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Dealing with Knee Problems

Consultant Orthopaedic and Traumalogy Surgeon
Regency Specialist Hospital


Early Diagnosis and Management of Knee OA

Knee osteoarthritis (OA) is the most common type of joint disease and leading cause of disability in elderly more than 70 years. It has a huge financial burden costing US$ 100 billion annually in USA.1 OA is an active disease process involving cartilage destruction, subchondral bone thickening, synovial inflammation and new bone formation. The functional changes occurring in an individual can be mild, moderate and severe.2

The main causes for knee OA are:2

  • Mechanical (previous injury, microtrauma and genetic factor)
  • Metabolic disease (diabetes mellitus, obesity, crystal deposition and heritable metabolic causes)
  • Ageing

Signs and Symptoms:
There are several signs and symptoms of OA, the most prominent of which are pain, stiffness, swelling and crepitus.3 Knee X-ray is generally used for the diagnosis. Kellgren–Lawrence grading system is a radiological classification of knee OA. It progresses from grade 0 to grade 4 and is based on x-rays.4 Knee Society function score is an objective scoring system to rate the knee and patient’s functional abilities such as walking and stair climbing.5

The process underlying OA cannot be reversed, but symptoms can usually be effectively managed with lifestyle changes, physical and other therapies, medications, and surgery. Lifestyle and home remedies include patient education, heat and cold, weight loss, exercise and physical therapy.6 American Academy of Orthopaedic Surgeons (AAOS) 2013 recommendation for symptomatic knee OA includes oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and tramadol for pain relief.7
Physiotherapy and self-exercises help in joint stiffness, effusion and synovitis, aid in swelling; whereas, physiotherapy and quadriceps strengthening exercises provide relief in crepitus.8

Other modalities of treatment include viscosupplement intra-articular injection such as Synvisc-One® which is cross-linked, has high molecular weight, and mimics healthy and young synovial fluid. The sites of injection are extension superolateral and flexion inferolateral.9-11

Total knee replacement (TKR) is an effective treatment for end-stage disease of the knee. TKR indications are frequent painkillers, reduced walking distance and night pain. The criteria for TKR include older patients with modest activity, younger patients with disabling systemic arthritis and post-traumatic arthritis.12

The leading cause of failure after TKR was polyethylene wear, followed by infection, arthrofibrosis, malalignment/malposition and component loosening. Although the infection rate was lower and the incidence of component loosening was higher in the younger patients when compared to patients >55 years of age, the differences did not demonstrate statistical significance.13
Early diagnosis is important to support and empower the patient to attend to lifestyle factors that influence the disease. In the early stages of the knee OA, X-rays are frequently normal. As the disease progresses, loss of joint space, subchondral sclerosis and osteophyte formation are seen. Regular follow-up helps to maintain management and adherence.14


  1. Osteoarthritis Action Alliance. Osteoarthritis Is Widespread and Costly – Both to Individuals and to the Nation. Available at: Accessed on 7 May 2019.
  2. Chen D, et al. Osteoarthritis: Toward a comprehensive understanding of pathological mechanism. Bone Res. 2017;5:16044.
  3. Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian J Int Med. 2011;2(2):205–212.
  4. Felson DT, et al. Defining radiographic incidence and progression of knee osteoarthritis: Suggested modifications of the Kellgren and Lawrence scale. Ann Rheum Dis. 2011;70(11):1884–1886.
  5. Scuderi GR, et al. The new knee society knee scoring system. Clin Orthop Relat Res. 2012;470(1):3–19.
  6. Mayo Clinic. Osteoarthritis. Available at: Accessed on 7 May 2019.
  7. AAOS. Treatment of Osteoarthritis of the Knee: Evidence-based Guideline 2nd Edition. 2013. Available at: Accessed on 7 May 2019.
  8. Anwer S, et al. Effect of home exercise program in patients with knee osteoarthritis: A systematic review and meta-analysis. J Geriatr Phys Ther. 2016;39(1):38–48.
  9. Stitik TP, et al. Synvisc® in knee osteoarthritis. Future Rheumatol. 2008;3(3):215–222.
  10. SYNVISC/Synvisc-One European Prescribing Information. Naarden, The Netherlands; Genzyme Europe B.V.; 2013.
  11. Balazs EA, et al. Hyaluronic acid in synovial fluid. I. Molecular parameters of hyaluronic acid in normal and arthritic human fluids. Arthritis Rheum. 1967;10(4):357–376.
  12. Medical Advisory Secretariat. Total knee replacement: An evidence-based analysis. Ont Health Technol Assess Ser. 2005;5(9):1–51.
  13. Kim KT, et al. Causes of failure after total knee arthroplasty in osteoarthritis patients 55 years of age or younger. Knee Surg Relat Res. 2014;26(1):13–19.
  14. Favero M, et al. Early knee osteoarthritis. RMD Open. 2015;1(Suppl 1):e000062. doi:10.1136/rmdopen-2015-000062.

