Knee Arthritis- Myths, Reality And Management
Knee osteoarthritis is one of the commonest problems faced by everyone. It is common because it is nothing else but age related ?wear and tear? of the joint. There is however a strong genetic involvement, too, and hence patients from the same age group may have a varying degree of arthritis.
The figure below shows the anatomy of the normal knee joint. The blue lining at end of the bones is known as the cartilage. In real life the cartilage looks like the inner side of a tender coconut i.e.; white, smooth and soft. The two ?C? shaped blue structures are the menisci which act like shock absorbers. During the aging process the menisci wear out and slowly the cartilage shows tiny cracks and finally the whole cartilage wears off. Finally one gets deformities like ?bow legs? where bones start rubbing against each other.
Osteoarthritis is a slow process and takes ages to develop. A mild pain on the inner side of the joint which is typically noted while getting up from a squatting position or while climbing stairs are the first signs of developing arthritis. Many of us experience this at around 40-45 years of life and most of us ignore it!
We all age but the degree of arthritis varies from patient to patient in the same age group. Apart from genetics there are many other factors which speed up the process of degeneration. We all know that we can not change our genes but we can alter certain other factors. Load is one of the important factors and our weight is borne by our knees! Therefore keeping one?s weight under check obviously helps. Another important point to note that the load borne by the knees while working against the gravity is six times the body weight. We orthopedic surgeons hence advise all patients with advanced arthritis to avoid climbing too many stairs and to avoid sitting on the floor because this involves 6 times extra load! This also means that if you are 10 kilos overweight then the knees carry 60 kg extra load while you climb stairs!
Many patients are told by their wise relatives to ignore this advice stating ?you will forget to sit down forever? or ?your body habits will change forever?. Please understand the scientific reason behind this advice. Similarly we advise elderly arthritic patients to use a walking stick. Use of a walking stick reduces the load on the knee by 50%! In reality my patients refuse to use a stick since they feel ashamed to use one!
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There is another myth that diet has a role to play in preventing arthritis. It is wise to remember that no diet will stop ageing! There are however few important points to remember though. A diet which can make you put on weight is obviously to be avoided. Anti oxidants are useful in our diet to prevent the damage caused by free radicals. Tea, carrots etc. which we regularly eat are good source of antioxidants and there is no need to consume expensive tablets!
Regular exercises are also very important to keep our muscles stronger. Stronger muscles support and load the knee better and prevent injuries.
In a nutshell I can say that following points are important in delaying the onset of the arthritis
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Regular Exercise
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Maintaining weight at the ideal level
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Once symptoms are noted avoid excessive loading viz. stairs and sitting on the floor.
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Always have a balanced diet
Let?s now turn to the remedies and the myths which surround these treatment options one by one.
Medicines
I see patients popping pills on their own and nobody thinks twice before popping a ?combiflam?! I must warn everyone here that all these drugs which are grouped under a common heading ? Non-steroidal anti-inflammatory ?drugs can damage our kidneys permanently. Please be careful and do not take drugs on your own. The safest bet is to take plain paracetamol for pain relief (Crocin or Metacin). Some patients feel that allopathic drugs are dangerous and take fast relief powders dispensed by quacks. I have got these powders routinely analyzed and they all have steroids in them! A popular ?vaidya baba? in south Bombay sells ?Sandhivat? tablets and there is a queue of 200 patients daily! On laboratory analysis they had pure steroids as the one and only ingredient!
Dietary Supplements
Glucosamine and Chondroitin sulphate are one of the most popular supplements used and prescribed. They are sold over the counter in the American supermarkets and loving sons and daughters send huge bottles of these ?wonder drugs?. Boswella is another popular drug sold by chains like Amway. Esterified fish oils have now joined this group.
These drugs fortunately do not have any side effects; however they may or may not act in the way it is advertised. They do not have any role at all in patients with advanced arthritis or in those whom we have already suggested a knee replacement. I have always noted that these drugs are sold primarily to patients who actually need a replacement of their knee! All patients dutifully take these drugs in the hope that a surgery will be avoided.
Knee Caps
Almost every single elderly person owns one of these popular caps. A support to an inflamed knee obviously helps BUT a long term use actually is detrimental to the knee. A long term use of any brace causes the knee muscle to loose their strength. A brace has to worn under supervision of a qualified orthopedic surgeon. I also see lot of patients buying expensive (3000 Rs) braces in a camp arranged by quacks. 400 to 500 patients are supplied with these braces which are again purchased in the hope that they will avoid a surgery. These quacks (none of them are even qualified orthotists) make these braces so rigid that the knee damage is accelerated! Then there are magnetic and other special belts, but remember that nothing can stop aging and all these are useless.
