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Orthopedics

Arthrosurface Procedure Provides Tool to Treat Difficult Conditions

MedialartrhosurfacebeforeWilliam A. Pakan, M.D., Section Chief, Sports Medicine, Crystal Clinic Orthopaedic Center, Orthopaedic Focus Winter 2011

Despite advancements in arthroplasty design and technology, there are still situations where current treatments fail us and our patients.

Relatively young patients with localized lesions from trauma, osteochondritis dissecans or chronic anterior cruciate ligament (ACL) injuries, and their subsequent degenerative changes, have proved challenging.  Patients with normal, weight-bearing X-rays, but Grade IV changes to the patellofemoral
joint, have also lacked a suitable solution for definitive treatment.Medialartrhosurfaceafter

The current use of arthroscopic debridement, microfracture, cartilage implants and total joint  arthroplasty have been met with some degree of disappointment for these conditions.

The development of an innovative resurfacing procedure has provided another tool for the treatment of some of these difficult conditions. Arthrosurface first received FDA approval in 2008.  To date, about 20,000 (all joints) total devices have been implanted, with 98 percent of them surviving. This is very meaningful given the type of patient that typically receives this implant.

The procedure is arthroscopically assisted with the addition of a small arthrotomy for the final implant.
Intraoperative mapping of the defect is performed and a patient-specific implant is chosen. Bone and cartilage removal is kept to a minimum. Precision reamers are used to create a bed for a low-profile implant.

These implants reconstruct a load-sharing surface without altering the normal biomechanics of the knee.  This allows patients to pursue a much more active lifestyle than they had preoperatively, or than is recommended after a total knee replacement. It is also possible to combine a resurfacing procedure with a ligament reconstruction such as an ACL. This stabilizes the knee while also helping to relieve activity-related pain from the coexistent arthrosis.

An additional benefit of the arthrosurface resurfacing procedure comes from the limited bone resection.
This allows for conversion to a primary total joint arthroplasty should further degenerative changes or an implant failure occur. The conversion is much easier than with traditional hemiarthroplasty. The use of revision implants with wedges or augments is usually unnecessary.

Proper patient selection and analysis of outcomes is very important.

The “ideal” candidate has unicompartmental arthrosis, good collateral ligament stability, minimal deformity, a reasonable (<30) BMI and limited medical comorbidities consistent with an elective surgical procedure.

A patient typically spends one night in the hospital postoperatively. This could eventually be reduced to an outpatient procedure in the future depending on the ability of the hospital to “carve out” the implant costs. Patients are encouraged to begin full weight bearing immediately and to start outpatient physical therapy to speed recovery.

The most difficult issue to discuss with patients relates to implant longevity and the significant cost. The short term results seem encouraging but we will need to await the long-term results until we know the true benefit. The implant materials are the same as standard total joint materials – cobalt chrome and high molecular weight polyethylene – and should wear well.

Most patients considering this procedure have generally failed other more traditional approaches and are trying to avoid a total joint. In this light, the less invasive nature of this procedure is appealing. Our preliminary results are encouraging and, in some cases, impressive.

Most patients considering this procedure have generally failed other more traditional approaches and are trying to avoid a total joint. In this light, the less invasive nature of this procedure is appealing. Our preliminary results are encouraging and, in some cases, impressive.

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