Watch this video of Professor Brian M Devitt, Consultant Orthopaedic Surgeon specialising in the Knee, presenting on ‘Moving forward with Knee Arthritis: what does the future hold?’.
This video was recorded as a part of SSC’s Online Public Information Meeting, focusing on Knee Arthritis.
Professor Brian M Devitt is an internationally trained Orthopaedic Surgeon with subspecialty expertise in Knee Surgery. He has a particular interest in sporting injuries, including Anterior Cruciate Ligament (ACL) Reconstruction, Meniscal Repair, Cartilage Restoration Procedures, Multi-Ligamentous Knee Reconstruction and Hamstring Repair.
Good evening. My name is Brian Devitt. I am an Orthopaedic Surgeon working at Sports Surgery Clinic in Santry, and I am a hip and knee specialist.
I have recently returned from Australia, where I have been working for the past eight years, and prior to that, I was in the USA and Canada. So it is a great pleasure to be able to speak to you today regarding Knee Osteoarthritis.
The title of my talk is ‘Moving Forward with Knee Osteoarthritis.
This is a picture of a lady I operated on a few years ago who is on a charity walk-through to Vietnam 18 months following her Knee Replacement. We learned a lot about Confucius while we were in Vietnam. Confucius has a great phrase, which is, I think, particularly for osteoarthritis. It doesn’t matter how slow you go as long as you don’t stop.
These are my three children, and they’re very cheeky, and when I try to tell them something, they say, Dad, tell me something I don’t know, so the idea behind this talk is to share with you some information you may not know about, and I’m happy to answer any questions afterwards.
We are going to talk about the basics.
What is Arthritis? What treatment works? The evolution of surgery, and what does the future hold?
We often hear this quip, it’s just a bit of wear and tear. Well, it can be, but typically when people require intervention, it’s more than just a bit of wear and tear.
Try telling this gentleman with his right knee that that’s just a bit of wear and tear. We can see severe arthritis with all this extra bone debris, and it’s amazing that people can actually cope and live with a knee that’s as badly Arthritic as this. In fact, he was complaining of pain in his left knee as well, which doesn’t look as bad but also has ‘a bit of wear and tear’.
We often see different varieties of arthritis when we look at people’s legs. You can see this as you walk down the street; you can see Normal alignment where people have pretty straight legs; you can see Varus alignment, where you’ve got both legs different; and finally, where you can see knocked knee alignment, which we refer to as Valgus.
Knees come in all different types and shapes, and we have to be able to manage them all.
What treatment works?
Here is a great quote from William Shakespeare which I learned when I was doing my Leaving Cert.
‘Eye of newt and toe of frog,
Wool of bat and tongue of dog,
Adder’s fork and blind-worm’s sting,
Lizard’s leg and howlet’s wing,
For a charm of powerful trouble,Like a hell-broth boil and bubble.
But none of them works whatsoever for Arthritis!
We often get people asking us to put crystals on our legs. Would it work if I took out some spices? Is that going to work? Today I’m going to tell you about the proven methods that work from evidence-based literature.
If you look at the conservative methods that work – these are very effective.
Physical Activity is important; just like Confucius said hundreds of years ago you have to keep moving.
Weight loss is probably the single best method of treating Arthritis non-operatively, and the reason for this is simple physics. The less load you have going through your knee, the less stress on your joints.
If you consider when you’re walking 1 to 2 times, your body weight goes through your knee. When you start walking down steps up to four times, your body weight goes through your knee. So if you could lose five kilograms, that’s 20 kilograms less going through your knee with every step. So it does work, and it’s the most effective means of conservatively treating arthritis in the knee.
Acupuncture has been shown to work well.
Massage can make you feel better if your muscles are a bit tight, but it hasn’t been shown to be hugely beneficial.
Bracing can help in certain circumstances but not all. Insoles – the same.
Glucosamine in fact hasn’t been shown to work, although it doesn’t cost much and it doesn’t do any harm. I’m not too bothered if people want to take it.
