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.
Arthritis, also referred to as osteoarthritis, 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.
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 over time either develops a bow-legged (Varus) or knock-kneed (Valgus) deformity. 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, is bow-legged, or knock-kneed. Additionally, 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” wear.
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.
Most arthritic conditions do not require surgery. Moreover, the first forms of treatment for arthritis of the knee which most patients should consider are non-invasive conservative treatments. These prove highly effective for most patients and include 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, as well as Vitamin D. This combined with an individualized program of stretching exercises (to improve flexion and especially extension of the knee) and strengthening exercises (to build quadriceps muscles) can yield satisfactory results.
Patients hoping to avoid 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.
The nutritional supplements combined with mild pain relievers such as Advil or prescription drugs such as Celebrex also facilitate the reconditioning program – 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 ongoing basis. 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. Stem cells, platelet rich plasma (PRP), and other advanced biological treatments, despite the internet hype, are extremely expensive and have not yet been shown in clinical trials to be beneficial in humans.
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.
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. It is ideal for active patients with a physiological age of 60 or younger. This procedure entails cutting the tibia, or leg bone, 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. This procedure is accomplished via minimally traumatic outpatient surgery. Immediate postoperative treatment allows immediate motion of the knee and weight bearing to tolerance. Bone graft has only proven necessary in those patients who are diabetic, tobacco abusers, or have other diseases likely to slow healing.
A Femoral Osteotomy is performed on those patients laterally affected by Arthritis and suffering from excessive knock-knee (valgus). It is ideal for active patients with a physiological age of 60 or younger. This procedure entails cutting the femur bone 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. This procedure is accomplished via minimally traumatic surgery on the outpatient basis, and immediate postoperative treatment allows immediate motion of the knee and weight bearing to tolerance. As there is complete bone to bone contact in this osteotomy, bone graft is unnecessary even for diabetics and smokers.
For arthritis of the patellofemoral joint not responsive to conservative measures, an Osteotomy of the Tibial Tubercle is performed. In this procedure, the tibial tubercle (knob of the knee) is sectioned and moved in the anterior and medial direction. It is then secured with screws. This procedure is accomplished via minimally traumatic surgery on the outpatient basis, followed by postoperative treatment allowing immediate motion of the knee and weight bearing to tolerance. As there is complete bone to bone contact in this osteotomy, bone graft is unnecessary. 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, and removal of the degenerative meniscus has proven to provide minimal to no benefit, while subjecting patients to all the risks of surgery, and is not used by Dr. Sanders.
When a patient suffers from severe arthritis in more than one compartment of the knee, a Total Knee Replacement is performed. This procedure is highly successful, and is appropriate in older people and occasionally in younger people when no better alternatives are available.