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September 25. 2013 7:34PM

What are the options to knee replacement surgery?

A LARGE PORTION of my working day is spent discussing the treatment options for painful knee arthritis. I have found that treatment of this very common problem is not “cookie cutter” and needs to be individualized to each patient.

The discussion about treatment options can be complicated and overwhelming. We, as an orthopaedic society, have not yet found a cure for global cartilage loss, which in its most basic terms describes what arthritis is.
We are making good advances with different techniques to regenerate cartilage in small areas of cartilage loss, usually in the younger age group, but the majority of arthritis patients who have more widespread cartilage damage are not candidates for these regenerative procedures.

The only course for these patients, to eliminate arthritis from the knee, i.e. a cure, is a knee replacement, where the damaged cartilage and the underlying bone are removed, and then replaced with metal and plastic parts. Though that is the only true cure, I initially steer patients away from that course of treatment for as long as possible. While other treatment options are not “cures,” they can give significant relief. And because arthritis is not a life-threatening process, living with it, as long as pain is controlled, is a completely reasonable option.

Conservative options are numerous. Arthritis is an inflammatory process, so, using an anti- inflammatory medication is the best option when considering oral medications. Ibuprofen or naproxyn are good over-the-counter choices. Tylenol can be as effective as these NSAIDS in certain patients. I do encourage my patients to take these with food as they can irritate the stomach. In patients that have a history of stomach upset or ulcers, more selective anti-inflammatory medications can be as effective for pain with decreased side effects. The cost of these medications is significantly higher. There are also prescription options if over-the-counter medications are not helpful. The use of glucosamine and chondroitin supplementation is a discussion in and of itself, but the bottom line is there probably aren’t any harmful effects and can improve pain in certain patients. As long as the cost is not prohibitive, it may be worth a try.

Certain types of bracing can be effective if chosen carefully and used to “unload” the damaged portion of the knee. Another method of “unloading” a painful joint is use of a cane. Some patients are surprised by the relief provided. Simply losing weight is very beneficial. The less weight born by the knee, the less symptomatic arthritis is. Weight loss is typically a difficult undertaking for most patients because their knees are so painful that exercise can be difficult, but, that being said, I encourage it strongly. Also, if patients do proceed to surgical intervention, decreased weight leads to decreased risk of some of the rare complications associated with knee replacement.

When patients are treated by an experienced physical therapist who has an accurate picture of the patient’s diagnosis and symptoms, treatments such as heat, cryotherapy, taping, hydrotherapy, ultrasound, and other more advanced electrical modalities can be successful in alleviating arthritis pain. Strengthening the muscles around the knee and improving motion is also helpful to patients with their postoperative recovery when knee surgery is undertaken.

One step up from the most conservative treatment options, but not as aggressive as surgical intervention, is injection treatment. This is simply another option for conservative, nonsurgical pain relief. Injectable steroids, like cortisone, decrease the level of inflammation in a knee. The duration of benefit is quite variable, but I’ve found that three months is about average. There is no downside to repeating these, but they are typically less and less effective the more they are used. When these widely used medicines become less effective, another type of injectable can be used, which can be broadly referred to as visco supplementation injections. There are various types made by different companies. This family of medications is a more expensive option than cortisone and are roughly as effective. Initially it was thought that this type of treatment worked by “lubricating” the joint, similar to oil in an engine. However, over years of study, the effect seems to be as an anti- inflammatory, similar to cortisone.

Once patients have exhausted all of the measures, discussion about joint-replacement surgery is in order. Other than the rare risks associated with any surgery, the reason to avoid knee replacement as long as possible is the simple fact that they do not last forever. It is analogous to changing a tire on a car. Knee replacements have a “tread life.” They will wear out over time. The time frame for the wearing out is much longer than in the older style of components but is still theoretically a concern. So, waiting as long as possible in the hopes of only needing one surgery to help with knee pain is desirable. . Knee replacements are quite successful, however, the outcome of the surgery is not dependent only on the success of the procedure itself but also the effectiveness of the rehabilitation which is very patient specific. Discussing the risks of surgery with your surgeon and having an accurate expectation about what the postoperative recovery entails is crucial to an excellent outcome. An educated, prepared patient stands a much better chance of a fully functional and pain-free outcome than a patient with no knowledge of the difficult, and sometimes painful, recovery process.

Knee arthritis in the United States is becoming much more prevalent and having a patient population that understands the treatment options will help with overall results and satisfaction.

Dr. Bryan Lawless is an orthopedic surgeon with Elliot Orthopaedic Surgical Specialists. For more information on knee arthritis, visit the American Academy of Orthopaedic Surgeons (AAOS) educational site OrthoInfo.org.


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