We recognise physical activity – so a lot of physiotherapists introduce Exercise Programs and Exercise Prescriptions, and I thoroughly recommend these as the first line of treatment for Arthritis because they are very effective.
We look at pharmacological treatments and see which are effective.
Anti-inflammatories are effective because they reduce the swelling within the Knee. The swelling has an adverse effect on your knee in that it shuts down your muscles, particularly your quadriceps. So your quadriceps are important for stance when you have fluid on your knee, you have a decreased ability to stand properly. You would have this sense that your knee gives way or goes back when you take a step. So Anti-inflammatories are effective.
Steroid Injections can be effective in certain cases, particularly when you’ve lots of inflammation. But when you have bone-on-bone Arthritis the steroid is not effective.
We would look at Hyaluronic Acid, which is not effective according to the literature. In certain circumstances where you have very young patients, you might try hyaluronic acid, but it hasn’t been shown to be beneficial.
In every case, Platelet-Rich Plasma (PRP) is another treatment where you take the blood, spin it down, take all the good bits and inject it back into the knee. This is effective in certain circumstances, but it’s typically the early Arthritis cases where it is effective. The evidence is still slightly dubious about its effectiveness in all cases.
Then we look at surgical treatment such as an Arthroscopic Washout. If you have Arthritis with a narrow joint space, there is very little role for Arthroscopy. Maybe 20 years ago, the treatment would have been to wash it out, but it doesn’t really help in the long term and can cause increased pain in the medium term in some cases.
Arthroscopic Meniscectomy, we have to consider that some people are on an early spectrum of developing Arthritis but might have a displaced or flipped meniscus – removing that offending article may be effective in some cases, but when you have a lot of Arthritis, it’s not very effective, even when you have a meniscal tear.
Some people describe a sensation as similar to having a stone in their shoe, but in their knee, and in those situations, it may be a flipped meniscus, and we can trim them, but we’d have to do X-rays to make sure you don’t have Arthritis as a background.
Doing an Osteotomy, so cutting the bone and realigning the bones, making those bow-legged knees straight, can be effective, but we typically would save that for younger patients as it is a harder surgery to get over.
And then Joint Replacement in the right setting is a very effective means of treating Arthritis.
So then we look at the different types of Knee Replacement that we have available – Total Knee Replacement (TKR) and Partial Knee Replacement.
When we look at a Total Knee Replacement, you can see we’re replacing the whole joint. The Total Knee Replacement is used for patients who have arthritis widespread within the knee and not just in one compartment.
Unicompartmental Knee Replacement (Partial Knee Replacement) is very effective if you just have isolated Arthritis on the inside of your Knee and no pain elsewhere. If you can point with one finger and say my pain is there, it’s on the inside doing a Unicompartmental Knee Replacement is a very good procedure.
It doesn’t take away the ligaments, which allows some early rehabilitation, making it easier for the patient and kinematics or the knee movement, which is more like their native knee, so people tend to do very well with that.
We also can do a Lateral Unicompartmental Knee Replacement, but it’s not as common, and you can also just replace it under the kneecap as well, but equally, that’s not as common.
The Unicompartmental Knee Replacement has had a resurgence because we’ve seen how effective it is for patients.
Methods of Knee Replacement
There are also different methods of how we can do a Knee Replacement. This is an example of Patient-Specific Instrumentation. We conduct CT scans beforehand to get a map of the patient’s knee so we see all the patient’s arthritis, and you can use these specific implants that you place on the patient’s Knee and they allow you to make the cut so you can get an accurate cut that’s specific to that patient.
These came into prominence probably around 15 to 20 years ago and seem to be a way of maybe improving the accuracy of Knee Replacement, but really, the outcomes haven’t been shown to give greater effectiveness to the standard of instrumented Knee Replacement that we currently do.
People have also looked at other methods of doing replacements you may have heard of Robotic Knee Replacements.
Now it’s not some robot coming into the room and replacing the surgeon! This is the surgeon controlling the robot that does the knee replacement.
