Delaying or Avoiding Osteotomy
Osteotomy, or correction of bow legs or knock knees, is sometimes recommended
for people with arthritis. The osteotomy procedure involves cutting the
top of the tibia or the bottom of the femur and either removing a pie-shaped
wedge of bone or adding one in to change the angle of the joint. There
are many variations of how to fix the new angle, with plates and screws,
wedges, or external fixators. These procedures have a high rate of complications
and when done to diminish knee pain in the setting of arthritis, last only
5 - 7 years when successful. We believe that many of these procedures might
be avoided if instead of changing the alignment, a new shock absorber (meniscus
cartilage) in combination with re-growing the articular surface (paste
grafting) is performed. Sometimes an osteotomy is required (especially
when the angle of the knees exceeds 10º from straight) but often when
less than that angle, we have found the risk and the prolonged recovery
to exceed the benefits gained. Biologic treatments such as cartilage replacement
combined with joint lubrication, glucosamine, and a careful exercise program
comprise modern biologic joint reconstruction.
If you have been advised to have an osteotomy, there may be biological
solutions that can be applied first such as:
meniscus cartilage replacement,
or articular cartilage paste grafting,
or
lubrication and exercise programs.
Lessons Learned From Our
First 100 Meniscus Allograft Transplants in Arthritic Knees
To determine if you are a candidate
for these procedures, please take a look at our consultation
information page, then e-mail us at avoidingosteotomy@stoneclinic.com
About Knee Arthritis Treatments
Knee joint arthritis is generally grouped into inflammatory arthritis
(rheumatoid, gouty, psoriatic, etc), osteoarthritis (which may be genetic),
and traumatic arthritis (usually from injury or loss of the meniscus cartilage).
We focus our discussion here on osteoarthritis and traumatic arthritis.
In these conditions, the white shiny surface that covers the ends of the
bones in joints is worn away or damaged exposing the bone underneath the
cartilage surface; similar to wearing the rubber down to the steel band
in your car tire. When the cartilage surface wears off, small fragments
of cartilage are sprayed around the joint. The fragments irritate the synovial
lining cells in the capsule of the joint. Those cells produce fluid (swelling).
The fluid contains enzymes that accelerate the breakdown of the cartilage
and cause pain. Most arthritis treatments are focused on diminishing the
swelling and reducing the pain. When they fail, surgeons have resorted
to realignment procedures, such as osteotomy, which changes the angle of
the joint and the location of the most force, or to artificial joint replacement
procedures. (Total Knee Replacement)
Biologic joint reconstruction procedures are focused on two strategies:
non-operative optimization of the joint health and operative replacement
of the damaged tissues with biologic structures such as re-growing the
cartilage surface and when necessary, replacing the fibrous shock absorber
in the knee called the meniscus cartilage. (Viscosupplementation
in the Symptomatic Treatment of Osteoarthritis)
The non-operative approaches include: treatments to increase the lubrication
in the joint.
Two methods exist: oral glucosamine which increases the natural production
of joint lubricants and lubricating injections such as Hyalgan, Supartz,
OrthoVisc, and Synvisc, to name a few. At The Stone Clinic we use both
methods.
Exercise programs are designed to decrease the force placed upon the joint.
The stronger the muscles around the knee joint, the less force is driven
into the joint surfaces. Gait is improved because limping further damages
both the affected joint and the surrounding joints including the hips and
back. With each step, a person puts 1 - 5 times their body weight on the
joint. Decreasing body weight by losing 10 pounds can decrease the force
on the joint by up to 50 pounds with each of the 2 - 3 million steps a
person takes every year.
Physical therapy programs that focus on manual treatment of the tissues
around the arthritic joints improve the range of motion of the joints,
and improve gait, balance, strength, and overall function. All patients
with arthritis benefit from a careful physical therapy assessment and a
custom-designed program. All of our patients participate in physical therapy
to avoid surgery or to recover from it with a better outcome than if they
had surgery alone.
Diet plays a role by optimizing weight, increasing joint lubrication by
consuming glucosamine, increasing bone strength with ingestion of calcium
and Vitamin D, and decreasing abnormal forces across the joint.
