Knee arthritis

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Applicable stage
  • Normal
  • Start of disease
  • Early stage
  • Mid stage
  • Late stage
  • Very late
Category
  • Diagnosis & staging
  • Self help
  • Mainline treatment choices
  • Non-Operative
  • Operative
  • Alternatives
  • All
  • Observation / <br> No Treatment

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Weight Loss info graphic
Weight Loss

Losing weight will slow down the joint wear, decrease pain and improve function.

Applicable stages
  • Start of disease
  • Early stage
  • Mid stage
  • Late stage
  • Very late
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    What is it?
    • Losing weight through diet and exercise has multiple benefits for knee arthritis patients.

    • Every 1 pound of weight increases the force through the joint by 3 - 6 times.

    • Losing weight will slow down the joint wear, decrease pain and improve function.

    • Obesity increases the risk of osteoarthritis (OA) and, once developed, worsens it.

    • It also increases the surgical and anaesthetic risks when these interventions are considered later on in treatment.

    Benefits
    • Losing even a few pounds can improve arthritis symptoms.

    • Studies say you can experience between a 21% and 33% decrease in arthritis symptoms just with weight loss

    • Weight loss slows down joint wear, the progress of arthritis, improves pain levels, activities of daily living (ADL) and overall mobility.

    • Other health benefits include decreased risk of cardiovascular and respiratory diseases and the development of type 2 diabetes.

    Risks
    • No major risks identified.

    • May crave food and find difficult to stick to the plan

    • Extreme sudden dieting may result in an electrolyte imbalance. It may also affect internal organ function (especially kidneys and liver).

    Cost
    • This is a low-cost option for both the patient and the NHS

    • These changes are unlikely to increase weekly shopping cost. This is especially true if you use available resources, shop intelligently and change habits.

    Limitations
    • Difficult to achieve significant weight loss in a short period of time.

    • Inability to tolerate changes in diet habits.

    • Immediate side effects include lack of energy, headaches and irritability. 

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    Observations / No Treatment info graphic
    Observations / No Treatment

    Applicable stages
  • Normal
  • Start of disease
  • Early stage
  • Mid stage
  • Late stage
  • Very late
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    5. Late stage
    6. Very late

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    Activity Modification info graphic
    Activity Modification

    Impact oriented activities can increase stress going through the joint.

    Applicable stages
  • Start of disease
  • Early stage
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    What is it?
    • Avoiding impact orientated activities that can increase stress going through the joint.

    • Find alternatives, such as swimming, or take steps to reduce the impact your current activities are likely to have.

    Benefits
    • Many arthritic patients report a decrease in the intensity of pain after modifying their activities.

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the long term.

    Risks
    • No major risks identified.

    • Pain may increase in the initial stages and some people may notice an increase in swelling.

    • Some may also have problems in adapting to new footwear.

    Cost
    • Low cost option for both the patient and the NHS.

    • May be some personal costs (e.g. footwear, exercise clothing and equipment)

    Limitations
    • Difficult to achieve improvement in a short period of time.

    • Minimal side effects reported.

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    Basic Exercise info graphic
    Basic Exercise

    Low impact exercises have been shown to have significant beneficial effects.

    Applicable stages
  • Start of disease
  • Early stage
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    What is it?
    • Low impact exercises that can have significant beneficial effects on arthritis symptoms.

    • These exercises can improve the strength of muscles around the joint, while also benefiting the bone and ligaments.

    • They also maintain movement in the affected joint.

    Benefits
    • Many arthritic patients report a decrease in the intensity of pain after modifying their activities.

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the long term.

    • There’s currently no randomised controlled trial to prove how this is benefiting patients.

    Risks
    • No major risks identified.

    • Pain may increase in the initial stages and some people may notice an increase in swelling.

    • Some may also have problems in adapting to new footwear.

    Cost
    • Low cost option for both the patient and the NHS.

    • May be some personal costs (e.g. footwear, exercise clothing and equipment).

    • There may also be minimal recurring expenses for accessing and maintaining health advice service, website subscriptions, access to physiotherapist and leaflet publications.

