Knee Osteoarthritis Explained with Mr Michael Leonard

We have our next speaker tonight. It’s Mr. Michael Leonard. We’re going to have a presentation. He’s going to talk about Osteoarthritis of the knee and about surgery or not surgery. And Mike’s going to join us live as well for a Q&A.

Good evening, everybody and welcome along to the meeting. My name is Mr. Michael Leonard, consultant orthopaedic surgeon at the Sports Surgery Clinic (SSC) here and I’m going to be giving a talk this evening on Knee Arthritis.

Knee Arthritis

We’re going to be discussing how it first presents, what the pathology is, how we manage it, all the way from the initial presentation to surgical intervention if required and the recovery after sight.

What is Knee Arthritis?

The common description of it is “wear and tear”, but it’s more than that. It involves a loss of the articulating cartilage within the joint, but it also affects the soft tissue lining of the knee, the muscles, the joint capsule, the ligaments. What happens in the process is the knee becomes stiff and sore and pain becomes an issue and functional debility all from this loss of the normal anatomy of the joint and as I say it affects all parameters of the joint itself.

Knee Arthritis is becoming more common, and it becomes more common with age but it’s not simply getting old. It is a pathological process that happens within the joint.

How does it present?

Initially it usually presents with some pain or discomfort in the knee particularly with walking up and down stairs. It may only present with pain at night. Stiffness is also an issue, stiffness after prolonged sitting, stiffness in the morning requiring the knee to be stretched out.

Movement issues

Movement can also be a problem. Reduced range of movement and people can notice a lack of an ability to fully straighten out the knee or indeed to bend the knee or flex the knee fully. Patients often complain of episodes of swelling, intermittent flare-ups of the knee, that sort of thing.

Function Issues

Functional issues that people have again are walking up and down hills, walking on uneven ground, playing golf, gardening, sitting comfortably in planes and public transport and keeping up with friends when playing golf or going for a walk.

X-Rays

On the subject x-rays that we see, two people can have very similar

x-rays, but very different symptoms and severity of symptoms. Therefore, arthritis is treated and knee arthritis on a case-by-case basis.

Why does Osteoarthritis happen?

Age

Age is the is the big risk factor. As we get older, the joints have undergone more cycling and more pressure and therefore you can develop degeneration.

Genetics

The genetics do count, many patients that I would see that have developed arthritis being in the knee or the hip will often give a history of a family member also having a similar problem.

Injury

Injury, particularly to the knee is very common. Certainly, in perhaps injury in an earlier decade from sport can

lead to the development of arthritic change in the knee down the line. The joint shape and anatomy and how we are all aligned is a little bit different and that can predispose some people to developing arthritis earlier than others.

Load

Load, the amount of body weight and extra body weight and high body mass index is certainly a risk factor for the development of arthritis and muscle weakness changes or joint control etc. The point of that is really is that arthritis is rarely just from one thing. It’s usually a combination of causes what we call multifactorial.

All these things come together to lead to the arthritic pattern that we see in most patients, most patients it’s a combination of all these things as opposed to just the one thing that we could we could point our finger at.

Where do I start if I’ve got knee pain?

This is coming back to the patient themselves. Your initial presentation is most people will initially attend their general practitioner, and their GP will assess the joint exclude other potential causes and then the initial management will be for pain relief.

Physiotherapy medications can be useful in certain situations and then you know when those more conservative modalities don’t prove effective the patient will often be referred into the Sport Surgery Clinic here where we will see the patient and review as necessary.

What actually works?

This is a question patients will ask me all the time. You know, surgery is an option, but it’s certainly not the first option and certainly not the only option.

There are much more conservative methods that can be employed from the initial presentation right up to the point where perhaps surgery becomes an option. What we do know is key, movement is medicine, even when the joint has arthritis, the one thing not to do is to not move your knee because of fear of making arthritis worse.

Not moving the knee will make your will make your arthritis worse, you need to bring in movement. The way we move the benefit

of movement is that it maintains flexibility in the joint, but it also maintains the flexibility in those soft tissues that surround the joint that I mentioned a few moments earlier can be involved in the arthritic process.

