Role of Ilizarov in Genu varum correction in Osteoarthritic Knee.
Journal Title: International Journal of Medical Science and Innovative Research (IJMSIR) - Year 2019, Vol 4, Issue 2
Abstract
Osteoarthritis (OA) is one of the most common chronic degenerative condition of joints especially in aging population. The role of inflammation in osteoarthritis has been somewhat controversial. Osteoarthritis is known by various name as degenerative arthritis, gono-arthritis, osteoarthrosis, hypertrophic arthritis or age-related arthritis. The pathological features include loss and erosion of articular cartilage, subchondral sclerosis and bony overgrowth (osteophytes). It may involve soft tissue structure in and around the joints. There is modest inflammatory cell infiltration in the synovial tissue, ligaments get laxed and bridging muscle becomes weak. The patient has difficulty in walking and has heavy impact on daily activity and day to day life style and this disease represents an ever-increasing burden on health care. The most prominent symptom that bring the patient to doctor is pain. There might be a group of patients, who do not have any symptoms but might be showing pathological and radiological evidence of OA.1 The main aim of treatment for OA of the knee is to alleviate pain and improve function in order to mitigate reduction in activity. However, most treatments are not curative as they do not modify the natural history or progression of OA. Guidelines for the medical management of osteoarthritis, as per the American College of Rheumatology 2012, emphasize the role of both non-pharmacologic and pharmacologic therapies. Initial management involves non-pharmacologic therapies including education, physio-therapies, mild to moderate exercises, various appliances, braces and weight reduction.2 Pain is decreased with mild to moderate exercise and leads to improved functioning in people with OA of knee. Moderate exercise does not accelerate the patho-physiology of knee osteoarthritis, whether or not there is evidence of pre-existing disease. In either case there appears to be improved physical functioning and reduction of pain and disability in those who exercise. Adequate joint motion and elasticity of peri-articular tissues are necessary for cartilage nutrition and health, protection of joint structures from damaging impact loads, function and comfort in daily activities.3 Patients were benefitted with conservative measures such as weight control, appropriate rest, exercise and the use of mechanical support devices. Reduction in weight by 10% improves the function by 28%. Low energy diet is useful in rapid reduction of weight and more significantly loss of body fat.4 Pharmacologic modalities recommended for the initial management of patients with knee OA includes acetaminophen, oral and topical NSAIDs, tramadol, intra-articular corticosteroids injections and intra-articular hyaluronate injections. As first-line pharmacologic therapy acetaminophen is recommended. If pain does not relieved with acetaminophen, analgesic-dose nonsteroidal anti-inflammatory drugs (NSAIDs) may be used (e.g. ibuprofen, naproxen). If symptom response to a lower NSAID dosage is inadequate, higher, anti-inflammatory dose may be used. Analgesic drugs relieve pain and do nothing more. In contrast NSAIDs also suppress inflammation along with reducing pain but are preferred by physicians and patients for short periods of time. However, these drugs have to be used with great care especially in the patients with co-morbidites due to the well known side effects. In addition, NSAIDs have been shown to have a deleterious effect on cartilage metabolism. Topical agents can be used in view to avoid side effects associated with the systemic use of these NSAIDs; but these topical formulations also have only been proven useful for short-term use for mild to moderate pain in mild joint degeneration.2,5 Intra-articular injections of corticosteroids, as indicated by a few studies, are only of short-term benefit for pain and function. Furthermore, some evidence indicates that they are not able to change the natural history of the disease and may also have negative consequences on knee structures. Glucosamine and chondroitin sulfate have not been clearly shown to be effective either, and they cannot be considered ideal agents for the treatment of pain from chronic severe cartilage degeneration or osteoarthritis. Among the available pharmacologic solutions, despite contradictory findings and controversies regarding its effective usefulness, intra-articular hyaluronic acid (HA) is widely applied in clinical practice, with good results reported in many studies. Platelet-rich plasma (PRP) is a simple, low cost, and minimally invasive method that allows one to obtain from the blood a natural concentrate of autologous growth factors and it would improve symptoms and function, possibly through the release of growth factors and bioactive molecules, in patients affected by knee degeneration in early stages.2,5-6,8 High tibial osteotomy as surgical modality for OA knee attained popularity in the 1960‘s following work by Jackson and Waugh & Debeyre and Patte in 1961 and is now a well-established procedure. It is a widely performed surgery to treat OA of medial compartment of knee. High Tibial Osteotomy can be performed with various techniques i.e. closing wedge, opening wedge, dome and ―en chevron‖ osteotomies, but opening (medial) and closing (lateral) wedge osteotomies are the most commonly performed.9,10 The medial opening wedge osteotomy was described, in France, by Debeyre and Artigou in 1972. HTO has been documented in literature showing consistently significant pleasing result. The main concept of HTO, as weight bearing axis is shifted to relatively unaffected lateral compartment in varus knees, It reduces knee pain and delays or slows down the destruction of the medial joint compartment, hence delay the need for a knee replacement. HTO avoids the majority of the issues associated with lateral closing wedge osteotomy such as the need to perform a fibula osteotomy, risk of compartment syndrome and injury to common peroneal nerve and malunion of the proximal tibia resulting in more demanding subsequent total joint replacement and bone stock loss etc. For all these reasons, the opening wedge HTO gained popularity and became a widely used alternative option.10-11 Unicompartmental knee arthroplasty (UKA) when compared with high tibial osteotomy (HTO) in terms of functional results was found to be superior, however there was no difference in specific knee score; HTO got slightly better results of the range of motion. Postoperative rate of revision and complications did not differ significantly between two groups. Unicompartmental/ Total knee replacement is the main stay of treatment in the western world. But the needs and habits of people in Indian sub-continent (squatting for toilet purposes and cross leg sitting/kneeling for prayer purposes) are little different. Hence, joint conserving surgeries suit such patients better than replacements. Moreover, most of these patients are manual laborers.12,13 Medial open wedge high tibial osteotomy could be fixed with: 1) Illizarov Fixator 2) Simple plate with bone grafting and 3) Locking plate without bone graft. Locking anatomical plate even without bone graft forms structurally stable construct and showed significant results in obese patients, osteotomies requiring large angle of correction and unstable osteotomies following lateral tibial cortex fractures.7,14
Authors and Affiliations
Mohit Dua
Keywords
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