Bill Stevenson has been waiting years for a new left knee. The active 84-year-old, a former civil servant, had his right knee replaced seven years ago.
“I played squash three times a week for about 25 years,” he says. “The surgeon thought all that stopping and starting wore out the meniscus in my knees.”
The right knee surgery happened fairly quickly, but the procedure for the left has been pushed back several times due to COVID-19.
Mr. Stevenson is trying to stay positive, but his lack of mobility is frustrating.
“I use a cane if I’m going more than half a block,” he says. “After a block, I have to slow down and rest.”
Mr. Stevenson is one of thousands of Canadians waiting for a knee replacement, a procedure that even pre-pandemic had wait times of six months or more, according to the Canadian Institute for Health Information.
A knee replacement, where the joint is surgically replaced with a synthetic one, is “a huge, invasive procedure and a major life event,” says Wayne Marshall, executive director of the University Health Network’s Osteoarthritis Centre in Toronto.
He says they are necessary when there are “marked, mechanical symptoms, such as cracking, locking and crunching.” In these cases, the cartilage within the knee has been worn away due to osteoarthritis, rheumatoid arthritis or an injury. If a person’s knee is unstable and they are in severe pain, Dr. Marshall will often recommend them for surgery.
But he says that each case is unique and requires a comprehensive exam and imaging, as well as patient reports. And severe disease on an X-ray doesn’t automatically mean a person needs surgery.
“You have to tailor the treatment to the story,” Dr. Marshall says, adding that some people have significant arthritic disease but few symptoms and others with milder disease can barely walk.
Luckily, the number of treatment options for damaged knees has grown dramatically in recent years.
On the surgical end, hospitals like Toronto’s Sunnybrook Health Sciences Centre are employing techniques such as osteotomy, whereby a surgeon leaves the patient’s knee joint but shifts weight off of the damaged side of the joint. This can relieve pain and improve joint mobility, while avoiding a major surgery.
Arthroscopic surgery, in which a surgeon makes a tiny incision to fix damaged or torn cartilage, torn ligaments or loose bone fragments, is also a less-invasive option.
More health centres are also focusing on joint preservation.
At Sunnybrook’s hip and knee rapid access clinic, physiotherapists and occupational therapists (OTs) aim to improve patients’ quality of life through exercise.
“We do see patients that were told they need surgery based on x-rays alone,” says Patricia Dickson, clinical supervisor, Sunnybrook’s Advanced Practice Provider Team. “But 30 per cent to 40 per cent do not require a surgical consult.”
Instead, OTs and physios assess the patient’s level of function and prescribe exercises that can improve their strength, balance and stamina.
“It’s really about what people tolerate and enjoy,” says Amy Wainwright, manager at Sunnybrook’s Holland Bone and Joint Program.
Says Ms. Dickson: “The stronger you are, the longer you will last before you need a surgical intervention.”
Injectables can also tackle pain. Often a doctor will inject cortisone into joint fluid to reduce inflammation. But these shots often only provide short-term relief for days or weeks, says Dr. Marshall.
“They can also accelerate degenerative changes if used too aggressively,” he says.
Hyaluronic acid injections can also replace the missing hyaluronic acid in the joint. With these injections, 50 per cent to 60 per cent of patients have pain relief for six to 12 months, on average, according to Dr. Marshall. They cost $500 to $600 per knee and are often covered by third-party insurance providers but not provincial health plans.
Dr. Marshall is a fan of platelet-rich plasma (PRP), a procedure in which a sample of a person’s blood is separated in a device called a centrifuge. It isolates plasma, the liquid component of blood, and platelets – the blood cells responsible for healing. This solution is injected into the synovial fluid surrounding the knee joint, with the hope that it will decrease inflammation.
The injections are expensive at $1,500 per knee, and most insurance plans don’t cover them, says Mr. Marshall. However, 70 per cent of his patients respond to PRP for six to 12 months.
Finally, Nstride injections are the newest PRP treatment. Like traditional PRP, with Nstride, a blood sample is spun in a centrifuge but in multiple steps so that plasma is divided to isolate proteins that reduce inflammation and swelling – and remove harmful proteins.
“It’s like a sniper shot,” Dr. Marshall says. “It’s very focused.”
He says Nstride, which costs the same as PRP, tends to yield results in days or weeks with long-term results similar to traditional PRP.
With little relief in sight, Stevenson counts the days to his surgery and tries to stay fit.
“I’m working out every day with the YMCA, and I’m feeling better,” he says.
But he also knows that he’s got a long recovery ahead. “[A knee replacement] doesn’t give you back a knee – it gives you an appliance,” he says.
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