Core Training

Osteoarthritis and arthroplasty

of the hip and knee

P
rimary osteoarthritis is a degenerative Table 1. Risk factors for the Table 2. Management of osteoarthritis
condition characterized by focal development of osteoarthritis
loss of articular hyaline cartilage, Non- Patient education
inflammation of synovial tissue Primary Secondary pharmacological
(conservative) Weight loss
and accompanying osteophyte osteoarthritis osteoarthritis
formation (Courtney and Doherty, 2014; Exercise
ConstitutionalAdvanced age Dysplasia
Clarke et al, 2015). Clinically this manifests Perthes’ Physiotherapy
as joint pain, stiffness and loss of function. Obesity disease
Secondary osteoarthritis is the result of Post trauma Pharmacological Analgesics (non‑steroidal
Female sex
underlying intra-articular disease (Table 1). Osteonecrosis anti-inflammatory drugs)
Biomechanical Joint injury Paget’s Topical treatments
Epidemiology disease
Reduced
Approximately 10 million people in the Intra-articular steroid
muscle
injections
UK suffer from symptoms attributable to strength
osteoarthritis; a large proportion of these Operative Joint preserving (arthroscopy,
Genetic Family history
experience constant pain and disability. It osteotomy)
is estimated that osteoarthritis will be the From National Institute for Health and Care Excellence
(2014) Joint obliterating (arthrodesis)
fourth leading cause of disability worldwide
by 2020 and currently results in over Joint replacement
36 million lost workdays per year (National radiate proximally to the hip, as the nerve (arthroplasty)
Institute for Health and Care Excellence, root supply is shared (L2–4). Radiographs From National Institute for Health and Care Excellence
2014; Briggs, 2015; Clarke et al, 2015). aid diagnosis, exclude differentials, stage (2014)
disease and facilitate operative planning.
Diagnosis Features include loss of joint space, Management
Osteoarthritis may be diagnosed clinically osteophytes, subchondral sclerosis and Management of osteoarthritis may be
in patients aged 45 years or older, suffering subchondral cysts (LOSS mnemonic) non-operative (non-pharmacological or
from activity-related joint pain, with or (Figure 1). pharmacological) or operative (Table 2).
without morning stiffness lasting no longer
than 30 minutes (National Institute for a b
Health and Care Excellence, 2014). Hip
osteoarthritis can cause hip and/or groin
pain, worse on weight-bearing, which may
radiate distally to the knee. Knee pain may

Mr Paul D Robinson, Senior House Officer,

Department of Trauma and Orthopaedics,
Salisbury District Hospital,
Salisbury SP2 8BJ
Miss Jo McEwan, Specialist Registrar,
Department of Trauma and Orthopaedics,
Salisbury District Hospital, Salisbury
Miss Vidhi Adukia, Senior House Officer,
Department of Trauma and Orthopaedics,
Queen Alexandra Hospital, Portsmouth
© 2018 MA Healthcare Ltd

Mr Makarahalli Prabhakar, Consultant,

Department of Trauma and Orthopaedics,
Salisbury District Hospital, Salisbury
Correspondence to: Mr PD Robinson Figure 1. a. Anteroposterior and (b) lateral radiograph of left knee showing characteristic
([email protected]) radiographic features of osteoarthritis. Yellow arrow: loss of joint space, red arrow: osteophyte,
blue arrow: subchondral sclerosis, purple arrow: subchondral cyst.

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 What You Need To Know About