    Limitations
    • Difficult to achieve improvement in a short period of time.

    • Minimal side effects reported.

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    Simple Pain Management info graphic
    Simple Pain Management

    Simple measures of pain control that is easily available without needing a healthcare professional’s advice.

    Applicable stages
  • Early stage
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    What is it?
    • These are first line methods to help control local pain and inflammation.

    • These simple measures are easily available and do not need a healthcare professional’s advice.

    • These measures include the local application of heat or cold, ointments, short term use of over-the-counter painkillers, walking aids or heel cushions.

    Benefits
    • Many arthritic patients report a decrease in the intensity of pain after modifying their activities.

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the long term.

    • Local anti-inflammatory gels have similar benefits as oral anti-inflammatory tablets.

    • A walking stick will help improve walking distance.

    Risks
    • No major risks identified.

    • You may experience skin irritation from local application of medications.

    • Be aware of bleeding ulcers, exacerbation of acidity symptoms or asthma.

    • Excessive use of medications can affect renal or liver functions

    Cost
    • Low cost option for both the patient and the NHS.

    • Patient: cost of over-the-counter medication and/or the purchase of a walking stick.

    Limitations
    • There are minimal side-effects for external physical methods.

    • Oral anti-inflammatory tablets have gastrointestinal side effects.

    • Generally, Paracetamol is less effective with moderate to severe arthritis.

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    Physiotherapy / Structure Exercise Programmes info graphic
    Physiotherapy / Structure Exercise Programmes

    Interaction with a professional therapist will allow for confirmatory diagnosis and planning of tailored physical therapy and exercise plans.

    Applicable stages
  • Early stage
  • Mid stage
  • Late stage
  • Very late
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    What is it?
    • Meeting with a professional physiotherapist.

    • This will allow for confirmatory diagnosis and the planning of physical therapy and exercise regimes tailored to you and your condition.

    • The goal of physiotherapy will be to improve your ability to do daily activities and increase strength to support the joint.

    • The physiotherapist will teach you proper posture and recommend devices, aids and appropriate exercises. They may also advise on modifications to your home or workplace.

    Benefits
    • Many arthritic patients report a decrease in the intensity of pain after modifying their activities.

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the long term.

    • Physiotherapy is low to moderately effective based on the stage of the disease. Studies say that patients can experience up to 70% improvement in pain in the early stages, especially when exercise and mobilisation is combined.

    • This will also improve your general fitness, and help with cardiovascular health and weight loss.

    Risks
    • No major risks identified.

    • Pain may increase in the initial stages and some people may notice an increase in swelling.

    Cost
    • Low cost option for both the patient and the NHS.

    • Patient: Some may wish to enrol in a gym and therefore have a membership fee cost.

    • NHS: £25 to £30 per session, costing approximately £200 per course.

    Limitations
    • Minimal side effects reported.

    • Physiotherapy will only work with adequate motivation and commitment.

    • This treatment requires regular visits to the physiotherapy centre, which may include a time and cost commitment including parking charges.

    • Exercises are based on an ability to perform, rather than a fixed goal.

    • Physiotherapy is not recommended if the patient has significant cardiac problems or exercise-induced cardiac arrhythmias.

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    Prescription Analgesics info graphic
    Prescription Analgesics

    Prescription analgesics may be appropriate when one is not yet ready to undergo operations and have not exhausted all non-operative methods.

    Applicable stages
  • Early stage
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Normal
    2. Start of disease
    3. Early stage
    4. Mid stage
    What is it?
    • Stronger analgesics or pain relief techniques may be required when the pain from arthritis is not controlled with simple techniques.

    • These can include the local application of Capsaicin or Transcutaneous Electrical Nerve Stimulation (TENS).

    • These methods may be appropriate when the patient is not yet ready to undergo operations and has not tried all of the non-operative methods.

    Benefits
    • There is fair to good evidence to support the use of a TENS device for pain management.

    • Modest to moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the long term.

    • Local anti-inflammatory gels have similar benefits as oral anti-inflammatory tablets. Capsaicin cream application can also bring down pain levels.

    • A walking stick will help improve walking distances.

