JBJS | Surgical Options for the Middle-Aged Patient with Osteoarthritis of the Knee Joint*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 12

Instructional Course Lecture | December 01, 2000

Surgical Options for the Middle-Aged Patient with Osteoarthritis of the Knee Joint*†

Arlen D. Hanssen, M.D.‡; Michael J. Stuart, M.D.‡; Richard D. Scott, M.D.§; Giles R. Scuderi, M.D.#

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2001 in Instructional Course Lectures, Volume 50. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).
†One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Zimmer, Warsaw, Indiana.
‡Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905. E-mail address for A. D. Hanssen: hanssen.arlen@mayo.edu.
Â§Department of Orthopedic Surgery, Harvard Medical School, 125 Parker Hill Avenue, Boston, Massachusetts 02120.
#Insall-Scott-Kelly Institute for Orthopaedics and Sports Medicine, 170 East End Avenue, New York, N.Y. 10128.

The Journal of Bone & Joint Surgery. 2000; 82:1767-1767

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Introduction

Arthritic disease of the knee joint hindering lifestyle choices in an active aging population has become increasingly frequent. The pathology within the knee joint can vary from localized unicompartmental arthritis to end-stage tricompartmental arthritis. Associated conditions include extensive meniscal degeneration, ligamentous instability, localized articular cartilage defects, limb malalignment, and joint-line obliquity. Nonoperative treatments to reduce the pain associated with joint inflammation include activity modification, weight loss, anti-inflammatory or analgesic medications, intra-articular injections, periarticular muscle-strengthening, and stress-offloading with braces or heel-wedges. However, when the pain and associated impairment do not resolve satisfactorily with nonoperative modalities, surgical intervention may be considered.

Surgical options include arthroscopic dè¡²idement, ligamentous reconstruction, realignment osteotomy, unicompartmental arthroplasty, and total knee arthroplasty. In the absence of infection or extensor mechanism disruption, arthrodesis of the knee is an extremely rare option for the active middle-aged patient. For the purposes of this discussion, the middle-aged patient will be defined in chronological terms as being between forty and sixty years of age. The decision process leading to good patient selection is often complex and depends upon many variables (Table I). Since most middle-aged patients with arthritis of the knee joint eventually have a total knee arthroplasty, analysis and comparison of several parameters are integral to selecting the best surgical option. These parameters include (1) the clinical results or survivorship associated with a given procedure, (2) the morbidity and attendant complications of the procedure, (3) the difficulty of eventual conversion to a total knee arthroplasty, and (4) the effect of a given procedure on the outcome of an eventual total knee arthroplasty³⁵.

The goal of patient selection for a surgical procedure in this young and active population should be extension of the lifetime of the natural knee joint when possible, but the effect on the outcome of eventual prosthetic arthroplasty also should be carefully considered. Although the principle of avoiding total knee arthroplasty for as long as possible in the middle-aged patient is appropriate, performing an alternative procedure that has a limited chance of success or one that has negative implications for the outcome of a subsequent total knee arthroplasty has no logical basis.

Therefore, both patient variables and the capabilities of the surgeon with a specific operative procedure must be considered. Many reports of clinical results underscore the importance of proper surgical technique, and many of the difficulties encountered with eventual total knee arthroplasty are due to suboptimal technical performance of the prior procedure. The underlying principle for a successful outcome for all of these surgical options is careful patient selection combined with good surgical technique.

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Fig. 1:: Arthroscopic view of a focal articular lesion of the medial condyle of the distal part of the femur. The axial limb alignment as seen on a full-length standing radiograph indicated that the weight-bearing line passed directly through the lesion. In addition to arthroscopic dè¡²idement or adjunctive surgical techniques such as osteochondral grafting or chondrocyte implantation, a realignment osteotomy is necessary to transfer the weight-bearing forces away from the lesion.

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Fig. 2:: Anteroposterior standing radiograph of the knee joint in a heavy fifty-two-year-old woman with progressive pain in the medial compartment. The symptoms are typical of degenerative arthritis, and mechanical symptoms of catching or locking are absent. Because of the advanced degenerative changes and the varus limb alignment, this patient is not a good candidate for arthroscopic dè¡²idement. Her body habitus is a relative contraindication to realignment osteotomy. Total knee arthroplasty or unicompartmental knee arthroplasty is the best surgical option.

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TABLE I: Variables Used for Selection of the Surgical Procedure

Historical

Age (chronological, physiological)

Activity level

Pain (severity, location, character)

Mechanical symptoms

Systemic inflammatory disease

Prior joint infection

Prior meniscectomy

Physical examination

Range of motion (total arc, flexion contracture)

Ligamentous deficiencies

Gait (adductor thrust)

Malalignment (magnitude, direction)

Body habitus

Patellofemoral findings (pain, stability)

Radiographic

Alignment (mechanical, anatomical)

Arthritic involvement (location, severity)

Joint-line obliquity

Periarticular deformity

Miscellaneous

Durability of results

Patient expectations

Surgeon capabilities

Potential complications

Postoperative recovery

Effect on subsequent total knee arthroplasty

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TABLE I: Variables Used for Selection of the Surgical Procedure

Historical

Age (chronological, physiological)

Activity level

Pain (severity, location, character)

Mechanical symptoms

Systemic inflammatory disease

Prior joint infection

Prior meniscectomy

Physical examination

Range of motion (total arc, flexion contracture)

Ligamentous deficiencies

Gait (adductor thrust)

Malalignment (magnitude, direction)

Body habitus

Patellofemoral findings (pain, stability)

Radiographic

Alignment (mechanical, anatomical)

Arthritic involvement (location, severity)

Joint-line obliquity

Periarticular deformity

Miscellaneous

Durability of results

Patient expectations

Surgeon capabilities

Potential complications

Postoperative recovery

Effect on subsequent total knee arthroplasty

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TABLE II: Survival Rates in Selected Series of High Tibial Osteotomies

*The average duration of follow-up was twelve to thirteen years.†Value for patients with a relative body weight of less than 1.17.‡Value for patients with postoperative alignment of at least 8 degrees of valgus.Â§The average duration of follow-up was nine years.#Value for twenty patients with appropriate postoperative alignment.**The average duration of follow-up was one year.

Study	No. of Patients	Rate of Survival
At 2 Yrs.	At 5 Yrs.	At 7 Yrs.	At 10 Yrs.	At 15 Yrs.
Berman et al.⁹ (1991)	39	87%	-	-	-	57%*
Cass and Bryan²¹ (1988)	86	94%	87%	-	69%	-
Coventry et al.²⁸ (1993)	87	-	87%	-	66%	-
			(96%)†		(91%)†
			(94%)‡		(94%)‡
Healy and Riley⁴⁵ (1986)	31	92%	88%	91%	80%§	-
Hernigou et al.⁴⁸ (1987)	93	-	90%	-	45%#	-
			(100%)#		(100%)
Matthews et al.⁸⁶ (1988)	40	86%**	50%	-	28%§	-
Ritter and Fechtman¹⁰⁹ (1988)	78	95%	80%	58%	58%	58%*
Rudan and Simurda¹¹² (1991)	128	-	-	-	80%	70%
Yasuda et al.¹³⁵ (1992)	86	-	88%	-	63%	-

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TABLE II: Survival Rates in Selected Series of High Tibial Osteotomies

Study	No. of Patients	Rate of Survival
At 2 Yrs.	At 5 Yrs.	At 7 Yrs.	At 10 Yrs.	At 15 Yrs.
Berman et al.⁹ (1991)	39	87%	-	-	-	57%*
Cass and Bryan²¹ (1988)	86	94%	87%	-	69%	-
Coventry et al.²⁸ (1993)	87	-	87%	-	66%	-
			(96%)†		(91%)†
			(94%)‡		(94%)‡
Healy and Riley⁴⁵ (1986)	31	92%	88%	91%	80%§	-
Hernigou et al.⁴⁸ (1987)	93	-	90%	-	45%#	-
			(100%)#		(100%)
Matthews et al.⁸⁶ (1988)	40	86%**	50%	-	28%§	-
Ritter and Fechtman¹⁰⁹ (1988)	78	95%	80%	58%	58%	58%*
Rudan and Simurda¹¹² (1991)	128	-	-	-	80%	70%
Yasuda et al.¹³⁵ (1992)	86	-	88%	-	63%	-

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TABLE III: Results of Distal Femoral Osteotomy

*The values are given as the average, with the range in parentheses.†End point of survival analysis.‡Value for patients who had isolated compartment disease.Â§Value for patients who did not have rheumatoid arthritis.#Value for patients who had valgus deformity without arthrosis.

Study	No. of Patients	Rate of Success (percent)	Duration of Follow-up* (yrs.)
Beaver et al.⁷ (1991)	42	83	3.6 (2-11.5)
Cameron et al.¹⁷ (1997)	49	87	7†
Conrad et al.²⁶ (1985)	16	62	6.5
Edgerton et al.³⁴ (1993)	24	71 (86‡)	8.3 (5-11)
Finkelstein et al.³⁸ (1996)	21	64	11 (8-20)
Healy et al.⁴⁶ (1988)	23	83 (93Â§)	4 (2-9)
Johnson and Bodell⁶² (1981)	53	70	3.6 (1-9.3)
McDermott et al.⁷⁸ (1988)	24	92	4 (2-11.5)
Mathews et al.⁸⁵ (1998)	21	57	3 (1-8)
Miniaci et al.⁸⁹ (1990)	35	86 (100#)	5.4 (2-16.7)
Terry and Cimino¹²⁹ (1992)	35	60	5.4 (2-19)

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TABLE III: Results of Distal Femoral Osteotomy

Study	No. of Patients	Rate of Success (percent)	Duration of Follow-up* (yrs.)
Beaver et al.⁷ (1991)	42	83	3.6 (2-11.5)
Cameron et al.¹⁷ (1997)	49	87	7†
Conrad et al.²⁶ (1985)	16	62	6.5
Edgerton et al.³⁴ (1993)	24	71 (86‡)	8.3 (5-11)
Finkelstein et al.³⁸ (1996)	21	64	11 (8-20)
Healy et al.⁴⁶ (1988)	23	83 (93Â§)	4 (2-9)
Johnson and Bodell⁶² (1981)	53	70	3.6 (1-9.3)
McDermott et al.⁷⁸ (1988)	24	92	4 (2-11.5)
Mathews et al.⁸⁵ (1998)	21	57	3 (1-8)
Miniaci et al.⁸⁹ (1990)	35	86 (100#)	5.4 (2-16.7)
Terry and Cimino¹²⁹ (1992)	35	60	5.4 (2-19)

Arthroscopy and Ligament Reconstruction

Although arthroscopic dè¡²idement of the knee joint cannot be directly compared with osteotomy, unicompartmental knee arthroplasty, or total knee arthroplasty according to the criteria outlined above, this procedure is often a potential alternative for some middle-aged patients with osteoarthritis of the knee joint. When appropriate, arthroscopic dè¡²idement may lengthen the useful lifetime of a knee joint; however, this procedure may have negative effects on the outcome of subsequent surgical procedures if it is used indiscriminately.

