Treatment modalities for patients with varus medial knee osteoarthritis

Abstract Osteoarthritis (OA) is one of the most common joint disorders in the Western population, which causes pain, stiffness, loss of function and disability. In patients with OA the cartilage, located at the ends of long bones, is damaged. OA is most prevalent in the knee joint. In case of varus malalignment the medial compartment of the knee is most commonly affected. The initial treatment of varus medial knee OA is non-operative, and consists of patient education, weight reduction, physical therapy, use of orthoses, intra-articular steroid injections and if needed pain medication. Orthoses are intended to unload the medial compartment of the knee. Not all patients experience benefit of orthoses and therapeutic effect vary between studies. Therefore the first aim of this thesis was to evaluate the therapeutic effect of orthoses in the treatment of varus medial knee OA. When non-operative treatment fails surgical treatment will mostly be considered. The surgical treatment consists of valgus high tibial osteotomy (HTO), unilateral knee arthroplasty (UKA) or a total knee arthroplasty (TKA). In case of isolated medial knee OA, a HTO or UKA is mostly the preferred intervention. OA is a chronic disease which could progress over years. One of the goals of a HTO is to slow down disease progression and to postpone the need for a TKA as long as possible, by unloading the diseased compartment. Multiple studies comparing different HTO techniques are published with a 1 or 2 year follow-up, however there is a lack of prospective long term results, especially for the relatively new opening-wedge technique. Therefore the second aim of this thesis was to study the long term results of both closing- and opening-wedge HTO. In general, results after TKA and HTO are good. However, a subset of patients has suboptimal improvement in pain, physical functioning, and quality of life and are not satisfied with their postoperative result. The explanation of these suboptimal results is not always completely physical. Psychological factors, such as anxiety and depressive symptoms or preoperative expectations, could be related to these suboptimal results. The ultimate goal of all orthopaedic procedures is patient satisfaction. Identification of modifiable risk factors for dissatisfaction could contribute to optimization of this important outcome. Therefore the final question addressed in this thesis is whether the different psychological factors are related to patient satisfaction after TKA. In Chapter 2 we summarized the literature about the therapeutic effect of orthoses in the treatment of knee OA. In this Cochrane review 13 studies including 1356 patients were included. Overall, quality of evidence found in these studies was moderate or low. The follow-up time varied from 1 – 24 months. No long term follow-up study determining the influence on progression of OA has been performed. We concluded that a valgus knee brace and a laterally wedged insole both have small beneficial effects in terms of improvement of pain, symptoms and functional outcome in patients with varus medial knee OA. No certain difference between both interventions was seen in this Cochrane review. The long term adherence was low for both intervention, especially the knee brace group. Moreover, there might be no difference in therapeutic effect between a laterally wedged insole and a neutral insole. In Chapter 3 we present the results of our biomechanical evaluation of the valgus knee brace and laterally wedged insole. In this study we performed gait analysis of patients with varus medial knee OA treated with one of these two interventions for six months. Gait analysis was performed at baseline and after six weeks of wearing the intervention. In this study we found that wedged insoles only unload the medial compartment at baseline. At baseline a reduction of the peak Knee Adduction Moment (surrogate measure of the medial load) of 3.6% was seen. No biomechanical alteration was seen after 6 weeks of wearing the insole. Valgus brace therapy did not result in any biomechanical alteration at baseline and after 6 weeks. So in this study we could not confirm that the beneficial effects of orthoses can be explained by a certain dynamical alteration, in other words a changed gait pattern. In Chapter 4 the six year results of our RCT comparing closing and opening-wedge HTO are presented. After six year opening-wedge HTO was associated with more complications (37% vs 9%), however closing-wedge HTO was associated with more early conversions to TKA (25% vs 8%). Of the patients who had no conversions to a TKA, no difference in clinical outcome and radiological alignment was seen. We present in Chapter 5 the results of a retrospective assessment of all patients who underwent a HTO in our clinic. We found in this study of 412 patients more adverse events in a closing-wedge group than in an opening-wedge group (28% versus 14%). Hardware was removed in 48% of the closing-wedge HTO’s and 71% of the openingwedge HTO’s. Another major adverse event was iliac crest pain, caused by harvesting the bone for spongiosaplasty (19,7% of the patients in the opening-wedge group). The survival of the opening-wedge group was significantly better than the closing-wedge group, when conversion to a prosthesis was taken as endpoint, however an equal number of patients were in need for a UKA or TKA in both groups. We summarized the literature about the influence of preoperative expectations on patient satisfaction after TKA in Chapter 6. In this systematic review 3 high and 5 low quality studies were included. Although it is a frequently assumed relation, we conclude in this review that there is only limited or conflicting evidence that high expectations lead to more dissatisfaction. However, moderate evidence was found that unfulfilled expectations lead to more dissatisfaction. In Chapter 7 we present the results of our multicenter study, in which we examined the prevalence of two important psychogical symptoms, namely depressive and anxiety symptoms in patients with end-stage OA of the knee. These psychological symptoms were measured with the Hospital Anxiety and Depression Scale, a widely used validated questionnaire. Besides, we determined the influence of these symptoms on the outcome of TKA. We found in this study a high prevalence of anxiety (20.3%) and depressive symptoms (22.7%) in a population with end stage knee OA. After surgery a significant decrease of the prevalence of these symptoms was seen. The prevalence of anxiety symptoms decreased to 14.8% and of depressive symptoms to 11.7%. Preoperative depressive symptoms predicted lower patient reported outcomes after surgery. Patients with preoperative anxiety or depressive symptoms were less satisfied postoperatively. The main topics of this thesis are placed in a broader perspective in Chapter 8. The limitations of this thesis and some recommendations for future research are discussed in this chapter

