Knee Osteoarthritis and Surgical Interventions Consideration in ageing with Associate Professor Sameer Viswanathan

In this podcast, Associate Professor Samir Viswanathan explores the multifaceted aspects of knee osteoarthritis, drawing on his extensive background in orthopedic surgery, including fellowships in hip and knee arthroplasty and foot and ankle surgery. He begins by addressing the prevalence of osteoarthritis, noting that it affects approximately 32 million adults in the U.S. and 2.1 million Australians, with a notable increase projected in the coming years. He emphasizes the significant symptoms associated with the condition, such as pain, stiffness, swelling, and reduced range of movement, and discusses the common risk factors, including age, obesity, genetics, and the higher incidence among females.

Professor Viswanathan elaborates on the diagnostic approach, particularly discussing the Kellgren-Lawrence grading scale for osteoarthritis, which aids in assessing the severity of joint degeneration. He underscores the importance of proper imaging techniques, advocating for a series of weight-bearing X-rays, including views that highlight specific joint compartments to capture the extent of arthritis. He cautions against relying solely on MRI scans unless there is ambiguity in diagnosis, as X-rays remain the gold standard for identifying osteoarthritis in the majority of cases.

The lecture progresses into the realm of non-operative interventions for knee osteoarthritis. Professor Viswanathan echoes the views of previous speakers on weight management and how it plays a critical role in alleviating symptoms. He discusses a range of non-surgical treatments—such as corticosteroid injections and acupuncture—acknowledging the mixed evidence on their efficacy but affirming their value in temporarily managing pain and delaying surgical intervention. He articulates a cautious approach to knee arthroscopy, reserved for specific cases, while detailing less common procedures like osteotomy and unicompartmental knee replacement, emphasizing patient selection and expectations for outcomes.

Transitioning to surgical options, he describes the satisfaction rates associated with knee replacements, highlighting a general positive response from patients. He contrasts expectations for knee replacement outcomes with those for hip replacements, stressing that the functional improvements from knee surgery may not always match patients' pre-operative aspirations. Key insights include managing patient expectations pre- and post-surgery, with a focus on educating patients about realistic outcomes, the potential for pain and stiffness, and the importance of rehabilitation.

Professor Viswanathan concludes the lecture by touching on the evolving nature of post-operative care and the financial implications of undergoing surgery. He highlights the advancements in surgical techniques that have reduced hospital stay durations significantly—from traditional long stays to now allowing many patients to return home just a few days post-operation. He discusses the introduction of no-gap surgery options, which lessen the financial burden traditionally faced by patients undergoing hip or knee replacements, ultimately leading to improved accessibility for older adults requiring these essential procedures. The lecture encapsulates a holistic view of knee osteoarthritis management, threading together clinical insights with practical considerations for both healthcare providers and patients.

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So, I have the great pleasure of introducing Associate Professor Samir Viswanathan.

So, Samir completed his studies at Sydney University, and then he completed

fellowships in hip and knee arthroplasty at Fairfield Hospital,

and then in foot and ankle surgery at Royal North Shore.

He's currently head of department of orthopedic surgery at Campbelltown Hospital,

and he was appointed conjoint Associate Professor at the Faculty of Medicine

at Western Sydney University.

As part of his public hospital duties, Samir also has quite a wide range of

experience in trauma surgery.

So welcome Samir, thank you so much.

Thanks Sam, and thank you everyone for taking time out on the weekend to be here. So.

Okay, so basically I'm going to talk about how osteoarthritis affects the knee.

And I think a lot of those topics, that topic has already been covered fairly extensively by now.

So I'll just go over some of those factors again.

So we'll talk about risk factors, imaging, when to refer, and non-operative interventions.

So yes, a little bit about me. I'm the head of department at Campbelltown Public Hospital.

Got my frscs in 2007 and

graduated from sydney uni in 99 and as

sam mentioned hip and knee arthroplasty fellowship and the

foot and ankle fellowship and when i first started

and when used to work with sam and wunjad out in campbell

town we uh i was mostly foot and ankle but as my practice has developed it's

become 60 hip and knee so what is knee osteoarthritis um it's a degenerative

joint disease characterized by the breakdown of cartilage and underlying bone

in the knee. All of us know this.

And the numbers are actually quite amazing.

In America, there's 32 million adults living with osteoarthritis.

And in Australia, it's 2.1 million Australians.

Interestingly, more females than males.

And it's projected to increase by 58% by 2032, too, it's not that far away.

So obviously, we all know this, the symptoms are pain, stiffness,

swelling, reduced range of movement.

Now, obviously, again, a lot of previous speakers have gone over the causes,

it's wear and tear, injury and trauma and repetitive stress.

Risk factors, it's mostly common in people over 50, and obesity and genetics,

and again, more common in females.

Now, this is a grading scale that we use in our rooms. We describe arthritis to each other.

