Osteoarthritis of the Knee (Knee Arthritis): "Degenerative Joint Disease" can cause pain, stiffness, and cartilage breakdown.

Figure 1 - The incision used for minimally-invasive quadriceps-sparing total knee replacement is much smaller than the one used for traditional knee replacement, and in the less-invasive procedure, the important quadriceps muscle and tendon are not disrupted as in traditional knee replacement. LifeART image ©2004 Lippincott Williams & Wilkins. All rights reserved.

Figure 2 - The skin incision for minimally-invasive quadriceps-sparing total knee replacement is typically about 4? in length, compared to about 8? or more for traditional total knee replacements.

Figure 3 - X-ray of a traditional total knee replacement. This operation is done for patients who have arthritis throughout the knee. Excellent long-term results are obtained in most patients.

Figure 4 - Model of a traditional total knee replacement. The patella (knee cap) is not shown in this model.

Management and treatment

Treatment

Simple steps that can be taken, which don’t have much risk, include avoidance of the activities that cause symptoms (activity modification) and weight loss (if appropriate). Some patients find nutritional supplements such as glucosamine and chondroitin to be helpful; however, the data on these products is somewhat inconsistent. They don’t help everyone.

Some patterns of osteoarthritis of the knee can be treated with an arthritis brace, such as a knee sleeve or an “Unloader” type brace.

Should those interventions not be satisfying, in consultation with one’s physician, the next steps might include over-the-counter pain remedies such as acetaminophen (Tylenol) and over-the-counter anti-inflammatories such as ibuprofen (Advil, Motrin) or naproxen (Naprosyn), among others. However, these pills are not for everyone, and if one hasn’t used them before, one should consider consulting one’s family physician first. Sometimes, prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs) can be prescribed, but again, this must be done in consultation with a physician, and these drugs do have risks and side effects associated with them.

In general, narcotic pills (“painkillers” like Tylenol #3, Vicoden, Percocet, oxycodone) and narcotic pain patches (fentanyl, Duragesic) should be avoided for most patients with osteoarthritis of the knee.

Joint injections, including intra-articular corticosteroid injections and “viscosupplement” injections like Synvisc, Hyalgan, Supartz and others can be helpful for some patients.

Patients with severe arthritis who have tried the above remedies sometimes can benefit from joint replacement surgery, either partial (unicompartmental) knee replacement or total knee replacement, which now can be done using a minimally-invasive quadriceps-sparing approach that can significantly shorten the recovery and decrease the pain following surgery.

Self-management

Health care team

Several kinds of health care providers participate in the management of osteoarthritis of the knee, including:

1. Family physicians and internists
2. Rheumatologists
3. Physical Medicine and Rehabilitation Specialists (Physiatrists)
4. OrthopedicSurgeons

Pain and fatigue

Several approaches can be used to manage the pain associated with osteoarthritis of the knee, including:

1. Activity modification, appropriate kinds of exercise, and weight loss when necessary may alleviate some knee arthritis symptoms
2. Nutritional supplementation (glucosamine and chondroitin) are helpful to some patients, although the literature on these supplements is not consistently in favor of their use
3. Non-narcotic pain tablets (acetaminophen/Tylenol) or over-the-counter non-steroidal anti-inflammatory drugs, if medically appropriate, sometimes are helpful
4. Prescription strength non-steroidal anti-inflammatory drugs (NSAID) are useful for some patients, though in general, long-term use of these drugs is discouraged
5. Arthritis unloader braces or knee sleeves are helpful for some patterns of arthritis
6. Joint injections (corticosteroid or “cortisone” injections; or “viscosupplement” injections such as Hyalgan, Synvisc, Orthovisc, or Supartz) might help
7. Total knee replacement surgery may be used if non-operative interventions don’t suffice; a minimally-invasive quadriceps-sparing approach can decrease the post-operative pain and length of convalescence in some patients undergoing this procedure.

Diet

Exercise and therapy

Medications

1. Nutritional supplementation (glucosamine and chondroitin) are helpful to some patients, although the literature on these supplements is not consistently in favor of their use
2. Non-narcotic pain tablets (acetaminophen/Tylenol) or over-the-counter non-steroidal anti-inflammatory drugs, if medically appropriate, sometimes are helpful
3. Prescription strength non-steroidal anti-inflammatory drugs (NSAID) are useful for some patients, though in general, long-term use of these drugs is discouraged
4. Joint injections (corticosteroid or “cortisone” injections; or “viscosupplement” injections such as Hyalgan, Synvisc, Orthovisc, or Supartz) might help

Surgery

Knee replacement is a surgical procedure that decreases pain and improves the quality of life in many patients with severe arthritis of the knees. Typically, patients undergo this surgery after non-operative treatments (such as activity modification, anti-inflammatory medications, or knee joint injections) have failed to provide relief of arthritic symptoms. Surgeons have performed knee replacements for over three decades, generally with excellent results; most reports have ten-year success rates in excess of 90 percent.

