A 57-Year-Old Man With Osteoarthritis of the Knee

In a Clinical Crossroads article published in February 2003,¹ Jess H. Lonner, MD, discussed the epidemiology, treatment options, and potential complications of osteoarthritis of the knee. The discussion focused on Mr V, a 57-year-old athlete with a history of persistent knee pain spanning 30 years. Mr V was an avid long-distance cyclist, estimating his annual cycling distance to be approximately 7000 miles. His pain had escalated gradually until it became difficult for him to stand for long periods or bend down to garden. His pain was controlled with 500 mg/d of naproxen. Radiographs of the left knee in 1999 revealed marked tricompartmental osteoarthritis with prominent osteophyte formation and severe joint space narrowing. Mr V received disparate therapeutic recommendations ranging from ongoing physical therapy to total knee replacement. At the conference, Mr V wondered if he should continue long-distance cycling and also questioned whether and when he should have total knee replacement surgery.

I decided to have the replacement in my left knee. The surgery went very well and my recovery was relatively quick. I had the surgery at the end of August 2003 and I was back to bicycling the following summer. Obviously, I was performing far below my full physical capacity, but I was out and about. The December following the operation, I was already hiking, with my physician's permission.

I did physical therapy with a visiting therapist who came 2 or 3 times a week, and that really helped a lot. Shortly after that, I was walking on crutches. Afterward, I went to another therapist and she helped me a great deal.

I just got back to riding in late April, after I had a bicycle accident and fractured my neck, which put me on the sidelines for a long time. All things considered, I’m riding pretty well, but a limited amount. I would say in an average week, I bike anywhere between 150 and 175 miles. Most of the time, I don't think about my replacement knee, it's just part of me. Obviously, I don't push the left leg as hard as I push the other leg. There are certain movements where I know my limitations, like bending my knee all the way—I can't do that anymore. But it works well. I’ve been hiking some technical terrain, and I know how far I can push it.

In general, my health is very good now. Some time ago, I was diagnosed with osteoporosis and I developed some arthritis in my right knee. According to my doctor, it is nothing to be concerned about right now. I was uncomfortable for a few weeks, and then it went away, and now I don't have any more pain.

I’m taking Fosamax [alendronate], 70 mg/wk, and a multivitamin.

Mr V's experience is illustrative of several important points. First, while we as clinicians advise patients regarding what we perceive to be the ideal treatment for them, depending on the extent of their arthritis, their social and occupational circumstances, and their expectations, ultimately it is the patients who must consider the treatment alternatives and pursue the one that is most appropriate for them. In this case, Mr V decided to undergo total knee arthroplasty rather than continue with a variety of nonoperative interventions because he believed that the pain was limiting his ability to function at a level that he considered satisfactory.

Second, Mr V is representative of an increasingly common demographic. As baby boomers age, we are seeing a growing number of patients with advanced knee arthritis, who are younger than 60 years old, live extremely active lifestyles, and want to continue to participate in their preferred activities or pursue new ones after total knee replacement surgery.^{2 - 3} This presents a unique challenge to designers of implants to develop materials and knee prostheses with improved durability that will sustain greater stress and loads than earlier generations of implants, and to surgeons to utilize techniques that accelerate the recovery process and reduce postoperative pain to accommodate an earlier return to work and other activities.

Third, Mr V has appropriately reduced the mileage that he rides on his bicycle, given that he understands that total knee implants will endure only a finite amount of repetitive loads and “cycles” across interfaces before they begin to wear or loosen.⁴ It is important that patients are advised regarding activity levels, expectations, and risks after knee replacement surgery.^{4 - 6} Mr V points out that he knows his limitations and he recognizes now where he needs to curtail his activities to accommodate the natural limitations that are inevitable with total knee replacements. While substantial pain relief and functional improvement are predictable in 95% of cases, our patients should be informed that some persistent limitations are not uncommon.^{4 ,6}

The only significant difference in how I would treat Mr V now compared with February 2003 is that I would use a minimally invasive approach, which is relatively sparing of the extensor mechanism. This technique accommodates insertion of an implant in a less intrusive manner, encouraging a more rapid recovery, earlier return to work, and less pain.^{7 - 10} Advocates of minimally invasive techniques for knee replacement surgery have reported exceptional early and midterm results, although not all surgeons have been able to replicate the benefits of minimally invasive surgery.¹¹ Certainly, those advanced minimally invasive techniques may best be left in the hands of select surgeons who spend the majority of their surgical time performing knee replacement procedures and who have perfected the techniques.¹²

Despite the fact that Mr V had a traditional approach to his total knee replacement, he remarks that his recovery was relatively quick. Mr V was an elite athlete in great physical shape. Today, in 2007, in addition to recommending weight loss if appropriate, I often recommend that patients enroll in a preoperative exercise program, either independently or with a physical therapist, because preoperative conditioning and strengthening can help to reduce postoperative pain and accelerate the recovery, although studies have not uniformly supported that notion.^{13 - 14}

Finally, Mr V notes that he has recently developed some arthritis in his contralateral knee. As we discussed in February 2003, the treatment for early mild arthritis of the knee initially begins with a number of nonoperative interventions, such as an exercise program, weight control, oral medications, and a variety of injections. If, however, those interventions fail, then knee arthroplasty procedures may be helpful. If he has focal arthritis, then an arthroplasty that resurfaces only the specific compartment of the knee (unicompartmental and patellofemoral replacements) can be very effective, with predictably good results.^{15 - 16} If, however, the arthritis is more advanced, then a total knee arthroplasty would be appropriate, with similar expectations that we have discussed in the past with Mr V.