Risks and Benefits

Carefully weigh the pros and cons of available remedies of knee osteoarthritis before taking the final decision about the best course for you
By Dr Abhishek Bansal

It’s no secret that good knees are an essential part of a healthy and active lifestyle. However, when injury or arthritis occurs, particularly osteoarthritis, one’s ability to bend and flex the knees can become restricted due to damage, inflammation and pain. Over time, the damage progresses and life becomes more difficult…and painful.
Deterioration of joint and surrounding tissue can make it difficult to perform basic daily activities, even while sitting or lying down. As cartilage wears and bone rubs against bone, pain and reduced mobility follow.
While age is a major risk factor for osteoarthritis of the knee, young people can get it, too. For some individuals, it may be hereditary. For others, osteoarthritis of the knee can result from injury or infection or even from being overweight. Here are answers to the questions about knee osteoarthritis, including how it’s treated and what can be done at home to ease the pain.

What Is Osteoarthritis?
Osteoarthritis, commonly known as wear-and-tear arthritis, is a condition in which the natural cushioning between joints – cartilage – wears away. When this happens, the bones of the joints rub more closely against one another with less of the shock-absorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move and, sometimes, the formation of bone spurs.

Who Gets Osteoarthritis of the Knee?
Osteoarthritis is the most common type of arthritis. While it can occur even in young people, the chance of developing osteoarthritis rises after age 45. According to the Arthritis Foundation, more than 60 million people in India have osteoarthritis, with the knee being one of the most commonly affected areas. Women are more likely to have osteoarthritis than men.

What Causes Knee Osteoarthritis?
The most common cause of osteoarthritis of the knee is age. Almost everyone will eventually develop some degree of osteoarthritis. However, several factors increase the risk of developing significant arthritis at an earlier age.

Age. The ability of cartilage to heal decreases as a person gets older.
Weight. Weight increases pressure on all the joints, especially the knees. Every kilo of weight one gains adds 3 to 4 kilos of extra weight on his knees.
Heredity. This includes genetic mutations that might make a person more likely to develop osteoarthritis of the knee. It may also be due to inherited abnormalities in the shape of the bones that surround the knee joint.
Gender. Women aged 55 and older are more likely than men to develop osteoarthritis of the knee.
Repetitive stress injuries. These are usually a result of the type of job a person has. People with certain occupations that include a lot of activity that can stress the joint, such as kneeling, squatting, or lifting heavy weights (25 kg or more), are more likely to develop osteoarthritis of the knee because of the constant pressure on the joint.
Athletics. Athletes involved in soccer, tennis, or long-distance running may be at higher risk for developing osteoarthritis of the knee. That means athletes should take precautions to avoid injury. However, it’s important to note that regular moderate exercise strengthens joints and can decrease the risk of osteoarthritis. In fact, weak muscles around the knee can lead to osteoarthritis.
Other illnesses. People with rheumatoid arthritis, the second most common type of arthritis, are also more likely to develop osteoarthritis. People with certain metabolic disorders, such as iron overload or excess growth hormone, also run a higher risk of osteoarthritis.

What Are the Symptoms of Knee Osteoarthritis?
Symptoms of arthritis of the knee may include:
Pain that increases when one is active, but gets a little better with rest
Swelling
Feeling of warmth in the joint
Stiffness in the knee, especially in the morning or when sitting for a while
Decrease in mobility of the knee, making it difficult to get in and out of chairs or cars, use the stairs, or walk
Creaking, crackly sound that is heard when the knee moves

How Is Osteoarthritis of the Knee Diagnosed?
The diagnosis of knee osteoarthritis will begin with a physical exam by a specialist doctor. The doctor takes a detailed medical history and notes any symptoms. Note is made of the factors that make the pain worse or better to help determine if osteoarthritis, or something else, may be causing knee pain. A family history of arthritis is also found out if anyone. Additional testing may be ordered, including:
X-rays, which can show bone and cartilage damage as well as the presence of bone spurs
Magnetic resonance imaging (MRI) scans
MRI scans may be ordered when X-rays do not give a clear reason for joint pain or when the X-rays suggest that other types of joint tissue could be damaged. Doctors may use blood tests to rule out other conditions that could be causing the pain, such as rheumatoid arthritis, a different type of arthritis caused by a disorder in the immune system.

How Is Osteoarthritis of the Knee Treated?
The primary goals of treating osteoarthritis of the knee are to relieve the pain and return mobility. The treatment plan will typically include a combination of the following:
Weight loss. Losing even a small amount of weight, if needed, can significantly decrease knee pain from osteoarthritis.
Exercise. Strengthening the muscles around the knee makes the joint more stable and decreases pain. Stretching exercises help keep the knee joint mobile and flexible.
Pain relievers and anti-inflammatory drugs. This includes over-the-counter choices such as paracetamol and ibuprofen. These over-the-counter medications should not be used for more than 10 days without checking with doctor. Taking them for longer increases the chance of side effects.
Injections of corticosteroids or hyaluronic acid into the knee. Steroids are powerful anti-inflammatory drugs. Hyaluronic acid is normally present in joints as a type of lubricating fluid.
Alternative therapies. Some alternative therapies that may be effective include topical creams with capsaicin, acupuncture, or supplements, including glucosamine and chondroitin.
Using devices such as braces. There are two types of braces: “un-loader” braces, which take the weight away from the side of the knee affected by arthritis; and “support” braces, which provide support for the entire knee.
Physical and occupational therapy. In case of having trouble with daily activities, physical or occupational therapy can help. Physical therapists teach ways to strengthen muscles and increase flexibility in joint. Occupational therapists teach ways to perform regular, daily activities, such as housework, with less pain.
Surgery. When other treatments don’t work, surgery is a good option.