    Risks
    • No major risks identified.

    • You may experience skin irritation from local application of medications.

    • Be aware of bleeding ulcers, exacerbation of acidity symptoms or asthma.

    • Excessive use of medications can affect renal or liver functions.

    Cost
    • Low cost option for both the patient and the NHS.

    • Patient: cost of over-the-counter medication and/or the purchase of a walking stick.

    Limitations
    • There are minimal side-effects for external physical methods.

    • Oral anti-inflammatory tablets have gastrointestinal side effects.

    • Generally, Paracetamol is less effective with moderate to severe arthritis.

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    Braces & Wedges info graphic
    Braces & Wedges

    Knee braces or appropriately placed heel wedges may help to redistribute the load.

    Applicable stages
  • Early stage
  • Mid stage
  • Works best in following stages
    1. Early stage
    2. Mid stage
    What is it?
    • Knee braces or appropriately placed heel wedges can help redistribute the load and avoid too much force going through the affected joint.

    • This method is only appropriate for a selected few patients who have a certain type of asymmetrical joint wear.

    • A physiotherapist will decide whether these are appropriate for you after a detailed assessment.

    Benefits
    • There is fair to good evidence for the use of heel wedges (bowleg) for various knees and knee braces for specific types of asymmetric joint wear (unicompartmental arthritis).

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the short term.

    • Potential to slow down the speed of deterioration and joint wear.

    Risks
    • No major risks identified with the use of these physical aids.

    • Avoid over-tightening of the brace to prevent pressure effects to the skin.

    Cost
    • Low cost option for the patient and a variable cost for the NHS.

    • NHS: Generally not an expensive option, but braces tend to be single-use and may need replacing.

    Limitations
    • In the initial stages of using heel wedges, patients may find that their balance is affected.

    • These interventions are not applicable to all types of asymmetric wear of the joint and therefore only a few patients will benefit from this.

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    Steroid Injection info graphic
    Steroid Injection

    This involves an injection of corticosteroid medication and local anaesthetic into the joint.

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Mid stage
    2. Late stage
    What is it?
    • The injection of corticosteroid medication and local anaesthetic into the joint.

    • This should decrease inflammation from the degenerating joint, which is causing pain and swelling.

    • This will be appropriate for selected patients who have tried other methods.

    Benefits
    • There is fair to good evidence for using intra-articular steroid injection. About two-thirds of patients benefit from this injection.

    • However, it is difficult to predict who will benefit most or how long the effects will last.

    • Moderate drop in pain, improvement in activities of daily living (ADL) and mobility in the short term.

    Risks
    • No major risks associated with the use of cortisone injection.

    • There is a minimal (0.5%) risk of introduction of infection.

    • Repeated injections can weaken the ligaments and may worsen the arthritis.

    Cost
    • This is a no cost option for the patient, and has a variable cost for the NHS.

    • NHS: Generally not an expensive option; the cost of treatment of infection, should it occur, could be expensive.

    Limitations
    • In the initial stages, some report exacerbation of pain, though this is usually short-lived.

    • Increase activity gradually a few days after receiving the injection.

    • Minor side effects include a change in local skin colour and fat atrophy.

    • The injection should be used with caution for patients with bipolar disorders, active infection, pregnancy/breastfeeding or recent vaccination.

    • Avoid this intervention if you have an allergy to the medication or to the local anaesthetics.

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    Microfractures info graphic
    Microfractures

    Arthroscopy of the knee (key-hole surgery) may be appropriate in only a small number of situations.

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Mid stage
    2. Late stage
    What is it?
    • The removal of damaged cartilage elements that cause pain or locking through arthroscopy (key-hole surgery) through the knee.

    • It is only appropriate in a small number of situations.

    • Any significant symptoms from damaged meniscus (shock absorbing) cartilage may improve from this.

    • Some select cases of severe isolated arthritis may also benefit from this. Usually for a young adult with a single surface injury or damage.

    • This is not recommended for obtaining diagnosis or for ‘washing out’ damaged joints.

