Joint preservation over replacement – repairing patho-biomechanics as key to a causal therapy of osteoarthritis

In November, Basel will host an EFORT Instructional Course (IC) on a somewhat neglected art: By detecting osteoarthritis (OA) early and repairing not only present damage but al so the underlying patho-biomechanics, total joint replacement can be delayed for many years or even made redundant altogether, says Professor Victor Valderrabano, MD PhD, Chairman of the Orthopaedic Department at the University Hospital of Basel.


Professor Valderrabano, after years of frequently updated announcements of novel advances in total joint arthroplasties, EFORT is offering an Instructional Course on Joint-Preserving Surgery (JPS) of the Lower Extremity, chaired by you. Why this topic, and why in Basel?

Professor Valderrabano: During recent years, we heard a lot about radical procedures like total joint replacement and arthrodesis, to the extent that joint-preserving procedures have slipped a bit out of sight. However, at a time when OA has expanded to affect billions of patients worldwide, with a tremendous socio-economic impact, one needs to look at the given possibilities for prevention. One essential pillar of prevention is JPS, performed as early as possible in the course of the disease.
The University Hospital of Basel, on the other hand, has a long-standing reputation for its commitment to research and clinical perfection in JPS. So hosting this IC is also a homage to my pre-predecessor, Professor Erwin Morscher. As you know, this year marks EFORT’s 20th anniversary. Basel is a native city of EFORT, which still has its headquarters here in Switzerland, and Professor Morscher was one of its founders. By hosting this course, you could say that we are bringing a piece of EFORT back home.

What are the primary causes for the current epidemic of OA?

Professor Valderrabano: Besides the age increase, our Western societies have turned from societies of workers, craftsmen and peasants to such of desktop lions and couch potatoes, thus causing an increase in body weight and a dramatic extent of musculoskeletal degeneration. Our sporting leisure activities, however, get more extreme and crazy every year. When you are physically inactive all week long, your proprioception, reaction and resilience will dwindle. So when you try to counterbalance that by an extensive weekend of snowboarding, you run a high risk of leisure time accidents such as fractures, or at least of overburdening your musculoskeletal system with resulting instabilities. Both frequently lead to OA even in younger people.


The idea of JPS is not new, but until recently, its success was limited. Why was that?

Professor Valderrabano: One reason is that conventional X-rays can display OA only at a stage where irreparable damage has already occurred. Our advanced means of imaging, e.g. SPECT-CT, can detect it much earlier, enabling adequate surgery to slow down its progression significantly. Even using these diagnostic possibilities, however, surgery intended as joint-preserving has often remained a “nice try” until now. This is because it only treats the existing damage without correcting the underlying biomechanical causes.

Thus, a more integral approach is needed?

Professor Valderrabano: Doubtlessly! And the strong intention of this IC is to convey that. For doing JPS right, you do not only need to know your craft as a surgeon; you must also understand biomechanics and orthobiology. The scope of JPS is to transform a bad biomechanical situation into an almost normative one. Therefore, you need not just to cut away some bone or cartilage, you also need ligament and tendon surgery to stabilize the joint, often in addition to correcting the axis, and so forth. This is a complex job, but if mastered, it can delay the necessity for a total joint arthroplasty for many years, and sometimes make it redundant altogether.

Can you give us a few highlights of the course?

Professor Valderrabano: We will have three-and-a-half days. One each for the hip, the knee, and the ankle, during which we will touch upon, in introductory lectures, all the important diagnoses and topics such as hip arthroscopy, cartilage repair, osteotomies, arthroscopic surgery of ankle degeneration, and so on. The lectures will be followed by workshops where Europe’s leading specialists will instruct the participants in how to perform these interventions. On top of this, we will present a live surgery on the morning of the first day, presumably an especially intricate multi-joint operation. In the cases of the Bern and the Dresden algorithm for hip JPS, we will also debate their pros and cons and see if maybe several diverging paths might lead to Rome.


A very tempting program indeed. Do you have a personal vision about future developments in this field?

Professor Valderrabano: If I ever have to get a total joint replacement, I would want to have my own three-dimensional autologous implant, grown from my own stem cells. But to bridge the time gap until medicine has advanced that far, we will need JPS, and I would want to have it done on me by well trained specialists. Who knows, maybe there is some hidden agenda behind this IC

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