General Orthopaedics
Orthopaedics is the branch of medicine related to the study and treatment of disorders of bones, joints and other parts of the skeletal system like muscles, ligaments etc.
The most common orthopaedic related problems are back pain, knee pain, fractures of bones and ligament sprains amongst others.
If you have been in any kind of an accident or fall leading to an injury with swelling and pain you should immediately head to the emergency department of a hospital. After the emergency doctors have seen you, usually an orthopaedic surgeon is called to check if there are any fractures or ligament sprains. In this scenario you will usually be required to get x-rays or an MRI or CT scan depending on which part of the body is suspected to have been injured.
Ankle twists are the most common type of orthopaedic injury.
This usually is very painful and is associated with quite a lot of swelling around the ankle. This could either be a fracture or a severe ankle ligament sprain. Either way, the first step for treatment is to diagnose the injury with an x-ray. The next step is to immobilise the joint with a plaster at the ER (Emergency Room) – either a P.O.P. slab or cast. Medicines will be started to reduce pain and swelling. The patient is given strict instructions to not put weight on the limb for several weeks and keep the limb elevated. If the diagnosis is of a severe, displaced fracture a surgical procedure may be required to achieve proper bone healing – this decision is made after seeing the x-ray. Likewise, fractures of other bones also do occur, usually after road traffic accidents. Immediate treatment at the ER and X-rays are mandatory to diagnose the fracture and then to decide whether it can be treated conservatively (without surgery) or requires surgery for the proper healing.
Surgical treatment is required when the fractured bone fragments are displaced away from each other and from their original position and when the fracture is next to a joint (like near the wrist or knee). Surgeries for fractures usually involve bringing the bone fragments back to normal position and holding them in place with screws or plates. These procedures give better chance of healing in proper position and faster than without surgery.
Knee Pain
Knee Joint
The Knee Joint is one of the most important joints in the body. It’s a large joint made up of 3 bones – the femur, tibia and patella. It is a hinge joint – i.e. it moves in only one plane (unlike the hip and shoulder joints)
The knee joint bears the whole weight of the body therefore it is the joint most commonly affected by pain.
The Knee joint can be compared to a Car with the different parts of the joint resembling the functions of the parts of a car.
1. Synovial Fluid – The Lubricant of the Joint. This helps to keep the joint moving smoothly. When this starts to dry up with age pain and difficulty in moving the joint starts.
2. Cartilage – the Tyres of the Joint – The cartilage is the smooth tissue that covers the lower end of the femur and the upper end of the tibia (the bones that form the knee joint). It is thanks to the cartilage that the bone ends don’t rub against each other while we walk. With wear and tear of the joint, due to ageing, the cartilage starts to wear off and the underlying bone gets exposed and start to rub against each other causing pain – this is called osteoarthritis. This resembles the tyres of a car, wherein the wearing out of the tyres cannot be reversed but require changing of the tyres i.e. Knee Replacement surgery.
Surgical treatment is required when the fractured bone fragments are displaced away from each other and from their original position and when the fracture is next to a joint (like near the wrist or knee). Surgeries for fractures usually involve bringing the bone fragments back to normal position and holding them in place with screws or plates. These procedures give better chance of healing in proper position and faster than without surgery.
3. Meniscus – the Shock Absorbers of the Joint – The meniscus is a tough tissue in the knee joint in between the two bones. There are 2 menisci – one on each side of the joint – and both are the shape of crescent moons. These menisci absorb the force that gets transmitted to the knee joint while we walk. The meniscus can get injured during twisting injuries usually sustained during certain sports like football and badminton.
4. Ligaments – the Stabilizers of the Joint – The Anterior Cruciate Ligament (ACL) and the Posterior Cruciate Ligament (PCL) are 2 strong rope like tissues that hold both the bones of the knee joint (femur and tibia) together and prevent abnormal movements between them. They stabilise the joint in this manner. Twisting injuries of the joint can cause injuries to the ACL or PCL and lead to instability or giving way sensation in the joint.
