Therapeutic Arthroscopic Procedures

Total Knee Replacement Glucosamine & Chondroitin Tablets


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What is it and why?

  • Applicable in some mid to late stages only
  • Best in stage 4 or 5.

  • Treatment does not involve Home/self-help
    Home/self-help
  • Treatment involves Hospital
    Hospital
  • Treatment involves Daycase procedure
    Daycase procedure
  • Treatment does not involve Inpatient procedure
    Inpatient procedure
  • Treatment does not involve Local anaesthetic
    Local anaesthetic
  • Treatment involves General anaesthetic
    General anaesthetic
  • Treatment involves Regional block / Spina
    Regional block / Spina
  • Pain
    Pain

    Worse for 2+ weeks

  • Mobility
    Mobility

    Affected 2+ weeks

  • Daily activities
    Daily activities

    Affected for 2+ weeks

  • Driving
    Driving

    No - 6+ weeks

  • Leisure activities
    Leisure activities

    Affected 2+ weeks

  • Light exercise
    Light exercise

    Affected 2+ weeks

  • Heavy exercise
    Heavy exercise

    Affected 6+ weeks

  • Light work
    Light work

    Affected 4+ weeks

  • Heavy work
    Heavy work

    Affected 2+ months

  • Intimate
    Intimate

    Affected 2+ weeks


Overview

What stage?

  • Arthroscopy is a key-hole surgical procedure where the inside of the joint can be inspected via a video camera and additional procedures can be carried out if necessary to decrease pain or improve function or both.
  • This may be appropriate in only a small number of patients with degenerative arthritis. For example, in some patients with genuine mechanical symptoms like locking from displaced meniscal (shock absorbing cartilage) tear or those with floating loose fragments within the joint may benefit from this.
  • In some selected cases of isolated arthritis on single quadrant may also benefit from this. This usually will be for a young adult with a single surface injury or damage from sporting injury.
  • It is not recommended for obtaining diagnosis or for ‘washing out’ debris from arthritic joints. Pain due to degeneration alone does not improve long term and therefore is not advised just for checking the joint. Such operations are not recommended by NICE.

 

What does it involve?

  • This is done under general anaesthetic as a day case procedure.
  • Minimum 2 incisions either side of the lower end of knee cap is placed to inspect and carry out the operation. Occasionally additional incisions may be placed.
  • If performed for genuine locking episodes, the damaged and displaced tear of the meniscus (displaced bucket handle tear) is removed and movement is restored.
  • If locking episodes are due to loose bodies within the joint these can be removed and improves the function.
  • Additional procedures like microfracture (making small holes into the bone) may be carried out for small area of isolated complete cartilage loss with an aim to stimulate fibro-cartilage growth. This is usually appropriate in earlier stages of the disease.

Effort/burden

  • One will have to undergo the procedure under anaesthetic and may have to use crutches for a period of time usually up to 2 or 3 weeks.
  • For patients who undergo microfracture, they may have to remain non-weigh bearing for up to 6w on crutches. Further period of protected weight bearing may be necessary.
  • One may have to consider time away from work, difficulty in various daily activities, and child care related issues and will not be ready to drive car for weeks.
  • One may have to undergo physiotherapy for a period of time after surgery.
    • Pain: Can get worse short term and can last for 2 to 3 weeks.
    • Mobility: Most need to use crutches for 2 to 3 weeks and sometime weigh bearing can be painful.
    • Daily activities: Inconveniences for many activities of daily living including bathing/showering, wearing trouser, climbing stairs, sleeping and turning while walking may be affected for 2 to 4 weeks
    • Driving: One may not be able to drive for minimum 2weeks. Furthermore driving will also depend on which leg was operated and if one was driving manual or automatic car.
    • Leisure activities: This may be limited for 2 to 6weeks. – For example taking a dog on a lead for a walk can be affected for up to 6weeks. Playing with children, kneeling down can be affected.
    • Light exercises: This can be affected for up to 4weeks. Exercises which require loading of the joint can be painful.
    • Heavy exercises: One may not be able to do heavy exercises for up to 6 or 8 weeks.
    • Light work: One may be able to return to desk based work within few weeks. However, prolonged sitting may be affected for few weeks.
    • Heavy work: One may not able be able to return to heavy manual job for 4 to 8 weeks depending on the nature of the job.
    • Intimate relationship: Due to pain on loading or during kneeling, intimate relationship will be affected for 2 to 4 weeks. However, discuss with you doctor regarding any specific questions. 

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.

Chances of cure

  • These simple measures will not cure arthritis.
  • However they will help to manage pain levels and improve ADL.
  • Microfracture may delay the deterioration of the arthritis.

Limitations and side effects

  • 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.

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.

What if no treatment is done?

  • Arthritis will continue to deteriorate
  • Symptoms will deteriorate, sometimes rapidly
  • May have a negative influence on other management options.

References

  •  

  • National Institute for Health and Clinical Excellence. Osteoarthritis: care and management (clinical guideline CG177). 2014. www.nice.org.uk/guidance/cg177
  • National Institute for Health and Clinical Excellence. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (Interventional procedures guidance IPG230). 2007. www.nice.org.uk/guidance/ipg230
  • Beaufils P, Roland B. ESSKA Meniscus Consensus Project. Degenerative meniscus lesions. European Society for Sports Traumatology, Knee Surgery and Arthroscopy, 2016. https://cdn.ymaws.com/www.esska.org/resource/resmgr/Docs/meniscus-consensus-project-s.pdf
  • Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: A clinical practice guideline. BMJ 2017;357:j1982
  • Bollen, S. (2018). An Open Letter to the Editor of The BMJ. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 34(1), 8–11. doi:10.1016/j.arthro.2017.11.010
  • Haddad, F. S., Corbett, S. A., Hatrick, N. C., & Tennent, T. D. (2019). The assault on arthroscopy. The Bone & Joint Journal, 101-B(1), 4–6. doi:10.1302/0301-620x.101b1.bjj-2018-1377

Total Knee Replacement Glucosamine & Chondroitin Tablets