London knee replacement surgery

As Queen reluctant to undergo knee surgery, what does recovery in older knee replacement patients entail?

The recent news story about the Queen turning down the opportunity for knee replacement surgery in order to carry on with her forthcoming engagements gives us the ideal opportunity to discuss knee surgery in older patients.

While most people the Queen’s age don’t tend to put themselves through the 200-plus engagements she goes through every year, we’re long past the stage where the older generation are expected to spend the rest of their lives sat in bath chairs – and today’s generation of seniors are certainly more active (and want to be) than their grandparents were. And when knee problems set in, many people in later life want to take advantage of new surgical advances.

A potential placebo effect

But is it worth it? A study conducted earlier this year by the John Hopkins School of Medicine in Baltimore looked into post-operation reports from people over 65 who had undergone arthroscopic partial meniscectomy – a procedure which involves shaving or cutting out damaged or torn tissue, which accounts for an estimated two-thirds of knee operations on the over-65s in the US.  And while the procedure is seen as a massively successful operation for younger patients who have suffered severe knee damage, the reports suggest it may not be the thing for seniors.

According to the study, which was published in February of this year, APM surgery only works on older patients as a placebo effect: the patient has had something done to their knee, therefore the knee must be better. In actual fact, studies prove that the procedure has little to no beneficial physical effect on patients over 65.

So, when is too old?

Then again, what the experts think about knee replacement surgery isn’t as important as what the patients feel after they’ve had it, and a few studies bear out the idea that it’s still worth it. A 2010 study found that patients aged 75 to 90 generally felt that knee surgery had improved the quality of their lives – out of the 48 people surveyed, all but one believed that having surgery was a wise decision.

A more recent study – conducted in 2014 – focused upon hip replacement surgery on people in their 90s and concluded that the results were comparable to a study group of younger patients – assuming that the older patient was generally in good health in the first place. However, and for obvious reasons, patients in their 90s stay in hospital for longer, and were more likely to be readmitted after three months – but infection rates were no different when compared to the younger study group.

So, in summary: it’s complicated, but not necessarily in a bad way. Some people of senior age will be happy to undergo London knee replacement surgery and feel better for doing so, while others will feel it’s not worth the bother and are willing to make accommodations to their lifestyle to work around their knee problems. Or, in the case of people like Her Maj, they’re just too busy to go through the downtime of surgery.

knee arthritis prevention

The importance of weight loss when living with knee osteoarthritis

We’re all aware of the main health benefits of controlled weight loss: the decrease in the risk of diabetes and heart disease. However, there is another significant benefit of maintaining a healthy weight – the impact on our joints.

It goes without saying that obesity can do serious damage to the joints, particularly the knee joints, and previous research has demonstrated that overweight and obese individuals with knee osteoarthritis can reduce pain by 50% and significantly improve function and mobility with a 10% or more weight loss over an 18-month period. Now researchers from the Wake Forest University in North Carolina have fleshed out those findings with more revelations.

The latest findings, which were published in Arthritis Care & Research, reveal that losing 20% or more of your body weight has the added benefit of continued improvement in physical health-related quality of life – along with an additional 25% reduction in pain and improvement in function.

Take the load off

The study, which involved 240 overweight and obese middle-aged adults who suffered from pain and knee osteoarthritis, divided the participants into four groups according to how much weight they lost over an 18-month period and put them through an assortment of interviews and tests.

The researchers found that the greater the weight loss, the better participants fared in terms of pain, function, 6-minute walk distance, physical and mental health-related quality of life, knee joint compression force, and IL-6, a marker of inflammation. Not only that, but when comparing the two highest groups – the ones which lost 10% of their body weight and the group which lost 20% – the latter group had 25% less pain and better function than the former, and a significantly better health-related quality of life.

There’s something fishy about knee arthritis prevention

The obvious explanation for this is that the less weight you put on your joints, there less chance there is of causing damage, which will lead to a welter of OA issues, but it’s not as simple as that, as another study into knee arthritis prevention from the University of Surrey bears out. According to their findings, a gram of fish oil per day could help reduce pain levels for osteoarthritis sufferers, as well as reduce inflammation in the joints – a key factor in knee pain.

