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. 2021 Dec 1;24:101723. doi: 10.1016/j.jcot.2021.101723

Role of joint distraction in osteoarthritis of the knee: Basic science, principles and outcomes

Hamid Rahmatullah Bin Abd Razak a,b,∗, João Pedro Campos a,c, Raghbir S Khakha a,d, Adrian J Wilson a,e, Ronald J van Heerwaarden a,f
PMCID: PMC8654974  PMID: 34938647

Abstract

The burden of knee osteoarthritis (OA) is increasing worldwide. Advanced tibiofemoral joint OA in young patients is particularly a problem with inferior results seen with total knee arthroplasty in this patient population. Knee joint distraction (KJD) has been evaluated recently as a joint preserving procedure for young patients with advanced tibiofemoral osteoarthritis, to delay the need for a primary total knee arthroplasty (TKA). This will decrease the risk for revision TKA later in life. KJD temporarily unloads the knee joint and keeps the tibia and femur separated over a course of 6 weeks. Outcomes of KJD appear promising. Through this article, the authors hope to share from their collective experience as well as the available literature on the basic science, principles of surgery and outcomes of KJD.

Keywords: Knee osteoarthritis, Joint preservation, Knee distraction, Arthrodiastasis, Surgical technique, Outcomes

1. Introduction

Knee osteoarthritis (OA) is a common progressive multifactorial joint disease and is characterized by chronic pain and functional disability.1 It is likely that excessive mechanical load or loss of mechano-protective mechanisms in the joint is an underlying process in many cases of disease, but there are other superimposed factors such as inflammation that modify its course.2 In 40% of individuals with early knee OA, pain may stabilize or improve over time, suggesting that the disease may remit and is not inevitably progressive.3

Prevalence and incidence increase with age and obesity. Despite been viewed as a disease mostly affecting older people, the estimated median age of knee OA diagnosis is 55 years, affecting 9% of US population by age 60.4 Global prevalence in younger ages is also significant (9% of 40–49 age group, 18% of 50–59 and 29% of 60–69.5 Longer life expectancy also means that the proportion of the population continuing physically demanding careers and sporting lifestyles into their fifth, sixth, and even seventh decades is increasing.6

Although widely accepted, efficacy of total knee arthroplasty (TKA) based on prosthesis survival is significantly lower for younger individuals (patients under 65 years of age), due to an increased risk for costly and less effective revision surgery, reaching up to one in three in those patients aged 50–55 years, with a mean time to revision of less than 5 years.7

Furthermore, considering patient satisfaction after total knee arthroplasty, it was shown that younger patients report lower clinical efficacy, mostly due to unrealistic expectations.8 Another undesirable outcome is that only 40% of patients below 65 years of age, who were employed before TKA, returned to work at a mean of 13.5 weeks after surgery.9 Most surgeons advise against high-impact activities following TKA, which precludes patients from participating in a wide range of sports.

In patients with monocompartment osteoarthritis, options include osteotomy or unicompartmental knee arthroplasty (UKA). Active and demanding activities seem more likely after medial UKA or HTO than after TKA.10,11 There is evidence that HTO has better results than UKA for active patients with a good range of motion of the knee.10,12 Although there are no significant differences in the clinical outcome between UKA and HTO at 12- and 24 months follow-up, HTO allows for a large corrective effect of the mechanical axis and the avoidance or postponement of TKA.13, 14, 15 Restoration of cartilage thickness following HTO has been reported in the literature.16,17

However, there are very limited joint preserving options for younger patients with bicompartmental tibiofemoral OA. Orthobiologic options are more suited for patients with early OA.18 HTO and UKA have shown unacceptably high failure rates for patients with bicomparmtental tibiofemoral OA.19,20 One option that has been recently extrapolated from the experience from treatment of advanced ankle OA is that of knee joint distraction (KJD). It is a more recently introduced joint-preserving procedure that is used for bicompartmental tibiofemoral knee osteoarthritis or unicompartmental OA with limited malalignment. In this review, we will explore the basic science, principles and the clinical outcomes of KJD.

2. Effect of joint distraction on cartilage

Despite multiple studies showing cartilage regeneration after KJD, the mechanism enabling the regenerative process is not yet clear. Systemic biomarker analysis with 2 years follow-up showed that KJD causes a sustained increase in collagen type-II synthesis marker PIIANP and an initial increase in collagen type-II degeneration marker CTX-II at 3 months, decreasing steadily from 6 months until 2 years, resulting in a statistically significantly increased normalized net collagen type-II synthesis at the end of the studies.21,22 It is important to keep in mind that while CTX-II is a cartilage breakdown marker, it is also a marker for (subchondral) bone turnover. Normalization of subchondral bone by ankle distraction over a period of 2 years was demonstrated by computer tomography analyses.23 As such, the initial increase in CTX-II could be a result of this bone remodeling process as well, alone or in combination with cartilage breakdown.

