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Dear Doctor, I really don't want a knee replacement at my age. Are there any other options?

05 June 2018

Q: I’ve been suffering from knee pain for a long time but I really don’t want a knee replacement at my age. Are there any other options?

A: Knee replacements are a very good solution for the right problem but in the young adult with arthritis there are several drawbacks even with the most advanced prostheses and surgical techniques. Satisfaction rates may not be as high as it won’t give you back the knee you had when you were younger and it certainly isn’t an upgrade. It is generally accepted that a knee replacement once implanted will start failing in 15-20 years but may do so earlier in a much more active patient. So trying different options before opting for a joint replacement procedure is a sensible decision.

  • Tablets: Anti-inflammatories help to reduce pain from inflammation. The joint surface doesn’t actually contain any sensory nerves to signal when it is being worn away in osteoarthritis. Instead inflammatory chemicals are released which carry the pain message to other parts of the joint which then relay the information to the nervous system. This is a slower process and often accounts for delayed pain particularly at night or after activity. Analgesics act on the pain signalling pathway. These can start with paracetamol and increase stepwise with weak-opioids up to strong opioids.

  • Physiotherapy: This is not just about giving you a few exercises on a sheet of paper. There are newer techniques and evidence based programmes such as ESCAPE enabling people to get back to usual activities and exercise.

  • Knee Supports: These are particularly helpful in those with malalignment of the knee joint by spreading load to less worn parts and providing some support against giving way. Useful in conjunction with physiotherapy.

  • Weight Loss: Up to 9x bodyweight goes through a surface area of a few cm2 so even losing a small amount of weight can make a big difference. People with high Body Mass Index are 500% more likely to get severe osteoarthritis.
  • Injection Therapy: Steroid injections can be performed at the time of the consultation and are usually no more painful than a blood test. This is essentially a targeted anti-inflammatory that stays in the knee joint and lasts as long as 6 months.

  • Viscosupplementation injections contain a gel-like fluid that claims to lubricate the joint and provide shock absorption.

  • Arthroscopy: No longer indicated for osteoarthritis but can help with mechanical symptoms associated with a torn meniscus (internal ‘shock-absorber’ of the knee). Arthroscopic Microfracture is a technique of punching small holes into exposed bone which is should normally be covered with cartilage. Useful in a small percentage of cases with a small area of defined cartilage loss.
  • High Tibial Osteotomy (HTO): Many people with early-onset osteoarthritis have a predisposing subtle alignment abnormality of the knee joint resulting in a large amount of the body weight force going through one part of the knee. HTO is a surgical procedure to realign the knee without damaging the joint surface at all. This redistributes the weight force across a wider surface of the knee providing symptomatic relief whilst maintaining your normal range of knee movement and function. 80% of people undergoing this surgery will have symptomatic benefit for 10 years or more and can have a normal primary knee replacement if and when necessary.
  • Newer Treatments: Stem-cells, cartilage transplant, KineSpring, Apostherapy, PRP, Shockwave, Coblation. The field is continually evolving with exciting new research as well as heavily marketed ideas without any solid evidence behind them. It can be difficult to sort the good from bad. A consultation with a specialist who keeps up to date with research and practises evidence-based treatments is key to a successful outcome.

Find out more about Mr Simon Pearce, Consultant Orthopaedic Surgeon practising at Spire Sussex Hospital.

The content of this article is provided for general information only, and should not be treated as a substitute for the professional medical advice of your doctor or other health care professional.

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