Furthermore, the study thoroughly recommends a calorie-restricted diet for overweight and obese people with OA issues, for two main reasons: to speed up weight loss, and also deal with high blood cholesterol, which is a key factor in osteoarthritis.

With osteoarthritis, prevention is better than cure – mainly because there is no cure yet. And as both studies bear out, the best shot we all have in preventing an ailment which affects over 8,750,000 people in the UK and 15% of the entire planet is a healthy lifestyle and a sensible diet. Bottom line: the more you have to lose, the more you have to gain.

depression and knee arthritis

Depression risk higher the worse knee arthritis becomes

 When you’re struggling to perform everyday tasks due to aching, painful joints, it’s no surprise that your mood will suffer. Data shows that rates of depression and anxiety can be between two and ten times greater than the rates of the general population, depending on the type of arthritis you’re suffering from.

A new study conducted by the University of Maryland in the US and presented at the recent Annual Congress of the European League against Rheumatism, claimed that depression and its side-effects was becoming a stronger factor in the cause and treatment of knee OA.

According to the study, which evaluated 1,652 patients with knee OA but who were below the screening threshold for probable depression, the chances of developing depression can rise to 20% – double that of the general population. Not only that, but depression in knee arthritis is associated with a lower quality of life, a higher mortality rate, and a greater reliance on healthcare.

The knock-on effects of knee arthritis

After assessing OA disease severity at baseline and on three annual follow-up visits – where they examined patients for minimum joint space width, 20-metre gait speed and measuring pain levels on a pain subscale of the WOMAC Index – the research team focussed upon the risks of the onset of depression amongst the study group. Their findings concluded that greater structural disease severity and decreased physical performance are associated with a statistically significant increased risk of experiencing depression.

Knee arthritis and depression link

The two diseases become enmeshed closely; anxiety and depression can lower the pain threshold and chronic pain is known to aggravate anxiety and depression. Inflammation associated with knee osteoarthritis also plays a role: in a 2016 study published in The Journal of Clinical Psychiatry, over 10,000 patient cases were reviewed and those displaying the symptoms of depression were found to have levels of a particular inflammation marker 31% higher than those with no depressive symptoms.

Furthermore, those suffering from arthritis and depression typically find physical activity and normal function becomes limited and often struggle to follow treatment programmes and therefore are at risk of developing further health problems.

It’s the little things that count

This factor was clearly demonstrated by another study conducted in Japan earlier this year, which examined the link between knee pain and function and depressive symptoms – but this time zeroed in on an older sample group (573 adults aged over 65) and the activities which depressed them the most. The study, conducted by Tokyo’s Keio University School of Medicine, discovered that the most problematic symptoms were pain at night while in bed, difficulty getting in and out of a car, and difficulty in putting on (and taking off) socks. Again, it’s clear that being encumbered by pain and difficulty while performing the most mundane tasks – things that younger people take for granted – are more of a factor than losing the ability to run or climb.

As well as the personal effects of depression on the general population, we’re also becoming more aware of the detriment it has on the economy. It has been estimated that depression costs the UK economy 15.8 work hours per annum, with an estimated 21% of all sick days in the UK are caused by workplace stress. The NHS prescribed a record number of antidepressants last year – over double the amount it dispensed a decade ago.

The importance of treating knee osteoarthritis effectively, whether through the management of symptoms or surgical intervention in the form of knee replacement surgery, is essential for preserving quality of life.

golf and knee arthritis

Ditch the golf cart if you have knee arthritis

If you’re into sport, chances are you’ve played golf. It’s often the go-to pursuit for so many retired professional sportspersons, and for obvious reasons: it allows you to stay competitive well into later life with minimal strain and stress. The health benefits are manifold, as well: it’s been estimated that you’ll be walking for over six and a half miles while playing the average round of golf, which more than takes care of your daily recommended walking distance.

That is, of course, if you’re not using a golf cart. On the face of it, golf carts are an absolute boon, especially for those of us suffering from knee osteoarthritis. And if you’re already suffering from knee arthritis, wouldn’t forgoing the cart aggravate your ailment even further? According to a study into golf and knee arthritis that has recently been published in America, it seems that the answer is ‘no’.

