Hip and Knee Questions and Answers.

Edited By: Seth S. Leopold, M.D.
Last updated Wednesday, February 09, 2005

Treatments for Knee Arthritis in Young Patients?

Unicompartmental ("Mini") Knee, Total Knee Replacement, or Osteotomy for Knee Arthritis in a Young Patient?

First of all, it is important to recognize how difficult – and how personal – this choice is. The final decision will be made based not only on symptoms, physical findings on a surgeon’s exam, and the x-ray pattern of arthritis, but also on the patient’s goals, expectations, job demands, and level of motivation. For those reasons, it is best made in consultation with a subspecialist in adult reconstructive knee surgery and joint replacement.

But by way of summary, it is possible to offer the following observations about each of those procedures:

1. Unicompartmental Knee Arthroplasty. Although these are now often implanted through a less-invasive surgical approach, which can significantly shorten the recovery period, unicompartmental knee replacement (“Uni’s”) are a type of joint replacement. As such, they really are not meant for people doing impact or twisting sports. Total knee replacements have been studied in patients aged 50 and under and have shown good results in that population, with 85-95% of the implants remaining in service 10 years after surgery. By contrast, we have fairly limited data on Uni patients of that age group. In most reports of older patients, Uni’s have a slightly (but not severely) lower 10-year success rate than total knee replacements. In their favor,Uni’s have a much shorter post-op recovery time, and most patients find Uni’s perform better and feel more normal than traditional total knee replacements. They also are fairly easily converted to total knee replacements if they should fail. I don't recommend it, but I know that some patients have returned to tennis, skiing, etc after knee replacement surgery (total or uni). That is a personal decision, and it needs to be made with the recognition that this likely increases the likelihood of premature failure. There has been a trend towards Uni’s in younger patients in this country, because that operation is perceived to be a less-invasive (and more easily revised) approach. But to be honest, we don't know if this is going to be a good thing; Unis are now being put into a population of more active patients than they've been really tested in. Only time will tell.

2. Total knee arthroplasty (TKA). Long considered the “gold standard” for knee arthritis surgery in older adults (age 60 and over), this operation also is being used more in younger patients in this country. As mentioned, there is reasonable clinical follow-up available on TKA’s in patients aged 50 and younger, showing that about 9 out of 10 implants remain in service at the end of the first decade; in older patients (age 60 and up), the likelihood is about 95%. TKA’s fail at the rate of about 1 or 1.5% per year on average, so it is possible to get at least a ballpark idea of the likelihood of an implant being in service at a particular duration of follow-up. Some patients go back to light doubles tennis and gentle skiing (assuming they were skillful skiers before), but by no means are all patients comfortable doing this, and I certainly don’t suggest that my patients do these activities after total knee replacement, nor do I promise anyone that they’ll be able to participate in these kinds of sports. The large majority — well over 90% — of patients in this age group are able to return to non-impact exercise (swimming, biking, or walking) for fitness following this surgery.

3. High-Tibial Osteotomy. This operation involves cutting and repositioning one of the bones around the knee joint. This is done to re-orient the loads that occur with normal walking and running so that these loads pass through a non-arthritic portion of the knee. That’s why it doesn’t work well if more than one compartment of the knee is involved--in those patients, there is no “good” place through which the load can be redistributed. This may be the operation of choicefor people (with the right pattern of arthritis) who want to return to impact sports. However, it has some disadvantages. In general, pain relief is less dramatic or complete compared to total knee replacement or Uni. Also, the likelihood of making 10 years after the surgery without needing another operation (usually a total knee replacement) is much lower than for either of the other operations we’re discussing: only 60-65% of patients who have an osteotomy have gone 10 years without a reoperation. Some surgeons believe that if the arthritis is are already severe (“bone-on-bone”), osteotomy is not likely to be satisfying. Some surgeons say — only half in jest — that the less you need the osteotomy, the better you do with it; that is, patients with severe arthritis don't do as well as patients with milder disease. Osteotomy also cannot be done in patients whose arthritis has resulted in significant loss of knee joint motion before surgery. In this country, there has been a general trend away from osteotomy altogetherbecause of some of the reasons listed aove.

Again, this complex and personal choice is best made with some guidance from a subspecialist in adult reconstructive knee surgery and joint replacement. Best of luck!

Surgery for Hip and Knee at the University of Washington

Disclaimer

This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.

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