The knee is a complex joint that is prone to injury or disease. There are many patients who seek medical attention for their knee problems. Some of the most common knee problems are osteoarthritis, ligament injuries, and meniscal injuries. In the past, patients with severe knee problems may have undergone surgery as a first line of treatment. What’s always been a challenge, however, is treating knee problems in the elderly and those with other medical problems. During the last twenty years, there has been a growing interest in the conservative treatment of knee problems. This is due partly to the growing evidence that surgery is not very effective or cost-effective in the treatment of many knee problems. Physical therapy and the use of aids such as knee braces have been shown to be very effective in the treatment of osteoarthritis. It has now been shown that a specific type of exercise called neuromuscular exercises can protect those at high risk of knee osteoarthritis from getting the disease. With such evidence, many patients with knee osteoarthritis can avoid the need for total knee replacement. High tibial osteotomy (HTO) is a surgical procedure performed to relieve symptoms of knee arthritis. This procedure has been largely replaced by joint replacement in many countries, as studies have shown no difference in clinical outcome between HTO and non-surgical treatment. However, in the young and active patient, there is still a role for HTO. The recent development of a synthetic implant for HTO provides an option for those wishing to avoid the use of bone graft.
Current Challenges in Knee Pain Treatment
It is important to distinguish between acute knee injuries and overuse problems. Acute injuries are usually associated with significant direct trauma and may be immediately disabling. Conversely, chronic overuse injuries can be insidious in onset with minimal initial disability though they can lead to far greater damage in the long term. There is a growing population of older individuals who are attempting to maintain active lifestyles leading to higher expectations of continuing high level function despite degenerative knee problems. Patellofemoral pain syndromes are recognised as one of the most significant sources of chronic knee pain and disability, particularly in the young and active population. It has been suggested that the abnormalities in patellofemoral alignment observed in many of these patients represent a continuum from normal alignment to frank instability and can lead to the development of patellofemoral arthritis. Primarily soft tissue injuries like ligament sprains and tears and meniscal tears have a strong influence on the later development of joint degenerative change. Accurately assessing the severity of these kinds of injuries and their potential for long-term effects on joint health has always been challenging.
Emerging Innovative Therapies
Minimally invasive procedures cover a very wide range of techniques and technologies that are performed through small incisions, as opposed to the one large incision from open surgery. The above procedure is another general example of invasive surgery. There are many benefits of MIP as compared to open surgery; MIP generally has less scarring, as well as shortened recovery time and reduced trauma to the tissues involved. A very specific and interesting area of MIP is the usage of osteotomy around the knee. This procedure involves cutting bones of the leg and realigning them, which can effectively relieve pressure off damaged areas of cartilage. Weight-bearing axis corrective ankle surgery is one such procedure, with remarkable results in the treatment of ankle and osteoarthritic knee pain.
Regenerative medicine is an upcoming field that involves substituting damaged tissue with new tissue that will heal again. An example is the usage of articular cartilage resurfacing, whereby the cells are removed and cultivated in vitro before implanting back into the defect. When it comes to this therapy, patient selection remains extremely important. Proper indications for the procedures need to be adhered to, and patients need to be informed of alternative therapy and the natural history of their problem. Success rates are also varied, and while it can be extremely beneficial, there is still the potential of wasting money when the effects are not long-lasting, so do consider carefully before choosing this option.
Regenerative Medicine
Microfracture is a surgical technique that is usually performed arthroscopically. It is most suited to smaller areas of damage to articular cartilage in younger patients. It involves debriding any loose or damaged cartilage, then using a pick to create multiple holes through the subchondral bone plate into the bone marrow. This releases pluripotential stem cells from the marrow to the site of damage, and makes a ‘superclot’ from the bone marrow blood and cells under the damaged cartilage. This then has the potential to form fibrocartilage repair tissue over the damaged area, but the results are fairly unpredictable and patients may require further surgery if the repair tissue breaks down.
There are numerous potential regenerative medicine treatments that might be called ‘innovative’ in comparison to today’s conventional techniques for delaying knee replacement. Most are not widely accepted nor established, and are only available in the private sector, but with rapid advances in medical technology and technique it is likely that regenerative medicine treatments will play a significant role in reducing the incidence of knee replacement for OA over the next decade.
