Osteoarthritis in the Young Active Male : Knee Preservation or Replacement ?

Left Medial Joint Space Narrowing in Moderate - Severe Medial Osteoarthritis

Osteoarthritis in the Young Active Male : Knee Preservation or Replacement ? A 52-year-old male carpenter is referred by his GP after failingnon- operative rehabilitation with his physio for Left medial knee osteoarthritic pain. His pain on a VAS is between 4 - 6/10, with a fair score on a Lysholm Knee Score of 60/100.  He stopped running sports 5 years prior due to medial pain. He stopped pivoting sports over 15 years earlier. At age 25 years he tore his Anterior Cruciate Ligament, however, this was never reconstructed, and he underwent a partial medial meniscectomy 10 years ago. 

On examination, his BMI is 27, walks with a varus thrust and his alignment is in varus (bow-legged). His Anterior Cruciate Ligament is incompetent with a Grade III Lachman test and a marked Pivot shift. He indicates medial pain.  He has a full range of motion and intact distal pulses. 

Plain radiographs show severe medial compartment osteoarthritis, and the MRI confirms a partially absent medial meniscus with extrusion. The Patellofemoral compartment and lateral compartment are normal on MRI. He is in 5 degrees of mechanical axis varus on alignment X-Rays. 

Opening Wedge HTO with ACLR

What are his operative options ? 

Always using joint preserving approach in young patients, particularly in males is the ideal approach.  An arthroscopy is not going to help him as his problem as is a combination of medial osteoarthritis and instability. Multiple randomized controlled trials suggest Arthroscopy does not help osteoarthritis symptoms.  A Unicompartmental Replacement (UKR) is contraindicated due to theAnterior Cruciate Ligament deficiency and while some surgeons undertake combined ACLR and UKR, that is a very controversial procedure in any age group, particularly in young males. 

A Total Knee Replacement would be a possible option, but at 52 he is very young for this. The AOA National Joint Replacement Registry would suggest a male under 55 years would have a failure rate of about 8-10 % by the 10 th year post implantation. As an option especially given, his lateral and patellofemoral compartments are well preserved, TKR would be a reasonable option if he was over 60 - 65, and happy to not run or jump ever again.