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A 60 year old patient from Holland with bilateral knee pain and the inability to walk more than 100 meters.
Toft, J. Vilas-Boas A, Rose T.
A 60 year old woman presented herself in our orthopaedic practice at Alphaklinik, Munich in the summer of 2003.
For the past 6 years she has been suffering from knee pain bilaterally which finally prevented her from doing active sports and more importantly she had to hand in her job resignation.
She has been treated sporadically with hyaluronic and cortisone injections and had extensive physiotherapy. At first the diagnosis in Holland was minor arthritis left > right knee with no immediate surgical need. However things changed rapidly and she has been confronted with the diagnoses of major arthritis soon after.
Total knee replacement was advised, however, the patient refused the operation and tried to find other solutions. In the meantime, however walking ability decreased and the pain in both knees has become almost unbearable.
At the day of admission to our clinic her ability to walk was less than 100 meters. A day without painkillers was unthinkable.
Our diagnosis was medial loss of cartilage and loss of the meniscus medially on the left knee. The right knee presented with a slightly better diagnosis with a remnant but torn meniscus and very thin cartilage.
Also, both knee had a bow leg malalignment
We proposed following plan: a bioprostheses for the left knee within the next year and-since a rapid progression was to be expected for the right knee-a bioprostheses for the right knee as as soon as the left knee has healed completely.
For explanation: under bioprostheses we understand an abrasion arthroplasty along with an osteotomy to correct the knee axis.
Arthroscopic abrasion arthroplasty was introduced approximately 20 years ago as an alternative to open debridement or total knee replacement for older patients with degenerative arthritis of the knee.1 The presumption was that the vascularity in degenerative arthritis was deep to the subchondral bone plate.2,3,4 Therefore, surgical penetration through the subchondral bone was advocated to achieve a repair tissue.2,3,4 This belief led to the concept of multiple deep drilling into the subchondral bone marrow of the degenerative lesion
The patient Mrs V went back to Holland relieved with the diagnoses and came back for surgery with Dr Toft in Alphaklinik for the left knee in June 2004 and for the right knee in December 2004.
Postoperative diagnoses were arthritis with cartilage lesion grade III/IV, rupture of the medial meniscus, synovialitis, lateral compression of the patella.
Performed surgery included partial resection of the medial meniscus, stabilising the rest meniscus, shaving – chondroplasty of the patella and trochlea, abrasion arthroplasty with micro fractures and also a osteotomy with a correction of 6 degrees. Osteosythesis with surfix and screws.
Surgery was performed in full anesthesia. As for pain medication, the patient received ibuprofen as needed and anti thrombosis injection for 3 weeks. To promote healing and regrowth of cartilage, crutches had to be worn for 12 weeks to avoid weight bearing on the operated knee. Control examinations were performed after 4, 8 and 12 weeks.
After 6 months, respectively, the patient came back for metal removal and cleaning of the operated knee.
The patient has been seen so far 6 times over the course of the last 2 years.
She has been extremely happy and relieved with the outcome.
The pain in her knees ceased immediately after surgery and up to this day she has never needed any medication again.
Her sports activities range from fast walking to biking and she is including skiing this winter.
When we talked to her on the phone in Mid November 2006, she expressed her grateful thanks to the team and the surgical technique. She was also very happy, that for the first time in six years she has been able to enjoy an amusement park with her family again!
Background
Between 1989 and 2002, 486 medial compartment abrasion arthroplasties with valgus osteotomy were performed at Alphaklinik. The Oxford Knee Questionaire was sent to 470 patients, of which 296 were correctly answered. All patients had grade III/IV (Outerbridge) cartilage lesions. 34 patients were bilateral. The minimum follow-up was 12 months, and the maximum was 14, 4 years, which means an average of 2, 99 years. The abrasion arthroplasty was performed with an abrader, combined with micro picks. The osteotomy was a closing-wedge osteotomy, with proximal fibular lysis and internal fixation. All patients followed a 12-week non-weightbearing protocol.
The mean knee score for patients treated by abrasion arthroplasty and osteotomy was 38, 10 ± 8, 04.
The vast majority of patients treated with the abrasion/osteotomy combination are very satisfied over a period of up to 15 years and only 2.5 percent of the patients received a total knee replacement so that the procedure is indeed an alternative to joint replacement. When compared to results for TKR and UKR, our results are better, with fewer and less severe complications. This treatment modality is particularly interesting for young patients and for patients who refuse joint replacement surgery like in this case.
The bioprosthesis is a special operation carried out predominantly in the Alphaklinik in Munich. For further reading we recommend:
www.alphaklinik.com
www.knie.de
You can also order the book by Dr Jürgen Toft: Arthritis
Literature
1. Johnson, L.L., (MD): Clinical Methods of Cartilage Repair; Arthroscopy Abrasion Arthroplasty; A Review. Clinical Orthopaedics and Related Research Number 391s, pp.S306-S317, 2001,
2. Campbell, C.J: The healing of cartilage defects. Clinical Orthopaedics 64; S.45-63, 1969
3. Carlson, H: Reactions of rabbit patellar cartilage following operative defects. Acta. Orthop. Scand. Suppl. 28, 1957
4. Mitchell, N, Shepard N: The resurfacing of adult rabbit articular cartilage by multiple perforations through the subchondral bone. J. Bone Joint Surg. 58A: S230-233, 1976
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