A knee replacement is a big operation and a big deal. There’s an ‘optimum time’ when it does become appropriate to go ahead with knee replacement surgery. However, if you don’t yet need a knee replacement, then for goodness sake don’t do it!
Knee replacement surgery is a major operation, associated with pain, hassle, time off work, time to do the rehab and potential risks, with never any absolute guarantee of a good and happy outcome. In addition, knee replacement surgery in younger people tends to be associated with a bigger long-term risk of the need for potential re-do (revision) surgery at some stage in the future, later in life. Therefore, before you commit to surgery the most sensible thing is to ensure that you’ve at least attempted whatever of the various non-surgical treatment options might be appropriate for you and your knee….
If your knee is painful, then maybe try taking some painkillers! When it comes to knee damage, pain is actually your friend – it’s your body’s way of telling you ‘DON’T DO THIS’ – i.e. ‘don’t cause more damage’. Painkillers and anti-inflammatories mask the symptoms but they don’t cure the actual underlying pathology. Therefore, it’s just not sensible to take painkillers / anti-inflammatories to allow you to continue with high-intensity exercise or sport with a damaged knee. If you do, then you’ll simply cause further joint damage, just without feeling it. Painkillers / anti-inflammatories can, however, help significantly in terms of continuing to cope with your daily activities, keeping fit (with light non-impact cardio work) and also, if needed, to stop a painful knee from waking you up at night.
Occasional painkillers / anti-inflammatories are fine; however, if you’re ‘popping pills’ regularly, then this is one of the potential signs that you could actually be approaching the time when you might need to take things further.
Everyone wants a simple, easy magic cure to their issues, but like most things in life, this really doesn’t exist with knees! There are various things that can be injected into a knee, but there tends to be an inverse relationship between the cost of these and their actual efficacy!
Steroid injections into the knee
The simplest, cheapest and most bona fide thing to inject into a knee joint is steroid (corticosteroid). This acts as a very powerful anti-inflammatory. It’s not like ‘being on steroids’, and the injection does not affect the rest of the body – it’s simply like having a massive dose of Nurofen inside the knee joint, exactly where it’s needed. The likelihood of a steroid injection working is highly variable, and it depend very much on what is actually damaged in the knee and how severe that damage might be. In addition, the effects can vary considerably between individuals. Basically, the more inflamed the joint is (warm, tender and swollen) then the more likely it is that a steroid injection will work. Broadly speaking, a steroid injection might work in maybe 75% or so of people with knee arthritis, although the percentage pain relief varies considerably. The injection may last just a few weeks or if could last as long as 6 months; however, again, this. Is highly variable.
The advantages of steroid injections are that they are quick, easy, very low risk and cheap. The disadvantages are that the injection might not work, any relief might only be partial, the benefits are only ever temporary, and there is some evidence that in the longer-term they may actually help make the joint worse.
CLICK HERE for further information about how steroid injections may actually increase the future risk of knee replacement surgery.
Hyaluronic Acid Injections
Hyaluronic acid is a viscous oily liquid that is one of the normal constituents of joint fluid. Some people say that it ‘lubricates’ the knee joint; some say that it has a chemical effect inside the knee. Some people swear by it. The good news is that it’s one of the least ‘chondrotoxic’ (i.e. damaging to cartilage cells) things that can be injected into a knee. The bad news is that a few years ago The American Academy of Orthopaedic Surgeons (the biggest orthopaedic organisation in the world) did a meta-analysis (a statistical review) of all the published evidence for the use of hyaluronic acid injections for knee arthritis… and they found that it gave no greater benefit than just placebo!
If you inject just saline (salt water) into people’s knees, then up to 40% will report an improvement in their knee pain, simply due to the power of mental persuasion! Hyaluronic acid is expensive – therefore, it’s difficult to advocate hyaluronic acid injections in preference to just a standard, cheap, tried and tested steroid injection. Personally, I never actively recommend hyaluronic acid – however, very occasionally, if someone is adamant that it worked wonders for them previously (elsewhere), and if they’re insisting that they want another injection, then I might be persuaded to go ahead with an injection, but only after I’ve explained all of the above information to them first.
Platelet-rich plasma injections
PRP is simply where a doctor takes a sample of a patient’s blood (about 15ml), the blood is spun down in a centrifuge, and then the liquid part of the blood (the plasma) minus the red and white blood cells, but including the platelets, is injected into the patient’s knee. The platelets are partly responsible for clotting, but they can also release growth factors. The growth factors can allegedly help with tissue repair and with reduction of inflammation.
The scientific literature looking at the results of PRP injections is a bit unclear, with many contradictory reports. Some papers have shown some benefit but others have shown that the injections are again no better than just placebo.
What’s clear, however, is that PRP injections are more invasive, more hassle and a lot more expensive than simpler options, such as steroids. PRP should probably therefore be reserved for younger patients who’ve already attempted the more tried-and-tested options first, but who still have bad symptoms whilst not yet wanting or being ready for more definitive treatments, like actual surgery.
‘Stem cell’ injections.
There is currently a lot of hype and some deeply misleading and disingenuous marketing out there by some ‘rogue stem cell clinics’ luring patients with the promise of ‘stem cell’ injections as a treatment for arthritis. This is absolutely nothing more than just a con! These injections are not stem cells and there is no proper scientific evidence to back up their use, and the ‘snake oil salesmen’ who are touting them to patients are charging several thousand pounds per injection!
The BBC has already investigated and exposed some of these conmen:
Plus please also read this specific article too:
The future of medicine / surgery lies in ‘tissue engineering’, and this almost certainly will include the use of stem cells. However, proper stem cells are harvested, carefully identified by their cell surface markers, and cultured in pure cells lines in a lab. Currently, stem cell research is very much in its infancy, and stem cell use is purely experimental, as part of multi-million-pound trials that at present are largely animal based.