Table 3. Approaches to the hip joint

Approach Anterior Anterolateral Lateral Posterior
Eponym Smith–Petersen Watson–Jones Hardinge Moore or Southern
Position Supine Lateral Lateral or supine Lateral or prone
Incision Anterior iliac crest to anterior Starting 2.5 cm postero-distally Starting 5 cm proximal to tip Starting 7 cm postero-proximally
superior iliac spine, extending to anterior superior iliac spine, of greater tuberosity, running to the greater tuberosity, running
distally towards lateral patella running down femoral shaft, distally in line with the femur down femoral shaft
centred on greater tuberosity
Structures at Lateral femoral cutaneous nerve, Femoral nerve, artery and vein Superior gluteal nerve, femoral Sciatic nerve
risk lateral femoral cutaneous artery nerve
Dissection Superficial: between sartorius Superficial: between tensor fascia Superficial: between tensor Superficial: split gluteus
and tensor fascia lata lata and gluteus maximus fascia lata and gluteus maximus maximus
Deep: between rectus femoris Deep: detach abductor mechanism Deep: split gluteus maximus Deep: detach piriformis and
and gluteus maximus and vastus lateralis obturator internus
Advantages Muscle sparing, low dislocation Low dislocation rate, good Good exposure of the femur Good exposure of acetabulum
rate acetabulum exposure and femur
Disadvantages Limited access to femur and Damage to abductors Damage to abductors High dislocation rate
posterior acetabulum
From Petis et al (2015)

Further review of osteoarthritis and non- joint may reveal stiffness, loss of motion and the operation of the 20th century (Knight et
surgical management can be found elsewhere crepitus. Neurovascular status of the limb al, 2011). Total hip replacements are now the
(Courtney and Doherty, 2014). Patients must also be assessed and documented. ‘Joint third most commonly performed operation
experiencing symptoms that substantially schools’ are useful in educating patients in the UK. Primary total hip arthroplasty is
impact on daily life and are refractory to non- regarding the surgical pathway. a highly effective medical intervention with
operative treatments should be considered Anticoagulants and non-steroidal anti- 96% of patients reporting an improvement
for surgical management (National Institute inflammatories should ideally be stopped in symptoms (Jenkins et al, 2013).
for Health and Care Excellence, 2014). preoperatively to reduce bleeding risk and Total hip arthroplasty involves
avoid acute kidney injury. Active infection replacement of the hip joint with two
Arthroplasty overview (e.g. urine infection, cellulitis) must be femoral components (stem and head) that
Arthroplasty (Greek, arthron – relating treated before surgery. articulate with two acetabular components
to joints, plastos – formed) involves the Nerve blocks, local anaesthetic infusions (shell and liner) (Figure 2).
surgical remodelling of a joint to restore and spinal anaesthesia are used to reduce pain
congruity. The primary aim is to relieve pain, and enable early mobilization. Mobilization
with the secondary aim of improving joint begins as soon as possible postoperatively and
function. Over 200 000 joint replacements the patient is discharged within 24–72 hours.
are performed annually in the UK, 92% Day case arthroplasty is gaining popularity.
Pelvis
as a result of osteoarthritis (National Joint Enhanced recovery pathways optimize
Acetabular cup
Registry, 2017). Other indications for perioperative wellbeing by reducing the
arthroplasty include inflammatory arthritis, surgical stress response, leading to reduced
Liner
trauma and developmental abnormalities. rates of readmission, complications and
length of hospital stay, and improved patient
Perioperative management satisfaction (Jones et al, 2014).
Clinicians should assess the impact of Femoral head
joint symptoms and exclude other causes Hip arthroplasty
of pain, e.g. trauma, bursitis, infection, Total hip arthroplasty has evolved significantly
neuropathy, referred back pain. A thorough since 1891 when Professor Glück used Femoral stem
© 2018 MA Healthcare Ltd

history is essential as 72% of patients with ivory to replace femoral heads damaged by
osteoarthritis have significant medical tuberculosis (Knight et al, 2011). Modern
comorbidities. Social histories help identify total hip arthroplasty began in the 1960s Cement restrictor
any community support that may be required with the Charnley low friction arthroplasty
postoperatively. Physical examination of the and has been so successful as to be labelled Figure 2. Components of a total hip arthroplasty.

