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Surgery versus conservative management of knee osteoarthritis26th April 2017
Arthritis pain can often be helped through a number of conservative treatments, although there is no way of curing the disease as yet.
It can sometimes take a while to ascertain the most appropriate course of treatment, as every case is different. However, there are plenty of options to try before resorting to surgery.
Many sufferers find that a combination of approaches can help to alleviate symptoms – by using painkillers and creams, for example.
Hot and cold packs
Applying ice packs or heat packs to the knee joint can dramatically reduce the stiffness and pain of arthritis. Many sufferers find that a hot-water bottle or wheat bag (that can be heated in a microwave) will provide instant relief for a while.
You can buy cold packs that you chill in the freezer before use or simply a bag of frozen peas wrapped in a cloth works just as well (just make sure you don’t eat them afterwards). Always remember not to put the hot or cold pack directly into contact with your skin as you don’t want to add burns to your list of ailments.
Although they can't repair the damage in your joints, painkillers can ease stiffness and pain in the knee joint, helping to make movement more comfortable. They can be particularly beneficial when taken before exercising, which is important to keep the knee's supporting structures in good condition. Ironically exercise is also beneficial (despite sounding somewhat counterintuitive) as it releases endorphins which act as natural painkillers.
Paracetamol is a popular painkiller, but it's important to take the correct dose to achieve maximum pain relief. The recommended dose for knee arthritis is 1g up to four times per day, which usually equates to two tablets, but check the packaging to make sure that you don't take too much, as paracetamol can be harmful if taken to excess.
Where knee pain is severe, you may be prescribed a stronger painkiller by your GP, which includes codeine. These tablets, such as Co-codamol, may affect your ability to drive and can cause dizzy spells in some people, so they may not be suitable for everyone. Again, read the packaging or if in doubt speak with your GP.
The strongest prescription painkillers are the opioids, but your GP will only prescribe these for very severe pain, as they have a number of side effects, including confusion, dizziness and nausea. Some opioids are available in patch form, which helps to administer a steady dose of the drug over time for maximum pain relief.
The main problem with painkillers is that over time your body can become used to it, meaning you may have to increase the dosage to achieve the same effect. Likewise there are side effects to such medication and it is not designed to be taken long term.
Where the knee joint is inflamed, you may experience better relief through the use of non-steroidal anti-inflammatory drugs, also known as NSAIDs. Ibuprofen is an over-the-counter example, whilst Naproxen may be prescribed if you require a stronger drug.
NSAIDs can affect the stomach, so your GP may prescribe further medication to take alongside them to minimise the side effects. Some people are unable to take these tablets, however, due to high blood pressure, diabetes or problems with circulation, and in these cases the use of anti-inflammatory cream on the affected area can be helpful.
Currently only available on prescription, capsaicin cream is made from the capsicum pepper plant. The cream needs to be applied to the knee joint three times each day, and within around two weeks the painkilling benefits should be noticeable. When first used, the cream can cause a slight burning or warming of the skin, but this should disappear within a few days of beginning to use it.
Also known as transcutaneous electrical nerve stimulation machine, a TENS machine seems to provide pain relief for some people. Electronic pulses are delivered to the body's nerve endings through adhesive pads attached to the skin around the knee, and this interferes with the pain messages being sent through the nerves.
There are various knee braces available that provide support for the knee. It's important to have one properly fitted, so if you are thinking of trying one, consult your GP or a physiotherapist for advice beforehand. These are referred to as unloading or offloading braces, whereby the focus is to shift some of the load from the affected part of the joint to another which reduces bone on bone contact and with it pain and inflammation.
Knee braces are now also recommended under the NICE Guidelines for Osteoarthritis care and management.
A corticosteroid injection directly into the knee joint can provide significant relief from pain for a few weeks. They are a good option for anyone who doesn't tolerate ibuprofen well or who has failed to gain relief from any other form of treatment. The injection is administered under local anesthetic and generally starts to take effect within 48 hours. Multiple injections can be given, but they tend to become less effective over time, and medical practitioners tend to limit their use to two or three times a year.
Hyaluronic Acid Injections
Where steroid injections fail to bring relief, it is now possible in some cases to have hyaluronic injections instead. This treatment is thought to replace synovial fluid from the damaged joint, although it doesn't work for everyone and the treatment has not been formally approved by NICE.
Often considered to be the last resort for the patient suffering with knee pain from osteoarthritis, surgery can replace all or part of the knee joint, depending on the severity of the disease.
Surgery may be considered for a patient where all attempts at conservative treatment have failed to provide relief. In many cases, the osteoarthritis has simply progressed so far that it is causing constant pain and making movement almost impossible. In other instances, surgery may be required because osteoarthritis has affected both sides of the knee joint, making it impossible to consider conservative treatments as a viable option.
Total Knee Replacement
Replacing the entire knee joint is an option for patients with severe knee osteoarthritis who have failed to respond to other treatments. Good results are usually seen within six weeks of the operation, but it can take up to a year to see the full benefit of the new joint. Although the patient can expect improved knee function and a huge reduction in pain, it is important to remember that an artificial knee is not as strong as the knee it replaced, and patients are advised against placing undue strain on the joint, such as by jogging, as this can cause the joint to wear out quickly.
A total knee replacement is also only designed to last between 10 and 15 years, so the younger you have this type of the surgery the greater the chance of undergoing a second knee replacement.
Partial Knee Replacement
Also known as unicompartmental knee arthroplasty, a partial knee replacement involves either the inner knee, the outer knee or the front of the knee where the thigh bone and kneecap meet. This type of surgery is used where a patient has very well-aligned knees, so anyone with knock knees or ligament injuries is ineligible. It's less invasive than total knee replacement, and recovery time is faster, but the operation is not always as successful at reducing arthritis pain significantly.
Also known as Femoral osteotomy or Tibial osteotomy, this procedure is suitable for those people under 60 who are physically fit and active but who have experienced significant damage to one side of their knee joint. The surgery realigns the knee structures to shift pressure away from the damaged side and towards the healthy side of the knee joint. Not only does this procedure reduce the pain felt from the joint, but it also provides the knee with another ten years or so of useful life before a total replacement becomes necessary.
Also known as keyhole surgery, a knee arthroscopy is performed through tiny incisions around the knee joint. Using a small flexible camera and tools, the surgeon can debride the knee, removing any loose pieces of bone and smoothing areas of cartilage. The joint is then washed through with a saline solution to remove debris that could cause pain and inflammation.
A great benefit of knee arthroscopy is that it allows the surgeon to view the structures of the knee and assess overall damage without resorting to major surgery. Arthroscopy is typically performed as an outpatient procedure, meaning that a stay in hospital is not required.
Which option is best?
This is a difficult question to answer as it depends on a multitude of factors including:
- The impact of the condition on your daily life
- The severity of the osteoarthritis
- What you want to achieve from the treatment (both short and long term)
- What kind of treatment you want to have i.e. can you afford to take time off work to have surgery or is it best to manage it conservatively in the first instance?
- The advice from your doctor / surgeon
What is important when making this decision is knowing your options. Your doctor / surgeon will also discuss these with you and the impact they can have, both post-surgery and post-rehabilitation.
If you’re ever in doubt then you need to ask as it is your knee, therefore you need to understand the impact or each option in being able to determine the best solution for you not only now, but for the future as well.