Broadly speaking, there are two types ways to insert a total knee replacement: the traditional approach, and the newer minimally-invasive (sometimes called quadriceps-sparing) approach.

Traditional total knee replacement involves a roughly 8” incision over the knee, a hospital stay of 3-5 days, and sometimes an additional stay in an inpatient rehabilitation setting before going home. The recovery period(during which the patient walks with a walker or cane) typically lasting from one to three months. The large majority of patients report substantial or complete relief of their arthritic symptoms once they have recovered from a total knee replacement.

Minimally-invasive quadriceps-sparing total knee replacement is a new surgical technique that allows surgeons to insert the same time-tested, reliable knee replacement implants through a shorter incision using surgical approach that avoids trauma to the quadriceps muscle (see figure 1), which is the most important muscle group around the knee. This new technique, which is sometimes called quadriceps-sparing knee replacement uses an incision that is typically only 3-4” in length (see figure 2), and the recovery time is much quicker – often permitting patients to walk with a cane within a couple of weeks of surgery or even earlier. The less-traumatic nature of the surgical approach also may decrease post-operative pain and diminish the need for rehab and therapy compared to more traditional approaches.

The main potential benefits of this new technique include:

More rapid return of knee function. Patients who undergo this procedure seem to get muscle strength and control back more quickly than patients who have had traditional total knee replacement. (See Video) This is because the quadriceps muscle and tendon are not divided in the course of the surgical exposure like in traditional knee replacement, and the kneecap is not everted (flipped out of the way) as it is in traditional total knee replacement.

Smaller incision. While this procedure would not be worth performing for cosmetic benefits, many patients do prefer the shorter incision. Traditional knee replacement incisions often measure 8” or longer; minimally-invasive quadriceps-sparing knee replacement incisions are about 4” in length for most patients.

Decreased post-operative pain. (See Video)This may be a function of the smaller incision and the fact that the incision stays out of the important quadriceps muscle/tendon group.

Same reliable surgical implants as Traditional Knee Replacement. Much has been learned about implant design in the nearly 40-year history of contemporary knee replacement. Minimally-invasive quadriceps-sparing total knee replacement is an evolution of surgical technique, which permits the use of time-tested implant designs (see figure 3 and figure 4). This gives some reassurance that while the surgical approach is new, the implants themselves have a good proven track record.

The major apparent risks of the procedure compared to traditional total knee replacement:

The procedure is new. Though surgeons have studied the approach, the studies are recent and have replicated (repeated and verified) by only a few groups of surgeon-scientists. These studies give some insight into which patients and patterns of arthritis are most suitable for this procedure, the relative novelty of the approach it is likely that as time passes we will discover more about the risks and shortcomings of this technique. Also, even an experienced knee replacement surgeon will have performed many more surgeries through the traditional approach than through the less-invasive method; we know that the more procedures one does, the more reliable the results are.

Joint aspiration

Joint injections can be effective at relieving the symptoms associated with osteoarthritis of the knee. Broadly speaking, there are two kinds of injections:

1. Corticosteroid injections (“cortisone shots”).These injections have been used to relieve arthritis symptoms--including pain, swelling, and inflammation--for over 50 years. Despite this, there have been surprisingly few well-designed scientific studies to determine which patients might benefit from this treatment, or how long the relief might last.

Just the same, cortisone shots are commonly used--and often are successful--in helping to relieve arthritis symptoms temporarily. Some patients are able to use them to get enough pain relief to hold off joint replacement surgery for months or even years. Cortisone shots are a treatment for pain; they do not alter the course of arthritis, and they do not cure the condition.

()

Splints or braces

1. Over-the-counter knee sleeves, usually made of neoprene (wet suit material). These can be purchased at drug stores and medical supply houses, and some patients find them to be supportive and comfortable.
   
2. Arthritis “Unloader” braces. These are custom-fitted to the knee by a bracing specialist (an orthotist) and a prescription is needed. They are not for every pattern of arthritis, and work best if the arthritis is limited either to the inside or the outside of the knee. They can be expensive; insurance sometimes covers part or all of the cost.

Alternative remedies

Nutritional supplementation (glucosamine and chondroitin are the most common forms of this) is helpful to some patients, though the science on this is not entirely supportive of their effectiveness.

Surgery for Knee Arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

How useful was this page or article? This article is rated out of 5 stars (137 ratings). Not useful at all Not very useful Useful Very useful Extremely useful