Importantly, tissue engineering for knees will require more than just ‘random’ cells simply injected into a joint, it will require:
- cells, but specifically within a
- scaffold, with the right
- growth factors and an appropriate
- environment (i.e. any instability stabilised, any malalignment corrected, and any missing meniscal tissue replaced – either by meniscal allograft transplantation or with a new (and better) generation of artificial meniscal scaffolds.
The most advanced technique currently available for ‘patching up’ a knee with premature degenerative changes is Biological Knee Replacement. This involves replacing a missing meniscal cartilage shock absorber by meniscal allograft transplantation, combined with also replacing missing articular cartilage at the same time, by articular cartilage grafting. Biological knee replacement is, however, a major and very complex surgical procedure, with not-insignificant risks, requiring very slow and restrictive post-operative rehab and with only a limited success rate (about 80% success at 5-year follow-up at best). Therefore, this is certainly not something to be taken lightly, and importantly, this is specifically a salvage procedure for younger patients who are too young for knee replacement surgery, who are trying to buy some extra time in order to delay (but most probably not avoid) eventual knee replacement. Unfortunately, Biological Knee Replacement is not a solution for older patients (>50 yrs) with fully-blown knee arthritis.
A lot of people swear by supplements, and the supplement industry is worth billions and billions of pounds. However, is there actually any genuine science to it?…
The most commonly taken supplements for trying to reduce the symptoms of knee arthritis are:
- Chondroitin Sulphate
- Omega-3 oils
A meta-analysis of the published data was performed back in 2010, with the results published in the British Medical Journal [CLICK HERE to read more]. The authors looked at whether Glucosamine alone, Chondroitin alone or both combined made any actual difference to the pain levels of patients with arthritis of the hip or knee, and whether taking the supplements made any difference in terms of the progression of the arthritis, as measured by X-rays. The conclusions were clear: that neither Glucosamine or Chondroitin, or both in combination, made any difference — i.e. they are both pointless!
A further more recent meta-analysis looking at a wider range of supplements, and also published in the BMJ [CLICK HERE to read more] showed that whilst some supplements might appear to show a small benefit for pain reduction in the short-term, the evidence for this is sparse and poor quality, and any short-term perceived benefit is probably just due to placebo. Importantly, however, none of the various supplements studied had any effect on mid-term to long-term pain or function.
So, the message here is clear: if you personally believe that any supplements you are taking are helping you, then they might actually be — but only purely through the effect of placebo alone! Should any doctor or scientist ever actively recommend the use of any supplement for the treatment of the symptoms of joint arthritis? — absolutely not!
The one exception to the above, which should be considered in a category all of its own is the use of Vitamin D (plus Calcium). A significant proportion of people in the UK are Vitamin D deficient, and therefore there is a good argument for people taking Vitamin D supplements + Calcium — however, this is specifically for bone strength (to try and avoid osteopenia / osteoporosis), and this is not a treatment for osteoarthritis.
The term ‘Physiotherapy’ covers a wide range of different things, including:
- hands-on treatments (manual therapy)
- rehabilitation and exercise advice (rehab therapy)
- a variety of associated potential treatments (e.g. shockwave therapy, TENS, massage, acupuncture) and, importantly
Orthopaedic Surgeons work very closely with Physiotherapists in a number of ways:
- physiotherapists can assess and help treat postural problems, that can frequently be an underlying factor contributing to knee pain
- physiotherapy is often the treatment of choice for a wide range of orthopaedic complaints (i.e. not surgery!)
- appropriate physiotherapy prior to surgery (pre-hab) can improve a patient’s strength and fitness levels, helping to increase the chances of a successful outcome from surgery
- early, regular, intensive post-operative physiotherapy is essential if you want to achieve a good outcome after knee replacement surgery.
Physiotherapy is specifically recommended by NICE as part of the treatment pathway for knee arthritis [CLICK HERE for further information].
CLICK HERE for further information about the role of physiotherapy in the treatment of knee arthritis, with specific advice from Lucy Mcdonald, Senior Physiotherapist at The Octopus Clinic in Central London.
If you do not already have a physiotherapist, then your knee surgeon should be able to recommend one for you.
A brace is not just a brace! — and there are many different types of knee brace.
Knee supports (just a simple cheap neoprene sleeve-like support from shops such as Boots) can make a painful knee feel slightly more comfortable, and they can increase one’s awareness of one’s knee, giving a feeling of slightly greater security. However, they are not a proper treatment for knee arthritis.
The main role of knee bracing for arthritic knees is for patients where the arthritis is specifically affecting just one side (inner/medial or outer/lateral) of the joint. An offloading brace is strapped on above and below the knee joint, with a hinged mechanism across the knee: as this mechanism is tightened, it applies a sideways force to the knee that can offload the affected side of the knee joint by as much 13%. This might not sound like much — but if you take a 100kg man, then this would be the equivalent of you trying to carry a 13kg weight around all day… which is clearly highly significant!
Offloading knee braces have been show to reduce pain, increase activity levels and delay or even reduce the need for knee replacement surgery in people with medial or lateral uni-compartmental arthritis of the knee.
Offloader braces are mechanically robust and are designed to last, and hence they are not cheap. Importantly, the best way to get an appropriate brace is to go to a specialised brace-fitting centre, to ensure that you have the right type of brace, that it’s the correct size, that it is fitted correctly to your knee and that it’s comfortable.
The brand of brace that I personally recommend is Össur, and the best offloader brace is the Össur Unloader One X.
CLICK HERE for further information about knee braces.