Strength

Strengthening is key, so, building the muscles that support and control the joint.

Aerobic Activity

Aerobic activity, what’s really good for somebody with an arthritic knee, walking, cycling, swimming, all these things. And I’ll often recommend to my patients. A lot of people that will come to me with arthritis in the knee will be avid walkers or golfers or indeed runners.

I will often recommend changing the exercise regime. Perhaps on a Monday to do some cycling, on a Tuesday some swimming, on a Wednesday to play golf, on a Thursday to do some yoga or Pilates, and just move things around all the time so you’re not overloading the knee all the time.

Physiotherapy

Now, that can be a little bit challenging for people in the initial stages to figure out what they’re supposed to do and not supposed to do, in that situation, attending a good physiotherapist is an excellent idea. Your physio can guide you with regards to the appropriate exercises to maintain movement, flexibility, and strength.

Weight Management

Now, weight management for knees is key, and we know there’s been numerous studies published where a high body mass index or being very overweight will certainly increase knee pain, particularly in the presence of arthritis. We also know that as a patient loses weight in general, the knee pain will reduce. What’s key and your physiotherapist will go through this with you. I’ve summarised it here at the end of my slide. A little discomfort when you start does not mean you’re damaging the joint.

Obviously, we never tell patients to force themselves through pain to exercise more, but a little bit of discomfort as you’re building up the flexibility and strength in your knee is okay.

Medications and injections

What can we use for knee arthritis?

Before we start talking about surgery there are many different useful tools, we can use Topical NSAIDS, so this is the type of gel that we use and these creams and gels can be very helpful for rubbing in around the knee and there’s various different modalities and this is something that I prescribe quite regularly and as do GPS.

The systemic exposure is less, but it’s still important these gels that people rub on our knees are still medications. Therefore, it’s important to use them appropriately and as prescribed.

Oral NSAIDs

Oral non-steroidal anti-inflammatories are the common ones we know about are the likes of Ibuprofen, Difene, Vimovo.

They’re all different types, they can be very beneficial, but we need to be cautious when using them as they can cause stomach upset, problem with the kidneys, if patients are on blood thinners, it can interact with those. Therefore, they must be used with caution.

Steroid Injections

Steroid injections can be very beneficial, and they can be used selectively to settle down an acute flare up of underlying arthritis or to indeed in the initial management of patients’ steroid injection can be very helpful, and we do use steroid injection quite regularly.

The aim of all of these interventions is to allow for enough symptom control to keep you moving. It’s not simply to cover up or hide or you know temporize the condition. It is to manage the arthritis and to allow you to maintain range of movement, flexibility and strength and indeed function.

Supplements, oils and diet

A question I’m often asked about is what about supplements, available oils, diets, all this sort of stuff. There’s plenty of claims that you know that we see that are out there in the in the media that will help with arthritis.

However, as doctors and surgeons, we’re always looking at ‘what is the evidence’, the actual evidence that this will help a patient.

What we do know that helps in overall health, arthritis, and keeping patients moving is a good diet. The Mediterranean diet is often one of those diets that has got a lot of evidence for and as we know the Mediterranean diet is one that focuses on a lot of fruit and vegetables, healthy eating pattern, not too much animal products, usual fish, that kind of stuff.

As discussed, it’s important to have a healthy weight. Your knee is designed to hold your normal body weight. It’s part of how we’re all made up, so, if you are a normal healthy body weight, which you can easily assess based on height, weight, etc., your knee is designed to hold that body weight.

As a result, it’s not about becoming underweight because becoming underweight does not help either because you lose muscle and strength. It’s all about maintaining your own normal healthy weight and a good adequate protein intake to maintain those muscles and strength, and exercise and strengthening remain the foundation for conservative care with knee arthritis.

Other things that are out there that we hear about, glucosamine, chondroitin, fish oil specifically for arthritis, no real supplement to date has shown to regrow cartilage. Therefore, there’s no real strong evidence for these other things.

It’s basically the simple actions works. Diet, exercise, maintaining movement, etc.

What can make Knee Arthritis symptoms worse?