The role of arthroscopy in the management of degenerative knee arthritis in the middle-aged yet active patient remains controversial^42,126. In well selected middle-aged patients with knee arthritis, arthroscopic dè¡²idement may be a valuable method for providing transient relief of symptoms^80,126. Although arthroscopic techniques are continuing to evolve, the natural history of the arthritic process is probably not altered by isolated arthroscopic dè¡²idement and lavage. Patients with less extensive arthritis as seen radiographically, less severe involvement of articular cartilage, and a younger age at the time of the operation have more worthwhile improvement¹. A short duration of pain and mechanical symptoms, and mild-to-moderate radiographic stages of arthritis, correlate with a better result^3,102.The true outcomes of most of these arthroscopic procedures are difficult to determine, as most investigators have used nebulous inclusion criteria, inadequate study designs, short-term follow-up, as well as limited outcome-based analyses.

The success of an arthroscopic procedure is often enhanced by the concomitant use of other surgical procedures such as ligament reconstruction and osteotomy. Ligament reconstruction can eliminate subluxation episodes and can decrease pain. Restoration of the mechanical axis, alone or in combination with ligament reconstruction, unloads the degenerated compartment. Marrow-stimulation techniques, including subchondral bone microfracture and osteochondral transplantation, are recommended for the treatment of focal chondral defects in normally aligned knees of patients younger than forty-five years of age. Meniscal transplantation is also indicated for patients younger than forty-five years and is not considered in the treatment algorithms for knee arthritis in older middle-aged patients^18,63.

Surgical dè¡²idement of the knee with degenerative changes involves lavage, partial meniscectomy, limited synovectomy, excision of osteophytes, loose-body removal, and cartilage-shaving or thermal chondroplasty^125,126. A carefully recorded history, physical examination, and standing radiographs remain the most important diagnostic tools. One should treat the patient's symptoms and not the magnetic resonance imaging study. The primary indications include a discrete chief complaint of well localized joint-line pain with an acute onset, persistent effusion, and catching or locking in a patient who has been treated unsuccessfully with a nonoperative program.

Excision of symptomatic degenerative meniscal tears or loose bodies can effectively relieve mechanical symptoms and may provide additional pain relief by removing the irritating products of joint degeneration. Occasionally, patients with advanced arthritis are candidates for arthroscopy for the relief of mechanical symptoms caused by meniscal tears, loose chondral flaps, or osteophytes, which appear to cause painful impingement or to block knee motion. It is important to emphasize the importance of axial limb alignment (Fig. 1). If the mechanical axis passes through the lesion, arthroscopy will be unsuccessful^43,113. There should be normal or nearly normal limb alignment, with only mild-to-moderate radiographic degenerative changes⁸⁷. Patients with a history of surgery or with arthroscopic evidence of severe (grade-4) chondromalacia are at risk for a poor outcome^43,76.

Patient satisfaction and a decrease in symptoms following arthroscopic dè¡²idement can be marked but also unpredictable⁸². Patients must be counseled about the underlying disease process, the limited goals of the arthroscopic procedure, the potential complications, and the possible need for future reconstructive surgery. Arthroscopic treatment of degenerative arthritis is associated with low morbidity, and serious complications are uncommon. Although the complications of arthroscopy are infrequent and minor, their prevalence appears to be increasing as these procedures become more technically demanding^113,118. Complication rates have ranged from 7 percent¹²¹ to 31 percent¹¹⁸, but they are minimized by careful patient selection combined with meticulous attention to detail. Patients older than fifty years of age are at higher risk for complications following arthroscopy^110,118.

The mechanism of pain relief following arthroscopic treatment of osteoarthritis is obscure, and several prospective, randomized studies have been conducted to address this issue. In one study, the results of arthroscopic dè¡²idement were compared, with use of The Hospital for Special Surgery knee scores, with those in a control group that had been treated nonoperatively⁸⁷. Arthroscopic treatment was deemed to have been useful, at a mean duration of follow-up of two years. Its main benefit was that it could be used to treat problems that coexisted with osteoarthritis, such as meniscal lesions and loose bodies. In another study, seventy-three knees were randomized to nonoperative treatment or arthroscopic dè¡²idement⁸⁷. The group treated with dè¡²idement had substantially better results at the one-year and five-year follow-up evaluations. In another study comparing the results of lavage only with those of arthroscopic dè¡²idement, some improvement in quadriceps isokinetic torque was noted after lavage, but neither procedure led to a marked decrease in symptoms⁴⁰. Finally, a prospective, placebo-controlled, blinded, randomized pilot study of ten patients with symptomatic osteoarthritis was performed⁹¹. Five patients had skin-puncture wounds only, three underwent arthroscopic lavage and dè¡²idement, and two had standard arthroscopic dè¡²idement. All five patients with only puncture wounds reported a decrease in pain at six months postoperatively; four of the five judged the procedure to have been worthwhile and stated that they would recommend it to family and friends. The three patients who had had lavage and dè¡²idement had similar results. Clearly, larger studies with a similar design are required before a more definitive statement on the placebo effect of arthroscopy can be made. Randomized, controlled trials with defined entry criteria, sufficient numbers of patients, and valid, reproducible outcome measures will allow the most unbiased assessment of the risks and benefits of arthroscopic procedures for the treatment of unicompartmental disease of the knee.

In summary, arthroscopic excision of torn, unstable, degenerative meniscal fragments that are causing joint-line pain, recurrent effusions, and mechanical symptoms is an effective procedure with limited goals. Carefully selected patients with normal or nearly normal limb alignment and mild or moderate unicompartmental degenerative disease can be considered for arthroscopic treatment if a nonoperative program has been unsuccessful. Treatment of chronic chondral injuries with arthroscopic dè¡²idement and chondroplasty provides unpredictable, incomplete, and transient relief of symptoms. Correction of the mechanical axis and elimination of pathological laxity are fundamental issues that must be recognized and addressed. Additional basic-science research and well designed clinical trials are necessary to determine whether arthroscopic dè¡²idement can relieve symptoms and delay further joint-surface deterioration.

Abrasion arthroplasty is an arthroscopic modification of the Magnuson "housecleaning" arthroplasty, designed to remove dead bone and to expose a vascularized surface and a tissue bed for clot attachment and subsequent fibrocartilage formation^61,79. In a retrospective study of 126 patients treated for unicompartmental arthritis who were followed for an average of sixty months, those who had had arthroscopic dè¡²idement alone had done as well as or better than those who had had abrasion arthroplasty and arthroscopic dè¡²idement¹¹. An important observation was that 18 percent of the patients had worsening of the arthritis after the arthroscopic procedure. In another comparative, retrospective study of 110 patients treated with arthroscopic dè¡²idement, those in whom the operation included abrasion arthroplasty had a better outcome than those treated with arthroscopic dè¡²idement alone; the results were best in patients younger than forty years of age³⁹. In the largest study, 131 patients treated with arthroscopic dè¡²idement (Group I) were compared with twenty-eight patients treated with dè¡²idement and abrasion arthroplasty (Group II)¹⁰⁷. In Group II, half of the patients had conversion to a total knee arthroplasty within three years after the abrasion arthroplasty. The prevalence of patients with worsening of the arthritis was higher after abrasion arthroplasty than it was after arthroscopic dè¡²idement alone, and it was concluded that the results of abrasion arthroplasty are unpredictable.

Chronological age is a consideration but not a contraindication in patient selection for reconstruction of the anterior cruciate ligament. Mild-to-moderate arthritis does not preclude reconstruction of the anterior cruciate ligament. Intra-articular ligament reconstruction has evolved into a reliable procedure with low morbidity. Reconstruction of the anterior cruciate ligament can improve stability and decrease pain in the arthritic knee. Endoscopic reconstruction of the anterior cruciate ligament with use of patellar tendon allograft provides acceptable clinical results with less pain and less morbidity after graft harvest in this lower-demand patient population. Occasionally, carefully selected patients with normal or nearly normal limb alignment and mild or moderate unicompartmental degenerative disease can be considered for reconstruction of the anterior cruciate ligament^94,116,117. In a study of fifty-three patients with chronic deficiency of the anterior cruciate ligament, articular cartilage fissuring or exposure of subchondral bone, and normal alignment who were treated with reconstruction of the anterior cruciate ligament with use of patellar tendon autograft, there was a decrease in pain in thirty-seven knees and elimination of giving-way episodes in forty-seven knees; forty-two patients were able to return to recreational activities⁹⁶.

The indications for reconstruction of the anterior cruciate ligament include recurrent episodes of symptomatic giving-way, despite a comprehensive nonoperative treatment program, and an unwillingness to modify activities. The goals of surgical intervention include pain relief, restoration of knee stability, and functional improvement in activities of daily living. Although reconstruction of the anterior cruciate ligament in the arthritic knee can improve stability both objectively and subjectively, can decrease pain, and can increase the patient's activity level, patients should be counseled that this is a salvage procedure and that it is not intended to facilitate a return to high-demand sports or repetitive impact-loading. These patients need to be cognizant of the limited goals of surgical treatment as well as the progressive nature of the arthritic disease process. The middle-aged patient with an anterior cruciate-deficient knee in the presence of a previous partial meniscectomy or early posttraumatic degenerative arthritis is not an ideal surgical candidate. Reconstruction of the anterior cruciate ligament is contraindicated in knees with full-thickness cartilage loss on opposing articular surfaces and in those with secondary bone changes resulting in joint instability⁹⁶.