Knee Pain & It’s Causes
Knee pain is a very common issue. It can happen in the older age group as well as in younger people. The causes of this pain is different in the different age groups.
The following are the different causes of Knee Pain –
1. Osteoarthritis –
(also referred to as OA knee) This is basically the wearing out of the cartilage layer of the joint leading to the uncovered bone surfaces rubbing against each other and causing pain.
This is similar to the wearing out of a car tyre.
It occurs in the older age group – usually above 50 years of age.
Diagnosis – This condition is diagnosed with simple x-rays. On an x-ray we normally see some gap in between the two bones which is where the cartilage lies (not visible on an x-ray). After the cartilage wears out the gap between the two bones disappears and both bone ends appear to rub against each other.
Treatment – OA knee progresses through 4 stages and the treatment is different for different stages.
In early stages (1, 2 and 3) surgery isn’t required.
a. Medicines include painkillers, ointments and supplements called chondroitin sulphate and glucosamine to strengthen the remaining cartilage.
b. Physiotherapy means exercises. This is the most important part of treatment of early OA knee. The whole aim is to strengthen the quadriceps muscles (the thigh muscles) so that the body weight which normally falls on the knee joint is taken by the muscle thereby offloading the joint.
The exercises for the knee joint are shown in the video attached.
Other good exercises for the knee joint are cycling and swimming.
c. Lifestyle Modifications – simple modifications in daily activities can reduce the pressure on the knee joint and pain. These include – avoidance of kneeling, squatting and sitting cross legged and minimising climbing up and down stairs.
It is always better to sit on a chair when doing activities and use Western commodes for toilet.
Treatment for Stage 4 OA of the Knee is surgical. There are 2 types of surgeries for the stage 4 OA – Total Knee Replacement (TKR) and Partial Knee Replacement (PKR or UKA).
These are explained in more detail in the attached videos and the next section.
2. Chondromalacia Patellae –
This is the most common cause of knee pain in young adults.
It is commonly seen in people in desk jobs like IT professionals as they sit for hours together without movement in the joint.
It is usually felt in the front of the knee and most commonly whole getting up after sitting for a long time.
The pain is caused by gradual softening of the cartilage leading to rubbing of the knee cap bone (patella) against the femur bone.
Another cause of discomfort is the jamming of the synovial fluid in the joint due to not moving it regularly.
Diagnosis –
X-rays help to diagnose the condition.
Treatment –
This condition never requires a surgery. Simple medications, lifestyle modifications and exercises (similar to the ones mentioned in OA knee) are usually enough.
A simple change to make while sitting at a desk is to make sure you get up every one hour and walk around for 5 minutes before sitting down to resume work.
3. Sports Injuries –
This kind of pain is again more common in younger adults.
It is a pain which occurs after a twisting injury to the joint either during sports like basketball or while dancing.
The pain is usually accompanied with swelling of the joint.
It is also associated with painful locking of the knee (if the meniscus is injured) or giving way sensation or instability (if the ACL is injured).
Diagnosis –
Sports injuries require MRIs to be diagnosed, not a simple x-ray.
Treatment –
Initially conservative treatment is tried in the form of medicines rest and gradual exercises while using a knee brace.
If the injury is severe and not improving with conservative treatment a surgery known as arthroscopy is required (also known as a keyhole surgery).
In this procedure a small incision is made in which a camera is passed to reconstruct the ACL or shave the torn meniscus.
4. Rheumatoid Arthritis –
This an autoimmune condition i.e. the immune system of the body attacks its own cells – leading to damage of the various joints of the body leading to pain and swelling.
This pain and swelling usually starts in the smaller joints of the body like those of the fingers and toes and then can progress to larger joints like the knees and hips.
It usually manifests in the mid 20s to mid 30s age.