Adverse events and survival after closing- and opening-wedge high tibial osteotomy: a comparative study of 412 patients

Purpose: Varus medial knee osteoarthritis (OA) can be treated with a closing-wedge (CW) or opening-wedge (OW) high tibial osteotomy (HTO). Little is known about the adverse event (AE) rate of these techniques. The purpose of this study was to examine the AE rate and survival rate of a consecutive series of 412 patients undergoing CW- or OW-HTO. Methods: Medical records were retrospectively screened, and all patients who underwent HTO from 1993 to 2012 at the Erasmus University Medical Centre were assessed with a self-administered questionnaire. Patients filled in the intermittent and constant osteoarthritis pain score, knee injury and osteoarthritis outcome score, and a general questionnaire focusing on AE. Results: Medical records of 412 patients (354 CW- and 112 OW-HTOs) were screened. Of the 358 eligible patients, 291 (81 %) returned their questionnaire. A total of 80 AE (17 %) were found in 466 osteotomies. In the CW-group, 47 (13 %) serious adverse events (SAE) and 2 (0.6 %) AE were found. In the OW-group, 17 (15 %) SAE and 14 (13 %) AE were found. The most common AE was in 14 (4 %) patients of the CW-group sensory palsy of the common peroneal nerve. The most common AE in the OW-group was persistent pain at the iliac crest [11 (9.8 %) patients]. Hardware was removed in 48 % of the CW-osteotomies and 71 % of the OW-osteotomies (p < 0.05). The probability of survival was 75 % after 10 years in the CW-group versus 90 % in the OW-group (p < 0.05). In both groups, an equal number of patients were “in need for prosthesis” according to OARSI criteria. Conclusion: OW-HTO was associated with more AE than CW-HTO. OW-HTO resulted in better survival than CW-HTO. However, in both groups an equal number of patients were in need for prosthesis. Level of evidence: Retrospective comparative study, Level III

Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study

Background: A subset of patients with total hip arthroplasty (THA) or total knee arthroplasty (TKA) has suboptimal postoperative results in terms of Patient Reported Outcomes (PROs), and psychological factors could contribute to these suboptimal results. Objectives: To examine the prevalence of anxiety and depressive symptoms in patients undergoing primary THA or TKA preoperatively and postoperatively, and the relationship between preoperative anxiety and depressive symptoms on PROs of THA and TKA. Design: In this prospective study patients were measured preoperatively, and 3 and 12 months postoperatively. Patients filled in the Hospital Anxiety and Depression Scale, Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS) and a satisfaction questionnaire. Results: Data were obtained from 149 hip and 133 knee patients. The prevalence of anxiety symptoms decreased significantly from 27.9% to 10.8% 12 months postoperatively in hip patients, and from 20.3% to 14.8% in knee patients. Depressive symptoms decreased significantly from 33.6% to 12.1% 12 months postoperatively in hip patients, and from 22.7% to 11.7% in knee patients. In hip and knee patients, preoperative depressive symptoms predicted smaller changes in different HOOS or KOOS subscales an Conclusions: Preoperatively, the prevalence of anxiety and depressive symptoms was high. At 3 and 12 months postoperatively, the prevalence of anxiety and depressive symptoms was decreased in both hip and knee patients. However, patients with preoperative anxiety and depressive symptoms had worse PROs 3 and 12 months after THA and TKA and were less satisfied than patients without anxiety or depressive symptoms. (C) 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. A

Do Laterally Wedged Insoles or Valgus Braces Unload the Medial Compartment of the Knee in Patients With Osteoarthritis?

Background: The results of conservative treatment of knee osteoarthritis (OA) are generally evaluated in epidemiological studies with clinical outcome measures as primary outcomes. Biomechanical evaluation of orthoses shows that there are potentially beneficial biomechanical changes to joint loading; however, evaluation in relation to clinical outcome measures in longitudinal studies is needed.Questions/purposes: We asked (1) is there an immediate effect on gait in patients using a laterally wedged insole or valgus knee brace; (2) is there a late (6 weeks) effect; and (3) is there a difference between subgroups within each group with respect to patient compliance, body mass index, and OA status?Methods: This was a secondary analysis of data from a previous randomized controlled trial of patients with early medial knee OA. A total of 91 patients were enrolled in that trial, and 73 (80%) completed it after 6 months. Of the enrolled patients, 80 (88%) met prespecified inclusion criteria for analysis in the present study. The patients were randomized to an insole or brace. Gait was analyzed with and without wearing the orthosis (insole or brace) at baseline and after 6 weeks. Measurements were taken of the knee adduction moment, ground reaction force, moment arm, walking speed, and toe-out angle. Data were analyzed with regression analyses based on an intention-to-treat principle.Results: A mean reduction of 4% (± 10) (95% confidence interval [CI], −0.147 to −0.03, p = 0.003) of the peak knee adduction moment and 4% (± 13) (95% CI, −0.009 to −0.001, p = 0.01) of the moment arm at baseline was observed in the insole group when walking with an insole was compared with walking without an insole. A m