In young patients with insufficiency of the anterior cruciate ligament, cartilaginous lesions in the medial compartment, and varus knee malalignment, a combined procedure consisting of valgus tibial osteotomy and reconstruction of the anterior cruciate ligament can be considered. This combined procedure has been performed occasionally in patients during the fourth and fifth decades of life, with encouraging results^{14,30,59,71,96,97,103}. The techniques have been performed either simultaneously or in stages, with ligamentous reconstruction done after healing of the osteotomy site^71,88. Again, it must be emphasized that this is a salvage operation; it is not intended to return athletes to competition⁸⁸.

Indications for a valgus-producing proximal tibial osteotomy include medial knee pain, degenerative arthritis involving the medial compartment, and a varus mechanical axis. Biplanar correction techniques address both limb alignment and pathological laxity. A posteromedial opening or anterolateral closing-wedge osteotomy reduces the tibial slope in the sagittal plane and increases stability in the anterior cruciate-deficient knee. In contrast, an anteromedial opening or posterolateral closing-wedge osteotomy increases the tibial slope in the sagittal plane and increases stability in the posterior cruciate-deficient knee. Contraindications to a lateral closing-wedge osteotomy include intra-articular erosion, primary femoral deformity, and laxity of the medial collateral ligament⁵⁹. The upper age-limit for combined osteotomy and ligamentous reconstruction in the presence of knee arthritis has not been definitively established. The decision process for this procedure is complex and requires careful synthesis of the pattern of ligamentous insufficiency, the location and extent of the arthritis, and the activity level and age of the patient.

Realignment Osteotomy

The goals of osteotomy include pain relief, functional improvement, and allowance of heavy functional demands that would otherwise be precluded by prosthetic replacement. The objective is to transfer the weight-bearing forces from the arthritic portion of the knee to a healthier location of the joint²⁷. This principle of force redistribution to increase the life span of the knee joint distinguishes osteotomy from other treatment modalities and is based on the concept that certain high-impact and loading activities are not sanctioned with prosthetic arthroplasty. Functional analysis of young patients following osteotomy has revealed that many patients are able to participate in running and jumping activities that would likely lead to damage of a knee prosthesis^50,93,99. Many patients recognize the potential for technological advances during the expected survival period of a knee treated with osteotomy and understand that "buying time" is a viable concept.

The surgeon should discuss all treatment alternatives with the patient and should convey that neither osteotomy nor arthroplasty will result in a "normal" joint. A longer postoperative recovery period with less pain relief after rehabilitation is expected following osteotomy. Prosthetic arthroplasty provides more complete pain relief and a shorter rehabilitation period, and it is more reliable than osteotomy in most patients older than the age of sixty years⁵⁵. These considerations must be balanced against the possible catastrophic complications of infection or prosthetic failure associated with arthroplasty in the young and active patient. It is important to recognize that both physiological status and lifestyle require careful consideration, as some younger sedentary patients may be better suited to treatment with arthroplasty. The key to success is careful patient selection combined with skillful surgical technique.

The ideal candidate for osteotomy is a thin active individual in the fifth or sixth decade of life who has localized, activity-related, unicompartmental knee pain; no patellofemoral symptoms; a stable knee; and full knee extension with flexion of at least 90 degrees⁹. The location and character of the pain, the desired activity level, and appropriate patient expectations are particularly important. Diffuse or nonspecific knee pain reduces the chance of a successful outcome. Patellofemoral symptoms or meniscal pathology should not be the primary cause of the pain. Substantial retropatellar pain should be a cautionary factor, but mild retropatellar pain does not preclude osteotomy if the primary indication for the osteotomy is unicompartmental tibiofemoral pain.

Symptoms related to knee instability will not be alleviated by osteotomy alone. Moderate or severe instability should not be present, but insufficiency of the anterior cruciate ligament does not adversely affect the outcome if the preoperative symptoms can be specifically attributed to an overloading of the degenerated joint compartment. Total knee arthroplasty is the treatment of choice for elderly patients with degenerative arthritis and instability⁶⁰.

Posttraumatic arthritis, osteochondritis dissecans, or a prior medial meniscectomy do not adversely affect the outcome, whereas prior combined medial and lateral meniscectomies predict a disappointing outcome^90,119. Tibiofemoral subluxation, excessive osseous erosion, and diffuse arthritic involvement are also associated with poorer outcomes. Obesity has been associated with lower success rates following high tibial osteotomy, as the surgical technique and the postoperative immobilization are more difficult in these individuals^28,86. The activity level of these patients should be carefully assessed, as sedentary overweight individuals may be better served by prosthetic replacement (Fig. 2).

The importance of patient selection is underscored by the results of thirty-nine high tibial osteotomies, many of which were performed without precise indications⁹. There were ten poor results in nine knees, four of which had a preoperative diagnosis of diffuse degenerative arthritis; two, inflammatory disease; one, prior septic arthritis; and one, posttraumatic arthritis with severe deformity. By current standards of patient selection, these patients would be considered poor candidates for realignment osteotomy.

Equally important for a successful clinical outcome is the quality of the surgical technique. In a series of thirty knees treated with tibial osteotomy, in which rigid patient-selection criteria were used, thirteen knees had a satisfactory outcome and seventeen, a poor outcome, at the fifty-one-month follow-up evaluation²³. There were no technical errors in any knee with a good result, and all had good correction of malalignment. Of the seventeen poor results, ten were in knees in which there had been a technical error: five of these knees had undercorrection, three had overcorrection, and two had joint penetration during the osteotomy. There were eleven complications. These results emphasize the adverse impact of a suboptimal surgical technique on the outcome of corrective osteotomy even when there has been good patient selection.

One reason for premature failure following osteotomy is undercorrection or overcorrection of the deformity. Like patient selection, the accuracy of postoperative alignment is a primary predictor of success. The difficulty lies in determining the so-called appropriate postoperative alignment, as recommendations have varied widely. Hernigou et al.⁴⁸ recommended 3 to 6 degrees of valgus; Cass and Bryan²¹, 10 to 12 degrees of valgus; and Rudan and Simurda¹¹², 6 to 14 degrees of anatomical valgus.

Currently, our goal of postoperative alignment is to place the weight-bearing line of the extremity within the middle to outer third of the lateral compartment of the knee. This method of measurement of the mechanical axis alignment does not always correlate with the specific ranges of measurement methods based on the anatomical axis because of differences in joint-line obliquity and femoral or tibial bowing. In general, when the goals of mechanical axis translation are achieved, the postoperative anatomical axis measures between 8 and 12 degrees of valgus.

In a series of ninety-three osteotomies, the fact that the overall five-year survival rate of 90 percent diminished to 45 percent at ten years obscures results in patients with good postoperative alignment⁴⁸. The twenty patients with good postoperative alignment had no failures after 11.5 years of follow-up. Coventry et al. reported that, for knees with at least 8 degrees of postoperative valgus, the survival rate was 94 percent at the five and ten-year follow-up evaluations compared with 63 percent for knees that were corrected to 5 degrees or less of valgus angulation²⁸. In another study, of 314 patients who were followed for ten to nineteen years, fifty-four of 170 patients who had undercorrection subsequently required revision surgery because of clinical deterioration compared with eight of 144 patients with normalized or overcorrected alignment¹⁰⁰. On the basis of this long-term experience, those authors suggested that the longevity of a knee with a properly performed high tibial osteotomy rivaled that of current prosthetic replacements.

The simultaneous performance of arthrotomy and joint dè¡²idement with osteotomy, although controversial, has been reported to enhance the final result⁸¹. Extrapolation of this experience would lead one to believe that some patients might benefit from arthroscopic dè¡²idement in conjunction with corrective osteotomy. In one study, the results of osteotomy and arthroscopic abrasion arthroplasty were compared with those of osteotomy alone². At the twelve-month follow-up visit, arthroscopic evaluation revealed a significantly higher prevalence of repair of grade-II cartilage in the group that had had both osteotomy and arthroplasty (p < 0.01); however, there was no difference in the clinical outcome between the two groups at two to nine years of follow-up.

Proliferation of fibrocartilage and regeneration of articular cartilage following osteotomy have been documented by second-look arthroscopy^51,101. Importantly, only overcorrected knees demonstrated cartilage regeneration, supporting the concept of mechanical realignment facilitating the reparative capacity of the knee joint after unloading. Another reason for considering arthroscopy is the desire to evaluate the stage of the arthritis in order to predict the efficacy of osteotomy; however, its prognostic value for this application has not been demonstrated⁶⁶.

It is clear that the reported outcomes of high tibial osteotomy have been quite variable. Patient-selection factors, good surgical technique, appropriate postoperative alignment, and the passage of time all affect the final clinical outcome. Many studies of high tibial osteotomy have revealed satisfactory clinical results after five to seven years of follow-up, with the percentage of such results then diminishing substantially (Table II)^{9,21,28,45,48,86,109,112,135}. It is often difficult to ascertain the effects of patient selection and technical error on the long-term outcome when evaluating many of these clinical series. As with high tibial osteotomy, the reported success rates with distal femoral osteotomy have been variable (Table III)^{7,17,26,34,38,46,62,78,85,89,129}.

The technical difficulties and the potential severity of complications associated with realignment osteotomy have undoubtedly contributed toward the decline in the popularity of this operative procedure. Complications have been divided into those related to evaluation and those related to technical error⁶⁷. Neurological injury following osteotomy ranks as one of the most adverse consequences of this procedure. Postoperative peroneal nerve palsy appears to be associated with the use of an external fixation device^51,83. Many external fixation techniques include a proximal fibular osteotomy, which is another etiological factor⁸³. Compartment syndrome is a rare yet devastating complication following osteotomy. Deep infection is also rare following corrective osteotomy, but the risk is higher when an external fixation device is used⁵¹. The frequency of thromboembolic disease is lower after osteotomy than that after total knee arthroplasty, and the proper method of prophylaxis is controversial.

Joint stiffness has been reported rarely following high tibial osteotomy, whereas it has been reported frequently following supracondylar osteotomy^23,34,62,85. Rigid fixation and an early range of motion minimize stiffness, but rapid healing of the osteotomy site and maintenance of postoperative alignment should take priority. The stiffness associated with supracondylar osteotomy makes surgical exposure for a subsequent knee arthroplasty more difficult in some patients¹³. An early range of motion also helps to avoid quadriceps atrophy and may aid in the prevention of patellar tendon-shortening following tibial osteotomy¹³³. The scarring and shortening of the patellar tendon often prevent eversion of the patella, and surgical exposure during a subsequent total knee arthroplasty may require specialized techniques¹³⁴. Difficulties with successful union are mentioned in essentially all reports on corrective osteotomy and are more common after supracondylar osteotomy than after high tibial osteotomy.

