eMedicine Specialties > Orthopedic Surgery > Knee
Lateral Compartment Arthritis: Treatment
Updated: Jan 19, 2007
Treatment
Medical Therapy
Valgus deformities of the knee are better tolerated than varus deformities and develop arthritic changes later (Langlais and Thomazeau, 1989; Maquet et al, 1967). Because lateral compartmental arthrosis usually develops later in life than medial compartment arthrosis, it is often better tolerated and has a lower incidence rate (Ahlback, 1968; Hernborg and Nilsson, 1977). As a result, nonoperative treatment may suffice to control symptoms early in the course of the disease, despite the absence of controlled studies to verify the efficacy of nonoperative treatment of lateral compartment arthritis.
Nonsurgical palliative modalities include weight loss, shoe modification, oral analgesics, quadriceps exercises, unloader bracing, activity modification, and the use of a cane during ambulation (Ogata et al, 1997).
Nonoperative treatment is of value in a limited number of patients who have valgus knees with lateral compartment arthritis. When the deformity is mild, treatment with analgesics, aerobic conditioning of the lower extremity muscles, activity modification, and weight reduction may alleviate symptoms. Initial nonoperative treatment can give the physician time to educate the patient about the disease, to understand the patient's needs, and to evaluate the patient's compliance with a treatment program. The knowledge gained can be valuable in planning surgical interventions. The use of an unloader brace in the flexible genu valgum deformity can be helpful in temporizing the situation until definitive surgical treatment. Pain relief with bracing may indicate that a corrective osteotomy or unicompartmental knee replacement would be effective.
Surgical Therapy
The surgical interventions available to treat lateral compartment degenerative disease of the knee are corrective osteotomy, hemiarthroplasty of the knee, and TKR.
Osteotomy
The theory behind corrective osteotomy is to unload the diseased lateral compartment by overcorrecting the pathologic malalignment of the lower extremity and to facilitate the reparative capacity of the knee joint once it is mechanically unloaded (Aglietti and Menchetti, 2000; Coventry, 1987; Coventry, 1973; Coventry and Bowman, 1982; Insall, 1993; Ivarsson et al, 1990; Majima et al, 2000; Stuart et al, 1990). The regeneration of articular cartilage and fibrocartilage proliferation has been demonstrated during repeat arthroscopy, compared with previous arthroscopic findings in knees that were overcorrected by an osteotomy (Odenbring et al, 1992).
General selection criteria for osteotomy for genu valgum include age younger than 65 years, isolated Ahlback grade I or II lateral compartmental arthrosis (Ahlback, 1968), minimum ligamentous laxity, >90° arc of motion of the knee, and a flexion contracture of <15-20° (Hanssen et al, 2001).
Knee extension loss >15° and flexion <90° are contraindications to a distal femoral corrective osteotomy (McDermott et al, 1988; Morrey and Edgerton, 1992). Severe ligamentous instability is another contraindication to osteotomy because there are no dynamic restraints to medial laxity, which will persist even if the alignment is correct (Insall). Poor results with femoral osteotomy have been reported in the presence of preoperative recurvatum of the knee, which may indicate that the knee is at an advanced stage in the arthritic evolution, with TKR being the appropriate option (Hernigou et al, 1992). A specific pattern of posterolateral arthritis has been described in young patients with a history of trauma and a previous lateral meniscectomy. Bone-on-bone contact can be observed in such cases with a PA flexion weight-bearing view but is not observed with standing radiographs in extension weight bearing, reflecting a rotatory problem that may not respond well to valgus osteotomy
(Stubbs, 1995).
A valgus malalignment of almost any magnitude in the knee joint is best corrected by a distal femoral osteotomy, with a medial closing wedge fixed internally (Cameron et al, 1997; Edgerton et al, 1993; Healy et al, 1988; Mathews et al, 1998; McDermott et al; Miniaci et al, 1990). Images 1-2 illustrate a knee treated with a medial wedge closing osteotomy. An opening wedge osteotomy of the distal femur with the apex of the wedge at the medial femoral cortex, supported by a tricortical autograft wedge and lateral plate fixation, also has been described (Terry and Cimino, 1992). To bring the knee joint line parallel to the floor by osteotomy, the deformity usually has to be corrected in the deformed distal femur itself (Cooke et al; Healy and Wilk, 1994; Insall; Shoji and Insall, 1973).
