Therapie der isolierten Femoropatellararthrose

What is the Level of Evidence Substantiating Commercial Payers' Coverage Policies for Total Joint Arthroplasty?

BACKGROUND

The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States.

METHODS

The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease.

RESULTS

282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA.

CONCLUSION

Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.

Patellofemoral arthroplasty: Current concepts

Isolated patellofemoral arthritis (IPA) is a debilitating condition characterised by a loss of articular cartilage on the patella facets, the trochlear groove or both. By definition, patients with IPA must have normal cartilage in the tibiofemoral compartments of their knee. It is therefore logical to pursue arthroplasty which corrects the abnormality while sparing healthy bone and preserving the knee's native kinematics, which is the premise underpinning patellofemoral arthroplasty (PFA). However, its use remains controversial, with many surgeons still favouring total knee replacement (TKR) in these patients. This paper provides a comprehensive review of PFA in the literature to date and concludes, in carefully selected patients, PFA is worthy of consideration as a functionally superior and economically beneficial joint-preserving procedure - delaying TKR until implant failure or tibiofemoral osteoarthritis progression.

Osteochondral autograft transplantation for isolated patellofemoral osteoarthritis

BACKGROUND

The purpose of this retrospective study was to evaluate clinical outcomes of osteochondral autograft transplantation (OAT) for isolated patellofemoral (PF) osteoarthritis (OA).

METHODS

OAT was performed in seven patients (six men, one woman; mean age, 61.1years) with isolated PF OA. The mean duration of follow up was 46.9months (range, 24-84months). Clinical outcomes were evaluated preoperatively and postoperatively according to the International Knee Documentation Committee (IKDC) objective score and the knee scoring system of the Japanese Orthopaedic Association (JOA) score. The International Cartilage Repair Society (ICRS) score was recorded in three cases that underwent second-look arthroscopies postoperatively. For morphological evaluation, the Kellgren and Lawrence (KL) classification and the modified magnetic resonance observation of cartilage repair tissue (MOCART) score were used.

RESULTS

The mean IKDC and JOA scores were both significantly improved. The percentage of normal and nearly normal on the IKDC score was increased from 28.6% (2/7) to 85.7% (6/7) (P=0.05). The mean JOA score was improved from 80.0 (range, 65.0-85.0) to 95.0 (range, 90.0-100) (P=0.0008). The mean ICRS scores were 10.3 (nearly normal) in the three cases that underwent second-look arthroscopies postoperatively. Regarding KL classification, the grade was unchanged in five cases (two cases in grade 1, three cases in grade 2) and improved in two cases (from grade 3 to 2, from grade 4 to 3). The mean modified MOCART score was 67.9 (range, 60.0-75) at 12-month follow up. There were no complications, and satisfaction was obtained in all cases. The study design was case series: level IV.

CONCLUSIONS

All clinical scores improved significantly postoperatively. Osteochondral plugs were transplanted perpendicular to the articular surface to obtain good congruity of the repaired articular surface. In this way, OAT is an effective procedure to prevent progression of isolated PF OA.

Patellofemoral Arthroplasty: Current Concepts and Review of the Literature

Patellofemoral osteoarthritis (PFOA) can be associated with anterior knee pain, stiffness, and functional impairment. Some authors report that PFOA affects approximately 9% of patients older than 40 years with a greater prevalence in females. Etiology of PFOA is multifactorial and is related to the presence of abnormal stresses at the PF joint due to knee- and patient-related factors. The need for a joint preserving treatment by isolated replacement of the injured compartment of the knee led to the development of PF arthroplasty (PFA). When a correct PF replacement is performed, PFA preserves physiologic tibiofemoral joint, thus allowing patients for a rapid recovery with a high satisfaction. The outcomes for PFA are quite variable with a trend toward good to excellent results, mainly owing to the improvement in surgical techniques, patient selection, and implant design. The development of the second generation of PFA improved the outcomes, which is attributed to the different trochlear designs. Recently, encouraging results have been provided by the association of PFA and unicompartmental knee arthroplasty (UKA). In many studies, the main cause of PFA failure is progression of tibiofemoral OA. The aim of this brief review of literature is to summarize the clinical features, indications and contraindications, surgical techniques, complications, and outcomes of PFA.

