Patient knee education is very important to Dr. LaButti, making sure you’re fully informed about your condition and care is important to the success of your treatment. Dr. LaButti is easy to talk to and will always take the time to thoroughly explain care and make sure all your questions are answered.
The following sections provide detailed clinical information about the knee, joint replacement and surgical alternatives and other information from Dr. LaButti.
Common causes of knee pain.
Trauma by direct or indirect injury.
Direct injury Fractures of the bone that extend into the knee joint can injure articular and meniscal cartilage, often leaving irregularities of the joint surfaces and sometimes loose fragments of cartilage. These irregularities and loose fragments can cause painful locking or grinding within the knee, resulting in irregular wear on the joint surfaces and post-traumatic arthritis.
When blunt trauma occurs to the knee without fracture, abnormal compression forces applied to the articular cartilage can result in microscopic injury to cartilage and underlying bone (bone bruise). This lessens the ability of the articular cartilage to handle normal joint forces and may lead to changes in the knee similar to osteoarthritis.
Indirect injury Ligament injury results from abnormal rotational or bending stress applied to the knee. Residual instability of the knee produces abnormal translational stresses to the articular and meniscal cartilage causing pain and swelling. Over time, these abnormal stresses can lead to degeneration of the joint surfaces.
Injury to the meniscal cartilage can occur with fractures, blunt trauma or ligament injuries. The torn meniscus may get caught within the joint causing painful snapping or locking of the knee. After being torn, the meniscus is less able to equally distribute the normal joint forces, leading to microscopic injury and eventual degeneration of the articular cartilage.
Arthritis is an inflammation of the joints that is painful and can even change the structure of the joint. Though often considered a disease of the elderly, it can strike at any age. There are several types of arthritis, but the most common is degenerative joint disease or osteoarthritis. This disease affects more than 20 million people in the United States.
Osteoarthritis is a joint disease that mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another easily. It also absorbs energy and cushions the ends of bones in joints. In osteoarthritis, the surface layer of the cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Bone spurs (small growths called osteophytes) may grow on the edges of the joint. Bits of bone and cartilage can break off and float inside the joint space. This causes more pain and damage.
Symptoms include pain in the involved joint that is typically worse with activity and relieved by rest, stiffness after periods of immobility, instability, limitation of motion, muscle atrophy and weakness. Osteoarthritis can result from ligament or meniscal injury and can be hereditary. Repetitive use, such as athletics, may be implicated as well.
If not treated, osteoarthritis can lead to disability. Medications, weight loss, exercise and walking aids can reduce pain and disability. In severe cases, knee replacement surgery may be helpful.
Osteoarthritis affects each person differently. In some people the disease progresses rapidly and in others slowly. People with osteoarthritis usually experience the following symptoms:
- Steady or intermittent joint pain.
- Stiffness in a joint after getting out of bed or sitting for a long time.
- Swelling or tenderness in one or more joints.
- A crunching feeling or grinding sound with motion of the joint.
Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees and hips. The cause of the disease for the most part is undetermined, but several factors may contribute including:
- Being overweight.
- The aging process.
- Joint injury.
- Stresses on the joints from certain jobs and sports activities.
Rheumatoid arthritis causes the synovium to become thickened and inflamed. In turn, too much synovial fluid is produced within the joint space, which causes a chronic inflammation that damages the cartilage.Â This results in cartilage loss, pain, and stiffness.Â Rheumatoid arthritis affects women about three times more often than men, and may affect other organs of the body.
Avascular necrosis is a disease resulting from the temporary or permanent loss of blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surfaces. This disease is also known as osteonecrosis, aseptic necrosis and ischemic bone necrosis.
Although it can happen in any bone, avascular necrosis most commonly affects the ends (epiphysis) of long bones such as the femur, the bone extending from the knee joint to the hip joint. Other common sites include the upper arm bone, knees, shoulders and ankles. The disease may affect just one bone, more than one bone at the same time, or more than one bone at different times.
Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis each year. Orthopedic doctors most often diagnose the disease.
The amount of disability that results from avascular necrosis depends on what part of the bone is affected, how large an area is involved, and how effectively the bone rebuilds itself. The process of bone rebuilding takes place after an injury as well as during normal growth. Normally, bone continuously breaks down and rebuilds â€” old bone is reabsorbed and replaced with new bone. The process keeps the skeleton strong and helps it to maintain a balance of minerals. In the course of avascular necrosis, however, the healing process is usually ineffective and the bone tissues break down faster than the body can repair them. If left untreated, the disease progresses, the bone collapses, and the joint surface breaks down, leading to pain and arthritis.
Symptoms are abrupt onset of pain initially only during weight bearing and later during non-weight bearing and even while at rest. In some patients, the pain becomes unbearable as the disease progresses, whereas in others, it does not.
