1. and
present
When is a joint replacementWhen is a joint replacement
necessary?necessary?

2. Treatment of osteoarthritis
There is no etiologic treatment for osteoarthritis.
 The aims of treatment are to control pain and
limit functional impairment.
 Before referring a patient for surgery, it is
essential to prescribe physiotherapy and to
achieve the best possible control of the disease
by medicinal means.
 Nonetheless, surgery is the "last chance
saloon" of treatment.
2 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Chevallier X. Arthrose : une maladie plus complexe qu’il n’y paraît. Rev Prat. 2012 ; 62 : 619-620.

3. When to refer an osteoarthritic patient
for surgery
 1. "Terminal" osteoarthritis
 The need for surgery is dictated by the severity of the disability and/or
pain osteoarthritis causes the patient.
 It is these symptoms and not the condition of the joint as visualised on the
x-ray or MRI scan that indicate the need for surgery:
a surgeon does not operate on pictures!
 In practice therefore, there are no set clinical, radiological or biological
criteria on the basis of which a joint replacement procedure is indicated.
 The impact of osteoarthritis on the lives of patients (their ability to use
transport, perform household chores or take part in leisure activities, etc.)
can be assessed using the Lequesne index.
3 Sellam J, Berenbaum F. Quand adresser au chirurgien un patient arthrosique ? Rev. Prat. 2012 ; 62 : 644

4. 4
According to Sellam 2012

5. When to refer an osteoarthritic patient
for surgery
 2. "Early stage" osteoarthritis in a deformed
or dysplastic joint
 A surgical opinion should be sought for patients with severely
deformed joints, treatment-refractory pain and moderate
osteoarthritis;
 Conservative surgery can be discussed for patients with early stage
symptomatic osteoarthritis in a dysplastic hip or a misaligned knee
(genu varum or genu valgum).
 An acetabular bolt or osteotomy can be proposed for a patient
aged less than 50 with a dysplastic hip (particularly subluxation
with an acetabular roof defect).
 These prosthetic devices have a limited life-expectancy and it is
better to delay using them in younger patients.
5 Sellam J et Berenbaum F. Quand adresser au chirurgien un patient arthrosique. Rev Prat 2012 ; 62 : 644.

6. Surgical treatment of knee osteoarthritis
Surgery is offered for patients with treatment-resistant,
painful and debilitating knee osteoarthritis.
Patients are referred for surgery on the basis of the pain and disability
they experience and not the radiological findings.
 The decision to replace the joint is made after a thorough assessment:
 clinical (age, functional requirement, comorbidities and knee range of
motion and laxity)
 and radiological (standard x-rays, including an axial view, leg alignment and
possibly a schuss view and images in an enforced varus or valgus positions).
The first factor taken into account is the severity of the osteoarthritis:
stiffness, extent of joint-space narrowing, spread into one or more
joint compartments and severity of misalignment.
 Age and function-demand are also determining factors.
6 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56

7. In the large majority of cases, tibio-femoral osteoarthritis arises
subsequent to or in combination with frontal misalignment
which tilts the joint to the side:
 medial tibio-femoral osteoarthritis is mainly seen with the genu
varum deformity,
 whilst lateral osteoarthritis arises more rarely with genu valgum.
The third compartment, or patello-femoral articulation, may
also be involved.
 This observation is the basis for conservative surgery:
correcting the misalignment results in a more even distribution
of stress on the two tibio-femoral compartments and helps
contain the joint degeneration.
7 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56
Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Knee osteoarthritis: conservative
treatment (1)

8. 8
Bilateral femorotibial knee osteoarthritis. Arthrography.

9. Osteotomies are particularly appropriate for patients aged
less than 60-65, especially when they have an active lifestyle.
 As a general rule, osteotomies are indicated for patients
whose symptoms are inadequately controlled by medical
treatments including viscosupplementation.
 Nonetheless, it is important to perform an osteotomy in
younger patients with symptomatic but tolerable
osteoarthritis before the condition becomes too severe.
Carrying out an osteotomy too late reduces the chances
of a successful outcome, while the patient is still considered
to be too young for a joint replacement.
 This type of procedure can delay the need for a knee
replacement by 12 years.
9
Varus osteotomy for knee osteoarthritis by
biomaterial implantation.
Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56
Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Knee osteoarthritis: conservative
treatment (2)

10. Knee osteoarthritis: replacement surgery
This is the procedure of choice for advanced osteoarthritis which
commonly affects two and even all three compartments and is
particularly prevalent in the over 65 age group.
 A knee replacement can involve:
 a single tibio-femoral compartment if only one is affected and the patient
does not present with severe misalignment or hypermobility
 or the whole knee, if the damage is more widespread.
 Complications
 immediate: early dislocation, infection or thrombophlebitis.
 delayed: delayed onset infection with or without septic loosening,
wear and tear of the artificial joint, mechanical loosening.
 Since loosening can be infectious or mechanical in origin, all cases
must be screened for infection before the artificial joint is replaced.
10 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56

11.  For dysplasia and secondary hip osteoarthritis in young patients aged less than
50 years old, conservative treatment, for instance an acetabular bolt or
osteotomy, is to be preferred as artificial joints have a limited life-expectancy
and are therefore to be avoided in younger patients.
 Conservative treatment is therefore acetabular bolting or an osteotomy.
11
Early and congestive superior
pole hip osteoarthritis. Frontal
reconstruction of a right hip CT
scan.
Sellam J, Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686
Hip osteoarthritis: conservative
treatment

12.  The decision to perform a total hip
replacement is taken not as a function of
radiologically-detected severity, but of
the pain, discomfort and disability
experienced by the patient.
 Hip replacements have a life-expectancy
of about 15 years, which explains why
surgeons are reluctant to recommend
them for younger patients.
 Because joint implants wear out over
time, younger patients often require
revision hip replacement surgery which is
a more complex procedure than the initial
operation.
12 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
Hip osteoarthritis: total hip replacement

13. Hand osteoarthritis: surgical treatment
 Osteoarthritis tends to affect several finger joints
which is why surgical treatment is to be avoided.
 Although rarely required, a trapeziectomy can be
proposed for thumb osteoarthritis if the joint is extremely
painful.
 Both arthrodesis and trapezometacarpal replacement
are possible in theory but rare in practice.
13 Sellam J et Berenbaum F. Arthrose. Rev. Prat. 2011 ; 61 : 675-686

14. Conclusion
 When treating patients with debilitating osteoarthritis,
surgeons have a variety of means at their disposal, to be
selected depending on:
the age of the patient,
the patient's condition (physiological age, activity)
and the nature of the osteoarthritis.
14 Huten D. Chirurgie de la gonarthrose fémoro-tibiale. Rev Prat. 2009 ; 59 : 1254-56