Diagnosis –
X-rays can tell us if the joints are destroyed (similar to OA knee)
A blood test called RA Factor gives us a confirmation of whether the person is actually suffering from Rheumatoid Arthritis.
Treatment –
Treatment of RA should be done by a Rheumatologist who prescribes anti-rheumatoid medication. In severe stages where the knee or hip joints are completely destroyed an orthopaedic surgeon may have to perform a Knee or Hip replacement surgery.
Total Knee Replacement – What You Need to Know
A knee damaged by arthritis is resurfaced by a surgical procedure called total knee replacement or knee arthroplasty or knee replacement. In this procedure, the bones and worn out cartilage that form the knee joint are cut away and replaced with a prosthesis (an artificial joint). The prosthesis is made of metal alloys, polymers and high-grade plastics.
During a total knee replacement, the damaged lower end of the femur (the thigh bone) is cut way and replaced with a metal surface and the damaged upper end of the tibia (leg bone) is cut away and replaced with metal implants and plastic spacer in between.
Total knee replacement helps in restoring knee function and relieving severe pain in cases of severely damaged or diseased knee joints. It is an effective and safe procedure to restore knee function by correcting the deformity. It helps in resuming normal activities.
Total knee replacement is for whom?
Total knee replacement is considered for those who have severe knee osteoarthritis, post-traumatic arthritis, rheumatoid arthritis and other rare destructive diseases of the knee joint with progressive pain. Patients with osteoarthritis and impaired knee function or decreasing daily knee function, chronic pain, inflammation, swelling, stiffness and progressively increasing pain are the candidates for total knee replacement.
Stiffness and severe pain make it very difficult to walk, get in and out of a chair, climb stairs and move downstairs. Difficulty in walking even a few steps without support like walker or cane can limit everyday activities. Patients feel moderate to severe pain while resting as well. Some patients have knee deformity.
To relive pain and improve functionality people resort to cortisone injections, medications, anti-inflammatory medications, physical therapy and other alternative options, but those cannot help in severe stages. In such cases, total knee replacement is the best and effective procedure.
Decision to undergo Total knee replacement: Your orthopaedic surgeon, you, your family and your family physician are involved in the decision to have total knee replacement. Your orthopaedic surgeon thoroughly examines and evaluates you to determine whether you are fit and will get maximum benefit from the procedure.
Is there any age restriction for the surgery?
There is no age or weight restrictions for the surgery. Orthopaedic surgeons recommend surgery based on the severity of the condition, disability and pain, but not age. Many patients who undergo TKR are between 50 to 80 years age. However, total knee replacement can be successfully done for all age group patients ranging from young adults to the elderly.
How are the outcomes or results of Total Knee Replacement?
For the majority of people (95%), the results are excellent. They get relief from pain and have improved mobility, functionality and better quality of life. The life expectancy of majority of the knee replacements is quite promising – which is expected to last for more than 15 years.
Most people can resume activities and routine work after six to 10 weeks of surgery. They can do daily activities, household chores, shopping and housekeeping. They can drive after three to four months after surgery, if they feel comfortable sitting in the car and possess good and sufficient power to control clutch, accelerator and brakes provided they are not taking narcotic pain medications and have muscle control.
Several low-impact activities can be resumed after recovery – such as swimming, walking, biking and golfing. However, you should talk to your doctor about the limitations that you may have. It is better to avoid high impact activities. Jumping jogging and other sports that carry risk should be avoided.
Bottom line
Patients after undergoing total knee surgery must follow all the instructions given by their orthopaedic surgeons, nurses and physical therapists. Physical therapy is an essential part of rehabilitation after total knee replacement.
Partial Knee Replacement – Is it Right for You?
Osteoarthritis of the knee is a condition that causes damage to the cartilage that protects the bones of the knee joint. The cartilage wears away gradually and this leads to knee pain and stiffness in the knee joint. In osteoarthritis, the damage can be confined to a particular area of the knee or widespread throughout the knee joint. If the damage is confined to a particular area of the knee, then the damaged area can be replaced with an artificial implant called prosthesis. The procedure is known as Partial Knee Replacement as opposed to replacing the whole joint (Total Knee Replacement).
