The knee is created by the femur, the tibia and patella. The end surfaces of these bones are covered by articular cartilage that can move one bone relative to another, minimizing friction.
The patella is a bone that is moving in the anterior knee, and over it passes the tendon of the quadriceps muscle and the combination of the patella tendon and creates extensive mechanism of the joint.
The knee is divided on the lateral, the medial and anterior compartment. The lateral compartment consists of the lateral femoral condyle and lateral tibial plateau , the medial compartment of the medial femoral condyle and tibial plateau in through the front end and consists of the patella and femoral trochlea.
Severe knee osteoartrhitis The osteoarthritic knee
Final stage knee osteoarthritis. The articular cartilage has been completely destroyed
1. Osteoarthritis. is the most common type of arthritis in the knee and is a slow, progressive degenerative <br />
disease in which articular cartilage shows a gradual decay. It starts usually after middle age ends <br />
especially in old age.
2. Rheumatoid arthritis. An inflammatory type of arthritis which destroys the articular cartilage and may occur at any age.
3. Traumatic arthritis. usually occurs after injury to the joint. This type of arthritis is like osteoarthritis and may develop after long periods of a fracture, damage link or tear of the meniscus that was not treated promptly.
SYMPTOMS
The pain due to arthritis has been a gradual evolution but the sudden emergence of severe pain may also occur. Usually the symptoms begin with pain after fatigue as the disease progresses and appears calm. The night pain usually means end stage osteoarthritis and surgery is now the only solution.
The affected joint may develop edema (swelling), become stiff, difficult to display in normal flow and range of motion (loss of the last degrees of flexion or extension).
The pain may be the reason why the patient feels weakness in the leg in the early stages. During disease progression by reducing the individual function of the affected joints leads inevitably to the development of muscle atrophy of quadriceps and hamstring muscles having longer objective the reduction of muscle force and occurrence of weakness of the leg.
VISIT TO ORTHOPAEDIC SURGEON
The Orthopaedics Surgeon specialist will examine the knee to determine whether it shows signs of inflammation such as severe edema (swelling), redness and increased local temperature.
Then we will carefully evaluate the scope and quality of motion of joints, it now points to palpation sensitivity occurs if there is fluid in it, we noticed any distortion, the way the patient walks though shows some form of lameness or inability to perform motions.
EXAMINATIONS
X-RAY
X-ray: normal knee
X-ray: knee osteoarthritis (red circle)
The simple X-ray control shows mainly the reduction of joint space, signifying the loss of articular cartilage and generated spurs. It can also be evaluated and the disturbance of the mechanical axis of the leg.
X-Ray: knee joint with severe degenerative osteoarthritis. There is no cartilage among the bones due to degeneration and this condition produce severe pain.
ULTRASOUND
Ultrasound reveals the knee osteophytes in medial compartment of the knee, suggesting advanced arthritis of the joint
CT- SCANOGRAM
The CT scanogram is the ideal tool for evaluation of anatomical and mechanical axes of the lower extremities, ie the evaluation of the percentage of the derogation and the deformation of the joint than normal.
CT scanogram. Normal mechanical axis of the lower limb
Knee osteoarthritis varus knee, the mechanical axis of the lower limb is not normal CT scanogram: evaluation of mechanical and anatomical axes of the legs to precisely determine the deformation thereof.
MRI
Magnetic resonance imaging helps the physician to a more detailed assessment of the problem by checking the status of articular cartilage, meniscus and ligaments, which will determine the topography of arthritis and the type of treatment to be followed.
MRI Knee joint. Severe degenerative osteoarthritis.
Patellofemoral impingment syndrome. The main patients symptom is anterior knee pain
BLOOD TEST
Specific blood tests will help in the diagnostic process of reasoning of arthritis (rheumatoid arthritis, gout, etc).
The conservative treatment includes a wide range of therapeutic agents that their effectiveness varies from person to person. The choice of an appropriate regimen should be tailored individually for each patient depending on the nature and severity of his problem.
The goal of treatment is to reduce pain, increase of joint function and the possible slowing the progression of wear.
In the early stages of disease treatment include:
• weight loss (if necessary)
• physiotherapy
• special splints
• walking aids (stick)
• Medication
• changes in the activities of individual
LIFESTYLE CHANGES
These lifestyle changes include the patient’s body weight loss, cessation of aggravating activities like running and start swimming and cycling and generally avoiding activities that demonstrably affect the condition of joints. Many patients with osteoarthritis have more pounds which certainly exacerbate the symptoms and disease progression. The loss would provide relief by upgrading the quality of life and prolonging the viability of the joints unencumbered.
