Alternative surgery for knee pain
Dr. A.K. Venkatachalam
Osteoarthritis, the commonest form of arthritis affects the knee joint most often in the Indian population unlike the west where OA of the hip is also prevalent.
The elderly no doubt are more severely affected and need joint replacements as a permanent solution to improve their quality of life and put an end to disabling pain. However, it is increasingly common to see many young people also suffer from the earlier manifestations of this disease. It is in this group of people that solutions have to be given diligently, considering the young age, increased demands of the knee, participation or involvement in sports and work. Joint replacements cannot obviously be a solution to these young men and women.
The articular cartilage, a smooth, elastic, shining tissue that covers the end of the long bones forming a joint, is responsible for lubrication, shock absorption, and pain-free movement. Unlike other tissues of the body, it has limited capability of regeneration and repair as it has no blood supply and nerve supply. This limited repair capacity decreases with aging and leads to depletion in the arthritis knee. Pain and stiffness ensue, necessitating in medication or surgery.
Osteoarthritis does not involve the whole of the joint to begin with. A localized area of cartilage damage called a lesion is the precursor and harbinger of the disease. If left untreated, lesions greater than 1.5 cm will lead to arthritis after 15 years.
Some generalized and local conditions predispose early cartilage damage. These are of a mechanical, chemical, or genetic nature and cause increased stress on the joints. People involved in sports and two-wheeler accidents, obese individuals, and those with mal-aligned knees can develop cartilage damage.
In the knee joint there are two important ligaments and a pair of ‘C’ shaped cartilage discs called menisci. These menisci serve to dissipate stress in the joints. They also help in lubrication, increase joint conformity and confer additional stability. The ligaments inside the joint are called the cruciate ligaments. These are torn during many sports, or two-wheeler accidents.
An ACL injury is the most common ligament injury. Un-repaired ACL’s lead to further tearing of the menisci and both in association can lead to osteoarthritis. Meniscal tears can occur in isolation in sports or domestic accidents.
After the importance of the menisci was realised and arthroscopic surgery came into vogue, attempts have been made to resect and remove only the damaged portion of the menisci and preserve the rest. However, it is not always possible to do so, especially if the damage is beyond repair and a total or subtotal menisectomy is necessary.
Some people have deformities around the knee. These may be situated in the thigh bone or leg bone. Normally, in the standing position, there should be no gap between the inner side of the knee and ankle joint. If a gap exists between the knees, then the person has bow legs (Genu varum) and if a gap exists between the ankles, then the legs diverge at the ankle, causing knock knees (Genu valgum).
Both these deformities can lead to one-sided wear of the knee joint and arthritis in one half of the knee. Surgical solutions are now available with well trained knee surgeons to prevent and treat early arthritis. These constitute the alternatives for knee pain in the young.
These reconstructive procedures attempt to restore the anatomy of the joints and are mainly of a biological nature. They do not involve joint replacement. Examples are as follows: * Knee ligament reconstruction - ACL reconstruction is possible through tiny key-hole incisions (arthroscopic surgery). Graft is taken from the patient’s own body (autograft) or from a brain dead person (allograft). This tendon graft is threaded through bony tunnels in the leg and thigh bones and is fixed with screws, buttons or other devices.
Meniscal suture - This is a procedure in which attempt is made to suture a torn meniscus if situated in a suitable position. Concomitant ACL reconstruction is required if there is an injury to this ligament also.
Meniscal transplant - This procedure is to be introduced shortly. In this, menisci are harvested from the knee joints of brain dead living donors or non-heart-beating donors. These are preserved and then grafted into the damaged knee.
Autologous cartilage implantation - Cartilage plugs are harvested from non-weight bearing portion of the knee and re-implanted into the lesions on weight bearing areas.
Corrective osteotomy - Malaligned joints can be corrected by an osteotomy in either the thigh bone or leg bone. After this surgery, stress across a joint is distributed more evenly and excess wear and tear from one half of the joint is avoided. Thus total arthritis is delayed.
These surgical alternatives are available to treat painful knees in young people. By availing these, one can continue with nature’s gift and postpone a joint replacement by a decade or more.
The author is a consultant orthopaedic surgeon at Knee & Shoulder Clinic, Chennai, Tel: 9282165002
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Advances in total knee replacement
Dr A K Venkatachalam
Osteoarthritis of knees affects predominantly the senior citizens’ age group. Increasingly large number of these people in our towns and cities are electing to have a total knee replacement to end their agony and lead a better quality of life.