Inactivity

Again, protecting the joint too much can sometimes work against you. Therefore, inactivity, and what inactivity will lead to is muscle loss. You get muscle weakness your knee will become stiff more painful and it’s a vicious circle.

Boom & Bust

Doing too much on a good day then needing days to recover. This is called the boom and bust. As I often say to patients consistency beats intensity every time. You need to have a consistent regular exercise program that does not leave your knees swollen and painful but does maintain your range of movement and your strength and your functional capacity. Now obviously for everybody that takes a bit of time to work out because we’re all individuals.

We need to work out how much and which exercise works for us the best and to stick to that program. Again, as I mentioned before if that proves challenging attending one of our physios here in the sport surgery clinic, they’ll be able to go through all that.

Poor sleep

Poor sleep can amplify underlying inflammation, arthritis, stress, fatigue, etc.

Excess load

Excess load. Again, more load can mean more symptoms, particularly at the knee. So again, we’re working on keeping our ideal weight and not being overweight.

Fear of Movement

Fear of movement when having arthritis in the knee means pain does not always equal damage. We don’t want fear avoidance where we feel like if we go for a walk, it will make our knee arthritis much worse. That’s not the case. Again, we need to figure out exercises that are good for our knees. As I mentioned, walking, cycling, swimming, all of these things and stick to a program to maintain the movement in the knee.

Deconditioning

We want to keep up our exercise. Fitness drops so, everyday tasks feel harder when we become deconditioned, if we become deconditioned and weak, everything becomes harder. Therefore, we need to maintain movement, strength, and function.

When is the time to see a surgeon?

Usually this will be dictated by a consultation between yourself, the patient, and your general practitioner. Usually, it’s a combination of symptoms that we would see when patients are referred to us here in the sport surgery clinic.

Pain

Pain being a big issue, pain that is not responding to the more conservative measures as we’ve gone through before such as analgesics, gels, injections, weight loss, and physio. When somebody has attempted to manage their symptoms with all of these modalities, but the symptoms persist, that’s when they’re referred when pain disturbs sleep at night, when walking or functional capacity is dropping or becoming less and less and people can no longer go for a walk with their friends, play golf at comfort.

As I mentioned, if work, hobbies, or independence are compromised, you should see a surgeon. The key really is not about when we’re talking when a surgeon looks at an X-ray with regards to whether surgery is needed. An X-ray, as I tell my patients all the time, is only half the picture.

Some patients can have very bad arthritis on an X-ray, but minimal symptoms, and they don’t need an operation, whereas some patients may have only mild arthritic changes on their X-ray, but very bad symptoms, and they do warrant an operation, and that’s why a good consultation with X-ray evaluation is necessary before making any decisions on to proceed with surgery.

Knee Arthritis

Knee arthritis is very common and the incidence of it is rising more. We’re seeing over a doubling of cases of knee arthritis over the last few decades. The majority of cases are occurring in older adults 55 to 60 and above.

However, we are seeing an increased onset in younger patients, it may be related to increased activity levels, increased body mass index, the increase in overall rates of obesity we see worldwide. These are all contributing factors.

Knee arthritis is now one of the most common causes of pain, reduced mobility, and loss of independence worldwide, so we’re seeing more and more of it.

The right treatment depends on the patient and the pattern of disease. This is an X-ray you can see here of an arthritic knee. You can see how on the inside of the knee that would be on the side where you see the bone contacting the bone. That’s the classic bone on bone arthritis that people are aware of where all of the underlying cartilage has been worn away.

The three Compartments of the Knee

When we as surgeons when we discuss the knee, we discuss the three compartments of the knee. The inside of your knee being the medial compartment, the outside of your knee being the lateral compartment and we also describe a compartment between your kneecap and the front of your knee.

75% of people that we see with knee arthritis, they don’t have arthritis throughout the entire knee, so, it’s in one or two of the compartments.

50% of patients have what’s called an Isolated Compartment, they just have arthritis at one part of the knee, not the whole knee. And the medial side or the inside of your knee is the most common place that we see where patients just have isolated arthritis in there. There are more and more good treatment modalities when it comes to surgery to manage that. That being the partial knee replacement or the Unicondylar knee replacement that we’re doing.