The idea behind this Knee Replacement is that we can get really accurate measurements of how the knee moves and measurements of the anatomy that you’re dealing with CT scans before the surgery, and the robot then allows us to do very accurate cuts, and these are cuts accurate to the micro millimetre so that we don’t have much variation when we’re applying the prostheses and you can also look at ways of balancing the knee very nicely so that the patient can move without any major difficulty.
But once again, there haven’t been a huge number of studies that have shown a proven benefit to having a Robotic Knee Replacement compared to an experienced Knee Surgeon done with standard instrumented techniques.
But I think Robotic Knee Replacement is likely to be the future of knee replacements, but the technology is constantly evolving. However, you’re better off picking an experienced surgeon for your Knee Replacement rather than just picking the fancy robot on the brochure in my opinion.
We look at all the companies, and robotics is obviously the new vogue and as surgeons, we’re like followers of fashion with different cuts of suits with different ties and shirts. We like to change the prostheses every now and again.
We do so based on registry data. Registry data is very important data that we take from people who follow up on knee replacement, there is a huge registry in Australia which is very informative, and it looks at how those prostheses go, how the knee replacement from the different companies are doing over time, and it can identify those prostheses that aren’t doing very well.
They’ve shown some of the early data with robotics that it is very effective, and they seem to have very good outcomes in terms of not requiring revision, as to whether they improve the patient outcome in terms of how they live, which is yet to be determined.
Future Of Knee Replacement
So what does the future hold in terms of knee replacement?
This is a picture of my family. My grandfather is this little fella here in Tipperary in the early 20th century, and notice he isn’t wearing shoes. And of this family, my grandfather had both knees replaced, his brother had both knees replaced, and his older brother had both knees replaced.
So I think I know what’s in my future in terms of knee replacement. But we do recognize with Knee Replacement that there is a genetic predisposition for replacements, and perhaps the future is trying to identify those individuals who have a predisposition for Arthritis and being able to alter genes or look at different methods of managing that individual.
What’s also in common with all of my predecessors is they’re all athletes. They all ran and played Hurling and Gaelic Football. So I think that’s probably as much a part of the genes as well is that you’re interested in playing a sport, and unfortunately, that can have its effect later on in your life.
But we also looked at other methods in terms of what the future holds.
We have a lot of smart fabrics nowadays that can help us with our rehabilitation, they can tell us which muscles we are activating, how our range of motion is with our knee, and follow us up with apps that can help us remind ourselves when we need to ice our knee, remind us when we need to do our exercises set goals for us.
I think that once we have this biofeedback, as we describe it, it’s very effective in improving the outcomes following surgery, but also the rehabilitation before surgery and hoping to avoid surgery as long as you can.
After all, I tell patients that their objective is to avoid people like me for as long as they can, but when you come to have a Knee Replacement, it’s a very effective procedure in that situation.
You might have heard of Stem Cell Therapy for Knee Arthritis, and this is an area where I get a little bit concerned because I am a professor of Orthopaedics, and we do a lot of research to see what the evidence base is. You didn’t see stem cells on my list earlier because the evidence isn’t there yet.
Unfortunately, a lot of people make a lot of money by trying to offer you the great panacea to treat arthritis without surgery, and this is not the way to do it, in my opinion.
Be careful what you read in the papers, and this includes scientific papers. If we look at the injection of Platelet-Rich Plasma for early-stage Osteoarthritis, we find that this study shows that it’s good; this other study shows it’s not so good when there is an equivalence between Hyaluronic acid and platlet-rich plasma, and this study shows that there is no difference between the two.
So it’s important that you take a lot of this information with a pinch of salt.
This study says that case in point, that we really have to do further analysis of these treatments to see if they are truly effective.
When it comes to stem cell therapy, obviously recently, I came from Australia, and the Association of Rheumatology and the Australian Orthopaedic Association have issued a warning regarding the use of stem cells that they should only be done in the setting of randomised controlled trials, which are carefully performed.
