patients
and 63% had an unstable meniscal dial meniscal tear at a mean
must be counseled that any surgical
tear. Only 44% of patients had a follow-up of 52 months. Following
benefits may be of brief duration and
clinically important reduction in surgery, 82% of patients reported a
that they may require arthroplasty in
pain as determined by the WOMAC reduction in pain, 14% had no
the future (Table 1). (The AAOS
scale at a mean follow-up of 2 years. change, and 4% had an increase in
The only factors that predicted im- pain. At 75 months postoperatively, Clinical Practice Guideline on the
provement at the time of surgery 75% of patients had not required Treatment of Osteoarthritis of the
were medial joint line tenderness, a further surgery. Dervin et al15 found Knee [Nonarthroplasty] suggests
positive Steinman test, and the pres- that medial joint line tenderness pre- that needle lavage not be used for
ence of an unstable meniscal tear at operatively and the presence of an patients with symptomatic OA of the
the time of surgery. The authors unstable meniscal tear at the time of knee. The Recommendation is
found that physicians were unable to surgery predicted a better outcome. graded B, equivalent to level of evi-
accurately predict who would benefit These studies suggest that meniscal dence I/II. The Guideline recom-
from arthroscopic débridement. débridement can be beneficial in pa- mends against performing arthros-
Despite these and other studies tients with mechanical symptoms copy with débridement or lavage in
that have shown minimal benefit that are attributed to a degenerative patients with a primary diagnosis of
with arthroscopic débridement, this meniscal tear. symptomatic OA of the knee. The
procedure may be beneficial in select Spahn et al21 examined factors that Recommendation is graded A, equiv-
patients. Steadman et al19 evaluated affected the outcome of arthroscopy alent to level of evidence I/II.)
69 knees in 61 patients with grade 3 in medial compartment OA in 156
or 4 OA according to the Kellgren- patients at a mean follow-up of 49 High Tibial Osteotomy
Lawrence radiographic scale. This months. The average age was 51.6 High tibial osteotomy (HTO) was
study excluded traumatic chondral years, and all patients had Kellgren- popularized by Coventry and Insall
lesions, but all other patients with Lawrence grade 2 OA. Seventy-one in the 1970s,22 and it remains an at-
advanced OA were included. Aver- percent of patients had poor out- tractive option in the attempt to pro-
age patient age was 57 years (range, comes overall. Factors that were as- long the lifespan of the native joint.
37 to 78 years), and follow-up was sociated with worse outcome in- The basic premise of an HTO is to
>2 years. At the time of arthroscopy, cluded history of OA >24 months, redirect the mechanical axis from the
the affected knee was insufflated to obesity, medial tibial osteophytes, degenerated area of the joint to the
expand the joint capsule, and partic- medial joint space <5 mm, smoking, relatively well-preserved compart-
ular attention was paid to perform- the presence of a tibial chondral ment. In most instances, the weight-
ing an aggressive lysis of adhesions grade IV defect, and the need for bearing load is shifted from a worn
to improve joint volume. At the time subtotal or total meniscectomy. Sig- medial compartment and passed
of follow-up, 9 knees (13%) had nificantly worse outcomes were through the healthier cartilage of the
been revised to a TKA. The presence noted in patients with four or more lateral joint space.
of kissing femoral-tibial chondral le- of these factors (Figure 2). Patients are not required to modify
sions, a lower insufflation volume, The role of arthroscopic manage- their activity levels, as they would be
and increasing patient age resulted in ment of OA in the younger patient with arthroplasty procedures. Thus,
a poorer outcome. The authors con- population remains controversial, HTO is indicated for patients who
cluded that arthroscopic manage- with the literature suggesting that ar- wish to remain active in high-load

July 2010, Vol 18, No 7 409

Management of Osteoarthritis of the Knee in the Active Patient

Figure 2

T2-weighted fat-saturated sagittal (A) and coronal (B) magnetic resonance images of the knee demonstrating a
complex posterior horn lateral meniscus tear (arrow) with an overlying cartilage defect (arrowheads). There is
bony edema under the lesion, as well. C, Arthroscopic image of the lateral compartment with a meniscus tear.
D, Postdébridement image demonstrating softening of the lateral tibial plateau and the presence of a partial-thickness
defect on the femoral condyle.

