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Therapeutic effects of segmental resection and decompression combined with joint prosthesis on continuous knee osteoarthritis.

Byline: Junlai Xue Changhong Wang Peng Liu Xiangchun Xie and Shan Qi

Abstract

Objective: To observe the therapeutic effects of segmental resection and decompression combined with joint prosthesis on continuous knee osteoarthritis (OA).

Methods: A total of 130 patients with knee OA were selected and randomly divided into an observation group and a control group (n=65). The control group was treated by segmental resection in combination with joint prosthesis and the observation group was treated by segmental resection and decompression combined with joint prosthesis. They were followed-up for three months.

Results: All patients underwent successful surgeries during which no severe complications occurred. During the follow-up period the overall effective rates of the observation group and the control group were 93.8% and 78.5% respectively which were not statistically significantly different (p less than 0.05). The observation group was significantly less prone to patellar instability infection and deep vein thrombosis compared with the control group (P less than 0.05). On the same day after surgery the knee joint scores and functional scores of the two groups were similar which evidently increased three months later with significant intra-group and inter-group differences (p less than 0.05).

Conclusion: Combining segmental resection and decompression with joint prosthesis gave rise to satisfactory short-term prognosis by effectively improving the flexion and extension of injured knee and by decreasing complications thus being worthy of promotion in clinical practice.

KEY WORDS: Knee osteoarthritis Joint replacement Segmental resection and decompression Joint prosthesis Complication.

INTRODUCTION

Knee joint is most prone to diseases due to complex structure and maximum burden in human body.1 Therefore knee osteoarthritis (OA) has become the main disease endangering the elderly with population aging thus being also known as senile arthritis.2 An epidemiological investigation showed that knee OA dominated in the reasons responsible for the labor deprivation of males older than 60 which was clinically manifested as joint pain deformity and movement disorders that affected the quality of life.3 Trauma gene age and obesity are the risk factors of knee OA that is pathologically manifested as progressive destruction of involved joint cartilage subchondral bone sclerosis and cartilage degeneration.4

Surgeries work well for knee OA treatment of which segmental resection and decompression can relieve clinical symptoms and improve knee joint functions by drilling decompression of early degenerative joint.5 Joint replacement with prosthesis has been widely applied to treat knee OA for which fixed-bearing prosthesis is always given first priority. The prosthesis can effectively improve the functions of knee joint.6 For the patients with continuous knee OA however even the internal fixation performed optimally is not enough without complete decompression due to the suppression of the spinal cord and nerve roots by protrusion of intervertebral disc and hyperostosis.

In this study the therapeutic effects of segmental resection and decompression combined with joint prosthesis on knee OA were studied aiming to provide clinical evidence for future reference.

METHODS

Study Subjects: A total of 130 patients with knee OA who were treated in our hospital from February 2011 to September 2013 were selected. This study has been approved by the institutional ethics committee of our hospital. Inclusion criteria: In accordance with the diagnosis criteria for knee OA; only one knee was involved; primary education level and above; without severe bone defects; 50-75 years old; without receiving internal or external treatment within two weeks before hospitalization; without history of knee joint surgery; without cerebrovascular liver or kidney diseases; without severe hypertension or diabetes mellitus. The patients complicated with knee joint fracture bone tumor bone tuberculosis rheumatoid gout or purulent infections were excluded. Written consent was obtained from all patients. The patients comprised 72 males and 58 females aged (65.44 3.12) years old (51~74 years old). The average disease course was (31.34 8.33) months (1 month ~ 16 years).

The flexion contractures ranged from 15 to 70 with the average of (38.0 10.23). The mean education duration was (16.34 2.12) years. According to the clinical symptoms there were 123 cases of knee joint pain 67 cases of rest pain 67 cases of atrophy of quadriceps femoris and 56 cases of knee joint swelling. The mean body mass index (BMI) was (21.34 1.89) kg/m2. They were randomly divided into an observation group and a control group and their gender age disease course flexion contracture education duration and BMI were similar (pgreater than 0.05).

Treatment methods: Prostheses were randomly selected without interfering factors. Replacement and decompression surgeries were conducted by the same panel of experienced surgeons according to requirements. LPS FLEX meniscal-bearing prosthesis (Zimmer USA) was used.

