Knee Study

Effnerstrasse 38, 81925 Munich, Germany
Alpha Klinik Tel: +49-89-998384-60 Ÿ E-Mail: toft@alphaklinik.de

Knee Unit Internet: www.alphaklinik.com
Abrasion Arthroplasty with Osteotomy for

Medial Compartment Osteoarthritis of the Knee:
A Viable Alternative to Unicompartmental or
Total Knee Joint Replacement?
A long-term study carried out by the Alpha Klinik
using the Oxford Knee Questionnaire
Author: Dr. Jürgen Toft
Introduction
The Knee Unit of the Alpha Klinik has now completed a study of 296 patients who underwent
abrasion arthroplasty plus an osteotomy for severe osteoarthritis involving the medial
compartment of the knee.
Objective
The objective of the study is to demonstrate that a combination of abrasion arthroplasty and
an osteotomy can be a viable alternative to replacement surgery – irrespective of age, and
with outcomes that are superior to the results reported in literature for TKR and UKR treating
practically the same pathology.
Methodology
Between 1989 and 2002, 486 abrasion arthroplasties with valgus osteotomy were performed
at the Alpha Klinik in Munich, Germany.
The Oxford knee questionnaire was sent to 470 patients, of which 296 were sent back. All
patients had grade III/IV cartilage lesions (bare bone) in the medial compartment, according
to the Outerbridge classification1. 34 patients were bilateral, i.e. both knees were affected.
The minimum follow-up period was 12 months, and the maximum was 14.5 years.
All of the operations were performed for medial compartment osteoarthritis of the knee with
near complete loss of the articular cartilage, as identified by magnetic resonance imaging
and full leg x-rays, and confirmed during the surgery by an arthroscopy.
All of the operations were performed by the same surgeon – Dr. Toft – utilising the same
surgical technique.
The outcome measure used in this study was the Oxford Knee Score (OKS). The 12-item
questionnaires are filled out by the patients and have been designed for total knee
replacement (TKR) surgery. The questions relate to knee pain or limitation of function. In the
evaluation, a maximum score of 48 can be reached for a near normal knee.
The post-operative protocol included a 12-week non-weight bearing period, daily use of a
CPM (continuous passive motion) machine and night-time use of a splint. Arthroscopic
revision with scar removal and evaluation of the repair cartilage was performed 6 months
after the operation, at which time the hardware was also removed. More vigorous exercise
was not allowed until 3 months after the operation.
1
“The etiology of chondromalacia patellae”, R. Outerbridge, 1961
Study: Abrasion Arthroplasty with Osteotomy for Medial Compartment Osteoarthritis of the Knee, Dec. 2003
Author: Dr. Jürgen Toft  2003 Alpha-Klinik GmbH Page 1
Results
The following questionnaire shows the results for each of the 12 questions from the Oxford
questionnaire.
The mean knee score for patients treated by abrasion arthroplasty plus micro-picking and
osteotomy was 38.
Question Scoring Categories No. Patients Percentage