The expected result of total knee arthroplasty following osteotomy must also be considered. The literature describing poor results of arthroplasty following osteotomy clearly indicates that technical difficulties or complications associated with the osteotomy lead to worse results after subsequent arthroplasty^13,65,134. The results of conversion of an osteotomy to a total knee arthroplasty compared with those of conversion of a unicompartmental knee arthroplasty to a total knee arthroplasty are discussed in the next section. The poorer long-term radiographic results of total knee arthroplasty following high tibial osteotomy occur in a specific subset of patients consisting of younger, heavier, more active males⁶⁰, which suggests that "buying time" with an osteotomy to avoid prosthetic replacement for as long as possible is a wise decision for these individuals. Although the current indications for osteotomy are relatively limited, the surgeon should be confident about performing a corrective osteotomy when the appropriate criteria are met. Successful long-term results are linked to careful patient selection, accurate surgical technique, and appropriate postoperative alignment.

Unicompartmental Knee Arthroplasty

Unicompartmental knee arthroplasty is a potentially attractive alternative to tibial osteotomy or total knee arthroplasty in selected osteoarthritic patients. Traditionally, unicompartmental knee arthroplasty has been reserved for patients with unicompartmental arthritis who have a sedentary lifestyle and are older than sixty years of age^4,8,44. However, there has been recent interest in performing this procedure in patients younger than sixty years as an alternative to tibial osteotomy or total knee arthroplasty^6,35,114.

The advantages of unicompartmental knee arthroplasty compared with osteotomy include higher rates of initial success and fewer early complications; also, when unicompartmental knee arthroplasty is performed bilaterally the two procedures can be done simultaneously, during the same anesthesia session, whereas when osteotomy is performed bilaterally the procedures are best spaced apart^57,132. The advantages of unicompartmental knee arthroplasty compared with total knee arthroplasty include retention of both cruciate ligaments and preservation of bone stock in the opposite compartment and the patellofemoral joint. Patients who have unicompartmental knee arthroplasty have less perioperative morbidity and an increased range of motion compared with those who have total knee arthroplasty^10,95,111. Manipulation, extensor mechanism complications, and deep periprosthetic infection are more common with total knee arthroplasty than they are with unicompartmental knee arthroplasty^35,111. Despite these advantages, unicompartmental knee arthroplasty has remained controversial for more than twenty-five years, as some authors have reported good or excellent results in most patients whereas others have reported less favorable results^{16,20,60,69,92,122}. The keys to a successful unicompartmental knee arthroplasty are stringent patient-selection criteria, careful surgical technique, and a proven prosthetic design^19,130.

As with the other alternatives, patient selection is of great importance. Contraindications to unicompartmental knee arthroplasty have included obesity, severe angular deformity, a valgus knee with medial laxity, absence of the anterior cruciate ligament, generalized arthritis of the knee, and inflammatory synovitis^84,130. Increased body weight has been associated with an increased rate of failure of unicompartmental knee arthroplasty⁴⁷. Unicompartmental metallic hemiarthroplasty is a rare but viable alternative for the patient with contraindications to osteotomy who is thought to be too young, heavy, and active for a metal-to-plastic arthroplasty¹³⁰. The ideal candidate for unicompartmental knee arthroplasty is a thin individual with localized pain attributable to unicompartmental arthritis who has only mild-to-moderate angular deformity and no ligamentous laxity of the knee joint.

Many reported failures of unicompartmental knee arthroplasty have been attributed to technical error^5,68,84,127. Slight undercorrection of the deformity with insertion of an adequate thickness of polyethylene are important contributors to a successful outcome²⁰. Progressive arthritis is generally caused by overcorrection of a varus deformity into valgus alignment^12,20,74,122.

The prosthetic design has also been associated with the long-term success of unicompartmental knee arthroplasty. In particular, major polyethylene wear, often related to the specific prosthetic design, has been a common finding in some studies^75,77,127. Other reasons that have been mentioned for accelerated polyethylene wear include inadequate thickness of the polyethylene insert, increased rotational freedom, reduced conformity of the articular surfaces, and metal backing on the tibial component^35,105. Use of a constrained unicompartmental knee-arthroplasty design has resulted in significantly more poor results than use of an unconstrained design (p = 0.0009)⁴⁹. A meniscal-bearing unicompartmental knee-arthroplasty design has been used in an effort to reduce polyethylene wear; however, these implants have been associated with initially inferior results and with the unique complication of meniscal-bearing dislocation^24,73. Other meniscal-bearing unicompartmental knee-arthroplasty designs may prove to be more successful⁴⁴. In addition, it has been noted that the current femoral component design has not been optimized and that the prevalence of femoral loosening may be reduced with design modifications^68,108,114.

In general, the initially good outcomes of unicompartmental knee arthroplasty appear to be comparable with the results of total knee arthroplasty in the first decade after the arthroplasty. Marmor reported the ten to thirteen-year results of sixty unicompartmental knee arthroplasties⁸⁴. He found that 70 percent of the knees still had a satisfactory result and that 87 percent were free of major pain. Scott et al. reported an 85 percent rate of survival at ten years after 100 unicompartmental knee arthroplasties¹¹⁵. Heck et al., in a study of 294 implants, reported a 91 percent rate of survival at ten years⁴⁷. Cartier et al. reported a 93 percent rate of survival at ten to twelve years after sixty unicompartmental knee arthroplasties²⁰. The highest reported rate of survival at ten years after unicompartmental knee arthroplasty is 98 percent, after 143 Oxford medial arthroplasties⁹². The longest duration of follow-up after unicompartmental knee arthroplasty (fifteen years) revealed an 87.5 percent rate of survival with use of revision surgery as the end point¹²². It should be noted that these are among the best results that have been reported, but they are somewhat inferior to most survival rates after similar time-intervals following modern total knee arthroplasty. It must also be remembered that these studies included many elderly patients with limited activity requirements; therefore, extrapolation of these results to a young and active patient population should be done with caution.

An early series of unicompartmental knee arthroplasties in middle-aged patients included twenty-eight patients younger than sixty years of age¹¹⁴. At the two to six-year follow-up evaluation, 90 percent had a good or excellent result and knee flexion averaged 124 degrees. Two revisions had been performed for femoral component loosening, and one tibial component was associated with asymptomatic progressive radiolucency. Both of these problems were believed to be due to the conformity of the fixed-bearing articulation. Those authors concluded that the results of unicompartmental knee arthroplasty in this patient population were comparable with those of osteotomy at an average of four years but were inferior to those of total knee arthroplasty in terms of the reoperation rate.

Of forty-six knees in patients between forty and sixty years of age who had a unicompartmental knee arthroplasty, thirteen had a revision at an average of 7.1 years³⁵. These patients had an average weight of 191 pounds (86.6 kilograms). A higher rate of failure due to polyethylene wear was observed in association with one of the prosthetic designs used in this study. If the nine knees with this specific type of prosthesis are excluded from the analysis, the remaining thirty-seven knees had a success rate of 86 percent at the time of final follow-up. Those authors concluded that, in younger, active patients, the ten-year survival rate should be 80 percent, provided that an adequate thickness of polyethylene and a proven prosthetic design are used.

Revision of an osteotomy to a total knee arthroplasty has been reported to be difficult because of wound problems associated with prior incisions, a distorted joint line, technical difficulties in obtaining adequate surgical exposure, and retained hardware. In contrast, it has been suggested that conversion of a unicompartmental knee arthroplasty to a total knee arthroplasty is associated with fewer problems related to the surgical exposure and fewer technical difficulties^58,70,72. The primary difficulty with conversion of a unicompartmental knee arthroplasty to a total knee arthroplasty has been the management of bone deficiencies^22,104. Bone-grafting, use of cement with screw augmentation, use of a long-stemmed tibial component, or a combination of these techniques is required in roughly 50 percent of patients⁵. Several studies have directly compared the results of conversion of an osteotomy to a total knee arthroplasty with those of conversion of a unicompartmental knee arthroplasty to a total knee arthroplasty^41,58. Although it is commonly believed that revision of a unicompartmental knee arthroplasty is easier than revision of a total knee arthroplasty, in one report of twenty-one revisions of unicompartmental knee arthroplasties it was concluded that these procedures were technically demanding and that 76 percent of patients had a major osseous defect at revision¹⁰⁴. Revision of a total knee arthroplasty is typically associated with a more difficult exposure and with global bone deficiency, whereas revision of a unicompartmental knee arthroplasty is usually associated with bone deficiency of only the medial tibial plateau and the femoral condyles⁷².

One may ask whether unicompartmental knee arthroplasty ought to be considered at all for the middle-aged patient. It may find its role as a conservative initial arthroplasty for patients with unicompartmental disease who have relative contraindications to tibial osteotomy, those who wish to avoid secondary angular deformity caused by osteotomy, those with very early changes in the opposite compartment, and some patients with bilateral involvement. If early loosening of the femoral component could be eliminated by changes in prosthetic design, unicompartmental knee arthroplasty could become very attractive as a conservative initial arthroplasty in selected younger patients. Operative techniques that utilize less invasive exposures and implants are currently being studied, and their use may further increase the appeal of this procedure by allowing a markedly shorter hospital stay and a rapid recovery.

Total Knee Arthroplasty

Total knee replacement has been shown to have durable and predictable results in elderly patients, providing pain relief, improving function, and correcting deformity^{25,36,54,56,131}. The possibility of multiple revisions due to loosening or wear initially discouraged the widespread use of total knee arthroplasty in young patients with degenerative arthritis³⁷. These concerns arose from the poor results observed in young patients who had had a total hip arthroplasty^32,64,120. However, the early results of total knee arthroplasty in young patients did not reflect the experience with total hip arthroplasty, and the initial reports often included many patients with rheumatoid arthritis or juvenile rheumatoid arthritis^{15,29,106,124}. On the basis of this initial success, the indications for total knee arthroplasty eventually were expanded to younger patients with osteoarthritis⁵³. As the indications continue to expand, the decision to proceed with total knee arthroplasty in young, active patients needs to be individualized after careful consideration of alternatives.

