Newer techniques for treatment of knee arthritis in young patients
Knee pain, stiffness and loss of function are extremely common symptoms seen in general population resulting in patients seeking treatment and advice from orthopaedic surgeons. Treatment primarily depends on the cause of pain, severity of symptoms and age of the patient. Arthritis (damage to the joint lining cartilage) is the commonest cause of pain and in majority of patients this damage occurs as a result of natural wear and tear with ageing (Osteoarthritis). In younger patients damage to the cartilage is usually localised to a small part of knee joint and often result from injury, mal-alignment (bowing) of legs. Knee replacement surgery is now a well established successful treatment for patients with severe arthritis. Total knee replacement is not indicated in patients with localised (small area) of cartilage damage due to injury and in patients with mild arthritis and mild functional deficit. Knee replacement should be avoided in younger patients where ever possible as it tends last considerably less as compared to older patients where it is expected to last 12-18 years. Artificial knees provide excellent pain relief but they lag in term of providing full functional recovery (bending, twisting movements and sensations) and hence many younger and active patients are not satisfied after knee replacement surgery.
Lot of research is being undertaken in developing treatments to preserve and to restore (repair) natural cartilage and to delay/prevent the need of knee replacement surgery. These treatments are particularly useful in younger patients and in patients with localised cartilage damage. Also some of these treatments can be performed through arthroscopic techniques (keyhole surgery) allowing quick recovery, minimal pain and early return to full function. The aim of these treatments is to repair the damaged structures, slow the progression of the damage and delay or prevent the need of an artificial joint.
Some of the cartilage restoration techniques used in current medical practise are mentioned briefly below.
Articular cartilage restoration techniques Arthroscopic debridement (knee arthroscopy)
Aided by a small camera (arthroscope) and using specialized surgical instruments like radiofrequency probes surgeons can locate damaged tissue and trim away areas of torn cartilage and remove the damaged tissue to reduce knee pain and improve knee function. Arthroscopic microfractureAided by the arthroscope, surgeons create small holes in the area of bone with complete loss of cartilage cover – called microfractures . Stem cells are released from the holes in the bone, which then assist in healing of the cartilage defect by forming a type of cartilage covering that resembles normal articular cartilage. These stem cells are stimulated by passive knee movement using a CPM machine following surgery to produce the cartilage.
Autologous cartilage cell implantation (ACI)Also called autologous chondrocyte implantation, or ACI, this is one of the most advanced techniques for cartilage regeneration. This technique allows surgeons to harvest cells from a patient’s own cartilage. The cells are then manipulated using tissue engineering in a laboratory and grown in a culture. In a second procedure, the cells are re-implanted in the knee to repair and resurface areas where there’s been cartilage loss.
Osteochondral autograftThis technique allows surgeons to remove a small section of the patient’s own bone and cartilage in an area that does not bear weight to serve as donor cartilage. The donor bone and cartilage is then transferred to the damaged part of the knee being repaired.
Allograft reconstructionFor larger areas of bone and cartilage loss, surgeons can implant a piece of freshly donated cartilage and bone that eventually functions as if it were the patient’s own tissue.
Meniscus Restoration techniques
In addition to the white glistening articular cartilage that coats the ends of our bones in our joints, the meniscus is another important cartilage structure that prevents then onset or progression of arthritis (cartilage breakdown). These two pads of cartilage provide a cushion in the knee joint connection between the thighbone (femur) and the shinbone (tibia). They are crescent-shaped discs that act as shock absorbers, provide protection to the knee joint from the weight of the body and enhance stability and mobility. The meniscal cartilage allows the knee joint to withstand the day-to-day pressures placed on it by walking, running, sitting and standing.
Preserving the meniscus
Surgeons repair the meniscus whenever possible, removing only the portions that are considered beyond repair. In the past, the first line of treatment for such injuries was complete removal of the meniscus. This could lead to problems later in life, including early development of arthritis. Today, we recognize the protective value of the meniscus and do everything we can to repair or replace it.
Replacing the meniscusFor patients who have had the meniscus completely removed in a previous surgery, the missing meniscus can be replaced with a human meniscus transplant. Unlike other forms of tissue transplantation, this procedure does not require patients to be on medications to prevent tissue rejection. To replace meniscus cartilage, surgeons can sew in a new meniscus that heals and functions much like it was the patient’s own. This leads to a more stable and less painful knee that might otherwise have developed progressive arthritis.
Lack of donor tissue remains a major limiting factor in meniscus and allograft cartilage transplant in our country.
Restoration of Limb alignment
Bowing of legs from younger age also contributes to development of early arthritis due to increased stress on inner compartment of the knee. Most of the above described cartilage and meniscus restoration procedures will fail if leg alignment (shape) is not correct. Abnormal shape (mal-alignment) of the legs can be surgically corrected by osteotomy(cutting the bone). Patients who have Bow legs and early degenerative changes usually respond well to High Tibial Osteotomy (HTO). The aim of corrective osteotomy is to shift the stress of weight bearing from damaged part of the knee to the healthy part of the knee joint. This procedure is indicated in younger patients with arthritis affecting only one part of the knee joint.
Above procedures are indicated, either alone or in combination, in young patients with localised area of damage to the knee cartilage. However, in patients with severe arthritis or damage involving whole knee joint, irrespective of the age of the patient, knee replacement surgery is the gold standard treatment providing consistent pain relief for many years.
Dr Jayant Arora
MS(Ortho), DNB(Ortho), MRCS(Edinburgh)
Fellowship in Joint Replacement and Arthroscopic Surgery, Newcastle, UK
Senior Consultant Orthopedics and Joint Replacement Surgeon
Columbia Asia Hospital
Gurgaon
00-91-9873830947
Very rarely it can present as "Snapping Elbow".Seen one chap today in the evening clinic with snapping of the elbow most likely due to a partial tear in ERCB, awaiting the MR results. Also came across a worm manisfestation (cystecercosis-- MRI pic above)) of the common extensor orign, presenting as tennis elbow a few months ago.
