Abstract
Osteoarthritis (OA) of the knee is a major public health problem whose prevalence is expected to grow dramatically commensurate with the aging of the population and increasing rates of obesity. Unfortunately, little progress has been made therapeutically to avert this epidemic. We hypothesize that the lack of effective interventions is due, in large part, to an overemphasis on pharmacotherapy and direct chondral repair. Instead, we propose that research and development efforts be aimed at addressing the aberrant biomechanics that are the primary driver in the progression of knee OA. In particular, technologies that “unload” the joint may reverse the structural damage, which is the cardinal feature of this disease. Re-establishing a favorable local mechanical environment may not only delay the requirement for an invasive joint reconstruction procedure but obviate the need entirely.
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References
Amendola A, Bonasia DE (2010) Results of high tibial osteotomy: review of the literature. Int Orthop 34:155–160
Amendola A, Panarella L (2005) High tibial osteotomy for the treatment of unicompartmental arthritis of the knee. Orthop Clin North Am 36:497–504
Andriacchi TP (1994) Dynamics of knee malalignment. Orthop Clin North Am 25:395–403
Andriacchi TP, Briant PL, Bevill SL, Koo S (2006) Rotational changes at the knee after ACL injury cause cartilage thinning. Clin Orthop Relat Res 442:39–44
Andriacchi TP, Koo S, Scanlan SF (2009) Gait mechanics influence healthy cartilage morphology and osteoarthritis of the knee. J Bone Joint Surg Am 91(Suppl 1):95–101
Aspden RM (2008) Osteoarthritis: a problem of growth not decay? Rheumatology (Oxford) 47:1452–1460
Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ, Felson DT (2007) A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis. Arthritis Rheum 56:1198–1203
Baliunas AJ, Hurwitz DE, Ryals AB, Karrar A, Case JP, Block JA, Andriacchi TP (2002) Increased knee joint loads during walking are present in subjects with knee osteoarthritis. Osteoarthr Cartil 10:573–579
Blanco FJ, Fernandez-Sueiro JL, Pinto-Tasende JA, Fernandez-Lopez JC, Ramallal M, Freire A, Galdo F (2008) Intra-articular hyaluronan treatment of patients with knee osteoarthritis waiting for replacement surgery. Open Arthritis J 1:1–7
Block JA, Shakoor N (2009) The biomechanics of osteoarthritis: implications for therapy. Curr Rheumatol Rep 11:15–22
Brandt KD, Dieppe P, Radin E (2009) Etiopathogenesis of osteoarthritis. Med Clin North Am 93:1–24
Brandt KD, Radin EL, Dieppe PA, van de Putte L (2006) Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis 65:1261–1264
Brandt KD, Radin EL, Dieppe PA, van de Putte L (2007) The futility of current approaches to chondroprotection–a different perspective: comment on the article by Felson and Kim. Arthritis Rheum 56:3873–3874
Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, Pols HA, Bierma-Zeinstra SM (2007) Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum 56:1204–1211
Brouwer RW, Raaij van TM, Bierma-Zeinstra SM, Verhagen AP, Jakma TS, Verhaar JA (2007) Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev: CD004019
Brouwer RW, van Raaij TM, Verhaar JA, Coene LN, Bierma-Zeinstra SM (2006) Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthr Cartil 14:777–783
Burr DB, Radin EL (2003) Microfractures and microcracks in subchondral bone: are they relevant to osteoarthrosis? Rheum Dis Clin North Am 29:675–685
Cerejo R, Dunlop DD, Cahue S, Channin D, Song J, Sharma L (2002) The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum 46:2632–2636
Chiodo CP, McGarvey W (2004) Joint distraction for the treatment of ankle osteoarthritis. Foot Ankle Clin 9:541–553
Clifford A, O’Connell M, Gabriel S, Miller LE, Block JE (2011) The KineSpring load absorber implant: rationale, design and biomechanical characterization. J Med Eng Technol 35:65–71