Stuart and Rand reported 38 good and excellent results at an average of five years after 44 total knee arthroplasties with cement in patients with rheumatoid arthritis who were less than forty years old¹²⁴. Dalury et al. reported the results of 103 total knee arthroplasties in patients younger than forty-five years old, most (87 percent) of whom had had a diagnosis of rheumatoid arthritis²⁹. At an average of seven years, there were two patellar fractures and one infection, but no knee had been revised because of component loosening. In another study, an average of six years after ninety total knee arthroplasties in patients with rheumatoid arthritis and osteoarthritis who were less than fifty-five years of age, the average Hospital for Special Surgery knee score was 87 points¹⁰⁶. In a study of only osteoarthritic knees, followed for an average of six years, there were fifty-five excellent and thirteen good results in patients who were fifty-five years of age or younger¹²³.

These short and intermediate-term results have withstood the test of time, even in more active patients with degenerative or posttraumatic arthritis. Duffy et al. reported the results of seventy-four consecutive total knee arthroplasties in fifty-four patients who were fifty-five years of age or younger (average age, forty-three years) at the time of the index procedure³³. All patients were followed for a minimum of ten years (average, thirteen years; range, ten to seventeen years). The preoperative diagnosis was rheumatoid arthritis in forty-seven patients; osteoarthritis in twelve; posttraumatic arthritis in six; osteonecrosis in three; hemophilia in two; and pigmented villonodular synovitis, tuberculosis, systemic lupus erythematosus, and achondroplasia in one patient each. All knees had a cemented condylar prosthesis. The functional knee score was 60 points at the time of the latest follow-up. Two knees had a revision: one, because of ligamentous laxity at three years, and one, because of aseptic loosening of the tibial component at thirteen years. At the last follow-up, there were no loose components. Duffy et al. concluded that total knee arthroplasty with cement in young patients is a reliable procedure that yields excellent results at thirteen years and has an estimated survival rate of 99 percent at ten years.

Since most long-term studies have had a larger percentage of older patients with a variety of diagnoses, including rheumatoid arthritis and multiple joint involvement, it is important that these results are interpreted carefully and are not extrapolated directly to younger patients with osteoarthritis. The latter subgroup of patients tends to be more active and more frequently employed as manual laborers, with activity requirements and demands that put higher stresses on the prosthetic surface and fixation. Diduch et al. specifically evaluated this subgroup in a study of 108 knees in eighty-four patients with a diagnosis of either osteoarthritis or posttraumatic arthritis³¹. Fifty-eight percent had had prior knee surgery, and all but one patient had a cemented posterior stabilized prosthesis. One hundred and three unrevised knees were available for clinical evaluation at an average of eight years (range, three to eighteen years), and thirty-six knees were followed for more than ten years. Postoperatively, the average Hospital for Special Surgery knee score was 92 points, the average Knee Society score was 94 points, and the average functional score was 89 points. All knees were rated as either good or excellent. The average Tegner activity score¹²⁸ improved from 1.3 points preoperatively to 3.5 points (range, 1 to 6 points) postoperatively. All but two patients had an improvement in their level of activity, while 24 percent had an activity score of greater than 5 points, indicating regular participation in activities such as tennis, skiing, bicycling, or strenuous farm or construction work. There were two revisions for late infection, one for polyethylene wear, and one for flexion instability. In all of these patients, the femoral and tibial components were well fixed. With failure defined as revision of either the femoral or the tibial component, the cumulative survival rate was 94 percent at eighteen years. Three additional patients required revision of a loose patellar component³¹. These durable results support the use of a cemented posterior stabilized prosthesis for the treatment of osteoarthritic knees in young, active patients when less invasive measures have failed.

Despite the good results obtained by several skilled surgeons and demonstrated by the clinical studies, common sense suggests that total knee replacement should continue to be considered with caution for some young patients. Deferment of the definitive surgical procedure for as long as possible may be the best option until the symptoms warrant total knee replacement. If total knee replacement is performed, these young patients need to realize that activities that involve high-impact loads, such as running and jumping, should be avoided. Finally, it should be remembered that, although the emerging data for long-term results at up to eighteen years in some patients are encouraging, these are incidental cases with specific implant designs³¹. The results should therefore be interpreted cautiously, as differences in prosthetic design and fixation variables may alter the outcomes in future long-term studies. Additional long-term information must be gathered before total knee replacement for the treatment of osteoarthritis in young, active patients is universally accepted.

References

Aichroth, P. M.; Patel, D. V.; and Moyes, S. T.: A prospective review of arthroscopic debridement for degenerative joint disease of the knee. Internat. Orthop.,15: 351-355, 1991.15351 1991

Akizuki, S.; Yasukawa, Y.; and Takizawa, T.: Does arthroscopic abrasion arthroplasty promote cartilage regeneration in osteoarthritic knees with eburnation? A prospective study of high tibial osteotomy with abrasion arthroplasty versus high tibial osteotomy alone. Arthroscopy,,13: 9-17, 1997.139 1997

Anderson, J. K., and Goldstein, W. M.: Arthroscopy in patients over the age of 50 years. Am. J. Arthrosc.,1: 15-18, 1991.115 1991

Ansari, S.; Newman, J. H.; and Ackroyd, C. E.: St. Georg sledge for medial compartment knee replacement. 461 arthroplasties followed for 4 (1-17) years. Acta Orthop. Scandinavica,,68: 430-434, 1997.68430 1997

Barnes, C. L. and Scott, R. D. Unicompartmental knee arthroplasty. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 42, pp. 309-314. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1993

Barrett, W. P., and Scott, R. D.: Revision of failed unicondylar unicompartmental knee arthroplasty. J. Bone and Joint Surg.,69-A: 1328-1335, Dec 1987.69-A1328 1987

Beaver, R. J.; Jinxiang, Y. U.; Sekyi-Otu, A.; and Gross, A. E.: Distal femoral varus osteotomy for genu valgum. Am. J. Knee Surg.,4: 9-17, 1991.49 1991

Berger, R. A.; Nedeff, D. D.; Barden, R. M.; Sheinkop, M. M.; Jacobs, J. J.; Rosenberg, A. G.; and Galante, J. O.: Unicompartmental knee arthroplasty. Clinical experience at 6- to 10-year followup. Clin. Orthop.,367: 50-60, 1999.36750 1999 [PubMed]

Berman, A. T.; Bosacco, S. J.; Kirshner, S.; and Avalio, A. Jr.: Factors influencing long-term results in high tibial osteotomy. Clin. Orthop.,272: 192-198, 1991.272192 1991 [PubMed]

Bernasek, T. L.; Rand, J. A.; and Bryan, R. S.: Unicompartmental porous coated anatomic total knee arthroplasty. Clin. Orthop.,236: 52-59, 1988.23652 1988 [PubMed]

Bert, J. M., and Maschka, K.: The arthroscopic treatment of unicompartmental gonarthrosis: a five-year follow-up study of abrasion arthroplasty plus arthroscopic debridement and arthroscopic debridement alone. J. Arthrosc.,5: 25-32, 1989.525 1989

Bert, J. M.: 10-year survivorship of metal-backed, unicompartmental arthroplasty. J. Arthroplasty,,13: 901-905, 1998.13901 1998

Beyer, C. A.; Lewallen, D. G.; and Hanssen, A. D.: Total knee arthroplasty following prior osteotomy of the distal femur. Am. J. Knee Surg.,7: 25-30, 1994.725 1994

Boss, A.; Stutz, G.; Oursin, C.; and Gachter, A.: Anterior cruciate ligament reconstruction combined with valgus tibial osteotomy (combined procedure). Knee Surg. Sports Traumat. Arthrosc.,3: 187-191, 1995.3187 1995

Boublik, M.; Tsahakis, P. J.; and Scott, R. D.: Cementless total knee arthroplasty in juvenile onset rheumatoid arthritis. Clin. Orthop.,286: 88-93, 1993.28688 1993 [PubMed]

Broughton, N. S.; Newman, J. H.; and Baily, R. A. J.: Unicompartmental replacement and high tibial osteotomy for osteoarthritis of the knee. A comparative study after 5-10 years' follow-up. J. Bone and Joint Surg.,68-B(3): 447-452, 1986.68-B(3)447 1986

Cameron, H. U.; Botsford, D. J.; and Park, Y. S.: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Canadian J. Surg.,40: 114-118, 1997.40114 1997

Cameron, J. C., and Saha, S.: Meniscal allograft transplantation for unicompartmental arthritis of the knee. Clin. Orthop.,337: 164-171, 1997.337164 1997 [PubMed]

Capra, S. W. Jr., and Fehring, T. K.: Unicondylar arthroplasty. A survivorship analysis. J. Arthroplasty,7: 247-251, 1992.7247 1992 [PubMed]

Cartier, P. Sanouiller, J. L., and Grelsamer, R. P.: Unicompartmental knee arthroplasty surgery. 10-year minimum follow-up period. J. Arthroplasty,,11: 782-788, 1996.11782 1996

Cass, J. R., and Bryan, R. S.: High tibial osteotomy. Clin. Orthop.,230: 196-199, 1988.230196 1988 [PubMed]

Chakrabarty, G.; Newman, J. H.; and Ackroyd, C. E.: Revision of unicompartmental arthroplasty of the knee. Clinical and technical considerations. J. Arthroplasty,13: 191-196, 1998.13191 1998 [PubMed]

Chillag, K. J., and Nicholls, P. J.: High tibial osteotomy. A retrospective analysis of 30 cases. Orthopedics,7: 1821-1822, 1984.71821 1984

Cohen, M.; Buechel, F.; and Pappas, M. J.: Meniscal-bearing unicompartmental knee arthroplasty. An 11-year clinical study. Orthop. Rev.,20: 443-448, 1991.20443 1991 [PubMed]

Colizza, W. A.; Insall, J. N.; and Scuderi, G. R.: The posterior stabilized total knee prosthesis. Assessment of polyethylene damage and osteolysis after a ten-year minimum follow-up. J. Bone and Joint Surg.,77-A: 1713-1720, Nov 1995.77-A1713 1995

