DOI: 10.12809/hkmj134191
EDITORIAL
Osteoarthritis of knees: the disease burden in Hong Kong and means to alleviate it
WH Yuen, FHKCOS, FHKAM (Orthopaedic Surgery)
Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Jordan, Hong Kong
It is a well-known fact that most developed cities
are facing the problems of ageing, and Hong Kong is
no exception. It is predicted that 21% of Hong Kong
inhabitants will be aged 65 years or above in year
2024, as compared to 13% in the year 2009.
1 In other
words, within 10 years, one in every five citizens of
Hong Kong will be seniors.
Knee osteoarthritis (OA) is one of the most
common degenerative diseases, and is one of the
commonest causes of disability in the elderly. The
prevalence of knee OA in Chinese men is similar
to that in Caucasian men, but is significantly higher
among Chinese women than Caucasian women.
2 3
The Beijing Osteoarthritis Study showed that in
the population group aged 60 years or more, the
prevalence of radiographic knee OA was 42.8% in
women and 21.5% in men, and symptomatic knee
OA occurred in 15.0% of women and 5.6% of men.
3
Hence, it is expected that in our ageing population,
the knee OA will generate more and more impact on
the health care system.
Conservative treatment for knee OA includes
lifestyle modification, weight reduction, use
of walking aids, physiotherapy, and analgesics.
Exercise interventions under the supervision by
physiotherapists are recommended for knee OA.
4 In
this issue of the Hong Kong Medical Journal, Lau et
al
5 have demonstrated the benefit of physiotherapist-designed
aquatic exercise in terms of physical and
psychosocial functioning.
Surgery for total knee replacement (TKR) is
indicated for end-stage knee arthritis and failed
conservative treatment. Total knee replacement is
a very effective treatment for OA knee in terms of
pain relief, improvement of function, and quality
of life. Owing to advances in prosthesis design,
surgical techniques, anaesthesia, and perioperative
pain management regimens, patients undergoing
TKR have a relatively more pleasant experience
and faster recovery than in the past. It is a form of
major surgery involving bone cuts and soft tissue
dissection, in which postoperative pain control is
very important both for the patient’s comfort and
to facilitate postoperative rehabilitation exercises.
In this issue of the Journal, Wu and Wong
6 showed
how the different modes of postoperative analgesia
method can benefit patients.
In a systematic review by Singh,
7 the utilisation rate for TKR has increased over the last two to three
decades and the demand will continue to increase in
the years to come. In a study of trends from Swedish
Register, the rates of primary TKR increased 5-fold
over a 20-year period.
8 A similar trend has also
been observed in Hong Kong. The rising demand is
related to the ageing of population, due to increased
longevity and increasing acceptance for TKR by
patients. The current demand for TKR has far
outstripped the supply, and is reflected in the longer
and longer waiting times in the public hospitals,
where it is not uncommon for patients to wait a few
years before receiving the procedure. This does not
even take into account the waiting time between the
referral and the first orthopaedic consultation.
Patients on the waiting list for TKR are usually
in excruciating pain and have significant functional
impairment. Some authors
9 10 11 12 have suggested that
long delays before surgery lead to deterioration
in terms of pain, functionality, and health-related
quality of life, which could eventually affect post-surgery
outcomes. On the contrary, other studies
have not revealed changes in pain control or self-reported
physical function, regardless of the duration
of the waiting list.
13 14 In the latter studies, however,
waiting periods were in general a few months only.
There is no report on the impact of waiting time in
terms of years, which is comparable to our current
situation. Irrespective of whether or not protracted
delay has a negative impact on outcomes, it is
beyond doubt that delays cause physical, social, and
emotional suffering to patients. In addition, there is
a considerable social and emotional burden on their
caretakers.
To alleviate this problem, the Hong Kong
Government and the Hospital Authority have injected
extra resources to establish two joint replacement
centres, one in the Hong Kong Buddhist Hospital
and the other in the Yan Chai Hospital. High-volume
joint replacement surgery can be performed in
these specialised centres, which can deliver more
efficient and cost-effective services. Following TKR
moreover, high-volume hospital throughput appears
to be negatively associated with mortality rates and
positively associated with implant survivorship.
15 16
Although the waiting times in Queen
Elizabeth and Yan Chai hospitals have been
markedly shortened, the two joint replacement centres cannot relieve the problem of long waiting
list in other regional hospitals. Currently, patients
can be referred from other hospitals to the joint
replacement centres to facilitate earlier surgery.
However, some patients refuse to have surgery in
an unfamiliar setting, preferring to attend their own
nearby regional hospitals with their familiar and
trustworthy orthopaedic surgeons. On the other
hand, the capacity of the two joint replacement
centres are about to be saturated. To relieve the
suffering of this group of patients, allocation of extra
resources to hospitals with long waiting list queues is
urgently needed.
Undoubtedly, our public health care system is
facing more and more challenges from a variety of
degenerative diseases associated with ageing; OA
of knee is just one. The current public health care
service is heavily subsidised by the Government, and
the public always complain about the long waiting
time for medical services in public hospitals. It is
therefore foreseeable that the present health care
model will not be sustainable. Health care reform is
therefore an imperative, if Hong Kong inhabitants
are to acquire an accessible and affordable quality
health care service for the future.
References
1. Hong Kong Population Projections 2010-2039. Hong
Kong: Census and Statistics Department.
2. Felson DT, Nevitt MC, Zhang Y, et al. High prevalence of
lateral knee osteoarthritis in Beijing Chinese compared
with Framingham Caucasian subjects. Arthritis Rheum
2002;46:1217-22.
Crossref3. Zhang Y, Xu L, Nevitt MC, et al. Comparison of the
prevalence of knee osteoarthritis between the elderly
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