What The Future Holds For Knee Replacement Surgery
We've got the lowdown on the latest surgical techniques.
At first, Emily Patenaude didn’t notice the pain. Waking up from general anaesthesia after undergoing a knee replacement at Victoria General Hospital in British Columbia, she was too high and happy. The hurt came a few days later, when she weaned herself off the prescribed opiates.
She knew it would be bad. Her surgeon and his team had been telling her so for months before making an incision in her left leg to remove her old, arthritic knee and replace it with a metal-and-plastic version. It all began 21 years earlier on a nursery ski slope. A turn gone awry caused a fracture that spiralled up from her ankle to her kneecap. Although it healed, unbeknownst to her, the initial trauma caused cartilage in the knee to begin to break down. Eventually, the joint became so weak, she appeared bow-legged on her left side.
Fast-forward to the summer of 2014, when she was taking care of her granddaughter. She was entertaining the young girl by hauling her around in a wheeled contraption until her knee was so swollen, inflamed and sore that she sank into a sofa and couldn’t get up for several months.
Osteoarthritis, the most common joint disorder in the world, had been stealthily creeping in for years.
Now, it was taking her hostage. A resident of Mayne Island, off the southwest coast of British Columbia, Patenaude could no longer walk the 2 ½ kilometres from her home to the local hardware store, where she worked, and wasn’t able to hike or sail. She could barely stand in her kitchen to prepare a meal.
In May 2015, just after her 63rd birthday, she travelled to Vancouver to see a sports physician. After studying her X-rays, he told her that she needed a knee replacement, stat. “There is no physiotherapy or series of exercises that will make you better on its own,” she was told. All she could do was strengthen the muscles around her knee to handle recovery and rehabilitation better after the procedure. Over the course of an hour or so, her orthopaedic surgeon would cut, resurface and drill holes into the three bones that make up her knee. He would attach them together again with a replacement that weighed about 420 grams and hammer it into place.
Even with the opiates at the beginning, once Patenaude was completely conscious, she recalls that “it hurt like heck” when she tried to shift her body. It was heck when she began rehab the week after surgery, as she tried to bend, straighten and lift, and it remained heck for the next two weeks. But she didn’t give up. She thought, My job is to get better, so she did. For a month, she went to the rehab clinic three times a week. Then it was cut down to twice a week. Finally, after two months, the therapist said she could do the rest on her own, with the occasional visit for a check-up. “It’s easy to think, I can just get a new knee, but I know better,” says the 66-year-old. “You have to be willing to do hard, painful work. But in the end, it’s so worth it.”
This is your healthy knee: three joints that fit together like pieces of a puzzle and function in concert as you bend, straighten and kick out to the side. It bears the brunt of your weight when you jump to shoot that ball into the net, race to the finish line in a marathon, pick up children or grandchildren or lift that bag of groceries containing bottles and tins. This is your knee on osteoarthritis: creak, pop, ouch. Despite advances in medical technology, the condition is very hard to fix because cartilage doesn’t have its own supply of blood, so it doesn’t heal itself.
When it comes to aging knees, the World Health Organization reports that osteoarthritis is the single most common cause of disability in older adults. A 2013 study suggests that between 10 and 15 percent of adults over the age of 60 have the condition to some degree. Citing data from the United Nations, the same study notes that, by the year 2050, when more than 20 percent of the world’s population will be over 60, a whopping 130 million people will suffer from osteoarthritis, with nearly one-third of them severely disabled. “Osteoarthritis is like grey hair,” says Toronto physiotherapist Candice Wong. “The only variable is to what extent you’ll get it.” Genetics plays a role in its development, as well as excess weight, activity levels and previous injuries. (Keep in mind, genetic tests help determine your body’s nutrition and training needs.)
Total knee arthroplasty (TKA) is the fastest-growing way to deal with this crippling problem.
According to the Organisation for Economic Co-operation and Development, between 2005 and 2014, there was a steady increase in TKAs in all of the member countries where data was available. In Europe, Austria had the highest number per capita, with 18,785 procedures performed in 2014, with Germany and Finland close behind. American surgeons have performed the most TKAs of all, with the numbers expected to grow 673 percent by the year 2030, to nearly 3.5 million procedures a year, from about 534,000 in 2005.