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Core Training

Table 4. Ideal arthroplasty bearing

Expose and incise joint characteristics
Preparation and draping Approach to hip joint
capsule
Minimal wear
Debris from wear not generating an immune
Dislocate hip Cut femoral neck Ream acetabular socket response
Low coefficient of friction
Low rate of dislocation
Fix femoral stem and
Fix socket and liner into Mechanically and chemically sound to minimize
Prepare femoral canal femoral head into the
the acetabulum fractures, scratching
femur
Cost effective

Reduce hip joint Closure ‘Hard on hard’ implants such as ceramic

on ceramic implants are hard wearing with
low friction and offer an attractive option
Figure 3. Basic surgical steps for a total hip replacement. for younger patients. However, they are
poorly tolerant of implant malposition and
Approach (Abdulkarim et al, 2013; Briggs, 2015). A fragments may cause third body wear of both
The best surgical approach to the hip risk of the cementing process is bone cement new and retained components.
joint remains controversial (Table 3). implantation syndrome, characterized by Metal on metal prostheses emerged to
Internationally the posterior and lateral hypotension, hypoxia and cardiac arrhythmias. try to overcome the issue of polyethylene
approaches are most commonly used (Petis Bone cement implantation syndrome is volumetric wear and dislocation. However,
et al, 2015). There has been interest in likely caused by embolization of fat and pseudotumour-like tissue reactions (aseptic
minimally invasive surgery, whereby the bone marrow debris. Cement fragments lymphocytic vasculitis-associated lesions)
incision is less than 10 cm through a direct can also cause third body wear and local form as a result of metal ion release
anterior or direct superior approach, but inflammation, leading to aseptic loosening following corrosion of the bearing surfaces
such approaches have not gained widespread and pain. Uncemented total hip arthroplasties (Clarke et al, 2015). Aseptic lymphocytic
use. The basic surgical steps are shown in avoid these limitations, but meta-analyses vasculitis-associated lesions result in large
Figure 3. indicate no significant difference in rates of areas of tissue destruction and necrosis,
revision, all-cause mortality or complications. associated with poor outcomes even after
Implant fixation (Abdulkarim et al, 2013; Vaishya et al, 2013; revision surgery. Systemic toxicity (neuro-
Prostheses may be cemented, uncemented López-López et al, 2017). ocular, cardiac, thyroid toxicity) as well as
(‘press-fit’) or hybrid (cemented stem, increased chromosomal abnormalities was
uncemented cup). The optimal method for Bearing surfaces found, primarily as a result of higher serum
total hip arthroplasty remains controversial. Various combinations of bearing surfaces cobalt levels. Studies indicate higher rates of
In 2003, 60% of total hip arthroplasties were exist (Tables 4 and 5). ‘Hard on soft’ implants implant failure, revision and mortality, and
fully cemented, 16.9% uncemented and such as ceramic on polyethylene and metal their use has fallen to 0.7% (Knight et al,
12.3% hybrid compared to 29.6%, 38.5% on polyethylene are most commonly used in 2011; National Joint Registry, 2017). UK
and 28.1% respectively in 2016 (Briggs, the UK (32%) (Clarke et al, 2015). national guidelines for managing patients
2015; National Joint Registry, 2017).
Bone cement is polymethylmethacrylate
plus additives including radio-opacifiers Table 5. Comparison of bearing surfaces
(barium sulphate), green chlorophyll to Prosthesis Advantages Disadvantages
distinguish cement from bone and antibiotics
Metal on ■■ Safe ■■ Aseptic loosening
(gentamicin or vancomycin). Cement is not
polyethylene ■■ Cost effective
adhesive, but rather functions as a grout
that interdigitates at the bone–implant ■■ Good long-term evidence available
interface providing immediate integration. Ceramic on ■■ Low wear ■■ Expensive
Uncemented prostheses have a porous ceramic ■■ Low friction ■■ Require expert insertion
surface to facilitate osseointegration, which
© 2018 MA Healthcare Ltd

requires biologic fixation by bony ongrowth ■■ Inert particles ■■ Fracture risk

(Vaishya et al, 2013). ■■ Dislocation risk
Advantages of cemented total hip Metal on metal ■■ Low wear ■■ Local and systemic toxicity
arthroplasty include a lower average cost
■■ Low dislocation rate ■■ Potentially carcinogenic
and improved short-term clinical outcomes.