Conrad, E. U.; Soudry, M.; and Insall, J. N.: Supracondylar femoral osteotomy for valgus knee deformities. Orthop. Trans.,9: 25-26, 1985.925 1985

Coventry, M. B.: Upper tibial osteotomy for gonarthrosis. The evolution of the operation in the last 18 years and long term results. Orthop. Clin. North America,,10: 191-210, 1979.10191 1979

Coventry, M. B.; Ilstrup, D. M.; and Wallrichs, S. L.: Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J. Bone and Joint Surg.,75-A: 196-201, Feb 1993.75-A196 1993

Dalury, D. F.; Ewald, F. C.; Christie, M. J.; and Scott, R. D.: Total knee arthroplasty in a group of patients less than 45 years of age. J. Arthroplasty,,10: 598-602, 1995.10598 1995

Dejour, H.; Neyret, P.; Boileau, P.; and Donell, S. T.: Anterior cruciate reconstruction combined with valgus tibial osteotomy. Clin. Orthop.,299: 220-228, 1994.299220 1994 [PubMed]

Diduch, D. R.; Insall, J. N.; Scott, W. N.; Scuderi, G. R.; and Font-Rodriguez, D.: Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J. Bone and Joint Surg.,79-A: 575-582, April 1997.79-A575 1997

Dorr, L. D.; Kane, T. J. III; and Conaty, J. P.: Long-term results of cemented total hip arthroplasty in patients 45 years old or younger. A 16-year follow-up study. J. Arthroplasty,,9: 453-456, 1994.9453 1994

Duffy, G. P.; Trousdale, R. T.; and Stuart, M. J.: Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results. Clin. Orthop.,356: 22-27, 1998.35622 1998 [PubMed]

Edgerton, B. C.; Mariani, E. M.; and Morrey, B. F.: Distal femoral varus osteotomy for painful genu valgum. A five-to-11-year follow-up study. Clin. Orthop.,288: 263-269, 1993.288263 1993 [PubMed]

Engh, G. A. and McAuley, J. P. Unicondylar arthroplasty: an option for high-demand patients with gonarthrosis. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 48, pp. 143-148. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1999

Ewald, F. C.; Jacobs, M. A.; Miegel, R. E.; Walker, P. S.; Poss, R.; and Sledge, C. B.: Kinematic total knee replacement. J. Bone and Joint Surg.,66-A: 1032-1040, Sept 1984.66-A1032 1984

Ewald, F., and Christie, M. J.: Results of cemented total knee replacement in young patients. Orthop. Trans.,11: 442, 1987.11442 1987

Finkelstein, J. A.; Gross, A. E.; and Davis, A.: Varus osteotomy of the distal part of the femur. A survivorship analysis. J. Bone and Joint Surg.,78-A: 1348-1352, Sept 1996.78-A1348 1996

Friedman, M. J.; Berasi, C. C.; Fox, J. M.; Del Pizzo, W.; Snyder, S. J.; and Ferkel, R. D.: Preliminary results with abrasion arthroplasty in the osteoarthritic knee. Clin. Orthop.,182: 200-205, 1984.182200 1984 [PubMed]

Gibson, J. N. A.; White, M. D.; Chapman, V. M.; and Strachan, R. K.: Arthroscopic lavage and debridement for osteoarthritis of the knee. J. Bone and Joint Surg.,74-B(4): 534-537, 1992.74-B(4)534 1992

Gill, T.; Schemitsch, E. H.; Brick, G. W.; and Thornhill, T. S.: Revision total knee arthroplasty after failed unicompartmental knee arthroplasty or high tibial osteotomy. Clin. Orthop.,321: 10-18, 1995.32110 1995 [PubMed]

Goldman, R. T.; Scuderi, G. R.; and Kelly, M. A.: Arthroscopic treatment of the degenerative knee in older athletes. Clin. Sports Med.,16: 51-68, 1997.1651 1997 [PubMed]

Harwin, S. F.: Arthroscopic debridement for osteoarthritis of the knee: predictors of patient satisfaction. Arthroscopy,,15: 142-146, 1999.15142 1999

Hasegawa, Y.; Ooishi, Y.; Shimizu, T.; Sugiura, H.; Takahashi, S.; Ito, H.; and Iwata, H.: Unicompartmental knee arthroplasty for medial gonarthrosis: 5 to 9 years follow-up evaluation of 77 knees. Arch. Orthop. and Trauma Surg.,117: 183-187, 1998.117183 1998

Healy, W. L., and Riley, L. H. Jr.: High tibial valgus osteotomy. A clinical review. Clin. Orthop.,209: 227-233, 1986.209227 1986 [PubMed]

Healy, W. L.; Anglen, J. O.; Wasilewski, S. A. ; and Krackow, K. A.: Distal femoral varus osteotomy. J. Bone and Joint Surg.,70-A: 102-109, Jan 1988.70-A102 1988

Heck, D. A.; Marmor, L.; Gibson, A.; and Rougraff, B. T.: Unicompartmental knee arthroplasty. A multicenter investigation with long-term follow-up evaluation. Clin. Orthop.,286: 154-159, 1993.286154 1993 [PubMed]

Hernigou, P.; Medevielle, D.; Debeyre, J.; and Goutallier, D.: Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J. Bone and Joint Surg.,66-A: 332-354, March 1987.66-A332 1987

Hodge, W. A., and Chandler, H. P.: Unicompartmental knee replacement: a comparison of constrained and unconstrained designs. J. Bone and Joint Surg.,74-A: 877-883, July 1992.74-A877 1992

Holden, D. L.; James, S. L.; Larson, R. L.; and Slocum, D. B.: Proximal tibial osteotomy in patients who are fifty years old or less. A long-term follow-up study. J. Bone and Joint Surg.,70-A: 977-982, Aug 1988.70-A977 1988

Hsu, R. W.: The study of Maquet dome high tibial osteotomy. Arthroscopic-assisted analysis. Clin. Orthop.,243: 280-285, 1989.243280 1989 [PubMed]

Hubbard, M. J. S.: Arthroscopic surgery for chondral flaps in the knee. J. Bone and Joint Surg.,69-B(5): 794-796, 1987.69-B(5)794 1987

Hungerford, D. S.; Krackow, K. A.; and Kenna, R. V.: Cementless total knee replacement in patients 50 years old and under. Orthop. Clin. North America,20: 131-145, 1989.20131 1989

Insall, J. N.; Lachiewicz, P. F.; and Burstein, A. H.: The posterior stabilized condylar prosthesis: a modification of the total condylar design. Two to four-year clinical experience. J. Bone and Joint Surg.,64-A: 1317-1323, Dec 1982.64-A1317 1982

Insall, J. N.; Joseph, D. M.; and Msika, C.: High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J. Bone and Joint Surg.,66-A: 1040-1048, Sept 1984.66-A1040 1984

Insall, J. N., and Kelly, M.: The total condylar prosthesis. Clin. Orthop.,205: 43-48, 1986.20543 1986 [PubMed]

Ivarsson, I., and Gillquist, J.: Rehabilitation after high tibial osteotomy and unicompartmental arthroplasty. A comparative study. Clin. Orthop.,266: 139-144, 1991.266139 1991 [PubMed]

Jackson, M.; Sarangi, P. P.; and Newman, J. H.: Revision total knee arthroplasty. Comparison of outcome following primary proximal tibial osteotomy or unicompartmental arthroplasty. J. Arthroplasty,9: 539-542, 1994.9539 1994 [PubMed]

Jakob, R. P. and Murphy, S. B. Tibial osteotomy for varus gonarthrosis: indication, planning, and operative technique. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 41, pp. 87-93. Park Ridge, Illinois, American Academy of Orthopaedic Surgeons, 1992

Johnson, B. G. Hanssen, A. D. and Morrey, B. F. Long-term radiographic analysis of cemented condylar total knee arthroplasty in patients with osteoarthritis who have had a prior high tibial osteotomy. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Orlando, Florida, Feb. 21, 1995

Johnson, D. L., and Bealle, D.: Meniscal allograft transplantation. Clin. Sports Med.,18: 93-108, 1999.1893 1999 [PubMed]

Johnson, E. W. Jr., and Bodell, L. S.: Corrective supracondylar osteotomy for painful genu valgum. Mayo Clin. Proc.,56: 87-92, 1981.5687 1981 [PubMed]

Johnson, L. L.: Arthroscopic abrasion arthroplasty historical and pathologic perspective: present status. Arthroscopy,2: 54-69, 1986.254 1986 [PubMed]

Joshi, A. B.; Porter, M. L.; Trail, I. A.; Hunt, L. P.; Murphy, J. C. M.; and Hardinge, K.: Long-term results of Charnley low-friction arthroplasty in young patients. J. Bone and Joint Surg.,75-B(4): 616-623, 1993.75-B(4)616 1993

Katz, M. M.; Hungerford, D. S.; Krackow, K. A.; and Lennox, D. W.: Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J. Bone and Joint Surg.,69-A: 225-233, Feb 1987.69-A225 1987

Keene, J. S., and Dyreby, J. R. Jr.: High tibial osteotomy in the treatment of osteoarthritis of the knee. The role of preoperative arthroscopy. J. Bone and Joint Surg.,65-A: 36-42, Jan 1983.65-A36 1983

Kettelkamp, D. B.; Leach, R. E.; and Nasca, R.: Pitfalls of proximal tibial osteotomy. Clin. Orthop.,106: 232-241, 1975.106232 1975 [PubMed]

Klemme, W. R.; Galvin, E. G.; and Petersen, S. A.: Unicompartmental knee arthroplasty. Sequential radiographic and scintigraphic imaging with an average five-year follow-up. Clin. Orthop.,301: 233-238, 1994.301233 1994 [PubMed]

Kozinn, S. C.; Marx, C.; and Scott, R. D.: Unicompartmental knee arthroplasty. A 4.5-6-year follow-up study with a metal-backed tibial component. J. Arthroplasty,,4 (Supplement): 1-S10, 1989.4 (Supplement)1 1989

Lai, C. H., and Rand, J. A.: Revision of failed unicompartmental total knee arthroplasty. Clin. Orthop.,287: 193-201, 1993.287193 1993 [PubMed]

Lattermann, C., and Jakob, R. P.: High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees. Knee Surg. Sports Traumat. Arthrosc.,4: 32-38, 1996.432 1996

