Osteoarthritis (OA)

Injecting a knee joint with a steroid can reduce the symptoms from arthritis, including pain and swelling. A steroid is a potent anti-inflammatory drug, and by injecting it directly into the knee joint, it acts locally with little systemic absorption. The common fears of steroid usage and side effects from this are related to systemic absorption of the steroid into the body, but by injecting steroids into the knee joint, the risks of side effects outside of the knee joint, in the body, are low. Steroids are an effective treatment option and will reduce pain and swelling. However it is usually a temporising phenomenon and the symptoms can return. Steroid injections can be repeated, but usually no more than two to three per year should be given. In my practice, I tend to reserve steroids for people with more advanced arthritis.

This is a combination of drugs that are commonly used by people with arthritis. The original studies that were done on this drug combination produced results showing that articular cartilage could be regenerated by the use of this drug. These studies were however, undertaken in animals including dogs and rabbits. Animal articular cartilage is different from human articular cartilage in that it has a regenerative capability which human articular cartilage does not have. However, there are some recent clinical studies, which suggest that there may be some symptomatic benefit from using Glucosamine and Chondroitin Sulphate.

This is potentially an exciting group of drugs which work by blocking Interleukin I. Interleukin I is a pro-inflammatory substance which promotes inflammation and the inflammatory molecule itself can cause the further breakdown of articular cartilage. Therefore by blocking this naturally occurring substance, it can reduce the physical and symptomatic effects of arthritis. There is some research work to suggest that it may even potentially reverse some of the arthritic destruction of the joint and so the x-ray appearances of arthritis, although this does require more study. These drugs are not yet licensed in the United Kingdom , but no doubt will become available soon.

This is a surgical technique involving a knee arthroscopy, which is undertaken with the intent to remove any mechanical problems within the knee such as loose articular cartilage flaps, degenerate meniscal tears or any loose bodies. Degenerate areas can be “tidied up” and the bone can be perforated by drilling or microfracture to cause bleeding and subsequently scar tissue infill to promote some degree of shock absorbing function back. However the tissue produced is not normal articular cartilage. The results of arthroscopic debridement are much better if the person demonstrates mechanical features in their knee, such as swelling, localised joint line pain or locking. Once again the effect of arthroscopic debridement tends to be temporary, but can last many months or even years. (Link to microfracture).

This is a technique that has been described for traumatic articular cartilage defects (below), where articular cartilage cells are actually taken from your knee and grown in a laboratory. The cells are then returned and are, at a second operation, re-implanted back into the knee, with the theory that normal articular cartilage is produced. The early short and medium term results in traumatic defects, is certainly promising. As our experience with this technique improves, the indications for it are also widening. It is a technique that I am now starting to do in people with localised articular cartilage degenerative disease, but certainly not in end-stage, bone on bone arthritis. The technique may be required to be done in combination with other procedures such as osteotomies about the knee.

Osteotomy is a term used to describe the surgical breaking of bones. The osteotomies about the knee can be done in the femur or the proximal tibia, depending on the type of arthritis. The aim of this treatment is to re-align the mechanical axis of the limb so as to move the mechanical axis from the arthritic compartment to the normal compartment of the knee.

Knee arthritis in the early stages can involve only one compartment of the knee such as the medial compartment, the lateral compartment, or the patellofemoral compartment. If arthritis and symptoms are truly related to one compartment, then it is much more logical to treat that affected compartment and leave the other compartment of the knee alone. In this situation, In this situation, a unicompartmental knee replacement can be undertaken. Most commonly, this will involve the medial compartment of the knee. However, isolated patellofemoral (knee cap) knee replacements can also be performed if the arthritis pattern is localised to the knee cap joint. The advantage of unicompartmental knee replacement is that it is a less invasive operation. It has a much quicker recovery period. There is less post-operative pain. There is less bleeding. The length of hospital stay is shorter. The range of motion achieved is usually greater. These comparisons are all made in relation to total knee replacements. The potential downside of unicompartmental knee replacement is that if arthritis and symptoms develop in the other compartments of the knee, then further surgical replacement may be required.

Total knee replacement is the mainstay of treatment for end-stage arthritis or symptomatic arthritis that does not respond or is unsuitable for the above-mentioned previous treatment options. It is a highly successful operation when performed correctly, with a greater than 95% success rate. It is however a major operation, and does have some potentially serious complications, which must be weighed up against the benefits before a decision is made to undertake total knee replacement surgery. Minimally invasive knee surgery is now a procedure that I now routinely perform which has the added benefits of quicker rehabilitation, shorter hospital stay and less pain in the short term, allowing a quicker return to function.