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 What You Need To Know About

Constraint refers to the degree of stability

the prosthesis provides under flexion–
extension and valgus–varus stress. There is
Femur (cut edge)
a spectrum of constraint: cruciate retaining
(least constrained), posterior stabilized,
constrained condylar and hinged knee
replacement (most constrained). Modularity
Femoral component describes the ability to add augments to the
prosthesis to compensate for bone loss. Tibial
Liner components are either modular, which have
a metal tibial tray with a polyethylene insert
(Figure 5), or non-modular consisting of a
Tibial component
single pothyethylene monobloc. The tibial
Figure 5. Modular knee prosthesis.
polyethylene insert can be mobile or fixed
which include the subvastus and mid-vastus within the tibial tray. A mobile bearing
approaches. Quadriceps sparing approaches allows rotation of the insert on the metal
Tibia (cut edge)
aim to preserve the quadriceps strength, tray, decreasing contact pressure to reduce
enable faster rehabilitation and decrease polyethylene wear.
postoperative pain, but these approaches may Implant selection depends on the
increase complications, implant malposition individual patient, the stability of the knee
and operative time. and degree of bone loss. Similarly to total
Figure 4. Components of total knee arthroplasty. hip arthroplasty, total knee arthroplasties
Prosthesis design can be cemented or uncemented (Figure
with metal on metal implants are available There are three key concepts in total knee 6). In 2016 62.2% of all primary total knee
(Medicines and Healthcare products arthroplasty design: femoral rollback, arthroplasties used cemented fixed bearing
Regulatory Agency, 2017). constraint and modularity. Femoral rollback cruciate-retaining implants (National Joint
describes the movement of the point of Registry, 2017). New designs continue to
Knee arthroplasty contact between the tibia and femur, which be developed, offering custom-designed
Primary total knee arthroplasty is the second becomes more posterior as the knee flexes, implants, patient-specific instrumentation
most common joint replacement and the enabling the knee to flex without impinging. and computer-navigated knee arthroplasty.
fourth most common surgical procedure
performed in the UK (National Joint Registry, a b
2017). The first knee replacements were
developed in the 1970s and implant design
continues to evolve. Total knee arthroplasty
involves the resection and replacement
of the distal femoral and proximal tibial
joint surfaces (Figure 4). Unicondylar knee
arthroplasty is available for patients with
osteoarthritis limited to one compartment,
usually medial. Patellofemoral replacements
can be performed in isolation, or through
resurfacing the patella with a polyethylene
button during total knee arthroplasty. In
young patients with unicompartmental
osteoarthritis, an osteotomy may be
preferable as this alters the mechanical axis
of the limb to off-load the painful arthritic
part of the joint.

Approach
The medial parapatellar approach is the most
© 2018 MA Healthcare Ltd

common; an anterior midline skin incision,

then an incision through the quadriceps
tendon that curves around the medial
border of the patella. There are additional Figure 6. a. Postoperative anteroposterior and (b) lateral knee radiograph following total knee
approaches, termed quadriceps sparing, replacement and skin clips (Stryker Triathlon cemented total knee system).

