Dr.A.K.Venkatachalam,



Consultant Orthoapedic surgeon,

Knee & Shoulder clinic, Besant nagar, Chennai

Arthritis has two main patterns- Inflammatory arthritis & Osteoarthritis. Inflammatory arthritis affects other systems also in addition to joints. Rheumatoid arthritis affects middle aged women mainly and can cripple a person. Early diagnosis is desirable to commence medication which is the mainstay of treatment. The usage of disease modifying drugs, gene therapy, and Joint replacements for irredeemable joints has made life easier and abolished confinement to a wheel chair.

Osteoarthritis is set to become one of the ten leading causes of morbidity as life expectancy increases. Aging and genetics cause primary osteoarthritis and occupation, lifestyle; injuries of the joint are factors responsible for the secondary form. Since increasing numbers of younger people are developing the precursors of the disease (cartilage lesion), it behooves the surgeon to recognize the symptoms and signs of the nascent lesion and provide advice on treatment options.

Arthrosis means degeneration and perhaps would have been a more appropriate term, however “arthritis" has found common acceptance. It means an affliction of “articular cartilage", the bearing and lining of joints by degeneration. Unlike other tissues, the regenerative capacity of articular cartilage is limited and can stabilize or progress to joint stiffness and pain, which are the clinical hallmarks of arthritis. It commonly affects the spine, hips, knees, ankles, and shoulder and finger joints. In Asians and Indians, Knee osteoarthritis is the main problem for the patient and surgeon. Evolutionally, the knee is not a very ancient joint and appeared about 70 million years ago. Most animals have bent knees and only Man, Elephant and the Bear have straight knees. The erect posture of Man predisposes him to develop wear on the inner half of the joint through which the axis of weight bearing passes. Obesity, occupational activities, injuries, loss of muscle strength and knee deformities are local adverse factors while female preponderance, genetics, dietary habits, smoking are general risk factors. Radiological measurement of Joint space narrowing (JSN) is the currently recommended method for monitoring disease progression of osteoarthritis. Patients with knee OA rarely show improvement of radiological narrowing despite taking medication, but many may remain stable over long periods. Since the disease progresses slowly in the knee, one of several options can be selected according to the severity and needs of the individual.

Let’s have an overview of the options and the recent advances.

Weight loss, exercise and braces

Ointments, heating pads, ice packs, and elastic or braces may provide symptomatic relief. Weight control also is helpful but will not reverse disease created by years of preceding obesity. The biomechanical force between the kneecap (patella) is 3 times one’s body weight with just normal walking and it increases to 5-7 times body weight with activities such as squatting, climbing stairs, and running. Thus loosing one kilo of weight can lead to a seven fold reduction of compressive joint forces. Exercise to strengthen the muscles of the hips and knees are beneficial. Walking within limit of pain, cycling and swimming are useful low impact activities. If one is not shy about using a cane in the same hand, this will alleviate pain by decreasing joint forces by 50%. Bracing is useful for one sided arthritis.

Medications- Painkillers are the first prescribed drugs by physicians. There was euphoria about COX-2 inhibitors about 5 years ago but the bubble over their safety has burst last year with adverse effects attributed to most of them, and all but Etoricoxib have been withdrawn by the manufacturers. Once again the older generation pain killers are back but there have always been gastrointestinal safety concerns in arthritic patient ingesting them for prolonged periods. They have to be used in moderation along with plain Paracetamol and need to be taken with food.

Injections- Steroids and Hyaluronic acid are the two intra articular preparations available. Steroids provide short term pain relief by cutting down on inflammation.

The invariable question which a patient asks his doctor is how many times it can be done and the answer is as long as the doctor feels safe (up to 3 times per year).

Hyaluronic acid acts as a lubricant and stimulates the synthesis of joint fluid and articular cartilage (visco supplementation). A course of six weekly injections is needed and can be repeated after 6 months. These measures may delay but not prevent the need for joint replacement.

Surgical treatments

Arthroscopy

The popularity of arthroscopic knee lavage has waned after a paper cited that it had no benefits as compared to sham arthroscopy. Insurance companies now insist on pre operative x-ray evidence of osteoarthritis for compensation in the US. Arthroscopy is mainly useful in the younger and middle aged person where therapeutic procedures can be done to treat localized lesions. These lesions are not visible on x rays and can only be diagnosed by an MRI scan or arthroscopy. In older persons, trimming of loose cartilage and meniscal tears and removal of loose bodies are indications for arthroscopy. Cartilage surgery can repair and regenerate small lesions of cartilage.

Meniscal transplant

This is a new procedure applicable to young patients with absent menisci (semilunar cartilages) of the knee. These C shaped discs act as shock absorbers and mobile bearings within the knee. They are damaged after a sports injury or road accident. Complete damage necessitates removal. These knees were doomed to develop arthritis. However “meniscal transplant" can slow down the progression to osteoarthritis. In this operation, a missing or damaged meniscus is replaced by a graft taken from a cadaveric or brain dead donor. The graft is stored at minus 80 degrees and inserted into a patient’s knee arthroscopically or by minimally open surgery.

Knee replacements

A Total knee replacement is becoming popular in our country although it has been around in the west for years. Most western trained orthopedic surgeons perform these operations for elderly patient who want permanent pain relief. It is a cost effective procedure as dependence on others is reduced, the need for medication goes down and quality of life improves. Technically it involves substituting the damaged portion with a metal prostheses and a polythene spacer. Improvement in metallurgy has imparted a survivor ship of 90% plus survivorship at 15 years. Joint replacements are major operations an involve hospitalization, rehabilitation and recovery. A common refrain from South Indian patients who have undergone a knee replacement is that they had severe post operative pain and that they cannot bend their knee enough. This is a limiting factor of majority of Knee implants as they do not allow knee flexion beyond 100 degrees. A new version is available which has an inherent bend of 155 degrees built into it. This prosthesis when implanted into a motivated person will enable him to get a good deal of knee bending. It is called a High flexion knee replacement. Asians, Middle east citizens need a more naturally functioning knee and this prosthesis helps them carry on their accustomed activities.

Minimally invasive Knee replacement

Less invasive surgery has become a hot and controversial topic over the last two years. Standard incisions can be reduced to one half by this technique. Improved instrumentation, surgical approaches, and computer assisted navigation improve the efficiency and reproducibility of the operation. The benefits to the patient are less blood loss, pain, minimum requirement of pain killers, shorter hospital stay, lesser rehabilitation and less expenditure.

Patients of all age groups can put an end to their Knee joint woes now and should not wait till the disease has stiffened joints; made muscles weak and caused bone loss. Procrastination will delay recovery and lessen the benefits that various surgical procedures have to offer.