Arthroscopic patelloplasty and circumpatellar denervation for the treatment of patellofemoral osteoarthritis

BACKGROUND

Patellofemoral osteoarthritis commonly occurs in older people, often resulting in anterior knee pain and severely reduced quality of life. The aim was to examine the effectiveness of arthroscopic patelloplasty and circumpatellar denervation for the treatment of patellofemoral osteoarthritis (PFOA).

METHODS

A total of 156 PFOA patients (62 males, 94 females; ages 45-81 years, mean 66 years) treated in our department between September 2012 and March 2013 were involved in this study. Clinical manifestations included recurrent swelling and pain in the knee joint and aggravated pain upon ascending/descending stairs, squatting down, or standing up. PFOA was treated with arthroscopic patelloplasty and circumpatellar denervation. The therapeutic effects before and after surgery were statistically evaluated using Lysholm and Kujala scores. The therapeutic effects were graded by classification of the degree of cartilage defect.

RESULTS

A total of 149 cases were successfully followed up for 14.8 months, on average. The incisions healed well, and no complications occurred. After surgery, the average Lysholm score improved from 73.29 to 80.93, and the average Kujala score improved from 68.34 to 76.48. This procedure was highly effective for patients with cartilage defects I-III but not for patients with cartilage defect IV.

CONCLUSIONS

For PFOA patients, this procedure is effective for significantly relieving anterior knee pain, improving knee joint function and quality of life, and deferring arthritic progression.

Surgical treatment of isolated patellofemoral osteoarthritis

BACKGROUND

Isolated patellofemoral (PF) osteoarthritis (OA) affects 9% of persons older than 40 years. Nonoperative treatment should be exhausted fully before surgical treatment.

QUESTIONS/PURPOSES

The purpose of this article is to review the literature after 2008 with the aim of answering the following question: Which of the following surgical procedures has the highest survival rate and the lowest revision rate in advanced isolated PF OA: patellofemoral arthroplasty (PFA), total knee arthroplasty (TKA) or lateral facetectomy.

METHODS

The search engine was MedLine. The keywords used were: PF OA and PFA. Three hundred and fifty-three articles were found between 2008 and 25 July 2013. Of those, only 23 were selected and reviewed because they were strictly focused on the topic and the question of this article.

RESULTS

The types of studies reported so far have a low level of evidence (levels III and IV). Most of them are prospective case series (level IV). Some are systematic reviews of level III studies. Reported survival rate of lateral facetectomy is 85% at 5 years, 67% at 10 years and 47% at 20 years. Reported failure rate of lateral facetectomy is 26% at 10 years and 16% at 12 years. The reported average time of reoperation is 8 years and 37% of such procedures fail. Survival rate of PFA has been reported to be 87.5% on average (range, 60-100%). The revision rate of PFA is 20%. Recent improvements in PFA design have resulted in improvements in short-and medium-term results, similar to those of TKA.

CONCLUSIONS

There is still no gold standard for the surgical treatment of isolated PF OA. However, PFA or TKA appear to be the most recommendable treatment in cases that do not respond to conservative treatment.

[Evidence-based treatment protocol to manage patellar dislocation]

Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Reliable data and prognostic factors for stability of the patellofemoral joint and satisfaction of the patient after either conservative or operative treatment have not been established yet. Until now, there are no randomized controlled trials for recurrent patellar dislocation at all. As a synopsis of the randomized controlled trials about first-time patellar dislocation, no significant difference between operative and conservative management is evident. This applies to both children and adolescents as well as to adults. There is a clear tendency towards first-line conservative therapy after traumatic patellar dislocation. Operative treatment is only required in case of accompanying injuries like osteochondral fractures or in case of recurrent dislocations. Further prospective randomized controlled trials with standardized operative and conservative treatment and patient cohorts of sufficient size are necessary in the future.