Minimally Invasive Procedures
Today, many centers of regenerative medicine are being established. The International Olympic Committee has taken an interest in these treatment modalities, and it is now available in certain countries in the form of injury treatment for athletes who can return to their sport fast, as well as knee preservation for the elderly. These are promising treatments, but at this time, there are still many up and coming research, and have not yet been covered by insurance.
The recent stem cell therapy and the platelet-rich plasma is an area of active research and a hot topic in sports medicine and orthopedic surgery. Injuries involving the ligament, muscle, and tendon are being treated with these procedures to heal and strengthen the tissues, preventing progression into arthritis, and thereby avoiding the more aggressive treatment of total joint arthroplasty. This treatment could also benefit patients postoperatively after meniscus removal or cartilage surgery.
It’s common problems such as acute and chronic pain, knee problems brought about by a sports injury, osteoarthritis and cartilage damage that increases day by day, the unfortunate but accelerating incidence of knee replacement, and what hope they could avail to avoid the high complications and failure rate of knee replacement surgery. Innovative technologies and procedures in regenerative medicine, and the trend toward more minimally invasive procedures that promote faster recovery with less postoperative pain, continue to keep knee surgery on the cutting edge.
Alternative Pain Management Techniques
Pain management is a fundamental aspect of healthcare, and any therapeutic intervention on a patient that pioneers a change to a painful condition through minimizing the symptom of pain is a positive one. There are many ways of introducing pain relief in knee osteoarthritis. They can be divided into non-pharmacologic and pharmacologic interventions. Non-pharmacologic strategies include undertaking physiotherapy, physical agents such as heat, cold, and electrical nerve stimulation, hydrotherapy, weight reduction, and ambulatory aids. Pharmacologic interventions include simple analgesia, non-steroidal anti-inflammatory drugs (NSAIDs), steroid injections, opioids, and surgical denervation of arthritic joints. Patient education and lifestyle modification are important yet often overlooked strategies. They do not fit neatly into the above categories. These include provision of one or more of the listed treatment options at a time other than the first presentation, to patients who may initially opt for or later accept a joint replacement. This is particularly relevant to younger patients. The benefit of delaying joint replacement in older patients and its impact on their perception of treatment satisfaction is as yet unknown. Alternative therapies are often sought by both patients and physicians in an attempt to alleviate joint pain. This can lead to a wide and uncontrolled introduction of new therapies into clinical practice. The efficacy of newer treatments is often not determined or is determined after the intervention has become popular. Randomized controlled trials (RCTs) have demonstrated that while total knee replacement provides a superior improvement in pain and functional status over non-operative treatment in severe knee osteoarthritis, there remains a difference in symptom severity among patients with less advanced disease. This raises the need for effective interventions to relieve pain in milder to moderate disease. The plethora of existing and emerging treatments, their varying efficacy, and the difference in patient preference for specific treatments have highlighted the need for a treatment algorithm to assist in making an informed choice from the available therapies.
Knee pain is the most common lower limb musculoskeletal problem present in Singapore today. With a growing active ageing population, knee joint injuries and the progression of post-traumatic knee osteoarthritis will become an increasing burden in healthcare systems and health-related quality of life. In order to maximally treat knee injuries and OA, whatever the model of care, healthcare provider or healthcare system, clinicians must always retain a patient-centered view. By retaining a patient-centered view, clinicians are able to individualize treatments in order to optimize patient-related clinical outcomes. This can now be achieved with a greater understanding of tissue injury and the use of targeted interventions to facilitate tissue repair and, more recently, tissue regeneration.
In summary, there are common dilemmas in diagnosis and treatment which need to be overcome in order to optimally treat knee injuries. Imaging techniques can often not give a prognosis or an accurate assessment of the nature and severity of the injury. In addition, surgery and conservative practices do not always result in successful treatment of joint surface injuries. Furthermore, knee joint injuries can often cause damage to other tissues within and surrounding the knee. With such difficulties, it is always difficult to decide on a form of treatment. It is crucial that a treatment offers a better long-term clinical outcome than the natural history of the injury, with minimal detrimental effects and complications. Based on the nature of emerging and established tissue repair and regenerative medicine interventions, it is likely that the treatment of knee joint injuries will continue to evolve and improve.