PHYSICAL THERAPY AND EXERCISES
The exercises and physiotherapy improve range of motion and flexibility of joints affected, and strengthen the muscles of the legs. The program of physiotherapy should be created in collaboration with the Orthopaedic Physiotherapist and adapted to the needs of each individual patient.
WALKING ASSISTIVE DEVICES
The use of supporting instruments such as walking stick or crutches vent joints affected over a specified period to remedy the acute phase of disease with pronounced symptoms.
The special walking test (electronically), and manufacture of special cleats, personalized for each patient, often offer a palliative solution to the patient’s symptoms after balancing the loads exerted on the knee. Generated in this way even distribution of forces due to the correction of mechanical axis of the joint.
The process of feet test is simple, painless and performed in a specialized clinic. The special soles that will be constructed from the data review, we will adjust the patient in his shoes easily.
BRACES
The special knee braces are divided into two types
• splints discharge
• splints support
These splints prevent discharge of joint load on the overburdened point of articulation (eg arthritis medial compartment), while the splint support support across the joint by improving the stability and functionality of this. The suitability of the prosthesis for each patient will be judged by the treating Orthopaedic.
Functional braces for protection and relief of symptoms of the affected knee.
In recent years the emergence of glucosamine sulfate, chondroitin and Hyaluronic acid, was the new treatment of osteoarthritis and can relieve the symptoms such as pain, stiffness without the side effects of anti-inflammatory drugs. Are two large molecules normally present in articular cartilage and are essentially food supplements, not drugs.
To achieve the utility of treatment should be taking them every day for long periods if they do not appear natural effects such as nausea, vomiting, allergic skin rash etc. Today is the drug of choice in many countries worldwide.
CORTICOSTEROIDS
The corticosteroids are a powerful anti-inflammatory agent and can be infused into the inflamed joint. Benefit is usually in the acute phase of disease in patients with moderate to severe pain, but his offer in advanced stages of disease is minimal. The duration of action of the drug varies depending on the makeup of the organism and stage of disease. Three injections per year are the maximum annual dose of the drug.
INTRARTICULAR HYALURONIC ACID INJECTION
The intrarticular injections of hyaluronic acid bring relief of symptoms of arthritis in a large percentage of patients who do not belong in the category of anti-inflammatory drugs or corticosteroids. The drug is a natural derivative of articulation and has strong lubricating properties that help improve mobility of the patient. Injections are made once a week for five weeks, twice a year. It is considered that assist in increasing production of hyaluronic acid from the same joint. The therapeutic effect of intrarticular injections can last for many months.
PRP (AUTOLOGOUS PLATELET RICH PLASMA)
The modern method today is the Autologous Conditioned Plasma.
Autologous blood products have created a growing interest for use in a number of orthopaedic therapies. The healing effects of plasma are supported by growth factors released by platelets which have anti-inflammatory action on the joint as well as the synovial membrane so thea the patient can relieve the symptoms of pain and stiffness. These growth factors may induce the healing response. The clinical results are very good and promising.
AUTOLOGOUS PROTEIN SOLUTION INTRARTICULAR INJECTION
Once osteoarthitis pain start it is hard to stop. The new autologous protein solution intrarticular injection is designed to produce a groundbreaking autologous therapy to treat pain and slow the progression of cartilage degradation and destruction in the knee. The N-STRIDE system is a cell concentration system designed to concetrate anti-inflammatory cytokines and anabolic growth factors to significantly decrease pain and promote cartilage health. The treatment does not require admission to the clinic and the procedure does not exceed one hour. Worldwide clinical trials report excellent results, with the method being increasingly applied to specialist centers – a 70% improvement in pain for two years after a dose of autologous protein solution.
OPERATIVE TREATMENT
Therapy
REHABILITATION
81-year-old woman before and after the personalized PSI right knee arthroplasty
Surgical treatment comes to provide a solution in cases where conservative treatment did not yield the expected results.
There are many treatment options today, which are:
• Knee arthroscopy
• osteotomy to correct the axis of the leg
• unicompartmental knee arthroplasty
• total knee arthroplasty
• in special cases chondrocyte transplantation (limited indications in osteoarthritis)
Severe osteoarthritis of both knees in a 70-year-old patient.
CT scanogram: Disturbance of the mechanical axis of the lower extremities
Heavy osteoarthritis of both knees, Deformity in valgus.
Radiological examination of the person himself, 72-year-old man.
Total right knee arthroplasty.
Two months after the right knee arthroplasty. The mechanical axis of the right lower limb has been completely corrected. Comparison with the left lower limb
Two months after the right knee arthroplasty.