Is Surgery Used to Treat Knee Osteoarthritis?
In treating the osteoarthritis in the knee with surgery, the options are arthroscopy, osteotomy, and arthroplasty.
Arthroscopy (Key Hole Surgery) uses a small telescope (arthroscope) and other small instruments. The surgery is performed through small incisions. The surgeon uses the arthroscope to see into the joint space. Once there, the surgeon can remove damaged cartilage or loose particles, clean the bone surface, and repair other types of tissue if those damages are discovered. The procedure is often used on younger patients (aged 55 and younger) in order to delay more serious surgery.
Osteotomy is a procedure that aims to make the knee alignment better by changing the shape of the bones. This type of surgery may be recommended if the patient has damage primarily in one area of the knee. It might also be recommended if one has a broken knee and it has not healed well. An osteotomy is not permanent, and further surgery may be necessary later on.
Joint replacement surgery (arthroplasty) is a surgical procedure in which joints are replaced with artificial parts made from metals or plastic. The replacement could involve one side of the knee or the entire knee. Joint replacement surgery is usually reserved for people over 50 years of age with severe osteoarthritis. The surgery may need to be repeated later if the joint wears out again after several years, but with today’s modern advancements most new joints will last over 20 years. The surgery has risks, but the results are generally very good.

Knee replacement surgery is a common solution that provides dramatic pain relief for more than 90 percent of patients. The vast majority of knee replacement procedures are used to treat osteoarthritis. The procedure—introduced in 1968—relies on a mechanical implant to replace severely arthritic or damaged knee joints. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements took place in the U.S. last year, and that number is expected to grow into the millions within the next twenty years. Total knee replacement (TKR), also called total knee arthroplasty (TKA), is considered one of the safest and most effective procedures in orthopedics.
Two different types of knee replacement exist: total and partial.

Total Knee Replacement
Total Knee Replacement makes up about 90 percent of all knee replacement procedures. During TKR, a surgeon repairs knee joint by covering the thigh bone with a metal covering and encasing the shinbone with metal & plastic. The prosthesis replaces the rough and irregular surfaces of the worn bone with smooth surfaces. In many cases, the surgeon also replaces the undersurface of kneecap with a plastic surface, in order to further reduce pain and provide a smoother functioning joint. The procedure involves some removal of bone and cartilage.
After a TKR, one should expect to spend three to five days at the hospital. Weight-bearing therapy is started early following the operation. In addition, some combination of physical and occupational therapy is started at the hospital. In most cases, the patient is likely be able to stand and walk, at least with the assistance of a cane or walker, before he leaves the hospital. Usually before exiting the operating room, the knee may be cradled in a knee brace and medical staff will monitor the flexion (bending in) and extension (extending out) limits of the knee. After discharge, the patient is likely to go home for recovery and rehabilitation. Some patients require home health care or assistance. The treating doctor will most likely prescribe physical therapy at a local clinic for continued rehabilitation, and the physical therapist there will then suggest exercises one can do at home. Most patients conclude rehabilitation within eight weeks—at which point he should be able to move around without assistance and resume his daily activities.

Partial Knee Replacement
If one receives a partial knee replacement, the surgeon will replace only the part of the knee that’s damaged or arthritic. The advantage to this approach is that it requires a smaller incision, involves less bone and blood loss and consequently, produces less pain. Patients undergoing partial knee replacement tend to experience a faster recovery time than those who have TKR. However, there are disadvantages, including the possibility that he will have to eventually undergo further surgery if arthritis develops in the parts of the knee that are not replaced.
Risks, Complications, and Considerations in TKR
Today, knee replacements are safe. Very few patients experience complications. The most common surgical complication is infection, which has been documented to occur in fewer than 2 percent of patients. When complications do occur, they may include: infection, blood clots, a problem with the implant, or persistent pain and damage to the blood vessels surrounding the knee as a result of the surgery. Thoroughly discuss the benefits and risks of TKR with the surgeon before making any decision about a procedure. One may also want to evaluate other considerations, such as: financial issues (the cost of surgery, follow-up care, and time off from work), hospital quality, and what to expect from your new knee.
TKR is an increasingly attractive and viable option if one is dealing with chronic knee pain or unable to participate in common activities. Approximately 90 percent of the replacement joints last 10 years, and about 80 percent function for 20 years. There’s a high probability that one will once again participate in activities such as walking, bicycling, golf, tennis and swimming. As the pain subsides and the ability to use the knee returns, the quality of life will most likely improve dramatically.

(The author is Consultant, Orthopaedics and Joint Replacement, Pushpanjali Crosslay Hospital, Vaishali)