Having a stroll won’t take its toll

Plenty of golfers suffering from knee arthritis seem to think that golf carts are a life-saver: in the late 80s, 45% of all golf rounds in America were played with a cart. Nowadays, that percentage has rocketed up to 69%. However, the new study – the first of its kind, conducted by the Shirley Ryan Ability Lab and Northwestern Medicine, and presented at the Osteoarthritis Research Society International Annual Meeting in Liverpool in April – demonstrates that playing a round on foot the course provides significantly higher health benefits. More importantly, walking is not associated with increased pain, cartilage breakdown or inflammation.

The study analysed the on-course habits of 15 participants – ten who had knee osteoarthritis and five who were of similar age, but were OA-free. The participants were invited to play 18 holes on foot one day, and then a round with a golf cart on a different day. The research team compared their heart rates to determine the intensity of exercise performed and took blood samples during each round to measure markers of cartilage stress and inflammation.

Dump the cart, exercise your heart

The researchers found that, prior to starting either of the rounds, the participants with knee osteoarthritis had an average pain score of 1.3 (on a scale of 0-10). When they played the round walking the course, they had an average 2.1-point increase in pain score. When they played the round using the golf cart, they experienced on average a 1.5-point increase – a difference that is deemed not clinically significant.

The research team also measured blood-based biomarkers of cartilage stress and inflammation. Although both methods of transportation caused an increase in these markers (as would be expected with regular walking), there was no difference between the rounds.

When walking the course, golfers with knee osteoarthritis spent more than 60% of the round with heart rates in the moderate intensity heart rate zone – which corresponds with other adequate exercise activities. When driving on a cart, however, golfers spent 30% of the round in that range. While this figure is lower, it still fulfils daily exercise recommendations.

So, while walking the course offers the most significant health benefits – and is not the aggravating factor on knee OA as first thought – the study found that riding the course with a golf cart during a round (and the walking that still comes with it) still offers cardiovascular benefits and helps fulfil daily exercise guidelines.

We know what excess body weight does to the joints, particularly the joints of OA sufferers, so the advice is clear: leaving the cart outside the clubhouse is a far better long-term option, because the idea that extended periods of walking is going to shorten your golfing lifespan is nothing to worry about. But the good news is that while walking is better than the cart, using the cart over not playing golf at all is still the better exercise option.

partial knee replacement

Partial vs full knee replacement examined

The argument between total knee replacement and partial knee replacement is one that has been raging for some time amongst the medical community. And so far, the battle is being won by the total replacement adherents: out of the 98,147 instances of knee replacement surgeries carried out in the UK in 2016, 91% of them were total knee replacements.

However, a new report conducted by researchers from Oxford University may start to turn the tide: according to their findings, many more people than first thought who are facing surgery for knee problems would be better off with a partial rather than total knee replacement.

As we know, partial replacements have long been seen as the suitable procedure for people who have suitable for people who have arthritis in just one side of the knee – usually the inner side, and only when the ligaments inside the knee are still strong. The benefits of partial knee replacement surgery are obvious: the patient has to contend with a smaller incision and minimally invasive surgery. However, the general rule of thumb has always been: if in doubt, take it all out in the form of a full knee replacement.

The case for partial knee replacement surgery

Recently, though, the research team – from the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) – examined real data from a very large range of patients about their operations, their GP visit and their own reported quality of life outcomes, and concluded that partial knee replacements can be better for certain patients and could save the NHS a fortune.

The key finding was that the choice between a partial or total replacement varied from surgeon to surgeon – as did the success of the operation. And the surgeons who carried out more partial replacements had better outcomes from them than surgeons who performed fewer of them. As Co-Lead researcher Prof David Murray pointed out, this was a very important finding.

“If surgeons aim to use partial knees in a quarter or more of their knee replacements this will substantially improve the results of knee replacement and will save money,” said Professor Murray. “In addition, more partial knee replacements will be done and more patients will benefit from this procedure.”

One size knee op may not fit all

According to the research team, the next step is to investigate the potential benefits of partial knee surgery in more cases. However, they are keen to stress this shouldn’t be an across-the-board mind-set: they went to great lengths in the report to stress that while their research demonstrates that partial knee replacements can be better and cheaper for patients over 60, the long-term benefits for partial surgery in the under-60 bracket are less clear when compared to those of total knee replacements.

