FAQ Category: Knee

The decision to have a joint replacement takes into consideration many factors. First, your age and general health are important. Previous treatment for arthritis is reviewed. There may be some conservative (nonoperative) care you haven’t tried that can help before thinking about surgery.

X-rays are taken to view the condition of the joint. The surgeon looks at the joint space and bone density when advising you. During the physical exam, joint range of motion and strength are measured. Function, activities of daily living (ADLs), and quality of life are also part of the decision-making process.

If you’ve tried all the recommended steps in conservative care without success, then you may be a good candidate for surgery. Even without pain, function and quality of life may be improved enough by a joint replacement to make it worth doing.

Your orthopedic surgeon is the best one to advise you on all the treatment options and timing.

Weight loss can be very difficult for some people. But there are many anecdotal stories and research results to show that obesity does contribute to joint degeneration and pain.

Many patients obtain relief of painful joint symptoms with a combination of treatments. Increasing their exercise and decreasing body weight combined with antiinflammatories or pain relievers has helped many people with joint OA.

In fact, this is the first line of treatment recommended. Some people are even able to stop taking medications after a significant weight loss.

There are many other added benefits reported from weight loss. Decreased fatigue, increased function, and improved mobility are just a few directly related improvements to your joint health. But the risk of diabetes, cancer, and heart disease also goes down resulting in improved longevity and quality of life.

When noninvasive or nonoperative treatment fails, patients may want to try injections. Steroid injection or alternately, the use of hyaluronic acid (HA) may be considered. With your physician’s help, you’ll be able to decide which treatment option might be best for you.

Local injection of steroids has some long-term side effects if used too often. But one to three injections can help break the pain cycle caused by inflammation.

HA injections have become an accepted form of treatment for patients who have GI intolerance of nonsteroidal antiinflammatories (NSAIDs). Studies show HA injections are safe and effective. The only downside is that the results (improvement) may be small.

HA injections aren’t a cure for osteoarthritis (OA). Regular, moderate exercise is still highly recommended for the long-term management of OA. Weight loss, good hydration and nutrition, and physical therapy may also help improve your symptoms and function.

Patients often want to delay or avoid joint replacement. Many doctors suggest pain relievers or nonsteroidal antiinflammatory drugs combined with exercise as an early treatment program. Patient education for improving posture and reducing biomechanical imbalances may be provided by a physical therapist.

Other treatment options can include steroid injections, glucosamine supplements, or bracing. Minor surgery such as arthroscopic debridement may be advised. The surgeon removes any frayed edges or loose fragments of cartilage.

This type of treatment is not routinely advised for all patients but may be most effective for low-grade OA.

Joint fluid therapy sometimes referred to as viscosupplementation or hyaluronan injections is a thick, elastic substance made from hyaluronan. Hyaluronan, also known as hyaluronic acid or hyaluronate (HYL) is found in normal joint fluid.

When injected directly into the knee joint, HYL helps restore the cushioning and lubricating properties of normal joint fluid. Three to five injections are used for knee osteoarthritis in patients who have not respond to more conservative therapy.

A recent study from the New Jersey Medical School suggests that combining HYL with a home exercise program is actually better than just HYL alone. Exercise by itself seems to benefit knee OA. Biochemical changes in the synovial fluid have been reported with exercise alone and with HYL alone.

Combining the two together may help increase the amount of hyaluronan that moves into the cartilage. Exercise seems to have the added benefit of helping expand and cleanse the cartilage to keep it in good condition. All indications are that exercise is very helpful for osteoarthritis and should be continued on a daily basis.

The main goals of treatment for osteoarthritis (OA) are to reduce joint pain and improve (or at least maintain) function. Function includes your daily activities to take care of yourself, mobility, and recreational activities.

Preventing or slowing the progression of changes to the joint tissues can be done with weight loss and exercise. Over-the-counter pain relievers work well for many patients with mild pain.

Some prescription medications may help patients with moderate to severe pain. The goal is to obtain the maximum benefit from the drug with the least amount of side effects or toxicities.

Many studies have shown the benefit of daily, moderate exercise on knee OA. Strengthening, stretching, and walking form the basis for a good, overall exercise program for this condition.

Exercise combined with hyaluronan injections have been shown to provide faster pain relief for patients with moderate to severe pain compared with injections alone.

The more you can do to educate yourself about this condition, the better able you will be to protect your joints and prevent further damage. The Arthritis Foundation offers many ideas for patients with OA and can be accessed at www.arthritis.org.

