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Knee Osteoarthritis and Degenerative disease treatment

Learn more about the conservative and surgical treatments for Knee Osteoarthritis.

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Osteoarthritis is the leading cause of cartilage pathology. There are lots of other causes e.g trauma, infection, inflammatory joint disease, Rheumatoid Arthritis as well as other lesser known pathologies.

People usually think that it is “wear and tear” and part of ageing. To a certain extent that is true but if it was, then we’d all have arthritis in old age but that doesn’t happen. When you look at the difference in cartilage structure between ageing and OA, there is a difference. This is summarised nicely in the table below:

Essentially, what appears to be happening in OA is an up-regulation and increased activity of enzymes that break down cartilage (MMPs) and down-regulation of the tissue inhibitors of these enzymes (TIMMPs). This leads to a breakdown of the cartilage.

The treatment for osteoarthritis (OA) and other degenerative joint disease depends on the severity of the problem.

Less severe osteoarthritis (Grades I-III) can be managed well with conservative measures, and our aim is to always try and preserve you own knee joint for as long as possible.

What are the conservative treatments for Osteoarthritis?

1. Lifestyle measures: weight loss, exercise & strength rehab

Sometimes basic measures can be taken to improve the health of your own body and knee joint resulting in a significant improvement of symptoms. We would always recommend starting with these measures whether you require any other form of treatment or not.

The outcome of any injections or surgery is much improved if the patient is motivated to improve the strength and muscle function around the knee joint as well as reduce the forces transmitted through the knee joint by reducing body weight.

 

2. Injections: Steroid, Hyaluronic Acid & PRP

Steroid Injections

The orthopaedic community has been using steroid injections for decades, and this still has a role to play when PRP can’t be used. However, steroids have been shown to upregulate MMPs and their action, causing them to work harder and break down the cartilage even faster. This then in fact accelerates OA and results in joint replacement surgery much earlier than necessary.

 We try to avoid the use of steroid injections. 

However, steroids can be effective for pain relief in severe OA and inflammatory conditions when joint replacement surgery may be too high risk.


Hyaluronic acid

Hyaluronic acid / Hyaluronan injections have been used for many decades to help treat joint and musculoskeletal problems. 

Hyaluronic acid injections are an effective method of treating knee joint pain and OA. These work by providing a lubricant and cushioning effect in the knee joint as well nourishing the cartilage.

Types available:

  • Ostenil
  • Ostenil Plus
  • Durolane
  • Synvisc / Synvisc one

 

PRP

PRP has emerged as a leading joint preservation treatment for OA. There is now lots of evidence to support the use of PRP in OA.

Platelets are isolated from patient’s own blood and injected into the affected area. This helps the healing process and reduces pain whilst improving function. This can help stop the progression of OA and delay or prevent the need for major surgery. 

PRP  is highly effective in reducing inflammation and furthermore, helps to slow down and stop the progression of osteoarthritis by downregulating the effect of the MMPs (enzymes that break down cartilage). PRP helps to improve the function of the chondrocytes (cartilage cells) and the production of healthy matrix leading to better cartilage and joint health.

PRP injections can be used in the early, mild and moderate stages where evidence supports benefit, however, is not appropriate to have PRP treatment when the joint has severe changes.   

PRP injections have been found to be more effective that hyaluronic acid and steroid injections.

PRP works best in grade I-III. It is not effective in grade IV.

What are the surgical options for Osteoarthritis?

There are multiple different surgical options available depending on the extent and pattern of damage that you have in you knee.

It must be noted that any surgery to address severe OA or degenerative pathology is a significant undertaking and should be treated with the appropriate respect to the risks, benefits and complications.

Surgery can only be offered once both the patient and surgeon are happy with the assessment, diagnosis and the surgical plan, and appropriate consent in place.

There are a wide variety of surgeries which may be considered, depending on a range of factors. Broadly, these can be split into: Joint preserving and joint replacement surgeries. 

What are the different types of joint preserving surgeries?

  • Osteotomy Surgery
  • Cartilage regeneration surgery
  • Stem cells and bio-scaffold surgery
  • ACI – Autologous Chondrocyte Implantation
  • Osteochondral Allograft Transplant
  • Focal resurfacing

What is Osteotomy Surgery (Limb re-alignment surgery)?

Knee osteoarthritis can develop due to underlying problems with leg alignment. There are 3 different types of leg alignment: 

  • Varus (bow legged)
  • Neutral (straight)
  • Valgus (knock kneed)          

In varus and valgus knees, the body weight and forces are acting excessively in one compartment or the other. In varus knees, the forces pass through the medial compartment and in valgus knees, the forces pass through the lateral compartment.

This leads to excessive wear and damage to cartilage in one part of the knee joint only, meaning that the rest of the joint remains relatively spared.

Osteotomy surgery aims to realign the leg and offload the forces from the arthritic part of the joint to the healthy part of the knee joint.

This means that knee replacement surgery can be avoided for a significant period of time and the native knee joint preserved.

 This is a particularly beneficial solution for younger patients with knee OA and once the alignment is corrected, the progression of osteoarthritis can be avoided in some cases.