4 – None 84 28%
3 – Very mild 92 31%
1) Describe the pain you usually have in your knee.
2 – Mild 70 24%
1 – Moderate 42 14%
0 – Severe 8 3%
4 – No trouble at all 175 59%
3 – Very little trouble 79 27%
2) Have you had any trouble washing and drying
2 – Moderate trouble 37 12%
yourself because of your knee?
1 – Extreme difficulty 5 2%
0 – Impossible to do 0 0%
4 – No trouble at all 102 34%
3 – Very little trouble 115 39%
3) Have you had any trouble getting in and out of the
2 – Moderate trouble 64 22%
car or using public transport because of your knee?
1 – Extreme difficulty 15 5%
0 – Impossible to do 0 0%
4 – No pain 180 61%
3 – 16-60 minutes 88 30%
4) For how long are you able to walk before the pain in 14 5%
2 – 5-15 minutes
your knee becomes severe? 1 0%
1 – Around the house
0 – Not at all; severe on walking 13 4%
4 – Not at all painful 117 40%
3 – Slightly painful 99 33%
5) After a meal, how painful has it been for you to 58 20%
2 – Moderately painful
stand up from a chair because of your knee? 13 4%
1 – Very painful
0 – Unbearable 9 3%
4 – Rarely / never 124 42%
3 – Sometimes / just at first 109 37%
6) Have you been limping when walking because of
2 – Often, not just at first 27 9%
your knee?
1 – Most of the time 27 9%
0 – All of the time 9 3%
4 – Yes, easily 84 28%
3 – With little difficulty 95 32%
7) Could you kneel down and get up again afterwards? 2 – With moderate difficulty 66 22%
1 – With extreme difficulty 11 4%
0 – No, impossible 40 14%
4 – Not at all 191 65%
3 – Only 1-2 nights 37 13%
8) Are you troubled by pain in your knee at night in
2 – Some nights 54 18%
bed?
1 – Most nights 10 3%
0 – Every night 4 1%
4 – Not at all 95 32%
3 – A little bit 106 36%
9) How much has pain from your knee interfered with
2 – Moderately 60 20%
your usual work?
1 – Greatly 32 11%
0 – Totally 3 1%
4 – Rarely / never 200 68%
3 – Sometimes / just at first 77 26%
10) Have you felt that your knee might suddenly “give
2 – Often, not just at first 12 4%
way” or let you down?
1 – Most of the time 5 1%
0 – All of the time 2 1%
4 – Yes, easily 232 78%
11) Could you do household shopping on your own? 2 – With moderate difficulty 22 7%
4 – Yes, easily 178 60%
12) Could you walk down a flight of stairs? 2 – With moderate difficulty 31 10%
Statistical Analyses
The following table demonstrates a statistical analysis of answers given to each of the
12 questions. It should be noted that the maximum attainable result per question was 4, and
that the overall average was approximately 3. It is evident from these results that the vast
majority of the patients were very satisfied with their result.
Table 1: Mean scores (0 - 4) for each individual question
We were also looking into the effect of the number of previous operations on the final
outcome as expressed in scores (see table 2).
It is clear that an increased number of previous operations lowers the attained scores,
although they are still higher than the scores reported in the literature for TKR or UKR.
Table 2: Scores in relation to the number of previous operations
In addition, when analysed by follow-up groups, the results have a clear tendency to become
better over time, with the highest scores reached by the patients with the longest follow-up
(see table 3). The results reported in the literature for osteotomies alone show the opposite
trend – they deteriorate over time, which highlights the importance of the abrasion part of the
surgery.
Table 3: Patients with longer follow-ups have better results
The following table demonstrates the comparison between the Alpha Klinik study and various
studies reported in the literature for UKR and TKR. It is clear that our results are superior to
any of the TKR or UKR results, notwithstanding the fact that our results improve over time.
Table 4: Patients with abrasion and an osteotomy had better scores than UKR and TKR patients
Histological Views
In figures (a) and (b) we demonstrate two histological views of repair cartilage, one taken 5
years after the surgery, the other 9 years after the surgery. While the 5-year sample still very
much resembles fibrocartilage, at 9 years the histology can hardly be differentiated from
original hyaline cartilage.
Figure a Figure b
Illustrative Cases
The 3 cases described below demonstrate both the improved vertical axis of the leg and the
reappearance of the medial joint line as a sign of cartilage regrowth as evidenced in the post-
operative arthroscopic views. It goes without saying that in the meantime all of these patients
are very happy with the health of their knees and have resumed full activity.
Case 1:
A 66-year-old former tennis player

reported a history of more than 10
years of pain and swelling in his right
knee following the removal of the
medial meniscus many years before.
The patient underwent abrasion plus

an osteotomy in June 2002.
The following pictures were taken in

January 2003, when the hardware
was removed and the knee was
scoped.
Case 2:
This 56-year-old self-employed car

mechanic had a knee fracture in his
youth that was overlooked and left
untreated.
He underwent abrasion and an

osteotomy in July 2002. The hardware
removal and rescope were in January
2003.
Case 3:
This patient is a 71-year-old house-

wife.
Abrasion and an osteotomy were

performed in October 2002. At the
time of the rescope and hardware
removal, the following pictures were
taken.
The patient can manage her house-

hold again without external help and
has no problems with the knee.
In Conclusion
In an overall assessment of our own results when compared with outcomes from TKR and/or
UKR, we can safely say that abrasion arthroplasty combined with a high tibial osteotomy is
indeed a viable alternative to replacement surgery.
Considering the fact that various authors found no repair growth following an osteotomy
alone, the additional attempt at resurfacing the bare bone appears to be worthwhile.
Furthermore, according to our own data and contrary to what has been claimed, the newly
grown repair cartilage remains in place and matures to a hyaline-like tissue over time.
In the light of possible complications with sometimes very poor outcomes from TKR and
UKR, it seems justified to treat medial compartment osteoarthritis with joint preserving
techniques such as abrasion arthroplasty with osteotomy.
Finally, as shown by various authors, TKR and UKR can still be successfully performed in
cases where abrasion failed or did not last long enough.
In summary, we feel that it is time to take a new and unprejudiced look at abrasion
arthroplasty. This study has demonstrated that the vast majority of patients treated with the
procedure are very satisfied over a period of up to 15 years, and that only 2.5 percent of the
patients later received a total knee replacement. If 97.5 percent did not feel a necessity to
have their knee replaced, then abrasion has proven itself and deserves a place in the
armamentarium for the treatment of severe osteoarthritis of the knee. With new cartilaginous
surfaces building where there was nothing to start with, we felt that “bioprosthesis” is a
suitable term to describe the result of abrasion arthroplasty, in analogy to prosthetic
resurfacing.

Knee Study

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Effnerstrasse 38, 81925 Munich, Germany

Alpha Klinik Tel: +49-89-998384-60 Ÿ E-Mail: toft@alphaklinik.de

Abrasion Arthroplasty with Osteotomy for

Question Scoring Categories No. Patients Percentage

Table 1: Mean scores (0 - 4) for each individual question

Table 2: Scores in relation to the number of previous operations

Table 3: Patients with longer follow-ups have better results

A 66-year-old former tennis player

The patient underwent abrasion plus

The following pictures were taken in

This 56-year-old self-employed car

He underwent abrasion and an

This patient is a 71-year-old house-

Abrasion and an osteotomy were

The patient can manage her house-

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