The cost benefits offered by partial knee replacement surgery are obvious – less theatre time, less equipment needed, and a patient occupying a hospital bed for an average of one day less. The benefits for the patient are similarly clear: less time in theatre, a quicker recovery time, and the fact that the patient feels more like they still have their own knee, instead of a ‘bionic’ one.

The lesson to be learned from this study is that surgery should always be tailored to the patient’s individual requirements which is the hallmark of Mr Jonathan Webb’s approach.

 

ACL tears in women

Why are women more susceptible to ACL tears?

It’s a conundrum which has bothered sports experts for years, and it’s borne out by statistical weight: women are two to four times more likely than men to tear the anterior cruciate ligament. But why? A recent study conducted by Duke University in Durham, North Carolina endeavoured to solve the mystery, and their findings make interest reading.

According to previous research, the reason why women are more susceptible to ACL tears pointed to an assumption that it was because their knees move differently – but the team at Duke weren’t so sure. So, they deployed a forensic approach to reconstruct injuries by examining bone bruises on the knees of 15 men and 15 women with torn ACLs.

While other studies have deployed patient interviews and slow-motion replays, the Duke team realised that video footage was ineffective in determining the precise position of the knee and the time of injury through footage. Instead, they used MRI scans taken within a month of the ACL rupture, identified bruises on the surface of the two large bones that collide when the ACL tears – the femur and the tibia – and then used 3D modelling and computer algorithms to reconstruct the position of the knee when the injury occurred. Their findings? Males and females actually have the same position of injury.

The team at Duke have been using their advanced imaging and modelling technology to great effect over the past decade in the field of ACL research, including debunking the notion that an inward buckling of the knee was the cause of an ACL tear, discovering that landing on an extended knee was the prime culprit. So, when they make a statement, the sports medicine world takes notice.

However, this current report still leaves us in the dark as to why women are more susceptible to ACL tears than men. Here’s what we know so far:

  • Women tend to have a narrower intercondylar notch – the groove in the femur through which the ACL travels – and a smaller ACL, which makes them more prone to injury.
  • Women typically have a wider pelvis, which makes the thigh bones angle downward more sharply than in men, which leads to more pressure applied to the inside of the knee, which can cause the ACL to tear.
  • Women’s ligaments tend to have more laxity, or ‘give’, than men’s, leading some experts to conclude that the excessive joint motion could be a factor in a higher ACL tear rate.
  • Research shows that the muscles stabilising the knee may take a millisecond longer to respond in women than in men, leading experts to speculate that this minuscule difference in contraction time could lead to a higher rate of injury.
  • Female athletes typically have weaker hamstring strength when compared to male athletes, leading to the hamstring having difficulty in balancing the power of the quadriceps, which in turn can lead to injury.

As with all athletes, regardless of sexual orientation, conditioning, strength training and proper coaching are your best defence against an ACL tear. Therefore, if you feel your training programme is lacking any of those factors, it’s time for a rethink.

knee pain

A new approach to lessening knee pain?

There’s a huge paradox facing the medical profession at the moment: while surgical innovations are being found all over the world, they all come at a huge cost to budgets and resources. And that dilemma is impacting on osteoarthritis professions more than most.

While the techniques and procedures have come on in leaps and bounds since the turn of the century, the demands foisted upon the profession are piling up.

However, a new treatment developed by the Vascular Institute of Virginia could provide a solution to waiting lists and precarious budgets: a minimally invasive treatment which could provide relief for people with knee osteoarthritis by blocking certain arteries in the knee, in order to reduce the inflammation that occurs with osteoarthritis. While it doesn’t repair the damage wrought by OA, it claims to reduce pain and improve flexibility.

In a small clinical trial of 13 sufferers of severe knee OA pain, researchers found that the treatment – known as geniculate artery embolization – led to reduced pain and improved knee function up to a month after treatment for the majority of patients.

