Patients are waiting longer than ever for surgery to replace worn-out joints. Cash-strapped NHS trusts are increasingly refusing, cancelling or delaying operations, and last week health chiefs admitted the 18-week treatment target will no longer be met.
Although 160,000 hip, knee and ankle replacements are carried out each year in Britain, it is only the most desperate people who are offered a procedure.
To make matters worse, doctors often have little to offer beyond painkillers or injections of anti-inflammatory steroid drugs.
The situation can feel hopeless. But the reality is certainly not. These days, there are numerous medically proven alternative treatments that will end discomfort and immobility, and could even spare some patients from a joint replacement.
Patients in Britain are waiting longer than ever for surgery to replace their worn-out joints
‘Joint-replacement surgery can eliminate pain, improve mobility and restore quality of life, but it is not the only option,’ explains Mark Wilkinson, Professor of Orthopaedic Surgery at the University of Sheffield and a spokesman for Arthritis Research UK.
‘Surgery carries risks and if you’re under 50 and active, the likelihood is that you’ll need another replacement later. So it is worth exploring other treatments that can delay or even eliminate the need for surgery.’
So what are the options for those who can’t have or are waiting for a joint operation, or don’t want to go under the knife? The good news is there are a host of treatments and procedures available to treat pain and improve mobility.
REALIGN THE KNEES WITH A ‘ROBOCOP’ LEG BRACE
How to make sure you get the best treatment
– First visit your GP. They will have access to your records and will help you find out whether the treatment is suitable and available.
– Bring this article to show them if you feel one of these treatments might work for you.
– If a treatment isn’t available in your area, you can be referred elsewhere. Search online and ask healthcare professionals before revisiting the GP.
– A consultant may decide that the treatment is not suitable for you. They should explain why and suggest an alternative.
– You are not legally entitled to a second opinion but doctors should always honour the request.l Some therapies will only be offered after first-line approaches such as painkillers, weight loss and steroid injections have been tried.
– Private medical insurance companies will be able to recommend doctors.
– The Private Healthcare Information Network (phin.org.uk) allows you to search by hospital, clinic, consultant, treatment, procedure or location. Your GP should still refer you.
WHAT: An ‘offloading’ knee brace is a fabric and lightweight plastic strap that exerts a gentle sideways pull to realign the joint, helping to restore movement and relieve pain.
HOW IT WORKS: In 2017, a joint study by Swansea and Cardiff universities found that 40 per cent of patients awaiting a total knee replacement felt they did not need the procedure after wearing an offloading leg brace for two years.
‘A patient needs specific knee problems for a brace to help,’ explains Dean Muldoon, a physiotherapist at the Royal Orthopaedic Hospital in Birmingham. ‘The pain needs to be caused by the joint being out of kilter on one side so that the brace can correct poor alignment. If the joint is pointing inwards slightly, we use a brace to pull the joint outwards and compensate for the inversion. It also works the other way round. But if the joint has damage throughout, a brace will not be suitable.’
Taking the pressure off the joint helps retrain the surrounding muscles to hold the joint correctly. But muscles are the best natural brace for the knee, so those wearing an offloading brace must stick to a rehabilitation programme outlined by a qualified physiotherapist.
HOW CAN I GET IT? Offloading braces are available on the NHS but you must get a referral from your GP to a specialist knee clinic to find out if you are eligible, and to be fitted. Most private healthcare providers offer leg braces. The most widely used is the Unloader One from manufacturer Ossur – it costs from about £600. The company also produces a hip brace, the Unloader Hip. Visit ossur.co.uk or call 08450 065 065.
PROS AND CONS: Minimally invasive, strong evidence it works, and affordable. But it doesn’t work for all types of arthritis.
YOUR OWN BLOOD COULD BE THE ANSWER
WHAT: Platelet-rich plasma (PRP) injections. The procedure involves taking a small amount of the patient’s own blood, centrifuging it to concentrate the platelets – the cells in the blood responsible for soft tissue healing – then reinjecting it into the affected joints.
HOW IT WORKS: Part of an emerging area known as orthobiologics – technology that harnesses the body’s own healing ability – PRP injections have been widely used in the sporting world for some time.
It is primarily offered on the NHS for tendon pain but there is some evidence it can be used to treat osteoarthritis-related joint pain. It’s not fully understood how PRP works but it is thought that growth factors in the platelets have an anti-inflammatory effect.
One new treatment involves taking a small amount of the patient’s own blood, centrifuging it to concentrate the platelets then reinjecting it into the affected joints, like the hip (shown)
The procedure – drawing about 60ml of blood, centrifuging twice then re-injecting – takes about 30 minutes, and patients can go home afterwards. Some patients only need one injection, while others will have three over several weeks. ‘You should start to feel the benefits after five days if it’s going to work for you,’ adds Mr Datta.
HOW CAN I GET IT? This treatment is available in a handful of NHS trusts. Speak to your GP about a referral. Privately it costs about £2,000 for three injections.
PROS AND CONS: Minimally invasive but it is expensive and requires top-ups.
ELECTRIC ZAPPER THAT RESETS NERVES
WHAT: Pulsed radiofrequency treatment (PRF) is an electrical treatment that works by ‘resetting’ a nerve to make it less reactive. Studies have shown that applying pulsed radiofrequency to certain nerves can block their ability to transmit pain.
