Gonarthrosis therapy

Orthopaedic aids for degenerative diseases of the knee joint

Gonarthrosis therapy

The holistic concept for gonarthrosis therapy

Gonarthrosis is a common disease among adults with a high prevalence in the over 60s. The features: progressive destruction of the joint cartilage, including the joint structures such as ligaments, bones, synovial and fibrous joint capsules, as well as periarticular musculature. Clinically, the disease is presented with inflammatory and non-inflammatory phases. Only a percentage of patients with radiologically diagnosed changes notice disruption or pain.1

The chronic progression with no prospect of a cure requires there to be long-term trust in the doctor-patient relationship. 

Guideline-compliant treatment of gonarthrosis pursuant to the Sk2 guidelines

The German Society of Orthopaedics and Orthopaedic Surgery (DGOOC), as the leading professional society, issued the S2k guidelines on gonarthrosis in January 2018.1 This contains key recommendations for therapy: 

Each patient needs a tailored therapy plan. Patient-specific criteria should be taken into consideration when choosing the suitable conservative or surgical forms of therapy, for example:

  • the degree of pain
  • the activity level
  • the mispositioning
  • the age of the patient
  • the extent of the arthrosis

Depending on the stage of the disease and the patient-specific factors, surgery should only be considered when conservative therapy cannot provide sufficient relief from pain and freedom of movement.

The medi gonarthrosis therapy concept is part of the conservative therapy measures listed in the S2k guidelines and comprises the following therapeutic phases: 

Selfmanagement gonarthrosis

Relief and stabilisation in conservative gonarthrosis therapy

Relief and stabilisation are important aspects in the conservative treatment of gonarthrosis. The attending physician can achieve both by using orthoses. Evidence shows a reduction in pain and functional improvements.1

Relief orthoses on the knee joint (unloader braces) work according to the 3-point principle.1

This means that using orthoses can lead to a varus or valgus correction of the leg axis. This relieves the overloaded compartment: Which in turn relieves the patient’s pain.

Pressure without orthoses

Pressure without orthoses

Pressure with orthoses

Pressure with orthoses: Protection provided by the 3-point principle

Knee adduction movement is significantly reduced by the orthoses

Medial gonarthrosis is the particular focus of the therapy. It develops when the adduction movement in the knee joint is increased.1 Numerous biomechanical studies have shown that knee adduction movement can be significantly reduced by orthotics.

In 2011, Müller-Rath and colleagues conducted a randomised clinical and gait analysis study using the medi M4s OA relief orthoses.2 Worn over a period of 16 weeks, the orthoses produced positive results for the patients:

  • a significant reduction in the knee adduction movement
  • improvement on the scale of how they felt
  • a significant improvement of functional knee and pain scores (Tegner, Insall, Lequesne, WOMAC score, VAS) 

Brace test before surgical corrective osteotomy

The valgus-producing high tibial osteotomy (HTO) is an established treatment option for varus gonarthrosis. A valgus-producing knee joint orthotic has a medial pressure relief effect similar to the HTO. 

The study2 showed that: The brace test with the M4s OA orthoses is well-suited for patients with borderline indications for a valgus-producing HTO. In the preoperational period, it provides the surgeon and patient with additional information on the expected postoperative clinical outcome and provides an assessment of the postoperative pain reduction.3

Patient-specific factors impact the regulation

When choosing the therapy measures and the corresponding aids, it makes sense to consider patient-specific criteria, such as their degree of pain, the severity of the arthrosis and range of movement.1

Advantages for you as a doctor if you treat patients with knee orthoses

  •  Indication-appropriate: 1,2
  • Relief at the knee joint
  • Pain reduction
  • Functional improvement
  • Tailored to the patient: a wide range of products, high-quality patient care
  • Cost-effective: Knee orthoses are regulation-compliant and budget-neutral
medi Soft OA lightmedi Soft OAM.4s OA comfort
Pain levellowmoderatehigh
Activity level lowhighmoderate
Misalignment lowmoderatehigh
Instability lowmoderatehigh
Arthrosis gradeGrade 1-2Grade 2-3Grade 3-4

Interview with Prof. Dr. Philipp Niemeyer about the use of medical aids in arthrosis therapy

Prof. Dr. med. Philipp Niemeyer studied human medicine at the University of Saarland and the Albert-Ludwig-University Freiburg. Starting in 2008, he worked as specialist in orthopaedics and trauma surgery at Freiburg University Hospital.

As specialist in orthopaedics and trauma surgery with a focus on “knee joint surgery”, he is a co-initiator of the “KnorpelRegister DGOU”4, an initiative of the working group Clinical Tissue Regeneration of the German Society for Orthopaedics and Trauma Surgery (DGOU). He is also a founding member of the German Knee Society (DKG) and, since 2013, has also been a board member of the Society for Arthroscopy and Joint Surgery (AGA).

Prof. Dr. Niemeyer, what importance do you attach to supports and other aids such as orthoses in arthrosis therapy?

