1. Introduction
Pain in the knees can lead to a very disabling condition, particularly as we age. It is important that the condition of the knee is thoroughly assessed to ensure appropriate treatment is prescribed. The general understanding of treatment options for knee pain is low. This document is intended to give you a better understanding of what is happening in your knee, possible treatment, and what a knee replacement involves. This will better prepare you to discuss your condition and available treatment options with your orthopaedic surgeon. Non-surgical treatments are always considered first. This can involve physiotherapy to strengthen the muscles around the knee, weight reduction to lessen pressure on the knee, simple pain medication or anti-inflammatories, or a course of injections into the knee to reduce inflammation and pain. If you have tried these treatments and continue to have such severe knee pain that your normal lifestyle is affected, then it may be time to consider a knee replacement.
1.1. Overview of knee pain treatment and knee replacement surgery
Surgery should always be the very last option after all other non-surgical methods have been explored, as any kind of surgery or invasive treatment will always carry certain risks. These need to be compared against the potential benefits of the surgery.
These conditions often produce much pain and discomfort. Knee pain can be managed in a variety of ways and will often depend on the cause of the pain. Options may include professional medical treatments or self-help remedies. In more serious cases, though, the possibility of surgery may need to be considered, such as knee replacement. Knee pain can greatly affect your quality of life and ability to function, and make it difficult to maintain a healthy level of physical activity, which is important for general health and preventing other health risk factors.
Knee pain and injury is an extremely common problem. Some common causes of pain in the knee include: – Injury to a ligament, such as the anterior cruciate ligament (ACL) – Injury to the meniscus (cartilage tear) – Osteoarthritis – Patella disorders – Tendinitis
1.2. Importance of seeking treatment in Singapore
Minimizing risks to the patient and gaining successful outcomes of the treatment is primarily the goal for improvements and interventions, particularly one that can improve functioning and activities of daily living so that patients can return to the lifestyle they are satisfied with. The evidence based practice and thrives with academic and clinical research. We have the regional health care funding to the amount of 6.3 billion Singapore dollars for research, innovation and enterprise for the period of 2010-2015. This continual research progress has shown attributed through patient outcomes and recovery. This has led to improved understanding of best treatment for knee pain and knee replacement surgery, ensuring patient’s satisfaction with the treatment provided and an improvement in overall quality of life. Patient satisfaction with treatment is of interest to patients, clinicians and the general public. This is often influenced by health status and the process of care received. By seeking treatment in Singapore, patients can be ensured that they will receive optimal treatment which will improve their health status and also quality of life.
The Joint Commission International (JCI) is the international arm of the Joint Commission on Accreditation of Healthcare Organizations, which evaluates and accredits American healthcare facilities. Every standard, including its stringent infection control processes, is looked into once we have successfully met the international standards for JCI accreditation. This is great benefit as patients can be assured of high quality patient care and effective treatment for their knee pain and knee replacement surgery, minimizing risks to patient and enhancing successful clinical outcomes at reduced costs.
In Singapore, healthcare facilities are accredited and well-established. While the emphasis on affordable and easily accessible healthcare is growing in Singapore, the high standards of medical management and stringent regulations make it a pressing argument as to why treatment for knee pain and knee replacement surgery should be sought here in Singapore.
2. Non-Surgical Knee Pain Treatment Options
NSAIDs (Non-steroidal anti-inflammatory drugs) are the most commonly used medication for knee pain. They are effective in treating pain that is caused by inflammation such as tendonitis, bursitis, and most types of arthritis. They are effective and are widely available both by prescription and over the counter.
There are many types of medications available for the individual with knee pain. Often, different levels of pain will dictate what type of medication is most appropriate. Acetaminophen (Tylenol) is often the first choice for treating mild to moderate pain. It is inexpensive and generally safe if taken in recommended doses. Its safety has been questioned in recent years, as there is a possibility of liver damage if taken in excessive doses or if taken by individuals with liver disease.
Exercise and physical therapy are sometimes overlooked as a treatment for chronic diseases. However, in the case of osteoarthritis and knee pain, exercise is instrumental in the successful management of the disease. Restoring and maintaining normal function is the primary focus of an individual with osteoarthritis. This is best achieved with an exercise program that emphasizes frequent low resistance activity. The use of a continuous passive motion (CPM) machine has also been proven effective in speeding recovery after various knee surgeries including ligament reconstruction. This is a device that slowly and gently bends and straightens the knee, preventing stiffness and maintaining the range of motion.
