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Knee replacement in Raipur

Osteoarthritis of the Knee

Osteoarthritis (OA) of the knee is one of the five leading causes of disability

among elderly men and women. It is more common in India than the western

countries. The risk for disability from osteoarthritis of the knee is as great as that

from cardiovascular disease.

Osteoarthritis of the knee usually occurs in knees that have experienced trauma,

infection, or injury. A smooth, slippery, fibrous connective tissue, called articular

cartilage, acts as a protective cushion between bones. Arthritis develops as the

cartilage begins to deteriorate or is lost. As the articular cartilage is lost, the joint

space between the bones narrows. This is an early symptom of osteoarthritis of

the knee and is easily seen on X-rays.

Osteoarthritis is a disease which affects the joints in the body. The

surface of the joint is damaged and the surrounding bone grows

thicker. ‘ Osteo ‘ means bone and ‘arthritis’ means joint damage and

swelling (inflammation). When joints are swollen and damaged they

can be painful. They can also be difficult to move. Some other words

are used to describe osteoarthritis, including ‘osteoarthrosis’,

‘arthrosis’ and ‘degenerative joint disease’.

Osteoarthritis of the knee is a very common form of osteoarthritis.

Other joints which are often affected include joints in the hands, the

spine, the hip joint and the big toe joint.

How does osteoarthritis of the knee develop?

To understand how osteoarthritis develops you need to know how

a normal joint works. A joint is where two bones meet. Most of our

joints are designed to allow the bones to move in certain

directions. The knee is the largest joint in the body, and also one

of the most complicated because it has many important jobs to do.

It must be strong enough to take our weight and must lock into

position so we can stand upright. But it has to act as a hinge, too,

so we can walk. It must also withstand extreme stresses, twists

and turns, such as when we run or play sports.

The knee joint is where the thigh bone (femur) and shin bone

(tibia) meet. The end of each bone is covered with cartilage which

has a very smooth, slippery surface. The cartilage allows the ends of the bones to move against each other almost without friction.

The knee joint has two extra pieces of cartilage (called meniscal

cartilages or menisci) which help to distribute the load evenly

within the knee. A normal knee joint is shown in Figure 1.

The joint is surrounded by a membrane (the synovium) which

produces a small amount of thick fluid (synovial fluid). This fluid

helps to nourish the cartilage and keep it slippery. The synovium

has a tough outer layer called the capsule which helps hold the

joint in place. The knee cap (patella) is another important part of

the knee joint. The underneath of the patella is also covered with

cartilage. The patella is attached to the thigh muscles by a very

large tendon. The patella is fixed to the bone just below the knee

joint at the front of the tibia.

The tendons are strong connecting tissues which attach the

muscles to the bones on either side of the joint. They also help to

keep the joint in place. When a muscle contracts it shortens, and

this pulls on the tendon attached to the bone and makes the joint

move. Figure 2 shows how the muscles are attached to the bones

above and below the joint.

The knee joint is held in place by four large ligaments. These are

thick, strong bands which run within or just outside the joint

capsule. Together with the capsule, the ligaments prevent the

bones moving in the wrong directions or dislocating. The thigh

muscles (quadriceps) also help to hold the knee joint in place.

When a joint develops osteoarthritis, the cartilage gradually

roughens and becomes thin. This happens over the main surface of

the knee joint or at the cartilage underneath the patella. The

surrounding bone reacts by growing thicker. The bone at the edge

of the joint grows outwards (this forms osteophytes or bony spurs)

(see Figure 3). This bone growth can affect both the femur and the

tibia, as well as the patella.

The synovium swells slightly and may produce extra fluid, which

then makes the joint swell. This extra fluid causes what some

people call ‘water on the knee’.The capsule and ligaments slowly thicken and shrink, as if they

were trying to push the joint back into shape. The muscles that

move the joint gradually weaken and become thin or wasted. This

can make the knee joint unstable so that it ‘gives way’ when you

put weight on it.

When we look at an osteoarthritic joint under a microscope, we

see that the joint is trying to repair itself. All the tissues are more

active than usual. New tissues, such as the bony spurs

(osteophytes), are produced to try to repair the damage. In some

types of osteoarthritis, especially in the small finger joints, the

repair is successful. This explains why many people have

osteoarthritis but experience very few problems. Unfortunately, in

osteoarthritis of the knee the repair does not usually work.

Osteoarthritis may then seriously affect the joint, making it painful

and difficult to move.

Osteoarthritis is a slow process that develops over many years. In

most cases there are only small changes which affect only part of

the joint. Sometimes, though, osteoarthritis can be more severe

and extensive.

