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  • Arthritis & Knee Replacement

    General Information

    General Information

    When people talk to Yorkshire Knee Clinic’s orthopaedic consultants about knee arthritis they are usually referring to osteoarthritis or “wear and tear” damage to the knee. Arthritis of the knee is also a term used for some inflammatory diseases of the joint which can also cause knee pain and a similar end result. One example of this type of arthritis is rheumatoid arthritis.

    Knee osteoarthritis is caused by damage to or the wearing down of the articular cartilage (joint surface) in any part of the knee joint. This results in bone grinding on bone in the knee, which is a painful and disabling condition.

    Knee osteoarthritis can affect any of the three main parts of the knee (the medial compartment, the lateral compartment, and the patello-femoral joint – ‘knee cap’), and the condition can affect one or more parts of the knee at any one time. The medial (inner) compartment is the commonest site for knee arthritis affecting a single compartment.

    You may find knee osteoarthritis arises as the result of a cartilage injury (it is well known that having a torn cartilage does increase the risk of developing knee osteoarthritis later in life), but it can also occur without any history of injury or damage to the knee.

    Symptoms of knee osteoarthritis

    Most of the patients who approach Yorkshire Knee clinic’s knee consultants about their osteoarthritis will experience knee pain to varying degrees. You might feel a relatively mild background ache in the knee which might interfere, for example, with sporting activities or a long walk. At the other end of the spectrum, you might experience constant severe disabling pain which makes walking very difficult or impossible.

    You may find it difficult to perform the normal activities of daily living because of arthritis of the knee, and the condition can be sufficiently severe to affect your sleep. You may continue to feel pain even when you are at rest.

    Sometimes, because of the roughening of the knee joint surface, you may feel catching, clicking, clunking or similar symptoms as well as pain. In more severe cases of knee osteoarthritis these are less significant than the underlying pain.

    Additionally, you may well see your knee joint swelling.

    Diagnosis of knee osteoarthritis

    Yorkshire Knee Clinic’s knee specialists can diagnosis osteoarthritis from the typical symptoms of this condition along with examination.

    If you have suspected knee osteoarthritis, our orthopaedic consultants will usually take an x-ray of the knee to confirm the diagnosis.

    Arthritis of the Knee

    Treatment of knee osteoarthritis

    If you have osteoarthritis of the knee you may well have undertaken some form of treatment before coming to see a knee surgeon at Yorkshire Knee Clinic. Perhaps you have tried simple pain killers, anti-inflammatory tablets, injections of cortisone or other substances. You may have already have had advice about weight loss or modifying your activities. You may also have discussed the range of treatments associated with physiotherapy including advice about using a walking stick etc.

    If our knee consultants suspect you have an early degree of knee arthritis and/or you are relatively young, it may be appropriate to have keyhole surgery (an arthroscopy). This will improve some of the mechanical symptoms (the clicking and catching), give some temporary relief by washing out the irritating debris within the knee, and define the exact problem with a view to later major surgery. However, knee arthroscopy treatment cannot reverse the damage or cure knee osteoarthritis itself.

    Eventually you and your Yorkshire Knee clinic knee surgeon may decide that the pain has reached the point where the only option is knee arthroplasty. Knee arthroplasty is a general term for knee replacement. Your knee replacement could be total or partial (unicompartmental).

    Total Knee Replacement

    Total Knee Replacement

    Total knee replacement surgery involves resurfacing the worn out parts of the knee using a metal component on the end of the femur and the top of the tibia, with a plastic bearing in between. Some knee surgeons also put a plastic component on the back of the kneecap. Replacement knee surgery relieves pain by removing the source of the pain – which is the bone grinding on bone; the knee lining is effectively resurfaced.

    Total Knee Replacement

    A total knee replacement operation usually takes place under a general or spinal anaesthetic. The final decision about this is down to the anaesthetist.

    Your knee surgeon will make an incision down the front of the knee. Total knee replacement surgery itself takes approximately one hour.

    When you wake up you will find that there is a firm bandage around your knee and sometimes we apply a light splint for comfort.

    Depending upon the anaesthetist, you may have had injections into the nerves which supply feeling to the lower leg. This is called a regional nerve block and the aim is to achieve some post operative pain relief.

    There may also be one or two small tubes coming out through the skin in the thigh. These are called drains. The aim of a drain is to remove some of the blood which unavoidably collects within the knee after surgery. During total knee replacement surgery there is little or no bleeding because most operations for knee replacement are done with a tourniquet applied to the upper thigh.