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Core Training

occurs in less than 1% of cases but can be implant wear and release of debris incites
KEY POINTS disastrous (National Joint Registry, 2017). local inflammation leading to activation
■■ Osteoarthritis is a degenerative disease Perioperative antibiotic prophylaxis aims of osteoclasts, release of cytokines and
of the articulate cartilage which presents to reduce this. Early onset prosthetic joint proteolytic enzymes and subsequent
clinically with joint pain, stiffness, loss of infections (≤6 weeks) may be managed osteolysis. Aseptic loosening is diagnosed
function and disability. with debridement, antibiotics and implant clinically by increasing pain, worse on weight
■■ Management of osteoarthritis may be retention. Late onset deep infections are bearing, in the absence of infection, but
non‑pharmacological, pharmacological associated with biofilm formation which radiographs may demonstrate radiolucency
or operative, which usually involves joint may require staged revision surgery. at the bone–prosthesis interface.
replacement.
Stiffness characterized by limited range The incidence of subclinical nerve damage
■■ Osteoarthritis is the most common of motion, functional impairment and post-total hip arthroplasty may be as high as
indication for arthroplasty with over dissatisfaction is a common and disabling 75%, but the incidence of significant nerve
200 000 joint replacements performed
problem post-total knee arthroplasty. Risk palsy is 1–3% (Table 7). The risk of major
annually in the UK.
factors include poor preoperative range vascular injury is 0.3% and is increased with
■■ Total hip arthroplasty is the most
of motion, obesity, socioeconomic status, the use of acetabular screws (Barrack and
commonly undertaken arthroplasty in
ethnicity and non-compliance. Methods Butler, 2003).
the UK, and the third most commonly
performed operation, with total knee
to improve stiffness include intensive
arthroplasty following. physiotherapy and continuous passive motion Specific complications
devices. Persistence of inadequate range of Total hip arthroplasty dislocation occurs
■■ Implants may be cemented, uncemented
or hybrid and can be composed of motion may be treated with manipulation in approximately 3% of patients. They are
several different material combinations under anaesthetic which attempts to address commonly posterior as a result of flexion,
with metal on polyethylene being used early abnormal scarring. Results are best if adduction and internal rotation of the hip
most commonly in the UK. undertaken before 12 weeks postoperatively. (a common composite movement required
Venous thromboembolism is the when putting on socks). The majority of
leading cause of perioperative mortality. patients with early postoperative dislocation
Complications Patients commonly receive chemical and/ are managed with closed reduction
General complications or mechanical thromboprophylaxis for alone. Recurrent instability may require
Infection is the most common complication up to 35 days, reducing the incidence of revision surgery. Dual mobility acetabular
following joint arthroplasty (Table 6) symptomatic venous thromboembolism components are useful in total hip arthroplasty
(Berry, 1999). Superficial wound infection to <1% and fatal pulmonary embolism to for complex cases such as osteoarthritis
is relatively common. Deep infection <0.1% (Berry, 1999). secondary to neuromuscular disorders and
Painful aseptic loosening is the most revision cases. The dual mobility construct
common cause of revision. Time-dependent enables articulation between the acetabular
Table 6. Complications associated
liner and shell, increasing the effective range
with total hip arthroplasty
Table 7. Causes of nerve injury and of movement and allowing the head–liner
Intraoperative Fracture (1–5%) the nerves commonly at risk post complex to function as a large femoral head,
total hip arthroplasty which decreases the risk of dislocation.
Nerve injury
Leg length discrepancy following total hip
Cause Idiopathic 47%
Leg length discrepancy or arthroplasty can cause pain, gait abnormalities
malposition Traction 20% and patient dissatisfaction. Preoperative
Cement reactions
templating and trial of components during
Contusion 19%
surgery before definitive implantation can
Anaesthetic complications Haematoma 11% reduce symptomatic discrepancies.
Postoperative Early Bleeding The majority of total knee arthroplasties
Dislocation 2%
are performed under a tourniquet to
Infection Laceration <1% minimize blood loss and reduce perioperative
Venous morbidity. Tourniquets can cause
Nerves at risk Sciatic (particularly the peroneal
thromboembolism division)
neurological injury and reperfusion injury
if applied for an extended period of time.
Dislocation Femoral
Late Aseptic loosening Obturator Conclusions
Osteoarthritis is a common cause of
© 2018 MA Healthcare Ltd

Periprosthetic fracture Superior gluteal nerve* morbidity worldwide, and its prevalence is
(<1%)
From Barrack and Butler (2003). *Damage to the increasing. Joint replacement is undertaken
Implant failure (0.27%) superior gluteal nerve causes weakness of the hip when symptoms become refractory to
abductors, leading to the characteristic Trendelenburg non‑operative management. It is likely
From Berry (1999) gait
that the demand for surgical intervention