    Benefits
    • There is poor to fair evidence to confirm that performing a partial meniscectomy improves locking episodes. It will not cure arthritis and does not work for degenerative tears.

    • Patients who have microfracture, especially on the thigh bone (femoral side) have a significant improvement for up to 5 to 7 years.

    Risks
    • Specific risks include infection, bleeding into the joint, deep vein thrombosis (DVT), pulmonary embolus (PE), persistent pain, complex pain syndrome, swelling at the incision site, anterior knee pain.

    • Some of the complications will need further treatment that may include surgery.

    Cost
    • There are significant costs for both the patient and the NHS.

    • Patient: You will need to take time off work, require help during initial stages and visit the hospital, GP surgery and physiotherapist, which may cost in taxis and parking.

    • NHS: Generally a moderately expensive option. However, the cost of treatment, if there’s a complication, will also add to the expense.

    Limitations
    • In the initial stages, some report exacerbation of pain, though this is usually short-lived.

    • Increase activity gradually a few days after receiving the injection.

    • Minor side effects include swelling, superficial infection,  side effects from the anaesthetic, inflammation from where the cannula was placed or a sore throat.

    • The procedure may not work, and expectations may not be met.

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    Osteotomy info graphic
    Osteotomy

    In some selected patients with single compartment arthritis, the affected part of the joint may be off-loaded by realigning the bone.

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Late stage
    What is it?
    • A controlled fracture (osteotomy) to realign the bone and off-load the joint.

    • This can only be done in selected patients with single compartment arthritis.

    • Very few patients will qualify for this intervention and are usually reserved for young patients who are not ready for a more extensive replacement type surgery.

    Benefits
    • There is good evidence for performing such procedures in some selected groups of patients.

    • It is likely to delay the need for a full knee replacement.

    Risks
    • This procedure includes all risks associated with major operations.

    • This can include: pain, bleeding, swelling, stiffness, superficial infection or inflammation, sensitive scar, change in appearance of the operated area, numbness, incomplete symptom relief, deep infection needing further treatment, puckering of scar, keloid or thickened scar, recurrence of the problem, urinary tract problems (e.g. infection or retention), needing catheter, nerve damage, blood vessel damage, fractures, deep vein thrombosis (DVT), pulmonary embolus (PE) or complex pain.

    • General complications including heart problems (attack, irregular heartbeats), lung-related problems (pneumonia, lung collapse), post-operative delirium, postoperative decline in brain function, kidney failure, pressure sores, diathermy burns, wrong side surgery, severe allergy to medications, damage to structures unrelated to surgery, the regret of undergoing surgery, removal of the implant, arthrodesis - fusion of joint, amputation and death.

    • Specific complications such as improper realignment, failure of osteotomy to heal, damage to surrounding structures by implant or screws, need for further surgery to treat infections and fractures.

    • Some of the complications will need further treatment which may also include surgery.

    • The need for performing a joint replacement in the future is a possible risk, as it is not possible to determine how long the benefits from an osteotomy will last.

    Cost
    • There are significant costs for both the patient and the NHS.

    • Patient: You will need to take time off work, require help during initial stages and visit the hospital, GP surgery and physiotherapist, which may cost in taxis and parking.

    • NHS: Generally a moderately expensive option, however, the cost of treatment can increase significantly should the need for treating complications arise.

    Limitations
    • All limitations and side effects after a major operation should be taken into account.

    • Scar sensitivity may limit some functions for months.

    • Knee pain may not completely diminish.

    • Pain might limit what you can do during a day.

    • Pain may get worse before it gets better, however, medication might help you with this.

    • There may be side effects from medications - especially painkillers and aesthetics (skin rash, constipation, liver or kidney damage). Please ask your doctor if you would like a full list of these possible side effects.

    • While you recover from the operation you may need to use physical aids such as crutches, boots or a plaster cast depending on the operation you have.

    • You will need to take care of the area that was operated on. This may mean using dressings and being careful with the surgical site.

    • You may need to visit your GP or hospital for follow up checks.

    • To get the most out of the surgery, you may need to visit a physiotherapist regularly.