In severe osteoarthritis the cartilage can become so thin that it no

longer covers the thickened bone ends. The bone ends touch, rub

against each other, and start to wear away. The loss of cartilage,

the wearing of bone, and the bony overgrowth at the edges all

combine to change the shape of the joint. This forces the bones

out of their normal positions and causes deformity.

What causes osteoarthritis of the knee?

Many factors seem to increase the risk of osteoarthritis developing

in the knee joint. The risk does increase as we get older, but

osteoarthritis of the knee joint is not a problem in all elderly

people. It often runs in families. Genetic factors are very

important. Genes may affect collagen, one of the main building

blocks of cartilage, or the way the bone reacts and repairs itself, or

even the inflammatory process.

Osteoarthritis of the knee is twice as common in women as in

men. It mainly occurs in women who are over the age of 50, but there is no strong evidence that it is directly linked to the

menopause. It is often associated with mild arthritis of the joints

at the end of the fingers (causing bony swellings called Heberden’s

nodes).

Osteoarthritis of the knee is also more common in some racial

groups than others. For example, it is more common in Afro

Caribbean people than in white people.

Osteoarthritis of the knee is common in people who are

overweight, especially middle-aged women. Being overweight also

increases the chances of osteoarthritis getting worse once it has

developed.

Normal use does not normally lead to osteoarthritis, and neither

does exercise (including running) unless it is excessive. However,

injuries to the knee joint often lead to osteoarthritis in later life. A

common cause is a tear of the meniscal cartilage or ligaments

after a twisting injury. This is a common injury in footballers, who

can face extra risks. The damaged cartilage can lead to

osteoarthritis in later life, and we now know that the operation to

remove the torn cartilage (meniscectomy) substantially increases

the risk of osteoarthritis developing after a number of years.

Does osteoarthritis of the knee vary for

different people?

Osteoarthritis of the knee affects different people in different ways.

Some people have a problem with only one knee, others with both

knees. Pain is the main problem for some people, while others find

their main problem is difficulty in walking. Some people may notice

little change in their condition over the years, while in other people

the osteoarthritis keeps getting worse. As a result, it is not very

helpful to compare the experience of one person with another, and

we cannot predict the eventual outcome for any one individual

with osteoarthritis.

How can I tell if I have osteoarthritis of the

knee?

People with osteoarthritis of the knee joint usually complain that

the knee is painful or aching. Your knee joint may feel stiff at

certain times, often in the mornings or after rest. Walking for a few minutes usually eases the stiffness. You may have pain all

around the joint or just in one particular place, and the pain may

be worse after a certain activity, such as using stairs. The pain is

usually better when you rest. It is unusual to have pain in the knee

joint which wakes you up at night, except in severe osteoarthritis.

You will probably find that your pain will vary. There may be good

days and bad days, or even good and bad months, for no apparent

reason. Changes in the weather may make a difference in some

people. All joints have nerve endings which are sensitive to

pressure. The nerve endings may respond to the drop in

atmospheric pressure which occurs before it rains.

If you develop more severe osteoarthritis, your movement will be

restricted. Walking any distance or climbing stairs can be a

problem. Sometimes your knee joint may give way because of

weak thigh muscles or damaged ligaments.

How do doctors diagnose osteoarthritis of the

knee?

Your doctor will be looking out for the problems mentioned above.

When your joints are examined, your doctor can feel the bony

swelling and creaking of the joint and see any restricted

movement. Your doctor will also be looking for tenderness over the

joint, and any extra fluid.

The thigh muscles are usually thinner and weaker than normal.

With very severe osteoarthritis in the knee, the knee joint will tend

to give way because of the damaged ligaments.

What tests can show osteoarthritis?

There is currently no routine blood test for osteoarthritis, although

blood tests are sometimes used to rule out other types of arthritis.

The x-ray is the most useful test to confirm osteoarthritis. Often it

will show the space between the bones narrowing as the cartilage

thins, and changes in the bone such as spurs (see Figure 4).

Although the x-ray helps the diagnosis, it cannot predict how much

trouble you will have. An x-ray that looks bad does not necessarily

mean a lot of pain or disability. Rarely, a magnetic resonance

imaging (MRI) scan of the knee can be helpful. This shows the soft

tissues (e.g. cartilage, tendons, muscles) which cannot be seen on an x-ray.

What are the prospects if I have osteoarthritis

of the knee?

Osteoarthritis does not always get worse. Most people with

osteoarthritis carry on a normal life and do not become severely

disabled. For many people, osteoarthritis reaches a peak a few

years after the symptoms start and then either stays the same or

gets a little easier. However, osteoarthritis of the knee can worsen

as the years go by, and it may become painful and disabling.