Physical therapy is often one of the first treatments prescribed for knee pain. The goal of physical therapy is to strengthen the muscles surrounding the knee in order to support the knee and to increase the range of motion. This is critical to decreasing pain and preventing further injury. As an individual’s specific condition will dictate what type of exercise or physical therapy is most appropriate, guided therapy by a medical professional is advised.
2.1. Physical therapy and exercise
Physical therapy is a critical component of non-surgical treatment for knee pain. Physical therapists will work with you to pinpoint problems in the knee, and this will act as a basis for the specific exercises that will help improve the knee’s function. The exercises are aimed to improve the strength of the muscles that surround the knee so as to provide more stability and support. Flexibility is also an important aspect of the exercise regime. It is important for the muscles around the knee to be as flexible as possible to allow for as much movement in the knee joint as possible. If the range of motion in the knee is limited, then the likelihood of further damage is increased, as the shock from any movements is absorbed directly by the knee and not spread about the other structures in the lower extremity. A home exercise program is a key part of treatment as well. The exercises programmed by the therapist should be done independently on the patient’s own time. This helps to speed up the recovery process as the patient is actively working to improve his/her condition, with the guidance of the therapist. Compliance in such a regime is the best way to ensure the optimal improvements in the knee’s condition. In very rare cases where a patient’s knee has been significantly deformed by an arthritic condition, a brace or other assistive device may be used to shift load away from the affected side of the knee and improve pain and function. This is usually inconclusive and is more a remedial method in comparison to the other forms of therapy.
2.2. Medications for pain management
Paracetamol is usually recommended as the first line of medication to try for osteoarthritis of the knee. Taking a regular dose for a trial period of 3 months will help to establish if it provides adequate pain relief. Paracetamol is a safe, simple, and generally well-tolerated medication, and it is suitable for most people. The maximum dose is 4 grams in 24 hours, and it should not be used in combination with opioid-based drugs. This drug has been shown to be as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of arthritic pain, and it is associated with a significantly lower incidence of side effects, particularly relating to the gastrointestinal tract. This is an important consideration for older people, those with higher medical risks, or those with cardiovascular disease.
There are different types of medications recommended for the treatment of knee osteoarthritis. The choice of drug and how it is given will be determined by the severity of your pain and factors such as your age, general health, and whether or not you are at increased risk of cardiovascular or gastrointestinal side effects. It may take time to find the best combination of medication and dosage which works best for you. Some types of drugs are available only with a doctor’s prescription, whereas others can be purchased over the counter. Always check with your doctor or pharmacist if you are unsure about the type or suitability of a particular drug.
2.3. Injections for knee pain relief
Intra-articular joint injections are a minimally invasive treatment option used to help relieve pain and inflammation in the knee. The decision to use joint injections can depend on what the cause of the pain is. Much of the time, this can be determined by using a local anesthetic injection. If this completely numbs the knee for a short period, then the pain is coming from the joint itself. There are many forms of injections that can be used. The three most common are steroid, hyaluronic acid, and PRP injections. A steroid injection involves using a synthetic form of cortisone and is used as a strong anti-inflammatory. This is often used to help reduce severe pain flare-ups, such as an arthritic flare or gout attack. This can provide pain relief that can last up to a few months, sometimes longer. It is a less invasive and cheaper option compared to some other injections. However, it will not stop or slow the arthritis process.
3. Surgical Treatment for Knee Pain
Total knee replacement surgery is the definitive treatment for end-stage osteoarthritis or other diseases affecting the knee joint, provided the patient is of satisfactory health and has a life expectancy greater than five years. The aim is to relieve pain, correct leg deformity, and improve the patient’s ability to perform activities of daily living. On average, greater than 90% of people who have a total knee replacement will have much less pain in the knee and a significant improvement in their ability to perform their everyday activities. Total knee replacements are not typically recommended for patients under the age of 50 as the artificial joint has a finite lifespan, usually 20 years, and would wear out in the patient’s lifetime and require a further operation. This can pose a problem in older patients as the subsequent operation to redo the knee replacement may be difficult to undergo. A newly revolutionary type of total knee replacement is the Gender Knee Replacement. People whose knee anatomy reveals a size difference between males and females, it is believed that the standard one-size-fits-all total knee replacement may not feel or function like their own knee. Citing the potential differences in the shapes of male and female knees, Gender Solutions was developed. This is the first knee replacement to address the anatomical shape difference between men and women. With the positive benefits of the total knee replacement surgery, post-operation physiotherapy is imperative to achieving the best results.