High Tibial Osteotomy

This is the commonest osteotomy operation performed, usually for varus knees with medial compartment OA.

Once the angles and the correction have been calculated, an incision is made over the top end of the shin bone (tibia) and the bone exposed. An incision is then made in the bone from the medial side of the tibia towards the lateral cortex of the bone. Care is taken to preserve the lateral cortex and the osteotomy site is gently opened which gradually corrects the axis of the bone to the desired point.

This is then carefully held in position and a strong plate applied to hold the bone in place.

This results in the body weight forces passing through the healthy part of the knee joint and therefore eliminating the pain.


Distal Femoral Osteotomy

This is less commonly performed and is usually for valgus knees with OA in the lateral compartment.

After careful planning, an incision is made on either the inside of the thigh or the outside of the thigh, just above the knee. The distal end of the femur is exposed, and an incision made in the bone. The desired correction is achieved, and a strong plate applied to hold the correction in place.

This results in the body weight forces passing through the healthy part of the knee joint and therefore eliminating the pain.

What is Cartilage regeneration surgery?

This is a very interesting and complex  area in knee surgery. Cartilage is a highly organised and  structurally beautiful tissue; able to withstand significant forces over a long period of time. (See blog on cartilage for more details).

 Unfortunately, the cartilage can be damaged from trauma or other pathologies like Osteochondritis Dissecans (OCD); this results in a painful lesion which if left untreated can progress to early joint degeneration and osteoarthritis. 

The lesions can be either “Chondral” (cartilage only defect)  or “Osteochondral” (cartilage plus some underlying bone).

 Thanks to advances in biological regenerative treatments and bio materials, we now have the ability to treat these defects effectively. Techniques used for cartilage regeration include:

  • Stem cells and bio-scaffold surgery
  • ACI – Autologous Chondrocyte Implantation
  • Osteochondral Allograft Transplant
  • Focal resurfacing

What is Stem Cell and bio-scaffold surgery and when is it used?

This approach is ideal for isolated small to medium sized lesions in the knee.

The lesion is assessed using a camera (arthroscopy) and if possible the operation is carried out using key hole surgery. If the lesion is inaccessible then the knee may be opened via a mini incision.

The area is prepared and a combination of stem cells and Hyaluronic acid based tissue allograft  is placed into the defect.

Stem cells – These cells are harvested from the bone marrow of the femur via the knee joint. They are known as BMdSC – Bone Marrow derived Stem Cells. These are high quality cells that have the potential to differentiate into any type of cell line. They are isolated via process called centrifugation.

Bio-Scaffolds – These are a type of synthetic bio compatible tissue that is used to repair the cartilage defect. The bio scaffold tissue is prepared and soaked in the stem cells and placed into the defect and sealed in place.

Over a period of 6-18 months the cells slowly turn into chondrocytes (cartilage cells) that produce healthy matrix and “Hyaline-like” cartilage. 

This eliminates the pain and stops the progression of the defect and therefore early joint degeneration.

What is Autologous Chondrocyte Implantation (ACI)?

ACI is seen as the gold standard for cartilage regeneration surgical treatment.

There are 2 steps to the procedure:

  • Step 1: Surgery is carried out to assess the lesion and harvest cartilage from the periphery of the knee. This allows the patient’s own chondrocytes to be isolated . The cells are sent to the lab, where the cells are expanded and turned into a cartilage transplant graft. This step takes around 8-12 weeks.
  • Step 2: Once the cartilage graft is ready, it is implanted into the knee in the desired area and fixed into place and sealed.

This is a great treatment as it produces true hyaline cartilage from the patient’s own cells, which is the ideal situation.

What is a Osteochondral Allograft Transplant?

This operation utilises donor tissue from the knee joint. The patient is assessed with a CT +/- MRI scan and the dimensions of the knee joint and the defect are measured.

An exact match donor is found and the tissue brought to theatre. The donor tissue is cleaned and any host cells removed to eliminate any compatibility issues.

The area of damaged cartilage is prepared and the donor cartilage and bone is cut using specialised equipment and the allograft is placed into the patient’s knee.

What is Focal resurfacing?

This procedure is utilised if other attempts at cartilage regeneration have failed or the lesion is too big to treat with the other methods.

This is essentially a mini arthroplasty procedure where a small part of the diseased joint is replaced with an implant.

Instead of cartilage, the damaged area is replaced with a polyethylene coated implant and fixed into the bone. This provides good coverage of the damaged area and allows the patient to weight bear without pain. 

As it is an arthroplasty procedure, it will eventually become loose and will require revision. The short to medium term results are good.


What are the types of Joint Replacement surgery?

In some cases where joint preservation techniques are inappropriate, joint replacement surgery may be required. The four types of joint replacement surgery are:

  • Partial knee replacement
  • Total knee replacement
  • Joint preservation surgery (Osteotomy surgery , Cartilage regeneration Surgery)
  • New – MAKO Robot Assisted Knee replacement surgery (Partial or Total)

For more information on joint replacement surgery, please see the 'Joint Replacement Surgery' treatment page.

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