We just normally go, it's grade four arthritis or grade one arthritis,

but it's actually the Kellgren-Lawrence grading scale.

I think it's a useful grading scale, especially when describing arthritis to other colleagues.

If you've got somebody with a grade one or a grade two who's come in with a

painful knee, it's most likely going to be a soft tissue injury or some very

early cartilage degeneration, possibly a meniscus tear.

Grade 3 and grade 4, it's clearly obvious on an x-ray.

And the answer is, you know, arthritis is the cause of the symptoms.

The diagnostic dilemma in the general practitioner's room is often when somebody

comes in with a grade 1 or a grade 2 and the arthritis isn't obvious.

What to do in that situation and what's the next investigation to order?

I often see patients who come to see me with an mri first or an ultrasound first,

and i often wonder why an x-ray wasn't

uh ordered and i think anyone who comes to you with knee pain almost regardless

of the age should get this series of uh x-rays i think they should get an ap

in a lateral a rosenberg in a skyline view and i think that weight-bearing view

is critical um so this an example on the on the.

Left, you've got a normal knee, and you can see that the joint spaces are well-preserved.

The joint space is actually cartilage, as we all know, so there's no wear and tear there.

Now, the weight-bearing view will clearly show you narrowing of that medial compartment.

The Rosenberg view, which is a slightly flexed view with a posterior to anterior

projection, is showing how extensive the medial compartment arthritis is there.

So I would urge you to order that series of x-rays and actually write that on your x-ray form.

So just to go back over that again, please mention weight bearing,

please mention a skyline patella.

And I think that will expose most of the arthritic changes in the average population

very early and probably don't need an MRI really.

And the only time you need an MRI is if you go back to that Kellgren-Lawrence

grading scale and you've got somebody who's coming in with a completely normal

weight bearing x-ray and you're going, why are they in pain?

Then I think an MRI is actually not an unreasonable thing to do.

So with this slide, I wanted to just take you through a lateral view.

A lateral view doesn't give you that much information. I particularly like a skyline view.

It can show you occult fractures that are not visible on this view.

And it can tell you about patellofemoral arthritis, which might not be readily

obvious on a standard lateral.

So order a skyline view. I think it's very informative. tells you about maltracking,

tells you about fractures, tells you about loose bodies that other views you might not see.

I still think x-ray is very relevant today. And please look at your x-rays.

Don't just look at the report from the radiologist, because radiologists make

mistakes, a lot of mistakes.

And they get typos, they get the sides wrong. So make sure you look at your images.

So I think a couple of things about MRI. MRI is readily available in Australia,

whereas colleagues of mine who work in the states for

them getting an mri is next to impossible for orthopedic surgeons

it's it's due to their funding model and they don't get mris

but when you get an mri it can be very

informative especially when as i said previously it's not obvious what the diagnosis

is and in this mri you've got on this t2 weighted image you've got bone edema

in the in the in the femoral condyle bone edema down in the tibia and you can

see irregularities in the joint surface.

So it can give you a lot of information, but generally MRI is better for looking

at meniscus injuries and ACLs.

And so I would urge you to limit your MRIs to when you're questioning whether

it's a soft tissue injury.

If you think it's osteoarthritis, focus on x-rays.

Don't waste your time on CT scans and don't waste your time on ultrasounds.

It's only making your radiologist upgrade their car that they're driving.

So with osteoarthritis, is don't bother with an ultrasound or a CT.

Okay, non-operative treatment. A lot of the previous speakers have talked about

non-operative treatment for hip and knee.

I think I'm not going to add anything new there. I think all of these things

work at some level, and I use them as delaying tactics for pushing people,

kicking the can down the road when someone's young, or when I think that their

arthritis is not that bad.

Because as Mujid previously said, doing a

procedure on someone who's got a little bit of knee arthritis

can often lead you with a patient you never lose who's

desperately unhappy so i think all these things work weight

loss particularly a lot of previous speakers have identified weight loss

as an important thing so yeah if you can as general

practitioners if you can get patients to lose weight often

the commonest thing i hear is i can't lose weight because my knee

is sore or because my hip is sore and we all know that

weight loss is from from your diet and not from the amount

of exercise that you do so and i'm not sure how

comfortable you all are prescribing the new

generation of weight loss drugs but if you could it would save

orthopedic surgeons a lot of hassles in terms of operating on large people and

in my population the patients that i operate on are often i'm surprised if i

get anyone with a bmi less than 40 in my practice so So it's really good if

I can get their weight down with Ozempic and Munjara.

So things like acupuncture and TENS, corticosteroid injections,

hyaluronic acid injections, the evidence in the literature is poor,

but there is no doubt that patients benefit in the short term from all these things.

Okay, so I'm not going to give you an extensive talk about the actual surgery.