Rarely, a laterally sloping tibial plateau may result in a valgus deformity in some knees (Johnson et al). In such cases, provided that the deformity is mild and the correction is <10°, a varus-producing tibial osteotomy can be successful (Bauer et al, 1969: Coventry, 1987; Marti, 2001). However, if major correction of a valgus deformity is attempted by a tibial osteotomy, the joint line obliquity is exaggerated by bone wedge removal, because most valgus knees have inherent superolateral obliquity of the joint line (Bauer et al; Cameron et al; Coventry, 1987; Coventry, 1973; Coventry and Bowman; Healy et al, 1988; McDermott et al; Shoji and Insall). Clinical failure occurs in such cases because of medial subluxation of the femur along the tilted joint line (Harding, 1976; Insall; Shoji and Insall).
Arthroscopy of the knee joint is indicated in the valgus knee if mechanical symptoms are suggestive of intra-articular pathology, such as an incarcerated lateral meniscus. However, knee arthroscopy performed routinely during corrective osteotomy for genu valgum is of questionable clinical value. Clinical outcomes of osteotomy patients with simultaneous arthroscopic debridement of the lateral compartment are not different from the outcomes of those patients who underwent osteotomy alone (Akizuki et al, 1997). Furthermore, the prognostic value of knee arthroscopy has not been demonstrated when the knee joint is visualized to evaluate the extent of degenerative disease before corrective osteotomy. Patellofemoral arthritis may be present in knees with an angular deformity (Elahi et al, 2000), and the specific observation of moderate or severe patellofemoral arthritis has not been demonstrated to affect the clinical results following corrective osteotomy of the knee (Keene et al, 1989; Odenbring et al).
The reported results of corrective osteotomy of the distal femur for genu valgum are variable, reflecting uncontrolled factors such as patient selection, surgical techniques, postoperative alignment, and follow-up time (Aglietti and Menchetti; Beaver et al, 1991; Cameron et al; Conrad et al, 1985; Cooke et al; Edgerton et al; Healy et al, 1988; Johnson and Bodell; Mathews et al; McDermott et al; Miniaci et al; Terry and Cimino). Of these factors, the influence of postoperative alignment of the extremity upon the clinical outcome is well documented.
In a report of knees corrected to neutral or varus (Edgerton et al), the success rate was 77% compared with a 60% success rate in those knees that had some residual valgus. Although no prospective clinical trials are available to guide the exact postoperative alignment following distal femoral osteotomy, a neutral alignment of the leg with the tibiofemoral angle of 0° is generally accepted as the desired postoperative correction (McDermott et al). The reasoning is that in the valgus knee that has been corrected to neutral, most of the weight-bearing load is transmitted through the medial compartment (Andriacchi; Maquet, 1980; Maquet, 1976; Shaw and Moulton); therefore, no need exists to overcorrect into varus.
In addition to the usual risks expected of a major reconstructive procedure, 2 complications have a higher incidence following supracondylar femoral osteotomy than in proximal tibial valgus-producing osteotomy.
First, joint stiffness is more frequent following a supracondylar osteotomy compared with proximal tibial valgus-producing osteotomy (Beaver et al, 1991; Cass and Bryan, 1988; Edgerton et al; Johnson and Bodell; Mathews et al), and it can complicate surgical exposure during subsequent TKR (Beyer et al, 1994). Avoiding entry into the knee joint may reduce the rate of this complication (Aglietti et al, 1987).
Second, supracondylar osteotomy of the femur is associated with a higher risk of nonunion than is proximal tibial osteotomy. Reported risks of nonunion following an osteotomy of the distal femur range from 4.2-19% (Beaver et al; Edgerton et al; Healy et al, 1998; Mathews et al; McDermott et al; Miniaci et al; Stahelin et al, 2000). Nonunion and hardware failure can be associated with medial placement of the fixation plate (Miniaci et al). The treatment of delayed union or nonunion consists of bone grafting of the delayed union or nonunion site with application of a lateral T-plate (Cameron, 1992).
TKR
If stringent patient selection criteria are used, few patients qualify for a corrective osteotomy to treat a genu valgum deformity. Because lateral compartment arthritis occurs later in life and because the deformity is generally well tolerated, most patients qualify for a TKR instead (Berruto et al, 1993).
The classification proposed by Krackow et al (1991) can serve as a guide to the deformities that are encountered while performing a TKR in the valgus knee. Valgus deformities of the knee have been classified by Krackow into the following 3 distinct types:
- Type I involves lateral femoral bone loss, lateral soft-tissue contractures, and intact medial soft tissues.
- Type II adds lengthened medial soft tissues.
- Type III is a severe valgus deformity with malpositioning of the proximal tibial joint line.
