Arthritis Treatment Options

Although knee arthritis cannot be cured, the symptoms can be treated very effectively. NICE (National Institute for Clinical Excellence) produced a report describing treatments for arthritis which are recommended and effective. These include:


  • Maintaining physical activities, although these may have to be modified, with emphasis on low impact exercise such as cycling and swimming, rather than jogging and walking.
  • Muscle strengthening exercises, particularly to improve the strength of the quadriceps muscles to enhance the shock absorber effect.
  • Reducing weight. It has been shown that reducing body weight by 15% has a significant effect on knee pain.
  • Pain relief. Simple analgesics are the most effective. Paracetamol taken regularly, supplemented by local treatment such as ice and heat on the knee, and anti-inflammatory gels can be helpful.
  • Using well cushioned shoes and occasionally using a walking aid when the knee is particularly sore can be helpful. Also, a simple support on the knee, such as an elasticated knee support of a Tubigrip can be very helpful.

When pain is more severe, and particularly when the knee is swelling regularly, non-steroidal anti-inflammatory drugs (NSAIDs) may be required, although these have side-effects, particularly causing indigestions and they can interfere with high blood pressure medication. They can be taken in combination with another drug, which protects the lining of the stomach and should be used for short courses, lasting for six to eight weeks. The other alternative is to inject cortico-steroids into the knee to suppress inflammation.

In general, these methods of treatment should be used as the main way of treating knee arthritis to begin with. It is important to persevere with this treatment, particularly keeping physically active, reducing weight and using strengthening exercises, all of which can be very effective. If this strategy fails however, a surgical opinion may be required.


Knee arthroscopy

Does keyhole surgery have a role to play in knee arthritis? The answer to this question is that it has a very limited role to play and is certainly not effective in established knee arthritis. Knee arthroscopy can be used in the earlier stages of arthritis when the symptoms are relatively short-lived (less than six months), when there is localised mechanical pain in he knee causing clicking and locking, which may be due to a degenerative tear of the meniscus. Keyhole surgery can be very effective under these circumstances when a “debridement” (clearing out the torn tissue and loose fragments from within the knee) to allow the knee to recover well, but does not necessarily guarantee long-term relief of symptoms.


Unicompartmental arthroplasty

If arthritis is confined to one compartment of the knee joint, and non-surgical treatment has been ineffective, resurfacing the damaged compartment of the knee can relieve knee pain very effectively. This procedure is termed a “unicompartmental arthroplasty” and involves implanting a metal and plastic bearing into the arthritic compartment of the knee. There are specific indications for this operation, which include to protect knee ligaments in arthritis which is confined to one compartment of the knee (although a degree of wear behind the kneecap does not appear to matter). In addition, symptoms must be very localised to the affected compartment of the knee and there should be good knee movement. The operation is most commonly performed for arthritis of the medial compartment of the knee, although it can also be effective for localised patello-femoral compartment arthritis and more rarely isolated arthritis in the lateral compartment of the knee.

Unicompartmental arthroplasty is still joint replacement surgery and there are risks of complications, including infection, knee stiffness, loosening and mechanical failure of the implants, and persistent knee pain. In a unicompartmental arthroplasty in particular, there is a risk of failure due to arthritis developing in the other compartments of the knee, causing a recurrence of knee pain. Under these circumstances, a re-do operation may be required to remove the implant and perform a total knee replacement.


Total knee arthroplasty

A total knee arthroplasty replaces the joint surfaces in all of the compartments of the knee joint. This a major operation and the final resort in the treatment of knee arthritis and is used for disabling symptoms that have not responded to non-surgical methods of treatment.

A knee replacement is a metal bearing with plastic insert, which acts as a low friction surface. The implants may be inserted with or without acrylic cement. In order to expose the knee joint to insert the implants, a great deal of soft tissue dissection is required, which cause the knee to bleed, resulting in swelling and bruising. The appearance of the knee after a knee replacement can be quite alarming, but settles quickly over the first two weeks and gradually knee function recovers over a period of three months, although recovery finally plateaus at about one year after surgery.

The main risks of undergoing a knee replacement are:

  • Infection (risk of approximately 1%)
  • Stiffening of the knee when knee will not bend as well as before the operation.
  • Thrombosis in the leg (DVT), which will require treatment with an anticoagulant.

Although the majority of patients benefit from knee replacement surgery, approximately 20% will not be satisfied with the outcome of the operation, usually due to persistent knee pain, which cannot always be explained.

Differences between unicompartmental arthroplasty and total knee replacement - RWN’s view

These are both major operations which require a metal implant to be inserted into the knee. This is an operation which can result in complications, but in the majority of patients who undergo this operation they will achieve satisfactory relief of their knee pain.

Approximately 20% of patients presenting with knee arthritis who require knee replacement surgery will be suitable for a unicompartmental arthroplasty. The main advantages of a unicompartmental replacement is that it is a less invasive operation, performed through a smaller incision, resulting in less swelling and bruising of the knee. For this reason, patients recover more quickly after the surgery and re-establish a better range of knee movement compared to total knee replacement. Overall, knee function is better but there are risks of failure, mainly due to persistent knee pain, or the development of arthritis in the other compartments of the knee. If this situation arises, a total knee replacement will be required.

Unicompartmental arthroplasty has an important role in the management of knee arthritis. The knee must be carefully assessed to make sure that it is suitable for a unicompartmental replacement, rather than a total knee replacement.

A total knee replacement is possibly a more predictable operation, in terms of pain relief, however, the knee function after a total knee replacement is less satisfactory compared to a unicompartmental arthroplasty. The main difference is that the range of knee movement is usually more limited and it is generally accepted that the range of movement that was present before the operation will be the range of movement that is achieved after a total knee replacement.

Overall, approximately 80% of patients are satisfied with the outcome of their total knee replacement.

Another aspect that needs to be considered is how long the knee replacement will last for. Modern designs of knee replacement, in the hands of an experienced knee replacement surgery, can be expected to last well over 10 years, with approximately 85% of implants still functioning well at 15 years. Figures for unicompartmental arthroplasty are less satisfactory because there is a high incidence of early failure, mainly due to persistent knee pain with arthritis developing in the other compartments of the knee. In my experience, unicompartmental arthroplasty has an 80% chance of lasting for 10 years.

Rehabilitation

Rehabilitation following all knee surgery is an essential part of the treatment. Without effort to perform exercises to move the knee and strength the muscles, the surgeon’s efforts will be to no avail. Following a knee replacement or an osteotomy, the worst time is the first six weeks, after which pain becomes less and it becomes easier to perform the exercises. Regular exercises performed every day for at least three months, is essential, working closely with a physiotherapist. It is usually possible to gradually increase activities but some compromise will be required, changing from high impact exercise to low impact activities such as cycling and swimming. In patients who have undergone unicompartmental or total knee replacement, activities such as golf, cycling, bowls and swimming are recommended. Personally, I have no objection to patients returning to playing tennis and skiing, as long as they adjust their ambitions to some extent.