Preventing Knee Replacement Surgery (Total Knee Replacement, TKR)

Osteoarthritis of the knee can be a disabling and painfully condition. By definition, osteoarthritis is the loss of the articular cartilage that covers the ends of the bones within the knee joint.  The knee joint is made up of two major bones: the femur (thigh bone) and tibia (shin bone).  There should be approximately 5 mm of cartilage covering the ends of the bones within the knee joint. Osteoarthritis is a condition in which the articular cartilage that covers the ends of the bones breaks down.

The articular cartilage typically provides a cushion for the knee.  When it is lost, a variety of symptoms occur including pain, stiffness, swelling and loss of motion.  Additionally, the leg begins to deform in appearance and can become either increasingly bowlegged (varus) or more knocked kneed (valgus). Further, osteophytes also known as bone spurs start to form within the knee joint.

In order to treat osteoarthritis, some people opt for a surgical option like total knee replacement (TKR).  In addition, there are also many nonsurgical ways to treat the condition.

Knee replacements give some patients significant pain relief and in other patients TKR can actually cause more pain. There are significant risks associated with knee replacement surgery ranging from: the formation of a blood clot that can migrate to the lungs and cause a pulmonary embolism to occur, to a surgical site infection that requires multiple additional surgeries and an extended period of IV antibiotics.  Other medical complications associated with a TKR are: heart attacks, stroke and blood loss requiring transfusion.

Further, it is important to recognize that joint replacement does not last forever. It will eventually wear out. There are scientific studies that show survivorship of the joint as short as ten years. Therefore delaying a total knee replacement or better yet, preventing it from ever needing to be performed, is ideal.  Non-surgical options for osteoarthritis of the knee can help to reduce pain, decrease stiffness, improve muscle strength and increase the knee’s range of motion.

osteoarthritis-in-kneeOnce there is widespread loss of articular cartilage within the knee joint it cannot be replaced with new cartilage. New cartilage can be grown or replaced when cartilage loss only involves small isolated areas.

The nonsurgical treatment of knee arthritis focuses on pain reduction, strength improvement and increasing range of motion along with the reduction of stiffness. Treatment options for osteoarthritis in the knee discussed in this article include: 1) hyaluronic acid injections, 2) unloader knee braces, 3) PRP (platelet rich plasma) and 4) physical therapy.

Hyaluronic acid (HA) is a naturally occurring fluid in the knee. It is produced by a group of cells that line the capsule of the knee called synoviocytes. When osteoarthritis occurs, the hyaluronic acid breaks down and changes in composition. Typically hyaluronic acid is a thick, viscous fluid that lubricates the knee joint.  With the advancement of osteoarthritis, the normal HA begins to change in composition and it loses its normal properties, becoming a thin watery type fluid.

The HA is delivered to the knee via an injection that only causes mild discomfort. The injection is performed in the office and takes less than 20 seconds to perform.  There are several different brands of hyaluronic acid on the market.  Some brands require a series of three injections and others are just one shot. By injecting the knee with the HA it can give pain relief up to a year or more in patients with osteoarthritis. Most insurance plans will pay for an injection every 6 months.  This injection is typically given if oral NSAIDs have already been tried.  Patients that are allergic to egg products are not eligible for the injections.

Another nonsurgical option for treating knee arthritis involves the use of an unloader knee brace. Unloader knee braces also provide an excellent way to provide pain reduction in patients with osteoarthritis. Most patients with knee osteoarthritis will have one side of the knee where the osteoarthritis is not as advanced. The outer half (lateral) of the knee joint is typically the side of the knee that is less affected by oa. The inner (medial) half of the knee is most commonly affected in patients with knee arthritis. The brace is called an “unloader” because it will unload the half of the knee that is most affected by the osteoarthritis.

The unloader knee brace is customized to either unweight the medial or lateral side of the knee depending on which side the oa is located. It forces the person to place more weight on the “good” side of the knee while walking.  The unloader knee brace is recommended for use with walking activities such as going to the grocery store, shopping in a mall, or sporting activities. The leg must be able to accommodate a brace. A leg that is too short or wide may not be a candidate for an unloader knee brace.

Platelet Rich Plasma or PRP is currently one of the hottest topics being researched in Orthopedics. PRP is being studied and used in treatment for an array of Orthopaedic conditions ranging from plantar fasciitis to treatment of osteoarthritis. The process involves drawing blood peripherally from the patient and then separating out the plasma rich portion of the blood. This is completed by using a centrifuge that separates the blood into different components. The portion that is injected into the knee contains growth factors and other important components of the blood that have healing potential. This process is easily performed in the doctor’s office.  A recent article in the American Journal of Sports Medicine noted that PRP decreased the production of NFKB, which is a major enzyme in the pathway of the formation of osteoarthritis.

Physical therapy is another way to help reduce the symptoms of knee arthritis.  This is highly encouraged by the National Arthritis Foundation.  There are three types of exercises that are recommended for patients with knee arthritis: flexibility, resistance and cardiovascular.

Flexibility exercises are very good for easing stiff joints which will help patients with their activities of daily living. It is recommended that the stretches be done in the morning. They can be easier to perform while in warm bath water.  Resistant exercises are important to build muscles around the arthritic joints. Building muscle helps to absorb the shock and protect the joint from further injury.

There are two types of resistance exercises: isometric and isotonic. Isometric are typically the easiest resistant exercises for the oa patient. The strengthening occurs with contraction of the different leg muscles without moving the joint.  Cardiovascular exercises use big groups of muscles. The best recommendation for cardio fitness in the arthritic knee patient is water aerobics or cycling. The National Arthritis Foundation is a great resource for exercise DVDs. A referral to a local physical therapist can also be helpful. I find that my patients like the personal instruction, and the physical therapist also helps the patient maintain proper technique.

If you are suffering from osteoarthritis in the knee and are interested in discussing your treatment options, give Orthopaedic Specialists a call today at 502-212-2663 for an appointment.

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