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  Last update: 29 January, 2009
Imuka 2009

Knee Arthritis

Early treatment of arthritis of the knee may improve the functional well-being and long-term outcome in patients. Nonoperative treatments to reduce the pain associated with joint inflammation include weight loss, anti-inflammatory or analgesic medication, intraarticular injections, periarticular muscle strengthening and stress offloading with braces or heel wedges.1

The reduction of joint reaction forces and symptoms of degenerative arthritis by a decrease in body mass is a fundamental concept in the management of arthritic joints.2 Obesity is an independent risk factor for the development of osteoarthritis in the knee,3 and this association is higher for women than for men.4 Women over the age of 50 with malalignment have a higher prevalence of degenerative arthritis of the knee than do age-matched control subjects in the general, nonaffected population.5 Weight loss by obese women decreases the risk of developing degenerative arthritis. A weight loss of 5.1 kg over ten years has been shown to decrease the risk of degenerative arthritis by >50%.6

Nonsteroidal anti-inflammatory medications are the most commonly used drugs for treatment of degenerative arthritis of the knee and other joints. These drugs, which inhibit cyclooxygenase 1 and 2, have analgesic and anti-inflammatory properties, but they can be associated with gastrointestinal and other side effects. In a short-term clinical trial in which acetaminophen and ibuprofen, in analgesic and anti-inflammatory doses, were compared as treatments for symptomatic arthritis of the knee, the efficacy of the two drugs was equivalent.7 When nonsteroidal anti-inflammatory drugs are used chronically, it is important for patients to have medical monitoring of the hepatic, renal and gastrointestinal systems.8 Specific cyclooxygenase-2 inhibitors have demonstrated clinical efficacy in the treatment of symptomatic arthritis of the knee, with decreased gastrointestinal and renal side effects. However, specific cyclooxygenase-2 inhibitors are more expensive, and risk-benefit and cost-benefit analyses must be completed to better define the role of these agents.8 Nutritional supplements (so-called nutriceuticals), such as glucosamine and chondroitin sulfate, have been touted as chondroprotective agents. Double-blind, placebo-controlled, randomised trials have shown that glucosamine is mildly effective for relieving pain associated with degenerative arthritis.9-12 In a study by Reginster et al.,13 212 patients with osteoarthritis of the knee were randomised to a glucosamine or a placebo treatment group. After three years of treatment, the glucosamine group had less joint-space narrowing and improved WOMAC (Western Ontario and McMaster University Osteoarthritis Index) scores when compared with the placebo group. However, we are not aware of any long-term studies demonstrating beneficial effects of glucosamine on the articular cartilage of an arthritic joint.9 Some patients with arthritis of the knee report improvement with use of topical analgesics (e.g. methyl salicylate, capsaicin and nonsteroidal creams) as either adjunctive treatment or monotherapy.2

Acute exacerbations of degenerative arthritis of the knee presenting pain, swelling and effusion can be treated with aspiration of the knee joint and intra-articular injection of a corticosteroid preparation. Corticosteroid injections are frequently combined with a local anaesthetic medication and can provide short-term symptomatic relief. However, these injections can increase the risk of damage to the articular cartilage of the injected knee joint, and they should not be repeated more than three or four times a year.14

Exercise, as an adjunct to weight reduction, has value in the treatment of an arthritic knee. Stretching to prevent contracture, maintain range of motion and increase muscle strength and dynamic stability of the knee can reduce symptoms associated with an arthritic knee.15 Quadriceps muscle weakness is common among patients with degenerative arthritis of the knee and may be a risk factor for this disease. Patient education programs and supervised fitness and walking sessions have been shown to improve functional status without worsening the symptoms of osteoarthritis of the knee.16

Three types of knee braces are commercially available for the treatment of a knee with degenerative arthritis: compression knee sleeves, supportive knee braces and unloading knee braces. Polypropylene, neoprene or elasticised knee sleeves may minimise swelling and provide a feeling of increased support and warmth about the knee without changing limb alignment, joint stability or mechanical function. Some patients report a feeling of security with a knee sleeve, possibly because of enhanced proprioceptive feedback.15 Supportive knee braces include hinged braces (for varus-valgus instability), anterior cruciate insufficiency braces (for anteroposterior and rotatory instability) and patellofemoral braces (for patellofemoral malalignment or instability). Unloading braces are designed to apply a varus or valgus force at the knee and relieve pain during activity by distracting the joint space of the involved compartment during weight-bearing and activity.17 Heel and sole wedges can realign the foot 5° to 10° in either the varus or the valgus plane. With a lateral wedge and insole, the shift in alignment reduces medial joint-space loading.18 Keating et al.19 evaluated 121 knees with medial arthritis in 85 patients who were treated with a lateral heel and sole wedge. Sixty-one of the 121 knees had a good or excellent result after four to 24 months of treatment. Knees with all grades of arthritic involvement showed improvement. Patients with stage-II disease according to the modified Outerbridge classification20 improved the most.

When nonoperative treatment of osteoarthritis of the knee fails to relieve pain and knee function is compromised, operative intervention is warranted. Surgical choices include arthroscopic debridement, joint reconstruction, or both. Joint reconstruction choices include osteotomy and knee replacement. Joint replacement can be or total.1

Arthroscopic debridement has long been considered an effective alternative in the treatment of osteoarthritis of the knee.21-23 However, a recent study by Mosely and colleagues called its value into question.24 They compared a placebo group with a group treated with arthroscopic joint lavage and another group treated with arthroscopic debridement. All three treatment groups had a decrease in symptoms up to two years after intervention. This study was confined to older men in a Veteran's Administration Hospital. The extent of the arthritic involvement of the knee (in one, two or three compartments) was not documented. Patients were not stratified according to degree of malalignment, body weight or type of symptoms. The authors concluded that arthroscopy of a knee with degenerative arthritis may not be indicated when there is only pain in the absence of other symptoms (such as catching, clicking, locking or giving way). Furthermore, they suggested that a decrease in symptoms after arthroscopy may be associated with a placebo effect. There have been several other retrospective studies of arthroscopic treatment of degenerative arthritis of the knee, with unfavourable results.25-27

The rationale for an osteotomy is based on the premise that excessive varus or valgus deformity leads to harmful stresses on the articular cartilage, which in turn lead to osteoarthritis. As long as overcorrection is avoided, corrective osteotomy of the knee is associated with biological improvement of damaged articular cartilage with maintenance of articular cartilage in the least degenerated compartment.28-37

knee arthroplasty is a potentially attractive alternative to tibial osteotomy or total knee arthroplasty in selected osteoarthritic patients. Traditionally, knee arthroplasty has been reserved for patients with arthritis who have a sedentary lifestyle and are older than 60. However, there has been recent interest in performing this procedure in patients younger than 60 as an alternative to tibial osteotomy or total knee arthroplasty.38

Total knee replacement has been shown to have durable and predictable results in elderly patients, providing pain relief, improving function and correcting deformity. The possibility of multiple revisions due to loosening or wear initially discouraged the widespread use of total knee arthroplasty in young patients with degenerative arthritis.37 These concerns arose from the poor results observed in young patients who had had a total hip arthroplasty. However, the early results of total knee arthroplasty in young patients did not reflect the experience with total hip arthroplasty, and preliminary reports often included many patients with rheumatoid arthritis or juvenile rheumatoid arthritis. On the basis of this initial success, the indications for total knee arthroplasty were eventually expanded to younger patients with osteoarthritis. As the indications continue to expand, the decision to proceed with total knee arthroplasty in young, active patients needs to be individualised after careful consideration of alternatives.38

References

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