Knee Arthritis and Joint Replacement

by Steve A. Mora MD


Introduction

A painful knee can severely affect your ability to lead a full active life. Over the last twenty five years, major advancements in artificial knee replacement have improved the outcome of the surgery greatly. Artificial knee replacement surgery is becoming more and more common as the population of the world begins to age.  This article touches on Knee Arthritis and Joint Replacement issues.

Causes

There are many conditions that can result in degeneration of the knee joint. Osteoarthritis is the most common cause that patients need to undergo knee replacement surgery. This condition is commonly referred to as “wear and tear arthritis”. Osteoarthritis can occur with no previous history of injury to the knee joint – the knee simply “wears out”. There may be a genetic tendency in some people that increases their chances of developing osteoarthritis.

The major problem in osteoarthritis is that the cartilage (the articular cartilage) on the surface of the bone inside the joint wears away. This results in bone rubbing against bone, the slick protective surface of the articular cartilage is absent. This causes pain.

Abnormalities of knee joint function resulting from fractures of the knee, torn cartilages and torn ligaments can lead to degeneration many years after the injury. The mechanical abnormality leads to excessive wear and tear – just like the out of balance tire that wears out too soon on your car. For more information of these injuries, see meniscus and cartilage injuries

Symptoms

The symptoms of a degenerative knee joint usually begin as pain while bearing weight on the affected knee. You may limp and the knee may become swollen with fluid. The degeneration can lead to a reduction in the range of motion of the affected knee – the knee bends less than normal and may lose the ability to completely straighten out. Bone spurs will usually develop and can be seen on x-ray. Finally, as the condition becomes worse, the pain may be present all the time and may even keep you awake at night.

Diagnosis

The diagnosis of a degenerative knee starts with a complete history and physical examination by your doctor. X-rays will be required to determine the extent of the degenerative process and may suggest a cause for the degeneration. Other tests may be required if there is reason to believe that other conditions are contributing to the degenerative process. Blood tests may be required to rule out systemic arthritis (such as Rheumatoid Arthritis) or infection in the knee.

Medical Treatment

Not all degenerative knee conditions require a knee replacement as the initial treatment. Your doctor may suggest several alternative treatments to put off the decision for replacing the knee as long as possible. Using a cane may help alleviate some of your pain and allow you to walk more comfortably. Anti-inflammatory medications may reduce the inflammation from the arthritis and reduce your pain.

Conservative treatments are non-surgical techniques that may prevent or delay the need for future surgical treatment. They should be considered the first line of defense against osteoarthritis of the knee:Diet modification can be used to help an individual lose weight. This reduces the wear and tear put on all joints of the body and can slow down or eliminate the deterioration process of the cartilage. Additionally, dietary supplements can be incorporated that are thought to help preserve healthy cartilage and bone.

Physical therapy can also help address the osteoarthritic condition. Exercise leads to stronger muscles and better flexibility, which creates more durable joints. Continued physical activity is a key to preserving joints, muscle and bone.

Medical treatment through medications can help an individual manage the onset of osteoarthritis. Over-the-counter Non-Steroidal Anti-inflammatory Medications (NSAIDs) such as Aleve® Motrin® and Tylenol® may be prescribed by your orthopaedic specialist to reduce swelling and pain. In some cases prescription medication, such as Voltaren or Naprosyn may be administered to address more severe cases. Newer NSAIDs such as Vioxx®, Celebrex® and Bextra® work very well and have been designed specifically for the treatment of arthritic joints. These newer prescription NSAIDs have few side-effects, especially stomach irritation (gastritis) or ulcer formation. Unfortunately, health insurance companies, especially HMOs, prefer not to spend the extra money and therefore do not approve these safer medications most of the time. Quite often, medical treatment can be used in combination with other conservative treatment methods. When taking NSAIDs for long term, the risk of suffering a stomach ulcer or bleed increases.

Injection treatments are sometimes incorporated into a treatment regimen to reduce the symptoms of osteoarthritis of the knee and are often successful in relieving pain and delaying the need for surgical intervention. Injectable medications include both traditional steroids which are injected by your doctor and newer viscous substances (viscosupplementations). Both are equally efficacious.

Oral Joint supplements, Chondroiting and Glucosamine Sulfate are available over the counter and provide a modest amount of pain relief in some, but not all patients, and only after taking them for more than 3 months. Both substances should be taken together. The brand name CosamineDS is the most popular brand but many others are probably as effective.

Surgery

Most degenerative problems will finally require replacement of the painful knee with an artificial knee replacement. The decision to proceed with surgery should be made jointly by you and your doctor only after you feel that you understand as much about the procedure as possible.

Once the decision to proceed with surgery is made, there are several things that may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after the surgery. The therapist will be able to begin the teaching process before the surgery to ensure that you are ready for the rehabilitation afterwards.

One purpose of the preoperative visit is to record a baseline of information. This includes your measurements of your current pain levels, functional abilities, the presence of swelling, and the available movement and strength of each knee.

A second purpose of the preoperative visit is to prepare you for your upcoming surgery. You’ll begin to practice some of the exercises you’ll use just after surgery. You’ll also be trained in the use of either a walker or crutches. Whether the surgeon used a cemented or noncemented approach will determine how much weight you’ll be able to apply through your foot while walking Finally, an assessment will be made of any needs you’ll have at home once you’re released from the hospital.

Finally, you may be asked to donate some of your own blood before the operation. This blood can be donated 3-5 weeks before the operation and your body will make new blood cells to replace the loss. At the time of the operation, you will receive your own blood back from the blood bank in case you need to have a blood transfusion.