Consultant Orthopaedic, and Trauma Surgeon
Gleneagles Kota Kinabalu Hospital


Early multimodal approach in the treatment of KOA

Knee osteoarthritis (KOA) is a heterogeneous group of conditions that lead to joint symptoms and signs, which are associated with defective integrity of cartilage, in addition to related changes in the underlying bone, synovial tissue, capsule and muscles.1,2 It is an imbalance between cartilage regeneration and damage.2 Hyaline cartilages have an extremely poor regenerative capacity.3

The lifetime risk of KOA is 44.7% with peak prevalence at the age of 65.1,4 Women are affected much more than men.1 It is 4th most common disability worldwide.5 Knee is the largest weight-bearing joint, which bears the brunt of the disease.6

The commonest presentation is pain on activity with morning stiffness and swelling.7 Advanced presentation includes deformities, contractures, stiffness and muscle wastings.7,8 Clinical signs include coronal deformities, capsular contractures, swellings due to free fluids and bony outgrowths.7,8 Diagnosis is performed by clinical examination and radiological imaging.8 There may be a great disparity between clinical presentation and radiological changes.7–9

Despite great advances made in understanding the pathophysiology of KOA, no treatment is currently available that can halt the biochemical and cellular cascade in osteoarthritis (OA).10 Current treatment still focuses on pain relief, maintaining function and halting the progress of early and moderate KOA.11 Surgical treatment is reserved for advanced KOA, unicompartmental diseases, isolated cartilage lesions, mechanical symptoms and severe deformities and stiffness.11,12

Treatment of early and moderate KOA is individualised and multimodal in nature with patient education, lifestyle modification, weight loss, physical therapy, analgesics and injections. Either hyaluronic acid (HA) or steroid injections are used for flare-ups.13–23 Considering a multimodal approach earlier in treatment targets early-stage OA and offers the potential to limit the symptom progression and structural deterioration.16,24

The optimal management of KOA requires a combination of non-pharmacological and pharmacological treatment modalities13–23

HA is a naturally occurring joint product that serves to lubricate joints.25 It also acts as a shock absorber and promotes cartilage regeneration and synthesis of ground substance.25,26 Externally administered HA also provides anti-inflammatory and analgesic properties and enhances endogenous HA production.25,26 HAs and hylan products have been shown to have an excellent safety and tolerability profile with a few serious side effects.26 In addition, combining HAs with other pharmacotherapies can also be considered, as this approach has been shown to be effective.26 American College of Rheumatology (ACR) and Osteoarthritis Research Society International (OARSI) position HA as a second-line treatment following non-pharmacologic therapies for persons who are unresponsive to acetaminophen or nonsteroidal anti-inflammatory drugs or cannot take these medications.26

Hylan G-F 20, a highly cross-linked HA provides far superior clinical properties compared to low-molecular noncross-linked HA products. With a molecular weight of 6 million daltons, it mimics endogenous HA.27 A single GF-20 injection can provide 6 months of symptomatic relief.27 Studies have shown that the combination of hylan G-F 20 with a corticosteroid improved pain scores for the first week compared to those injected with hylan G-F 20 alone. Patients diagnosed with OA within a year were more likely to benefit from hylan G-F 20 than those patients who had been diagnosed longer than a year.26

In conclusion, multimodal approach combining non-pharmacological and pharmacological treatments is still the best option for the management of OA, as recommended in the guidelines of ACR and OARSI.