Sometimes osteoarthritis gets better on its own, but this is

unusual. Doctors cannot predict the outcome for individuals,

although if you are overweight, bow-legged and often have a

swollen knee you will probably do worse. However, there are a

number of treatments that can improve symptoms, and certain

changes in lifestyle can greatly reduce the risks of osteoarthritis

progressing. Regular appropriate exercise, protecting the joints

from further injury, and maintaining an ideal weight through

healthy eating will all help. (See arc booklet ‘Diet and Arthritis’

and leaflet ‘Keep Moving’.)

How can osteoarthritis of the knee be treated?

There are no cures for osteoarthritis. But there are many

treatments. Treatment can help to:

relieve the discomfort and pain

reduce the stiffness

reduce any further damage to the joint.

Can drugs help?

At the moment there are no drugs which are proven to stop

osteoarthritis worsening. But several drugs can help you deal with

the symptoms. Painkillers (such as paracetamol) and anti

inflammatory and paprika (capsaicin) creams to rub into the knee

can help pain and stiffness. Some people find them more helpful

than others. (See arc leaflet ‘Drugs and Arthritis’.)

Anti-inflammatory drugs (NSAIDs) help some people more than

paracetamol but they can cause stomach ulcers. New NSAIDs

called COX-2s are less likely to cause stomach problems but have been linked with increased risks of heart attack and stroke, so they

are not suitable for people who have had either in the past, or for

people who have uncontrolled high blood pressure. All NSAIDs

may cause other side-effects such as rashes, headaches and

wheeziness. (See arc leaflet ‘Non-Steroidal Anti-Inflammatory

Drugs’.)

Sometimes an injection of steroids may help, either into a tender

spot around the knee or even into the joint itself. The effect can

last for several months. Injections of hyaluronan (Synvisc,

Hyalgan, Durolane) may also help by supplementing the joint’s

natural synovial fluid.

Can surgery help?

Most people with osteoarthritis of the knee will never need

surgery. But operations are sometimes used for badly damaged

joints. These include joint replacement. A replacement knee joint

is shown in Figure 5. Doctors will consider this for someone who is

barely able to walk and who is in constant pain.

Sometimes, if your knee locks, ‘keyhole’ surgery techniques are

used to ‘wash out’ loose fragments of bone and other tissue from

the joint. This is called arthroscopic lavage and is sometimes

carried out during the course of a diagnostic arthroscopy. Rarely,

additional procedures may be carried out – such as smoothing the

surfaces of the joint, removing flaps of damaged hard cartilage,

and trimming torn soft cartilage. This is called debridement. These

techniques may offer pain relief in the early stages of

osteoarthritis, but they cannot repair the damage caused by the

osteoarthritis.

What can I do to help myself?

You can make a major difference to your osteoarthritis of the knee

in two ways:

1. Lose weight (if overweight). Many people with osteoarthritis of

the knee are overweight. Studies have shown that people who

lose weight have fewer knee problems in the future than those

who do not. Being overweight is also bad for your general health

and increases the risk of heart disease, strokes and diabetes. So you should eat a balanced, healthy diet and keep your weight as

close as possible to the ideal for your height and age.

2. Quadriceps (thigh muscle) exercises. The quadriceps muscles

at the front of the thigh become weaker in everyone with

osteoarthritis of the knee, because the normal nerve supply to

the muscles is reduced. To overcome this it is essential to

exercise the quadriceps muscles as often as possible (see the

exercises below). It has been proved that strengthening these

muscles not only improves your mobility but also reduces pain.

Studies have shown that patients who can lose weight and do

these exercises can improve their osteoarthritis most.

Can swimming or pool treatment help?

Swimming can be a very good way of exercising and keeping fit as

it causes little pain. Water supports the body’s weight so that little

force goes through the joints as you exercise. Also, warm water

relaxes muscles and joints and is very soothing, allowing joints to

move more freely.

Prescribed exercises in a hydrotherapy pool can help get muscles

and joints working better, without undue pain. Supervised

swimming in natural spa waters is an ancient treatment – it is the

exercise that helps rather than any healing properties of the water

itself! (See arc leaflet ‘Hydrotherapy and Arthritis’.)

How active should I be?

Joints do not wear out with normal use. In general, it is much

better to use them than not to! However, you must strike a

sensible balance between too much activity and too much rest.

Most people with osteoarthritis find that their joints stiffen up if

kept still for too long.Quadriceps (thigh muscle) exercises

The most important thing is to choose exercises which you can do

regularly. The easiest one to do is when sitting down in a chair.

1. Straight-leg raise: sitting Get into the habit of doing this every

time you sit down. Sit well back in the chair with a good posture.

Straighten and raise the leg, hold it for a slow count to 10, then slowly

lower it. Repeat this several

times with each leg – at least 10 times with each. If this can be done

easily, repeat the exercises with a weight on the ankle (buy ankle

weights from a sports shop or improvise, for example with a tin of peas

in a carrier bag wrapped around the ankle).