And the benefit of that is that we’re just addressing the medial side or indeed the lateral side or the patellofemoral side, the joint between the kneecap and the femur without having to replace the entire knee, and what we’ve seen over the years is an almost 600% increase in the use of partial knee replacements over a recent 10-year period. These have been published in peer-reviewed medical literature.

Total Knee Replacement or Partial Knee Replacement

When we look at somebody who’s undergone all of the other treatment modalities, the injection therapy, physio, weight loss, and medication, and they come to require an operation for their knee arthritis, the common question is, do we need to do a partial knee replacement or a full knee replacement? Both surgeries can lead to great outcomes and are highly successful in almost all patients.

Partial Knee Replacements

The partial knee replacement is an ideal operation for a patient who has isolated compartment disease, so, only one part of the knee has been affected. The benefit of the partial knee is it’s a resurfacing, we remove the damaged compartment, and we put in a new compartment, but we leave the rest of the knee alone.

What we call kinematics or the normal movement of your knee is preserved and we just resurface the damaged part.

Total Knee Replacement

In a total knee replacement that is done for patients that have more advanced or widespread disease and that involves a replacement of the entire knee joint. Also, the total knee replacement outcomes are very good. However, it is a bigger operation for the knee where we’re replacing the entire knee joint and often times the recovery takes longer.

Overall outcomes are excellent from both operations.

Current Evidence for Partial Knee Replacement

Partial knee replacement, as I mentioned, we’ve seen a huge increase in the amount of these that we’re doing.

And again, what we’re doing here is it’s a very targeted replacement of a damaged area of the knee as opposed to replacing the entire knee. Also, it’s proving more and more successful. In the medical literature where we study these patterns, we’re seeing very positive outcomes. We’re seeing higher patient satisfaction; patients are much happier, less pain, better physical health scores, return to sport, both low and high impact sports, reduced length of stay in hospital, reduced surgical time, reduced blood loss.

Another thing we look at which is called the forgotten joint score where the knee feels like their own, where a patient will say their knee just feels like their own knee, that they almost forget that they’ve had a knee replacement is higher in partial knee replacements than total knee.  That is really where as knee surgeons, we want to get our patients to a point where we ask them, “How’s your knee doing?” And they’ll say, “It’s great. Feels like my other knee or it feels like my knee before it ever gave me any pain.”

That’s really where we want to go. And the partial knee replacement is a very good option there. It seems to be based on all the research and literature that we look at is the way forward for the appropriately selected patient.

You have decided on surgery- what happens next?

If you’ve seen your surgeon or once you’ve seen your surgeon here in the sport surgery clinic and you’ve decided you’re going to go ahead and have your knee replaced, be that a partial knee replacement or full knee replacement, there’s a process that we go through here at the Sports Surgery Clinic and indeed worldwide.

Pre-Assessment

There’s a pre-assessment clinic where you come into the hospital a few weeks before your surgery and all of your medications will be checked. You’ll have some health screening done where you have some blood tests, chest X-ray, ECG just to make sure everything is okay for the surgery.

As I tell my patients all the time, it’s not like a health check for your mortgage or we’re trying to find Olympic athletes. It’s basically a checkup to make sure that everything is okay and that you’ll be safe to have your operation. I often tell people that get worried if they’re coming in to have a health screen that something you know they won’t pass. It’s not that case. It’s a case just to make sure you’re safe to have your operation.

Keep Moving

I always advocate that you know if you’re coming in for your operation keep the knee moving. I tell patients all the time the stronger and fitter your knee is before the operation the quicker you recover.

It’s almost called prehabilitation, you maintain your movement, maintain your strength, and you’re putting money in the bank from the point of view of your recovery. The stronger you are coming in, the stronger you’ll be as you leave and the quicker you recover.

You can obviously make plans for home when you get home, how you’re going to move around the house, maybe have some help at home from family etc.

On the Day

On the day of surgery, you’ll get all the fasting instructions, etc. lifts home, etc. can all be worked out.

Usually, most patients that are coming in either for a partial knee and total knee replacement are admitted on the day of surgery. The operation is done under a spinal anaesthetic which is a small injection into your back. Which is much more superior from the point of view of pain relief, reduce risk of clotting, faster mobilization, etc. than general anaesthetic.

