Forum: Recognise importance of knee preservation surgery in osteoarthritis guidelines

Singapore recently released its updated clinical guidelines on knee osteoarthritis. The guidelines reflect a commendable effort to promote patient-centred care and shared decision-making. However, a significant gap remains that could affect long-term outcomes for many Singaporeans.

The guidelines emphasise conservative management and reserve surgery largely for advanced disease, particularly in the form of knee replacement. While effective, total knee replacement is not without limitations, with up to one-third of patients experiencing persistent pain. In younger patients, the ideal knee replacement is often one that can be delayed or avoided. What is notably absent is meaningful recognition of knee preservation surgery.

Orthopaedic practice has evolved beyond a “wait until it’s bad enough” model. There is now strong evidence supporting procedures such as high tibial osteotomy, cartilage repair and meniscal preservation – interventions that restore biomechanics, slow degeneration and extend the native knee’s life.

Research from the Singapore Knee Preservation Society and international centres shows that, in appropriately selected patients, these procedures can significantly improve function and delay or prevent knee replacement.

A recent study reported 10-year survivorship of 92 per cent for medial opening wedge high tibial osteotomy – a commonly performed knee preservation procedure – in Asian populations. This superior outcome, compared with Western cohorts, likely reflects cultural and lifestyle demands – particularly the need for deep knee flexion, such as kneeling and sitting cross-legged – functions that knee replacements cannot reliably replicate. The issue is not just technique, but also timing and indication. Many patients are referred too late, when preservation is no longer feasible, resulting in missed opportunities.

Public education and clinical guidelines must evolve. Patients should not simply be told to delay surgery, but to pursue the right surgery at the right time.

Future guideline updates should adopt a more nuanced pathway that integrates knee preservation alongside conservative care and joint replacement. This would better reflect current evidence and enable timely referrals to appropriate specialists.

Singapore has the expertise to lead in this space. Recognising knee preservation surgery within national guidelines would improve long-term joint health and quality of life. As Singaporeans are living longer and more active lives, we should be proactive in managing osteoarthritis – this is where knee preservation surgery comes to the fore.

Lee Kong Hwee
President
Singapore Knee Preservation Society