In partial knee replacement surgery only the worn-out bone and tissue of the knee joint is replaced while conserving the unaffected cartilage and knee joint.
Partial knee replacement is also known as unicompartmental knee replacement, unicondylar knee replacement or unicondylar knee arthroplasty or partial knee resurfacing.
Partial Knee Replacement is for whom?
If you have advanced osteoarthritis with severe pain and walking difficulty and your symptoms are becoming severe day by day, you must consult your orthopaedic doctor. Your doctor will recommend knee replacement surgery if non-surgical treatment options are no longer beneficial to you. The doctor preferably recommends partial knee replacement if your arthritis is confined to one compartment of your knee joint – as shown in the figure.
Image showing the X-ray of a patient who is the right candidate for partial knee replacement. The image shows severe arthritis limited to one compartment of the knee joint.
The Goal of Partial Knee Replacement
The main objective of your orthopaedic surgeon is to determine whether you are fit and get maximum benefits from the procedure. To fulfil this objective, the orthopaedic surgeon thoroughly examines and evaluates you.
For ensuring a good functional outcome and longevity of a partial knee replacement, confirming whether you are the right patient for partial knee replacement is important. Therefore, your surgeon further evaluates you by taking additional parameters into consideration like special x-rays.
Diagnosis
Your orthopaedic surgeon thoroughly evaluates you based on the symptoms you have, your medical history and the location of pain. Your doctor will test the mobility of your knee joint to know the condition of the ligaments and knee joint. This can be done by testing the knee for a range of motion. Your doctor will order X-rays and other imaging tests to detect the affected area of the knee joint and the extent of damage cause to the knee joint due to arthritis.
Bottom Line
Knee joint is a complex structure as its movement depends on muscles, ligaments, joint surface and the tendons that surrounds the joint. In a partial knee replacement, more of these structures remain unaltered and therefore the movement and mechanics of your knee joint remain more natural and normal as compared to a total knee replacement. Therefore, partial knee replacement feels more comfortable. However, for better outcomes, patients who have undergone partial knee replacement must follow all the instructions given by their orthopaedic surgeons, nurses and physical therapists.
Advantages of Partial Knee Replacement
The advantages of partial knee replacement include smaller incisions, less pain and faster recovery time. This is a preferred procedure for patients whose knee disease is confined to just one area of the knee. Patients who undergo partial knee replacement spend less time in the hospital and return to daily activities sooner.
More About Partial Knee Replacement
If you have a knee condition (whether it is a mild discomfort or a diagnosed case of arthritis) and you are looking for treatment options, it is very important that you understand how your knee works.
Your knee is the largest joint of your body and supports the entire weight of the body. Two bones called the femur (the upper bone) and the tibia (the lower bone) come together to make up your knee joint. Both the bones are covered with a softer tissue called cartilage that absorbs any shock that may fall on your knee. Additionally, you also have certain elastic tissues called the ligaments which hold the bones together and facilitate knee movement.
What Is Arthritis?
The cartilage that protects the knee bones from shock wears out over time with use. When that happens, the bones are left bare open to one another and any kind of movement of the knee will result in friction of the bones. This friction not only hampers the smooth movement of the knee but also is painful.
The degree of pain and the difficulty in the movement will increase gradually as more and more of your cartilage tissue gets worn out. Based on this degeneration, you may be at one of the 4 stages of arthritis.
Treatment For Arthritis
The treatment for arthritis depends on how severe your condition is. If you have ever looked into an X-ray of the knee, you will see that in a healthy knee, there is a gap between the two bones. Tis gap is normal. As wearing out of the cartilage occurs, the gap starts to reduce until, in stage 4, there is no gap in between the bones.
