Achy joint treatments that could be the bees' knees
For millions of people in this country, knee pain is part and parcel of their daily lives. Victoria Lambert takes a look at some of the treatments…
AROUND one in five people aged over 45 has osteoarthritis, where the cartilage that cushions the bone in our knees wears thin. It’s a growing problem, says orthopaedic surgeon Mark Wilkinson, who is also a professor of orthopaedics at the University of Sheffield.
"The incidence is increasing because of our ageing population, and because rates of obesity, a major risk factor for knee osteoarthritis, are rising," he says.
There is no cure and treatments focus on relieving pain until the joint deteriorates so much that a replacement is necessary. Yet, increasingly, such treatments are being called into question.
A recent study discovered that cortisone injections – one of the most common treatments to ease pain and reduce swelling in osteoarthritis – could do more harm than good.
Scientists from Boston University found that the steroids in these jabs could speed up the joint’s disintegration – hastening the need for a knee replacement. One theory is that the steroids may be toxic to cartilage in some cases.
"We’ve been telling patients that even if these injections don’t relieve your pain, they won’t hurt you," the study leader, Dr Ali Guermazi, a professor of radiology, wrote in the journal Radiology. "We are now seeing that these injections can be harmful to the joints."
Meanwhile, although prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac and ibuprofen, can reduce pain, they can bring side-effects, too, such as stomach irritation. And a review in The Lancet in 2016, which analysed results from 74 trials, found that paracetamol had at best a 4 per cent chance of improving osteoarthritis pain.
So where does that leave the millions of people in the UK with painful knees?
When teacher Angela Raynes, 65, found herself plagued by debilitating knee pain, she chose a new approach.
She’d had intermittent knee pain since she was 16, and two years ago the pain in both knees began to make it hard to walk and drive long distances.
Scans revealed severe osteoarthritis, but Angela, from North Thoresby in Lincolnshire, turned down a steroid jab and double knee replacement.
"I knew the recovery period would be hard as I live on my own," she says.
After researching online, she chose a new treatment where fat cells are extracted from the tummy and then injected into the knee – it’s thought they help encourage the tissue to repair itself.
Angela had the procedure in 2018 – it took a day and her knees are now pain-free. "I have my life back. I can work, drive long distances and walk on the beach again."
Other new treatments are starting to replace older procedures. Here we explore which cutting-edge techniques may benefit you.
Jabs may make sore joints worse
OLD STYLE: More than 70,000 people in the UK have at least one cortisone (steroid) injection each year as a short-term fix to reduce the swelling of osteoarthritis.
Such jabs have a 70 per cent success rate, says Chinmay Gupte, a consultant orthopaedic surgeon at The Wellington Hospital in London and Imperial College Healthcare NHS Trust, and the effect can last for three months.
However, they can also reduce the activity of the immune system, which, says Mr Gupte, "may even accelerate the arthritic process and increase risk of infection when you do have an operation".
Another option is lubrication gel jabs. Hyaluronic acid, for example, is thought to mimic the joint’s natural lubricants, but Mr Gupte says they don’t work for everyone.
NEW APPROACHES: Injections of platelet-rich plasma (PRP) – the patient’s blood is spun to separate out cells called platelets – is an ‘interesting’ new option, says Nima Heidari, a consultant orthopaedic surgeon at The Regenerative Clinic in London.
Platelets contain growth factors thought to stimulate cartilage repair. The National Institute for Health and Care Excellence (NICE) says that, while safe, PRP therapy has limited efficacy.
Angela had the 45-minute Lipogems procedure, which involves harvesting up to 350ml of fat cells from the tummy via syringe. This is then cleaned and injected into the affected knee.
"There they release compounds that seem to stop cell death and encourage proliferation of the local tissues to repair themselves," says Mr Heidari. "They also seem to have a pain-killing effect."
The procedure is only available privately and costs £6,400. The results last two to three years.
A review this year concluded the therapy "will have an important role in the conservative treatment of osteoarthritis", reported the journal Knee Surgery, Sports Traumatology, Arthroscopy.
However, Professor Wilkinson says: "There is no good clinical trial evidence that injection of stem or fat cells has any impact on symptoms or disease in arthritis."
Cut to your shin can keep you moving
OLD STYLE: "Arthroscopies, a form of surgery to repair damaged cartilage, were readily performed 20 years ago, but are quite ineffective," says Mr Gupte. "These operations are not recommended in most patients, unless there is a loose piece of bone or gristle."
NICE says the procedure should only be given to people with a clear history of the knee locking.
NEW APPROACHES: Osteotomies, where the bone is cut so it can be moved to the correct position, are a good choice, particularly where there is some natural misalignment, says Mr Heidari.
"It allows us to change the shape of the tibia bone – the larger shin bone in the lower leg – then fix it in a new position, where the limb is straight, using metal plates and screws. It’s not a cure, but decreases pain and can keep the knee going for longer before more intervention is needed."
Tibial osteotomies are available on the NHS and privately, costing around £8,000.
Repairs made with donated bone
OLD STYLE: Nearly 100,000 knee replacements are carried out each year on the NHS. "This is a great operation," says Professor Adrian Wilson, a London-based knee and sports injury specialist. "In the over-65s, success rates are high and the new joint can last 25 years.
"In younger patients, the failure rate becomes more of a problem and in the under-55s, one-third of all patients has to have a replacement within seven years."
This is due partly to these patients being more active so putting extra pressure on the new joint, says Mr Heidari.
NEW APPROACHES: There are three compartments to the knee: the kneecap, the inside (medial) compartment and the outside (lateral) compartment – increasingly, patients are being offered replacement of only one or two of these, instead of a full artificial joint.
"Replacement of one compartment is well-established," says Mr Gupte. "Trials are under way for the replacement of two compartments, but this is still debated."
Those under 50 who need a new joint may be offered a knee allograft – where donated cartilage and bone replaces the patient’s own, although this is still in development, says Mr Gupte.
Prescription-strength anti-inflammatory drugs, such as diclofenac and ibuprofen, are effective, but can cause stomach irritation.
Paracetamol can cause liver? damage as a result of overdosing over time. While codeine – a more powerful painkiller which inhibits pain signals – was reported by the authoritative Cochrane group in 2014 to be little better than a placebo and, as an opioid, is also addictive.
Professor Mark Wilkinson explains: "The new painkiller closest to approval is tanezumab, an antibody to nerve growth factor. However, it is still in trials."
APPA, another new drug, contains plant compounds that might have an anti-inflammatory and cartilage- protecting effect. It is in the early stages of testing.
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