“You first have to differentiate within the group of aids. As I see it, the primary function of a support is its positive influence on the self-perception of the affected joint, which also gives supports an important role in arthrosis therapy. However, in order to stabilise or relieve pressure on a joint, orthoses are primarily used in arthrosis patients, especially in case of gonarthrosis. If this is due, for example, to a varus misalignment, special orthoses provide relief by protecting the leg from slipping sideways. The current S2k gonarthrosis guideline thus also confirms the importance of these aids in cases of arthrosis, as they can relieve pain and promote the mobility of patients with gonarthrosis1.”

Do you see supports and orthoses as undergoing a process of continuous development?

“Yes, definitely. Orthotic care has become much more individualised – not only with regard to the patient, but especially with regard to patterns of injury or illness. Orthoses are much more specific today, matching the pattern or stage of disease. I see a clear development in the case of the gonarthrosis orthoses: functionality used to be their main strength, while the important parameter of user comfort was rather limited. Manufacturers have responded with appropriate solutions such as soft orthoses, thus improving the user comfort for patients.”

What possible future developments do you see?

“The user comfort of the aids still has room for improvement despite the many changes in recent years. Nor would I be surprised by further developments in terms of sensor technology, providing patients with important feedback during therapy; for example, how far they should stretch or bend their knee.”

What is the basic therapy for arthrosis?

“The course of arthrosis is characterised by different stages. Treatment begins by clarifying the cause of the arthrosis and identifying and quantifying the patient’s risk factors. Certain risk factors can be reduced, including, for example, in case of gonarthrosis related to overweight and lack of exercise, instability of the joint and axial malalignment of the knee. For example, an orthosis can be used to simulate an axial correction of the knee. The Brace Test consists of a patient with a leg axis malalignment such as valgus leg alignment being fitted with an orthosis that corrects the leg axes. If the aid brings about the desired relief and thus reduces the patient’s pain, an osteotomy or provision of a permanent orthosis makes sense. An orthosis can nevertheless also be used to treat asymmetrical load distributions conservatively over the long term. Both methods are very helpful in the early stages of the disease.”

What other measures are used as part of conservative arthrosis therapy?

“A practical measure including for other typical forms of arthrosis such as hip or ankle arthrosis is weight reduction in overweight patients. This can be achieved by eating a healthy, balanced diet and getting regular exercise. Patients with a healthy weight should nevertheless also take care to maintain a healthy lifestyle. Supports, physiotherapy that strengthens musculature and short-term use of painkillers can also help. There is no single cure-all for arthrosis. Conservative therapy ultimately consists of several components.”

When is surgery inevitable?

“Joint-preserving surgery should already be considered at an early stage, as this can halt the further progression of the disease. This is the case, for example, with marked axial misalignment and focal, i.e. punctuated and local, cartilage damage. Surgery is nevertheless also useful for meniscus ruptures where there is a chance of preserving the meniscus by means of sutures.”

Could you give us a specific example?

“The primary goal is to eliminate the cause of the arthrosis. Axial misalignment is the number one arthrosis-related knee problem. In this case, surgery is usually performed and the joint remains intact. Although the symptoms could often be alleviated by wearing an orthopaedic shoe insole, this does not result in the same biomechanical improvement as axial correction of the knee through surgery. Aids such as insoles and orthoses are nevertheless indispensable in arthrosis therapy.”

How important is patient self-management in case of arthrosis?

“Very important. Patients who take responsibility for themselves are very likely to achieve a better therapy result. This applies to both conservative and post-operative therapy.”

How can doctors, the physiotherapists and specialist retailers motivate patients to practise self-management?

“By providing patients comprehensive information about their illness and the therapy options. If patients understand why individual measures are useful or even necessary in their case, they are usually also motivated to actively participate in the process. Experience shows that the therapy is also more successful in this case.”

What role do additional services provided by manufacturers of aids, such as therapy apps, play here?

“New possibilities such as apps already begin to promote patient self-management during therapy. I think this approach is very important and expect it will increase patient compliance with therapy. Patients should be given feedback when they do the right thing, or be reminded of important measures such as maintaining correct extension and flexion.”

What should be taken into account from a medical point of view?

“Although independent training or exercise is generally advisable, it should be carried out after consultation with the attending physician, who provides advice on the type, intensity and scope of the exercises the patient can safely do.”

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Sources:

1S2k gonarthrosis guideline; German Society of Orthopaedics and Orthopaedic Surgery (DGOOC); AWMF registration number: 033-004. Published online at: https://www.awmf.org/leitlinien/detail/ll/033-004.html (last accessed on: 18.03.2019)

2 Müller-Rath R et al. Klinische und ganganalytische Untersuchung einer valgisierenden Kniegelenkentlastungsorthese in der Therapie der medialen Gonarthrose. Z Orthop Unfall 2011;149(2):160-165.

3 Minzlaff P et al. Valgus bracing in symptomatic varus malalignment for testing the expectable "unloading effect" following valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2015;23(7):1964-1970.