High tibial osteotomy is a surgical procedure for the treatment of osteoarthritis. It is generally recommended for younger individuals who have early-stage osteoarthritis that damages only one side of the knee. This is often a result of a specific injury. In the procedure, a wedge of bone is removed from the tibia (shinbone) below the knee to change the angle of the knee joint. This shifts the weight from the damaged side of the knee to the other, healthier side. Although high tibial osteotomy is successful in alleviating pain, it is also associated with many post-operative complications and a long rehabilitation period.
Osteoarthritis is the most common joint disorder. It is a chronic, slowly progressing degenerative disease that affects the joints. There are a variety of causes of osteoarthritis but the most common is ageing. By the age of 70, almost everyone has some degree of osteoarthritis. This is because the biological and biochemical processes that repair damaged cartilage do not work as well in older people. The changes in the knee from osteoarthritis often lead to pain and difficulty with mobility.
Singapore, like other rapidly ageing Asian countries, is facing an increasing burden of knee osteoarthritis. Knee osteoarthritis is a major cause of impaired mobility and quality of life, and costly joint replacement surgery is often the only recourse for patients with advanced disease. There is thus an unmet medical need for less invasive, less costly and more widely applicable treatments for this condition.
Non-Surgical Treatment Options for Knee Pain
In choosing a good physical therapist, it is recommended that the therapist is experienced, and it is preferable to look for one who has had previous working experience with local or international sports teams. This is because they are more likely to be updated with current therapy techniques and have the ability to find methods to modify your present therapy program to allow you to continue participation in social, occupational, or recreational activities.
As an example, a current research study has shown that strengthening the quadriceps muscle is highly effective. In a random prospective trial of around 250 middle-aged subjects with knee osteoarthritis, it was clearly shown that those who participated in a high-intensity exercise program with quadriceps strengthening exercises had a considerable decrease in pain and a considerable increase in function relative to those not assigned to the intervention.
After diagnosing the knee pain, it frequently occurs that the primary advised course of action is physical therapy. Specific exercises and physical activities can help enhance the muscles that support the knee joint. These muscles act as an organic knee brace, and if they are strong, they can greatly decrease the loads endured by the knee joint.
A person suffering from knee pain often seeks aid for a non-surgical cure. There are numerous alternatives in knee pain Singapore that offer good results. Below is an overview of those alternatives.
Physical Therapy
Physical therapy is an important part of the treatment for knee pain. Physical therapy includes strengthening exercises, weight control, and low-impact exercise. It is particularly useful for people with arthritis. There are several reasons why exercise is beneficial for people with knee pain. Lack of exercise can cause the muscles to weaken. Weak muscles are unable to adequately support the knee, which can cause more pain. Conversely, the pain in arthritic knees often leads to inactivity, which can make the problem worse. Inactivity can also lead to other health problems, such as increased body weight and weakened bones. Lastly, the use of therapies, such as heat, ice, electrical stimulation, and ultrasound, are often employed in an attempt to alleviate pain and improve function in patients with arthritic knees. Overall, the goal of physical therapy in patients with knee pain is to improve the strength and function of the muscles surrounding the knee in order to better support the joint and to maintain a healthy lifestyle that includes regular exercise. This, in turn, can prevent progression of knee degeneration and decrease the chance of eventual joint replacement.
Medications
Medications can be used to relieve pain and to treat the underlying conditions which contribute to the knee pain. Several different classes and types of medication can be used; the one chosen will depend on the individual and the specific condition. Simple painkillers such as paracetamol may be used to relieve the pain of knee osteoarthritis. Anti-inflammatory medication such as ibuprofen or aspirin can be used to reduce inflammation and pain in acute injuries such as a ligament sprain. This class of medication is also used to treat knee pain associated with acute gout attacks. Tablets to inhibit acid production in the stomach and to protect the stomach lining can reduce the risk of stomach irritation and ulceration. This class of medication provides relief for knee pain occurring as a result of knee joint rheumatoid arthritis. Glucosamine and/or chondroitin sulfate are also commonly used medications for knee osteoarthritis. These come in many forms and are often thought of as nutritional supplements. They are thought to have structure-modifying properties on the cartilage and are believed to reduce pain and improve function. Finally, stronger painkillers such as opioids and/or morphine-based medications can be used for more severe knee pain. This class of medication requires closer monitoring by a medical professional due to their potential for misuse and dependency.
Injections
The most convincing study supporting stem cell therapy for cartilage repair was done at the University of Erlangen, Germany. The research team used cells from the fat tissue of arthritic patients, inserted the cells into a hyaluronic scaffold, and then implanted the tissue-engineered construct into the knee joint of the same patient. After the 12-month study, arthroscopic evaluation and MRI scans showed that the new tissue had the same characteristics as native cartilage and increased meniscal volume. Although this study used external funding and did not involve a commercially available product, this is a big step to showing that stem cell therapy is a promising option for cartilage repair.
