Knee Joint Preservation: A boon for Early Arthritis

In today’s world, knee pain is a strikingly common complaint across all age groups. While it has traditionally been linked to aging and osteoarthritis of the joint, an alarming number of young and middle-aged individuals now suffer from knee injuries and early degenerative changes. These conditions can lead to secondary arthritis, which brings several consequences. They can limit daily routines, disrupt sports activities, and significantly reduce one's quality of life.

Why ‘Knee Preservation’?

Historically, the treatment options for persistent knee pain due to arthritis were conservative therapy or early knee replacement surgery. While knee replacement (arthroplasty) is suitable for older patients, it is not ideal for younger, more active individuals. ‘Knee preservation’ has emerged as a middle ground. This approach not only addresses pain but also aims to avoid or delay joint replacement altogether. It does so by restoring the native knee joint anatomy and biomechanics.

What is ‘Knee Preservation’?

Knee preservation includes various treatment modalities designed to maintain and restore both the structural integrity and function of the native knee joint. Instead of replacing damaged parts with a prosthesis (as in total knee replacement), these techniques aim to repair damaged tissue, correct malalignment, and redistribute mechanical loads. This process can effectively slow or halt the progression of joint degeneration/arthritis.

Customized Approaches

Knee preservation is a patient-specific approach. By focusing on the root cause of symptoms, such as cartilage defects, ligament injuries, meniscal tears, or bone deformities, knee preservation offers patients a second chance at pain-free mobility with their native joint.

Why ‘Preservation’ over ‘Replacement’?

Knee replacement has revolutionized joint care, especially for elderly individuals with grade 4 end-stage tricompartmental osteoarthritis. However, it is not ideal in the early stages of arthritis. Candidates who should consider knee preservation rather than replacement include:

• Young, active individuals under 60 years of age

• Athletes or manual laborers

• People wishing to return to high-impact sports

• Patients with localized knee issues instead of generalized arthritis

  
  

Concerns with Early Joint Replacement

While early onset of arthritis is real, the concerns about ‘early' joint replacement for younger patients include:

• Limited lifespan of knee replacement prostheses (implants)

• Restrictions on impact sports and strenuous physical activities

• Loss of natural joint feel (proprioception)

• Risks associated with major invasive surgeries: infection, stiffness, implant loosening, or wear over time requiring revision surgery

  
  

Knee joint preservation aims to avoid these limitations by protecting the native joint for as long as possible.

Ideal Candidates for Knee Preservation

Ideal candidates for knee preservation include:

• Young to middle-aged adults (typically ages 18 to 55 years)

• Individuals with focal cartilage lesions or meniscal injuries

• People with ligament instability (e.g., ACL tears)

• Patients experiencing patellar (kneecap) dislocations or maltracking

• Individuals with bow-legs (varus) or knock-knee (valgus) deformities

• Patients with early osteoarthritis, particularly affecting one of the three compartments of the knee joint

  
  

NON-SURGICAL Treatment Options under Knee Preservation

1. Rest and Acute Pain Management: Non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce acute pain and swelling in the knee joint, especially during flare-ups due to excessive activity.

2. Physiotherapy: Supervised exercises and rehabilitation are the first line of defense while recovering from an injury and in the long run. Custom exercise regimens help restore function and ease pain.

3. Lifestyle Modifications: Certain activities like squatting, sitting on the floor, and stair climbing can aggravate ongoing degenerative processes in the joint. Avoiding these can be beneficial. Maintaining an active lifestyle with regular non-impact exercises, like walking, cycling, and swimming, further supports knee health.

4. Weight Reduction: Excess body weight places additional strain on knee joints. Weight reduction strategies under supervision can significantly offload the knee joints, improving overall joint health.

5. Cartilage Supplement Medications: Naturally produced substances like glucosamine and chondroitin are available as over-the-counter supplements. While glucosamine aids in joint cartilage repair, chondroitin helps prevent certain enzymes from breaking down cartilage.

6. Off-loading Braces: External aids like knee braces can provide relief by taking some pressure off an arthritic compartment of the joint.

   
   

7. Intra-Articular Injections:

   1. Steroids: Prescribed to reduce inflammation inside the joint. However, it’s essential to limit the number of injections due to potential deleterious effects on remaining cartilage.

   2. Viscosupplementation with Hyaluronic Acid (HA): This lubricant, found in synovial fluid, can be injected to ease pain and stiffness, although it does not stop arthritis progression. Injections may need to be repeated after a few months.

   3. Platelet Rich Plasma (PRP): Platelets contain growth factors that aid in healing injuries. A concentrated form, prepared from the patient’s blood, can be injected into the joint. While it may not lead to complete cartilage regeneration, it can significantly improve symptoms.

      
      

SURGICAL Treatment Options in Knee Preservation

1. Meniscus Repair: Menisci play critical roles in shock absorption, joint lubrication, and load transmission. Loss of meniscal tissue can accelerate osteoarthritis. Early intervention is vital for healing and restoring joint function. Arthroscopic repairs are a minimally invasive option. Meniscal transplantation is also available for those with complete meniscus loss.

   
   

2. Cartilage Restoration Surgery: Native hyaline cartilage does not regenerate once damaged. Various techniques are available for treating focal chondral defects.

• Microfracture: Creates holes in the defect to release bone marrow stem cells, forming a fibrocartilage patch—best for small lesions. However, fibrocartilage is less durable than native hyaline cartilage.

• OATS (Osteochondral Autograft Transfer System): Transplants healthy cartilage from non-weight bearing areas of the joint to the defect using bone plugs—ideal for medium-sized focal defects.

• ACI (Autologous Chondrocyte Implantation): Harvests cartilage cells from the patient’s knee, cultures them, and re-implants them into the defect. This technique requires two surgeries but yields hyaline-like cartilage, which is effective for larger lesions.




3. Ligament Reconstruction: Injuries to ligaments like the Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) destabilize the joint and lead to early cartilage wear. Early arthroscopic reconstruction helps restore native joint biomechanics.

   
   

4. Limb Re-alignment with Osteotomy:

High Tibial Osteotomy

For individuals with bow-legs (varus) or knock knees (valgus), limb re-alignment surgery in the form of an osteotomy corrects the deformity to distribute forces equally in both medial and lateral compartments. This procedure involves cutting the bone, adjusting the knee alignment, and fixing it with a metallic plate and screws.

Choosing the Best Treatment

Knee preservation is not a one-size-fits-all solution. The choice of treatment modality depends on multiple factors, including age, activity level, and the type and grade of pathology. A comprehensive evaluation should include:

• Detailed patient history and clinical examination

• Weight-bearing radiographs and mechanical axis analysis

• MRI for soft tissue and cartilage assessment

• CT scans for rotational and bony deformity assessment (if necessary)

  
  

Based on these findings, a personalized plan may involve combining multiple procedures, such as ACL reconstruction, meniscus repair, and high tibial osteotomy.

Effectiveness of Knee Preservation

When chosen by the right candidates at the appropriate stages, knee preservation can yield significant benefits:

• 85-95% return to pre-injury activity levels

• High patient satisfaction rates

• Delaying knee replacement by 5 to 15 years

• Lower complication rates compared to knee replacement

• Restoration of joint longevity and quality of life

  
  

Conclusion: Preserve, Don’t Replace

Why replace something that can be preserved? It’s all about treating early and smartly, giving the body a chance to heal, recover, and thrive using its own natural structures. To conclude, knee preservation represents the future of orthopedic care: biological, evidence-based, individualized, and full of promise!