Non-operative Treatment

In our opinion total knee replacement is not a conservative operation. In the procedure your complete joint surface is removed and it is replaced with plastic and metal components. You become dependent on the function of these components and any failure of the components can result in pain and loss of function. We feel you should exhaust all reasonable nonoperative measures to control pain and maintain function prior to considering total knee replacement.

Arthritis of the knee is, by definition, a wearing away of cartilage. The cartilage that lines the knee is an exceptional material. It is smoother than any man-made bearing. The cartilage has no nerve endings in it and therefore, any motion between cartilaginous surfaces does not cause pain. In a patient with arthritis, as the cartilage wears away, debris is generated which causes an inflammatory response which produces pain and also accelerates the destruction of the joints. As compared to cartilage, the underlying bone does have nerve endings in it and also is not a good bearing material, motion between bones without cartilaginous surfaces may cause significant pain.

The mainstay of non-operative treatment is to control this process by decreasing the force applied across the joint, as well as decreasing the number of times that force is applied. In order to decrease the force several things can be done; the first is weight loss. Any excess weight causes significant extra force across the joint which increases the joint destruction as well as pain. Because of the muscles acting across the knee joint, normal walking causes a force across the knee approximately three to five times body weight. Therefore, if you are 20 pounds overweight, the force across the knee is increased by almost 100 pounds. Even small amounts of weight loss will decrease the force about the knee, slow down the destruction of the knee joint and decrease pain.

Another way to decrease the force is to use a cane or crutch. Usually it is used in the opposite hand, but can be used in the hand on the same side as the involved knee. Avoidance of high stress activities such as impact loading (e.g. jumping or jogging) or heavy lifting (greater than 20 pounds) also will be helpful in decreasing the force about the knee. Walking exceptionally long distances (greater than a mile) increases the number of times that the joint load is applied and this will also add to the deterioration of the joint.

The use of anti-inflammatory medications is also an important mainstay of non-operative treatment. Aspirin is the most commonly used anti-inflammatory medication but many people cannot take it because of either allergy or gastrointestinal difficulties. There are many aspirin substitutes that are currently on the market but are significantly more expensive than aspirin. There are many aspirin substitutes currently available which may have fewer side effects and more convenient dosage frequencies, but they are considerably more expensive. Some of these include Motrin, Naprosyn, Tolectin, Feldene, Voltaren, Lodine etc. For these drugs to achieve maximum effectiveness they must be taken regularly to maintain an effective level in the blood. An appropriate trial of one of these medications should be two weeks of continuous dosage. side effects should be monitored, and the drug discontinued if they occur. Chronic long term use requires monitoring of blood and urine tests by your doctor.
Exercise is useful mainly to maintain muscle tone and range of motion. Isometric exercises and gentle range of motion exercises should be sufficient because arthritis is often a problem of "wear and tear". Vigorous exercise and the use of weights only results in further deterioration of the joint.

Heat is also helpful to decrease stiffness and relieve pain. Superficial heat such as provided by liniments and appointments, etc. do not deliver the heat deep enough to be beneficial. The best is a hot water bottle or hot pack because the temperature can be controlled and they deliver a significant amount of heat deep to the joint. Use of a heated whirlpool or spa may also be helpful. Use of a heating pad can be helpful but care must be taken to avoid burning the skin.

Occasionally a Cortisone Injection can be helpful providing temporary relief for up to six months. Repeated cortisone injections (more than three) can cause damage to the knee and should be avoided.
In summary, the non-operative treatment of arthritis of the knee involves weight loss (if overweight), the use of a cane, use of an anti-inflammatory medication, avoidance of activities that cause increased force across the knee, gentle exercises to maintain muscle tone and range of motion, the use of heat and occasionally a cortisone injection.