A 57-Year-Old Man With Osteoarthritis of the Knee

DR SHIP: Mr V is a 57-year-old man who has had knee pain for at least 30 years. He lives in Boston with his wife, with whom he owns and runs a business. He has managed care insurance and sees his primary care physician, Dr P, at Beth Israel Deaconess Medical Center. Mr V dates the onset of his left knee problems to a soccer injury at age 26. He was diagnosed with rupture of 2 ligaments and underwent a course of physical therapy. His pain diminished over time, but he was aware that his left knee was never again at “100%.” He continued his active athletic life, which included soccer, bicycle racing, and running at least 3 times per week. About 15 years ago, however, pain in his left knee recurred and became severe enough that he stopped running and moved largely to long-distance cycling. Thirteen years ago he underwent an arthroscopic debridement. This improved his level of function and decreased his pain for approximately 2 years, but symptoms subsequently recurred. He has since had several courses of physical therapy but has found the recommended exercises to be so painful that he could not complete them. Despite persistent, often severe, knee pain, Mr V remains a very active long-distance (“ultra marathon”) bicyclist, cycling in qualifier events and races of more than 700 miles (1120 km). He estimates his annual cycling distance to be about 7000 miles (11200 km), a number that he views as a marked reduction from his previous distance of between 10000 and 12000 miles (16000-19200 km) annually. In addition, he continues to lift weights and work out regularly. His knee pain has progressed, however, so that he often has severe pain after standing for long periods as he needs to during work, and he is unable to garden because of pain brought on by bending his left knee. He was prescribed naproxen, 1000 mg/d, but finds that 500 mg/d is effective at “helping” with the pain, and he is hesitant to take the higher dose. Other than knee pain, Mr V is very healthy. He has no other medical problems and has had no other surgical procedures. He follows a vegetarian diet and neither smokes nor drinks. In addition to the naproxen, he takes garlic pills. He is not allergic to any medications. There is no family history of osteoarthritis. On physical examination, Mr V was 5’10” tall and weighed 155 lb. His left knee appeared slightly larger than his right but had no erythema or warmth. When standing, he had varus deformities of both knees and a slightly antalgic gait. Range of motion on the left knee was 5° to 120° compared with 5° to 140° on the right. Collateral and cruciate ligaments were stable. Crepitus was noted. There was a moderate effusion in the left knee and a palpable semi-membranous bursa. There was no distal neurovascular compromise in either knee. Hip range of motion was full and pain-free bilaterally. Radiographs of the left knee in 1999 revealed marked tricompartmental osteoarthrosis with prominent osteophyte formation and severe joint space narrowing. The medial joint space was the most narrowed compartment. There was subchondral sclerosis, most prominently also in the medial hemijoint space, and lateral subluxation and varus angulation were noted. Significant subchondral cystic changes were identified involving the tibial plateau centrally as well as the medial femoral condyle, thought to represent geode formation from osteoarthrosis. Total knee replacement has been offered to Mr V, but different orthopedists have varied in their recommendations regarding the timing of the surgery. Mr V wonders whether and when he should plan to undergo knee replacement and how long he can expect the prosthesis to last.