Most people after a partial or total knee go home the following day or a day or two afterwards. That just depends on how quickly they progress with physiotherapy and their rehabilitation.

What can I expect after surgery?

Day zero to one you’ll be up and walking with physiotherapy.

First couple of weeks the wound will be healing up, and you’ll be keeping that nice and clean and dry. Walking a little and often, not overdoing it and using ice intermittently. So I advise all my patients for the first four to six weeks to ice the knee three or four times a day,  but you’re only icing it for 10 to 15 minutes and, you’re going to use those commercially available reusable ice packs. That really helps settle the knee down.

At around 6 weeks, the vast majority of patients are moving independently. The knee isn’t swelling etc. incision heal movement is good.

Then moving forward for the following few months after the surgery, it’s just about building back up that strength and stamina and function. We usually record our recovery in weeks. Now for anybody who’s struggling with any of that obviously we can alter or tailor their regime and get them more physiotherapy as required if they’re struggling with range of movement. It’s a dynamic process but this is sort of the guideline as to how it works for most people.

Why experience matters?

Experience is very important and all the research that’s out there will tell us that you know if you’re having knee surgery you know the volume of the surgery that’s carried out by your surgeon and in the unit that you’re going to is absolutely key from the point of view of success.

Here in the Sports Surgery Clinic, there is specialist orthopaedic assessment and shared decision- making highly experienced anaesthetic nursing and physiotherapy teams that do these operations every day and rehabilitate these patients every day.

We establish pathways from initial assessment through discharge. We use evidence-based implants and techniques for our surgery, and the same aim is throughout.

The aim now when people come in for knee replacement surgery is that it’s a pain-free procedure and there’s guided rehabilitation and we’re always there for patients at any stage down the line if there’s questions or concerns be it in the hospital or during that initial recovery phase or even down the line.

Five things to remember

Arthritis should not automatically mean giving up the things you enjoy. Keep moving. Exercise does not “wear out an arthritic joint”. Exercise is good. maintains movement, maintains function.

Strength matters. Therefore, you got to keep strength in the knee.

Be sceptical of miracle cures that we see out there that come along all the time. You are better off to look at evidence-based medicine. So, what is the evidence as opposed to something you might see online?

Seek help when arthritis starts controlling your life. For example, if your pain or stiffness really starts to impact on what you can do on a day-to-day basis, that’s where you seek help. As I said, initially it’s usually your general practitioner and then referral onwards as required.

If we need a joint replacement. It’s designed to restore quality of life. When we do a joint replacement, we’re trying to make a situation where a patient is suffering with pain and stiffness to a situation where they’re not. The process is now streamlined. the operations, the recovery, the rehabilitation and the touchstone for patients to come back to the sport surgery clinic should they develop any problems or issues is always there.

It depends entirely on how symptomatic the patient is. I mean obviously somebody in their 40s would be young to have a knee replacement, but it wouldn’t be unheard of.

Therefore, you would try all modalities to avoid a knee replacement in a younger patient such as weight optimisation, exercise, injection therapy, physiotherapy. However, sometimes in certain circumstances, if a patient’s arthritis has advanced to that stage and all other modalities have been tried and the patient is still in a lot of pain with difficulty, then it’s not unreasonable to do any replacement even in patients younger than their 40s, even in their 30s.

It is the prudent thing to do to exhaust all conservative measures first of all.

Yes, so specifically on partial knee replacement, there’s definitely more and more evidence coming out that in the correctly chosen patient, it does offer a definite advantage over total knee replacement with regards to recovery, return to sport, return to high activity, reduced complications from surgery, etc.

Therefore, in the correctly chosen patient there’s more and more evidence in favour of a partial knee replacement and then robotic partial knee replacement a bit like robotic total knee replacement, there are pros and cons to it but there’s no outstanding evidence that it’s superior but it can be of help in certain circumstances.