The Artificial Knee

There are two major types of artificial knee replacements:

  • Cemented Prosthesis
  • Uncemented Prosthesis

Both are still widely used. In many cases a combination of the two types are used. The patellar (knee cap) portion of the prosthesis is commonly cemented into place. The choice to use a cemented or uncemented artificial knee is usually made by the surgeon based on your age, your lifestyle, and the surgeons experience.

Each prosthesis is made up of four parts:

  • The tibial component (bottom portion) replaces the top of the lower bone, the tibia.
  • The femoral component (top portion) replaces the two femoral condyles and the groove where the patella runs.
  • The patellar component (kneecap portion) replaces the joint surface on the bottom of the patella that rubs against the femur in the femoral groove.

The femoral component is made of metal. The tibial component is usually made up of two parts – a metal tray that is attached directly to the bone and a plastic spacer that provides the bearing surface. The plastic used is very tough and very slick – (so slick and tough that you can ice skate on a sheet of the plastic with out much damage to the material).

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

Rehabilitation

While you are in the hospital:

  • Range of Motion (ROM)
  • Ambulation (walking)
  • Exercises

The physical therapist will schedule your first inpatient visit shortly after surgery. Treatment will address the range of motion in the knee. Gentle movement will be used to begin to help you regain both the bending and straightening of the knee. If you are using a CPM (continuous passive motion) device, it will be checked for alignment and settings. Next, you’ll go over your exercise regimen. When you are stabilized, your therapist will assist you up for a short outing using your crutches or your walker. Treatment will proceed on a one to two time per day basis. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, get up and down flight of stairs and access the bathroom. It is also important that you regain a good muscle contraction of the upper thigh muscle (quadriceps) and that you gain improved knee range of motion.

After you leave the hospital:

  • Home health needs

Once discharged from the hospital, your therapist will likely see you for in home treatment. This is to ensure you are safe in and about the home. You should be seen for at least one visit for the safety check and to review your exercise program. In some cases you may require up to three visits at home before beginning outpatient physical therapy.

As you progress:

  • Outpatient progression

Welcome to outpatient physical therapy. Several key areas will be addressed. Your therapist may choose one or more modalities such as heat, ice, or electrical stimulation to help reduce persistent swelling or pain. Continue to use your walker or crutches. If you had a cemented procedure, you’ll advance the weight you place through your sore leg as much as you feel comfortable. If yours was a noncemented procedure, place only the toes down until you’ve had a follow-up x-ray and your doctor or therapist directs you to advance the amount of weight through your leg (usually by the 5th or 6th week postoperatively). Range of motion exercises and techniques will be used to help you regain full bending and straightening of the knee. An exercise program will be developed including strengthening, balance, and endurance, and functional activities. Your strengthening program will address key muscle groups including the buttock and hips, thigh, and calf muscles. When you are safe in putting full weight through the leg, several balance exercises can be chosen to further stabilize and control the knee. Endurance can be achieved through stationary biking, lap swimming, and using and upper body ergometer (upper cycle). Finally, a select group of exercises can be used to simulate day-to-day activities, like going up and down steps, squatting, raising up on your toes, and bending down. Specific exercises may then be chosen to simulate work or hobby demands.

Complications

As with all major surgical procedures, complications can occur. Some of the most common complications following knee replacement are:

  • Thrombophlebitis
  • Infection
  • Stiffness
  • Loosening

This is not intended to be a complete list of the possible complications, but are the most common.

Thrombophlebitis

Thrombophlebitis, sometimes called Deep Venous Thrombosis(DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots within the veins. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary = lung, embolism = fragment of something traveling through the vascular system). Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible!

Some of the commonly used preventative measures include:

  • Pressure stockings to keep the blood in the legs moving
  • Medications that thin the blood and prevent blood clots from forming.

Infection

Infection can be a very serious complication following an artificial joint. The chance of getting an infection following artificial knee replacement is probably somewhere around 1%. Some infections may show up very early – before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work, or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

Stiffness

In some cases, the ability to bend the knee does not return to normal after an artificial knee replacement. Many orthopedic surgeons are now using a machine known as a CPM machine (Constant Passive Motion) immediately after surgery to try and increase the range of motion following artificial knee replacement. Other orthopedic surgeons rely on physical therapy beginning immediately after the surgery to regain the motion. It is not clear which is the best approach. Both approaches have benefits and risks, and the choice is usually made by the surgeon based on his experience and preferences.

To be able to use the leg effectively to rise from a chair, the knee must bend at least to 90 degrees. A desirable range of motion should be greater than 110 degrees. Balancing of the ligaments and soft tissues (during surgery) is the most important determining factor in regaining an adequate range of motion following knee replacement, but sometimes increasing scarring after surgery can lead to an increasingly stiff knee. If this occurs, your surgeon may recommend taking you back to the operating room, placing you under anesthesia once again, and forcefully manipulating the knee to regain motion. Basically, this allows the surgeon to breakup and stretch the scar tissue without you feeling it. The goal is to increase the motion in the knee without injuring the joint.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. There have been great advances in extending how long an artificial joint will last, but most will eventually loosen and require a revision. Hopefully, you can expect 10-15 years of service from an artificial knee, but in some cases the knee will loosen earlier than that. A loose prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the knee.

 

You can read about alternatives to joint replacement on my blog article.  Thank you.

 

 

About Steve A. Mora MD:

Steve Mora MD Small

Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he earned top of his class honors with his induction into the Alpha Omega Alapha Medical Society honors. He completed his Orthopedic Surgery training USC. He then completed a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County.  Dr. Mora’s practice focus on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement and ACL reconsctruction. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Some of the procedures he performs include Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, knee ligament reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.

 

Steve A. Mora MD, Orange County ACL Surgeon.  You can request an appointment with me by calling 714 639-3750 or going to my web page www.MyOrthoDoc.com

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