Although bionics is really referring to the combination of biology with electronics, in today’s culture it has come to mean anything artificial like joint replacements. Given this definition, it’s likely that longer lifespan is a major contributing factor to the increasing number of bionic adults.

The World Health Organization (WHO) reports knee osteoarthritis as a common cause of disability in older adults around the world. With the aging of America, we are likely to see more of this over time.

But it isn’t just Americans. Studies show an even larger number of people with knee OA in Asians than in Western groups. This is true even though Asian people have lower body weight. Being overweight or obese is a major risk factor for hip and especially knee arthritis.

According to a study in Thailand, Asian adults who squat or sit on the floor for long periods of time each day are at increased risk for knee OA. This is a common occupational hazard for the farming community in southeast Asia who often use the squatting position while working.

OCD stands for osteochondritis dissecans. OCD refers to a problem in the knee where the layer of bone underneath the cartilage separates from the bone. The piece of bone and cartilage separate most often at the end of the femur (thigh bone).

If the fragment detaches even partially, surgery is needed to put it back in place. If the problem is bad enough, the fragment may have to be removed.

If the loose bone fragment is in a weight-bearing area of your bone, the surgeon tries to reattach it if at all possible. Tiny metal pins or screws are used to hold the fragment in place. If for any reason the bone has to be removed, donor bone from a bone and tissue bank may be used to fill in the defect.

Another way to repair this problem is called an autograft. Tissue taken from the patient’s own knee is used. In this case, surgeons graft a small amount of bone (osteo) and cartilage (chondral) from the donor site to put into the hole left by OCD.

With any of these methods problems can develop. For example, infection around the donor or graft site can occur. Shaping the graft to fit the same shape as the defect isn’t always possible.

New methods for dealing with this problem are under investigation. For example, a new technology called autologous chondrocyte implantation (ACI) is currently being developed. It involves using cartilage cells (chondrocytes) to help regenerate articular cartilage.

And a new repair technique has shown good results in as little time as three months. Plugs of bone are taken from inside the patient’s own knee. The plugs are used like pegs or pins to hold the torn fragment in place. The bone cells help stimulate the formation of new bone cells. Healing time is cut in half compared to using pins or screws.

To know what goes on exactly, you’ll have to ask your surgeon which repair technique he or she is planning to use.

Your surgeon has probably explained the pros and cons of either waiting or taking action now. If you have not had this discussion, it would be a good idea to contact him or her by phone to review your options.

There is no clear way to know what is best. Each patient must be considered individually. Studies have not been done to show the optimal time for revision surgery once there are signs of bone changes or implant loosening.

In general, some surgeons advise a wait-and-see approach when patients do not have painful symptoms and the process is slowly progressing. Eventually the problem will probably get worse and revision surgery will be required. In such cases, the patient should stay in close contact with the surgeon to determine the best time for the operation.

On the other hand, surgery is recommended right away for patients who do have painful symptoms and/or when the X-ray shows rapid bone changes. Any time bone support is eroding, instability can occur making matters even worse. Removing and replacing the failed implant can help restore function and prevent further joint damage.

Osteolysis is a term used to describe a problem common to artificial joint replacements. It refers to an active process of bone breaking down and dissolving. Particles called debris wear off the implant. This starts a process of bone degeneration.

As the body tries to clean up the loose particles of plastic or metal, the bone grows away from the implant, causing it to loosen. A second or revision surgery may be needed. The surgeon will remove the damaged implant, smooth the bone, and reinsert another (new) implant.

Osteolysis caused by wear debris occurs for a variety of reasons. Patient activity is probably the most important one. Increased activity puts greater load over time on the joint replacement.

The implant itself is part of the problem. Manufacturers are working to improve implant materials and design. And finally, the surgery is a factor. Balancing the ligaments and restoring normal joint alignment are important in the long-term wear and tear on the joint.

The new adjustable unloader braces have become very popular. Pain relief and reduced stiffness in the knee is accompanied by improved function and performance. A recent study at the University of Chicago Motion Analysis Lab may have the answer to your question.

They took 10 athletes with known knee arthritis from poor knee alignment that caused medial joint space narrowing and arthritis. The medial side of the joint is closest to the other knee.

Each athlete either wore a custom-fit or off-the-shelf unloader brace for four or five weeks. After a two week break, each athlete switched to whichever brace wasn’t worn the first time. Braces were worn daily for an average of eight or nine hours.