Absolutely, I advise all my patients either pre- or post-op to use the exercise bike. I say this to patients all the time. If there’s one exercise to do, if you have a problem with your knee, whatever it is, yeah, I mean with the with the odd rare exception, but if it’s we’re talking about knee arthritis tonight and the exercise bike pre-post-op, it’s brilliant. Range of movement gets all the strength.

You’re not weight bearing, you’re not putting a lot of pressure through the knee, but you’re maintaining the flexibility of the joint and you’re strengthening up the surrounding muscles.

I also recommend to patients to buy a good stationary exercise bike or else join a gym. The reason I say that because people always ask me then, what about a road bike? Unfortunately, we don’t live in Portugal or the south of Spain and half the year it’s wet and rainy and people won’t go on it.

If you have one in the house or you’re a gym goer. It has got to be user friendly or people won’t use it. Therefore, I would recommend either a gym or if you’re going to buy one, buy a good one because if you buy cheap ones, they’re uncomfortable and again you won’t use it. Whereas, if you invest a bit of money and buy a good one, you will use it.

Generally, you want to leave it six weeks.

That would be sort of the general advice we would give patients. Now, you know, everybody, we have a Thromboprophylaxis protocol where everyone goes on aspirin for approximately four weeks after a knee replacement. I would say that probably beyond the 4-week time the risk is less but generally we would say 6 weeks unless it’s an emergency and then you have to go somewhere you know but I would generally advise my patients if we’re booking a knee replacement that if for example if they had a family wedding in the near future, I would always say go to the wedding come back and then we’ll do the knee replacement.

Well, it’s down to each individual, it’s hard to say it always will, but there’s very strong evidence that I mean, as your weight goes up, if you have an arthritic knee; your pain and symptoms will go up, but the opposite is true. There’s a lot of evidence out there that if you’re overweight and you lose weight, that your knee pain will drop. As a result, getting back to your normal BMI is healthy for all aspects.

There’s no doubt that your knees, I say this to patients all the time, your knees are designed to carry your normal weight. Therefore, it’s not about losing a huge amount of weight and becoming underweight because your knees are designed to carry your weight, but if you’re if you’re walking around with extra weight on board, that force is all going through the knee.

The two main things are to optimise your BMI and exercise.

Yeah, so from my perspective the number one test is a weight bearing X-ray of the knee because that will show you the degree of arthritis. What part of the knee? It may be just one part. It may be all parts of the knee involved. It’s a very simple straightforward test weightbearing X-ray of the knee.

It’s hard to say if it’s inevitable. I mean again it depends on an individual basis, with regards to doing a double knee replacement, certainly the younger the better for that particular operation.

Now, more and more we’re doing what we call bilateral. To just make it clear to everybody listening, if you’re talking about a bilateral hip or knee replacement, that means you’re having both knees or hips replaced at the same sitting, same time.

Bilateral hip replacements they’re becoming kind of a fully acceptable procedure and the risks when compared with one hip versus another hip at a spaced-out time is almost the same. As in bilateral hip replacements are very safe.

Bilateral partial knee replacements are very safe. Bilateral total knee replacements do come with an increased risk of medical complications such as cardiac issues, stroke, clots, etc. So, if you’re doing bilateral total knee replacements, ideally the younger and fitter the better for that particular operation.

Again, it depends if you know the modern implants that we use now, you’re talking survivorship of 95% plus at 25 to 30 years.

Yeah. I mean people can play tennis after knee replacement surgery.

What people find very hard generally to do is stuff where you’re down on your knee. Therefore, kneeling down that that can be challenging for patients after a knee replacement. Now you know if you’re still playing tennis comfortably the question is you know you’d have to decide do you need a knee replacement or not and that depends on what your pain level and your functional restrictions are like.

Again, if your pain is bad enough and you’re willing to go through the rehab and recovery you’re likely to have a very good outcome, and yes, you you’ll be able to get back to likes of cycling, hiking, swimming, tennis, golf is all achievable.

No, so partial knee replacements we do for people with isolated compartments. Usually, the inside of the knee or the outside of the knee less. There is a certain percentage that go on to require a full knee replacement, but that’s becoming less and less because of proper patient selection, improved surgical technique, improved implants. Therefore, the answer is no. It’s not inevitable, you’ll go on to need a full knee replacement.