Patients with knee pain now comprise of at least 30 percent of Orthopaedic practice in urban population. The clinical presentation varies from subtle knee pain arising after activity to severe incapacitating pain which limits the activity of an individual to household.
Osteoarthritis Knee usually affects men and women in their fifties or sixties. It has a genetic predisposition, but more important factors are excessive weight, lack of exercise, sedentary lifestyle, previous trauma. The importance of weight reduction and regular activity can not be over-emphasized. Most patients offer pain as the limiting factor in their willingness to comply with the physiotherapy and exercise regimen.
Osteoarthritis develops due to progressive loss in the cartilage layer of the articular surface, mediated by chemical markers like Interleukins; and by lack of glycoproteins in the synovial fluid. Gradually, the two articular surfaces come in contact with each other, and the pathology migrates from a chemical to purely mechanical one.
Radiographs serve an important role in diagnosis. Loss of joint space and formation of osteophytes makes for an easy diagnosis.
The treatments offered for Osteoarthritis knee vary from- Physiotherapy/ Analgesics/ Bracing - to Arthroscopy- to Knee Replacement.
Early Osteoarthritis knee wherein the joint space is still preserved, and there is minimal osteophyte formation; can be successfully managed with painkillers and Supplementation of Inflammtory marker inhibitors. The role of Glycosaminoglycans is debatable.
In patients who present with moderate to severe pain, there is limited role of Arthroscopic joint lavage; wherein the joint is entered via two small 1 cm incisions, and the interior is visualized with a camera. this offers a short term relief, but provides a good alternative for patients who are medically unfit to undergo major operations.
Patients with severe arthritis, are usually offered Joint Replacement as a definitive solution. The most important factor in the success of a knee replacement is good patient selection. A patient with good compliance for physiotherapy and having a knee pain which is substantially limiting his quality of life is a good candidate for surgery.
The availability of technology has made knee replacement one of the commonly performed surgeries in Orthopaedic practice. The options include a Unicondylar knee Replacement or a Total Knee Replacement. The former is advocated for patients with a single compartment involvement, and those with mild deformities. Total knee Replacement is offered for a bi- or tri- compartmental arthritis.
The technical options among the various types of Knee replacement implants include- (a) Cruciate Substituting, (b) Cruciate retaining. The former involve resection of the Anterior Cruciate ligament and substitution by an inbuilt mechanism in the implant design. The latter involves retention of the Anterior Cruciate ligament. Rotating platform designs are also popular these days.
The important judgment regarding the various types depends on the status of knee deformity, and the functional status of ligaments.
Total Knee replacement is one of the commonly performed surgeries today. The note of caution need to be exercised both on the part of the patient and the treating surgeon to restrain the influence of market forces in making the correct judgment. Total knee replacement offers significant improvement in the patient's status, provided the selection criteria are strictly adhered to. A few complications that need special mention include- Deep vein thrombosis, Pulmonary Embolism, Infection, Implant Loosening.
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