X-rays of leg alignment and computerized motion analysis were measured at different walking speeds and while going up and down stairs. The custom-fit brace was able to maintain better knee alignment, especially during the stair activities. Stiffness was reduced much more with the custom-fit brace.

The researchers reported that the closeness of the brace fit on the leg is important. Anyone with a medial joint alignment problem can benefit from an off-the-shelf type brace. The better results needed by athletes come with the use of a custom-fit brace.

Many athletes use elastic bandages and/or neoprene sleeves over and around the knee joint. There are different reasons for their use. Sometimes the athlete just wants to keep the joint warm and moving freely.

In other cases, there’s been a minor injury and the sleeve offers support. Studies show these external sleeve supports can also improve proprioception. Proprioception is the joint’s sense of its own position.

Proprioception is an important sensation to prevent injury. As the joint moves, it makes adjustments for any sudden changes or off-balance positions. Good proprioception helps prevent joint injuries. An injured joint often has altered or deficient proprioception. A sleeve can help increase proprioceptive input.

The sleeve does not change the joint alignment. That’s where a brace fits into the picture. If your joint pain is from uneven alignment causing uneven joint wear and tear, then a brace to correct the alignment may be needed.

Some athletes wear both the sleeve and the brace. The combination helps improve proprioception while unloading the joint. The result can be decreased pain and improved function. For an athlete that can mean improved performance.

Using your own tissue to repair a torn ligament such as the ACL is called an autograft. Using tissue from a donor bank is referred to as an allograft. In either case, once the tissue is transplanted and in place, the graft dies.

This means the cells are no longer viable. It’s the structure of the tendon that remains. This structure is called a collagen matrix. The body sends in blood vessels to destroy the old collagen in the matrix. The tissue is gradually replaced with new collagen cells. Living cells fill in along the matrix until a new structure is formed.

Many studies have been done to compare the results using allograft versus autograft tissue. Patients with allograft ACLs have reported slight deficits in knee flexion and pain behind the kneecap. Rerupture may occur slightly more often with allograft tissue when the graft is taken from the patellar tendon.

Otherwise, it appears that strength and activity levels are about the same with either type of graft. There may be a slight delay with less graft incorporation with allograft tissue. Some researchers suggest a delayed or prolonged rehab program for these patients.

With your own tissue, you won’t likely experience this delayed remodeling and can progress through knee loading activities on schedule.

Reports vary on return to sports activity levels based on many different factors. Age, gender, and preinjury level of participation are just a few of these variables. Type of injury (ACL alone, ACL plus meniscus tear, ACL plus meniscus and/or cartilage tear) can make a difference.

And results may vary depending on the type of repair done (allograft versus autograft). An allograft uses tendon tissue from a donor bank. Autograft means the surgeon harvests tissue from the patient to use as a graft.

Many studies report normal or nearly normal results for about 70 to 75 per cent of the patients in both groups. This does mean that about 25 per cent report less than normal results with reduced activity levels.

A recent study comparing just allograft repairs showed a general decline in sports activity for all patients from two to five years. A decline was seen from two to four years with an even greater report of decline in function after five years. The authors suspect patients may protect the joint at first, become deconditioned, and later experience the ongoing effects of decline with aging.

There is also the possibility of memory bias. This refers to the fact that some patients remember their physical condition and sports ability before treatment as being better than after treatment. Perceived skills and abilities and actual function may not be the same.

If your surgeon says your knee is stable, then a proper rehab training program may be all you need to get you back in the game. Make a follow-up appointment for testing. Share your personal sports activity goals with the doctor, and see if there’s anything holding you back physically.

Patellar baja refers to the position of the patella or kneecap. In patellar baja, the kneecap rides down low over the femur (thighbone).

This can just be the way you were born. More often it occurs as a result of the patellar tendon shortening after surgery or injury. Either way, a patellar tendon that is too-short can pull the patella downwards.

A recent study of stiff knees after total knee replacement (TKR) identified patellar baja as a possible cause. Women were at higher risk of patellar baja. Younger age was also a factor but age was linked with joint stiffness after TKR, not the patellar baja.

There are many, many possible reasons for a failed joint replacement. Studies show that poor motion before the operation has a strong link with poor motion afterwards. Younger women actually do have poorer results compared with other ages and gender.

Even the patient’s personality has been identified as a possible contributing factor. Patient’s who do not tolerate pain well and especially those who do not follow the rehab program have increased rates of knee stiffness after a total knee replacement (TKR).