Arthroplasty of both knees in the same patient. The valgus deformity has been completely corrected. The photo was taken 6 months after the second surgery (left knee)
X-ray of the knees after the two joint replacement surgeries
1. KNEE ARTHROSCOPY
Arthroscopy is the most modern orthopedic surgical method in the world, which allows the specialized Orthopedic surgeon to diagnose and intervene therapeutically using surgical instruments the size of a pencil which are inserted into the joint through two holes in the anterior-lateral surface of the knee.
The arthroscope contains optical fibers that transmit the image they receive from the inside of the knee and with an external processor they project it onto a monitor (television).
From the image projected on the monitor, the Orthopedic Surgeon carefully examines the inside of the knee in great detail and decides on the nature of the problem as well as its treatment.
During arthroscopy, the doctor can insert special surgical instruments through the second hole, thus acting diagnostically and therapeutically. With the tools normalize the worn articular cartilage removes the free particles (parts of cartilage or meniscus), ‘washing’ the joint by removing the molecules that cause inflammation.
If a rupture of the meniscus or ligament is detected, their repair is performed simultaneously.
Early knee arthroscopy can delay the progression of osteoarthritis, and therefore the need for more serious surgical procedures such as arthroplasty.
Many times osteoarthritis occurs in only one compartment of the joint, the medial, lateral or anterior, without serious changes in the other two compartments. Osteotomy is one of the solutions to address this problem.
The disruption of the mechanical axis of the lower limb (knee valgus or valgus-crooked feet), that is, the loss of its correct alignment, which may be due either to the particular construction of the lower limbs of the individual or to other reasons, is the main cause of uneven wear of the joint.
Valgus deformity in the knees. Disturbance of the mechanical axis of the lower limbs. Extensive burden on the outer compartment of the joint
A 30-year-old woman with a neurological problem and valgus in the left knee, which causes recurrent patellar dislocation
Disorder of the mechanical axis of the woman. The patella is in a subluxated position (not in its normal position) – black circle
Osteotomy of the femur for the correction of valgus knee with a special plate (ARTHREX PUDU PLATE)
Knee deformity. Disturbance of the mechanical axis of the lower extremities. Extensive loading of the medial compartment of the joint
Osteotomy is suitable for people under 60 years of age and for active individuals.
The orthopedist will assess the distribution of loads in the joint and will surgically create a new order within it, essentially unloading the area with the greatest wear and shifting forces to healthier areas of the knee.
There are two types of osteotomy:
1. valgus osteotomy of the proximal part of the tibia and
2. radiculopathy osteotomy of the distal part of the femur.
Osteotomy relieves pain and delays the progression of osteoarthritis.
X-ray images during surgery. Valgus osteotomy of the tibia, placement of a special titanium plate.
Radiological images of knee valgus osteotomy with plate placement.
Surgical image. The osteotomy plate has been placed.
Postoperative result, complete correction of the mechanical axis of the lower limb. The distribution of loads on the joint is balanced.
The patient is admitted to the clinic on the day of surgery without having eaten or drunk anything. The duration of the operation is approximately one hour and is performed under general or spinal anesthesia.
Postoperatively, a special splint is worn on the lower extremity and walking is done with the help of crutches for 6 – 8 weeks.
The patient remains in the clinic for two days to receive full nursing and medical care. Return to activities takes approximately 3 – 4 months.
A 42-year-old man with medial compartment arthritis in both knees (especially the right one). It was decided to perform an open-angle valgus osteotomy.
The mechanical axis, especially of the right lower limb, has been completely disrupted
Preoperative radiography that highlights the disruption of the mechanical axis as well as arthritis in the medial compartment of the knees (especially the right – arrow)
Three months after surgery on the right knee with osteotomy of the tibia. The mechanical axis has been fully restored while the intense and persistent pain that the patient felt in the knee has completely disappeared
3. UNICONDYLAR KNEE REPLACEMENT
Many times osteoarthritis occurs in only one compartment of the joint, on the medial, lateral or anterior side, without serious changes in the other two compartments.
Until recently, in these cases, the entire joint and both condyles were replaced, i.e. the so-called total knee arthroplasty, thus sacrificing the healthy femoral condyle, the menisci and the anterior cruciate ligament.
Unicompartmental arthroplasty concerns the medial or lateral compartment and is based on the replacement of only one condyle and the corresponding surface of the tibia affected by osteoarthritis.
The main reason for replacing a part of the joint that is affected is to stop the friction between bones that are no longer covered by cartilage due to its wear and tear and cause intense pain.
Schematic illustration of the appearance of osteoarthritis in only one compartment of the knee.
The implants applied to the affected area provide smooth surfaces that move comfortably without causing pain, and thus the person undertakes activities that he or she may have abandoned due to severe symptoms.
This is a significant advantage for younger patients who may need a second surgery in the future when the first one shows a significant degree of wear.