Partial knee replacement surgery is indicated for patients with end-stage osteoarthritis isolated to one of the 3 compartments of the knee with involvement of the underlying bone. The aim is to alleviate symptomatology and improve function. It is contraindicated in patients with inflammatory arthritis, significant ligamentous instability, or complex angular deformities. The surgery involves resurfacing of the diseased compartments with metal and plastic prosthesis. With current advancement in prosthesis design and instrumentation, the surgery can be done through a smaller incision and more accurately than in the past. This can enable quicker recovery time and the possibility of the surgery being done as a day procedure. The long run survivorship of partial knee replacements compared to total knee replacements is still an area of debate.
Arthroscopic knee surgery may be indicated to remove loose bodies, cartilaginous fragments, or release adhesions. It is most commonly indicated for the mechanical symptoms of a meniscal tear causing locking or catching. The surgical technique involves small 1cm incisions on either side of the patella with insertion of a small camera to visualize the inside of the joint. Additional small incisions are then used for insertion of the arthroscopic instruments to do the surgery. It is typically done as a day surgery procedure. Physiotherapy is then usually required to restore the full range of motion of the knee to prevent the development of arthrofibrosis.
3.1. Knee arthroscopy
Surgical treatment for knee pain is offered when other motion control, strength, and medicine treatments have failed to relieve pain or improve the condition of a damaged knee. In most instances, it is not an absolute option, therefore the pros and cons of the surgical procedure must be weighed up in terms of an expected improvement in the quality of life. Arthroscopy for degenerate knees (other than torn cartilage) is not beneficial. The success of knee arthroscopy will depend on a thorough physical, orthopedic, and rehabilitation assessment and strict attention to treatment indication. Period of progressive functional impairment primarily due to increasing pain, likely to affect employment and lifestyle, with objective evidence of a disabling mechanical derangement such as swelling or knee locking. Recommended: a planned sequential program of non-operative modalities, including activity modification and/or weight loss, exercise, physical therapy, strength training, and the use of an assistive device such as a walking aid or unloader brace. An arthroscopy is unlikely to be of benefit if these measures have not been unsuccessful.
3.2. Partial knee replacement surgery
There are many cases where damages to the knee joint only occur in one part of the knee. This can be limited to the patella-femoral compartment or the medial or lateral side of the knee. Patients in this situation have traditionally been treated with a total knee replacement (TKR). However, total knee replacement is a bigger surgery which removes all the surfaces of the joint. Partial knee replacement (PKR) is a more conservative treatment option which involves only replacing the damaged part of the knee. This has the potential advantage of a more rapid recovery and more normal knee function post-surgery. Like TKR, the operation involves replacing the joint surfaces with artificial implants. This can be done as an open procedure or via keyhole surgery. Keyhole surgery requires a smaller incision and has the benefits of a quicker recovery, less pain, and a smaller scar.
3.3. Total knee replacement surgery
In the recovery ward, you will be monitored by the nursing staff. Once you recover from the anesthesia and are in a condition to go home, your length of stay in the hospital will be dependent upon your progress. A physiotherapist will educate you on a static quadriceps exercise, how to use a walking aid, and stair ambulation. Follow-up treatments might include hot or cold packs, electrical stimulation, whirlpool therapy, massage, or ultrasound. The goals are to prevent blood clots and regain knee strength and motion. You will continue to use a walking aid until you meet with your surgeon in about 10 days post-op who will then determine if you are able to walk safely without one. The average duration for using walking sticks is around 6 weeks post-operatively.
First, the surgeon makes an incision in the skin over the knee and then moves the kneecap to expose the joint. Next, the damaged surfaces of the bones and the cartilage are removed. After that, the metal components are fixed to the end of the thigh bone and the top of the shin bone. Then, a plastic component is inserted which will act as an articular and cartilage. After the metal and plastic components are set, the kneecap will be prepared and an artificial kneecap (usually plastic) will be cemented.
Total knee replacement (or total knee arthroplasty) is a surgery performed to resurface the knee joint. The surgeon cuts away damaged bone and cartilage from your thighbone, shinbone, and kneecap and replaces it with an artificial joint made of metal alloys, high-grade plastics, and polymers. Some of the latest designs reproduce the knee’s circular motion as closely as possible.