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 What You Need To Know About

will grow as the population ages. Total hip review of adult elective orthopaedic services in Orthop Rev 3(2): 16. https://doi.org/10.4081/
England: Getting It Right First Time. www.boa. or.2011.e16
arthroplasty and total knee arthroplasty ac.uk/pro-practice/a-national-review-of-elective- López-López JA, Humphriss RL, Beswick AD et al
are among the most commonly performed orthopaedic-services-in-england/ (accessed 23 (2017) Choice of implant combinations in total
orthopaedic surgeries and are associated with February 2017) hip replacement: systematic review and network
Clarke A, Pulikottil-Jacob R, Grove A et al (2015) meta-analysis. BMJ 359: j4651. https://doi.
excellent clinical outcomes. Controversy Total hip replacement and surface replacement for org/10.1136/bmj.j4651
remains regarding the best method for the treatment of pain and disability resulting from Medicines and Healthcare products Regulatory
implant fixation and choice of bearing end-stage arthritis of the hip (review of technology Agency (2017) All Metal-on-Metal (MoM)
appraisal guidance 2 and 44): systematic review hip replacements: updated advice for follow-
surface, but these should be tailored to the and economic evaluation. Health Technol Assess up of patients. MDA/2017/018. www.gov.uk/
individual needs of the patient.  BJHM 19(10): 1–668, vii–viii. https://doi.org/10.3310/ drug-device-alerts/all-metal-on-metal-mom-hip-
hta19100 replacements-updated-advice-for-follow-up-of-
Figure 5 is reproduced by kind permission from Smith Courtney P, Doherty M (2014) Osteoarthritis. Br patients (accessed 20 January 2018)
and Nephew. J Hosp Med 75 (Sup5): C66–C70. https://doi. National Institute for Health and Care Excellence
Conflict of interest: none. org/10.12968/hmed.2014.75.Sup5.C66 (2014) Osteoarthritis: care and management in
Jenkins PJ, Clement ND, Hamilton DF, Gaston P, adults. NICE guideline CG177. www.nice.org.
Abdulkarim A, Ellanti P, Motterlini N, Fahey T, Patton JT, Howie CR (2013) Predicting the cost uk/guidance/cg177 (accessed 22 February 2017)
O’Byrne JM (2013) Cemented versus uncemented – effectiveness of total hip and knee replacement: National Joint Registry (2017) 14th Annual report.
fixation in total hip replacement: a systematic a health economic analysis. Bone Joint J 95B(1): www.njrreports.org.uk/Portals/0/PDFdownloads/
review and meta-analysis of randomized 115–121. NJR%2014th%20Annual%20Report%202017.
controlled trials. Orthop Rev 5(1): 8. https://doi. Jones EL, Wainwright TW, Foster JD, Smith pdf (accessed 20 January 2018)
org/10.4081/or.2013.e8 JRA, Middleton RG, Francis NK (2014) A Petis S, Howard J, Lanting B, Vasarhelyi E
Barrack RL, Butler RA (2003) Avoidance and systematic review of patient reported outcomes (2015) Surgical approach in primary total hip
management of neurovascular injuries in total hip and patient experience in enhanced recovery arthroplasty: anatomy, technique and clinical
arthroplasty. Instr Course Lect 52: 267–274. after orthopaedic surgery. Ann R Coll Surg Engl outcomes. Can J Surg 58(2): 128–139. https://
Berry DJ (1999) Epidemiology: hip and knee. Orthop 96(2): 89–94. https://doi.org/10.1308/00358841 doi.org/10.1503/cjs.007214
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org/10.1016/S0030-5898(05)70073-0 Knight SR, Aujla R, Biswas SP (2011) Total hip cement. J Clin Orthop Trauma 4(4): 157–163.
Briggs T (2015) Executive summary. A national arthroplasty – over 100 years of operative history. https://doi.org/10.1016/j.jcot.2013.11.005

25 UN
Organised by

% TI
D L4
IS T
C H M
O A
UN Y
6th national conference

TE 20
D 18
RA
Osteoporosis 2018
TE
Queen Elizabeth II Centre, London
18th June 2018
Highlights will include:
• Bisphosphonates for treating osteoporosis
• Incorporating falls management into osteoporosis management
• Assessing efficacy of hormone therapies
• Gender disparities in osteoporosis
• Osteoporosis in youth and adolescence
• Treatment of osteoporosis: current best practice update

Follow us on Twitter: @MAHealthEvents

Tweet about the conference: #osteoporosis18
© 2018 MA Healthcare Ltd

To book your place:

( Call us on +44(0)20 7501 6761
8 www.mahealthcareevents.co.uk/osteoporosis2018

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