Arthritis can affect any joint in body, but knee arthritis is particularly very common. Arthritis is inflammation of the joint and is associated with pain, swelling and limitation of motion. Arthritis is the most common cause of chronic knee pain.
KNEE JOINT ANATOMY
The knee joint is formed by the femur (thigh bone), tibia (shin bone) and patella (knee cap). Articular cartilage (soft and smooth tissue) is present at the ends of these bones and helps in movement of joint. There are two menisci present between the tibia (shin bone) and femur (thigh bone). They act like a shock absorber and cushion the knee. The joint is lubricated by the fluid formed by the covering of the joint called synovium. (Fig 1)
TYPES AND CAUSES
There are various types of arthritis. The most common are: osteoarthritis, rheumatoid arthritis and post-traumatic arthritis
It is the most common type of arthritis. It is an age-related wear and tear type of arthritis. In this type of arthritis, the cartilage wears away and bone rubs on bone causing pain and limitation of motion. Painful bone spurs are formed in this type of arthritis. (Fig 2)
Rheumatoid arthritis is an inflammatory type of arthritis. It is an autoimmune condition in which body’s immune system attacks own tissue (joint, cartilage and ligament). It affects multiple joints and other organs in the body. In the joint, synovium (lining of knee joint) gets inflamed and swollen, causing pain, swelling and limitation of the joint and ultimately leads to destruction of the joint.
This is the type of arthritis which develops after a fracture involving the joint or after meniscal injuries or ligament injuries. Arthritis might take years to develop after an injury.
Common symptoms are pain, swelling, limitation of motion and stiffness. Morning stiffness is common in the rheumatoid type of arthritis. Clicking and grinding sensations are common. Loose fragments of cartilage in the joint can cause locking of knee.
Your doctor will perform a detailed physical exam and check joints other than knee. He will check for swelling, tenderness, crepitus and range of motion of the joint/joints. He will order X-rays to evaluate the bone and joint, as well as an MRI or other tests to evaluate muscle and soft tissue if needed. (Fig 3 and 4 showing normal and arthritic knee X-rays).
Your doctor might order a blood test in case he thinks you have rheumatoid arthritis.
Treatment options include non-operative and operative options. It depends on multiple factors, including age and severity of arthritis. In early stages of arthritis, the non-operative option can give some temporary relief. However, arthritis might keep progressing and ultimately lead to bone and bone arthritis which will need knee replacement surgery.
- Activity modification: Avoiding impact activities, weight reduction
- NSAIDS (like ibuprofen or naproxane): Carries gastric side effects
- Celecoxib (Celebrex): Fewer gastric side effects, carries risk of heart problems
- Physical therapy: Can help to strengthen the muscle and get more mobility.
- Brace: Unloader brace or supportive brace can help
- Cane: In opposite hand to reduce the load on arthritic knee
- Cortisone injection (intraarticular in the knee): Reduces the inflammation and pain. Effects are unpredictable and differ from patient to patient. Sometimes the relief can last for months and in some it can’t even last for days. The doctor will discuss the risk and benefits associated with it. If needed it can be repeated after 3 or 4 months.
- Viscosupplementation or called as lubrication injection (hyaluronic) in the knee: These are either a series of 3 injections or one combo injection. The results again vary from patient to patient and it may take weeks before you notice a difference. The period that this type of injection gives relief varies. If it has reduced symptoms, then it can be repeated at 6 months.
- Glucosamine and chondroitin sulfate: These are dietary supplements for the joint. There is not enough scientific evidence to prove they help, but some people get good relief of symptoms when they keep taking them regularly.
SURGICAL TREATMENT OPTIONS
Once the nonsurgical treatment doesn’t relieve symptoms and arthritis is severe and disabling, the surgical option might be beneficial for you. As any operation carries risk, your doctor will discuss the risks and complications associated with the operation in detail.
- Arthroscopy: It is used to treat associated meniscal tear if arthritis is very mild. It is not the option to treat arthritis.
- Osteotomy: In this, either the tibia (shin bone) or femur (thigh bone) is cut and realigned to relieve the pressure on one of the affected compartments of knee. It is indicated in early stages of arthritis involving only one compartment of the knee and in younger people.
- Partial knee replacement (Robotic): Robot-assisted partial knee replacement is a new technology to treat knee arthritis involving only one or two compartments of knee. The robot offers better precision in putting the components in correct alignment, and offers a positive clinical outcome in addition to improving the long-term survival of prosthesis. The knee has three compartments, including the inner (medial), outer (lateral) and patellofemoral (behind the knee cap) (fig 1). If only one or two of these compartments are involved, then you can replace only those leaving ligaments and other compartments intact. Partial knee replacement has record of faster recovery then total knee replacement. (fig 5)
- Total knee replacement: When all the three compartments are involved, total knee replacement is the best option. The damaged cartilage is removed from lower end of the femur (thighbone), upper end of tibia (shinbone), and patella (kneecap), and replaced with an artificial joint made of metal titanium alloys, medical grade plastics and polymers. (fig 6)
Physical therapy is the mainstay of treatment after the operation. It starts the next day after your knee operation is completed and while you’re still in the hospital, then continues after discharge from the hospital with at-home visits from a physical therapist.
After couple of weeks, you can start going to outpatient therapy until functional range of motion and the strength of your knee are restored, which is usually 3 to 6 months after the operation. For pain control after your operation, a special technique known as a ‘multimodal pain control model’ is used. It’s very important to control the pain while rehabilitating the knee so knee functions are restored as fully as possible.
After knee surgery, pain medications will be prescribed along with blood thinners to prevent blood clots. Based on scientific data, more than 90% of patients feel dramatic pain reduction and great improvement in performing daily activities after total knee replacement. These types of surgeries often improve the quality of life for patients who decide to undergo knee replacement surgery, particularly when they feel their quality of life is compromised because of knee pain and dysfunction.
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