The repair of hyaline cartilage in KJD is supported by canine in-vivo studies demonstrating beneficial changes in proteoglycan and collagen turnover.24 These findings in canine models are supported by recent delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) evaluation of outcomes in patients following KJD.25

Synovial fluid biomarkers showed changes in degenerative and regenerative pathways.26 These results suggest that joint unloading by KJD stimulates intrinsic intra-articular conditions that promote cartilaginous tissue regeneration maintained at 2 years follow-up.

Contrary to the above, Hunziker reported that KJD is unlikely to benefit patients with OA as joint immobilization is known to cause cartilage degeneration.27 However, in KJD while the joint is immobilized by external fixators, patients are encouraged to fully bear weight to induce changes in the intra-genicular pressure, which is known to enhance cartilage repair.

3. Principles of knee joint distraction

KJD is a surgical procedure in which the two osteochondral ends of a knee joint are progressively pulled part over a period of 3 days, through a total distance of 5 mm, which is maintained for a 6-week period. The distraction is generally maintained by an external fixator (Fig. 1). KJD as a treatment modality was first described by Intema et al.28 In their landmark paper, they performed KJD using two monotube external fixators (Monotube Triax, Stryker, Kalamazoo, MI, USA) in a parallel system, one each on the medial and lateral aspect of the knee joint, with the patient under general anaesthesia. Each end of the monotube was attached to the femur and tibia by a 6-mm pin. The knee joint was initially distracted by 2 mm. The authors recommended placing the pins further away from the joint line to avoid contamination for possible knee arthroplasty in future. A further distraction of 1 mm/day over the next 3 days was performed for a total distraction of 5 mm. The patient was allowed to fully bear weight on the distracted knee joint and reviewed in the outpatient setting every 2 weeks. At each visit, the monotubes were removed temporarily and the knee was cycled on a continuous passive motion device for 3–4 h. The tubes and pins were removed permanently at the 2-month mark. The patient then underwent aggressive physiotherapy to restore range of motion. From this pilot study, it was learned that the onset of treatment effects measured in blood and urine samples already took place in the first 6 weeks, and that loss of range of motion after KJD was not a concern. In subsequent studies, a 6-week protocol of continuous KJD treatment has been used, initially with the same external fixator frame as used in the pilot study, and more recently with a dedicated KJD frame such as Arthrosave's KneeReviver.29,30 We believe that the painful osteoarthritic knee joint can by unloaded by creating extra joint space width of 5 mm (+maximum 2 mm) for 6 weeks (+maximum 5 days) with maintenance of the natural intra-articular fluid pressure changes during loading and unloading of the joint (resulting from an axial displacement of maximum 3 mm). Patients should be encouraged to walk, bearing full weight as tolerated with aids if needed, to load and unload the joint axially. Pain determines the amount of weight bearing and this must be achieved without overloading the joint or the device.

Fig. 1.

Fig. 1

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A 41-year-old female with left knee tricompartmental OA with asymptomatic PF joint OA. A: Weightbearing AP radiograph. B: Weightbearing lateral radiograph. C: Full-length weightbearing radiograph showing slight varus alignment. D: Patient standing with knee joint distraction frame applied around the left knee. E: Weightbearing AP radiograph 4 weeks after KJD. F: Weightbearing lateral radiograph 4 weeks after KJD. G: Weightbearing lateral radiograph l.5 years after KJD. H: Weightbearing AP radiograph 1.5 years after KJD treatment showing joint space widening and reversal of subchondral OA bone changes. Abbreviations – OA: osteoarthritis, PF: patellofemoral, AP: anteroposterior, KJD: knee joint distraction.

4. Indications

  • •

    Patients < 65 years of age

  • •

    Significant persistent primarily tibio-femoral pain resistant to previous adequate conservative treatment

  • •

    Radiological signs of primarily tibio-femoral cartilate loss (joint space narrowing); Kellgren & Lawrence Grade 2–4 (indicated for tibial or femoral osteotomy)

  • •

    End-stage tibiofemoral OA (indicated for UKA or TKA)

  • •

    Asymptoamtic patellofemoral joint OA

5. Contraindications

  • •

    Patients 65 years or older

  • •

    Arthritic pain predominantly caused by patellofemoral OA

  • •

    History of septic arthritis of the knee joint

  • •

    Lower limb malalignment exceeding 10° of varus or valgus and/or knee flexion contracture exceeding 15°

  • •

    Patient weight exceeding 120 kg

  • •

    Increased risk of venous thromboembolic events

  • •

    Perceived psychological difficulty with external fixator treatment and inability to cope with pin tract care