    • These are likely to be affected after the operation:
      - Family life
      - Sleep
      - Intimate relationships
      - Leisure activities
      - Driving
      - Work

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    Partial Knee Replacement info graphic
    Partial Knee Replacement

    This involves a surgical procedure to replace a portion of the knee which has worn out more.

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Mid stage
    2. Late stage
    What is it?
    • A surgical procedure to replace a portion of the knee that is most worn out.

    • Each of the three knee compartments can be replaced in separate procedures.

    • This tends to be offered to younger patients with an intention to delay or avoid a full knee replacement when it’s likely they’ll outlive the full knee replacement and will later require complex surgery to correct it.

    Benefits
    • There is good to very good evidence for performing such procedures in a selected group of patients. (96% survival at 5y when patients are correctly selected).

    • Moderate success is reported for patellofemoral replacement.

    • Recovery from this operation can be quicker than a full knee replacement.

    • This is likely to delay the need for a full knee replacement in many patients.

    Risks
    • There is a high revision rate to full knee replacement (20% according to NJR data).

    • Pain, bleeding, swelling, stiffness, superficial infection or inflammation, sensitive scar, change in the appearance of the operated area, numbness, failure of tendon or muscles to heal, incomplete symptom relief, deep infection needing further treatment, puckering of scar, keloid or thick scar, recurrence of problem, urinary tract problems (infection, retention) needing catheter, nerve damage, blood vessels damage, deep vein thrombosis (DVT), pulmonary embolus (PE) and complex pain.

    • General complications include heart problems (attack, irregular heartbeats), lung-related problems (pneumonia, lung collapse), post-operative delirium, postoperative decline in brain function, kidney failure, pressure sores, diathermy burns, wrong side surgery, severe allergy to medications, damage to structures unrelated to surgery, the regret of undergoing surgery, removal of the implant, arthrodesis - fusion of joint, amputation and death.

    • Specific complications for this procedure, such as improper realignment of the implant, dislocation of plastic, damage to surrounding structures by the implant, need for further surgery to treat infection and fractures.

    Cost
    • There are significant costs for both the patient and the NHS.

    • Patient: You will need to take time off work, require help during initial stages and visit the hospital, GP surgery and physiotherapist, which may cost in taxis and parking.

    • NHS: Generally an expensive option, however, the cost of treatment can increase significantly should the need for treating complications arise.

    Limitations
    • All limitations and side effects after a major operation should be taken into account.

    • Scar sensitivity may limit some functions for months.

    • Knee pain may not completely diminish.

    • Pain might limit what you can do during a day.

    • Pain may get worse before it gets better. However, medication may help you with this.

    • There may be side effects from medications - especially pain killers and aesthetics (skin rash, constipation, liver or kidney damage). Please ask your doctor if you would like a full list of these possible side effects.

    • While you recover from the operation you may need to use physical aids such as crutches, boots or a plaster cast depending on the operation you have.

    • You will need to take care of the area that was operated on. This may mean using dressings and being careful with the surgical site.

    • You may need to visit your GP or hospital for follow up checks.

    • To get the most out of the surgery, you may need to visit a physiotherapist regularly.

    • These are likely to be affected after the operation:
      - Family life
      - Sleep
      - Intimate relationships
      - Leisure activities
      - Driving
      - Work

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    Total Knee Replacement info graphic
    Total Knee Replacement

    This involves a surgical procedure to replace all 3 compartments of the knee joint.

    Applicable stages
  • Late stage
  • Very late
  • Works best in following stages
    1. Late stage
    2. Very late
    What is it?
    • A surgical procedure to replace all three compartments of the knee joint.

    • This is generally offered when the arthritis is widespread and other treatment methods have failed.

    • This is also offered as a salvage procedure when partial knee replacement or osteotomies have failed.

    • Total knee replacements last for a very long time (95% last for over 10 years). However, they do have a finite life. Whether the plastic wears or there’s another complication, further surgery may have to be performed.

    Benefits
    • There is good to very good evidence for performing these procedures. 96% survival at 10 y when patients are correctly selected.

    • Good to excellent success is reported for knee replacement. However, patient satisfaction rate varies with different studies varying between 80% and 95% satisfied.