    Your knee surgeon will usually advise you to begin rehabilitation and physiotherapy the day after your total knee replacement surgery.

    > FIND OUT MORE ABOUT PHYSIOTHERAPY WITH YORKSHIRE KNEE CLINIC

    For a total knee replacement, your stay in hospital is likely to be 3-4 days. If you have had removable stitches or metal skin clips put into the skin these will be removed approximately 10 and 12 days after total knee replacement surgery. If you have had dissolving stitches put in the skin, you won’t need them removing as they will dissolve over time.

    You will need to continue physiotherapy following your total knee replacement on an outpatient basis until you have made an appropriate recovery. Your knee surgeon will give you a check up appointment 6 to 8 weeks after your surgery.

    One of the things to remember about total knee replacement is that, although the most rapid recovery takes place over the first weeks, it can take up to six months to make a full recovery.

    Click below to watch the case study video

    Mobile bearing knee replacement

    In total knee replacement or unicompartmental knee replacement, the plastic bearing which sits between the two metal components may be fixed (a fixed bearing knee replacement) or mobile. A mobile bearing total knee replacement means that the plastic is not fixed rigidly to the tibial component, and can move around in a number of planes. Depending on the actual implant used this movement may take place backwards and forwards, sideways, rotation or a combination.

    The benefits of these types of implants are still theoretical and laboratory based, but the idea is that there may be a reduction in the wear of the plastic and therefore the long term loosening. There are also some claims that function and range of movement of the knee may be improved. There is no solid evidence for this yet.

    Minimally invasive knee replacement (MIS)

    Minimally invasive surgery has evolved rapidly over the last few years with some excellent advances and some problems globally. The most extreme MIS techniques (involving very small incisions with modified surgical instruments and implants) have not been performed by YKC surgeons and have largely been discontinued due to complications.

    Surgeons from the Yorkshire Knee Clinic have been involved in the assessment of more rational MIS knee replacement surgery and a randomised controlled trial of MIS vs. standard knee replacement surgery performed in Harrogate was published in 2012 (‘The Knee’) which demonstrated the potential for a reduced length of stay in the MIS patients with no evidence of increased problems.

    Our knee surgeons use the smallest incision which allows safe and satisfactory implantation of the knee replacement. The combination of this approach, rapid mobilisation and improved pain control has led to excellent patient outcomes following both partial and total knee replacement.

    Benefits and risks of knee replacement

    Severe pain is the main reason for having a knee replacement. If you are suffering associated problems such as deformity of the knee because of the arthritis (e.g. bow legs) and reduction in function, you should see an improvement in these following knee replacement but these in themselves are not a reason for having the operation.

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection
    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis
    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage
    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness
    Sometimes, despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your knee surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening (amongst other things). Occasionally, this can occur in the first few years.

    Partial knee replacement

    Partial Knee Replacement

    If your knee arthritis affects only one of the three major compartments of the knee you may be suitable for a unicompartmental (sometimes called a half knee) replacement. The most usual site for this is the medial (inner) compartment of the knee.

    Partial Knee Replacement

    Approximately 25% of patients with established knee arthritis may be suitable for a medial unicompartmental replacement. There are some theoretical and actual benefits of this procedure: the incision is smaller, you will typically spend less time in hospital and your speed of rehabilitation should be quicker with lower overall risks of complications like infection. Patients who have had a medial unicompartmental knee replacement often report their knee feels more ‘normal’ than those with total knee replacements.

    There is some evidence that the long-term survival of a unicompartmental knee replacement is slightly shorter than that of a total knee replacement, however the potential benefits can outweigh this risk. A Yorkshire Knee Clinic study of patient-reported outcomes (assessing the functional results of knee surgery) has demonstrated better function in patients with unicompartmental knee replacements.

    Benefits and risks of knee replacement

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options including bracing, osteotomy (re-alignment) or the new offloading device (KineSpring).

    If your knee arthritis has resulted in associated problems such as deformity of the knee (e.g. bow legs) or a reduction in function, these will improve following knee replacement – but in themselves are not a reason for having the operation.

    Please watch the case study video below

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection
    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis
    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage
    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness
    Sometimes despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your knee surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening amongst other things. Occasionally, this can occur in the first few years.