They survey the market and hope to get the best deals in terms of functional outcome, surgical and post surgical care and costs. Many a time they are dissuaded by skeptical relatives or friends to have the surgery. Since cultural, social and religious requirements of Indians are different from the West, the operation has to be tailored to the specific needs of our countrymen.
In this article I shall discuss some recent advances and the implications of these on the outcome of the surgery. The main factors that deter people from having any major operation for a non-life threatening condition are fear and perceived high cost. Fear may stem from the thought of postoperative pain the risks of anesthesia, surgery itself.
Ideally a major replacement should be done by well trained and qualified surgeons. Experience of joint replacement is gained by overseas or Indian fellowship training. Infrastructure of the hospital is vitally important. The operating theatres should provide ‘‘ultra clean air’’ with ideal parameters.
Exponential Laminar airflow is ideal where air is changed 25 times per hour. The delivered air is treated by special HEPA (high efficiency particulate air filters) with 99.99 percent efficiency so that the chance of infection is reduced to the level of %. No colony forming units of bacteria should be present. It would be correct to say that facilities are limited for these standards. Costs are not exorbitant when compared to the west and only amount to one tenth of the cost in the West. A price range of Rs 1.75 lakh to Rs 2.5 lakh is quoted by surgeons and hospitals for standard prosthesis designed and manufactured in the West.† Increasingly large number of UK and USA citizens are being lured to undergo this surgery because of these low costs. The quality of care in selected hospitals matches that in the West.
Let us look at some of the recent advances in a total knee replacement 1) Minimally invasive surgery: If you ask your friend who has undergone a knee replacement, about the worst thing about the surgery, he or she is likely to blame the amount of post operative pain. Some amount of post-op pain is inevitable from any operation. The amount of tissue dissection in normal knee replacements causes iatrogenic damage to the lining of the joint and results in pain postoperatively. A minimally invasive knee replacement is carried out through a smaller incision and produces less amount of pain. In this procedure the same prosthesis is implanted using smaller incisions and specially designed instrumentation. Duration of hospitalisation will be lesser, there is no need of transfusions, pain is lesser and the cosmetic effect is better. Rehabilitation will also occur faster, a return to normal activity may be possible in 6 weeks.
2) Alternative modes of anesthesia: Many anesthetists and surgeons prefer regional and local modes of abolishing operative pain. Spinal, Epidural and local nerve blocks may be administered by skilled anesthetists. The benefits are increased safety as there is less stress upon the body. Diabetics, hypertensives, and people with ischemic heart disease can undergo safe surgery. As the patient is not unconscious and is only sedated, he is unlikely to feel postoperative nausea and vomiting. A drink or light meal can be given soon after surgery as tolerated and this comes as a big boon to many elderly who are unable to tolerate overnight starvation and thirst.
3) Multi-modal pain relief: Instead of relying on opioids, multimodal analgesia employs a battery of pain relief methods and drugs. Pain relief is near total and the patient will not regret that he experience at all. Ic packs, oral drugs, pain pumps, epidural anesthesia are all used to make your experience as pleasant as possible.
4) High flexion knee prosthesis: Special knee implants are available which provide more flexion or bending at the knee to suit Indian, and South Asian habits of kneeling for prayer, or sitting cross legged on the ground for meals or social purposes. Muslims in particular need this to offer prayers. Even westerners have begun to appreciate the benefits of high flexion knee prosthesis as they can pursue hobbies like gardening and are also gratified for the ability to do recreational acts. The design features of such knees incorporate cut outs at the front, rotating platform or mobile bearings, increased bony resection at the back amongst others.
5)Navigational surgery: In this age of computers, navigational surgery has some benefits to offer. Not only can the trained surgeon perform the operation through smaller incisions, the seating of the implants could be more accurate. Perfectly positioned implants are less likely to loosen over time. Only selected prosthesis and not all types of knee prosthesis can be implanted through less sophisticated systems and this could be a disadvantage. Costs could be slightly higher in such centres. A knee replacement offers permanent pain relief from osteoarthritis and could be made more attractive by doctors who have embraced the latest techniques and advances.
(The author is a knee specialist in Chennai and can be contacted at akvenkat@gmail.com or mobile 9282165002)
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