Medicine & Physiotherapy
The lesser the gap is, the more severe is your condition. If the gap has reduced only slightly, you may have Stage 1 and Stage 2 arthritis. At this stage, pain medication and cartilage strengthening medicines can help you slow down the progress of arthritis. Additionally, physiotherapy can help you shift the ‘heavy-work’ to the neighbouring muscles and de-stress your knee joint. On this note, understand that these forms of treatment can only prevent arthritis from moving to a graver stage; they cannot undo the damages that have already taken place.
Joint Replacement Surgery
In the X-ray image, if the bones are touching in any area, you have reached Stage 3 or Stage 4 of arthritis based on how much of the bones are touching. At this stage, surgery is the most efficient choice of treatment. At Stage 4, you must go for a total knee replacement. Some x-rays show reduction in only the inner part of the knee joint; this is known as anteromedial arthritis. In these situations you can opt for a partial knee replacement or Unicondylar Replacement Surgery.
Unicondylar Knee Replacement
Unicondylar Knee Replacement, also known as partial knee replacement replaces only the damaged portion of the knee. When your knee starts wearing out, the damage, generally, starts at the medial (inner) portion. If you are diagnosed at that stage, we can perform a surgery on that portion only.
How Is Unicondylar Knee Replacement Done?
In a Unicondylar Knee Replacement, the worn out area of the bone is scraped out and a smooth metal prosthetic is implanted in that area. The metal implant complements the decayed bone. As for the cartilage, a plastic (polyethene) is used that makes the movement of the implanted metal smooth. The rest of the healthy bone and cartilage are left intact.
After the surgery, the new implant and the rest of your natural bone can be maintained and preserved with conservative medical care.
Why Is Unicondylar Knee Replacement Better Than Total Knee Replacement?
Unicondylar Knee Replacement can only be done on patients where the damage is localised to the medial section of the knee and has NOT spread across the entire joint. This procedure only benefits the patients who fall under that criterion.
The candidature of unicondylar knee replacement has to be judged very carefully. Once your knee condition passes the candidature, you can benefit highly from this procedure.
The benefits of Unicondylar Knee Replacement are –
[Watch Dr. Adarsh explain about unicondylar knee replacement here.]
1. Less Invasion: In this procedure, the surgeons will not need to cut open the entire knee. They will only make a small cut in the affected area. This will prompt less surgical injury to the surrounding soft tissues.
2. Less Surgical Complication: Every surgery will be associated with some forms of surgical ‘downs’ like blood loss, infection etc. But in this procedure, since you have a smaller incision, the chances of such risks are much less. Hence, post-surgery, you will not feel as tired as you might feel after a total knee replacement.
3. Quicker Recovery: Again, because of a smaller incision, you can recover quicker and you can bounce back to your normal life faster.
4. Preserves Natural Knee: When your surgeons perform a unicondylar knee replacement on you, they leave the healthy section of your knee untouched (as opposed to a total knee replacement where the entire, both the healthy and damaged section, is scraped off). This way, your natural tissue of the knee is preserved. Even if you have a smaller degree of arthritis in the other section of the knee, that section can be managed with traditional medicine.
5. Scope Of Extension: Now, say, that the healthy section of your knee has not responded well to conventional medicine. In that case, the partial replacement can be extended to a total knee replacement. Just because you have done a unicondylar replacement, it does not mean that you have lost out your chances of getting a total replacement, if required.
The scope of unicondylar knee replacement has been increasing with every new technique that comes out. Now, it has been proven that even obese people and sportspersons (or people with a high degree of physical activity) can opt for a partial knee replacement and get successful results.
However, you must remember that to avail the benefits of unicondylar knee replacement, you must seek treatment before arthritis spreads all over your knee in which case, you will only be able to take a total knee replacement.
If you are facing troublesome arthritis or any discomfort in your knee, you can approach our knee experts at Sunshine Hospitals. If you have any questions regarding any treatment or your condition, you can submit your query here.