How geniculate artery embolization works

The procedure begins with the insertion of catheters into key arteries in the knee through small incisions in the skin, with the help of medical imaging. Once the connections were made, microspheres are injected into the arteries, which block the flow of blood. The procedure takes between 45 to 90 minutes and doesn’t require hospitalisation or follow-up physical therapy. Out of the 13 test subjects, eight of them reported a decrease in pain, reduced joint stiffness, and improved physical function in the knee – and none of the thirteen subjects reported any major problems resulting from the procedure.

Why geniculate artery embolization could reduce pain

Geniculate artery embolization focuses on blocking arteries in the knee for a particular reason: because OA researchers believe that chronic inflammation in the joint causes new blood vessels to form and grow into the cartilage, the synovial membranes that line the joint capsule and the nearby bone – bringing new sensory nerves with them. By blocking these newly-formed vessels, the cycle of inflammation and damage is broken.

That’s the theory, in any case: another, more long-term study monitored 72 similar patients over an average of two years. And while 86 percent of them reported improved symptoms, a third of them had to undergo the procedure a second time.

So, is GAE the magic bullet for knee OA? While certain experts have estimated that it would be more expensive than most standard drug treatments for mild-to-moderate knee osteoarthritis, it could be a real solution for more severe incidences – particularly when you factor in the elimination of recovery time after knee replacement surgery. For now, the jury continues to be out – but we’ll be following any further developments with interest.

arthritis and ageing

Arthritis and ageing

We are fast becoming an ageing population and, according to Arthritis Research, we’re getting even older than we think, as the average lifespan of the world’s population goes up by five whole hours every day, meaning a child born a year from today will statistically live 76 days longer than one born today. Good news if you’re planning on having a long life – not so good news if you’re planning to live that life free of arthritis, one of the most common ailments that afflict us as we age.

While it’s true that arthritis is not an age-specific malady – research proves that the average ages that people develop it is between 30 and 60, and many babies are born with it – the fact remains that arthritis and ageing go hand-in-hand, and will have a profound effect on the society of tomorrow – after all, in a world where people are already starting to retire later in life, arthritis is going to have a major effect on our ability to keep going.

FoxO on the run

So why does the risk of arthritis increase as we get older? A recent study conducted by the Scripps Institute in California investigated that very dilemma. And according to their findings, the key to delaying and even avoiding arthritis is all down to a certain protein.

FoxO proteins get their name from the term ‘forkhead box’, which describes the shape of the motif formed by scores of amino acids which bind to a DNA structure. Also known as the Winged Helix, they play a very important role in the regulation of genes that perform a range of tasks – including cell growth, proliferation, differentiation, and longevity.

Previous research conducted at the Scripps Institute determined that a lack of FoxO develops in cartilage as our joints age and that people with osteoarthritis have a marked decrease in the genes our cells needed for autophagy, which is the process that allows our cells to remove and recycle damaged elements in order to stay healthy.

No FoxO, no lubricin

For the new study, researchers used mice with FoxO deficiency in cartilage and a control group of mice with no FoxO deficiency, in order to monitor how FoxO proteins affect maintenance of cartilage throughout adulthood. They noticed a severe difference in the mice with FoxO deficiency: their cartilage degenerated at much younger age than in the control mice. The FoxO-deficient mice also had more severe forms of post-traumatic osteoarthritis induced by meniscus damage and were more vulnerable to cartilage damage during treadmill running.

Researchers deduced that the FoxO-deficient mice not only had autophagy defects, but they also were unable to produce enough lubricin – a lubricating protein that normally protects the cartilage from friction and wear. This deficiency was associated with a loss of healthy cells in a cartilage layer of the knee joint called the superficial zone.

In other words, if you’re lacking in FoxO proteins, the problems start – and the cells in the cartilage can’t do the necessary repair jobs. Hopefully, the next step will be to discover why FoxO proteins drop off as we age, and how we can keep them there for as long as possible.

While we wait to discover why these proteins deplete as we age and how the process can be reversed, there are certain steps you can take to minimise the development of osteoarthritis.