By removing less bone during the first operation, it makes it easier to perform revision using total knee arthroplasty at a later time if necessary.
In summary, unicompartmental arthroplasty has significant advantages over total knee arthroplasty, which are:
• It is a safe surgical procedure with minimal
surgical wound
• no blood transfusion required
• reduced risk of infection
• reduced risk of thromboembolic events because intramedullary guides are not used
• shorter hospital stay
• lower rate of postoperative pain
The conditions for the application of the method are considered to be:
• ability to bend the knee at least 90º
• knee extension deficit less than 10º
• non-inflammatory arthritis autoimmune disease (rheumatoid or psoriatic arthritis)
The duration of the surgical procedure usually does not exceed 90 minutes. The stay in the clinic is 2-3 days for the patient to receive the necessary medical and nursing care.
A few hours after surgery, the patient steps on the operated lower limb with the assistance of a trapezius crutch (walking), and begins a physical therapy program that will continue at home for a few days.
Unicompartmental arthroplasty is a modern minimally invasive surgical method that allows the patient to delay total joint replacement for many years.
The surgical procedure for applying the unicompartmental arthroplasty is over. Final image.
Schematic illustration before and after the surgery of the unicompartmental knee arthroplasty.
Direct comparison of unicompartmental knee arthroplasty (left image), with total knee arthroplasty (left image).
In unicompartmental arthroplasty, 2/3 of the joint is preserved, while in classic total arthroplasty, the entire joint is replaced
Article in the British magazine 50 plus (Greek edition) – 2016
4. TOTAL KNEE ARTHROPLASTY
Advanced arthritis of the knee. The articular cartilage has completely disappeared, especially in the medial compartment (right of the image)
Knee arthroplasty
One of the most important developments in the history of orthopedics is the total replacement of the knee joint with special materials. The first operation was performed in 1968 and to this day, the improvement of surgical techniques and materials constantly upgrades its effectiveness.
Patients who are candidates for surgery:
• Severe pain in the joint that limits daily activities such as walking, climbing stairs, etc.
• Moderate or severe pain during rest during the day and at night.
• Chronic inflammation of the knee accompanied by edema (swelling) that does not improve significantly with medication and rest
• Deformity of the knee axis inward or outward.
• Knee stiffness: inability to fully flex and fully extend the joint
• Failure of anti-inflammatory drugs to treat the pain.
• Inability to control the side effects of these medications
• Inability to improve symptoms with other therapeutic methods such as intra-articular cortisone or hyaluronic acid injections, physical therapy or other minor surgical procedures (arthroscopy).
The age of most patients undergoing total joint replacement is from 60 to 85 years, but the Ortho
HOME REHABILITATION
Instructions for your surgical wound
• Keep the incision area clean and dry. Changing bandages placed on the day of your departure from the hospital must comply with the instructions of the attending orthopedic surgeon.
• Do not soak in the operated knee until you remove the stitches. These are usually removed 12-15 days after the day of surgery.
• Tell your doctor if the wound begin to pull fluids.
• Measure the temperature of your body twice a day and tell your doctor if it exceeds the 38 º C.
• Edema (swelling) in the operated limb is normal for first 3-6 months.
medication
Take the medication as determined by your orthopedic surgeon. For about a month after the surgery should take a daily injection in your abdomen, around the navel, for the prevention of venous thromboembolism.
The antibiotics will continue for only a few days after your discharge (pills by mouth). Each time you visit the dentist will highlight that you have total knee arthroplasty for you cover everything with antibiotic treatment.
nutrition
On discharge from the hospital will already eat normally as you eat before surgery. The orthopaedist may recommend you taking iron supplements and vitamin C to help in quicker recovery of your powers and better wound healing.
Narrow as possible to take coffee and avoid alcohol completely. It is very important not to gain weight. The emphasis will entrust the resected joint and not only this.
Summary of physiological activities
On your return home you should stay active. But beware, do not overdo it. As time passes you would find out as to improve the ability to move and increase muscle strength and your endurance.
Physiotherapy
Continue the exercise program for two months after surgery. The stationary bike helps to increase muscle strength and maintain flexibility in the muscles surrounding the knee.
Driving
If he has replaced his left knee and have a car with automatic transmission can start driving one month after surgery. If the surgery was to avoid right knee to lead the first 3 months.
Sleep
You can sleep safely as you wish, tummy, back or side.
Back to work
Depends on the kind of work practice. It usually takes 3 months to return to work.
Other activities
You can walk as you want to remember, however, that walking is not a substitute for the exercises that your doctor tells you. Swimming is good exercise tool and can be started 6-8 weeks from the day of surgery. Avoid exercises that strain is generally much the resected joint, such as lifting heavier than 15 pounds.