Levine, W. N.; Ozuna, R. M.; Scott, R. D.; and Thornhill, T. S.: Conversion of failed modern unicompartmental arthroplasty to total knee arthroplasty. J. Arthroplasty,,11: 797-801, 1996.11797 1996

Lewold, S.; Goodman, S.; Knutson, K.; Robertsson, O.; and Lidgren, L.: Oxford meniscal bearing knee versus the Marmor knee in unicompartmental arthroplasty for arthrosis. A Swedish multicenter survival study. J. Arthroplasty,,10: 722-731, 1995.10722 1995

Lewold, S.; Robertsson, O.; Knutson, K.; and Lidgren, L.: Revision of unicompartmental knee arthroplasty: outcome in 1,135 cases from the Swedish Knee Arthroplasty study. Acta Orthop. Scandinavica,,69: 469-474, 1998.69469 1998

Lindstrand, A., and Stenstrom, A.: Polyethylene wear of the PCA unicompartmental knee. Prospective 5 (4-8) year study of 120 arthrosis knees. Acta Orthop. Scandinavica,,63: 260-262, 1992.63260 1992

Linschoten, N. J., and Johnson, C. A.: Arthroscopic debridement of knee joint arthritis: effect of advancing articular degeneration. J. Southern Orthop. Assn.,6: 25-36, 1997.625 1997

McCallum, J. D. III,, and Scott, R. D.: Duplication of medial erosion in unicompartmental knee arthroplasties. J. Bone and Joint Surg.,77-B(5): 726-728, 1995.77-B(5)726 1995

McDermott, A. G. P.; Finklestein, J. A.; Farine, I.; Boynton, E. L.; MacIntosh, D. L.; and Gross, A.: Distal femoral varus osteotomy for valgus deformity of the knee. J. Bone and Joint Surg.,70-A: 110-116, Jan 1988.70-A110 1988

McEldowney, A. J., and Weiker, G. G.: Open-knee Magnuson debridement as conservative treatment for degenerative osteoarthrosis of the knee. J. Arthroplasty,,10: 805-809, 1995.10805 1995

McGinley, B. J.; Cushner, F. D.; and Scott, W. N.: Debridement arthroscopy. 10-year followup. Clin. Orthop.,367: 190-194, 1999.367190 1999 [PubMed]

MacIntosh, D. L., and Welsh, R. P.: Joint debridement - a complement to high tibial osteotomy in the treatment of degenerative arthritis of the knee. J. Bone and Joint Surg.,59-A: 1094-1097, Dec 1977.59-A1094 1977

McLaren, A. C.; Blokker, C. P.; Fowler, P. J.; Roth, J. N.; and Rock, M. G.: Arthroscopic debridement of the knee for osteoarthrosis. Canadian J. Surg.,34: 595-598, 1991.34595 1991

Maquet, P.: Valgus osteotomy for osteoarthritis of the knee. Clin. Orthop.,120: 143-148, 1976.120143 1976 [PubMed]

Marmor, L.: Unicompartmental arthroplasty of the knee with a minimum ten-year follow-up period. Clin. Orthop.,228: 171-177, 1988.228171 1988 [PubMed]

Mathews, J.; Cobb, A. G.; Richardson, S.; and Bentley, G.: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics,,21: 437-440, 1998.21437 1998

Matthews, L. S.; Goldstein, S. A.; Malvitz, T. A.; Katz, B. P.; and Kaufer, H.: Proximal tibial osteotomy. Factors that influence the duration of satisfactory function. Clin. Orthop.,229: 193-200, 1988.229193 1988 [PubMed]

Merchan, E. C., and Galindo, E.: Arthroscope-guided surgery versus nonoperative treatment for limited degenerative osteoarthritis of the femorotibial joint in patients over 50 years of age: a prospective comparative study. Arthroscopy,,9: 663-667, 1993.9663 1993

Miller, M. D., and Fu, F. H.: The role of osteotomy in the anterior cruciate ligament-deficient knee. Clin. Sports Med.,12: 697-708, 1993.12697 1993 [PubMed]

Miniaci, A.; Grossman, S. P.; and Jakob, R. P.: Supracondylar femoral varus osteotomy in the treatment of valgus knee deformity. Am. J. Knee Surg.,2: 65-70, 1990.265 1990

Morrey, B. F.: Upper tibial osteotomy for secondary osteoarthritis of the knee. J. Bone and Joint Surg.,71-B(4): 554-559, 1989.71-B(4)554 1989

Moseley, J. B. Jr.; Wray, N. P.; Kuykendall, D.; Willis, K.; and Landon, G.: Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am. J. Sports Med.,24: 28-34, 1996.2428 1996 [PubMed]

Murray, D. W.; Goodfellow, J. W.; and O'Connor, J. J.: The Oxford medial unicompartmental arthroplasty. A ten-year survival study. J. Bone and Joint Surg.,80-B(6): 983-989, 1998.80-B(6)983 1998

Nagel, A.; Insall, J. N.; and Scuderi, G. R.: Proximal tibial osteotomy. A subjective outcome study. J. Bone and Joint Surg.,78-A: 1353-1358, Sept 1996.78-A1353 1996

Neuschwander, D. C.; Drez, D. Jr.; and Paine, R. M.: Simultaneous high tibial osteotomy and ACL reconstruction for combined genu varum and symptomatic ACL tear. Orthopedics,16: 679-684, 1993.16679 1993 [PubMed]

Newman, J. H.; Ackroyd, C. E.; and Shah, N. A.: Unicompartmental or total knee replacement? Five-year results of a prospective, randomised trial of 102 osteoarthritic knees with unicompartmental arthritis. J. Bone and Joint Surg.,80-B(5): 862-865, 1998.80-B(5)862 1998

Noyes, F. R., and Barber-Westin, S. D.: Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage. Am. J. Sports Med.,25: 626-634, 1997.25626 1997 [PubMed]

Noyes, F. R., and Barber-Westin, S. D.: Arthroscopic-assisted allograft anterior cruciate ligament reconstruction in patients with symptomatic arthrosis. Arthroscopy,,13: 24-32, 1997.1324 1997

Noyes, F. R. Barber-Westin, S. D. Butler, D. L. and Wilkins, R. M. The role of allografts in repair and reconstruction of knee joint ligaments and menisci. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 47, pp. 379-396. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1998

Odenbring, S.; Tjornstrand, B.; Egund, N.; Hagstedt, B.; Hovelius, L.; Lindstrand, A.; Luxhoj, T.; and Svanstrom, A.: Function after tibial osteotomy for medial gonarthrosis below aged 50 years. Acta Orthop. Scandinavica,,60: 527-531, 1989.60527 1989

100

Odenbring, S.; Egund, N.; Knutson, K.; Lindstrand, A.; and Larsen, S. T.: Revision after osteotomy for gonarthrosis. A 10-19-year follow-up of 314 cases. Acta Orthop. Scandinavica,61: 128-130, 1990.61128 1990

101

Odenbring, S.; Egund, N.; Lindstrand, A.; Lohmander, L. S.; and Willè¬¬ H.: Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study. Clin. Orthop.,277: 210-216, 1992.277210 1992 [PubMed]

102

Ogilvie-Harris, D. J., and Fitsialos, D. P.: Arthroscopic management of the degenerative knee. J. Arthroscopy,7: 151-157, 1991.7151 1991

103

O'Neill, D. F., and James, S. L.: Valgus osteotomy with anterior cruciate ligament laxity. Clin. Orthop.,278: 153-159, 1992.278153 1992 [PubMed]

104

Padgett, D. E.; Stern, S. H.; and Insall, J. N.: Revision total knee arthroplasty for failed unicompartmental replacement. J. Bone and Joint Surg.,73-A: 186-190, Feb 1991.73-A186 1991

105

Palmer, S. H.; Morrison, P. J.; and Ross, A. C.: Early catastrophic tibial component wear after unicompartmental knee arthroplasty. Clin. Orthop.,350: 143-148, 1998.350143 1998 [PubMed]

106

Ranawat, C. S.; Padgett, D. E.; and Ohashi, Y.: Total knee arthroplasty for patients younger than 55 years. Clin. Orthop. . 248: 27-33, 1989.24827 1989

107

Rand, J. A. Role of arthroscopy in osteoarthritis of the knee. Arthroscopy,,7: 358-363, 1991.7358 1991

108

Riebel, G. D.; Werner, F. W.; Ayers, D. C.; Bromka, J.; and Murray, D. G.: Early failure of the femoral component in unicompartmental knee arthroplasty. J. Arthroplasty,,10: 615-621, 1995.10615 1995

109

Ritter, M. A. , and Fechtman, R. A.: Proximal tibial osteotomy. A survivorship analysis. J. Arthroplasty,3: 309-311, 1988.3309 1988 [PubMed]

110

Rodeo, S. A.; Forster, R. A. ; and Weiland, A. J.: Current concepts review. Neurological complications due to arthroscopy. J. Bone and Joint Surg.,75-A: 917-926, June 1993.75-A917 1993

111

Rougraff, B. T.; Heck, D. A.; and Gibson, A. E.: A comparison of tricompartmental and unicompartmental arthroplasty for the treatment of gonarthrosis. Clin. Orthop.,273: 157-164, 1991.273157 1991 [PubMed]

112

Rudan, J. F., and Simurda, M. A.: Valgus high tibial osteotomy. A long-term follow-up study. Clin. Orthop.,268: 157-160, 1991.268157 1991 [PubMed]

113

Salisbury, R. B.; Nottage, W. M.; and Gardner, V.: The effect of alignment on results in arthroscopic debridement of the degenerative knee. Clin. Orthop.,198: 268-272, 1985.198268 1985 [PubMed]

114

Schai, P. A.; Suh, J. T.; Thornhill, T. S.; and Scott, R. D.: Unicompartmental knee arthroplasty in middle-aged patients: a 2- to 6-year follow-up evaluation. J. Arthroplasty,,13: 365-372, 1998.13365 1998

115

Scott, R. D.; Cobb, A. G.; McQueary, F. G.; and Thornhill, T. S.: Unicompartmental knee arthroplasty. Eight- to 12-year follow-up evaluation with survivorship analysis. Clin. Orthop.,271: 96-100, 1991.27196 1991 [PubMed]