Although corticosteroid injections can provide relief from knee pain, there is also evidence that the cortisone can cause damage to the cartilage in the joint. Therefore, this treatment is not suitable for people with mild arthritis and should be used with caution in those with articular cartilage damage. If surgery is not an option, autologous blood injections can be considered. This involves taking 20ml of the patient’s blood, centrifuging to extract the platelet-rich plasma (PRP) and re-injecting the PRP into the damaged area. This release of growth factors helps repair and regenerate tissues. However, to obtain a larger chance of regenerating the damaged tissue, mesenchymal stem cell (MSC) injections are a better alternative. MSCs are undifferentiated cells that have the potential to replace and regenerate damaged cells and tissues. This mode of treatment is fairly new and long-term studies have not been conducted, however, the theoretical advantages are substantial.
Surgical Treatment Options for Knee Pain
While various non-surgical options to treat knee pain, such as medication, physical therapy, and injections, are preferred, certain injuries and conditions may require surgical intervention. The three most common surgical procedures will be explained. Arthroscopic procedures are performed to treat meniscal tears and articular cartilage lesions primarily. In an arthroscopic examination, a surgeon makes several small incisions around the joint and inserts a pencil-sized instrument with a tiny camera on the tip to project the image onto a television screen, allowing the surgeon to see the inside of the knee. Small instruments about the width of a pencil are used to make any necessary repairs, such as removing torn cartilage or repairing a torn meniscus. This procedure only requires small incisions, which means the recovery period is shorter, and it is usually performed on an outpatient basis.
Arthroscopy
Arthroscopy is a surgical procedure commonly used to visualize, diagnose, and treat internal knee joint problems. The word “arthroscopy” comes from two Greek words, “arthro” (joint) and “skopein” (to look). The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Arthroscopy uses some small incisions to manipulate the instruments and another incision to insert the instruments; therefore, the recovery time is generally shorter than traditional surgery. This is often important for the athlete or patient who depends on minimally invasive procedures. It is especially relevant for injuries in the knee joint. An event from the late 20th century is illuminating in this regard: the President of the United States at the time underwent successful knee arthroscopy, and the subsequent demonstration of quick recuperation raised public awareness about its potential benefits.
Partial Knee Replacement
This picture shows metal resurfacing parts on the end of the femur (F), the tibia (T), and the kneecap. The metal and plastic parts are shaped in such a way as to allow continued function of the knee joint. The metal is usually cobalt chrome, and the plastic is typically a very tough polymer.
Partial knee replacement is a highly successful procedure. When performed on the right patient, results are typically excellent. In order to determine whether a patient is a good candidate for partial knee replacement, it is best to start out discussing the matter with a surgeon.
Partial knee replacement, a procedure that replaces a portion of the knee joint, is an alternative to total knee replacement for patients whose disease is limited to just one area of the knee. Although there are non-surgical options available for patients with arthritis, many with serious pain or limited function may consider partial knee replacement.
Total Knee Replacement
Total knee replacement is one of the most successful procedures in all of medicine. In the same study above, 96% of patients said they would have the surgery again. 80% of patients also stated that at 5 years follow-up they were completely satisfied with their operative results. The surgery consists of resurfacing the damaged and worn-out areas of the knee with metal and plastic components, resurfacing the bones that form the knee joint. This operation is a great option for patients with advanced knee arthritis, especially those with knees that are no longer aligned properly or have large deformities. The surgery will help to correct this problem, restore the alignment in the knee, and prolong the life of the knee joint, helping the patient to return to normal functional activities. Total knee replacements are lasting longer, with 85-90% of them lasting 20 years, depending on the patients’ levels of activities. New plastics, metals, and surgical techniques are making knee replacements last longer and longer, with new designs in knee replacements, such as a movable knee replacement for patients who only have one functioning knee joint. Patients typically spend 3-7 days in the hospital post-operative, followed by a 7-week period of rest and recovery. They will then need to start a period of formal physiotherapy. Although this operation has great long-term results, it is important for patients to control symptoms and be informed of their operative options and what the best exact time is to go ahead with the surgery. Often times, it is better to have the surgery before large deformities develop, as the effects of arthritis can make the surgery less effective in correcting the problem. Total knee replacements are irreversible, and so it is important to be certain of the decision before undergoing the surgery.