Deie M, Ochi M, Adachi N, Kajiwara R, Kanaya A (2007) A new articulated distraction arthroplasty device for treatment of the osteoarthritic knee joint: a preliminary report. Arthroscopy 23:833–838
Felson DT, Goggins J, Niu J, Zhang Y, Hunter DJ (2004) The effect of body weight on progression of knee osteoarthritis is dependent on alignment. Arthritis Rheum 50:3904–3909
Felson DT, McLaughlin S, Goggins J, LaValley MP, Gale ME, Totterman S, Li W, Hill C, Gale D (2003) Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med 139:330–336
Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ (1992) Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med 116:535–539
Flegal KM, Carroll MD, Ogden CL, Curtin LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. JAMA 303:235–241
Gross KD, Hillstrom H (2009) Knee osteoarthritis: primary care using noninvasive devices and biomechanical principles. Med Clin North Am 93:179–200
Henriksen M, Simonsen EB, Graven-Nielsen T, Lund H, Danneskiold-Samsoe B, Bliddal H (2006) Impulse-forces during walking are not increased in patients with knee osteoarthritis. Acta Orthop 77:650–656
Hunter DJ, Lo GH (2009) The management of osteoarthritis: an overview and call to appropriate conservative treatment. Med Clin North Am 93:127–143
Hunter DJ, Niu J, Felson DT, Harvey WF, Gross KD, McCree P, Aliabadi P, Sack B, Zhang Y (2007) Knee alignment does not predict incident osteoarthritis: the Framingham osteoarthritis study. Arthritis Rheum 56:1212–1218
Hunter DJ, Sharma L, Skaife T (2009) Alignment and osteoarthritis of the knee. J Bone Joint Surg Am 91(Suppl 1):85–89
Hunter DJ, Zhang Y, Niu J, Goggins J, Amin S, LaValley MP, Guermazi A, Genant H, Gale D, Felson DT (2006) Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis. Arthritis Rheum 54:1529–1535
Hurwitz DE, Ryals AR, Block JA, Sharma L, Schnitzer TJ, Andriacchi TP (2000) Knee pain and joint loading in subjects with osteoarthritis of the knee. J Orthop Res 18:572–579
Iorio R, Robb WJ, Healy WL, Berry DJ, Hozack WJ, Kyle RF, Lewallen DG, Trousdale RT, Jiranek WA, Stamos VP, Parsley BS (2008) Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am 90:1598–1605
Khan FA, Koff MF, Noiseux NO, Bernhardt KA, O’Byrne MM, Larson DR, Amrami KK, Kaufman KR (2008) Effect of local alignment on compartmental patterns of knee osteoarthritis. J Bone Joint Surg Am 90:1961–1969
Kirkley A, Webster-Bogaert S, Litchfield R, Amendola A, MacDonald S, McCalden R, Fowler P (1999) The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 81:539–548
Koo S, Andriacchi TP (2007) A comparison of the influence of global functional loads vs. local contact anatomy on articular cartilage thickness at the knee. J Biomech 40:2961–2966
Krohn K (2005) Footwear alterations and bracing as treatments for knee osteoarthritis. Curr Opin Rheumatol 17:653–656
Lafeber FP, Intema F, Van Roermund PM, Marijnissen AC (2006) Unloading joints to treat osteoarthritis, including joint distraction. Curr Opin Rheumatol 18:519–525
Ledingham J, Regan M, Jones A, Doherty M (1993) Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 52:520–526
Lindsey CT, Narasimhan A, Adolfo JM, Jin H, Steinbach LS, Link T, Ries M, Majumdar S (2004) Magnetic resonance evaluation of the interrelationship between articular cartilage and trabecular bone of the osteoarthritic knee. Osteoarthr Cartil 12:86–96
Maillefert JF, Hudry C, Baron G, Kieffert P, Bourgeois P, Lechevalier D, Coutaux A, Dougados M (2001) Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: a prospective randomized controlled study. Osteoarthr Cartil 9:738–745
Messier SP, Gutekunst DJ, Davis C, DeVita P (2005) Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 52:2026–2032
Morse KR, Flemister AS, Baumhauer JF, DiGiovanni BF (2007) Distraction arthroplasty. Foot Ankle Clin 12:29–39
Nelissen EM, van Langelaan EJ, Nelissen RG (2010) Stability of medial opening wedge high tibial osteotomy: a failure analysis. Int Orthop 34:217–223