Segmental resection and decompression were both performed for the observation group whereas the control group was only subjected to segmental resection. After epidural anesthesia or general anesthesia layers of tissues were incised in the middle of the anterior knee joint until the patella in the center of which was drilled an approximately 8 mm vertical hole that extended below the cartilage after the flap was pulled open. After incision of the joint capsule the patella was dislocated outwards while flexing the knee. Then the periosteum was dissected and two rows of external bone cortexperforating holes (three holes per row) were drilled 2 cm below the platform of medial condyle to perform depressive resection. Sharp dissections were carried out both inwards and outwards in the proximal patella and a part of the infrapatellar fat pad was resected following regular protocols. A trial model was used before prosthesis implantation to simulate the responses after replacement.

After the model was removed the bone cross section was rinsed and dried. Subsequently the prostheses were fixed on the cross sections of the femur and the tibia. Afterwards the stability and movement of the prostheses were re-checked. Homeostasis was conducted after the surgery and drains were placed with anti-infection treatment. Then tissues were sutured layer-bylayer and the incision was closed and subjected to sterilized dressing. Finally the lower limb was bandaged with elastic bandages. Subsequently the patients began to take exercises under instructions to recover the movements of knee joint ankle joint and hip joint.78 Observation indices: Surgical evaluation: The surgical time of knee joint replacement as well as blood loss and blood transfusion case number during surgery were observed.

Outcome evaluation (three months after surgery): Cured: Disappearance of all symptoms such as pain and swelling normal knee joint movement and negative tourniquet test; markedly effective: disappearance of most symptoms such as pain and swelling unrestricted knee joint movement and negative tourniquet test; effective: disappearance of almost all clinical symptoms mildly restricted knee joint movement and positive tourniquet test; ineffective: inability to meet the above requirements and positive tourniquet test.

Table-I: Surgical prognosis.

Group###Case number (n)###Surgical time (min)###Blood loss (ml)###Blood transfusion case number (n)

Observation group 65###124. 5310. 34###354. 3915. 08###4 (6. 2%)

Control group###65###125. 9811. 73###356. 9314. 08###5 (7. 7%)

2 or t###0. 187###0. 067###0. 056

P###greater than 0. 05###greater than 0. 05###greater than 0. 05

Table-II: Therapeutic effects.

Group###Case No.###Cured###Markedly effective###Effective###Ineffective###Overall effective rate

Observation group 65 45 16 4 0###93. 8%

Control group###65 31 20 10 4###78. 5%

2###9. 234

P###less than 0. 05

Knee joint function evaluation: Knee joint score and functional score were evaluated three months after surgery based on the Knee Score System established in 1989 by American Association of Hip and Knee Surgeons.9

Complications: The patients were followed-up for three months to observe complications such as patellar instability infections and deep vein thrombosis.

Statistical analysis: All data were analyzed by SPSS 13.5. The numerical data were expressed as mean standard deviation (x s). Comparisons were performed by t test and independent samples t-test. The categorical data were compared by Chisquare analysis. Pless than 0.05 was considered statistically significant.

RESULTS

Surgical prognosis: All patients had the surgeries successfully during which no severe complications occurred. The surgical time of knee joint replacement as well as blood loss and blood transfusion case number during surgery were similar (Pgreater than 0.05) (Table-I).

Therapeutic effects: Three months after surgeries the overall effectiveness of the observation group and the control group were 93.8% and 78.5% respectively which were not statistically significantly different (Pless than 0.05) (Table-II).

Functional scores of knee joint: On the same day after surgery the knee joint scores and functional scores of the two groups were similar which evidently increased three months later with significant intra-group and inter-group differences (Pless than 0.05) (Table-III).

Postoperative complications: During the followup period the observation group was significantly less prone to patellar instability infection and deep vein thrombosis compared with the control group (Pless than 0.05) (Table-IV).

Case analysis: Ms. Wang female 65 years old who had suffered from right knee OA for over six years.

Both knees were painful and the joint movement was apparently restricted. Three months after

Table-III: Functional scores of knee joint (x s).

Group###Case No. (n)###Joint score###Functional score

###0th day###Postoperative 3 months###0th day###Postoperative 3 months

Observation group 65 16. 864. 29###48. 556. 32^ 8. 573. 04###19. 454. 09^

Control group###65 16. 345. 12###32. 308. 31^ 8. 562. 99###13. 235. 12^

t###0. 213###9. 344###0. 087###7. 334

P###less than 0. 05###less than 0. 05

Table-IV: Postoperative complications (n).