Table 1 dates for HTO. Patients should also

have range of motion of ≥90°. Because
Predictors of Outcome Following Arthroscopic Débridement for Knee
Osteoarthritis of a frequent necessity to overcorrect
the malalignment, HTO should not be
Variable Likely to Benefit Unlikely to Benefit
performed in patients who are unwill-
Age <40 yr >75 yr ing to accept a valgus deformity. Some
Compartment Medial, single compartment Tricompartmental, lateral, have suggested that obesity is a relative
tibial contraindication to HTO.23
Joint space preservation >5 mm <5 mm Several techniques, including open-
Alignment Neutral Valgus ing wedge, closing wedge, oblique
Duration of symptoms <6 mo >1 yr plane, and ball-and-socket osteot-
Symptom location Localized Diffuse omy, have been described. Because of
Weight Body mass index <30 Body mass index >30 their relative technical ease, opening
Effusion Present Absent wedge and closing wedge osteoto-
mies are the most commonly per-
formed types of HTO. They are
activities. In such patients, HTO can tions, the clinical applicability of HTO distinguished by two important differ-
be performed as an isolated or a has been refined by several contraindi- ences. First, opening wedge HTO in-
combined procedure. The most com- cations. Because HTO shifts the me- volves incision and osteotomy on the
mon indication for HTO is the treat- chanical axis away from the most se- same side as the joint degeneration,
ment of unicompartmental varus or verely degenerated area to another, less such as a medial incision and osteot-
valgus gonarthritis; however, HTO affected area of the joint, the procedure omy for medial compartment disease,
also can be effective in unloading is contraindicated in persons with pre- whereas a closing wedge osteotomy re-
pressure on the focal cartilage le- vious meniscectomy and/or significant quires work on the opposite side, such
sions, such as in osteonecrosis and degeneration of the other knee com- as a lateral incision and osteotomy for
adult osteochondritis dissecans. Sim- partment. Persons with inflammatory medial compartment disease. Second,
ilarly, HTO has been recently ap- diseases (eg, rheumatoid arthritis) opening wedge osteotomy may require
plied as an adjunct in chondral resur- and/or those aged >65 years are less the insertion of a wedge-shaped corti-
facing and meniscal transplantation desirable candidates because of the high cal bone graft between the cut bone
procedures in which malalignment likelihood of diseased cartilage in all edges (Figure 3), whereas with closing
has been considered to be a contribu- compartments of the knee. Patients with wedge osteotomy, angular correction
tor to the cartilage injury. symptomatic patellofemoral arthritis is attained by removing a wedge of
Despite its potentially broad indica- are not considered to be good candi- bone.

410 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

Figure 3

Medial opening wedge high tibial osteotomy (HTO). A, AP weight-bearing radiograph of the knee demonstrating loss of
joint space, predominantly on the medial side. B and C, Sequential T2-weighted fat-saturated sagittal magnetic
resonance images demonstrating loss of the medial meniscus and degeneration of the cartilage. D, Early postoperative
AP radiograph following opening wedge HTO. E, AP radiograph obtained 3 months following HTO demonstrating graft
consolidation.

Table 2
Results of Select Recent Series of High Tibial Osteotomy to Manage Varus Gonarthrosis
Mean Follow-up Mean Age
Study Number in Years (range) (yr) Technique Outcomes

Niemeyer et al28 43 pts 2 (6-24 mo) 47.3 Opening wedge, using 68% good or excellent
plate and autologous
iliac crest bone graft
Omori et al26 37 pts 17 (14-24) 59 Closing wedge using 77% good or excellent
(48 knees) threaded pins and
figure-of-8 wiring
Akizuki et al24 132 pts 16 (16-20) 63 Closing wedge using a 98% survival at 10 yr,
plate 90% survival at 15 yr
Gstöttner et al27 111 pts 12 (1-25) 54 Closing wedge using a 80% survival at 10 yr,
(134 osteotomies) staple 66% survival at 15 yr
Chiang et al29 16 pts 15 (13-16) 58 Dome-shaped, using 68% good or excellent
(19 knees) external fixation
Polyzois et al30 95 pts 8 (5-11) 69 Closing wedge using 61% good/excellent
plate
Tang and Hender- 67 knees 6.5 (1-21) 49 Closing wedge using 75% survival at 10 yr,
son25 plate or staple 67% survival at 15 yr

