Too young to get osteoarthritis?
Published on 18 April 2013
New research could reduce the high risk of osteoarthritis developing in younger people as a result of commonly-performed surgery to repair torn cartilage in the knee. Jane Tadman reports.
Osteoarthritis is a condition that affects most people as they get older or become fatter. But the third main risk factor for developing the condition is an injury to the joint.
And that’s why at the age of just 16, fit, active teenager Peter Draper from Stoney Stanton in Leicestershire is at as much risk of getting osteoarthritis as an overweight, sedentary 60-year-old.
That’s because while playing rugby at school Peter was the victim of a bad tackle which ruptured the anterior cruciate ligament (ACL) in his knee. After months of extreme pain, he had surgery to reconstruct his ACL and to repair the damage to his meniscus – cartilage tissue that acts as a shock absorber in the knee.
Meniscal tears are the most common form of knee injury, often occurring as a result of sport, leading to pain, swelling and locking of the knee. They do not heal after being torn or damaged because they have a poor blood supply.
Such was the extent of Peter’s injury he had to have a second operation, this time an arthroscopic procedure called a meniscectomy, during which 60% of the meniscus in his damaged knee had to be removed.
And although this operation has so far been a success, unfortunately Peter is now at 14 times greater risk of developing osteoarthritis than the average man-in-the-street.
Meniscectomy might be effective at reducing pain, but cutting out so much shock-absorbing material from a weight-bearing joint like the knee is bound to make someone much more prone to developing joint disease.
Some people who have had a meniscectomy still have pain afterwards, despite surgery, and show signs of developing early osteoarthritis. So far this hasn’t happened to Peter, but it could – and soon.
However, there is now hope for people like Peter.
Researchers in Coventry have recently been awarded funding from Arthritis Research UK, to find out if surgery to replace the meniscus can effectively reduce the risk of osteoarthritis.
“Essentially, we want to find out if an operation called a meniscal transplant, which replaces the part of the knee joint that acts as the shock absorber with donor cartilage, can cut this risk,” explains Nicholas Smith, a specialist registrar at University Hospital of Coventry and Warwickshire in Coventry.
“This could have major implications for people who develop osteoarthritis due to injury, and for whom there is currently very little treatment.”
Meniscal transplant surgery has been performed by surgeon Tim Spalding in Coventry for several years.
“The meniscus acts as a shock absorber for the knee, and spreads the load across the weight-bearing areas,” explained Mr Smith, who has been awarded a three-year clinical research fellowship of £185,000 from the charity to carry out the project.
“If you take it out you increase the risk of osteoarthritis, so the idea of putting back is to decrease the risk,” he adds. “At the moment meniscal transplant is done mainly for pain relief and is very successful; however some recent studies have suggested it may also protect against osteoarthritis. Our study may provide further evidence that this is the case.”
Mr Smith plans to perform a small clinical trial to find out more about the effectiveness of meniscal transplantation in reducing the risk of osteoarthritis. He will recruit 20 people between the ages of 16 and 50 who have pain after having a meniscectomy.
One group will have meniscal transplant followed by intensive rehabilitation and physiotherapy, and the other group will wear a knee brace, plus intensive rehabilitation and physiotherapy. Their knee joints will be scanned for signs of early arthritis four times over a 12-month period and the results compared.
Until recently, imaging techniques were not sufficiently refined to assess small changes in cartilage that denote early arthritis accurately. However, the advent of sophisticated imaging techniques such as MRI and sensitive software analysis packages means that researchers can now detect early very signs of arthritis in the joints.
“Peter won’t be taking part in the trial as he currently doesn’t have pain in his knee, but he and his parents are concerned about his increased risk of osteoarthritis, especially because he is so young, and they want to know more about whether meniscal transplant would protect his knee against it,” adds Mr Smith.
“If we can prove the effectiveness of meniscal transplant surgery in protecting against osteoarthritis, he is the kind of person who’ll benefit in the future.”
“Peter was playing rugby at school and had a bad tackle which ruptured his anterior cruciate ligament,” explains mum Keely Draper. “We weren’t aware of the extent of the problem at the time; we took him to the hospital and they said it was bruising.
“However, over a few months he began to be in a lot of pain, and the knee started to give way. The scream and cry he gave when it gave way was horrendous.”
Peter was referred to the Leicester Royal Infirmary where he had an MRI scan and in October 2009 had surgery to reconstruct his ACL and repair the damaged meniscus. This was followed by a long period of rehabilitation and physiotherapy in hospital and then at home.
However, he was told that his knee was very badly damaged and fragments of torn cartilage remained, so in summer 2012 he had to have a meniscectomy.
Peter was then referred to consultant surgeon Mr Spalding who explained that he would need to be monitored to see what happens to the knee.
“He had to give up contact sports, which was hard because he loves his sport and he’s doing an A level in PE,” says Mrs Draper. “But he’s an extremely level-headed lad, and instead, he has taken up archery and cycling, which is really good as it builds up muscle in his legs.”
At some point he will need a meniscal transplant – maybe in six or 12 months’ time. “They want to do it before his knee is too damaged,” she adds. “Mr Spalding was very good and explained everything to us, and said: ‘Go away, enjoy life; get on with things and if you feel any pain or discomfort comeback to me.’ So far he’s had occasional swelling in his knee and takes painkillers.”
Peter had plans go into the RAF but his family have been told that he probably wouldn’t currently pass the medical. However, things might change and he is keeping his options open.
Says Mrs Draper: “We’re keeping our fingers crossed for the future; it’s a little bit worrying. We’re a little bit scared about surgery because of the amount of time it takes to recover and all the physio and rehab. It took a long him to get over the ACL reconstruction and he missed out socially.
“It sounds awful to say, but when you’re older, you’ve had the chance to do things and don’t have as much to lose, but when you are that age it’s worse, somehow.”
Arthritis Research UK is launching a major new research centre of excellence later this year, looking at the link between exercise, injury and osteoarthritis. Arthritis Today will keep readers up-to-date.