Alternatives to Total Knee Replacement

Management of the Degenerative Knee

Osteoarthritis is the most common form of arthritis and the leading cause of disability in adults. It is a progressive irreversible condition involving the loss of cartilage which leads to pain and sometimes deformity primarily in weight-bearing joints like the knee. It is associated with age, obesity and previous trauma or other disorders that affect joint mechanics.

The most common symptoms of arthritis are stiffness, pain and eventual deformity and loss of joint motion. There are many ways to treat arthritis of the knee ranging from conservative management to more aggressive management such as knee replacement.

Typically knee replacement is the last line of defense for arthritis of the knee. Although a good treatment option, not every patient is a candidate for a knee replacement. Factors that may place patients in this category are declining health, age, or simply because the patient does not desire such an aggressive means of treatment. Patients often come in and ask the orthopedic physician, "Doctor, what are my alternatives to knee replacement?" There are several options ranging from things that can be done at the home to thing that can be done in conjunction with the orthopedic physician which encompass, but are not limited to, exercise, medications, injections, bracing and arthroscopy, all of which can individually or in conjunction with each other help prolong, or even eliminate, the need for a knee replacement.

Exercising regularly can help maintain joint motion and, in turn, reduce the symptoms associated with arthritis by preserving muscle support in the affected joints. Exercises that are low impact or non-weight-bearing are of most benefit. Typically water exercises, bicycling, and stretching programs such as yoga can reduce symptoms and preserve musculature in the lower extremities. Exercising is also important because it can, in turn, help promote weight loss. Weight loss is not only important for orthopedics because it decreases the amount of stress across the joint, but it also improves the overall health and well being of the arthritis sufferer.

An inflammatory medication such as Ibuprofen, Naprosyn, Celebrex and Vioxx are very helpful alternatives to decreasing the amount of inflammation in the joint. Many patients are better able to cope with their symptoms. Recent advances in medicine have given us medications that are more and more specific to arthritis pain and produce fewer side effects than the traditional anti-inflammatory medications. Although some of these medications are more expensive than the over-the-counter anti-inflammatories, more and more insurance companies are beginning to accept them because of their efficacy. Anti-inflammatory medication such as Ibuprofen and Naproxen can be purchased over-the-counter, but the more specific medications such as Celebrex and Vioxx can only be obtained with a prescription from your doctor.

Localized injections to the arthritic joints have proven very effective in the treatment of the degenerative knee. Injections are simple, and for the most part, painless procedures. They can offer weeks to several months worth of relief. There are two different kinds of injections currently available for the knee. The first is the steroid type injection that acts as a potent anti-inflammatory in the joint itself. Unfortunately physicians usually limit the amount of injections to each joint to two to three times annually with the understanding that each subsequent injection will become less and less effective. The introduction of lubricating injections to the knee has recently become more and more popular. These lubricating injections are typically made of hyaluronic acid. In the healthy knee this substance is responsible for elasticity, lubrication and joint motion. Typically patients with arthritis have decreased amounts of this substance. These injections are now available and typically come in series of three to five injections. Patients receive one injection per week with relatively good results. Typically the injections are effective for approximately six months when they work and most insurance companies do allow you to repeat the series on a six-month basis. It is important to understand that injections, whether they be with steroids or lubrication, do provide significant pain relief, but they do not delay the progression of osteoarthritis.

A wonderful over-the-counter treatment that has gained popularity recently is the use of glucosamine and chondroitin sulfate or a combination of the two. These are both products that are extracted from animal products and sold over the counter as dietary supplements. The theory behind these two drugs is that they do several things for the joint. There is the apparently decreased inflammation, the preservation of cartilage and some studies have shown that they produce new cartilage. Both of these drugs are considered safe and effective when taken individually, as well as in combination with each other. As mentioned earlier, they are sold over the counter and are extremely safe in treated osteoarthritis. Unfortunately some are rather pricey and most insurance companies will not pay for them.

Specialized braces can be very helpful in knee arthritis. Most braces are designed to create forces, which transfer the stress from one area of the knee where the cartilage is bad to another area of the knee where the cartilage is in good shape. Unfortunately these braces are only helpful in cases where there is still some healthy cartilage remaining in the knee. Unfortunately some braces can be uncomfortable and are contraindicated in those patients that are obese, secondary to poor fitting techniques and the increased risk of skin breakdown.

There is a less invasive surgical procedure available for patients with arthritic knees. Arthroscopy, or the knee scope, can be a wonderful means of reducing the amount of pain associated with arthritis. Arthroscopy requires only small incisions around the knee with the insertion of instruments and camera's to evaluate and "clean up the knee". Degenerative cartilages can be trimmed and smoothed and additionally the lining of the knee can be trimmed which will in turn decrease the amount of inflammation. The typical recovery time for a knee arthroscopy is between four to six weeks, whereas a typical recovery for a knee replacement can range from three to nine months. Unfortunately the benefit of arthroscopy decreases as the degree of arthritis increases. Typically an advanced arthritis arthroscopy is of little value.

In situations where knee replacement is not warranted or the patient does not meet age requirements or health requirements to receive a total knee, or more specifically, the patient does not want a total knee, there are several alternative means to knee replacement. We have mentioned several more popular ways of preventing the need for knee replacement today. Of course, there are several others and each day, with more and more advances in technology, knee replacements are becoming less and less invasive and providing better range of motion to the patient. Remembering that not every patient is a candidate or desires a knee replacement, it is good to know that there are alternative means to prevent and preserve the arthritic knee and prevent the need for knee replacement.