    • Clinical success, as measured with patient-reported outcome measures, are generally good to excellent but is in discordance with patient expectation evaluation.

    Risks
    • There is a high revision rate to full knee replacement (20% according to NJR data).

    • Pain, bleeding, swelling, stiffness, superficial infection or inflammation, sensitive scar, change in the appearance of the operated area, numbness, failure of tendon or muscles to heal, incomplete symptom relief, deep infection needing further treatment, puckering of scar, keloid or thick scar, recurrence of problem, urinary tract problems (infection, retention) needing catheter, nerve damage, blood vessels damage, deep vein thrombosis (DVT), pulmonary embolus (PE) and complex pain.

    • General complications such as heart problems (attack, irregular heartbeats), lung-related problems (pneumonia, lung collapse), post-operative delirium, postoperative decline in brain function, kidney failure, pressure sores, diathermy burns, wrong side surgery, severe allergy to medications, the regret of undergoing surgery, removal of the implant, arthrodesis - fusion of joint, amputation and death.

    • Specific complications include the improper realignment of the implant, damage to surrounding structures by the implant, rupture of extensor tendons, stiffness, anterior knee pain, need for further surgery to treat infection and fractures.

    Cost
    • There are very high costs for both the patient and the NHS.

    • Patient: You will need to take time off work, require help during initial stages and visit the hospital, GP surgery and physiotherapist, which may cost in taxis and parking.

    • NHS: Generally an expensive option, however, the cost of treatment can increase significantly should the need for treating complications arise.

    Limitations
    • All limitations and side effects after a major operation should be taken into account.

    • Scar sensitivity may limit some functions for months.

    • Knee pain may not completely diminish.

    • Pain might limit what you can do during a day.

    • Pain may get worse before it gets better. However, medication may help you with this.

    • There may be side effects from medications - especially pain killers and aesthetics (skin rash, constipation, liver or kidney damage). Please ask your doctor if you would like a full list of these possible side effects.

    • While you recover from the operation you may need to use physical aids such as crutches, boots or a plaster cast depending on the operation you have.

    • You will need to take care of the area that was operated on. This may mean using dressings and being careful with the surgical site.

    • You may need to visit your GP or hospital for follow up checks.

    • To get the most out of the surgery, you may need to visit a physiotherapist regularly.

    • These are likely to be affected after the operation:
      - Family life
      - Sleep
      - Intimate relationships
      - Leisure activities
      - Driving
      - Work

    View

    Therapeutic Arthroscopic Procedures info graphic
    Therapeutic Arthroscopic Procedures

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Mid stage
    2. Late stage
    What is it?
    • Applicable in some mid to late stages only
    • Best in stage 4 or 5.
    Benefits
    • There is fair evidence to support removal of damaged meniscus in genuine locked knee to help with pain and function. It will not cure the arthritis and does not work for simple degenerative tears.
    • Range of movement especially extension may improve for a period of time.
    • There is small to very small improvement in pain short term; but long term improvement is controversial.
    Risks
    • All risks associated with surgery and anaesthesia.

    • Specific risks related to the procedure include infection, bleeding, stiffness, deep vein thrombosis, pulmonary embolism, swelling along the port site, delayed wound healing or break down, sensitive scar, anterior knee pain, persistent pain and clicking, complex pain syndrome and more.

    • The procedure is not recommended by NICE as an effective treatment for arthritic knee.

    Cost
    • For patient: Time off from work, cost of help needed during the initial stages including cost of visits to hospital, GP surgery, physiotherapy, taxi fares, parking charges etc.
    • Cost for NHS: Generally moderately expensive option. Cost of treatment of complication should they require treatment will also add to the expense.
    Limitations
    • In the initial stages, some may report exacerbation of pain which is short lived.
    • It is advised to gradually increase activity level a few days after surgery.
    • Minor side effects include swelling, superficial infection or side effects from anaesthetic, inflammation from the place where cannula was placed or sore throat.
    • The procedure may not work and expectation may not be met.