You can do a knee arthroscopy. By the time you get a picture like this with

advanced cartilage destruction, advanced meniscus tears, this is probably the

wrong operation, as a few of the speakers have said.

There are some situations which might be exceptions, like there's a large loose

body, a bucket handle meniscus tear that's preventing a patient from extending their knee.

In those situations i'd offer a knee arthroscopy but i'd very very repeatedly

stress that i'm not going to make you better you're going to be back in three

months you're going to be unhappy with the results of this operation so i keep

stressing that but yeah i do offer it in select situations,

osteotomy uh mustafa talked about this uh specifically useful when you've got

a younger patient a thinner patient with intact cruciate ligaments good range

of movement an osteotomy might save them from having a knee replacement,

but it does make their subsequent knee replacement slightly harder.

Unicompartmental. So I've had good results in patients who, again,

are slightly older, thinner, with intact cruciate ligaments,

and if they point to their knee, and it's in their medial compartment,

and they say, that's where my pain is, and I've got no other pain elsewhere, then a uni will work.

Um but if the pain is more diffuse if the patient's unclear

where the pain is from i'll err towards a total so um

that's one of the benefits of knee surgery they can often localize the pain

much better than other joints in the foot and ankle it's hopeless patients will

just point at the whole ankle and the foot as the source of the pain and they

won't localize it very well but with the knee medial compartment they'll point

right at the medial joint line and say this is where my pain is,

Then we have patellofemoral replacements, rarely done, and I think the results

are very poor in the registry, Australian Joint Registry, 20% revision rate

last time I checked, so I haven't offered that in my career.

I've done one or two, and I don't offer it to patients that frequently.

Okay, this is the majority of what I do.

I do about four knee replacements for every hip, and it's got to do with the

patient profile where I work basically.

Satisfaction rate, as other speakers have spoken about, is around 80 to 90%

with knee replacements.

So pain relief, 85 to 90% will get significant pain relief.

And functional improvement in 70 to 85 percent

so the results aren't perfect so if you take away all the

knee replacements that have had wound complications that have

had infections that have had instability you take

them all out of the equation you've got a good x-ray and you're happy with the

operation 85 to 90 will be happy and 70 to 85 will have a functional improvement

so there's a significant number

of people that don't get you know the the improvement that you want.

And I always tell my knee replacement patients, please don't talk to your hip

replacement friend or colleague.

And I think Munjin has just brought that up in that last talk as well.

So older people have a higher satisfaction and younger people have a lower satisfaction

rate. I think it's very important.

And that's why I often use those other medications and injections as a temporal

thing to kick the can down the road, to delay the surgery till they're more age-appropriate.

I love the fact that under 50 or 50 is considered young because I'm very I'm

approaching that barrier when I'm going to be an oldie so I think as for patients

in that age group try and delay the joint replacement as much as possible.

With knees specifically stiffness and my personal feeling is if they're stiff

before the knee replacement they're going to be stiff afterwards.

Persistent pain is also an issue.

So it's very important that we identify the appropriate patient for the operation.

And as my career has gone on, I can almost, as soon as I see the patient walk

into the room, I can tell who's going to do well from a knee replacement.

1% infection rate across all surgeons, across all facilities,

and that's a fantastic result because infection in a knee replacement or a hip

replacement is catastrophic.

So we can't just simply whack on some antibiotics and hope it'll go away.

Often everything has to come out. So this is another thing that I've recognized,

and it's backed by literature, is that depression and anxiety is going to be

associated with a lower satisfaction rate.

Um now my i can't say that i have any special skill in picking up depression

or anxiety i just my consultations are 15 to 20 minutes with patients so i don't

spend that long with them,

but uh you can tell they're super anxious or the super uh depressed uh patients

i'm not sure what to do about them whether i should delay things and send them

off to a psychiatrist or a psychologist I'm not sure that that works,

but I can tell you from personal experience,

patients who are anxious before the surgery often don't get such a good result.

You've got to calm them down.

You've got to get them to talk to groups, social media, calm them down before

they have this operation.

So the initial satisfaction rate is actually quite high after the first year,

but it tends to drop over time. and people think it drops because of persisting

pain, persisting stiffness.

Stiffness is really a thing that depresses people because they don't realize

that a knee replacement is not going to allow you to sit on the floor.

It's not going to allow you to kneel that easily.

Squatting is going to be difficult. So I think the key is unmet expectations.

So I spend less time telling patients about the operation and more time about

what to expect after the operation.

I tell them that for the first six weeks, you're not going to like me for the,

you know, the range of movement is going to be zero through to.

100 degrees, 120 degrees maximum. On the table, you'll be bending to 140,

but afterwards, due to all the swelling and stiffness, things will gum up a little bit.

So I spent a lot of time trying to water down their expectations.

I like to under-promise and over-deliver.

And I think patients are pleasantly surprised when they do better,

because I've painted such a dark picture for them before the operation.