Injections
Orthopedic surgeons occasionally inject steroids and sometimes special injections like Hyluronic acid. Under no circumstances a joint should be injected by anyone else than a qualified orthopedic surgeon. I have recently done an arthroscopy in a patient who received an injection from her rheumatologist. The injection was given right inside the cartilage which got destroyed and this lady had a huge defect in the cartilage. Hyluronic acid injections are much safer and but expensive. Hyluronic acid injections are effective only if used in well selected cases. Once again it is important to realize that these injections are not alternatives to surgery.
Physiotherapy
Physiotherapy to many patient means exercises and to some it means yoga! Physiotherapy consists of two important parts. One part does involve exercises, which are tailored according to a patient?s need. Normally exercises are prescribed by the treating orthopedic surgeon and taught or supervised by the physiotherapist. In conditions like osteoarthritis of the knee these exercises are to be done life long. Many patients do it for 10 to 15 days and forget about them! Exercises are given to increase or build up the strength of the thigh (quadriceps) muscle and one needs a minimum 6 weeks to build up the required muscle mass. A good muscle control loads the joint well and helps to reduce the pain in arthritic joints. It is also important to do these exercises on a routine basis even if there is no pain. The most important point to remember is that exercises have no side effects like drugs and they do not cost anything!
The second part of the physiotherapy is also known as ?modalities? or to the common man as ?lights?. Physiotherapists use various machines which give out rays of different wavelengths e.g. short wave diathermy and these help to reduce pain. These modalities again are without any serious side effects. I have seen patients going directly to the physiotherapists and ?asking? for physiotherapy! Please remember that the physiotherapy routine works best in the recovery stage when pain is under control. It is mandatory that an orthopedic surgeon has scrutinized the knee carefully.
Since there are no side effects involved the physiotherapy routine can be repeated any time.
Surgery
A surgery is generally advised as the last resort and there are many different surgeries performed according to the stage in which the patient presents. A totally worn out knee will eventually need to be replaced i.e. a total knee joint replacement. The word total has a particular meaning here i.e. both the compartments between the thigh and the leg bone as well as the knee cap are replaced. This is important because we now have a facility to replace only the worn out compartment viz. unicompartmental knee replacement. We can as a rule of thumb say that all other surgeries apart from total knee replacement surgery are basically surgeries to delay the total knee replacement. A replaced joint also eventually wears out in about 15 to 20 years and hence it is important to perform the total knee replacement as late as possible. This calculation is important because the patient then undergoes only one surgery in his life time. If a replaced joint wears out it too can be replaced but it is always better to have one surgery rather than two!
Bow leg deformity in an 87 year old lady
87 year old lady after surgery . Note the correction
In a young arthritic patient we can perform an Osteotomy to realign the bowed or bent knee. Osteotomy means cutting the bone to realign it. In an old medically unfit patient who can not undergo a knee replacement we do an arthroscopic washout (inserting a telescope and washing the knee joint). We can also replace only ?half? or the ?involved? knee which is popularly known as ?uni-compartmental? knee replacement. A uni compartmental knee finally gets converted to a total knee replacement and similarly an Osteotomy just delays the inevitable knee replacement.
Myths about the joint replacement surgery
Scientific data and our clinical experience have now proved beyond doubt that the operation of total knee replacement is one of the most successful operations performed across all specialties. A simple cataract operation or an operation for hernia has a bigger complication rate than this surgery. The failure rate of a replacement surgery is as low as 2%.
Let us look at the common misconceptions surrounding this very successful surgery. A large number of patients are worried about there age vis-a vis a successful surgery. I have to remind you all that arthritis is a disease of the aging population and the average age of patients undergoing a knee replacement is 65 years. Anesthesia techniques have developed so much that there is hardly any risk involved in the surgery. Apart from the risk the advances in the anesthesia techniques have made this surgery virtually painless. Almost all surgeries are done under what is known as ?combined spinal-epidural? anesthesia. Patients are therefore awake during the entire operation. The epidural analgesia is continued for 3 days after the surgery to make sure that there is no pain.
The second most important myth is that it takes 3 months to recover from the surgery! The reality is that patients get discharged on the 7th day after the surgery and go home not only walking but climbing the stairs! There is no physiotherapy required at home and most of our patients walk unaided within a month.
It is worth mentioning that patients who need replacement for both the knees can be operated for both the knees at the same sitting. This ?one stage? surgery has many benefits. The most important benefit is that the patient undergoes only one anesthesia. The total stay in the hospital is halved and this culminates into a massive saving on the hospital bill as well.
I actually recommend all my prospective patients to talk to patients who have undergone replacement surgeries in the past. This simple exercise most of the times reduces anxiety and clears all doubts.
Conclusion
Knee arthritis is unavoidable since it is related to aging.
Though the wear and tear can not be prevented it can definitely be slowed down.
Genetics plays an important part in knee arthritis.
Regular exercises with good balanced diet and good lifestyle can delay the onset of this condition.
Recent advances in surgical techniques, anesthesia and engineering have converted the surgery of joint replacement to a safe, painless and long lasting solution to this painful and debilitating condition.
