Mr Sood’s article in Practice Matters magazine describes the joint-preserving options that are available for people suffering from knee arthritis. This will be of interest to those patients who are keen to avoid or to delay knee replacement surgery but who wish to explore other pain relieving options.

The full-text of the article appears below.

If you would prefer to read the article in the magazine click here.

Joint preservation options in knee arthritis

Although the treatment for established knee arthritis is joint replacement,  joint preservation as an alternative has evolved in recent years.

Medical interventions

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 & 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.

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) 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.

Surgical interventions

As knee replacements have a finite lifespan, especially in younger and active patient, the aim in joint preservation surgery is to eliminate or delay the need for such surgery.

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.

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

A new and novel device that 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 arthroscopically-assisted 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.  Joint preservation is an exciting and continuously evolving field.

Kinespring system acts like a shock absorber and lies beneath the skin on the inner side of the knee.  The joint is not disturbed during the placement of the device and so no future treatment options are compromised.  No bone is cut and it is not a joint replacement device.

It has the advantage that patients receiving it can be active on the knee as soon as the wound has healed.  Kinespring is showing great promise in the field of knee joint preservation.

For further details about this exciting technique please click here to view an informative presentation.

Partial and Total Knee joint replacements are very successful procedures, giving affected patients a “new lease of life”. We offer all types of replacement to our patients and we carefully select the best type for each patient individually based on various factors.

The KineSpring device is showing great promise in selected patients with arthritis limited to the inner side of the joint.    It can help to delay or avoid the need for partial knee replacement.

• the previous replacement reaching the end of its life and wearing out
• complications developing either early after the original procedure or some years later, such as, infection, the artificial joint working loose from the bone or fractures around the artificial joint.

The three main stages of a revision knee replacement are:

• removal of the existing components and bone cement with minimal damage to the patients bone
• reconstruction of any existing bone loss using by bone graft or other materials
• securely implanting the new components whilst ensuring that the knee is balanced, well aligned and stable

This sort of surgery takes about twice as long as the time taken to perform a  first time knee replacement.  It also carries significantly increased risks of complications compared to the original joint replacement.  These are discussed in detail with our patients prior to their revision procedure.

Re-do surgery is complex and challenging, and the best results are achieved by surgeons who specialise in the various techniques that may be needed to achieve a successful re-do surgery and therefore a well-functioning revision joint replacement.  There is also little doubt that the best results are achieved by those who perform this sort of complex surgery regularly. Mr Sood has undergone specialist training in some of the best hospitals in the world to perform complex and revision hip replacement and performs revision joint replacement procedures on average once a week.  He is one of fewer than 5% of UK surgeons who perform this number of revision procedures.  He prides himself in achieving excellent outcomes for his revision patients, a proportion of whom have already had unsuccessful revision procedures to the same joint performed elsewhere.

It is indicated for patients who have widespread knee arthritis, rather than arthritis confined to one part of the joint, in whom all appropriate joint preservation techniques have been exhausted.

It is performed through a surgical incision over the front of the knee joint about 8-12cm long. Patients are usually discharged from hospital after 3-4 days.

Modern total knee replacement using implants with a good track record, as used by us, is a reliable procedure that regularly delivers 15-20 years of pain free mobility.

Further information

Please click here to view a very useful guide about Total Knee Replacement produced by Arthritis Research UK.

Partial medial knee replacement

This technique is used when the inner (medial) side of the knee joint alone is worn out and needs to be replaced in patients in whom all appropriate joint preservation techniques have been exhausted.  It is performed through a 7-9 cm mini surgical incision on the inner side of the knee.  The fact that a mini-incision is used helps more rapid recovery of movement in the knee. Patients can put full weight through the leg as soon as they are comfortable and more rapid rehabilitation than after a total knee replacement is usual. Patients are usually discharged from hospital after 2-3 days.

If after some years arthritis develops in the other parts of the knee and causes pain from these sites, the partial replacement can be converted to a total replacement.

Partial Patellofemoral replacement

This technique is used when the knee cap joint alone is worn out and needs to be replaced in patients in whom all appropriate joint preservation techniques have been exhausted.  It is performed through a similar type, but shorter, surgical incision as a total knee replacement located along the front of the knee joint.  Patients rehabilitate more rapidly than after a total knee replacement, but in our experience slightly more slowly than after a partial medial knee replacement. Patients are usually discharged from hospital after 2-3 days.

If after some years arthritis develops in the other parts of the knee and causes pain from these sites, the partial replacement can be converted to a total replacement.

Inner (medial) side arthritis

In such cases we perform a medial opening-wedge high tibial osteotomy.  The operation is performed high up on the inner side of the shin bone through a 10-12cm surgical incision.  A plate is placed on the bone under the skin to hold the newly aligned bone in place until the osteotomy heals. This takes as long as a broken bone usually takes to heal (12 weeks) but, unlike previous plates, the plates that we use allow patients to put full weight on the leg as soon as they are comfortable. Crutches are recommended for 6 weeks.

Opening-wedge tibial osteotomy

Outer (lateral) side arthritis

In such cases we perform a lateral opening-wedge distal femoral osteotomy.  The operation is performed low down on the outer side of the thigh bone through a 10-12cm surgical incision.  A plate is placed on the bone under the skin to hold the newly aligned bone in place until the osteotomy heals. This takes as long as a broken bone usually takes to heal (12 weeks) but, unlike previous plates, the plates that we use allow patients to put full weight on the leg as soon as they are comfortable. Crutches are recommended for 6 weeks.

Opening-wedge distal femoral osteotomy

Possible procedures include:

• closed lateral release
• medial plication
• medial patellofemoral ligament (MPFL) reconstruction
• distal realignment procedures, such as tibial tuberosity transfer