Arthritis of the Knee
Arthritis, which actually means joint inflammation, is a disease that indiscriminately affects nearly one in seven people in the
United States. Arthritis represents more than 100 different diseases. It most often affects areas around the joints where bones meet -
such as in the knee. The ends of the bones are protected by cartilage, which acts as a shock absorber and prevents bones from rubbing
together. Enclosed in a capsule called the synovium, the joint moves smoothly and without friction. Muscles and tendons also play a
role in this fluid movement. When an injury or condition causes damage to the articular cartilage - further aggravated by unconditioned
muscles and secondary deformities, arthritis is the inevitable outcome. The once fluid movement of the affected joint is replaced with friction.
It is a condition diagnosed in young and old, active and inactive - sometimes resultant from natural degeneration or in a young patient because
of injury. The major problem is loss of the articular cartilage and the occurrence of secondary deformities caused by wearing down of the bones.
In today's society, the prevalence of obesity has made it an epidemic.
Despite the many ways in which a patient can develop arthritis, it is simply the overriding condition once it develops - the cumulative
result of earlier problems or lifetime of normal to excessive wear. By the time patients with earlier knee problems become elderly, there is only
one common knee problem - arthritis.
Generally, arthritis of the knee affects either the lateral compartment (outside), medial compartment (inside), or the patellofemoral compartment.
Occasionally a patient is affected in two or all three compartments.
Symptoms
When a patient has arthritis of the knee, it is apparent. The knee hurts when walking and may even ache at night
preventing sleep. Popping and grinding may accompany it. In cases that are more serious, patients may develop a
deformity - a knee that does not fully straighten, or a limb that becomes over time either at the knee, bow-legged
(Varus)
or knock-kneed (Valgus).
These are the principal deformities that people face in serious arthritic cases.
An inspection of the knee will demonstrate that the leg does not fully straighten out, is bow-legged, or knock-kneed. The knee is swollen.
There will be tenderness when the joint lines are palpated. An X-ray taken with the patient standing will reveal that the joint space
is narrowing. Rather than the normal four millimeters of joint space, it shows significantly less. And in severe cases, it may show an
absence of joint space resulting in "bone on bone."
Treatment
While the articular surface changes of arthritis are not reversible, there are a number of things patients can do to improve joint
function and reduce pain. It is always preferable to approach a condition non-surgically, by utilizing a specific nutrition and exercise program.
Non-Surgical Treatments
Most arthritic conditions do not require surgery. Moreover, the first forms of treatment for arthritis of the knee most patients should
consider are non-invasive conservative treatments, which prove highly effective for most patients. Dr. Sanders underscores the importance
of weight loss, and exercise. These plans are among the most successful conservative treatments at the SandersClinic. Often times weight
reduction alone can significantly improve the patient's condition. Dr. Sanders may also prescribe anti-inflammatory medication and nutritional
supplements, rich in Glycosaminoglycans and Chondroitin Sulphate. This combined with an individualized program of stretching exercises to
improve flexion and especially extension of the knee, as well as strengthening exercises to build quadriceps muscles, yields tremendous results.
Patients hoping to avoid more invasive surgery may begin this reconditioning program that also incorporates, as necessary, a Step Box
for performance of closed chain quadriceps exercises, and Elite Seat, to assist patients in reaching physiologic hyperextension,
equal to the normal leg. The cold compression of a Cryo/Cuff®is provided to reduce swelling and ease pain after the exercise program.
Nutritional supplements, such as Nutriex Sportcombined with mild pain relievers such as Advil or prescription drugs such as
Celebrex also facilitate the reconditioning program, by addressing the challenges the body faces during the strengthening phase.
Occasionally injections are beneficial to arthritis patients, though the results are short-lived and not the preferred treatment. Dr. Sanders may use a
Cortisone injection for an arthritic patient needing to attend a weekend event, though rarely on an on-going basis. And while such injection medications
such as Synvisc helps decrease the friction in the baring surfaces, it is expensive and only marginally more effective than Advil.
These are the principals of conservative treatment. The emphasis is to get down to an optimal body weight, exercise in an age appropriate fashion,
and, most importantly, to get the knee to full symmetrical hyperextension equal to the non-affected knee. Patients with symmetrical hyperextension
rarely need surgery. And the majority of Dr. Sanders' patients see improvement with these methods.
Dr. Sanders does not endorse the use of braces. They are likely to compress the venous system and restrict knee motion. He believes that the best brace
is strong quadriceps. And the use of ace bandages are discouraged, as they are not found to be helpful and place the patient at risk of blood clots by
restricting blood flow.
Conservative Surgery
Though the conservative, non-surgical reconditioning treatment is effective for the majority of patients, some may require additional treatment. In these
cases, there are several conservative surgeries available.
A Tibial Osteotomy
is performed on those patients medially affected by Arthritis and suffering from an excessively bow-legged (varus) limb. This procedure entails cutting the tibia, or
leg bone, and inserting a bone graft in order to shift the stress from the arthritis-affected medial compartment onto the stronger lateral compartment. The result is a more
knock-knee (valgus) stance, as pressure is relieved from the medial compartment to the normal lateral compartment. The immediate postoperative treatment after a tibial osteotomy
is similar to that of a total knee replacement, but patients must stay on crutches until the bone graft incorporates, generally six weeks.
Less frequently, a Femoral Osteotomy
is performed on those patients laterally affected by Arthritis and suffering from excessive knock-knee (valgus). This procedure entails cutting the femur bone and inserting a bone
graft in order to shift the stress onto another compartment. The result is a more bow-legged (varus) stance as pressure is relieved from the lateral, arthritis-affected area to the
stronger, normal medial compartment. The immediate postoperative treatment after a femoral osteotomy is similar to that of a total knee replacement, but patients must stay on crutches
until the bone graft incorporates, generally six weeks.
For arthritis of the patellofemoral joint not responsive to conservative measures, a Maquet Osteotomy is performed. In this procedure, the tibial tubercle (knob of the knee)
is sectioned and moved anteriorly. It is then secured with one or two screws. This procedure does not require a bone graft. It helps relieve pressure between the kneecap and the
thighbone and corrects the poor alignment of the kneecap on the femur. More details about this procedure are present in Patellofemoral Disorders.
Arthroscopic surgery for debridement of the arthritic knee has proven to provide minimal benefit, while subjecting patients to all the risks of surgery, and is not used by Dr. Sanders.
In the future, there will be another conservative surgery available for these types of patients. This will involve the implantation of lab-cultivated articular cartilage.
Currently this option is in the experimental stages and not yet available for general use.
When a patient suffers from severe arthritis in more than one compartment of the knee, a Total Knee Replacement is performed.