So people shouldn’t be selling this commercially to make money from patients. This should be part of the study so we can understand more about the effectiveness of stem cells.
So just be cautious if people are offering it without being part of the study, which is further evidence of that.
How long does it take to recover from knee surgery?
While recovery can be variable following knee surgery, typically, if you look at the different stages, most patients walk without crutches by roughly 4 to 6 weeks following surgery. In terms of pain-free existence, people tend to have some pain at night in particular, which lasts up three months, but the time it takes for people to feel like they haven’t had a Knee Replacement can be anywhere between six months to 12 months.
So it can vary, but most of the time, people feel an improvement in knee pain reasonably early afterwards, but they may have some pain related to swelling.
When can I drive following a knee replacement?
I think it depends on the individual. In terms of your ability to move your foot is not that much hampered by knee replacement. It’s not like you’re driving a combine harvester, so you don’t have to flex your knee quite a lot.
I always recommend that people shouldn’t be on any narcotic medication and should feel comfortable in themselves to drive. So it’s typically anywhere up to six weeks where you’d recommend driving, but it’s on an individual basis.
Could you explain aspiration as a way of reducing swelling of the knee caused by aggravated osteoarthritis? Does it help?
This is a very good question. We recognise that swelling in the knee can be quite painful and also result in a sense of instability because when you have fluid in your knee, it stops the muscles in the front of your knee from working correctly. These are very important for your ability to stand.
The difficulty in terms of aspiration is if you consider the presence of fluid in your knee as analogous to smoke in a room. If your removing fluid from the knee, it’s the same as opening the door to let the smoke out of the room. However, if you don’t put out the fire, the smoke will just re-accumulate once you close the door again.
So the key is to understand why the fluid has developed. If it’s not settling with anti-inflammatory medication perhaps an aspiration and an injection of steroids may be beneficial, but I wouldn’t recommend repeated aspirations as every time you stick a needle in a joint you run a risk of introducing infection.
Jane has had two arthroscopies on her right knee, one was in March 2001. Now her knee is very sore, especially after walking, and it is swelling. Any suggestions on what she should do?
Well, I would certainly advocate getting an x-ray, a weight-bearing x-ray, for this lady just to assess if there is Arthritis.
Some of the simple non-operative means are very effective. I mentioned weight loss in my talk. If you are carrying any weight, just reducing your weight by two kilos can have an effect of eight kilos less going through your knee when you walk.
Activity modification, so avoid doing things that hurt you. Taking anti-inflammatory medication and engaging in low-load exercises such as cycling, swimming and pilates.
Avoid walking on uneven ground and hiking, for example, as that type of walking can be quite painful.
What about walking in a swimming pool following a Total Knee Replacement? Does it help recovery?
Once the wound is healed, I’m happy for patients to get into the swimming pool almost immediately. So after two weeks or so. Hydrotherapy, as we refer to it, is very, very effective because your body weight is eliminated. What you can do on dry land you are able to do way easier in water, and it improves your range of motion. For the best part, it’s enjoyable, gets you out of the house and helps get your independence back.
That’s what it’s all about.
What sports can’t you do after a knee replacement?
Well, I wouldn’t start running ultramarathons – it wouldn’t be the best idea, nor playing rugby, but certainly, I’d be happy for people to get back to cycling, and walking too.
Running is probably not the best idea in that you tend to wear out your joint a bit more quickly, but if you want to do it, go for a little run.
When I was working in Australia, they all wanted to surf, so that’s quite a level of knee flexion. If they’re able to do it, I’m happy for them to do it.
Golf is absolutely fine, but it’s a good walk ruined, is it not?
Do Hyaluronic Injections help against Knee Replacement?
A person has been recommended to get an injection of Arthrosamid for knee pain as an arthroscopic procedure has not worked. Any information on this?