In the past 20 years, more than a cellent function in 77% of patients at gree of correction, which must fall
dozen articles have been published 17 years (Table 2). between acceptable parameters, such
documenting the outcomes following Several factors have been identified as 5° to 13° of valgus for varus
HTO for unicompartmental gonar- that contribute to deterioration over gonarthrosis. Finally, increasing age
thritis. Comparisons are limited by time. The most important factor, as and obesity have been confirmed by
varied fixation techniques and mea- initially described by Insall and Agli- several studies to be detrimental
sures used to assess outcome. Sur- etti,31 is time. HTO should not be to the long-term effectiveness of
vivorship (judged as conversion to perceived to be the ultimate solution HTO.32,33
TKA) has been reported to be to the problem of joint degeneration; Patients with isolated lateral com-
as high as 98%24 and 70%25 at 10- rather, it is a procedure that can de- partment OA can be treated with
and 20-year follow-up, respectively; lay TKA, sometimes for >20 years. distal femoral osteotomy. The indi-
Omori et al26 reported good and ex- Another important factor is the de- cations and contraindications are

July 2010, Vol 18, No 7 411

Management of Osteoarthritis of the Knee in the Active Patient

Figure 4 flexion or extension contractures,

are candidates for UKA. With im-
provements in UKA prosthesis de-
sign, wear properties of the polyethy-
lene, and surgical technique, the
indications have expanded to include
younger patients, patients with mild
patellofemoral OA, and some pa-
tients with anterior cruciate ligament
(ACL) deficiency35 (Figure 4).
Recent studies have specifically ad-
dressed the outcomes of UKA in a
younger patient population. Schai
et al36 evaluated 28 UKAs in patients
aged <60 years, with patient age at the
time of surgery averaging 52 years.
Follow-up was 2 to 6 years. Good or
excellent results in terms of function
and pain relief were achieved in 90%
of patients. The average activity level
according to the Tegner and Lysholm
score improved slightly, from 2.3 points
preoperatively to 2.7 points at follow-
up. Of the 28 knees, 9 (32%) demon-
strated radiolucent lines about the tib-
AP (A), lateral (B), and sunrise (C) radiographs demonstrating isolated
medial compartment arthritis. Note the preservation of the patellofemoral joint ial component, and 2 had incomplete
space. AP (D), lateral (E), and sunrise (F) radiographs following radiolucent lines at the bone-cement in-
unicompartmental knee arthroplasty. terface on the femoral side. The authors
found no correlation between activity
level and the presence of tibial radio-
lucent lines. Loosening of the femoral
largely the same as those for HTO. Unicondylar Knee component at the prosthesis-cement in-
The intent of the osteotomy is to Arthroplasty terface necessitated revision in two pa-
place the plane of the joint parallel tients; one underwent another UKA and
Early outcomes of unicompartmental
to the ground or to have a minimal the other was converted to TKA.
knee arthroplasty (UKA) in the
degree of obliquity relative to the Asymptomatic slowly progressive radi-
1970s and early 1980s were disap-
normal anatomy. Recent studies have olucency was noted in one tibial com-
pointing,31 with the result that many
demonstrated results similar to the ponent. The authors concluded that
surgeons treated unicompartmental
outcomes of patients who underwent UKA in middle-aged patients was suc-
HTO. Backstein et al34 followed 40 OA with either HTO or TKA. How- cessful but that it was not better than
patients with distal femoral osteot- ever, with the growing interest in less TKA in terms of survival. Pennington
omy for 10 to 15 years. The 10-year invasive procedures and the publica- et al37 reviewed 41 patients aged ≤60
survival rate of the distal femoral tion of better long-term results in years who underwent UKA (average
varus osteotomy was 82%, but the several recent series, UKA has under- age, 54 years). All patients who un-
15-year survival rate was just 45%. gone a resurgence.35 derwent the procedure were de-
(The AAOS Clinical Practice Guide- The indications for UKA have scribed as being physically active and
line on the Treatment of Osteoarthri- changed significantly in the past 10 engaged in high-demand activities.
tis of the Knee [Nonarthroplasty] to 15 years. Classically, low-demand At 11-year follow-up, the Hospital
cannot recommend for or against an patients aged >60 years who have a for Special Surgery score was excel-
osteotomy of the tibial tubercle for low body mass index, intact ligamen- lent in 93% of patients and good in
patients with isolated symptomatic tous structures, and isolated medial 7%. Three patients required revi-
patellofemoral OA.) compartment OA, but who have no sion: two for extensive tibial osteoly-

