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Osteoarthritis of the Knee

Osteoarthritis of the knee is a very common condition that affects over 10% of the adult population. It typically starts as a gradual onset of knee discomfort and pain when weight bearing. It can progress to a more constant background pain, present at rest and at night, occasionally interfering with sleep. The background pain is typically aggravated by activity and ultimately can start to interfere with routine activities of daily living and quality of life.

Management options include non-surgical and surgical treatments. Ideally, the non-surgical treatments should be exhausted before surgical treatments become necessary.

Non-Surgical Treatments

Education

Patients who understand their condition have been shown to manage their knee arthritis better. Please read all about it, as education helps. Useful websites include orthogate.org and patient.co.uk

Activity Modification

There is no role for rest! This means enjoying as many activities as your knee will allow, while obviously avoiding activities that aggravate your pain. Cycling, swimming and a cross trainer are comfortable ways to exercise without aggravating your knee pain. Try not to let your knee pain interfere with your daily activities and exercise routine.

Weight Loss

This is a vital part of managing your arthritis. The less weight your knee has to hold, the less symptomatic and painful your knee will be. Your knee takes six times your body weight when you ascend a step, so every extra kilogram is multiplied by six. Also, fat cells secrete chemicals that exaggerate your pain levels. Weight loss is really critical.

Physiotherapy

It is important to attend a chartered physiotherapist for quadriceps strengthening and resistance exercises. These can make a huge difference to reducing the pain associated with osteoarthritis. Your local chartered physiotherapist is a vital part of your treatment.

RICE

Your improvement will have “ups and downs” so use Rest, Ice, Compression and Elevation for acute flare-ups of your pain.

Supports

Heel wedges, knee sleeves and more rigid “off-loading” braces can help to re-align the knee and reduce pain levels. Simple neoprene knee sleeves are available in most chemists and well worth trying.

Glucosamine

This is an “over the counter” medication that has been shown to give some symptomatic relief and help slow the progression of osteoarthritis. Talk to your pharmacist regarding allergies and potential interactions with your current medications before you start.

Painkillers

You are always better to mask your pain and remain active, rather than limit activities because of pain. All painkillers, be they gels or tablets, should be taken on an "as needed" basis initially, increasing to "a regular basis", as pain progresses. I suggest you start with an anti-inflammatory gel (as needed and then regularly). When tablets become necessary, Paracetamol should be tried first (as needed and then regularly), followed by an anti-inflammatory tablet. Both Paracetamol and the anti-inflammatory tablets can be taken together if necessary. If the pain persists despite Paracetamol and an anti-inflammatory, a morphine type painkiller may be necessary (either patches or tablets). Please ensure you consult with your GP - who will guide you up the steps of the analgesic ladder.

Injections

Injecting the knee with Hyaluronic acid can be useful. The literature suggests that 60% of patients will note some improvement for a 12-month period.  

Surgical Treatments

Surgical treatments include knee arthroscopy (keyhole surgery), re-alignment operations and knee replacement surgery. Knee arthroscopy essentially washes out the joint and can occasionally provide excellent relief. Total knee replacement is the definitive solution for the pain of knee arthritis. This type of surgery is major surgery and should only be considered when all the non-surgical options have been exhausted.

Knee Arthroscopy & Washout

This is “keyhole” surgery using a camera and shaver inserted into the knee to remove any loose fragments and tidy up inside the joint. The response to the arthroscopy is a little unpredictable, but can work well, providing more information regarding the degree of arthritis and offering a window of opportunity to make physiotherapy easier.

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Knee Replacement Surgery

Knee Replacement surgery involves resurfacing the knee joint to eliminate the painful rubbing of “bone on bone”. Knee replacement surgery is generally very successful, with 85% of patients satisfied with their outcome after one year. However the international literature shows that at least 15% of patients can be dissatisfied, so one must make the decision very carefully, as complications can arise. The key to a successful outcome following knee replacement is good pre-operative education and setting clear and reasonable expectations for the surgery. It often takes 1 year to fully recover after a knee replacement operation.

When you have a knee replacement operation, your native, painful knee is replaced with metal on plastic - so it will never work "like a new knee". The expectations following the surgery must therefore be realistic. The primary goal of the surgery is to avoid complications and to ease your knee pain. Secondary goals are to return you to an acceptable functional level, such as long walks, doubles tennis etc. 

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Complications of Total Knee Replacement

Knee replacement surgery has a complication rate of up to 6%, with major complications occurring in 2% of patients. Infection can occur in up to 1% of patients, which would necessitate antibiotics and possibly further surgery. Clots can develop in the leg in 1.3% of patients and can travel to the lung in 0.8% of patients (a pulmonary embolus). We will give you Aspirin for 4 weeks after the surgery. We will also get you moving your legs and walking as soon as possible to reduce this risk. Other significant medical complications can arise in 1% of patients, with more minor medical issues (e.g. urinary tract infections, delayed wound healing) in 2% of patients. Large studies suggest that up to 2% of patients can have unexplained knee discomfort ("Medically Unexplained Symptoms") despite the wound and x-rays looking normal. Approximately 5% of patients may need a manipulation of the knee under anaesthetic - to improve their post-operative range of motion. The best predictor of post-operative range of motion, is the pre-operative range of motion. Up to 70% of patients will report a 'knocking sensation' within the knee - which is the metal on plastic sound and absolutely nothing to worry about.  All patients have a small area of skin numbness on the outer side of the wound.

Please note that obesity and inflammatory arthritis (Rheumatoid Arthritis or Psoriatic Arthritis) increase the risk of developing complications, in particular the infection risk is significantly increased. Weight loss is an essential part of treating knee osteoarthritis.

I tell patients that it can take 3 months to get over their operation, but that they should find gradual improvements as each week progresses.

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