Osteoarthritis, the commonest form of arthritis affects the knee joint most often in India. Elderly afflicted by this chronic painful disease need joint replacements as a permanent solution to improve their quality of life and put an end to disabling pain. However it is increasingly common to see many young people also suffer from the earlier manifestations of the disease. In this group alternate solutions have to be recommended considering the age, increased demands like participation in sports and work. Joint replacements cannot obviously be a solution to young men and women.
Osteoarthritis is a age related wear of Articular cartilage which covers the end of the long bones in a joint. It is smooth, elastic, shining tissue. It is responsible for lubrication, shock absorption, and pain-free movements. Unlike other tissues of the body, it has limited capability of regeneration and repair as it has no blood supply and nerve supply. This limited repair capacity decreases with aging and leads to depletion in the arthritis knee. Pain and stiffness ensue, necessitating medication or surgery.
Osteoarthritis does not involve the whole of the joint to begin with. A localized area of cartilage damage called a lesion is the precursor and harbinger of the disease. If left untreated, lesions greater than 1. 5 cm will lead to arthritis after 15 years.
Some generalized and local conditions predispose to early cartilage damage. These are mechanical, chemical, and biological. Occupations, Obesity, mal-alignment or structural damage can predispose to cartilage damage.
Ligaments and menisci stabilize the knee. Menisci dissipate stresses, help in lubrication, increase joint conformity and confer additional stability. The ligaments inside the joint are called the cruciate ligaments. These are torn in many sports, or two wheeler accidents. An ACL injury is the commonest ligamentous injury. Unrepaired ACL's lead to further tearing of the menisci and both in association can lead to osteo-arthritis.
Meniscal tears can occur in isolation in sports or domestic accidents. After the importance of the menisci was realized and arthroscopic surgery came into vogue, attempts are made to resect and remove only the damaged portion of the menisci and preserve the rest. However, it is not always possible to do so as the damage is beyond repair and a total or subtotal Menisectomy is necessary. Such knees are also predisposed to develop secondary osteoarthritis (occurring in younger persons at an earlier age) cf Primary osteoarthritis which occurs in the elderly.
Some people have deformities around the knee. These may be situated in the thigh bone or leg bone. Normally in the standing position, there should be no gap between the inner side of the knee and ankle joint. If a gap exists between the knees, then the person has bow legs (Genu varum) and if a gap exists between the ankles, then the legs diverge at the ankle, causing knock knees (Genu valgum). Both these deformities can lead to one sided wear of the knee joint and arthritis in one half of the knee.
Surgical solutions are available to prevent or treat early arthritis. These alternatives avoid knee pain from arthritis.
These knee reconstructive procedures attempt to restore the anatomy of the joint and are mainly of a biological nature. They do not involve joint replacement. Examples are
1) Knee ligament reconstruction- ACL reconstruction is possible through tiny key-hole incisions (arthroscopic surgery). Graft is taken from the patient's own body (autograft) or from a brain dead person, (allograft). This tendon graft is threaded through bony tunnels in the leg and thigh bones and is fixed with screws, buttons or other devices.
2) Meniscal suture- This is a procedure in which attempt is made to suture a torn meniscus if situated in a suitable position. Concomitant ACL reconstruction is required if there is an injury to this ligament also. This is done through arthroscopic surgery.
3) Meniscal transplant- This procedure is to be introduced shortly. In this menisci are harvested from the knee joints of brain dead living donors or non heart beating donors. These are preserved and then grafted into the damaged knee.
4) Reparative cartilage procedure are available to salvage localised cartilage defects and prevent their progression to extensive involvement. These are microfracture wherein small holes are made in the raw area to generate a super clot and in growth of fibro cartilage. In mosaicplasty, cartilage plugs are harvested from non weight bearing portion of the knee and re-implanted into the lesions.
5) Corrective osteotomy- Mal-aligned joints can be corrected by an osteotomy (division of bone). After this surgery, stresses across a joint are distributed more evenly excess wear from one half of the joint is minmized. This again prevent rapid progression of osteoarthritis and can postpone the need for a replacement.
These surgical alternatives are available in Chennai to treat painful knees in young people and prevent progression to arthritis. By availing these alternate surgical procedures where one is indicated, one can preserve and continue with natural cartilage and postpone or avoid joint replacement by a decade or more.
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