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​Is surgery for osteoarthritis of the knee becoming less popular?

6th March 2018

The pain of osteoarthritis of the knee can be almost unbearable, and as one of the most common forms of joint problems, it affects a huge number of patients every year. Eventually, when the knee joint becomes severely damaged, the only real solution is surgery, but there are plenty of options available to sufferers before reaching that point.

Non-surgical solutions to knee pain

The first thing that most patients are advised to do is to lose weight. Being overweight, even only slightly, puts additional stress on the structures of the knee which causes increased levels of pain. Lessening the load on the knee can be extremely helpful in reducing pain, and also increases the likelihood of being able to undertake moderate exercise, which is important, even for damaged joints.

There are a number of pain-relieving gels and creams available on prescription and over the counter to help to combat the pain of knee osteoarthritis. From capsaicin creams, derived from the capsicum pepper plant, to gels containing ibuprofen, topical applications can provide good relief from pain for many sufferers.

Painkillers can be purchased from chemists and pharmacies, with stronger medication available on prescription from your GP. From paracetamol through ibuprofen, naproxen and opioids, there are plenty of options, so if you don't achieve success with one regime it's important to keep trying until you find a solution that works for you.

Injections into the knee

Nobody wants to undergo unnecessary surgery. There is always a risk when general anaesthetic is involved, and surgery always increases the chance of introducing infection deep into the knee structures, so any form of knee surgery tends to be a last resort, when all other options have been exhausted.

Before resorting to surgery your medical team is likely to look at other forms of treatment, such as injections into the knee joint. Corticosteroid injections are usually a first line of defence before surgery, although the results are variable. Some people respond extremely well to steroid injections, whilst others maintain they receive very little relief. Usually the results tend to be quite fleeting, with sufferers reporting a noticeable reduction in symptoms for a few weeks. Even where the results are successful, the injections often have to be repeated in order to keep the knee joint mobile and pain free. Most doctors recommend no more than two or three injections per year, and the injections tend to be less effective over time.

A new treatment currently undergoing tests is the injection of hyaluronic acid into the affected joint. Tests are currently inconclusive, but some people report good results from the treatment. The theory is that the hyaluronic acid provides fluidity to the damaged cartilage, allowing the bones of the knee joint to pass smoothly over the structures without snagging, thus relieving pain. However, currently the treatment is in such early stages that it is impossible to predict whether this will become a regular treatment for the condition.

Surgery

There are a number of surgical options for an osteoarthritic knee, from total knee replacement to arthroscopy, where keyhole surgery is used to clean out debris from the joint in the most non-invasive way.

During total knee replacement surgery, the ends of the shin bone and the femur are 'capped' with either metal or plastic prostheses, which allows them to move against each other smoothly, to restore function to the knee. Although this procedure generally reduces pain and restores function to the knee, a knee replacement is never as strong as the original structure, and the patient has to take good care of their new joint. High-impact sports are discouraged, and patients are generally advised that the replacement joint has a limited life span of around ten years. Recovery time is usually around six weeks for the initial stages, and up to a year for full recovery.

A partial knee replacement only replaces a section of the damaged joint, either the medial compartment (inner knee), the lateral compartment (outer knee) or the patellofemoral compartment at the front of the knee, where it joins the thigh bone. In partial knee replacement, only the damaged compartment is treated. This option is only suitable for patients with well-aligned knees and is not possible for patients with ligament injuries or inflammatory forms of arthritis. As it is less invasive than total knee replacement, patients usually recover more quickly, but many of them maintain that the operation does not always successfully treat the accompanying pain of arthritis.

A knee osteotomy is sometimes performed on patients where appropriate. This surgery is suitable for younger sufferers, usually under 60, who have severe wear and tear on one side of the knee joint only. This is caused by the unsatisfactory alignment of the knee joint and is treated by introducing a small 'wedge' of bone, or artificial bone, to encourage weight to be forced onto the less damaged side of the joint. Done appropriately, the procedure is thought to postpone total knee replacement surgery for as long as another ten years. Patients may undertake high-impact sports following recovery from a knee osteotomy, unlike total knee replacement surgery, making it a good option for sports people who want to continue in their profession.

Knee arthroscopy is the least invasive form of surgery to the knee. Also known as keyhole surgery, tiny incisions allow access to a flexible camera and surgical tools, with which the surgeon removes small, loose pieces of bone and cartilage that have been irritating the joint. The procedure allows the surgeon to study the knee joint closely to ascertain the degree of arthritis damage to the joint, which provides a good assessment of the likelihood of further surgery in the near future.

The use of arthroscopy on the knee is constantly being evaluated as some surgeons are not convinced that it is a worthwhile procedure. However, it is not particularly invasive and requires only minimal recovery time, making it a good option for someone who may need a total knee replacement later on.

Risks of knee surgery

All surgery carries a degree of risk, and knee surgery is no exception. Some patients experience postoperative bleeding in the joint, while others complain of ligament, nerve or blood vessel damage. The kneecap can be dislocated during surgery, and bones can sometimes fracture around the site of the replacement. Scar tissue or bone can form around the replacement, causing a loss of movement, and some people develop an allergic reaction to the cement used to attach the prosthesis to the bone. Damage to nerves around the wound can cause loss of feeling. Infections and blood clots are always a risk following surgery. Occasionally patients will develop osteolysis, where particles of the replacement metal or plastic migrate into the body.

Knee replacement statistics

In the UK, there are over 70,000 knee replacement surgeries every year, a figure which is increasing steadily. Around four-fifths of the numbers are women, with the majority of patients over the age of 70. However, there is a trend towards younger people requiring knee surgery in increasing numbers, although researchers are at a loss to explain this phenomenon. They suspect that a rise in obesity amongst younger patients could be accountable for the trend.

With the life of a knee replacement reckoned to be around ten years, surgeons are understandably reluctant to perform knee surgery on younger patients who will need further surgery in the following years, which is leading to a greater uptake of conservative treatments to hold the disease at bay for as long as possible.

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