Regenerative Medicine for Knee Pain
Stem cell therapy has been all over the media in recent years and has received vast interest in the treatment of numerous conditions. Stem cells are unspecialized cells that have the potential to create, or ‘differentiate’ into, other types of cells. They have the ability to replicate to either make more stem cells or differentiate into the specific cells that serve a specific function, e.g., a muscle cell. In theory, this could enable the body to repair tissues that it was previously unable to. The first stages of a stem cell treatment simply involve extracting the stem cells from a sample of the patient’s blood, bone marrow, or adipose (fat) tissue. These are then processed and prepared before being injected into the knee. There are still many uncertainties about the therapeutic use of stem cells due to their complex nature and the huge variety of stem cell sources and preparation methods. Currently, there is very little high-quality evidence to support the use of stem cell therapy for knee conditions, and thus it remains a costly option mostly only available in the form of private treatment.
The platelets release granules containing growth factors that are thought to jump-start the healing process. The therapy is often given as a single injection but may require several depending on the severity of the condition. It is being used for a variety of injuries, with the best evidence being in patellar tendinopathy and mild to moderate knee osteoarthritis. Results of the trials are somewhat mixed, but this is likely due to the variability in the preparation techniques and the different PRP products used. In general, PRP appears to be a safe option with promising results for knee soft tissue injuries and early knee osteoarthritis.
Regenerative medicine encompasses all the methods that inject a substance to enhance the body’s own healing of lesions or injured tissues. In general, the earlier treatments have focused on reducing symptoms, but the regenerative approach is looking to restore more normal, functioning tissues. The most researched regenerative medicine therapy is Platelet Rich Plasma (PRP) therapy. This involves taking a sample of your own blood and centrifuging it to extract the platelet-rich component. This is then injected into the knee.
Platelet-Rich Plasma (PRP) Therapy
The potential advantages of PRP treatment include the simplicity of the procedure and lack of significant adverse effects, opening a new door to treatment of mild tissue injury and early osteoarthritis. The evidence of benefit is increasing, with some studies showing significant improvement in function and pain of the knee with osteoarthritis, with lasting effect up to 12 months, while others have demonstrated a possible slowing of the degenerative process. High-level clinical evidence (randomized controlled trials) is still lacking, but PRP is a promising therapy, provided the correct formulation is used.
This involves taking the patient’s own blood, separating the platelet-rich plasma (PRP) from other blood constituents, and then injecting this PRP into the patient’s knee. The alpha-granules of platelets contain growth factors that promote tissue healing, and several studies have shown beneficial effects in early osteoarthritis of the knee, although results may vary.
Stem Cell Therapy
Stem cell procedures from the embryos are typically experimented by taking the cells from inside the blastocyst. These cells, at the initial stage, divide because they are still primitive and not yet divided into a specific kind of cell type. The blastocyst is destroyed in the process, so this aspect is for and argued against embryonic stem cell research and therapy. Embryonic stem cell therapy is being done on animals at the moment, trials and tests on humans are still on hold.
Stem cells are the multicellular organisms that initially have the capability of changing into a wide range of various cell types in the body at the initial stage. For example, liver cells, muscle cells, blood cells, and some more types of cells. They can divide through the process of mitotic division and maintain the same form of stem cell. These are known as daughter cells. There are two major types of stem cells: adult stem cells and embryonic stem cells. The stem cells that are primarily obtained from adult humans in a small amount of body tissue are known as adult cells. The adult stem cells can be reigned into their primitive state and can be changed into the mature form of the type of cell which is specific to organs.
Prolotherapy
Prolotherapy can be beneficial for chronic sprains, strains, partial tears of ligaments or tendons, tendinosis, and subluxation of a joint. It is a safe and effective mode of treatment with a high rate of success. A written document shows that in most patients, the pain was relieved, the joint became stronger, and 82% of patients felt that without this treatment, surgery would have been the only other option. This rate of success is higher than that of most surgical procedures to repair ligaments or tendons.
Prolotherapy is a minor procedure done in the office of a trained physician. Prior to the injections, the skin is cleaned and local anesthesia is applied. The solution is then injected directly into the tissue or joint being treated. The procedure does involve some brief pain and discomfort as the healing process is kicked off. Usually, 4-6 injections are given in the affected area and done 3-4 weeks apart depending on the injury. This is to prevent further damage to the tissue or joint while fully allowing full rehabilitation of the affected area. A knee brace or some limitation of the activity of the joint may be necessary for some time after the injections. Full recovery of Prolotherapy treatment may take 3-6 months.
Prolotherapy stimulates the body’s natural response mechanism resulting in the formation of new, normal ligament or tendon, resulting in a permanent repair. This is done by injecting a small amount of a dextrose (sugar water) solution into the damaged ligaments or tendons at their attachments to the bone. This leads to local inflammation that increases the blood supply and flow of nutrients to the area. The increased blood supply and flow of nutrients then stimulate the tissue to repair itself. The procedure also increases the diameter and strength of the ligament or tendon, leading to a tight and strong bond to the bone. Studies have shown that the tissue which has been reformed is 50% stronger than tissue formed with normal surgical repair. This can help to prevent further degeneration to the knee joint, which is a common outcome of chronic knee pain.
