NEW STRIDES FOR AGEING KNEES

Surgical advances and research are bringing hope to arthritic knees

Surgical advances and research are bringing new hope to arthritic knees.

At first, Emily Patenaude didn’t notice the pain. When she woke from the general anaesthesia after undergoing a knee replacement she was too high and happy. The pain and tenderness came a few days later, as she weaned herself off the prescribed opiates. She knew it would be bad. Her surgeon and his team had explained this to her during the months leading up to the operation. It would involve cutting an incision into her left leg, removing her old, arthritic knee and replacing it with a metal and plastic version.

It all began 21 years earlier on a learner’s ski slope. An awkward turn caused a fracture that spiralled up from her ankle to her kneecap. Although the injury healed, the initial trauma caused the cartilage in her knee to break down; eventually the

joint became so weak, she appeared bow-legged on her left side.

Fast-forward to June 2014, when Emily was taking care of her granddaughter. After pushing the little girl around in a stroller, her knee was so swollen, inf lamed and sore that she sat down on a sofa to rest and couldn’t get up for several minutes.

Osteoarthritis, the world’s most common joint disorder, had been stealthily creeping in for years. It had taken Emily hostage; she could no longer walk the 2.4 kilometres from her home to the local hardware shop where she worked – or hike or sail. She could barely stand in her kitchen to prepare a meal.

Frustrated, in May 2015, just after her 63rd birthday, she went to see a sports doctor. After studying her X-rays, he told her she would need a knee replacement. “There is no physiotherapy or series of exercises that will make you better on their own,” she was told.

Instead, all she could do was strengthen the muscles around her knee in order to help her recovery and rehab after the procedure. Over the course of an hour, her orthopaedic surgeon cut, resurfaced and drilled holes into the three bones that make up her knee, then attached them together again with a replacement that weighed around 420 grams. Then he carefully hammered it into place.

Even with the opiates following the operation, Emily doesn’t mince words, “It hurt like … heck” every time she tried to shift her body. It was painful when she began rehab the week after surgery, as she tried to bend, straighten and lift, and it remained so for at least the next two weeks.

But she didn’t give up. My job is to get better, she thought. So she did.

For a month, she went to the rehab clinic three times a week. Then it was cut down to twice a week. Finally, after two months, the therapist said she could do the rest on her own, with the occasional visit for a check-up.

“It’s easy to think, I can just get a new knee but I know better,” the 66 year old says. “You have to be willing to do hard, painful work. But in the end, it is so worth it.”

THIS IS A HEALTHY KNEE: three joints that fit together like pieces of a puzzle and function in concert as you bend and straighten it and kick out to the side. It bears the brunt of your weight as you jump to shoot that ball into the net, race to the finish line in a marathon, pick up children, or lift a heavy bag of groceries.

This is an osteoarthritic knee: Creak. Pop. Ouch. Despite advances in medical technology, the condition is very hard to fix because cartilage does not have its own blood supply and so does not heal itself.

The World Health Organisation has found that osteoarthrit is is the single most common cause of disability in older adults. A 2013

study on age-related knee conditions states that between ten and 15 per cent of adults over the age of 60 will have some degree of osteoarthritis.

The same study notes that by the year 2050, when more than 20 per cent of the world’s population will be over 60, a whopping 130 million people will suffer from osteoar thr it is, with nearly one- thi rd of them severely disabled.

Physiotherapist Candice Wong puts it this way: “Osteoarthrit is is like grey hair. The only variable is to what extent you’ll get it.”

Genetics play a role in its development, as does excess weight, your level of activity or lack thereof, and any previous injuries.

A total knee replacement ( TKR), also known as an arthroplasty (TKA), is the fastest-growing way to deal with this crippling problem. According to the latest figures from the Australian Orthopaedic Association, in 2016, 52,836 TKRs were performed in Australia and 7,765 in New Zealand. In the US, more than 1.1 million TKRs are performed annually.

In Europe, Austria had the highest number per capita, with 18,785 procedures performed in 2014. But US surgeons have performed the most TKRs of all, with numbers expected to grow 673 per cent by 2030, to nearly 3.5 million procedures a year, from approximately 534,000 in 2005.

According to Dr Lawrie Malisano, President of the Australian Orthopaedic Association, the procedure’s popularity is due to one factor: “Knee replacement is a very successful operation.”

I nt roduced back in the 1970s, the procedure makes sense, says Dr Christopher Kaeding, an orthopaedic surgeon. The rate of symptom relief exceeds 85 per cent. But Dr Kaeding warns that a patient’s new freedom comes at a cost, especially if you get a TKR in your 50s or early 60s. This group has seen a 20-fold increase in the procedure in the past two decades – because the replacements don’t last forever. Although the procedure and the materials used – alloys of cobalt-chromium and titanium and plastic – have been refined over the years, the simple effects of wear, tear and mechanics are bound to take their toll.

“Total knee replacements last for between 12 and 20 years and each time they’re replaced, the results – the mobility, flexibility and ability to handle weight – are less than what they were before,” says Dr Kaeding.

THE SURGERY WAS PAINFUL, AS WAS REHAB. BUT EMILY DIDN’T GIVE UP. HER JOB WAS TO GET BETTER. SO SHE DID

In addition, several studies have found that since ‘younger’ patients are likely to be more physically active, the need for a revision knee replacement may be up to two times higher than in older patients. And that, says Dr Kaeding, is why the latest thinking is to avoid having a TKR until the last possible moment.

Just ask Marjukka Rasanen, an accountant for whom ef fort less bending and stretching is now a distant memory. When she was 20, while rushing to pick up the mail in her parents’ home, Marjukka slipped, dislocating her right kneecap and badly straining her lateral collateral ligament, which runs along the outside of the knee. “I needed major surgery that had me in a cast for three weeks from my foot to my pelvis,” she says.

Twenty years later, Marjukka, by then married with two children, was lightly jogging when she slipped, going down on the same knee. Even without a doctor’s diagnosis, she knew. “I’d dislocated my kneecap once again,” she says. “This time, surgeons cut my shinbone, securing it in a different position to keep the kneecap in place.”

Now 53, Marjukka, who has osteoarthritis in both knees, is delaying having a TKR, despite experiencing days when she can’t take even one small step without pain.

In the meantime, to help avoid stiffness, she attends a Pilates class every week, jogs in a pool and does stretching and strength exercises while sitting at her office desk. Nothing else has worked, not the surgical repositioning of her shinbone, not an operation to repair the cartilage and not injections of cortisone, a steroid commonly used to relieve joint pain as an injury heals.

Is there hope for new alternatives in the future? Yes, say experts such as Mats Brittberg, a professor in the cartilage research unit at the University of Gothenburg in Sweden.

“At one point it was thought that stem cells could be used to repair the joint by producing new cartilage,” says Professor Brittberg. “But that hasn’t happened. While they do relieve the symptoms, it’s very expensive.”

For Emily Patenaude, she can now crouch, walk and climb, and was able to go on a five-month sailing holiday with her husband. And that angry red scar? Faded and pink.