‘My brace saved me from a total knee replacement’
Simon Holborn, a 44-year-old print and packaging expert from Bath, had an offloading brace called the Ossur Unloader fitted two years ago, having previously been told his only option was a complete knee replacement.
Simon says: ‘Five years ago I was playing cricket and hyper-extended my left knee – when it sort of bends backward instead of forward in the normal range of motion.
‘After that I felt like the knee simply wasn’t supporting me. Then about three years ago I injured it again when lifting heavy boxes.
‘I was on high doses of daily painkillers and in constant pain. My GP referred me to an orthopaedic consultant, who diagnosed me with osteoarthritis and said a full knee replacement was imminent. Then out of the blue I had a call from the prosthetics company Ossur, who had spoken to the consultant. They wanted me to try their Unloader One brace, which would realign my knee, as part of a trial.
‘I wear the brace from the moment I get up until the evening when I get home. Within a few weeks I noticed I wasn’t reaching for the painkillers half as much, even though I was walking more.
‘In July scans showed I now only need a partial replacement on the load-bearing side.
‘I’m starting a new round of physiotherapy in October and making lots of lifestyle changes, including giving up smoking and improving my diet. I’m hoping that my knee will keep improving.’
HOW IT WORKS: The procedure is carried out under local anaesthetic, or sometimes sedation. A doctor uses X-ray or ultrasound to locate the nerve close to the joint, then inserts an electrode needle next to the affected nerve.
Once the needle is in the correct position, a high-frequency current is applied to the nerve for around ten minutes. After the nerve is treated, the knee is bandaged and the patient discharged. The procedure takes about two hours and patients may experience a small amount of bruising and discomfort once the local anaesthetic has worn off. Pain relief may take several weeks to kick in, and the onset is usually subtle, becoming progressively better, and lasting between six and 12 months. The knees, hips and shoulders are all areas that respond to PRF. A 2013 study published in the journal Anesthesiology And Pain Medicine found that all 57 patients who had the procedure experienced a significant reduction in pain.
HOW CAN I GET IT? PRF for joint pain is not available on the NHS. Privately it costs about £2,000 per session.
PROS AND CONS: A good option for those resistant to traditional painkillers and steroid injections or unsuitable for joint replacement. However, it is expensive and does not offer long-term relief.
REHYDRATE THOSE CREAKY JOINTS
WHAT: Viscosupplementation is a procedure that involves injecting a joint with hyaluronic acid (HA), a component of the synovial fluid, which is found inside joints and provides cushioning and nutrients to the cartilage.
HOW IT WORKS: HA is a jelly-like substance that cushions the joint, dampens inflammation and facilitates movement.
Simon Holborn, pictured with wife Julie and daughter Hannah, has a leg brace that releases tension and weight on the load bearing side of his left knee
The injection is most commonly used in the knee but can also be used in the ankle and shoulder. A 2005 review of 63 trials concluded that viscosupplementation was an expensive but effective treatment for osteoarthritis in the knee, saying it reduced pain and increased function for up to 26 weeks.
The treatment, which takes about 20 minutes, can be particularly helpful for those who have failed to respond to anti-inflammatory painkillers, analgesics, physiotherapy and weight loss.
Some patients experience a small amount of bruising, bleeding or numbness immediately after the injection but this usually disappears after a few hours.
It usually takes between five and 14 days for pain relief to be felt, and a top-up treatment will be required six to 18 months later.
Around 160,000 hip, knee and ankle replacements are carried out each year in Britain (file image)
HOW CAN I GET IT? The treatment is not routinely used for osteoarthritis by the NHS. Privately, each injection costs about £500.
PROS AND CONS: Minimally invasive and targeted treatment. Expensive and you’ll need top-ups.
TWO ‘ALTERNATIVE’ OPTIONS… THAT WORK!
WHAT: Osteopathy – a gentle type of soft tissue manipulation – can help improve joint flexibility and reduce inflammation by physically stimulating the circulation, helping drain fluid from the joint. Acupuncture involves ultra-fine needles being inserted for a short amount of time in various areas around the body. It is found to have a pain-relieving effect.
HOW IT WORKS: Tim Allardyce, registered osteopath and spokesman for the Institute of Osteopathy, explains: ‘Stiff joints can lead to stiff muscles which can leave you seized up, so people often need stretching. We don’t do loads of yanking and crunching though.’
A pilot NHS study published last year found that osteopathy reduced trauma and referrals to an orthopaedic surgeon by 44 per cent.
Evidence suggest that acupuncture works to reduce pain by triggering release of neurotransmitters called endorphins and enkephalins as well as the hormone cortisol that helps control inflammation.
Acupuncture could solve joint pain. It involves ultra-fine needles being inserted for a short amount of time in various areas around the body
Dr Mike Cummings, medical director of the British Medical Acupuncture Society, says: ‘Acupuncture taps into the central nervous system to turn the volume down on pain.’
HOW CAN I GET IT? Osteopathy and acupuncture are available in some NHS trusts. Private costs range from £35 to £45 per session.
PROS AND CONS: Treatments can help boost mobility but they do not reverse damage.