    Patello-femoral (Knee Cap) Resurfacing

    Knee Cap Resurfacing

    If your arthritis affects only the joint between the knee cap and femur (the patello-femoral joint) it may be suitable for patello-femoral resurfacing. In patello-femoral resurfacing, your Yorkshire Knee Clinic knee surgeon places a plastic component on the back of the knee cap and a metal component on the front of the femur leaving the main knee joint between the tibia and the femur alone. Patello-femoral resurfacing is a relatively new technique compared to total knee replacement, but is successful in patients who have a certain type of osteoarthritis. Your knee surgeon may discuss this with you.

    Benefits and risks of knee replacement

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options including bracing, osteotomy (re-alignment) or the new offloading device (KineSpring). Associated problems such as deformity of the knee because of the arthritis (e.g. bow legs) and reduction in function, will improve following knee replacement but in themselves are not a reason for having the operation.

    Please watch the case study video below

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection
    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis
    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage
    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness
    Sometimes despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your orthopaedic surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening amongst other things. Occasionally, you may find this occurs in the first few years.

    Customised Knee Replacement Surgery

    Customised Knee Replacement Surgery

    Patient specific instrumentation, computer navigation and robot-assisted surgery.

    Our knee surgeons are constantly evaluating the potential benefits of new techniques designed to assist knee surgeons more accurately position the components of knee replacements. Computer-navigated (assisted) surgery has been used for complex cases for some years but its value in routine cases is less proven.

    Special instruments personalised to the individual patient (based on MRI or CT scans) are now available. The potential benefits of these are to improve the accuracy of bony cuts (required for positioning the implants) in an attempt to improve the alignment and rotational position of knee replacements. Long-term benefits could be seen in terms of both function and life expectancy of the knee replacements but there is no firm evidence for this.

    These customised instruments (which take 4-5 weeks to manufacture) are now routinely available to assist knee replacement surgery. Similar personalised instruments have now been created to assist unicompartmental knee replacement with encouraging early results.

    Yorkshire Knee Clinic’s orthopaedic consultants continue to monitor advances in robot-assisted surgery and custom-made implants but so far their clinical- and cost-effectiveness remain uncertain.

    Joint Offloading Treatments

    Joint Offloading Treatments

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options, where various techniques and tools transfer the load on the worn side of the knee to the other.

    Simple knee ‘offloader’ braces have often proved effective, but users tend to abandon them in the long term or use them occasionally. High tibial osteotomy offers a more permanent offloading treatment although it also permanently alters the anatomy of the leg. This can potentially affect the outcome of future treatment options, especially knee replacement.

    High tibial osteotomy

    High Tibial Osteotomy

    High tibial osteotomy (HTO) involves cutting the tibia just below the knee joint to realign it. In cases of osteoarthritis affecting only part of the knee, and especially in relation to relatively young and active patients, your Yorkshire Knee Clinic knee surgeon may consider this process.

    The surgery works by taking the weight off the worn out side of the knee and transferring it to the healthy side of the knee. Once you have fully recovered you should be able to recommence whatever activities you wish as long as you understand that the arthritic part of the knee can still deteriorate.

    Only a small proportion of patients with knee arthritis are suitable for this treatment, and the success of partial knee replacement has reduced the use of (and need for) the technique. HTO pain relief is not as reliable as with a knee replacement, but in appropriately selected patients there may be a 75% chance of a good result (i.e. the pain being better than it was before surgery) at 10 years from surgery.

    HTO does, however, have an important role in the treatment of some patients with knee instability following complex ligament injuries.

    KineSpring Load Absorber

    KineSpring Load Absorber

    In an attempt to deliver the effectiveness of bracing and HTO (see above) without some of the disadvantages, Yorkshire Knee Clinic’s Nick London has been one of the knee surgeons evaluating a new device, developed and tested in clinical trials over the last few years. After initial encouraging results in Australia and the European COAST trial, the treatment is now available to private and NHS patients. If you have wear on the inner side (medial) of the knee that affect your activities, you may be considered for this device, which can help:

    • 1. Reduce pain/discomfort with activities
    • 2. Increase activity levels
    • 3. Delay knee replacement surgery

    It is important to know that although early results are encouraging in the majority of patients, this new technology is still under evaluation and not all patients are suitable.

    You can find further information from http://www.moximed.com

    (Nick London holds a consultancy agreement with Moximed for development and surgeon-training.)

    Talk to us about your knee pain. Contact Yorkshire Knee Clinic now.