Palmoski MJ, Brandt KD (1982) Immobilization of the knee prevents osteoarthritis after anterior cruciate ligament transection. Arthritis Rheum 25:1201–1208
Pham T, Maillefert JF, Hudry C, Kieffert P, Bourgeois P, Lechevalier D, Dougados M (2004) Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis. A two-year prospective randomized controlled study. Osteoarthr Cartil 12:46–55
Radin EL (2004) Who gets osteoarthritis and why? J Rheumatol Suppl 70:10–15
Radin EL (2005) Who gets osteoarthritis and why? An update. J Rheumatol 32:1136–1138
Radin EL, Burr DB (1984) Hypothesis: joints can heal. Semin Arthritis Rheum 13:293–302
Radin EL, Parker HG, Pugh JW, Steinberg RS, Paul IL, Rose RM (1973) Response of joints to impact loading. 3. Relationship between trabecular microfractures and cartilage degeneration. J Biomech 6:51–57
Radin EL, Paul IL, Rose RM (1972) Role of mechanical factors in pathogenesis of primary osteoarthritis. Lancet 1:519–522
Radin EL, Rose RM (1986) Role of subchondral bone in the initiation and progression of cartilage damage. Clin Orthop Relat Res 213:34–40
Rinonapoli E, Mancini GB, Corvaglia A, Musiello S (1998) Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop Relat Res 353:185–193
Roos EM (2005) Joint injury causes knee osteoarthritis in young adults. Curr Opin Rheumatol 17:195–200
Schipplein OD, Andriacchi TP (1991) Interaction between active and passive knee stabilizers during level walking. J Orthop Res 9:113–119
Sharma L, Chang A (2007) Overweight: advancing our understanding of its impact on the knee and the hip. Ann Rheum Dis 66:141–142
Sharma L, Eckstein F, Song J, Guermazi A, Prasad P, Kapoor D, Cahue S, Marshall M, Hudelmaier M, Dunlop D (2008) Relationship of meniscal damage, meniscal extrusion, malalignment, and joint laxity to subsequent cartilage loss in osteoarthritic knees. Arthritis Rheum 58:1716–1726
Sharma L, Lou C, Cahue S, Dunlop DD (2000) The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. Arthritis Rheum 43:568–575
Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286:188–195
Tetsworth K, Paley D (1994) Malalignment and degenerative arthropathy. Orthop Clin North Am 25:367–377
Thorp LE, Sumner DR, Wimmer MA, Block JA (2007) Relationship between pain and medial knee joint loading in mild radiographic knee osteoarthritis. Arthritis Rheum 57:1254–1260
Toda Y, Tsukimura N (2006) A 2-year follow-up of a study to compare the efficacy of lateral wedged insoles with subtalar strapping and in-shoe lateral wedged insoles in patients with varus deformity osteoarthritis of the knee. Osteoarthr Cartil 14:231–237
Toda Y, Tsukimura N, Segal N (2005) An optimal duration of daily wear for an insole with subtalar strapping in patients with varus deformity osteoarthritis of the knee. Osteoarthr Cartil 13:353–360
Tunggal JA, Higgins GA, Waddell JP (2010) Complications of closing wedge high tibial osteotomy. Int Orthop 34:255–261
Wilson DR, McWalter EJ, Johnston JD (2009) The measurement of joint mechanics and their role in osteoarthritis genesis and progression. Med Clin North Am 93:67–82
Wing RR, Phelan S (2005) Long-term weight loss maintenance. Am J Clin Nutr 82:222S–225S
Wright TM, Maher SA (2009) Current and novel approaches to treating chondral lesions. J Bone Joint Surg Am 91(Suppl 1):120–125
Yanai T, Ishii T, Chang F, Ochiai N (2005) Repair of large full-thickness articular cartilage defects in the rabbit: the effects of joint distraction and autologous bone-marrow-derived mesenchymal cell transplantation. J Bone Joint Surg Br 87:721–729
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Waller, C., Hayes, D., Block, J.E. et al. Unload it: the key to the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 19, 1823–1829 (2011). https://doi.org/10.1007/s00167-011-1403-6
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DOI: https://doi.org/10.1007/s00167-011-1403-6