50% of patients over the age of 65 have radiographic evidence of knee osteoarthritis.
Pain is the most common symptom in patients with knee osteoarthritis. Associated symptoms can include swelling and stiffness. Patients often have difficulty with walking, climbing stairs, getting in and out of cars, standing from a sitting position and other everyday activities.3 The symptoms of knee osteoarthritis are initially experienced during and after physical activity, however, as the condition progresses, the symptoms are present at rest and also at night times. More than 1 in 2 Australians with osteoarthritis report moderate to severe pain. 1 in 6 Australians with osteoarthritis report high or very high psychological distress.
Knee osteoarthritis has no specific cause, however several factors contribute to the onset and progression including:
Joint injury and trauma
Repetitive joint-loading tasks
Labour intensive work activities.
The clinical examination of the knee joint follows the classic textbook description of “look, feel and move”. On inspection (“look”) the knee is assessed for deformity such as varus or less commonly valgus alignment, quadriceps muscle wasting, joint swelling / enlargement, abnormal gait (antalgic, stiff etc). The palpation (“feel”) assesses for joint effusion, joint line tenderness, grinding / crepitus with joint motion. The “move” part of the examination aims to find limitation in the knee motion both in extension and in flexion. The examination of the hip joint for hip joint pain or irritability is an important step to exclude a hip joint pathology that can cause referred knee pain.
The diagnosis of knee osteoarthritis is a clinical diagnosis. It can be made based on:
Background risk (population prevalence)
Person’s risk factors for osteoarthritis (e.g. age, gender, body mass index, occupation)
Plain radiograph is usually not needed but can be considered for atypical presentations1 and also for assessing the radiographic severity of the osteoarthritis. There is however a poor correlation between radiological evidence of osteoarthritis and symptoms.4 If X-rays are required for diagnosis they must be weight-bearing X-rays.
A typical knee osteoarthritis diagnosis can be made if a person:
Is aged 45 years or older
Has activity-related knee pain
Has morning stiffness that lasts less than 30 minutes
Has crepitus with active knee motion
Has joint enlargement
Has no detectable joint warmth.
Additional features that may be present include:
Instability or stiffness
Joint line tenderness
Pain on patellofemoral compression.
At present there is no cure for osteoarthritis and the disease is long-term and progressive. The treatment aims to manage symptoms, increase mobility and maximise quality of life. Current management guidelines for osteoarthritis recommend conservative (non-surgical) management using a combination of non-pharmacological and pharmacological treatments,1,5 followed by surgical management once the conservative management fails to be effective.1,6
Non-pharmacological management includes:
Patient education and self-management
Physiotherapy: preservation of range of motion, muscle (quadriceps) strengthening, proprioception
Low impact exercise: walking, swimming, cycling
Weight loss for overweight patients.
Pharmacological management is based on paracetamol and nonsteroidal anti-inflammatories (NSAIDS). Although there is no clinical evidence for or against the use of paracetamol in patients with knee osteoarthritis, it may be reasonable to trial paracetamol for a short duration due to the low risk profile, low cost and lack of simple analgesics in patients who do not tolerate NSAIDS, then discontinue use if not effective. Tramadol is an opioid-like pharmacological agent that has shown good clinical efficacy in controlling pain in patients with knee osteoarthritis. Tramadol should only be used on a short duration and as a PRN medication.
Once the symptoms and the functional disability are unable to be controlled using conservative measures, surgical management may be indicated. The most common surgical modality to manage knee osteoarthritis is a total knee replacement. Arthroscopic procedures are not effective in the treatment of knee osteoarthritis.7
Total knee replacement surgery involves the replacing of the worn out chondral surface of the knee joint with a metal implant. In 2017 more than 55,000 total knee replacements were performed in Australia.8 This represents a 150% increase compared with the number performed in 2003.8 Patient selection prior to knee replacement surgery is very important as the dissatisfaction rate after the procedure can be as high as 18%. The causes for dissatisfaction include unrealistic patient expectation, low grade radiographic osteoarthritis at the time of surgery, inadequate surgical technique. Significant advances in the surgical technique compared with the early days of knee replacement surgery have allowed for improved outcomes and survival of knee implants. Recent studies assessing patient satisfaction have shown 98% satisfaction rate in patients with balanced knee replacements using pressure sensors during knee replacement surgery.9 Currently a combination of computer navigation, robotic technique and artificial intelligence is showing good promise that the dissatisfaction rate will decrease in the not too distant future.
Dr Razvan Stoita, MBBS FRACS
Dr Razvan Stoita is an experienced specialist orthopaedic hip knee surgeon with expertise in hip and knee replacement surgery, sports knee injuries such as cartilage repair and restoration, knee ligament reconstruction (ACL, PCL, MCL, LCL, MPFL) and trauma of the hip and knee.
Dr Stoita has a particular interest in Patient Specific Joint Replacement through the use of Computer Navigation and Robotic Knee Replacement.
He performs the following operations:
Hip Replacement Surgery and Revision Hip Replacement Surgery
Knee Replacement Surgery and Revision Knee Replacement Surgery including Robotic Knee Replacement
Realignment Knee Surgery (Young patients with arthritis)
Arthroscopic Knee Surgery (meniscal disorders and ACL reconstruction).
Knee Cartilage Preservation such as OATS(osteochondral autograft transfer system) and bone marrow stimulation.
Dr Stoita completed his Orthopaedic Training in Sydney. He travelled to London, United Kingdom where he did further subspecialty training in complex surgery of the hip and the knee with leading UK orthopaedic hip and knee surgeons, Mr. S. Bridle and Mr. P. Mitchell at the St George’s Hospital and The Elective Orthopaedic Centre at Epsom, Surrey. This was complemented by a clinical fellowship in pelvic and acetabular reconstruction with world leading surgeons at the St George’s Hospital, which is the largest pelvic and acetabular trauma unit in London. Dr Razvan Stoita also visited the world-renowned Helios Endo-Klinik in Hamburg, Germany for further training in primary and revision joint arthroplasty and periprosthetic infection treatment.
T (02) 8005 5111
Hurstville Private Hospital
Suite 4, Level 3
37 Gloucester Road
Hurstville, NSW, 2220
1. National Institute for Health and Care Excellence. Osteoarthritis: care and management in adults. Clinical Guideline 177. London: NICE, 2014.
2. Melbourne EpiCentre. Counting the cost. Part 1 - healthcare costs: the current and future burden of arthritis. Melbourne: Arthritis Australia, 2016.
3. Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology (Oxford). 2000;39(5):490-6.
4. Kinds MB, Welsing PM, Vignon EP, Bijlsma JW, Viergever MA, Marijnissen AC, et al. A systematic review of the association between radiographic and clinical osteoarthritis of hip and knee. Osteoarthritis Cartilage. 2011;19(7):768-78.
5. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16(2):137-62.
6. NSW Agency for Clinical Innovation. Musculoskeletal network: osteoarthritis chronic care program model of care. Sydney: ACI, 2012.
7. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-8.
8. AOA (Australian Orthopaedic Association) 2017. Australian Orthopaedic Association National Joint Replacement Registry Lay Summary: Hip and Knee replacement. Annual Report 2017 (supplementary report). Adelaide: AOA.
9. Gustke KA, Golladay GJ, Roche MW, Jerry GJ, Elson LC, Anderson CR Increased satisfaction after total knee replacement using sensor-guided technology. Bone Joint J 2014 Oct;96-B(10):1333-8.