Non-arthroplasty options for hip, knee and ankle arthritis in adults

Guest Editors

Degenerative joint disease (DJD) is often seen as a problem of the elderly and arthroplasty is considered a panacea to treat large as well as some small joints. Adults also suffer from arthritis, and it is estimated that 5% of the population aged 35–54 years has radiographic signs of knee osteoarthritis (OA).¹ The data on the progression of such radiological arthritis to clinical manifestation is limited. Thorstenson et al.² have studied 148 cases with chronic knee pain (mean age: 45 years). 54 of their cases who had radiological evidence of arthritis at entry into the study progressed over a period of 5 years in 54% patients. Similar data is not available for hip and ankle joints, but the perception is that it is bound to increase as we are living longer and wish to remain active. Femoroacetabular impingement (FAI) and ankle instability-related arthritis are some examples. Apart from occupational and sports-related joint injuries, other causes of lower limb arthritis in the young are malalignment,³ trauma sequalae, avascular necrosis (AVN), hip dysplasia, Perthe's disease, and rare genetic disorders such as skeletal dysplasia. There is also a large racial variation in the lower limb alignment adding another dimension.³ In parts of the world where the population is still very young and health care resources are limited, management of young arthritic patients poses a real problem. Arthroplasty is not an ideal option for young people because of the risk of wear and needs for one or more revision surgeries during their lifetime. Revision joint replacement procedures are expensive and functional outcomes are not as good as primary arthroplasty. Hence, treatment modalities that preserve the native joint function for as long as possible should be explored in adults. In this issue, we have put together non-arthroplasty surgical and Orthobiologics options for the hip, knee, and ankle arthritis.

Non-union of fracture neck of femur affects many young patients in the Low and Middle-Income Countries (LMIC) and osteotomies that improve local biomechanics provides a good alternative to arthroplasty. Hip arthritis is frequently secondary to conditions that disrupt the congruity of the hip joint and often affect the young. Magu et al.⁴ describe modified Pauwels' osteotomy to treat non-union of fracture neck of femur. Perthe's disease and missed hip dysplasia are a common cause of hip pain in young adults and Vrgoc et al.⁵ discuss the role of Chiari Pelvic Osteotomy. Primary or secondary FAI is also receiving attention as a cause of hip arthritis and Cross et al.⁶ explore the role of hip arthroscopy in these conditions. AVN of the femoral head is a devastating condition across all ages and management is challenging. Steroids are a common cause and Birla et al.⁷ discuss the risk factors. Bakircioglu et al.⁸ present the range of non-arthroplasty surgical options for this crippling condition and Lee et al.⁹ explore cell therapies for AVN.

The Orthopaedic speciality derives its name from straightening crooked limbs, and correction of malalignment is of particular interest around the knee. In this issue we cover different types of osteotomies that can be considered to realign the knee.^{10, 11, 12, 13} Orthobiologics is a rapidly evolving and exciting addition to our practice. Vaish et al.¹⁴ and Solanki et al.¹⁵ explore the concept of biological reconstruction of the joint.

Arthrodiatasis or joint distraction is an option to rest and unload the joint surfaces. It is emerging as a joint preservation procedure for the knee and ankle OA in young people due to a better understanding of cartilage biology and inherent healing mechanisms. Bin Abd Razak et al.¹⁶ and Fragomen¹⁷ explore articulated joint distraction for knee and ankle respectively.

We hope this issue will enrich the reader's armamentarium to deal with hip, knee, and ankle arthritis in adults and delay or alleviate the need for the arthroplasty. We have chosen procedures that can be performed in an austere healthcare environment. Orthobiologics are expensive but with the wider use technology the costs are likely to be within the reach of many. We encourage younger orthopaedic surgeons to read this issue to explore the options of retaining native joints. We thank Prof. Raju Vaishya (Editor-in-Chief) and the JCOT staff for giving us this opportunity and supporting us throughout. We also thank all the contributors who, despite their busy lives, set aside time to write the articles.