Other Treatment Options

Other Options:

Activity Reduction

The main thing with arthritis pain is to try to work within your limits and accept some lifestyle changes. By the time you need a knee replacement, you will certainly not be able to manage labouring work and you will not be able to run and your surgeon will tell you that you should not attempt to return to such activities after a knee replacement.

Weight Reduction

An important lifestyle change, both for coping with arthritis and to be kind to your knee replacement. Unfortunately, by the time you have arthritis, it is very hard to exercise enough to burn off a lot of calories. That means having to eat less. There are many diets out there, but cutting out carbohydrates, and especially sugar does work. You should obtain expert advice, either from a dietitian or your GP, or at least from an authoritative book, to make sure any diet is appropriate for you and your general health.

If all else fails, and for those whose obesity is a hazard to their health, you should discuss with your doctor about being referred to a bariatric surgery unit. That doesn't automatically mean that you would have the surgery, as they would first make sure that other options had indeed been exhausted, and that it was the best option for you, and you could then decide.

Pain Relief

The mainstays of pain relief are simple analgesics and by anti-inflammatories. Ordinary paracetamol with or without some codeine is the baseline for short periods of pain relief as required. Nurofen Plus has a low dose anti-inflammatory together with codeine, and can used instead or in addition. But if you have been prescribed anti-inflammatories (also known as NSAID's: Non-Steroidal Anti-Inflammatory Drugs) then it it not safe to take over-the-counter anti-inflammatories as well.

There are also many herbal and other alternative remedies on offer that may help some people, but that is beyond the scope of this discussion. However, two popular options are glucosamine and chondroitin sulphate (shark cartilage). These substances theoretically may be building blocks that assist in the body’s attempt to repair the wear and tear process. As such, they would need to be taken long term. Not that they could actually heal the arthritis, but hopefully the process could be slowed down a bit, and feel a bit better in the meantime. Most people would also want to feel some relief of pain within the first one to three months to justify the costs of continuing with such treatment.

Fish oil is also an effective anti-inflammatory, especially in larger doses, such as 10-15ml of liquid a day, or about 5 capsules twice a day (which is more palatable but more expensive). There are plenty of other options, like green-lipped mussel extract for example, and fads that become popular from time to time. Your pharmacist may offer some advice, and doctors may have their own views, but when there is no sound scientific support, it is up to the individual whether any of these remedies is felt to be of any benefit.

Physiotherapy

This can help settle pain when it is temporarily worse, improve the stiffness that develops with arthritis and provide advice on maintenance of flexibility and good muscletone, and sensible activity and light exercise.

Sometimes a simple knee support can be helpful for those times when you have to spend some time on your feet, but not at rest as it may restrict circulation. It is trial and error to find one that is both comfortable and supportive for your knee. Your physiotherapist can help make a suitable choice.

Many people ask if magnets are of any use. This another one of those things with no scientific proof or logic, which is up to the individual. Many swear by their magnets, and many find them useless.

A walking stick maybe an insult to your dignity but can take some of the load off a painful knee. A physiotherapist can show you the correct way to use a walking stick in the opposite hand. Even if you don’t use it regularly, it would still be useful for those occasions that you are out and on your feet for sometime.

Joint Lubricant

People with arthritis often wish we had a grease gun we could use on their knee. Something approaching that has been available for a number of years in the form of injections of “joint lubricant”. Hyaluran is a huge molecule that occurs in the joint fluid and in the articular cartilage (“gristle lining”) on the surface of the bone. Whether it works as a lubricant or by helping the body’s attempt to repair the arthritis or simply by improving the pain is unclear. In fact, it is rather unpredictable in its effect for each individual and experience suggests that about one person in five thinks it is great, two in five think it helps a bit and two in five find that it doesn’t really help at all. If it does work, it should last about 6 – 8 months, and can be repeated indefinitely if need be. The product costs $450 for a single injection (or previously a course of three), for which there is no rebate from your health fund or Medicare.

Cartilage Cell Graft

Another relatively new treatment, which is quite revolutionary, is to graft cultured chondrocytes (cartilage cell graft) into the knee. Unfortunately, at least until now, this is only suitable for a select few individuals with localised areas of joint surface damage and is not suitable for treatment of arthritis, or for older individuals with less repair potential. But who knows what the future may hold. There is a lot of research being done.

Unicompartmental Knee Replacement

There has been a lot of media hype about minimally invasive partial knee replacement (also referred to as a Unicompartmental Knee Replacement, or UKR). This is an excellent option for those people whose arthritis is basically localised to one of the three knee compartments (medial, lateral, patello-femoral). The pain and hospital stay are much less, (but I would not recommend day surgery!) and the overall recovery much quicker, and the final result much better. Often the knee can feel virtually normal again.

With regard to the media hype from a few years ago, this amounted to a rediscovery and popularisation of an operation that some knee surgeons have been doing successfully for many years. The pendulum has swung back to since then with everyone rediscovering the limitations of what can be expected. Inevitably, as more and more were done in the last decade or so, some found that the results weren’t as good as hoped in a fair percentage of people, and so we are now seeing a swing back to the more conservative but more invasive total knee replacement (TKR).

The operation itself is more technically demanding to get exactly right than a total knee replacement. Also it is not possible to predict for certain that arthritis will not progress in the other compartments. If there is already significant wear in the other parts of the knee, a TKR would be more reliable. Even with carefully selecting who should have a partial knee replacement, perhaps 5 – 10% will suffer significant breakdown of other parts of the knee within five years or so. That may then require conversion to a Total Knee, or sometimes a further partial knee replacement can work very well.

Some surgeons have a philosophy that it is acceptable to do a partial knee replacement that might break down in five to ten years, as a temporary solution. The alternative philosophy is that a partial knee replacement should only be done when it can be expected to be a long term or permanent solution, and this requires a different approach to selecting a proven prosthesis and getting the technical aspects exactly right, as well as making sure that you are the right person, with the right kind of arthritis for that operation. Many knee surgeons have excellent records of success with partial knee replacement by using good judgement to select those who would best benefit, and then getting the operation technically correct, and in those circumstances, it is an excellent option, often with outstandingly good results that can last as long as a TKR.

Osteotomy

For those individuals who have arthritis predominantly in one compartment of their knee, particularly the medial compartment, and especially those who are still too young or too active for a knee replacement (partial or total), a good option is an osteotomy to cut and reset the bone adjacent to the knee, to realign the whole lower limb. This works by unloading the worn compartment and transferring the load into the other compartment. The results are not as good, or as long lasting, as successful knee replacement surgery, but this is a good way of getting back some quality of life and controlling the pain, so that a knee replacement can be postponed to a more suitable and less active age. Generally therefore, this is an operation for younger people, and especially when just the medial compartment has become very worn and painful, and is no longer manageable with medication and sensible limitation of activity. It would unusual for someone over the age of 60 to be considered for an osteotomy, as a partial or total knee replacement would give a better result and last longer, possibly for the rest of their lives. On the other hand, it is well proven in the statistics coming out of national joint registries that the younger the age at which a knee replacement is done, the higher the risk of early failure and need for revision surgery. This is particularly true for partial knee replacements, and so it is particularly for the younger, more active people with just one worn out compartment that a High Tibial Osteotomy (HTO), or a lower femoral osteotomy,  is appropriate, rather than a partial knee replacement.

Every person with knee arthritis needs to be thoroughly individually assessed and have all reasonable options discussed before a decision is agreed between them and their surgeon regarding the best solution for their particular situation.