Causes of Avascular necrosis:
Avascular necrosis has several causes. Loss of blood supply to the bone can be caused by an injury (trauma-related avascular necrosis or joint dislocation) or by certain risk factors (non-traumatic avascular necrosis), such as some medications (steroids), blood coagulation disorders, or excessive alcohol use. Increased pressure within the bone also is associated with avascular necrosis. The pressure within the bone causes the blood vessels to narrow, making it hard for the vessels to deliver enough to blood to the bone cells.
When a joint is injured, as in a fracture or dislocation, the blood vessels may be damaged. This can interfere with the blood circulation to the bone and lead to trauma-related avascular necrosis. Studies suggest that this type of avascular necrosis may develop in more than 20 percent of people who dislocate their hip joint.
Corticosteroids such as prednisone are commonly used to treat inflammatory diseases, such as systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, and vasculitis. Studies suggest that long-term, systemic (oral or intravenous) corticosteroid use is associated with 35 percent of all cases of nontraumatic avascular necrosis. However, there is no known risk of avascular necrosis associated with the limited use of steroids. Patients should discuss concerns about steroid use with their doctor.
It is not clear exactly how the use of corticosteroids sometimes can lead to avascular necrosis. They may interfere with the body’s ability to break down fatty substances. These substances then build up in and clog the blood vessels. This reduces the amount of blood that gets to the bone. Some studies suggest that corticosteroid-related avascular necrosis is more severe and more likely to affect both hips (when occurring in the hip) than avascular necrosis resulting from other causes.
Excessive alcohol use and corticosteroid use are two of the most common causes of nontraumatic avascular necrosis. In people who drink an excessive amount of alcohol, fatty substances may block blood vessels, causing a decreased blood supply to bones that results in avascular necrosis.
Other risk factors:
Other risk factors or conditions associated with nontraumatic avascular necrosis Gaucher’s disease, pancreatitis, radiation treatments and chemotherapy, decompression disease, and blood disorders such as sickle cell disease.
Nonsurgical treatments for osteoarthritis of the knee.
Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medicines, surgery and nontraditional treatment approaches.
- Exercise is one of the best treatment options. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general fitness. The amount and form of exercise will depend on the joints affected, their stability and whether a joint replacement has already been done.
- Rest and joint care treatment plans include regularly scheduled rest. Patients must learn to recognize the body’s signals to stop or slow down. Canes and orthotics are used to protect joints and take pressure off them. Braces provide extra support for the weakened joints. They also keep the joint in proper position during sleep or activity. Splints should only be used for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness.
- Pain relief can include nondrug and drug protocols. Warm towels, hot packs or a warm bath or shower can relieve joint pain and stiffness. In some cases, cold packs can relieve pain or numb a sore area. Always check with your physician or physical therapist what treatment is best. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.
For more severe pain, patients will often have to turn to pain medication. Physicians prescribe medicines to eliminate or reduce pain and to improve functioning. Physicians must consider the intensity of the pain and potential side effects of the medicine. The following types of medicines are commonly used in treating osteoarthritis:
Acetaminophen: is a pain reliever that does not reduce swelling. It does not irritate the stomach and is less likely to cause long-term side effects than nonsteroidal anti-inflammatory drugs (NSAIDs).
NSAIDs: they fight inflammation and relieve pain. Some can be purchased over the counter and others require a prescription. Each is a different chemical, and affects the body differently. NSAIDs can cause stomach irritation and affect kidney function. The longer the person uses NSAIDs, the more likely they are to have side effects ranging from mild to serious. Always tell your health care provider what medications you are taking, since some drugs may interact with potentially dangerous side effects.
COX-2 inhibitors: Are a new class of NSAIDs that reduce inflammation with fewer gastrointestinal side effects. These medications occasionally are associated with harmful reactions ranging from mild to severe. Always consult your physician or pharmacists if you have any questions or concerns.
- Topical pain-relieving creams, rubs, and sprays, which are applied directly to the skin.
- Mild narcotic painkillers, which are very effective, may be addictive and are not commonly used.
- Corticosteroids are powerful anti-inflammatory hormones made naturally in the body or manmade for use as medicine. Corticosteroids may be injected into the affected joints for temporary pain relief. This is a short-term measure, and is not recommended for more than two or three treatments per year.
- Hyaluronic acid, a medicine for joint injection used to treat osteoarthritis of the knee. This substance is a normal component of the articular or hyaline cartilage.
Showing the most promise as a natural treatment to arthritis is the combination of glucosamine and chondroitin sulfate. They are building blocks of joint cartilage and are considered a food supplement. They can be as effective as ibuprofen for approximately 75% of people suffering from joint pain.
Glucosamine works to normalize damaged joint cartilage and protect it from further harm. The recommended dosage of glucosamine sulfate for osteoarthritis is 1,500 mg daily. It may take anywhere from one to four months to experience partial pain relief.