  • Manage occupations risks – certain occupations involve repetitive movements which can increase wear and tear on your joints
  • Maintain a healthy weight – extra weight means extra stress on your joints. Controlling our blood sugar levels is also important as diabetes can trigger inflammation. It also makes a regular exercise harder which leads us to our next preventative measure
  • Keep moving – low impact exercise, whether aerobic or strength training can help you maintain healthy joints and strengthen the supporting structures of the knee or hip
  • Rest – regular exercise is important but do not overdo it and if an activity is causing discomfort then you should discontinue it until you’ve received advice from an expert

For more advice, call us on 0203 195 2443.

Bristol Joint Replacement Centre

Mr Jonathan Webb heads up new joint replacement service in Bristol

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Bristol patients in need of hip or knee surgery now have a new joint replacement service dedicated to getting you moving as quickly as possible.

Knee specialist Mr Jonathan Webb has brought together a team of experienced and expert joint surgeons to form the Joint Replacement Centre at Nuffield Health Bristol Hospital, The Chesterfield. The surgical team have all performed a high volume of hip and knee replacement procedures over the years and offer the highest levels of clinical care and expertise, backed by Nuffield’s unrivalled commitment to patient care.

Mr Webb, who was instrumental in bringing together the consultant team, explains: “We have chosen to join together as an expert clinical team, following many years of working alongside each other in Bristol, to provide the best possible care for patients requiring hip and knee replacements.

“The Joint Replacement Centre programme is based on the latest clinical evidence and best practice, delivered by highly specialist, carefully selected orthopaedic surgeons. We are there to support patients all along the way; from assessment, diagnosis and treatment through to recovery and beyond.”

Stiffness after knee replacement surgery

How to treat a stiff knee after replacement surgery

After going through the challenges of knee replacement surgery, there’s nothing more demoralising than becoming afflicted with knee stiffness and often patients can experience a similar lack of mobility to their pre-surgery state. Although it’s not a complication that Mr Jonathan Webb’s knee replacement patients commonly experience, it’s worth addressing.

There are two main options for the practitioner when it comes to knee stiffness after knee replacement surgery: the first is to accept that the patient still has a way to go before the new knee ‘beds in’, and to recommend a regime of exercise and manual therapy whilst being overseen by a trained physical therapist, to gradually ease the knee into its workload. As a matter of fact, most practitioners will try this route as a matter of course.

If that doesn’t work – or in cases where it’s clear that the replacement knee procedure hasn’t ‘knitted’ effectively – then further surgery is advised and there are a number of options to explore:

MUA procedure

‘MUA’ stands for Manipulation Under Anaesthesia, and it does what it says on the tin: the patient is anesthetised, then the surgeon moves the joint through a full range of motion in an attempt to break through areas of fibrosis and scar tissue.

An arthroscopic exam and debridement

This involves examining the joint with an arthroscope (a camera fitted into the head of a needle) to see what’s preventing the knee joint from working, and then removing any dead, infected or damaged tissue therein, in order to give the living tissue the room it needs to do its business.

An open incision with revision

Simply put, the practitioner deduces that the new implant has been improperly positioned or has moved since it was fitted – or has malfunctioned – and goes in for a remove-and-replace procedure.

But which works best? A systematic review recently conducted by the Department of Orthopedics at New York’s Mount Sinai Hospital in New York City attempted to answer that question, by reviewing all of the articles on the three surgical techniques over a 42-year period. Although the bulk of the information over the years was sketchy at best, they managed to break down what they discovered by age, sex, time lapse between the replacement and adjustment procedure, and which technique was deployed.

The study concluded that the majority of procedures were conducted between two weeks and three months after the initial replacement surgery,

Results of each treatment approach were measured using change in knee motion and total motion. Any complications that affected the patients’ recovery or outcomes were also analysed.

The findings included:

  • Manipulation under anaesthesia (MUA) and arthroscopy are more effective in removing adhesions and other tissue debris than open surgery
  • MUA alone (without arthroscopy) appears to give the treated knee the most motion
  • Using an open incision to gain access to the joint had the worst results overall
  • The earlier the MUA, the better the results – but later MUA treatment is still effective

The moral of the story is that if you’ve had knee replacement treatment and you’re still struggling to get up the stairs, don’t assume that it’s something that will correct itself – get in touch with your practitioner as soon as possible so they can effectively eliminate any stiffness after knee replacement surgery.