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SUNDAY JANUARY 25, 2015

Treatment of knee osteoarthritis:

optimising your surgical option

(Part 1)

BY DR. LEE WOO GUAN

(Consultant Adult Reconstructive Orthopedic and Sport Surgeon)

LD may mean gold, but not necessarily for your knees.

The painful feeling as they age might be due to osteoarthritis, the most common form of arthritis. This develops
when the natural cushions between the joints, known as
cartilage, wears away. Once it is gone, there is constant
friction between the exposed surfaces the bones, which inflames them,
causing pain, stiffness and even outgrowths. Without the shock-absorbing properties of cartilage, the joint is also more likely to sustain trauma
from physical blows and excessively strenuous activities. Left untreated,
osteoarthritis may result in bone damage, deformity and even disability.

Fig 1: This wear-and-tear condition is not exclusive to geriatrics.

Young and middle-aged people can experience the human bodys
fragility too. Those who engage in sport activities for prolonged periods are especially susceptible to it.
Q: What causes OA of the knee?
A: Although the root cause of OA is unknown, the risk of developing
symptomatic OA is influenced by multiple factors such as age, gender and inherited traits that can affect the shape and stability of your
joints. Other factors can include:
A previous knee injury
Repetitive strain on the knee
Improper joint alignment
Being overweight
Exercise or sports-generated stress placed on the knee joints
Q: What are the symptoms of OA of the knee?
A: Symptoms of OA of the knee include:
Pain while standing or walking short distances, climbing up or
down stairs or getting in and out of chairs
Knee pain with activity
Start up pain or stiffness when activities are initiated from a sitting position
Stiffness in your knee joint after getting out of bed
Swelling in one or more areas of the knee
A grating sensation or crunching feeling when you use your knee
I will explain about the latest understanding on the special anatomy
of the knee and its function.

Anatomy of knee

Articulating surface

Fig 2: Front and side views of knee joint

The knee joint is the largest synovial joint in the body. It consists of
Articulation between the femur and tibia, which is weight bearing
Articulation between the patella and the femur, which allows
the pull of the quadriceps femoris muscle to be directed anteriorly over the knee to the tibia without tendon wear
Knee thus possesses features characteristic of both a ginglymus
(hinge joint) and a trochoid (pivot joint) articulation. The complex
flexion-extension motion is a combination of rocking and gliding.
The rocking motion in the first 20 degrees of flexion better meets
the requirements for stability of the knee in the relatively extended
position, whereas the gliding motion as the joint unwinds permits
more freedom for rotation.
The femoral condyles are two rounded prominences that are
eccentrically curved.

Arthroscopic Surgery
Fig 4: Dr. Lee performing knee arthroscopic surgery
In this type of surgery, the surgeon inserts a thin tube with a tiny
camera on the end through a small opening in your skin to view the
inside of your knee. The surgeon can then remove damaged cartilage - the smooth covering that protects the bones in the joint. The
knee can be cleaned or flushed to remove loose bone or cartilage
pieces that may be causing pain.Most people can get back to their
usual activities a few days later. The recovery usually isnt painful.
Arthroscopic surgery may provide short-term relief from pain. It
can also delay the need for more complex surgery.

Fig 3. Articulating
surface of the knee
joint
The surfaces of
the femoral condyles that articulate with the tibia
in flexion of the
knee are curved or
round. Whereas
the surfaces that
articulate in full
extension are flat.
Two fibrocartilaginous menisci, one on each side, between the
femoral condyles and tibia accommodate changes in the shape of
the articular surfaces during joint movements. weight is transmitted
directly on the medial side as Medial meniscus shares 50% of the load
transmitted through medial condyle while lateral meniscus shares
70-80% of it. So the damage to medial meniscus raises the stress by
100% while damage to lateral meniscus raises the stress by 200-300%
and accelerates the degeneration. The articular surfaces of the knee
are not congruent. On the medial side, the femur meets the tibia like a
wheel on a flat surface. On the lateral side, it is like a wheel on a dome.
Only the ligaments acting in concert with the other soft-tissue structures provide the knee with the necessary stability.
Q: How is OA treated?
A: Whether your OA is mild or severe, your doctor will most likely recommend certain lifestyle changes to reduce stress on your knee joints.
Additional disease and pain management strategies may include:
physical therapy, viscosupplement injections, over-the-counter pain
medications, nonsteroidal anti-inflammatory drugs (NSAIDs) or topical pain relieving creams.
Please speak with your doctor if your symptoms arent responding
to non-surgical solutions, or your pain can no longer be controlled by
medication. You could be a candidate for surgery.
Screening and early treatment are essential. Detecting the signs
osteoarthritis and addressing it early can reduce the need for major
surgery afterwards, and thus enable the patient to enjoy a fuller range
motion than can be achieved if treatment is delayed.
Such signals from the body consist of pain and stiffness when performing tasks like squatting, kneeling and climbing stairs, as well as
swollen joints, a grating sensation or sounds when the affected joints
move, loss of flexibility, and joints that look larger than usual.
Women should particularly take note of these signs, as they are
more likely to suffer from this degenerative condition than men.
Genetic factors and hormones also put women at a disadvantage
where joint health is concerned. Osteoarthritis seems to run in families, and there appears to be a particular genetic link among women.
Women whose mothers had osteoarthritis will probably find they
develop it in the same joints and at around the same age. In addition, oestrogen protects cartilage from inflammation. The oestrogen
levels in women decrease after menopause, and they may have a
higher risk of developing osteoarthritis after they lose that protection.
Unfortunately, many women have a fourth risk factor obesity.
The most common surgical knee intervention performed for OA
is a total knee replacement. During this procedure, the natural joint
is removed and replaced with an artificial implant. This treatment
option is usually offered to patients with advanced osteoarthritis of the
knee.
Total knee replacement is not always optimal for patients with
early to mid-stage osteoarthritis in just one or two compartments
of the knee. For patients with partial OA of the knee, Partial Knee
Resurfacing may be the more appropriate solution.
You may only require an arthroscopic surgery, you may need an
partial knee replacement, or you may need a total replacement. Most
substantial knee pain problems can be helped or cured by modern
orthopedic surgery.
Part 2 will be continued next Sunday.

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