4. Considerations for Knee Replacement Surgery in Singapore
When considering knee replacement surgery in Singapore, it is important for patients to choose the right surgeon and hospital. According to MOH, there are 3 restructured and national specialty centers for orthopedics while the rest have the basic competencies. If the patient has local and moderate knee arthritis, surgeries can be done in the polyclinics and smaller GP clinics with the minor surgeries scheme in a much lower cost. It is better if patients can seek a surgeon who specializes in knee replacement surgery. These surgeons can be found in private and restructured hospitals. A list of available orthopedic surgeons and their subspecialty can be obtained from the Singapore Orthopedic Association. This is important as it is known that volume of cases and surgeon’s experience has an effect on the outcome of knee replacement surgery. Surgeon’s experience and case volume will determine the length of stay in hospital, perioperative complications, costs and satisfaction level with the procedure. High volume and experienced surgeons will have shorter stay, low complications, lower cost and better satisfaction. The right surgeon should be the determining factor of which the hospital that it should be done. The rate of the procedure and quality of implant ‘match’ the cost from a better off government class B2/C or easier said a private hospital.
The cost of knee replacement surgery in Singapore affects local and foreign patients who seek this medical treatment among other surgical treatments for arthritic knee. Time to time MOH (Ministry of Health) will allow Medisave to be used to cover part of the cost of the surgery. However, it is still costly and many Singaporeans need to top up with cash for the surgery. Knee replacement surgery is also one of the procedures where hospital medical bills insurance plan comes into good use. Patients will need to check and ensure that the insurance plan covers most if not all of the expenses to avoid paying from their pocket. Foreigners seeking knee replacement surgery in Singapore may find it cheaper compared to Western Countries even after factoring in the cost of living and exchange rate. However, price should not be the sole determinant on the choice of undergoing knee replacement surgery.
It is indicated that the choice to undergo knee replacement surgery is dependent on many factors to consider. Apart from medical indications, willingness in going through the surgery is a very important factor. The considerations for knee replacement surgery in Singapore should involve issues like the cost of surgery, choosing the right surgeon and hospital to recovery and rehabilitation after surgery and potential risks and complications of knee replacement surgery. These issues are very important in determining the success of surgery and the outcome. The main contribution of this section is to provide the patient with adequate information to make an informed decision on whether to go through knee replacement surgery in Singapore.
4.1. Cost of knee replacement surgery in Singapore
Due to the increased technology used in knee replacement surgeries and the extended hospital stay often involved in a more complicated case, knee replacement surgery usually costs more than arthroplasty. In general, the cost for knee replacement surgery is similar to the cost for hip replacement surgery. These two of the most cost-effective surgical interventions are likely to remain so, suggesting that despite burgeoning numbers of procedures, the prevalence of the underlying conditions and the need for surgery will not change. These relatively effective and safe surgical treatments are not threatened by other costly treatment options for severe knee and hip osteoarthritis in the foreseeable future. The study by Kurtz et al. based on the US National Inpatient Sample found the average private payer hospital charge for a TKR to be $50K in the years 2008 – 2014. Surgeon and anesthesiologist charges were $10K and $2K, respectively. This is very similar to the cost of a THR during the same period. Although there are variations within the US itself, in general surgery costs are higher in the US than in most other developed countries. A single country case study using a decision tree analysis determined the cost of a primary TKR in Singapore Dollars to be $18-19K in the years 2002 – 2005. Patients looking specifically for private hospital care are likely to pay a higher price. Using Medisave, 85-95% of the national bill can be offset depending on the complexity of the procedure, whether it is a day surgery or requires hospital stay and the type of implant used. These factors contribute to the total cost. As a patient, it may be helpful to make an inquiry on your own on the cost calculators available on the Ministry of Health website for private and restructured hospitals to determine the Medisave withdrawal limit. Understanding the hospital bill can maximize the appropriate usage of your Medisave and minimize the out-of-pocket cash expenses. The bill size and actual cash outlay will be lesser for patients with higher Medisave balance and greater Integrated Shield Plan coverage.
4.2. Choosing the right surgeon and hospital
Ideally, you should find a surgeon that is well versed in both traditional and minimally invasive methods of total knee replacement. It takes a very experienced surgeon to do MIS TKA well. For best results with this method, a surgeon should be doing about 100 conventional knee replacements a year and be very familiar with computer and robotic navigation. Unfortunately, there are many surgeons that attend a weekend course on MIS TKA and then start promoting themselves as MIS TKA surgeons. In the right hands, there are definitely benefits to this method. However, poorly executed MIS TKA has a higher complication rate and no better results than conventional knee replacement. So don’t be afraid to ask your surgeon for specific details about their experience and results with both methods.
