Is knee preservation surgery a viable option for a 45-year-old patient with grade 2 osteoarthritis involving the patellofemoral joint and medial joint?

Knee Preservation Surgery for Grade 2 Osteoarthritis with Patellofemoral and Medial Compartment Involvement

For a 45-year-old patient with grade 2 osteoarthritis involving both the patellofemoral joint and medial compartment, knee preservation surgery is a viable and appropriate option that should be strongly considered before proceeding to total knee arthroplasty. 1, 2

Why Preservation Surgery is Appropriate at This Stage

Your patient's age (45 years) and relatively early-stage disease (grade 2) make them an ideal candidate for joint-preserving procedures rather than arthroplasty. The American Academy of Orthopaedic Surgeons specifically recommends realignment osteotomy as an option in active patients with symptomatic unicompartmental OA and malalignment as an alternative to or temporizing measure before total knee replacement 1. Total knee arthroplasty in patients under 45 years remains controversial and less acceptable, as it has been characterized by some as "a knee joint amputation" in younger individuals 3.

Specific Preservation Options Based on Compartment Involvement

For the Medial Compartment Component

High tibial osteotomy (HTO) should be considered if there is pathological varus malalignment (>5° varus on hip-knee-ankle angle). 1

• The goal is to correct varus to 3-8° of valgus, shifting load from the diseased medial compartment to the healthier lateral compartment 1
• This procedure is specifically indicated for patients under 60-65 years of age with intact lateral compartment and active lifestyle 1
• The American Academy of Orthopaedic Surgeons provides moderate evidence (Grade C) showing no difference in outcomes and complications between realignment osteotomy and unicompartmental knee arthroplasty for medial compartment OA 1

Critical prerequisite: Obtain standing full-length hip-to-ankle radiographs to measure actual mechanical axis and hip-knee-ankle angle before considering HTO 1. If alignment is normal or near-normal, HTO is contraindicated as it can create iatrogenic valgus deformity leading to lateral compartment overload 1.

For the Patellofemoral Component

Patellofemoral arthroplasty represents a joint-conserving solution specifically for isolated patellofemoral degenerative disease in younger patients. 3

• Second-generation patellofemoral prostheses (such as the Avon patellofemoral prosthesis) have consistently achieved good to excellent results in primary treatment of patellofemoral degenerative disease in younger patients 3
• This procedure preserves the tibiofemoral joint, which is particularly valuable when medial compartment disease is only grade 2 3
• Patellofemoral replacement can be successful in selected patients with isolated patellofemoral OA 2

Conservative Management Must Be Exhausted First

Before proceeding with any surgical preservation procedure, implement a structured 3-6 month trial of conservative management 4:

• Eccentric quadriceps strengthening targeting the vastus medialis obliquus as the cornerstone of treatment 4
• Patellar taping for short-term pain relief and functional improvement (Grade B recommendation from the American Academy of Orthopaedic Surgeons) 5
• Topical NSAIDs preferentially over oral formulations to eliminate gastrointestinal hemorrhage risk 4
• Avoid lateral heel wedges as they have limited evidence for effectiveness and may worsen symptoms 5

Approximately 80% of patients with patellofemoral symptoms recover completely within 3-6 months with appropriate conservative treatment 4.

Procedures to Avoid in This Patient

Do not perform arthroscopic lavage and debridement. These procedures do not alter disease progression and should not be used as routine treatment for osteoarthritis 2.

Avoid combined lateral facetectomy, lateral release, and medialization of the tibial tubercle. Despite theoretical appeal, clinical outcomes are not superior to other surgical procedures, and longer-term results are needed before recommendation 6.

Algorithmic Approach to Decision-Making

1. Confirm diagnosis and staging with standing full-length hip-to-ankle radiographs, anteroposterior, lateral, and tangential patellar views 1, 4

2. Measure mechanical axis to determine if varus malalignment (>5°) is present 1

3. If varus malalignment present: Consider HTO for medial compartment unloading 1

4. If alignment normal but patellofemoral symptoms predominate: Consider patellofemoral arthroplasty after conservative management failure 3, 2

5. If both compartments symptomatic with normal alignment: Sequential or staged procedures may be necessary, though this represents a more complex scenario requiring subspecialty consultation 3

Common Pitfalls to Avoid

• Never proceed to preservation surgery without documenting adequate 3-6 month conservative treatment trial 4
• Do not perform HTO in patients with normal alignment, as this creates iatrogenic valgus deformity and accelerates lateral compartment arthritis 1
• Avoid corticosteroid injections into patellar supporting structures, as they inhibit healing and predispose to spontaneous rupture 4
• Do not recommend complete immobilization, as this worsens outcomes through muscular atrophy and deconditioning 4

Expected Outcomes

The key to successful long-term outcomes with preservation surgery is optimal patient selection, preoperative counseling, and good surgical technique 7. At 45 years of age with grade 2 disease, your patient has the potential for excellent outcomes with joint preservation, delaying or potentially avoiding the need for total knee arthroplasty 1, 3, 2.