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M.S. ORTH (Pune),M.Sc., ORTH. (London) Dipl. LAMP (CARDIFF)
Consultant Joint Replacement Surgeon
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When it comes to knees, there are generally two kinds of problems:
  • Mechanical knee problems
  • Inflammatory knee problems
  Some knee problems result from injury, such as a direct blow or sudden movements that strain the knee beyond its normal range of movement. Osteoarthritis in the knee, results from wear and tear on its parts. However, inflammation that occurs in some rheumatic diseases, such as rheumatoid arthritis, can also damage the knee.  
  Arthritis in the knee most often refers to osteoarthritis. In this disease, the cartilage in the joint gradually wears away. In rheumatoid arthritis, which can also affect the knees, the joint becomes inflamed and cartilage may be destroyed. Arthritis not only affects joints, it can also affect supporting structures such as muscles, tendons and ligaments.  
  Rheumatoid arthritis or osteoarthritis: which is it?  
  Osteoarthritis may be caused by excess stress on the joint from deformity, repeated injury, or excess weight. It most often affects middle-aged and older people. A young person who develops osteoarthritis may have an inherited form of the disease or may have experienced continuous irritation from an unrepaired torn meniscus or other injury.  
  Rheumatoid arthritis often affects people at an earlier age than osteoarthritis. Another cause of knee arthritis in the young in India is road accidents where there is high-energy trauma which often involves joints. Any fracture that causes joint line incongruity very often leads to secondary arthritis. The American Academy of Orthopaedic Surgeons says only one in four people with knee osteoarthritis need surgery.  
  Non-surgical treatments include losing weight, special exercises, medication and supportive devices like shoe inserts, braces and canes. When surgery is necessary, surgeons may turn to arthroscopic surgery to clean out the knee or repair torn cartilage; osteotomy to cut the shinbone or thighbone to improve the knee joint's alignment; or knee arthroplasty, which involves replacing severely damaged knee joint cartilage with metal and plastic.  
  For some people with limited cartilage loss, cartilage grafting is an option. In cartilage grafting, cartilage is either transplanted from another part of the body into the knee or a sample of knee cartilage is removed and cultured in a lab. This new technique holds a lot of promise for young people with knee cartilage injury.  
  There is also a place for viscosupplementation in certain patients in the early stages of arthritis. In this treatment modality, synovial fluid is replenished thereby increasing the joint lubrication and enhancing the shock absorption capacity. It also has an indirect effect on pain control through as yet unclear mechanisms.  
  Surgical treatments specifically for this younger population are emerging, including partial knee resurfacing. The procedure involves removing only damaged cartilage and minimal bone and implanting a small replacement. Surgeons at the Cleveland Clinic use a system called UniCAP, which treats damaged surfaces on the inside or outside of the knee as well as under the kneecap. This is a knee resurfacing method and is designed for minimally invasive surgery and allows retention of the meniscus and cruciate ligaments. It is not yet available in India.  
  When considering surgery it is important to recognize how difficult – and how personal – this choice is. The final decision will be made based not only on symptoms, physical findings on a surgeon’s exam, and the x-ray pattern of arthritis, but also on the patient’s goals, expectations, job demands, and level of motivation. For those reasons, it is best made in consultation with a specialist in adult reconstructive knee surgery and joint replacement.  
  But by way of summary, it is possible to offer the following observations about each of those procedures:  
  Unicompartment knee replacement:  
  Although these are now often implanted through a less-invasive surgical approach, which can significantly shorten the recovery period, unicompartmental knee replacement (Uni’s) are a type of joint replacement.  
  As such, they really are not meant for people doing impact or twisting sports. Total knee replacements have been studied in patients aged 50 and under and have shown good results in that population, with 85-95% of the implants remaining in service 10 years after surgery. By contrast, we have fairly limited data on Uni patients of that age group. In most reports of older patients, Uni’s have a slightly (but not severely) lower 10-year success rate than total knee replacements.  
  In their favor, Uni’s have a much shorter post-op recovery time, and most patients find Uni’s perform better and feel more normal than traditional total knee replacements. They also are fairly easily converted to total knee replacements if they should fail. There has been a trend towards Uni’s in younger patients, because it is believed that the operation is perceived to be a less-invasive (and more easily revised) approach. But to be honest, we don't know if this is going to be a good thing; Unis are now being put into a population of more active patients than they've been really tested in. Only time will tell.  
  Total Knee Replacement:  
  Long considered the ‘gold standard’ for knee arthritis surgery in older adults (age 60 and over), this operation also is being used more in younger patients in this country. As mentioned, there is reasonable clinical follow-up available on TKA’s in patients aged 50 and younger, showing that about 9 out of 10 implants remain in service at the end of the first decade; in older patients (age 60 and up), the likelihood is about 95%. TKA’s fail at the rate of about 1 or 1.5% per year on average, so it is possible to get at least a ballpark idea of the likelihood of an implant being in service at a particular duration of follow-up.  
  The large majority — well over 90% — of patients in this age group are able to return to non-impact exercise (swimming, biking, or walking) for fitness following this surgery.  
  High Tibail Osteotomy:  
  This operation involves cutting and repositioning one of the bones around the knee joint. This is done to re-orient the loads that occur with normal walking and running so that these loads pass through a non-arthritic portion of the knee.  
  It is very important to select the correct patient for this procedure. This may be the operation of choice for people (with the right pattern of arthritis) who want to return to impact sports. However, it has some disadvantages. In general, pain relief is less dramatic or complete compared to total knee replacement or Uni. Also, the likelihood of making 10 years after the surgery without needing another operation (usually a total knee replacement) is much lower than for either of the other operations we’re discussing: only 60-65% of patients who have an osteotomy have gone 10 years without a reoperation.  
  Some surgeons believe that if the arthritis is already severe (bone-on-bone), osteotomy is not likely to be satisfying. Osteotomy also cannot be done in patients whose arthritis has resulted in significant loss of knee joint motion before surgery.  
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