412 Journal of the American Academy of Orthopaedic Surgeons

 Brian T. Feeley, MD, et al

sis, and one for continuing knee pain scores. Both groups had an average viewed the results of 52 cemented
and a progressive tibial radiolucent functional Knee Society score of 96 TKAs in patients aged ≤55 years (av-
line. Nine knees showed progression (out of 100). Although there was erage age, 53 years; range, 29 to 55).
of OA in the unresurfaced compart- only short-term follow-up, it is Average time to follow-up was 12
ment, but none required conversion worth noting that no patient in ei- years (range, 10 to 15 years). Only
to TKA, and none of these patients ther group had radiologic evidence two patients required revision at <10
had a worsening Hospital for Special of loosening. In vivo kinematics of years, one for sepsis at 1 year and
Surgery score. The overall survival the knees that underwent ACL re- one for instability at 8 years. Six pa-
rate was 92% at 11 years. construction and UKA in a step-up tients required revision at >10 years,
Chronic ACL deficiency leads to exercise and in deep knee flexion all for osteolysis and loosening. The
medial meniscal tears and medial
have been shown to be equal, as overall survival rate was 96% at 10
compartment OA; treatment options
well.39 Thus, combined management years and 85% at 15 years.
for these patients are limited. Tradi-
of ACL deficiency with medial com- Although these studies document ac-
tionally, ACL deficiency was a con-
partment OA with ACL reconstruc- ceptable survival rates, a significant
traindication to UKA for the man-
tion and UKA warrants further in- limitation is that activity level before
agement of medial compartment OA
vestigation and long-term follow-up and after surgery is not documented in
because eccentric loading and exces-
studies because the early results are any of them. In an earlier study, Duffy
sive wear occurred on the tibial poly-
quite promising. et al43 found that although objective
ethylene component. However, this
knee scores and survival were good
has not always been borne out in
Total Knee Arthroplasty in a group of patients aged ≤55 years
the literature. Hernigou and Des-
who underwent TKA, the functional
champs38 retrospectively reviewed Results of knee replacement have con-
score improved from 45 points to 60
the results of 99 UKAs at a mean tinued to get better with improvements
points (range, 0 to 100). It will be
follow-up of 16 years. At the time of in polyethylene durability and prosthe-
important to determine functional
the arthroplasty, the ACL was con- sis design. Advances in design have led
outcome and ability to return to an
sidered to be normal in 50 knees, to survivorship rates of 90% at 10 to
active lifestyle in younger, higher-
damaged in 31, and absent in 18. Of 15 years, as well as better pain relief and
demand patients with tricompart-
the 18 knees with ACL deficiency at functional improvement.40 Despite
mental OA who require TKA.
the time of surgery, 11 had not failed good clinical results with long-term
The types of acceptable activity
at final follow-up. The mean poste- follow-up in older persons, TKA is
following TKA are of considerable
rior tibial slope in these 11 knees usually reserved as a final treatment
debate as well. Bradbury et al44
was <5°. Seven knees in which the option, especially in younger, active
found that 49% of patients partici-
ACL was absent at the time of the patients.
pated in sports at least once a week
arthroplasty were revised. In these Few studies have specifically evalu-
before TKA, and 65% returned to
knees, the tibial prosthesis was im- ated the results of TKA in patients
sports after TKA. Most of these pa-
planted with a posterior slope of aged <60 years. This is likely be-
tients returned to activities such as
>8°. The authors concluded that re- cause, until recently, most surgeons
bowling, but 20% retuned to higher-
sults in the ACL-intact and ACL- believed that age <60 years was a
demand activities such as biking and
deficient groups were similar when contraindication to TKA. Dalury
tennis. Healy et al45 reviewed athletic
the tibial component had a slope of et al41 reviewed 103 cemented TKAs
activity after joint arthroplasty. They
<7°. in patients aged <45 years, most of
included responses from 58 members
Another option for persons with whom were diagnosed with rheuma-
of The Knee Society who were sur-
ACL deficiency is to reconstruct the toid arthritis or juvenile rheumatoid
veyed to determine recommenda-
ACL in conjunction with the UKA. arthritis. At 7-year follow-up, there
tions for sports participation for pa-
Pandit et al39 performed ACL recon- were no revisions for aseptic loosen-
tients following knee replacement
struction in conjunction with UKA in ing or wear; however, this popula-
surgery (Table 3).
15 patients and matched these results tion is likely not as high-demand as a
to a group of 15 patients with intact similar cohort with posttraumatic or
ACL. At 2.5 years after the proce- primary OA. Similarly, Spahn et al21 Return to Sports
dure, no difference was found be- reported no revisions in 57 patients
tween the groups with regard to Ox- aged <50 years at 9 years following Traditionally, most outcome data
ford Knee Scores and Knee Society surgery. Duffy et al42 recently re- following knee procedures have been

