Nowadays, knee pain is a strikingly common complaint across all age groups. While it’s been traditionally associated with ageing and primary osteoarthritis of the joint, an alarming number of young and middle age individuals are now dealing with knee injuries leading to secondary arthritis. The consequences? Limitations in daily routine, disruption of sports activities and a significant decline in quality of life.

Why ‘knee preservation’ ?

Historically, treatment options for persistent knee pain in arthritis have been either conservative therapy or an early knee replacement surgery. While knee replacement (arthroplasty) can be considered for older patients, it is not an ideal option for the younger, more active population. ‘Knee preservation’ has emerged as a middle path solution that not only addresses the pain but also aims to avoid or delay joint replacement altogether by restoring the native knee joint anatomy and biomechanics.


What exactly is ‘Knee Preservation’?

It includes various treatment modalities designed to maintain and restore the structural integrity and function of the native knee joint. Rather than replacing the damaged parts with a prosthesis (as in total knee replacement), these techniques attempt to repair the damaged tissue, correct malalignment, and redistribute mechanical loads, thereby slowing or halting the progression of joint degeneration. It’s a customised patient-specific approach. By addressing the root cause of symptoms, be it cartilage defect, ligament injury, meniscal tear, or bone deformity; knee preservation offers patients a second chance at pain-free mobility with the native joint.


Why ‘Preservation’ over ‘Replacement’?

Knee replacement has revolutionised joint care for the elderly, especially those with grade 4 end-stage tricompartmental osteoarthritis. However, it is not ideal in the early stages of arthritis. 

Candidates who should consider knee preservation rather than replacement include: 

  • young, active individuals under 60 years of age, 
  • athletes or manual labourers
  • individuals who wish to return to high-impact sports
  • patients with localised knee problem rather than generalised arthritis. 

The concerns with ‘early' joint replacement in a younger age group are:

- Limited lifespan of knee replacement prosthesis (implant)

- Restrictions on impact sports and strenuous physical activities

- Loss of natural joint feel (proprioception)

- Risks of a major invasive surgery: infection, stiffness, implant loosening or wear over time needing a revision surgery.

Knee joint preservation aims to avoid these limitations by protecting the native joint for as long as possible.

Who is an ideal candidate for Knee Preservation?
  • Young to middle-aged adults (typically 18 to 55 years)
  • Focal cartilage lesions or meniscal injuries
  • Ligament instability (e.g., ACL tears)
  • Patellar (knee cap) dislocations or maltracking
  • People with bow-legs (varus) or knock-knee (valgus) deformities
  • Patients with early osteoarthritis, particularly involving one out of three compartments of knee joint. 


What are the NON-SURGICAL treatment options under Knee Preservation? 

  1. Rest and Acute pain management: Non-steroidal anti-inflammatory drugs help in reducing acute pain and swelling in the knee joint, which can happen due to an acute flare-up of the arthritis after an excessive activity.
  2. Physiotherapy: Supervised exercises and rehabilitation are the first line of defence while recovering from an injury and even in the long run. A customised exercise regimen helps in restoring the function and easing out the pain.
  3. Lifestyle modifications: Certain activities such as squatting, sitting on the floor, stair climbing can aggravate the ongoing degenerative process in the joint. Avoiding them helps in the long run. Maintaining active lifestyle with regular non-impact exercises such as walking, cycling, swimming helps further.
  4. Weight reduction: As stated earlier, knee joints wear the brunt of excess body weight, making them work harder. Weight reduction strategies under supervision can make a significant difference by offloading the knee joints.
  5. Cartilage Supplement Medications: Naturally produced chemicals in the body like glucosamine and chondroitin are also available in packaged supplements over the counter. While glucosamine has a role to play in the repair of joint cartilage, chondroitin acts to prevent certain other enzymes from breaking down the joint cartilage.Off-loading 
  6. Braces: External aids like a knee brace can benefit in certain cases by providing relief by taking some pressure off an arthritic compartment of the joint.
  7. Intra Articular Injections: Steroids: These are prescribed to reduce the inflammation inside the joint, if patient fails to respond to oral medications. Although the indications are limited, multiple injections should be avoided due to deleterious effects of steroids on the remaining cartilage.      