###Group###Case No.###Patellar instability###Infection###Deep vein thrombosis###Total

###Observation group 65 1 1 0###2 (3. 1%)

###Control group###65 3 3 3###9 (13. 8%)

###2###3. 982

###P###less than 0. 05

segmental resection and decompression combined with replacement of fixed-bearing prosthesis the pain was relieved accompanied by significantly improved joint movement (Fig.1 and Fig.2).

DISCUSSION

It is well-known that knee joint burdens maximum loads in human body. Particularly knee OA is a chronic arthropathy characterized as degeneration and destruction of joint cartilage as well as hyperostosis.10 The elderly are most prone to knee OA and the prevalence rate of those older than 60 years old is approximately 50%. Moreover such rate is increasing annually with population aging.11

Pathologically knee OA begins in the joint cartilage and thereafter subchondral bone joint capsule and articular soft tissue are injured and structurally altered thus stimulating synovial hyperplasia inducing joint swelling and aggravating pain and joint movement disorders.12 Upon knee OA intraosseous pressure increases because venous drainage in the bone marrow of spongy cartilage is hindered which raises the resistance to venous return and leads to nutritional blood flow disorders thus damaging bone and cartilages.13

Currently knee OA is treated by alleviating pain delaying cartilage degeneration improving joint function and preventing or decreasing deformity. Traditionally surgeries are performed to reduce intraosseous pressure and to mitigate pain and functional disorders.14 In contrast segmental resection and decompression can relieve pain by sharply reducing the pressure through segmental drilling. Meanwhile drilling slowly constructs collateral circulation by opening copious capillary beds which alleviates venous stasis as a result. However joint replacement is needed to maintain the therapeutic effects.15

As a novel surgical protocol total knee replacement maintains correct prosthesis positions and soft tissue balancing and stability targets osteotomy and prosthesis implantation accurately and keeps equidistant joint space during flexion and extension. The ten-year survival rates of most prostheses have exceeded 95% without causing pain or functional loss.16 In this study there were no severe complications in the surgeries. The surgical time of knee joint replacement as well as blood loss and blood transfusion case number during surgery were similar (pgreater than 0.05).

During decompression the position of suppressed nerve root is located by imaging. Particularly it is vital to entirely expose the anatomic landmark and to ensure surgical safety by separating outward the Longus colli muscle and by pulling it.17 Besides decompression allows an appropriate matching between the femur and articular surface while maintaining high degree of flexion as well as backward rolling of femur on the tibial plateau thus improving the prognosis.18 In this study the knee joint scores and functional scores of the two groups were similar on the same day after surgery which remarkably increased three months later with significant intra-group and inter-group differences (pless than 0.05).

It is well-established that fixed-bearing prosthesis cannot simulate the kinematic characteristics of normal knee joint and therefore fails to circumvent the contradiction between low joint stress and free movement. In addition relative motion between the femur and the tibia is bound to produce high shear force that loosens the interface between prosthesis and bone. However lumbar spinal stenosis can be effectively treated by subtotal laminectomy and local decompression combined with intervertebral pedicle-screw internal fixation and local decompression is reliable for interbody fusion surgeries.19 During the follow-up period the observation group was significantly less subject to patellar instability infection and deep vein thrombosis compared with the control group (pless than 0.05). Patellar instability as a common complication in clinical practice results from the unrestricted rotations of the tibia and the femur during flexion and extension.

Hence such patients are highly recommended to take functional exercise. Besides as one of the most serious complications of joint replacement postoperative infections may result in complete failure to which particular attention should be paid. Furthermore deep vein thrombosis which results from reduced lower limb movement owing to severe knee joint deformity and pain should be appropriately controlled and prevented. In summary combining segmental resection and decompression with joint prosthesis gave rise to satisfactory short-term prognosis by effectively improving the flexion and extension of injured knee and by reducing complications thus being worthy of promotion in clinical practice.

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Authors' Contributions:

JX and SQ designed the study and prepared the manuscript. CW PL and XX collected data and analyzed the results.
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Publication:Pakistan Journal of Medical Sciences
Date:Dec 31, 2014
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