Introduced back in the 1970s, the procedure makes sense, says Dr. Christopher Kaeding, an orthopaedic surgeon and executive director of the sports medicine program at Ohio State University in Columbus. The rate of symptom relief exceeds 85 percent. But Dr. Kaeding warns that all of this newfound freedom comes at a cost, especially if you get a total knee replacement in your 50s or early 60s. This group has seen a 20-fold increase in the procedure in the past two decades because the replacements don’t last forever. Although the procedure and materials used – alloys of cobalt-chromium and titanium and plastic – have been refined over the years, the simple rules of wear, tear and mechanics are bound to take their toll. “Total knee replacements last between 12 and 20 years,” he says. “Each time they’re replaced, the results – mobility, flexibility and ability to handle weight – are less than what they were before.”
In addition, several studies in Finland and the US have found that since “younger” patients are likely to be more physically active, the need for a revision knee replacement may be up to two times higher than in older patients. And that, says Dr. Kaeding, is why the latest thinking is to avoid having a total knee replacement until the last possible moment. Just ask Marjukka Räsänen, an accountant in Helsinki for whom effortless bending and stretching are but a memory. When she was 20, while rushing to pick up the mail in her parents’ home, she slipped, dislocated her right kneecap and badly strained her lateral collateral ligament, which runs along the outside of the knee. “I needed major surgery that had me in a cast for three weeks, from my foot to my pelvis,” she says.
Twenty years later, Räsänen, by then married and a mom of two, was jogging while warming up for a karate class. All of a sudden, she slipped and went down on the same knee. Even without a doctor’s diagnosis, she knew. “I’d strained or torn the ligament and dislocated my kneecap once again,” she says. “This time, surgeons cut my shinbone and secured it in a different position to keep the kneecap in place.
Now 53, Räsänen, who has osteoarthritis in both knees, is delaying having a TKA, despite days where she can’t even take one small step without pain. In the interim, to ward off stiffness as much as she can, she attends a Pilates class every week, jogs in a pool and does strength training and stretching at her desk in the office. Nothing else has worked, including the surgical repositioning of her shinbone, an operation to repair the cartilage and injections of cortisone (a steroid commonly used to relieve joint pain while an injury heals). Here’s more expert advice to help relieve joint pain.
Is there hope for more knee replacement alternatives in the future?
Yes, say experts like Dr. Kaeding and Mats Brittberg, a professor in the Cartilage Research Unit at the University of Gothenburg in Sweden. But some are further away than others, including a biological way to make cartilage repair itself (otherwise known as the “holy grail”). “At one point, it was thought that stem cells [undifferentiated cells that can transform into specialized ones] could be used to repair the joint by producing new cartilage, but that hasn’t happened yet,” says Brittberg.
“While such a treatment could relieve symptoms, it’s very expensive and pharmaceutical companies need to demonstrate that it would have consistent results. It’s a very difficult task.” Dr. Kaeding says that more headway is being made on focused repairs with something that mimics real articular cartilage. “Think of an asphalt road that has one pothole,” he says. “There have been significant strides in filling that pothole, but we’re a long way from completely resurfacing the road.” Back on Mayne Island, Patenaude was able to go on a dream trip with her husband on their 27-foot sailboat, Avaré, and spend five months exploring the fjords in northern BC. Crouching, walking, climbing and sitting were just fine. And that angry red scar? It’s now pink and faded.
Holding out hope for new and improved options for a knee replacement
A partially bionic knee
The NUsurface Meniscus Implant, a synthetic, polymer-based meniscus replacement, has been in use in Europe since 2008. It provides patients in dire pain with something that falls between prescriptions for non-inflammatory medications and a total knee replacement to prolong the life of the knee.
Bridging the gap
Unlike standard surgery, where a graft harvested from elsewhere in the knee is used, this anterior cruciate ligament (ACL) surgery uses a sponge bridge to connect the torn pieces of a ligament. This graft doesn’t always take, and osteoarthritis typically sets in 15 to 20 years later.
Not your usual supplement
Chondroitin sulfate capsules, which are widely available, are supposed to slow the progression of arthritis. Now, the pharmaceutical-grade supplement has proven to be a little stronger – enough to give hope to aging patients who are worried about what nonsteroidal anti-inflammatory drugs (NSAIDs) are doing to their insides.
To avoid a knee replacement later in life, start strengthening your joints now and incorporate these knee exercises in your fitness regime.