copyright 2000, Joint
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.
Arthrodesis or Knee Fusion
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
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
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.
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.
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.