Biologic joint treatments are the future of joint replacement. By restoring
healthy tissue to damaged joints, active athletic lifestyles are permitted
and encouraged.
OSTEOARTHRITIS OF THE KNEE
Practical considerations
Osteoarthritis of the knee, or degenerative joint disease, is an arthritic
condition in which the protective covering (articular cartilage) which
lines the bones on the tibia, femur and/or patella has begun to erode and
become soft and frayed. As the cartilage deteriorates, the bones begin
to rub together causing pain, swelling and a decreased ability to tolerate
various activities.
In treatment of this condition, we have found a few things in particular
to be very helpful in reducing the symptoms associated with this problem.
Activity modification:
First and foremost, modification of those activities that increase symptoms
is essential. Finding the level of activity that your knee can tolerate
with given activities will help in making the time spent performing them
more comfortable. For instance, if you find that 1 - 2 days of doubles
tennis a week is tolerable and does not significantly increase pain and
swelling, then that is your guideline. If, however, your knee really bothers
you every time you try to play singles or more than a couple of days a
week, then it is time to listen to your body. It is helpful to equate your
knees to a “bank account”. You will have to budget your knee
money in order not to have pain that debilitates (or bankrupts) you.
Shoe wear:
The use of shock absorbing insoles and/or cushioned shoes is also very
helpful in reducing the pounding to the joint throughout the day. Modification
of shoe choice to accommodate insoles and preferably wearing a running-type
shoe that has a significant amount of cushion can reduce the ground reaction
force onto the joint by up to 20%. The less often you stress the joint
repetitively, the less overall damage in the long run. Go to a reputable
running store and try on at least 3 pairs of running shoes. Choose the
one that feels the best to you.
Unloading wedges:
If the standing posture of your knees is either bowlegged (varus) or knock-knee
(valgus), then this also increases the stress onto the joint. We have found
the use of unloading wedges in your shoes is also helpful in taking that
load off the involved side of the joint and distributing it more evenly
onto the knee. This aids not only in pain relief, but also decreased wear
onto the joint.
Unloading knee braces:
Custom-made or off-the-shelf knee braces are another way that equipment
may be utilized to reduce the forces onto the joint. If your physician
feels that you are a candidate for an unloading brace, then one can be
fit to your leg and used for activities that typically produce pain or
symptoms. Some wear their brace just for activity, while others wear their
brace more often throughout the daytime.
Glucosamine:
Glucosamine sulfate is a substance synthesized by the body and naturally
present in cartilage. It is believed that it somehow stimulates cartilage
cells to produce certain compounds that are the building blocks of articular
cartilage. We have found that 1500 mg of glucosamine daily to be the most
effective dosage. This can be obtained at most health food stores as a
pill or in grocery stores in the form of Joint Juice.
Body weight:
Maintaining a healthful weight helps to reduce the extra stress onto the
joint. This is accomplished by regular exercise, good dietary intake, and
maintaining a healthful lifestyle.
Pain management:
Pain management techniques such as moist heat packs, warm baths and jacuzzis
help to relax sore muscles and relieve the tightness and soreness. Also
good to use as a warm-up prior to a good stretching and strengthening program.
The use of cold packs for 15 minutes is very effective when the knee feels
acutely irritated or inflamed, or any time after prolonged activity. The
use of over-the-counter drugs such as acetaminophen (Tylenol) which is
a non-aspirin pain reliever can also prove beneficial. Always consult your
physician before taking any anti-inflammatory medication regularly.
Exercise:
Exercise is a critical component in the treatment of osteoarthritis because
it helps strengthen the muscles that surround the joint and helps aid in
shock absorption. Other benefits of exercise include improved stability
throughout the day, increase in joint flexibility which lessens pain, and
helping to keep the remaining cartilage healthy by supplying it with the
oxygen and nutrients that the joint needs. Stationary bike with light to
no resistance beginning slowly is one form of exercise that is non-pounding.
Pool exercises such as leg lifts, smooth gentle kicking strokes with a
kickboard focusing on the hip, and deep water running with the use of a
flotation belt are also very effective in increasing strength without increasing
symptoms. Keeping flexible through daily stretching exercises is also critical. |
