Knee surgery alternatives

Knee replacement surgery may not be the best solution for painful osteoarthritis.

Health Agenda magazine
July 2016

Around 1.8 million Australians live with the discomfort of osteoarthritis. It’s the most common type of arthritis and people who have the problem in their knees can experience stiffness and excruciating pain, as the cartilage cushioning the bones in the joint gradually breaks down.

According to the Australian Orthopaedic Association National Joint Replacement Registry, 57,256 knee replacement operations were performed across the country in 2015, and osteoarthritis is by far the most common reason for surgery.

Surgery may not be the answer

However, some health professionals are voicing concerns about how often surgery is being used to manage osteoarthritis. A 2014 report by the Australian Commission on Safety and Quality in Health Care found the management of common health conditions varies considerably depending on where people live, including how readily knee arthroscopy is recommended. Arthroscopic procedures involve keyhole surgery to remove bone fragments, remove or repair torn ligaments, realign kneecaps or flush the joint of infection.

Professor Villis Marshall, the commission’s chair, says the findings bring home the importance of patients being better educated about their options when making decisions about healthcare. “Patients fully informed about the implications of various options and how these align with their own values will often make different choices about their care,” he notes.

Earlier this year an episode of Tonic, the ABC’s health documentary series, also questioned if patients are going under the knife unnecessarily in an attempt to relieve osteoarthritis. It raised the question as to whether people have realistic expectations of their recovery and surgery outcomes.

The University of New South Wales’ Professor of Orthopaedic Surgery, Ian Harris, who appeared in the episode, is particularly concerned about arthroscopic surgery for osteoarthritis. “Evidence spread over a dozen years or so has shown repeatedly that, for osteoarthritis, arthroscopy is no better than pretending to do an arthroscopy.” he says.

“If someone has an infected knee you might do arthroscopic surgery to wash it out or, if you have a torn cruciate ligament, you might have an arthroscopic procedure to reconstruct the ligament, but most arthroscopies are being done for degenerative knees and we know the procedure is no more effective than a placebo,” Professor Harris says.

Understanding surgery’s limitations

In cases of severe arthritis, he says knee replacement surgery can be a valid option but adds it’s important people have realistic expectations of what surgery will and won’t achieve. “I think people expect a little too much. Studies have shown patients over-estimate the benefits of surgery,” says Professor Harris.

“Knee replacement surgery can be effective if you have significant arthritis, pain and loss of function. It will give you a better knee, but it doesn’t give you a normal knee. As a rough rule of thumb, 20 per cent of patients will be dissatisfied with the outcome of their knee replacement. It’s not a perfect operation.

“And I’d warn people that it is a painful procedure and your knee will give you considerable pain after the operation. Expect it to take some months before your knee has improved to the degree it will improve.”

Weight loss is key to treatment

Dr Lawrence Malisano of the Australian Orthopaedic Association agrees surgery should be an ‘end of the line’ option and that other treatment should be explored first. Weight loss and remaining within a healthy weight range is important, with research showing losing five to seven per cent of your body weight can reduce painful arthritic symptoms by lessening the pressure on worn knee joints.

“Weight is responsible for a lot of problems with knees,” he says. “A patient may need to decrease the amount of exercise they do but do it more frequently. Instead of walking five kilometres at a time they might need to walk two kilometres three times a day.

“A sensible approach to exercise is important but physical activity is key because you need muscle mass. If you don’t do much physical activity an inflammatory process occurs in the knee but the more muscle you have, the less inflammation there is.”

He says taking medications such as anti-inflammatories combined with paracetamol may also provide relief. “Surgery has to be a careful consideration – it’s never a ‘come in, let’s replace your knee joint, tomorrow’ situation. There has to be good management and assessment of the problem,” Dr Malisano explains.

Help with weight management

HCF’s Osteoarthritis Healthy Weight for Life program has been designed to help eligible members* with diagnosed knee osteoarthritis who have a BMI of more than 28. The program aims to assist weight loss, boost general health, reduce joint pain, and improve the knee replacement surgery outcomes.

HCF member David Campbell, 56, from Maitland in the Hunter Valley, NSW, took part in the 18-week program after surgery to repair a meniscus tear in his right knee. During the arthroscopic procedure in November 2014 his surgeon diagnosed osteoarthritis. “I injured my knee playing touch footy but I’d been having trouble for a while,” Campbell explains. “My knees felt quite sore. I had physiotherapy but it didn’t resolve the tenderness so I saw a surgeon,” he says.

Before surgery Campbell, a committed sportsman, asked how the procedure would impact on his hobbies. “I thought running would be out of the question because of the pounding impact but I was keen to continue kayaking and cycling. It’s important to ask questions and be clear about the outcomes and treatment options,” he says.

In a win for both his waistline and knees, Campbell lost 12 kilos in 18 weeks through the HCF program. He says the information about healthy eating and portion sizes was particularly helpful.

“I re-educated myself to have more reasonable portions. A healthy-sized portion was smaller than I normally ate. I also learned about the healthiest types of food to eat and what to avoid,” he says. “I had to buy new clothes because my waist shrank by around six centimetres and I have noticed benefits for my knees. The tenderness and discomfort have gone. They also used to click a lot and I can’t remember when they last clicked!”