The question: I injured my knee in an accident some time ago and I continue to have pain. I’m just in my 50s. Is my only option a total knee replacement?
The answer: Rest assured you are not alone. Many people develop knee pain at an early age. They may have hurt the joint playing sports or at the workplace or in a motor vehicle collision. And some unlucky souls are simply born with poor bone alignment that predisposes them to osteoarthritis.
Orthopaedic surgeons generally agree that you should postpone a knee replacement until it is absolutely necessary.
Certainly an artificial knee may be the best way to restore mobility and ease discomfort if the joint has severely deteriorated. But a prosthetic device will never work quite as well as your natural joint, said Moin Khan, an associate professor of orthopaedic surgery at McMaster University in Hamilton.
The difference in the way the new joint feels and functions can lead to some dissatisfaction, particularly among younger patients who want to maintain a fairly active lifestyle, he added.
“So, there’s a growing focus in orthopaedics and sports medicine to extend the life of joints as long as possible,” Dr. Khan said.
To achieve this end, surgeons have developed “joint preservation” procedures designed to repair minor injuries, reduce pain and prevent or slow down the advance of osteoarthritis.
One form of joint preservation is bone marrow stimulation, or microfracture, which can trigger healing in damaged cartilage – the protective shock-absorbing tissue at the end of bones. It involves removing the damaged cartilage and then drilling a few small holes into the bone to reach the underlying marrow, a source of regenerative cells.
“Imagine that a cartilage defect is like a pothole in the road,” Dr. Khan explained. “If you drill into the bone marrow, the body will fill in the surrounding space with a type of scar tissue know as fibrocartilage, just like patching a pothole.”
He noted that fibrocartilage is not as durable as the original cartilage, but it can reduce pain for at least a few years.
Another way to fix an isolated defect is osteochondral autologous transplantation. “You can move pieces of cartilage from one part of the knee where it is not needed as much and transfer it to the area of injury,” said Jihad Abouali, an assistant professor of orthopaedic surgery at the University of Toronto.
In certain cases, the defect can be repaired with cartilage from a deceased donor, similar to the use of organ transplants to treat failing hearts and other body parts. The drawback is that there’s a limited supply of donated cartilage.
Some joint preservation procedures could be considered a pre-emptive strike – basically correcting poor bone alignment before it has a chance to cause harm.
For instance, in people who are bowlegged or knock kneed, the body’s weight may be unevenly distributed, causing excessive wear on certain parts of the joints. This can contribute to the early development of osteoarthritis.
However, the unbalanced load can be redistributed through an operation called a realignment osteotomy, said Alan Getgood, an associate professor of orthopaedic surgery at Western University in London, Ont.
Some of the bone is cut and reshaped “to essentially straighten the leg,” Dr. Getgood explained.
Osteotomies – and to some extent other joint preservation measures – depend on catching cartilage damage in the early stages before it becomes widespread.
“Once you have degeneration of the whole joint, it’s difficult to start patching multiple areas,” Dr. Khan said.
For that reason, it’s critically important to have sufficient heath care funding for these time-sensitive surgeries, Dr. Getgood said. In Ontario, the cost of doing the procedures usually comes out of hospital budgets. He would like to see the province dedicate money specifically for joint preservation.
“Getting these young, working-age patients into appropriate care more quickly can have a significant impact on reducing the socioeconomic impact of their injuries,” he said.
It is also worth mentioning that the field of joint preservation continues to evolve. Researchers are studying ways to grow replacement cartilage in a lab.
As well, in recent years, biotech companies have introduced numerous biological injections – such as platelet rich plasma (PRP), derived from a patient’s own blood – that may aid healing. But patients have to pay out of their own pockets for PRP, which varies from $500 to $700 for each injection, because it isn’t covered by provincial health insurance. And there’s a lack of clear data about its effectiveness. “The clinical trials often come up with different results,” Dr. Getgood noted. That ambiguity makes it hard for doctors to provide their patients with reliable guidance.
In many respects, joint preservation procedures are simply buying time – helping to delay the need for a prosthesis.
That may not sound like a major benefit. But it’s important to keep in mind that “joint replacements don’t last forever,” Dr. Abouali said.
“We know that the younger you are when you get a total joint replacement, the less time it will last in your knee,” he added. That’s because younger people tend to be more active than older folks and are more likely to wear out the device and ultimately need a new one.
“Joint preservation is becoming more popular because patients do better if they can keep their own knee as long as possible,” Dr. Abouali said. Then, by the time they actually require a joint replacement, it’s hoped that the device will last them the rest of their life. After all, it’s not a surgical procedure that most people want to undergo multiple times.
Paul Taylor is a former Patient Navigation Adviser at Sunnybrook Health Sciences Centre and former health editor of The Globe and Mail.