Numerous Options Available for Those Suffering From Knee Pain by Gina Shaw As the baby boom generation (some 76 million Americans) hits their 50s, many are discovering that all those years of jogging and pick-up basketball have taken a toll on their knees. Knee osteoarthritis is a hard-hitting problemóalthough estimates vary widely, with at least half of all Americans over 65 showing some signs of the degenerative condition in one of their knees. Sore knees, according to the Arthritis Foundation, contribute to some 7 million visits to the doctor and account for more than 250,000 total joint replacement surgeries every year in the United States alone. Worldwide, the World Health Organization reported in 1997 that up to 40 percent of people over the age of 70 suffer from osteoarthritis of the knee. So whatís to be done about those aching knees? There are a lot of nonsurgical options for sufferers. For starters, consider losing weight. Each additional pound you pack on adds four times the pressure on your kneesóthink of the relief if you take off just five pounds. Other approaches include heat and cold therapy, nonweight-bearing exercise to keep joints supple, an array of medications, and supplements such as glucosamine. But eventually many people with moderate to severe knee osteoarthritis will begin thinking about surgery. Does it really work? What approach should you try? And are there any new options? Before total knee replacement, there is an intermediate surgical step called arthroscopic knee surgery that, some say, can relieve pain and stave off replacement for at least five years. Others, however, question the value of arthroscopic surgery, saying it is no better than a placebo. A Texas study, reported in the New England Journal of Medicine last July, found that patients who had arthroscopic knee surgeryóeither debridement, which removes worn and damaged cartilage by cutting it away, or lavage, which flushes the cartilageóexperienced no more pain relief than patients who had a placebo surgery. ìThe fact that effectiveness of arthroscopic lavage or debridement in patients with osteoarthritis of the knee is no greater than that of placebo surgery demands that we examine the risk we are exposing these patients to,î said lead investigator Dr. Nelda P. Wray, a health services researcher at the Houston Veteran Affairs Medical Center and Baylor College of Medicine, where the surgeries were performed. Not so fast, said Dr. Robert P. Nirschl, director of the Nirschl Orthopedic and Sportsmedicine Clinic in Arlington, Va., and a leading authority on sports medicine. A study he published in the journal Arthroscopy last October contradicts the Baylor study, finding that 28 of 36 patients were successfully saved from total knee replacement for at least five years. ìArthroscopy for arthritic knees is unquestionably effective, but you have to select appropriate knees and do appropriate things,î said Nirschl. So what is the ìrightî knee for arthroscopic surgery? The answer is one that has evidence of an actual mechanical problem, such as a bone spur or fragment in the joint that is blocking the hinge. ìIf you deal with any knees that have pain issues, and donít select only the knees that have real mechanical problems, then youíre obviously going to have less success with arthroscopic surgery, because thereís likely to be nothing mechanical for you to fix,î Nirschl said, noting that the Texas study used no such criteria. With new technologies evolving rapidly, putting off knee surgery for even just five years could make all the difference. ìWeíre nearing the point where we can use biological replacement materials, such as cartilage cells, to replace what is missing in the knees. Metal and plastic will become obsolete,î Nirschl said. ìOnce you do a total knee replacement, youíve burned your bridges and eliminated the possibilities for these new technologies coming along.î Already, a new computer system is helping to give more precision to current knee replacement techniques. The Computer-Assisted Orientation System (CAOS), used now by about a dozen surgeons nationwide, serves as a sort of global positioning system for knee prosthesis, pinpointing the precise alignment for placement. ìIt eliminates human error and selects the correct knee orientation regardless of tissue,î said Dr. David R. Lionberger, who specializes in joint replacement surgery at the Methodist Hospital in Houston and performs about 25 to 30 knee surgeries a month using the system. ìIt continuously updates the orientation during surgery so you know exactly where you are at any time. You immediately know if something moves or is positioned inaccurately.î Despite the exciting advances, many experts caution that surgery should be viewed as a last resort, especially for active people in their 40s and 50s. At a briefing during the 2002 meeting of the American Academy of Orthopaedic Surgeons, Mayo Clinic surgeon Dr. Arlen D. Hanssen advised middle-aged knee pain patients to try a combination of exercise (joint-sparing activities such as swimming and biking), medication and physical therapy before moving on to surgery. Joint replacement in particular might not suit the needs of an active baby boomer as well as it does a 65-year-old who may be slowing down a bit because the surgery requires a decrease in physical activity. ìA middle-aged person who loves singles tennis potentially risks repeat surgeries by putting their artificial knee through premature wear and tear,î Hanssen said at the meeting. ìMiddle-aged patients whoíve had knee surgery recommended to them should try less aggressive alternatives first.î Gina Shaw is the medical writer for The Washington Diplomat.