116

Shelbourne, K. D., and Wilckens, J. H.: Intraarticular anterior cruciate ligament reconstruction in the symptomatic arthritic knee. Am. J. Sports Med.,21: 685-689, 1993.21685 1993 [PubMed]

117

Shelbourne, K. D., and Stube, K. C.: Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an isolated autogenous patellar tendon ACL reconstruction. Knee Surg. Sports Traumat. Arthrosc.,5: 150-156, 1997.5150 1997

118

Sherman, O. H.; Fox, J. M.; Snyder, S. J.; Del Pizzo, W.; Friedman, M. J.; Ferkel, R. D. ; and Lawley, M. J.: Arthroscopy - "no-problem surgery." An analysis of complications in two thousand six hundred and forty cases. J. Bone and Joint Surg.,68-A: 256-265, Feb 1986.68-A256 1986

119

Slawski, D. P.: High tibial osteotomy in the treatment of adult osteochondritis dissecans. Clin. Orthop.,341: 155-161, 1997.341155 1997 [PubMed]

120

Solomon, M. I.; Dall, D. M.; Learmonth, I. D.; and Davenport, J. M.: Survivorship of cemented total hip arthroplasty in patients 50 years of age or younger. J. Arthroplasty,,7 (Supplement): 347-352, 1992.7 (Supplement)347 1992

121

Sprague, N. F. III: Arthroscopic debridement for degenerative knee joint disease. Clin. Orthop.,160: 118-123, 1981.160118 1981 [PubMed]

122

Squire, M. W.; Callaghan, J. J.; Goetz, D. D.; Sullivan, P. M.; and Johnston, R. C. : Unicompartmental knee replacement. A minimum 15 year followup study. Clin. Orthop.,367: 61-72, 1999.36761 1999 [PubMed]

123

Stern, S. H.; Bowen, M. K.; Insall, J. N.; and Scuderi, G. R.: Cemented total knee arthroplasty for gonarthrosis in patients 55 years old or younger. Clin. Orthop.,260: 124-129, 1990.260124 1990 [PubMed]

124

Stuart, M. J., and Rand, J. A.: Total knee arthroplasty in young adults who have rheumatoid arthritis. J. Bone and Joint Surg.,70-A: 84-87, Jan 1988.70-A84 1988

125

Stuart, M. J.: Treatment of chronic chondral injuries. Sports Med. and Arthrosc. Rev.,2: 50-58, 1994.250 1994

126

Stuart, M. J. Arthroscopic management for degenerative arthritis of the knee. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 48, pp. 135-141. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1999

127

Swank, M.; Stulberg, S. D.; Jiganti, J.; and Machairas, S.: The natural history of unicompartmental arthroplasty. An eight-year follow-up study with survivorship analysis. Clin. Orthop.,286: 130-142, 1993.286130 1993 [PubMed]

128

Tegner, Y., and Lysholm, J.: Rating systems in the evaluation of knee ligament injuries. Clin. Orthop.,198: 43-49, 1985.19843 1985 [PubMed]

129

Terry, G. C., and Cimino, P. M.: Distal femoral osteotomy for valgus deformity of the knee. Orthopedics,,15: 1283-1290, 1992.151283 1992

130

Thornhill, T. S., and Scott, R. D.: Unicompartmental total knee arthroplasty. Orthop. Clin. North America,20: 245-256, 1989.20245 1989

131

Vince, K. G.; Insall, J. N.; and Kelly, M. A.: The total condylar prosthesis. 10- to 12-year results of a cemented knee replacement. J. Bone and Joint Surg.,71-B(5): 793-797, 1989.71-B(5)793 1989

132

Weale, A. E., and Newman, J. H.: Unicompartmental arthroplasty and high tibial osteotomy for osteoarthrosis of the knee. A comparative study with a 12- to 17-year follow-up period. Clin. Orthop.,302: 134-137, 1994.302134 1994 [PubMed]

133

Westrich, G. H.; Peters, L. E.; Haas, S. B.; Buly, R. L.; and Windsor, R. E.: Patella height after high tibial osteotomy with internal fixation and early motion. Clin. Orthop.,354: 169-174, 1998.354169 1998 [PubMed]

134

Windsor, R. E.; Insall, J. N.; and Vince, K. G.: Technical considerations of total knee arthroplasty after proximal tibial osteotomy. J. Bone and Joint Surg.,70-A: 547-555, April 1988.70-A547 1988

135

Yasuda, K.; Majima, T.; Tsuchida, T.; and Kaneda, K.: A ten- to 15-year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis. Clin. Orthop.,282: 186-195, 1992.282186 1992 [PubMed]

136

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TABLE I: Variables Used for Selection of the Surgical Procedure

Historical

Age (chronological, physiological)

Activity level

Pain (severity, location, character)

Mechanical symptoms

Systemic inflammatory disease

Prior joint infection

Prior meniscectomy

Physical examination

Range of motion (total arc, flexion contracture)

Ligamentous deficiencies

Gait (adductor thrust)

Malalignment (magnitude, direction)

Body habitus

Patellofemoral findings (pain, stability)

Radiographic

Alignment (mechanical, anatomical)

Arthritic involvement (location, severity)

Joint-line obliquity

Periarticular deformity

Miscellaneous

Durability of results

Patient expectations

Surgeon capabilities

Potential complications

Postoperative recovery

Effect on subsequent total knee arthroplasty

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TABLE I: Variables Used for Selection of the Surgical Procedure

Historical

Age (chronological, physiological)

Activity level

Pain (severity, location, character)

Mechanical symptoms

Systemic inflammatory disease

Prior joint infection

Prior meniscectomy

Physical examination

Range of motion (total arc, flexion contracture)

Ligamentous deficiencies

Gait (adductor thrust)

Malalignment (magnitude, direction)

Body habitus

Patellofemoral findings (pain, stability)

Radiographic

Alignment (mechanical, anatomical)

Arthritic involvement (location, severity)

Joint-line obliquity

Periarticular deformity

Miscellaneous

Durability of results

Patient expectations

Surgeon capabilities

Potential complications

Postoperative recovery

Effect on subsequent total knee arthroplasty

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TABLE II: Survival Rates in Selected Series of High Tibial Osteotomies

Study	No. of Patients	Rate of Survival
At 2 Yrs.	At 5 Yrs.	At 7 Yrs.	At 10 Yrs.	At 15 Yrs.
Berman et al.⁹ (1991)	39	87%	-	-	-	57%*
Cass and Bryan²¹ (1988)	86	94%	87%	-	69%	-
Coventry et al.²⁸ (1993)	87	-	87%	-	66%	-
			(96%)†		(91%)†
			(94%)‡		(94%)‡
Healy and Riley⁴⁵ (1986)	31	92%	88%	91%	80%§	-
Hernigou et al.⁴⁸ (1987)	93	-	90%	-	45%#	-
			(100%)#		(100%)
Matthews et al.⁸⁶ (1988)	40	86%**	50%	-	28%§	-
Ritter and Fechtman¹⁰⁹ (1988)	78	95%	80%	58%	58%	58%*
Rudan and Simurda¹¹² (1991)	128	-	-	-	80%	70%
Yasuda et al.¹³⁵ (1992)	86	-	88%	-	63%	-

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TABLE II: Survival Rates in Selected Series of High Tibial Osteotomies

Study	No. of Patients	Rate of Survival
At 2 Yrs.	At 5 Yrs.	At 7 Yrs.	At 10 Yrs.	At 15 Yrs.
Berman et al.⁹ (1991)	39	87%	-	-	-	57%*
Cass and Bryan²¹ (1988)	86	94%	87%	-	69%	-
Coventry et al.²⁸ (1993)	87	-	87%	-	66%	-
			(96%)†		(91%)†
			(94%)‡		(94%)‡
Healy and Riley⁴⁵ (1986)	31	92%	88%	91%	80%§	-
Hernigou et al.⁴⁸ (1987)	93	-	90%	-	45%#	-
			(100%)#		(100%)
Matthews et al.⁸⁶ (1988)	40	86%**	50%	-	28%§	-
Ritter and Fechtman¹⁰⁹ (1988)	78	95%	80%	58%	58%	58%*
Rudan and Simurda¹¹² (1991)	128	-	-	-	80%	70%
Yasuda et al.¹³⁵ (1992)	86	-	88%	-	63%	-

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TABLE III: Results of Distal Femoral Osteotomy

Study	No. of Patients	Rate of Success (percent)	Duration of Follow-up* (yrs.)
Beaver et al.⁷ (1991)	42	83	3.6 (2-11.5)
Cameron et al.¹⁷ (1997)	49	87	7†
Conrad et al.²⁶ (1985)	16	62	6.5
Edgerton et al.³⁴ (1993)	24	71 (86‡)	8.3 (5-11)
Finkelstein et al.³⁸ (1996)	21	64	11 (8-20)
Healy et al.⁴⁶ (1988)	23	83 (93Â§)	4 (2-9)
Johnson and Bodell⁶² (1981)	53	70	3.6 (1-9.3)
McDermott et al.⁷⁸ (1988)	24	92	4 (2-11.5)
Mathews et al.⁸⁵ (1998)	21	57	3 (1-8)
Miniaci et al.⁸⁹ (1990)	35	86 (100#)	5.4 (2-16.7)
Terry and Cimino¹²⁹ (1992)	35	60	5.4 (2-19)

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TABLE III: Results of Distal Femoral Osteotomy

Study	No. of Patients	Rate of Success (percent)	Duration of Follow-up* (yrs.)
Beaver et al.⁷ (1991)	42	83	3.6 (2-11.5)
Cameron et al.¹⁷ (1997)	49	87	7†
Conrad et al.²⁶ (1985)	16	62	6.5
Edgerton et al.³⁴ (1993)	24	71 (86‡)	8.3 (5-11)
Finkelstein et al.³⁸ (1996)	21	64	11 (8-20)
Healy et al.⁴⁶ (1988)	23	83 (93Â§)	4 (2-9)
Johnson and Bodell⁶² (1981)	53	70	3.6 (1-9.3)
McDermott et al.⁷⁸ (1988)	24	92	4 (2-11.5)
Mathews et al.⁸⁵ (1998)	21	57	3 (1-8)
Miniaci et al.⁸⁹ (1990)	35	86 (100#)	5.4 (2-16.7)
Terry and Cimino¹²⁹ (1992)	35	60	5.4 (2-19)