And as far as I’m aware, there’s always a variety of these trade names. But I think Arthrosamid is hyaluronic acid. So it’s like the jelly I mentioned in my talk. It can be effective in early or very osteoarthritis. Once you get to bone a bonus of arthritis, it’s not all that effective. But, you know, if you’re a young person, we try to avoid joint replacements, as I mentioned, for as long as possible. So it might be an option in those situations.
What is the lifespan of a knee replacement? I’ve been informed that I’m too young for one yet.
As for the lifespan of a knee replacement, I’ve heard a very nice description of this. If you consider the failure rate of a knee replacement is probably 1% per year. So if you get to 20 years, the chances of you retaining that joint replacement are 80%.
The reality is the earlier you have it, the more action you’re going to put through that knee. So therefore, it’s probably going to fail more quickly if you’re younger.
If you’re 80 years of age, when you have your knee replacement, it’s going to outlast you, I would say.
Fiona- How often can you have a steroid injection?
It depends. For some reason, this number of three seems to come up. I only have it when the symptoms are cured by the injection, or at least helped by the injection.
If you’re getting an injection and pain coming back in six weeks, I’m assuming that you haven’t put the fire out. So you need to look more deeply at what the problem is.
Can Knee Arthritis cause thigh muscle pain?
Yes, any arthritis can cause a huge amount of pain. I think sometimes the thigh muscle pain can relate to the position the knee is held in. If your knee is held in flexion, you put a huge amount of stress through your quadriceps, which are the muscles at the front that can cause thigh pain.
But we would often investigate this and other sources. You can get pain from your hip, which also goes to your knee. So it would be very advisable to look at the hip in addition to the knee if you’re investigating that as a physician.
If you’ve had one knee replaced, will you have to replace your other one in the future?
It depends on what the reason for the arthritis is. If you’ve had a traumatic event on one knee, you may not get pain in the other.
If it’s more of a genetic issue, you will likely have the same problem on both sides.
I often tell people if the pain had a gender, the pain would be male because men can’t multitask. So you only get pain one joint at a time. So once you’ve got rid of the pain in one joint, the other often becomes painful, unfortunately.
A person has a diagnosis of osteoarthritis. Is it common to experience cramp-like pain in calf muscles because of this?
It’s very common. Yes. A lot of the time, it’s because you have fluid at the back of your knee. You’ve often heard the phrase a Baker’s Cyst.
A Bakers Cyst is not pathological -it’s where the fluid collects. So just like the bakers, when they’re reading on the ground with arthritis in the front of their knee, what happens is the fluid collected at the back, and that’s why they could see it or feel it, and your calf muscle is attached to the back of your knee hence you get calf cramping.
It’s probably not a great idea to constantly take anti-inflammatories. So If somebody is taking a lot of these, should they seek guidance from a Physician?
Yes, I think so. It happened a lot in the past. That’s why Joint Replacement was such a revelation when it came to prominence because people were taking anti-inflammatories or aspirin, earlier versions of drugs. They were getting gastric ulcers as a result.
So, anti-inflammatories should be intermittent use for swelling and shouldn’t be taken long-term.
If I have to get a Knee Replacement, what kind of medical checks should I have?
Brian– I suppose it depends on someone’s age, really, and their fitness level. At Sports Surgery Clinic, we engage people in our Pre-Assessment Clinic.
As surgeons, we don’t like surprises at the time of surgery, so if you can be fully optimised for surgery, that is the best thing. That means it’s safest, and the anaesthetist is happy; we do an ECG and some blood tests. If necessary, there is cardiology, we can do an echocardiogram to assess the function of the heart.
So all of these things are important but not always necessary for every individual.
How soon after a knee replacement can I play Golf?
You can start putting if you wish inside six weeks. You can start chipping after that, but before you get the big dog out and start doing a Happy Gilmore, I would look at three months.
How long does it take to recover from Kneecap Resurfacing?
It depends on when and how it’s done if it’s an isolated procedure or part of a joint replacement.
If it’s an isolated procedure, it’s a similar recovery to TKR you’re talking six weeks to three months.
If done as part of a joint replacement, it makes no difference in terms of recovery from normal joint replacement