Leading Consultant Orthopaedic and Specialist Knee Surgeon Mr Raghbir Singh Khakha, from Guys and St Thomas Hospitals London and the OS Clinic in London, advocates for joint preservation – whether in the form of joint realignment surgery or pioneering hydrogels – as the most promising solution for alleviating pain and immobility caused by knee osteoarthritis. With the rising prevalence of this condition in the Middle East, Mr Khakha emphasizes the importance of key non-surgical options that are now at the forefront of treatment, often delaying the need for joint replacement surgery.
It goes without saying that the best joint a patient can have is the one nature gave them. However, a recent study on the epidemiology of osteoarthritis in Africa and the Middle East has highlighted a troubling increase in the number of years patients suffer from this condition.1 Alarmingly, the rate is higher in the Middle East compared to most other regions globally. Having treated patients from the Middle East for approximately 10 years, I often see individuals with advanced arthritis presenting very late.
At a time when there are exciting treatment developments, particularly for knee osteoarthritis, I am frequently asked why this remains such a significant health concern in the region. The global focus in research and clinical advancements is now on preserving the joint’s natural architecture before considering joint replacement surgery. While joint preservation surgery has been a cornerstone of orthopaedics for decades, recent improvements in the procedure and postoperative management, along with advancements in hydrogel injections, reinforce my belief that joint replacement surgery should be a last resort.
Why is the Middle East so susceptible to knee osteoarthritis?
Several factors contribute to the rising cases of osteoarthritis in the region. Improved healthcare and increased life expectancy mean more people are living with arthritis, a condition often associated with aging. Additionally, vitamin D deficiency, common in the region, can exacerbate bone-related problems.
In younger populations, increased physical activity and sports participation can lead to injuries that cause early osteoarthritis. Cultural practices, such as kneeling during prayer and sitting cross-legged, can also strain the knee joints.
Globally, rising obesity rates place additional stress on joints, particularly the knees, accelerating the progression of osteoarthritis. This debilitating condition significantly affects mobility and often requires regular pain relief, impacting daily activities as well as cultural and social engagements.
These issues can all contribute to the acceleration of osteoarthritis, which can be an extremely debilitating condition. It can significantly affect mobility, and often requires regular pain relief, just for those affected to be able to function normally and go about their day-to-day activities. But, just as important, it can also have a huge, detrimental effect on cultural and social activities in this part of the world.
Current treatment options
There are various ways to manage osteoarthritis, with varying success rates. Simple measures include weight loss, physiotherapy, and anti-inflammatory medications, both oral and topical. However, as arthritis progresses, these treatments may become less effective.
For many, joint replacement surgery is the ‘end stage’ treatment for osteoarthritis. While this can be effective for older patients, younger patients often experience poorer outcomes, with up to 20% reporting worse function and mobility post-surgery. Additionally, older patients with other medical issues face significant risks, making the decision for joint replacement surgery a serious one.
A more recent and desirable treatment option that I have been involved in from a surgical and research perspective is joint realignment surgery, such as an osteotomy. This procedure is particularly suited for many in the Middle East, where arthritis often affects a single part of the knee joint, causing the lower limb to bow or to become knock-kneed. Osteotomy corrects this deformity, offloading the arthritic part of the knee joint without replacing it. This minimally invasive procedure can significantly reduce pain and delay the need for joint replacement surgery, with up to 80% of patients not requiring joint replacement at 15 years. It also has no long-term impact on activity levels.
Non-surgical advancements, such as hydrogel injections, also offer promising results. Arthrosamid (an injectable polyacrylamide hydrogel), for example, is the first ‘manufactured’ injection to offer a sustained improvement in knee pain. It is a hydrogel injected directly into the knee cavity and permanently combines with the tissue in the knee joint.2 It is this unique characteristic that provides a significant reduction in your knee OA pain over a longer period3,4 – with a single treatment. In the data demonstrated so far, the pain relief can be sustained between three3 to four years4 and in the under 70 years old, approximately 80% of patients5 respond to treatment. This non-invasive option is suitable for most patients, including those with additional medical conditions or early-onset arthritis. It is also a good option for those who may not be medically suitable to undergo major surgery.
Looking ahead
In the next 5-10 years, I anticipate that more patients with osteoarthritis will explore all non-surgical options before considering major surgery. I also foresee an increase in patients opting for joint-preserving surgical options, such as osteotomy and potentially joint distraction, which involves temporarily holding the joint apart to reduce pain.
Importantly, neither hydrogel injections nor joint-preserving surgeries preclude future joint replacement if needed. These options allow patients to enjoy many more years of improved function and pain-free living, which is invaluable.
References:
- https://pubmed.ncbi.nlm.nih.gov/36945659/
- Christensen, L., et al. (2016). Histological Appearance of the Synovial Membrane after Treatment of Knee Osteoarthritis with Polyacrylamide Gel Injections: A Case Report. Journal of Arthritis. Vol 5: 217.
- Bliddal, H., et al. (2024) 3 year follow-up from a randomized controlled trial of intraarticular polyacrylamide hydrogel injection in subjects with knee osteoarthritis. Poster LB-31, OARSI 2024 World Congress on Osteoarthritis.
- Bliddal, H., et al. (2024) A Prospective Study of Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: Results From 4 Years After Treatment. Presented at EORS 2024.
- Data on file.