       - Platelet Rich Plasma (PRP) : Platelets contain growth factors that are used by the body in the process of healing injuries. A concentrated form of platelets prepared from a person’s own blood can be injected into the joint in cases of early arthritis. Although complete cartilage regeneration does not occur, but the symptoms can get better significantly.           

    - Viscosupplementation with Hyaluronic Acid (HA): Synovial fluid containing hyaluronic acid is a lubricant produced by the body within the joint space. Supplementation of hyaluronic acid externally in the form of injections may help ease out the pain and stiffness in certain cases, even though it does not stall the progression of arthritis. Injections might need to be repeated after a few months once the symptoms recur.    

What are the SURGICAL treatment options in Knee Preservation ?

1. Meniscus Repair: 

Meniscus plays a critical role in shock absorption, joint lubrication, and load transmission. Hence, loss of meniscal tissue and its function initiates and accelerates osteoarthritis. Meniscus tear is one of the commonest initial events in the cascade of early osteoarthritis.Meniscus tears need to be addressed in early stages so as to achieve a complete healing and restore the joint function. Arthroscopic repairs is the minimally invasive technique available.Meniscal Transplantation can be an option in patients with complete loss of a meniscus. In this, a meniscus allograft from a cadaveric tissue lab is implanted into patient’s knee. The indications are quite narrow for this procedure. 

2. Cartilage Restoration Surgery: 

Native hyaline cartilage of knee joint does not regenerate once damaged. Focal chondral (cartilage) defects, if left untreated, can lead to early osteoarthritis. Various effective techniques are available which may be arthroscopic or open. These include: 

Microfracture: Involves creating holes into the defect to release bone marrow stem cells to form a fibrocartilage patch. It is best for small lesions. Limitation is that the fibrocartilage is less durable than the native hyaline cartilage.

OATS (Osteochondral Autograft Transfer System): Transplants healthy cartilage from non-weight bearing portion of the joint to the defect in the form of bone plugs. Ideal for medium-sized focal defects.

ACI (Autologous Chondrocyte Implantation): Cartilage cells are harvested patient’s knee joint, cultured in the lab, and re-implanted into the defect. Requires two surgeries but provides hyaline-like cartilage and is effective in bigger lesions.

3. Ligament Reconstruction: 

Injuries to the ligaments of knee joint such Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) destabilise the joint, disturb the biomechanics and lead to early cartilage  wear off. Early intervention in terms of arthroscopic reconstruction helps restore the native joint biomechanics.

4. Limb re-alignment with Osteotomy: 

In individuals with bow legs (varus) or knock knees (valgus), either the medial or lateral compartment of knee gets overloaded and undergoes early degeneration. Limb re-alignment surgery in the form of an osteotomy corrects the deformity, distributing the forces equally in both medial and lateral compartments. Earlier the correction, better are the outcomes.Osteotomy involves cutting the bone, correcting the knee alignment and fixing it with a metallic plate and screws. This osteotomy can be performed in the thigh bone (distal femoral osteotomy / DFO) or the leg bone (high tibial osteotomy / HTO) depending on the location of deformity. 

Choosing the Best Possible Treatment

Knee preservation is not a one-size-fits-all solution. The choice of treatment modality depends on multiple factors, including age, activity level, and the type and grade of pathology. A comprehensive evaluation should include:

- Detailed patient history and clinical examination

- Weight-bearing radiographs and mechanical axis analysis

- MRI for soft tissue and cartilage assessment

- CT scans for rotational and bony deformity assessment (if necessary)

Based on these findings, a personalised plan may involve combining multiple procedures, such as ACL reconstruction, meniscus repair and high tibial osteotomy.

Effectiveness of Knee Preservation

When chosen in the right candidate at the appropriate stage, knee preservation can yield significant benefits.

- 85-95% return to pre-injury activity levels 

- high patient satisfaction rates 

- delaying knee replacement by 5 to 15 years, 

- lower complication rates compared to knee replacement

- Restoration of joint longevity and quality of life

So, to summerise..

Why replace something that can be preserved! 

It’s all about treating early and smartly, giving the body a chance to heal, recover, and thrive using its own natural structures. To conclude, knee preservation represents the future of orthopaedic care: biological, evidence-based, individualised and full of promise!