Surgery versus conservative care for arthritic knees
For patients with severely arthritic knees, the decision to have a total knee arthroplasty (TKA), or total knee replacement, is more straightforward than for patients with mild to moderate arthritis. Patients with mild to moderate arthritis are not advanced enough for a total knee replacement but the options for resolution are limited. Deciding what approach to use to improve range of motion, function, and satisfactory pain relief will depend largely on your expectations and desired activity level.
The options include physical therapy, cortisone injections, joint fluid injections, and/or arthroscopic surgery. Typically most patients go into the medical system because of knee pain. This is usually accompanied by stiffness and loss of range of motion. These deficits usually result in a decrease in function and limitation of activities. The treatment approach will most likely start conservatively and progress to more invasive.
Complicating factors in the decision making process include co-existing meniscus (cartilage) tears, loose bodies (joint mice), joint stiffness, and deformity. These are all limiting factors to conservative measures. They are also limiting factors for full recovery and return to activities that are more advanced than daily living.
Cortisone injections are a good first line treatment. They help reduce inflammation and pain while also improving range of motion. They won’t however remedy any deformity, fix a tear, or smooth out arthritic development. Usually they will provide some fairly acute pain relief. Synthetic joint fluid injections are designed to provide longer lasting pain relief and improved range of motion, but in our clinical experience they are 50/50. The only down side to the synthetic joint fluid is cost. They are rarely covered by insurance. The upside is that we have never seen a patient’s condition worsen from the injection.
When the condition progresses or fails to respond to a cortisone or synthetic joint fluid injection, the patient may require physical therapy and/or arthroscopic surgery. There has been a reasonable amount of research comparing arthroscopic surgical intervention to physical therapy for patients with osteoarthritis and meniscus tears of the knees. The majority of the studies conclude that physical therapy is just as beneficial or perhaps more beneficial than surgery even after long-term follow-up. However, the picture is not quite so straightforward.
A study published in the New England Journal of Medicine (NEJM) in 2013 revealed no significant differences in function between patients undergoing arthroscopic debridement and patients receiving physical therapy alone at the 12-month point of the study. Interestingly enough, approximately 30% of the patients assigned to the physical therapy group opted for surgery within 6 months. If we consider the previously mentioned complicating factors, their presence could be a reason that the patients did not meet their treatment expectation and eventually opted for arthroscopic surgical debridement.
Patients in this population are often trying to maintain an active lifestyle. But when we look at the measures used to determine outcomes in the studies, the main outcome measure does not take into account recreational activity. This measure is the Western Ontario and McMaster Universities Osteoarthritis Index or WOMAC. It does account for symptoms, stiffness, pain, and activities of daily living but it does not account for community activities and recreational activities. If the studies looked closer at community activities and recreational activities, the results may have been different. Future studies should look into this since the older population is maintaining vigorous exercise habits longer.
The question remains, what to do with an arthritic knee? If we take into account the current state of research combined with clinical practice experience and factor in efficiency, the following pathway could be an effective route: Patients with knee pain, reduced range of motion, and poor function would opt for an injection to start the process. The goal of the injection is to reduce pain, improve some range of motion, and restore daily function. The injection will not make your legs stronger. If additional treatment or strengthening is required, physical therapy would be next. The goal of physical therapy would be to resolve stiffness, improve range of motion, reduce pain, and restore community and recreational activities. If the injection and/or physical therapy do not provide an adequate outcome based on the patient’s expectations, arthroscopic surgery to improve the joint architecture becomes an option. Physical therapy would follow this surgery to reduce swelling and restore function. Lastly, if the patient’s condition still displayed postoperative deficits but were not a candidate for a TKA, some type of synthetic joint fluid injection could be of benefit to delay having the more invasive TKA.
Choosing the path to treat an arthritic knee can be a complicated one. Gather information from your orthopedic surgeon, physical therapist, or other trusted medical professionals before jumping into highly invasive procedures. We have found that the stepping stone approach listed above has been the most beneficial and efficient.
Dr. Buchberger is a licensed chiropractor, physical therapist, certified strength and conditioning specialist and Diplomate of the American Chiropractic Board of Sports Physicians with 32 years of clinical sports injury experience. Dr. Buchberger can be contacted at 315-515-3117, www.activeptsolutions.com or www.shouldermadesimple.com