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    Glucosamine & Chondroitin Tablets info graphic
    Glucosamine & Chondroitin Tablets

    Applicable stages
  • Early stage
  • Mid stage
  • Works best in following stages
    1. Early stage
    2. Mid stage
    What is it?
    • These are protein supplements which are thought to help to rebuild the cartilage in the joint.

    • Not a NICE approved procedure.

    Benefits
    • Some studies show that these tablets may decrease the pain for some patients. Sponsored studies also show that, in some cases, the supplements can reverse the joint wear.

    • Some patients also report a decrease in the swelling.

    Risks
    • Patients with seafood allergies, especially prawn allergies, should not take this medication as it can set off a reaction.

    • This treatment is not recommended by NICE as an effective treatment for an arthritic knee.

    Cost
    • The cost of these tablets is low for the patient and there is no cost for the NHS

    • Patient: Cost may vary depending on where you purchase the tablets; it's usually up to £1 a day for the treatment. It is best practice to purchase the tablets from reputable pharmacy stores.

    • If you're looking to purchase the vegan version, which is derived from seaweed, this is likely to be more expensive.

    • NHS: No cost for the NHS as this is not a prescription medication.

    Limitations
    • The knee pain may not diminish completely

    • The tablets might be too big to swallow, so you may have to break them. Liquid versions are available but are generally more expensive.

    • Some may develop a bloated feeling or loose stools in the initial stages. This tends to settle down over a period of time.

    • This treatment may interfere with the control of diabetes, so requires careful monitoring of blood glucose levels in diabetic patients.

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    Viscosupplement Injections info graphic
    Viscosupplement Injections

    Applicable stages
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Mid stage
    2. Late stage
    What is it?
    • Injection of gel-like material to cushion and mobilise the knee.

    • Two available types are available; Synvisc and Hyalgan.

    • Both are manufactured from hyaluronic acid, which is a natural substance in the joint cartilage.

    • This procedure is not NICE approved.

    Benefits
    • Some studies show that these injections may decrease the pain in a select group of patients.

    • Some also report a decrease in swelling.

    • In some patients, these injections may also slow down joint wear. However, it's difficult to identify who will benefit from this.

    Risks
    • Severe exacerbation of pain, infection, allergy, redness, persistent swelling, nausea, stomach pain, limp, swelling of hands or feet, back pain, headache, dizziness, runny nose and repeated sneezing are all reported risks.

    • This procedure is not recommended by NICE as an effective treatment for an arthritic knee.

    Cost
    • This is a moderately low-cost option for both patients and the NHS.

    • Patient: Cost may vary depending on local arrangements. Some commissioning bodies do not authorise the use of these injections, so the procedure may need to be done under a private setting. This can cost up to £225 per injection plus an additional cost of a private consultation.

    • NHS: Between £8.80 to £45.00 per injection based on local arrangements.

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    Platelet Injection info graphic
    Platelet Injection

    Applicable stages
  • Early stage
  • Mid stage
  • Late stage
  • Works best in following stages
    1. Early stage
    2. Mid stage
    What is it?
    • Injection of concentrated platelets derived from the patient's own blood.

    • Growth hormones stored within the platelets are released into the arthritic joint and stimulates cartilage growth.

    • This is a NICE approved procedure that must be done under strict audit rules as available evidence is not robust.

    Benefits
    • Some studies show that these injections may decrease the pain in a select group of patients.

    • Some patients also report a decrease in the swelling.

    • In some patients, these injections may slow down joint wear. However, it is difficult to identify who will benefit from this.

    • This may delay the need for more invasive surgery.

    Risks
    • Exacerbation of pain (14%), infection, redness, persistent swelling (which may take between two and four weeks to settle) are reported risks.

    • Some may develop dizziness, sweating or fainting at the time of the injection.

    • Overall, this is a low-risk procedure.

    Cost
    • This is a low cost option for both patients and the NHS

    • Patient: Cost may vary depending on local arrangements. Some commissioning bodies do not authorise the use of these injections, so this may have to be done under a private setting. This can cost up to £250 per injection plus the additional cost of a private consultation.

    • NHS: £600 to £1500 per series of injections based on local arrangements and the type of harvest system used.