Because of the contracted lateral soft tissues, ligamentous balancing during TKA in the valgus knee may require extensive releases on the lateral side of the joint. Correction of valgus deformity in TKA has been associated with an increased risk of patellofemoral instability and peroneal palsy. The incidence of posterolateral instability has been reported to be as high as 4% in such knees (Laurencin et al, 1992). The incidence of peroneal palsy after routine TKR has been estimated as less than 1%, with the incidence in valgus knees reported at 3-4% (Krackow et al, 1991; Washington et al). A technique of graduated intra-articular release of the posterolateral capsule and the iliotibial band and preserving the popliteus may reduce the risk of posterolateral instability and peroneal palsy following TKA in the valgus knee (Miyasaka et al).
The correction of severe angular deformities may require both the release of soft tissue on the lateral side and ligament tightening on the medial side (Healy, 1998; Krackow, 1990). Severe bone loss and dysplasia of the lateral femoral condyle may necessitate the use of bone grafts or metal blocks to augment the femoral component. A reasonable option in the patient who is elderly with a severe valgus deformity may be the use of primary constrained implants. Images 3-4 illustrate a severe valgus deformity treated with a primary constrained TKR.
Three clinical series have reported that conversion of a supracondylar femoral osteotomy of the knee to a TKA does not compromise the ultimate result of arthroplasty (Beyer et al; Cameron and Park, 1997; Finkelstein et al, 1996). Some authors have found conversion of a previous varus osteotomy to TKA more technically demanding (Finkelstein et al), whereas others report increased difficulty when total joint arthroplasty is performed after supracondylar varus osteotomy (Beyer et al).
Unicompartmental knee replacement
In selected patients, a unicompartmental knee arthroplasty may be the optimal option for pain relief from isolated lateral compartment arthritis (Cartier et al, 1996; Marmor, 1984; Ohdera et al, 2001; Scott and Santore, 1981; Squire et al, 1999). Images 5-6 illustrate the treatment of lateral compartment arthritis with a unicompartmental knee replacement; compared with osteotomy, unicompartmental knee replacement has a higher initial success rate and fewer early complications (Scott and Santore). In addition, when compared with a tricompartmental knee replacement, unicompartmental replacement preserves both cruciate ligaments and, therefore, almost-normal knee kinematics (Cartier et al; Scott and Santore; Walton et al, 2006); the surgery can be performed through a smaller incision, with reduced blood loss, expense, and morbidity. Bone stock is preserved in the opposite compartment and in the patellofemoral joint, making revision surgeryeasier to perform—at least in
theory.
Contraindications to unicompartmental arthroplasty include eburnated bone at the patellofemoral compartment or in the opposite compartment, subluxation of the femur on the tibia, fixed lateral contractures, and a significant inflammatory component to the arthritis (Cartier et al; Marmor; Scott and Santore; Squire et al). In these situations, a TKR is the preferred option.
Author's preferred treatment
If the patient complains of predominantly mechanical symptoms, such as painful catching in the lateral part of the knee joint, and if evidence exists of intra-articular pathology, such as a torn lateral meniscus that is depicted on an MRI, arthroscopy of the knee is undertaken. Removal of the torn portion of the meniscus can relieve preoperative symptoms and allow assessment of the degree of arthritic change in the lateral compartment of the knee and elsewhere. The integrity of the cruciate ligaments and the degree of inflammatory changes in the knee can be evaluated during arthroscopy, and this information is of value in planning future surgical treatment.
A distal femoral osteotomy is the author's preferred option for the young, active, and heavy individual, with the goal of correcting the alignment to neutral. An opening wedge osteotomy is preferred, because this can be performed with a smaller incision, and the hardware can be placed on the biomechanically favorable lateral aspect of the femur. The operation is performed through a midline incision to facilitate later TKR.
In the older patient who presents with isolated lateral compartment symptoms and radiographic-evident disease, a unicompartmental knee arthroplasty is preferred. Preoperative selection criteria for a unicompartmental arthroplasty include an AP radiograph of the knee joint with a varus stress applied to the extremity. If this radiograph demonstrates normal alignment of the extremity and opening of the arthritic lateral joint space, a lateral unicompartmental knee arthroplasty is performed.
For patients who have diffuse symptoms in the knee, a history of inflammatory arthritis, obesity, fixed lateral contractures, and evidence of degenerative disease in the medial or patellofemoral compartments of the knee, a TKR will provide more predictable results.
Follow-up
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Arthritis Center. Also, see eMedicine's patient education articles Knee Pain and Knee Joint Replacement.
Complications
For complications related to specific surgical procedures, see Treatment, Surgical therapy.
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Further Reading
Keywords
degenerative joint disease, knee arthrosis, gonarthrosis, genu valgum