  1. Sarzi-Puttini P, et al. Osteoarthritis: An overview of the disease and its treatment strategies. Semin Arthritis Rheum. 2005;35(1 Suppl 1):1–10.
  2. Hunter DJ, Bierma-zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745–1759.
  3. Salgado AJ, et al. Tissue engineering and regenerative medicine: Past, present, and future. Int Rev Neurobiol. 2013;108:1–33.
  4. Ondrésik M, et al. Chapter 4: Osteoarthritis. In: Oliveira JM, Reis RL, editors. Regenerative strategies for the treatment of knee joint disabilities. Cham: Springer; 2016. pp. 55–72.
  5. Symmons D, et al. Global burden of osteoarthritis in the year 2000. ResearchGate. Geneva: World Health Organization. 2003.
  6. Vincent KR, et al. The pathophysiology of osteoarthritis: A mechanical perspective on the knee joint. PM R. 2012;4(5):S3–9.
  7. Hsu H, Siwiec RM. Knee osteoarthritis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019.
  8. Swagerty DL, Hellinger D. Radiographic assessment of osteoarthritis. Am Fam Physician. 2001;64(2):279–286.
  9. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskeletal Disorders. 2008;9(1):116.
  10. Wojdasiewicz P, et al. The role of inflammatory and anti-inflammatory cytokines in the pathogenesis of osteoarthritis. Mediators Inflamm. 2014;2014:561459.
  11. Sofat N, Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Clin Rheumtol. 2014;9(2):197–276.
  12. Lespasio MJ, et al. Knee osteoarthritis: a primer. Perm J. 2017;21:16–183.
  13. Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18(4):476–499.
  14. Jordan KM, et al. EULAR recommendations 2003: An evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62(12):1145–1155.
  15. Hochberg MC, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465–474.
  16. Langworthy MJ, et al. Conservative treatment modalities and outcomes for osteoarthritis: The concomitant pyramid of treatment. Phys Sportsmed. 2010;38(2):1–13.
  17. Fransen M, et al. Physical therapy is effective for patients with osteoarthritis of the knee: A randomized controlled clinical trial. J Rheumatol. 2001;28(1);156–164.
  18. Jaksch W, et al. 4 years after withdrawal of rofecoxib: Where do we stand today? Rheumatol Int. 2008;28(12):1187–1195.
  19. Bellamy N, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005328.
  20. Wang CT, et al. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A meta-analysis of randomized controlled trials. J Bone Joint Surg. 2004;86-A(3):538–545.
  21. Kemper F, et al. Tolerability and short-term effectiveness of hylan G-F 20 in 4253 patients with osteoarthritis of the knee in clinical practice. Curr Med Res Opin. 2005;21(8):1261–1269.
  22. Brown TJ, et al. Turnover of hyaluronan in synovial joints: Elimination of labelled hyaluronan from the knee joint of the rabbit. Exp Physiol. 1991;76:125–134.
  23. Bruyère O, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: A report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum. 2014;44(3):253–263.
  24. Bennell KL and Messier SP. Osteoarthritis: Strength training, self-management or both for early knee OA. Nat Rev Rheumatol. 2010;6(6):313–314.
  25. Bowman S, et al. Recent advances in hyaluronic acid based therapy for osteoarthritis. Clin Transl Med. 2018;7(1):6.
  26. Reid MC. Viscosupplementation for osteoarthritis: A primer for primary care physicians. Adv Ther. 2013;30(11):967–986.
  27. AAOS. Treatment of Osteoarthritis of the Knee: Evidence-based Guideline 2nd Edition. 2013. Available from: Accessed on 17 October 2019.


Consultant Orthopaedic, Sports and Traumalogy Surgeon
KPJ Damansara Specialist Hospital


PRP helps in knee OA: Myths and facts

What is platelet-rich plasma (PRP)?
Osteoarthritis (OA) is a degenerative disease involving joint damage; an inadequate healing response and progressive deterioration of the joint architecture that commonly affects the knee and/or hip joints. 1 Autologous blood-derived products possess much promise in the repair and regeneration of tissue and have important roles in inflammation, angiogenesis, cell migration and metabolism in pathological conditions, including OA.1

Even though blood is mainly a liquid (called plasma), it also contains small solid components (red cells, white cells and platelets). Platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins known as growth factors that are significant in the healing of injuries.2

PRP is plasma with many more platelets than in blood. The concentration of platelets and, thereby, the concentration of growth factors can be 5–10 times greater (or richer) than usual.2

Which are the conditions where PRP can be used for treatment?2

  • Chronic tendon injuries
  • Acute ligament and muscle injuries
  • Post-surgery
  • Knee arthritis
  • Fractures (delayed healing)

How is PRP prepared?