Good surgeons are generally well organized. They take time to discuss with you the procedure and will ensure that you are well informed about what to expect before, during and after surgery. Your surgeon should also be willing to spend time with you discussing any concerns that you may have. An individualized approach to patient care is also important. This means that your surgeon considers your lifestyle as well as your occupation when recommending the surgery. For example, if you are young and wish to continue with very high level recreational activities, your surgeon may dissuade you from having the surgery done too soon. This is because the lifespan of most knee replacements is 15-20 years and the longer one can delay it, the less likely it is that they will outlive their artificial joint. On the other hand, if you are older and less active, the surgery may be advisable if more conservative measures have not been successful. In Singapore, the government has recently launched a pilot program to accredit public and private hospitals on a set of criteria, which includes outcome measures and standards of care, in a bid to raise quality in the health care industry. This is certainly something to look out for in the near future.
In order to ensure a successful surgery, it is essential that you choose an orthopaedic surgeon who is well-trained and experienced in doing knee replacement surgery. Although any doctor can perform surgery, to achieve the best results, it is essential to find a surgeon that is an expert in his or her field. Ask your surgeon how many surgeries of this type they have performed and what percentage of their patients have had significant improvement. A good surgeon will be candid with you and will have no qualms about discussing their success rate.
4.3. Recovery and rehabilitation after knee replacement surgery
There are different kinds of knee surgery such as total knee, partial knee, and knee cap replacement. Your doctor will discuss with you the kind that will be most beneficial to you. Knee replacement and strengthening the muscles that support it enables many people to delay the joint replacement indefinitely. There are no medicines or treatments to repair a joint that is completely worn out. Less invasive surgeries such as arthroscopy are not effective for advanced arthritis. Joint kinesitherapy is a method of treatment to restore the knee joint to its best function. This is a critical aspect of treatment for those with arthritis, which should begin as soon as arthritis is diagnosed. The second treatment is using the best people and the orthopedic surgical techniques. These involve placing the hip joint back into the correct place for the body. This is often compared to putting the tire back onto the rim of a wheel. The hip joint is a ball and socket joint. Often the ball has not developed into the correct spherical shape before it is dislocated. Similarly, the socket is often too shallow. Because of this, the hip is unstable and dislocates easily. In Britain, the average patient leads a normal life for 5 years before having a total hip replacement. In other countries such as Australia, the hip is replaced sooner to avoid abducting polio. Immediately after surgery, a machine will be used to move the hip and prevent stiffness. This is followed by a period of bed rest and then walking with crutches. The evolution of artificial joints has been rapid. They were first used in the 1960s. At this time, they were not very mobile and the materials used often broke. This led to complications and further surgery was required. In the 1980s, improvements were made to the materials used and the surgical technique so that joints could last for 15 years. Now, artificial hip and knee joints are made from metals and plastics. They are mobile and well-shaped. This enables safer surgical techniques, less joint wear and tear, and decreased likelihood of dislocation. Joint replacements are also shown in operation 2 to be very successful with 90-95% of people having a hip or knee replacement reporting a dramatic reduction in pain and a significant improvement in their mobility.
4.4. Potential risks and complications of knee replacement surgery
Some of the potential risks and complications that could be encountered are infection, blood clots, implant failure, and wear. An infection can occur after the surgery, and in more serious cases may require another operation to remove the knee replacement and insert a spacer for 6 weeks with 6 weeks of intravenous antibiotics. After this time, another replacement will have to be attempted. If the infection has not cleared at this stage, the knee may have to be fused or in severe cases, amputated. Blood clots can form in the leg veins after surgery. This can be detected by an ultrasound scan. If a blood clot travels to the lungs (known as pulmonary embolism) this can be fatal. Blood clots can be prevented with medications such as warfarin, injections or tablets of heparin or low molecular weight heparin. It is also possible to have an allergic reaction to the anesthesia that is used, or any of the medications given in hospital. Implant failure and wear can happen over time. The average lifespan of a knee replacement is 20 years. If a patient is relatively young, there is a greater chance that the implant will wear out or fail. A knee replacement that has worn can cause pain and swelling, and in some cases a revision surgery may be needed. In more severe cases when an implant has failed, a knee replacement may have to be changed to a knee fusion. This is done to prevent movement between the joint that is causing severe pain when the implant has failed. This involves joining the thigh and shin bones with internal fixation and usually a bone graft is needed.