  • •

    Others: bone abnormalities such as severe osteopaenia or osteoporosis which may affect bone pin fixation, and soft tissue and vascular abnormalities that may prevent bone pin insertion or joint distraction

6. Results of knee joint distraction

6.1. Clinical outcomes

Jansen et al. and van der Woude et al., through their two randomized clinical trials have shown that clinical outcomes following KJD are comparable with that following either a HTO or a TKA.22,31 In another study, it was seen that KJD was able to delay the need for TKA for up to 9 years in 47% of patients with Stage IV knee OA.31 Interestingly, there was a gender-based predisposition for survivorship with males demonstrating a significantly longer delay to TKA as compared to females. Besselink et al. also demonstrated that there was clear clinical improvement in patients following KJD.25 In all studies, patients managed with KJD reported significant improvements in their pain scores from baseline to one-year post-procedure.22,25,31,32

6.2. Structural outcomes

Just as regenerative cartilage tissue was observed in a canine model after KJD,24 similar improvements in chondral thickness were noted on radiographs and magnetic resonance imaging in patients following KJD too.31 However, analysis of repaired cartilaginous tissue after KJD using dGEMRIC showed no difference between patients undergoing KJD and HTO.25 Interestingly though, there was a positive correlation between increase in cartilage quality and clinical outcomes. OA severity appears to be the strongest predictor for cartilage regeneration. Patients with Kellgren-Lawrence (KL) grade ≥ 3 demonstrated a significant regeneration following KJD while patients with KL grade ≤ 2 did not.32

6.3. Return to sports and work

There has been only one study reporting outcomes based on return to sports and work. Hoorntje et al. compared return to sports (RTS) and return to work (RTW) rates between KJD and HTO. RTS and RTW following KJD was comparable to HTO with no significant differences. 79% and 94% of patients returned to sports and work respectively at 1-year following KJD compared to 80% and 97% following HTO.33

6.4. Health economics

There has only been one study to date which evaluated the cost-benefit of KJD.34 Van der Woude et al. reported that KJD reduced the number of knee replacement procedures in the younger age categories of patients. In a model that starts with KJD as a dominant strategy in managing KOA in young patients and at a willingness to pay EUR20 per QALY gained, there was strong evidence for cost-effectiveness of KJD compared to a model that starts with TKA.

7. Complications and limitations of knee joint distraction

The most common complication reported in literature was pin site infection requiring antibiotics.35 The overall risk of developing pin site infection across all clinical studies was 69% (95% CI: 57–87%). The risk of developing pin site infection requiring oral antibiotics was 57% (95% CI: 33–82%). The risk of developing pin site infection requiring intravenous antibiotics was 10% (95% CI: 1–18%). Pin site infection requiring surgical management was rare. Manipulation for stiffness was also rare, only performed in one out of 62 patients.35

8. Pearls and pitfalls

8.1. Pearls

  • •

    Careful patient positioning with extended leg in an elevated neutral position eases medial and lateral access for pin insertions and frame connection

  • •

    Fluorscopic control with optimal anteroposterior and lateral visualization guarantees optimal bone pine placement proximal and distal to the knee joint, according to the surgical technique designed for the KJD device used

  • •

    Insertion of a K-wire penetrating the skin and soft tissues may be helpful in localizing the femur before bone pin insertion in case of bulky soft tissues

  • •

    Dedicated KJD frames (Fig. 1) enable parallel placement of bone pins with guiding sleeve placements through the frame

  • •

    Careful patient instruction regarding pin site care greatly reduces the risk of pin tract infections

  • •

    Cadexomer iodine ointment can significantly reduce the risk of pin tract infections and related complications36

8.2. Pitfalls

  • •

    As KJD is a relatively new treatment modality, surgeons should undertake detailed instructions and training prior to their first procedure

  • •
    All complications known to external fixator treatments may occur in KJD including:
    • o
      Pin-site infection, sometimes leading to osteomyelitis
    • o
      Nerve injury at site of insertion of pins
    • o
      Vascular injury at site of insertion of pins (Serious internal bleeding may cause compartment syndrome especially in the anterolateral tibial compartment)
  • •

    Precautions should be taken against thromboembolic events as the knee joint is immobilized in extension for 6 weeks

  • •

    Re-operation may be necessary for pin breakage or loosening

  • •

    Following removal of the frames, manipulation of the knee joint is necessary to prevent knee stiffness (However a temporary loss of flexion is seen in many patients in the first months after KJD before resolution)

9. Conclusion

KJD is a clinically effective joint-preserving procedure in young patients with unicompartmental OA with limited malalignment and in patients with advanced bicompartmental tibiofemoral OA. Clinical and structural outcomes tend to last at least between 5 and 10 years, delaying the need for a first UKA or TKA in younger knee OA patients, therefore decreasing the risk for revision surgery later in life.

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