Joint preservation options in knee arthritis
By Mr Manoj Sood
Although the treatment for established knee arthritis is joint replacement, joint preservation, as an alternative, has evolved in recent years.
injections, where healing cells from the patient’s blood are injected into the knee, can also help improve pain, although more evidence is needed before these can be routinely recommended.
These aim to preserve joint function for as long as possible, without recourse to surgery. As no medical treatments are currently available to slow down or reverse cartilage degeneration, surgical treatment may eventually be required.
Physiotherapy and dietary supplements There is good evidence that structured physiotherapy can help relieve some of the symptoms of arthritis, making this an important first step in treatment. Glucosamine and chondroitin sulphate are constituents of normal cartilage matrix and, although some patients who take these experience significant improvement in knee pain, clinical evidence for their effectiveness is mixed.
Arthroscopic debridement This can help relieve the pain of arthritis and is carried out through key-hole surgery (arthroscopy). It involves smoothing over loose cartilage, resecting bony osteophytes and trimming meniscal tears. Although a little controversial in arthritis, leading knee surgeon Steadman has described a very specific and detailed debridement procedure (‘the package’), which resulted in a number of his patients delaying the need for replacement surgery, for a significant period of time.
Injections Steroid injections in patients with significant arthritis can have detrimental effects if a subsequent replacement becomes necessary, and rarely provide long-term benefit. Viscosupplementation injections, comprising hyaluronic acid (which occurs normally in the knee) can give pain relief. They normalise the chemical environment in the arthritic knee. Some have improvement in their symptoms for many months and are happy to have this simple injection repeated, periodically. Platelet rich plasma (PRP)
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As knee replacements have a finite lifespan, especially in the younger and active patient, the aim in joint preservation surgery is to eliminate or delay the need for such surgery.
Re-alignment osteotomy In arthritis confined to one side of the knee, this established technique can take the load off the painful arthritic side and place it on the opposite, normal side. This involves incompletely dividing the bone, realigning it, and securing in this new position with a plate. In appropriate cases, osteotomy can delay the need for joint replacement surgery by 8-10 years.
Kinespring device Is a new and novel device which is being evaluated in appropriate patients, with isolated medial compartment arthritis. The device is a mechanical load absorber placed on the inner side of the knee to offload this part of the joint, and relieve pain. It lies outside the joint and the procedure involves no bone resection and is not a joint replacement, so future options of partial replacement or osteotomy are not compromised. Partial resurfacing This is a new technique being used in patients with large cartilage defects or localised arthritic areas. Through a mini-incision or arthroscopicallyassisted technique, a metal implant, with an overlying artificial plastic cartilage is inserted, restoring the smooth joint surface. There is minimal bone loss and this represents a ‘mini replacement’ of the damaged cartilage area. Thus, a variety of treatment options are available as an alternative to joint replacement in appropriate cases. Joint preservation is an exciting and continuously evolving field.
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