#condition

Arthritis

When people talk about arthritis, they are normally referring to osteoarthritis.
Osteoarthritis is ‘primary’ when it occurs gradually with age due to wear and tear, and there is a strong genetic component to this, with arthritis often running in families. The most commonly affected joints for osteoarthritis are the knees, the hips and the finger/thumb joints.
If osteoarthritis develops secondary to other previous specific damage to the joint, such as fractures, meniscal tears or ligament tears, then this is termed ‘secondary osteoarthritis’.
Rheumatoid arthritis is completely different. This is much less common and it is a systemic auto-immune type disease where the synovial lining of the knee becomes inflamed, which then causes secondary damage in the joint.
The main symptoms that can arise from an osteoarthritic knee are pain, swelling and stiffness, particularly with attempts at any kind of exercise. If there are also torn/loose bits of cartilage or bone in the joint as well (which is common in arthritic knees) then you might also get clicking, catching, giving way or locking.
The mainstay of treatment for early arthritis of the knee is to try the various non-surgical (conservative) treatments available. This includes painkillers, anti-inflammatories, physiotherapy, the KNEEASE device, off-loading knee braces, walking aids and joint injections (with steroid/cortisone or hyaluronic acid).
If there are torn or loose bits of meniscal cartilage or articular cartilage in an arthritic joint that are causing sudden sharp pains and mechanical symptoms such as painful clicking, catching, giving way or locking, then a ‘tidy up’ of the joint with a knee arthroscopy can help significantly, by reducing pain, increasing function and keeping the knee going for longer, delaying the time when something bigger and more definitive might need to be done.
If the arthritis is severe enough and if a patient’s symptoms are bad enough to justify it, then the only real way to properly cure an arthritic knee is to have a joint replacement.
If only one part of the knee is badly damaged, then a partial knee replacement might be feasible. Otherwise, if the damage is more severe/widespread, then a total knee replacement will be needed.

Introduction

There are two major types of arthritis: osteoarthritis and rheumatoid arthritis.

Rheumatoid arthritis is an auto-immune disease where the synovial membrane lining the knee becomes inflamed, and multiple joints become swollen and painful, leading to breakdown of the articular cartilage and widespread damage in the joint. Rheumatoid arthritis is a condition that is best treated by a Consultant Rheumatologist, although Orthopaedic Surgery can also often be required to replace joints if they become too damaged.

Osteoarthritis is far more common than Rheumatoid. Osteoarthritis is partly genetically caused and partly from simple wear and tear. If a joint is damaged by trauma then this can also increase the risk of osteoarthritis then gradually developing, and in this case it is referred to as ‘secondary osteoarthritis’.

Symptoms

Arthritis in a knee can cause the following symptoms:-

Pain (which tends to be a dull, deep, achy pain that may radiate down the shin and which is worse during or after exercise).
Swelling (from excess joint fluid, called an effusion), which is due to irritation/inflammation of the synovial joint lining, which produces excess synovial joint fluid.
Stiffness (from bony spurs called osteophytes forming in and around the joint, from thickening of the joint capsule, and from tightening up of the surrounding muscles, tendons and ligaments)
Mechanical symptoms (catching sensations, giving way, locking), which can occur is there is any unstable or loose articular or meniscal cartilage damage.

Treatment

The treatment of knee arthritis should be tailored to the stage of the disease, the severity of the patient’s symptoms, the degree of potential functional impairment caused and the expectations, age and functional aspirations of the patient.

In general, it is appropriate to always try and start with the smaller, easier, less-invasive, safer treatments first, escalating things as necessary depending on how the symptoms respond.

Non-surgical (conservative) treatments

The non-surgical treatments available for knee arthritis include:-

Rest and avoidance of aggravating activities
Supplements such as omega oils, glucosamine or chondroitin
Simple painkillers and/or anti-inflammatories
Physiotherapy, to try and get the muscles as strong as possible, to ‘protect the joint’ and to improve function and pain
Aids such as walking sticks
Knee braces (such as a medial offloading knee brace if the arthritis is limited, for example, to just the medial side of the knee and if there is any malalignment)
Joint injections, with either steroid (cortisone) or hyaluronic acid (Synvisc, Durolane or other similar brands)

There are various potential surgical treatments available for the management of knee arthritis. Again, the specific surgical treatment that might be appropriate for any particular patient will depend on what specifically is damaged in the joint, which areas of the joint are affected, the severity of the damage, the severity of the symptoms, what other potential treatments or operations the patient might already have tried or had done, and the age (physiological age) of the patient.

Surgical treatments

The surgical treatments available are:-

Knee arthroscopy
Biological knee replacement (meniscal transplantation and articular cartilage grafting)
Realignment osteotomy
The Episealer focal resurfacing implant
Partial knee replacement
Total knee replacement

The role of knee arthroscopy in knee arthritis

This is a very important subject to understand fully and clearly, as there is a lot of confusion and even disinformation out there about the potential role of knee arthroscopy in arthritic knees.

Arthroscopy is excellent for dealing with unstable or loose pieces of articular cartilage or torn meniscal cartilages. Small areas of exposed bare bone can be treated by microfracture. Thickened inflamed synovial tissue can be trimmed. Debris in the joint can be washed out. A thorough and careful tidy up of all the damaged areas in an arthritic knee joint can make a very big difference to some patients’ knee symptoms, reducing pain, eliminating mechanical symptoms, improving function and keeping people going for longer, delaying the time when something bigger like a joint replacement might actually become necessary.

If a patient’s knee is normal, then of course having an arthroscopy would not give any positive benefit. If there is a lot of debris and damage in the joint, particularly if there are arthritic/degenerative meniscal tears and/or loose bodies, then although it will not actually reverse or cure the arthritis, an arthroscopy can help enormously. If there is severe arthritis in the joint, with widespread areas of bare bone exposed, then an arthroscopy is less likely to make any major or significant difference to the patient’s symptoms.

It is therefore all about choosing the right operation at the right time for the right patient, and this is an important clinical decision that should be entirely between the patient and their doctor.