Collect blood:1,3

30–60 mL of blood is drawn from the patient’s arm.


Separate the platelets:3

  • The blood is then placed in a centrifuge.
  • The centrifuge spins and separates the platelet-rich plasma from the rest of the blood components.

Extract platelet-rich plasma:1,3

Extract 2–6 mL of platelet-rich plasma.

How does PRP work?
Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.2

This can be done in either of the two ways:2

  • PRP can be carefully injected into the injured area.
  • PRP can also be used to improve healing after surgery for some injuries.

Role of PRP in knee OA1

When can PRP be used in OA?

  • PRP is used for very selective cases of early OA where the cartilage is still preserved, which aids in healing.1

Is PRP effective in advanced stages of OA?

  • PRP has shown positive effects only in stages 1 and 2 OA. In advanced OA, PRP may not be effective as there is no cartilage left for healing process.1

What is the difference between viscosupplementation and PRP?

  • Viscosupplementation gives a cushion in between the articular surface, and usually provides better pain relief even in more advanced stages of OA but the relief may have shorter duration.4,5
  • In knee OA, PRP injections aim to stimulate cartilage repair and offer relief to other osteoarthritic symptoms, potentially delaying the need for joint replacement surgery. Adverse effects are likely to be reduced due to the patient’s own protein use and bioactive molecules can be concentrated to achieve the desired dosage.1

Myths and facts6,7
If you are considering PRP or thinking it would work for you, make sure you separate the fact from myths before you move forward with the treatment.

  • Myth: PRP is a risky surgical procedure.
    Fact: Studies on knee OA has not reported any major adverse effect with the use of PRP and all have reported the modest benefit on validated functional outcome scales.6
  • Myth: Too young for PRP therapy.
    Fact: PRP did better in younger patients with more localised OA and was comparable to hyaluronic acid in more advanced diseases.6
  • Myth: PRP is only for cell regrowth.
    Fact: PRP has reputation as a “natural healer” and use of PRP by professional athletes and celebrities has created a lucrative market.6
  • Myth: PRP is too expensive.
    Fact: A handmade standard PRP can be prepared reliably and cost-effectively without using a commercial kit.3
  • Myth: PRP treatments are experimental/unproven.
    Fact: There is reasonable evidence that PRP may be effective in chronic degenerative tendinopathy when other conservative treatments have been tried and failed.6
  • Myth: Stem cells come from unborn embryos.
    Fact: In PRP therapy, stem cells are harvested from the patient’s own body. This improves the likelihood of the adapting cells when they are reintroduced to your body.7

PRP could be effective only in the early stages and when there is injury and some cartilage left for healing, and not in the advanced stages. Initial studies on the use of PRP in OA are positive, but further studies should be conducted prior to its recommended use.


  1. O'Connell B, Wragg NM, Wilson SL. The use of PRP injections in the management of knee osteoarthritis. Cell and Tissue Research. 2019;376(2):143–52.
  2. OrthoInfo. Platelet-Rich Plasma (PRP). Available at: . Accessed on 05 September 2019.
  3. Cook CS and Smith PA. Clinical update: Why PRP should be your first choice for injection therapy in treating osteoarthritis of the knee. Current Reviews in Musculoskeletal Medicine. 2018;11(4):583–92.
  4. Cianflocco AJ. Viscosupplementation in patients with osteoarthritis of the knee. Postgraduate Medicine. 2013;125(1):97–105.
  5. Harmon KG and Rao AL. The use of platelet-rich plasma in the nonsurgical management of sports injuries: Hype or hope? ASH Education Program Book. 2013;2013(1):620–6.
  6. Wang HL and Avila G. Platelet rich plasma: Myth or reality? European Journal of Dentistry. 2007;1(4):192.
  7. Dhurat R, Sukesh MS. Principles and methods of preparation of platelet-rich plasma: A review and author’s perspective. Journal of Cutaneous and Aesthetic Surgery. 2014;7(4):189.