    Limitations
    • Knee pain may not completely diminish.

    • For some patients, pain may get worse after the injection. It is not possible to predict who will become worse after the injection.

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    Stem Cell Treatment info graphic
    Stem Cell Treatment

    Applicable stages
  • Mid stage
  • Late stage
  • Very late
  • Works best in following stages
    1. Late stage
    What is it?
    • A bone marrow harvest that’s centrifuged and immediately injected into the joint that has worn out.

    • Alternative sources include fat cells and subchondral bone cells. These may be grown in a lab before injection.

    • Typically, a course of treatment involves between 1 and 3 injections.

    • Evidence is still not clear on which is the best type of stem cell to use.

    • Not NICE approved.

    Benefits
    • Some studies show that stem cell injections may decrease pain for a select group of patients.

    • In some patients, this treatment may slow down joint wear. However, it's difficult to identify who will benefit from this.

    • This may delay the need for more invasive surgery.

    Risks
    • Severe risks include pain, infection, redness and persistent swelling.

    • There are anecdotal serious complications like macular degeneration and blindness, stroke and concerns about potentially stimulating cancer cell overgrowth.

    Cost
    • There is a high cost for both the patient and the NHS.

    • Patient: Cost may vary depending on local arrangements. Some commissioning bodies do not authorise the use of these injections, so the treatment may have to be done under a private setting. This can cost up to £8000 per course, not including the cost of a private consultation. Some insurance companies will not cover this cost.

    • NHS: The exact cost is not known; however, it's likely to be as much as the cost in the private sector.

    Limitations
    • Your knee pain may not diminish completely.

    • The pain may actually get worse after the injection for some patients. It's not possible to predict who will become worse after the injection.

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    Chondral Graft info graphic
    Chondral Graft

    Applicable stages
  • Late stage
  • Works best in following stages
    1. Late stage
    2. Very late
    What is it?
    • Taking cartilage from an area where there is less stress and transplanting it to an area where there is significant damage.

    • This is best for localised stage 5 or 6 diseases and usually recommended for 16 - 30-year-olds secondary to sporting injuries.

    • NICE recommends performing this only under audit/new procedure guidelines with good clinical governance.

    • Can only be offered by an experienced surgeon.

    • The procedure is done under anaesthesia

    Benefits
    • Some studies show that this treatment may decrease the pain in a select group of patients.

    • In some patients, this may slow down joint wear. However, it is difficult to identify who will benefit from this.

    • The procedure may delay the need for more invasive surgery.

    Risks
    • Severe risk of pain, infection, redness, persistent swelling, stiffness, anterior knee pain (especially on kneeling) and all other complications associated with open surgery.

    • The risks are very similar to that of a total knee replacement.

    Cost
    • This is a high-cost option for both the patient and the NHS.

    • Patient: Cost may vary depending on local arrangements. Some commissioning bodies do not authorise the use of these graphs, so some patients may have to have this done in a private setting. This can cost between £8,000 and £10,000 not including the cost of a private consultation. Some insurance companies will not cover this cost.

    • NHS: Exact cost is not known, but is likely to be as much as the cost in the private sector.

    Limitations
    • Your knee pain may not completely diminish.

    • The procedure may not work at all.

    • You may have to be non-weight bearing for six weeks. Drains may be used to decrease bleeding and blood clot formation.

    • It may take between six and nine months to know if the graft has been successful or not.

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    Alternative Medicine info graphic
    Alternative Medicine

    Applicable stages
  • Early stage
  • Mid stage
  • Late stage
  • Very late
  • Works best in following stages
    1. Early stage
    2. Mid stage
    3. Late stage
    4. Very late
    What is it?
    • A form of treatment that is not usually considered.

    • This can be chiropractic treatment, homoeopathy, Tai Chi and more.

    Benefits
    • There is a lack of solid evidence, especially when treating advanced arthritis.

    Risks
    • Unquantified: but it is likely to be lower than any surgical intervention.

    Cost
    • These treatments are not available on the NHS.

    • Patient: Cost is variable based on the type of treatment chosen and practitioners.

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