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Alternatives to Knee Replacement

copyright 2000, Joint Replacement Institute
Used here with permission 


Total knee replacement is elective surgery. It is life-enhancing surgery, not life-saving surgery. The decision to undergo total knee replacement surgery is yours. It is important that you be aware of your options, other than total knee replacement surgery. You may simply decide not to have surgery and live with your arthritic knee. In this case, you may choose to avoid strenuous and painful activities. You should, however, adopt some gentle exercise, such as walking. You may benefit from some moist heat, massage or other forms of physical therapy. Weight loss can be very helpful in reducing pain from arthritic knees by reducing the stress, and is good for your general health as well. There are a number of medications, both anti-inflammatory medications and pain medications, that can help you live with arthritis. There are also medicines that can be injected directly into the knee, such as cortisone and newer products that improve lubrication. Unfortunately, the arthritis is progressive in most cases. A cane or a crutch may be required in order to walk. 

The following is a list of alternatives to total knee replacement surgery you may wish to explore. 

Specialized Braces

Arthroscopy

Cartilage Transplantation

Osteotomy

Uni-compartmental arthroplasty

Arthrodesis or Knee Fusion

Specialized Braces

There are specialized braces that can be helpful in some cases of knee arthritis. These braces are designed to create a force which transfers load from an area of the knee where the cartilage is more worn, to an area of the knee where the cartilage is less worn. These braces are helpful in cases where there is still some cartilage remaining in the knee, and the pressure of the brace causes less discomfort than the knee arthritis. 

Arthroscopy


There are less invasive surgical procedures available which can be helpful in some cases. These include arthroscopy. Arthroscopy requires only small incisions around the knee which allow the insertion of small instruments, which are about the size of a pen or pencil. With arthroscopy, degenerated and worn cartilage can be trimmed and smoothed, which reduces the source of inflammation. Additionally, the lining of the knee (the synovium), can be trimmed, and this also decreases inflammation. Patients who have knee arthroscopy almost always go home the same day. Recovery from surgery occurs over a couple of weeks. Unfortunately, the benefit of arthroscopy decreases as the degree of arthritis increases. In advanced arthritis, arthroscopy is of little value.

Cartilage Transplantation

It is now possible to transplant articular cartilage from one location to another. Healthy cartilage, from an area of the knee that does not bear weight, can be transplanted into another area of the knee where weight-bearing cartilage has been damaged. Cartilage transplantation is best for localized areas of damaged cartilage in an otherwise healthy knee. Unfortunately, in most cases of osteoarthritis and rheumatoid arthritis, the degeneration and wear of articular cartilage involves the majority of the joint surfaces. Cartilage transplantation is not a good option in such cases.

Osteotomy

Some cases, where the leg is imperfectly aligned, can be treated by an osteotomy. An osteotomy is an operation that cuts the bone, either above or below the knee, and re-aligns the knee to a better position. This is a bigger operation than an arthroscopy and patients usually stay 1 or 2 days in the hospital. It takes 6 to 8 weeks for the bone to heal. Physical therapy is usually required to restore knee motion and strength. Complete recovery takes a number of months. An osteotomy is a good operation, especially for younger patients, and those where the leg is clearly not straight and the cartilage wear is confined to one portion of the knee. Unfortunately, the success of an osteotomy decreases as the degree of arthritis increases.

Uni-Compartmental Arthroplasty

In a few cases, only a portion of the knee joint surfaces have worn out and need to the replaced. When only a portion of the knee is replaced, this is called a uni-compartmental arthroplasty. Patients usually stay 2 or 3 days in the hospital and it takes a couple of months for the knee to recover. Physical therapy is usually required to restore knee motion and strength. Unfortunately, in most cases of arthritis, the joint surfaces are diffusely worn. Uni-compartmental arthroplasty is, therefore, less commonly performed than total knee replacement.

Arthrodesis / Knee Fusion

In cases when the risk of failure of total knee replacement is considered to be very high, an arthrodesis, or knee fusion may be recommended instead. In this operation, the ends of the femur and tibia bones are cut flat, the cut ends are pressed together such that the leg is just slightly bent, and then held in this position by pins, or plates and screws. Over a couple of months the ends of the bones grow together, hence the term knee fusion. The knee fuses in a nearly straight position and cannot be bent. Although the knee no longer moves, it is not painful and most patients walk with only a slight limp.