There may even be a genetic basis for your poor results. Tissue sampling and analysis has shown chemical changes during the healing phase in patients who end up with stiff joints. The body doesn’t clear the joint of inflammatory cells. There’s a build-up of too much protein called reactive oxygen and nitrogen species (RONS).

Scientists are studying ways to prevent this build-up as well as stiffness from other causes as well. There’s still hope for you now with continued rehab. Your age is in your favor there. It may take longer and may require persistence on your part, but restoration of normal to near normal motion is possible.

If you have already done all this, then an operation to manipulate the joint and break the scar or fibrosis holding the joint may be needed. If that doesn’t work, then a second or revision operation can be done. Your surgeon will be able to advise you what treatment might work best for your situation.

The exact cause of stiffness remains unknown. In general, joint and muscle stiffness seem to increase as we age. This is true whether or not we have arthritis. There are several theories to explain stiffness with and without arthritis.

The first and simplest is that we dry out as we age. The slippery viscoelastic properties of soft tissues start to decrease with time. With fatigue and aging we start to move slower, less often, and with a smaller arc of motion.

The result is an increase in the cross links between collagen tissue. In other words, the tissues stick together more and slide less. We experience this as stiffness.

In the case of osteoarthritis (OA), actual changes occur in the cartilage inside the joint and in the soft tissues around the joint. Inflammation and swelling further reduce motion in the joint. Without a smooth, freely moving joint, the viscoelasticity starts to decrease even more. The joint feels stiff with loss of motion.

Scientists don’t know why some days are better than others. Changes in the weather may be part of it. The joint has sensors that respond to changes in the barometric pressure. Older adults with OA are usually good predictors of weather changes for this reason. Nutrition and hydration may also be factors.

Research is ongoing in this area as there is great interest in preventing and reducing stiffness in the aging adult population.

It doesn’t appear that disease severity matches up with level of stiffness for patients with osteoarthritis (OA). We aren’t sure just why this is. Narrowing of the joint space from OA certainly causes joint pain and loss of motion.

Stiffness may be more a factor linked with the soft tissues. Muscle around the joint and cartilage inside the joint may be the real source of the stiffness. Research is ongoing to measure stiffness, discover its cause, and find a cure.

Body type and size may make a difference but this hasn’t been proven yet. People of all sizes and shapes experience stiffness but researchers are looking for trends or patterns based on body mass index (BMI).

Your surgeon will review any complications from the surgery and what can happen afterwards. From a recent update on failed ACL repairs, we can tell you the most common pitfalls after primary (first) ACL repairs.

Up to one-third of all ACL repairs result in stiffness with loss of joint motion. This can occur because of scarring inside the joint from being immobilized too long, infection, or for unknown reasons.

Loss of flexion isn’t as much of a problem as loss of knee extension. If you can’t straighten your knee all the way, you may end up limping when you walk. This is a real problem if you happen to be an athlete because it interferes with running as well.

Rehab is essential to regain muscle strength and motor control needed for normal motion and activity. If the muscles don’t fire at the right time, you may not be able to respond fast enough to sudden movements or stress on the joint. You could end up reinjurying the ACL repair.

Fortunately, failures of ACL repairs don’t happen very often. If you follow your surgeon’s instructions and complete your rehab program from start to finish, you will likely have a very good final outcome. Most people are able to return to their full preinjury level of activity, including recreational or competitive sports.

Studies of meniscal strength can only be done on cadavers (human bodies preserved for study). So there may be some differences between lab results and the human body.

Most of the studies so far have shown the strength of the repaired meniscus is still greater than would ever be applied to the knee during everyday activities.

Repair systems vary and include sutures or implants. The materials of the sutures also varies. Implants are usually absorbed by the body over time. For larger tears, the surgeon may use a combination of sutures and implants. This is called a hybrid fixation technique. It’s not clear yet how strong this method is.

Researchers report that distraction forces have been the biggest focus of study. Shear forces, which are more likely to cause meniscal tears, are not as easy to reproduce in a lab. The movement includes rotation with the foot planted and weight through the knee. Flexion angle of the joint may make a difference, too.

An unexpected, fast movement with torque (twist) while in the standing position is the mechanism most likely to cause re-injury. In the young athlete, returning to sports too early is a risk factor. For older adults, slipping on ice or getting in the way of a fast moving dog are the most common links to meniscal reinjury.

The first six to eight weeks are the most important during the healing process. It’s likely that if you follow your rehab program, you won’t be in any danger of disrupting the sutures.