Mylène Jansen

404 Chapter 19 KJD years after HTO, and researching (long-term) outcomes in these patients could give interesting insights in the process of joint preservation. KJD could also be combined with other treatments, such as pharmacological or cell-based therapies, as has been speculated upon but never tried. 8 These possibilities all allow patients to retain their native knee for as long as possible and require minimal bone ‘cutting or removal’, which patients deem important when considering surgical interventions for knee OA. 26 It is also essential that, before choosing KJD as treatment to postpone TKA, patients have really exhausted conservative treatment options first, which is a criterion that should be considered before recommending KJD but, in general clinical practice, is not always followed. 27 Figure 1 : Envisioned treatment effect of knee joint distraction (KJD). In blue the conventional way of placing a total knee arthroplasty (TKA) at a young age because of lack of alternatives ending up with significant loss of quality of life later in life. In red the alternative using KJD as joint-preserving treatment, postponing a first TKA for years towards an age at which a first prosthesis preforms better and preferably lasts a lifetime with gain of quality of life. Moving forward with KJD requires patients to have actually access to the treatment. In order to achieve this, it will have to be implemented in regular clinical practice, which means it should be reimbursed by patients’ health insurance. In the past years, the first steps towards reimbursement by the Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa) have been taken. The systematic review and meta-analysis ( chapter 2 ) and the 2 year follow-up data of the RCTs ( chapter 4 ) were used as part of the process to obtain reimbursement, in which the National healthcare institute (Zorginstituut Nederland; ZiN) performed an evaluation of the ‘state of knowledge and clinical practice’ (Stand van de Wetenschap en Praktijk; StWP) for KJD as treatment for relatively young (<65 years) knee OA patients indicated for TKA. It was concluded that while KJD was considered a promising treatment, the current evidence is