March 29, 2023

Arthritis experts are calling for NHS patients to be offered knee realignment surgery that could save them from expensive and invasive joint replacement surgery.

Nearly 100,000 knee replacements are performed privately and on the NHS each year, but surgeons say one in 10 patients can have a knee osteotomy – a cheaper and less invasive operation that improves movement.

The procedure involves grafting a small piece of bone, less than an inch thick, into the top part of the lower leg bone, called the tibia. This relieves pressure on the knee, reducing arthritis pain, but leaving the joint largely intact.

‘At the moment there are around 3,000 knee osteotomy operations performed each year, both privately and on the NHS in the UK, but we believe that up to 10,000 patients could benefit,’ says orthopedic surgeon Matt Dawson.

Knee arthritis accounts for a million GP appointments a year, with three in five people aged 35 to 60 affected to some degree by the problem. It happens when the cartilage that lines the joint wears thin, causing friction when you move.

REALIGNED: Knee osteotomy scan, showing how the bone graft is clamped in a cut at the top of the tibia and supported by a metal plate

This results in the swelling, stiffness, and pain typical of the condition. The more active a patient is, the faster this happens.

Weight loss and pain medications can help. However, recent research suggests that another commonly given treatment, injections of anti-inflammatory steroids, does little to prevent further deterioration.

The only cure is knee replacement with a prosthesis, which costs the NHS around £6,500 per knee. Surgeons are reluctant to perform this surgery on younger people because the more the prosthesis is used, the faster it wears out, meaning they may need a second or even third replacement.

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Mr Dawson, who works in Newcastle upon Tyne, Penrith and Lancaster, says: ‘How long a knee replacement takes depends on how active a patient is. A 70-year-old may not survive the implant, but if you operate on a reasonably fit 50-year-old, you may have to perform a second replacement after about 15 years.’

After the second and third knee replacements, movement is more limited due to the development of scar tissue. “In these cases, an osteotomy may be preferable because the joint is preserved,” adds Dawson.

In some patients, the wearing away of cartilage is due to a natural misalignment of the joint, which means more pressure is exerted by the inside of the knee.

In these cases, a knee osteotomy, which costs the NHS £5,000 per knee, can help – and means patients never need the more invasive surgery. Welsh rugby player Gareth Anscombe, 31, underwent an osteotomy in 2020 after knee pain threatened to end his career – and returned to the field two years later. Research shows that 95 percent of patients who undergo knee osteotomy are still pain-free after five years.

“If the condition continues to worsen, they can get a knee replacement,” says Dawson. “But if you catch patients early enough, before their arthritis gets really bad, you could nip the problems in the bud, so they never have to have an implant.”

Knee osteotomy was first performed in the 19th century and was commonly offered until the 1960s. It fell out of favor when knee replacements became widely used.

“The techniques weren’t that advanced, so osteotomy used to be risky and not that successful,” says Mr. Dawson, who has performed nearly 1,000 osteotomies – two-thirds of them on the NHS. ‘Now that we have scanning technologies to measure the bones, we can determine exactly how much rearrangement is needed to get the best results.

‘We have patients who walk straight away and after about two weeks they can put weight on the joint. At six weeks they no longer need a cane, although the leg will not feel completely normal for the next few months.’

Patients should also undergo regular physical therapy for three months after surgery.

Dr. Thomas Olbrich, 52, an avid runner and mountaineer from Middlesbrough, has undergone osteotomy operations on both knees.

“I’ve been hammering my knees all my life,” he says. “I think it was inevitable that wear and tear would catch up with me at some point.”

Dr. Olbrich started experiencing pain in his knees five years ago and scans showed they had arthritis.

After being told he was a good candidate for osteotomy due to the anatomy of his knee, he underwent the first procedure in 2019 and the second in 2022 – both privately, through insurance.

“The recovery took about six months each time,” he says, “but I’m very impressed with the results. I am pain free and can do a lot of running and mountain climbing again.’

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