2. Straight-leg raise: lying Get into the habit of doing straight-leg

exercises in the morning and at night while lying in bed. With one leg

bent at the knee, hold the other leg straight and lift the foot just off the

bed. Hold for a slow count of 5 then lower. Repeat with each leg 5

times every morning and evening.

3. Muscle stretch At least once a day when lying down do the

following exercise. First, place a rolled-up towel under the ankle of the

leg to be exercised. Then bend the other leg at the knee. With the

straight leg, use your leg muscles to push the back of the knee firmly

towards the bed or the floor. Hold for a slow count of 5. Repeat with

each leg 5 times. Not only does this exercise help to strengthen the

quadriceps muscles, but also it prevents the knee from becoming

permanently bent.

4. Clenching exercises During the day, whether standing or sitting,

get into the habit of clenching and releasing the quadriceps muscles. By

constantly stimulating the muscles, they become stronger.

For most people with osteoarthritis the best advice is ‘little and

often’: a little rest, followed by a little exercise. For example, do

the housework or gardening in short spells interrupted by short

rests. Avoid sitting in one place for too long – get up and stretch

the joints from time to time. Break up a long car journey with

frequent stops to walk around.

Activities which cause severe pain afterwards are probably best avoided. If for some special reason you do need to do a lot extra,

it can help to take a painkiller before you start. Even if the activity

does cause extra pain you are unlikely to damage the joint, but

your doctor or therapist will advise you if you are worried about

this. (See arc leaflet ‘Keep Moving’.)

Can heat or other remedies help?

Warmth or other remedies applied to the affected area often

relieve the pain and stiffness of osteoarthritis. Heat lamps are

popular, but you can get a similar effect more cheaply with hot

water bottles (be careful, though – it is easy to burn yourself with

either). There are also many creams, available at the chemist, that

can produce localized heat.

These measures make no long-term difference to the disease, but

they can give you temporary relief. Used carefully, they are safe

and soothing. Some people feel that copper bracelets help,

although there is no evidence that these or other such measures

can affect osteoarthritis.

What else can I do?

There are a number of things you can do:

Make sure that you do not keep your leg bent in the same position

for long periods. For example, do not put pillows under your

knee at night. This may ease your pain for a while, but if you do

it regularly it will affect the muscles and may leave your leg

permanently bent. Even if the pain is severe, always fully

straighten the knee several times a day.

Wear cushioned training shoes as much as possible to act as a shock

absorber for the knee.

Keep using your knee, but rest it when it becomes painful and start

again later.

Use a stick to take the weight off the joint if you need to, but keep

moving!

Use a hand-rail for support when climbing stairs. Go upstairs one at

a time with your good leg first. Come downstairs with your bad

leg first followed by good, always using a rail for support.

Questions and answersDoes the weather really affect osteoarthritis?

As mentioned earlier, painful joints are often sensitive to the

weather. They tend to feel worse when the atmospheric pressure

is falling, such as just before it rains. This helps to explain how

some people with osteoarthritis can predict rain, and why joint

pains seem linked with the damp.

However, there is no evidence that different climates have any

long-term effect on osteoarthritis or its outcome. The weather may

temporarily affect symptoms but not the arthritis itself. There is no

point in moving to a different area in the hope of curing

osteoarthritis. Osteoarthritis occurs all over the world, in all types

of climate.

Who should I listen to?

Many well-meaning people offer advice. Magazines and the media

are full of articles on arthritis and its treatment. Some offer new

hope, others offer a special diet or medicine with miracle

properties. Discuss things with your doctor before spending money

on new unproven ideas.

How important is it to keep my spirits up?

Depression, low morale, and poor sleep can all make pain worse –

they can lower your threshold to pain.

If you become depressed, your pain may feel worse. You might go

to the doctor and be given bigger doses of tablets to relieve the

pain. But sometimes what you really need is help for the

depression and the demoralising effect of arthritis. If the

depression is lifted, the pain becomes less. Some antidepressant

drugs help pain directly.

A positive and hopeful approach is half the battle, though this is

easier said than done. Make every effort to make life fuller and

more interesting than before. Your morale will drop after too much

rest and inactivity, whereas hobbies and interests take your mind

off your problems. Sleep is important. Taking a painkiller last thing

may help if pain disturbs your sleep. If you have enjoyed vigorous

activity and sport, you may have to develop less active pastimes,

but there is no reason to let osteoarthritis get you down or stop

you doing most everyday activities. Cycling and swimming are particularly good for knee problems.

Dr ANKUR GUPTA MS (Ortho)

Sadbhavana Hospital, Raipur