Surgical Alternatives to Total Knee Replacement

Jonathan Hersch, M.D. { Orthopaedic Associates USA }

Osteoarthritis (OA) is a progressive, degenerative disease in which the cartilage of the knee joint slowly wears away. Cartilage serves as a cushion between the bones of the joint to allow smooth motion. When the cartilage wears away due to OA, the result can be severe debilitating pain.

The good news is that the majority of people with knee arthritis can be successfully treated without surgery by

• Activity Modification
• Weight Loss
• Eexercise
• Medications

Only about 25% of people with knee OA will eventually need surgery. Unfortunately there is no real "cure" for OA, so operations have been developed to alleviate the pain by replacing the missing cartilage with some other material that serves the same function as the cartilage. A total knee replacement involves replacing the entire surface of the knee with a metal and plastic prosthesis. The results of a total knee replacement are excellent with a >10 year success rate of about 90%. Eventually, however, a prosthesis may loosen or wear out so that a second surgery is needed. In many patients, only a portion of the knee is arthritic and other options are available.

Surgical alternatives include:

• Arthroscopic surgery
• Cartilage Grafting
• Osteotomy
• Partial knee replacement

Arthroscopy

Arthroscopy is a surgical procedure that uses small incisions and a tiny camera to look inside the knee. Cartilage damage can easily be seen throughout the knee. In the early stages of arthritis, small flaps of cartilage can break loose and cause catching and locking of the knee. This cartilage can be cleaned out through the scope, thereby relieving symptoms. Also, many patients with knee OA develop loose bodies of cartilage that float around the knee. These can be removed as well.

Cartilage Grafting

Some knees have limited or contained cartilage loss from trauma or early arthritis that can be treated by replacing the cartilage loss. This can be done in various ways depending on the size of the area. Arthroscopy can be used to take plugs of cartilage form one area of the knee and place it into the cartilage defect. This procedure is similar to a hair transplant. The plugs will fill the area and can relieve the pain. When there are greater areas of cartilage loss, samples of a patient's cartilage are drawn through an arthroscope and grown in a lab. Later, these newly grown cells are re-implanted into the knee and will cause new cartilage to grow in the patient's knee. This relatively new technology has shown great success in preserving the knee joints of thousands of patients.

Osteotomy

An osteotomy may be recommended if damage to the knee cartilage is primarily in one section of the knee. This procedure involves reshaping the bones to improve knee alignment. The surgeon repositions the joint to move the axis of weight bearing for the limb away from the damaged area. An osteotomy can restore function and diminish pain. New research indicates it may even stimulate the growth of new cartilage. Many people who have an osteotomy may still eventually need a total knee replacement; however, for these patients, this procedure often grants the patient more time before a knee replacement is necessary. This may ensure that the eventual replacement lasts a lifetime. Often, an osteotomy will be performed in conjunction with a cartilage grafting procedure.

Partial Knee Replacement

If your arthritis is limited to one side of the joint, your surgeon may recommend a partial knee replacement. This can be performed through much smaller incisions resulting in less trauma to the knee then occurs with a total knee replacement. Recovery time is much quicker and patients are generally out of the hospital within 48 hours.

The choice of treatment for knee arthritis should be a joint decision between the patient and the surgeon. The purpose of treatment is to reduce pain, increase function, and improve overall quality of life. With a total knee replacement, all of these goals can be achieved with >90% success. However, for some patients, a less invasive option may exist. Each patient's treatment should be individualized to decide which options are right for that patient.

With all the advancements in orthopaedic medicine, the arthritic knee doesn't have to limit your enjoyment of life.