July 2010, Vol 18, No 7 413

Management of Osteoarthritis of the Knee in the Active Patient

Table 3
Activity Recommendations Following Total Knee Arthroplasty: 1999 Knee Society Survey
Recommended/Allowed Allowed With Experience Not Recommended No Conclusion

Low-impact aerobics Road cycling Racquetball Fencing

Stationary cycling Canoeing Squash Inline skating
Bowling Hiking Rock climbing Downhill skiing
Golf Rowing Soccer Weight lifting
Dancing Cross-country skiing Singles tennis
Horseback riding Stationary skiinga Volleyball
Croquet Speed walking Football
Walking Tennis Gymnastics
Swimming Weight machines Lacrosse
Shooting Ice skating Hockey
Shuffleboard Basketball
Horseshoes Jogging
Handball

a
NordicTrack
Adapted with permission from Healy WL, Iorio R, Lemos MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29(3):377-388.

used to define success or failure sporting and recreational activi-

based on return to activities of daily ties.46,47 In contrast, only 63.6% of Summary
living. Recently, however, because of patients were able to return to sports
The treatment of OA of the knee in the
changing attitudes and technological following TKA.46 Even among those
young, active patient remains a chal-
advances, treatment goals for OA who are able to return to sport after
lenge to the orthopaedic surgeon. Ini-
have advanced beyond performance TKA, most return to a lower level of
tial nonsurgical management with ex-
of basic activities. Within the past activity and at a decreased frequen-
few years, there has been an increas- ercise, activity modification, NSAIDs,
cy.48,49 The reasons for such a low re-
ing interest in defining acceptable and viscosupplementation may improve
turn to sport after TKA are varied,
athletic activity and expectations fol- symptoms but will not dramatically al-
but >40% curtail athletic activity as
lowing surgical intervention for knee ter the natural history of the disease
a precaution.45 Despite concerns of both
OA. Little information is currently process. Surgical treatments, when used
surgeons and patients, no evidence ex-
available to guide athletes following for the proper indications, offer patients
ists correlating increased nonimpact
HTO. The assumption is that HTO a good potential solution for their ar-
athletic activity with aseptic loosening.
is performed to allow the patient to thritis and allow for a return to athletic
Dahm et al50 found that 12% of pa-
return to her or his desired level of activities. Treatment should be guided
tients who underwent TKA partici-
sporting activities. based on the patients’ symptoms and
Several articles have addressed the pated in activities that were not rec-
expectations.
topic of athletic activity in persons ommended by their physician;
undergoing UKA and TKA; the however, this group did not have a
guidelines for activity following ar- higher incidence of complications or References
throplasty are summarized in Table failure. Mont et al51 recently com-
3. Although the recommended list of pared the outcomes of high-activity Evidence-based Medicine: Levels of
activities does not differ between versus low-activity patients follow- evidence are described in the table of
UKA and TKA, the expected athletic ing TKA. At a mean follow-up of 7 contents. In this article, references 6,
activity does. Separate studies have years, the outcome score was 96 in 16, and 17 are level I studies. Refer-
reported that >90% of athletically low-activity patients and 95 in high- ences 2 and 5 are level II studies.
active patients who undergo UKA activity patients. There was no differ- References 7, 8, 40, 46, and 51 are
can expect to return to their desired ence in the failure rate. level III studies. Level IV studies in-

414 Journal of the American Academy of Orthopaedic Surgeons

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416 Journal of the American Academy of Orthopaedic Surgeons