So the ideal, totally patient, I think.

And I think I'm recognizing this i'm 15 years into being an

orthopedic surgeon now and i'm i'm now recognizing that

they are an older patient with bad arthritis

on the x-ray and bad symptoms okay

so every now and then you'll see someone with a

very average looking x-ray and incredible pain and

you've got to investigate them more and see what's going on here and

don't jump into an operation straight away um but

if they've got a really bad x-ray and they've got no pain i often

tell them wait till wait and come back you know i take munjid's

point about uh not waiting too long because of

muscle atrophy and all that but maybe a referral to a physiotherapist um

to get some rehab and work on their range of movement and their strength maybe

the right thing to do okay and i try to explain to patients a total knee replacement

is not a new knee i try and explain it's an artificial knee it's it's not going

to return you to your 20s when you could run and squat and lunge and play sport.

Explain to them it's going to click and clunk you're going

to feel it's not going to feel like it used

to when you were younger and i tell them this is the most important thing do

not compare it to friends who've had a hip replacement hip replacements

totally different ball game patient satisfaction super high return to function

super high knee replacements unfortunately don't do as good as hip replacements

okay so you can do it in any number of ways right and i'm not going to i'm not

going to stand here and tell you that one way is better than the other.

I think robotics is a new technology which is entering every aspect,

but ultimately it's a tool.

And if you use a tool poorly, you'll get a poor result.

I use patient-specific instruments because in my practice, I found that it's

become the most efficient way of doing a knee replacement.

But I've also just used a standard instrument.

I mean, you know, that works as well. And every now and then,

when I can't get a patient-specific instrument.

I just go back to the good old way of doing a knee replacement that I learned when I was a registrar.

So the arguments about mechanical alignment versus kinematic alignment,

orthopedic surgeons will argue amongst each other till they go blue in the face.

I'm yet to be convinced that there is a strong argument for one over the other.

I think ultimately like the approaches to the hip, it all evens out.

Now, a few things have changed. When I was a medical student,

patients used to come into hospital and spend nearly two weeks in hospital after

a hip or an ear replacement.

But now, the stay in hospital is down to two or three nights,

and you get rehab in the home.

And I send patients home on oral anticoagulants, so they don't have to inject themselves.

Rehab in the home is actually quite a big, big change. The funds are now sending

physios to the patient's home, rather than the patient stay in the hospital for two to three weeks.

And I think it's a big difference. Now, the only patient who I think really

needs to stay for rehab is someone who's fairly firm to start off with,

and has a lot of stairs in front of the house, doesn't have family supports,

lives on their own. That person may need to stay a bit longer.

But I think most people, especially in the era of enhanced recovery after surgery

protocols can go home day two to day three and most patients are surprised when

you tell them that you're going to go home in two or three days they think you're

trying to rip them off or the fund is not paying them but the evidence is clear,

with all our new techniques patients are pain-free the day of surgery pain-free

the next day it's only the second day that pain really hits them so after even

after a knee replacement which is a particularly painful operation.

The first day, no pain. It's the second day that it really hits you.

And then we send you home day three. So as long as you have enough pain relief

and you get a physio to visit you at home, I think you don't need to stay in hospital for two weeks.

All right so i'm going to talk a little bit about health funds mainly

because this is relevant to macquarie university hospital my

predominant practice is in campbell town but i've started consulting here and

i've been consulting here for two years now and i get a lot of patients who

essentially come to see me after word of mouth i'm not saying i'm better than

my colleagues i'm a standard orthopedic surgeon but no gap uh surgery is very

important because prior to this,

surgeons were charging seven to eight thousand dollars out of pocket for a hip or knee replacement.

Thanks to hcf medibank private at nib we get

paid appropriately almost ama rates i'm being

up front here because we're all medical colleagues but we don't have to pass

this to our patients we don't have to pass these costs on to our patients for

a pensioner who's got a health fund but has no way of has to dip into their

savings has no way of earning money seven thousand dollars is a lot of money, out of pocket,

as the gap for the surgeon, the anesthetist,

assistant, and then the pathology afterwards, the radiology afterwards.

All of this used to be out of pocket expenses for someone in their 60s and 70s.

Not anymore, if they're a member of these funds.

So we get paid appropriately. We don't charge the patient. It's a winner for

everyone. Everyone wins out of this arrangement.

It's only for hip and knee and at Macquarie and a couple of other hospitals.

Um most of the surgeons here so

nib is i have a personal arrangement with nib so and

all surgeons can opt in or opt out um and some

choose to and some chose not to so but the ultimate benefit i think is to your

patients you've got a pensioner in your room who's afraid of having a knee replacement

or hip replacement they don't have to worry about the cost anymore okay they previously

it would have been a big out-of-pocket expense for them.

Right. Thank you for your attention.