Patients who include chondroitin sulfate have a slight additional benefit. Other joint-protective compounds include:
- Vitamins A, B6, and C, and the minerals copper and zinc, are all required for the body’s manufacture of collagen and normal cartilage.
- Vitamins A and C, when used in combination, may help slow down the deterioration of afflicted cartilage.
- Vitamins C and E, used in combination, protect cartilage from free-radical destruction.
Benefits of knee replacement.
A successful knee replacement is defined as freedom from pain and restoration of motion as well as function. A successful knee replacement will allow a person to return to most routine activities of daily living. Once your new joint has completely healed, you will clearly see the benefits of surgery. These include:
- Dramatically reduced joint pain.
- Increased movement and mobility.
- Increased leg strength (exercise is required).
- Correction of deformity.
Improved quality of life and the ability to return to some recreational activities such as walking, playing golf or riding a bike.
High-impact sports such as running, jogging and jumping will be discouraged because they can add unwanted stress on your new joint. Lifting of weights greater than 20 pounds should be avoided as well. You can certainly enjoy low-impact sports such as golf, dancing, walking, hiking, bicycling, cross-country skiing, bowling and swimming.
Risks of knee replacement.
As with any major surgery, there are potential risks and complications you should be aware of before you have total knee replacement surgery. A major cause of failure in total knee replacement is loosening of the prosthesis, either mechanical or by bacterial infection.
There is a very small chance of infection in a total knee replacement (1 out of 100 in first time knee replacements and 4 out of 100 for revision knee replacement), but if infection does occur it is extremely difficult to treat. If infection occurs, salvage of the prosthesis is dependent on several factors including:
- Type of bacteria.
- Patient health.
- Length of time from the knee replacement.
- How long the infection has been present.
In late or chronic infections, removal of the prosthesis is usually necessary. A spacer made of antibiotic loaded cement is placed and re-implantation of a new prosthesis is planned after several weeks of intravenous antibiotics. This a two stage procedure is usually successful in eradicating the infection.
Great measures are taken to help reduce infections, which include
- The use of sterile instruments, drapes, gowns and gloves.
- The patient’s leg is thoroughly cleaned with an antiseptic agent and all other areas are covered with sterile drapes.
- Space Helmets (body exhaust filtration systems) are worn by the surgical team, mainly during revision surgery.
- The patient is given prophylactic antibiotics prior to surgery and is generally continued for 24 hours following surgery, longer in cases of revision surgery.
- Because a bacterial infection from your mouth could infect your new joint, complete all dental work before surgery and always consult your physician before scheduling any post-operative dental work.
Mechanical loosening is when the implant loosens from their boney attachment, the motion between the bone and implant will cause pain, bone destruction and ultimately failure. An ideal candidate has approximately a 3% chance of loosening in a 10 to 15 year period. In non-ideal candidates such as patients who are younger and excessively over weight, chances of loosening increase. Excessive wear can contribute to loosening and leading to revision surgery.
Other complications include the formation of blood clots in the leg or pelvis. Blood clots can cause chronic swelling in the affected leg and even travel to the lungs causing a pulmonary embolism, a potentially life threatening problem. Be assured your doctor will take necessary precautions to avoid blood clots that include:
- The use of blood thinning medications.
- Elastic stockings.
- The use of plastic boots that inflate with air to compress the muscles in your leg.
- Early mobilization beginning on the first day after surgery.
Over 90% of patients having total knee replacement surgery will be able to completely extend the knee and bend it beyond 90 degrees. In a small percentage of patients internal scarring can result in reduced motion and some pain.
Other risks include strain on the heart and lungs resulting in heart attack, stroke or death; anesthetic risks; and possible damage to nerves, arteries and veins that can affect the circulation and function of the leg.
Overall, the risks are usually quite low and the chances of success greatly outweigh a chance of failure. If you have any concerns, always be sure to speak with your doctor.
The right knee replacement for you.
Surgeons can choose from a wide variety of knee replacement implants produced by various manufacturers. Materials and clinical engineering of these implants vary, and typically surgeons only use one or two product lines based upon the results they see afterward and ease of using the components. When selecting the implant for your knee replacement surgery your surgeon will consider:
- Your age, activity level, weight and degree of arthritis.
- The implant’s track record of long-term stability and adhesion called fixation.
- The implant’s material.
- The implant’s ability to reestablish your normal function.
- The surgeon’s comfort level with the surgical instruments associated with the preferred implant
- The surgeon’s confidence in the implant’s clinical success rate and product quality.
Knee replacement surgery.
The indication for knee replacement surgery is disabling pain from a moderately severe or severe arthritis which limits the patient’s ability to perform daily living activities such as getting in and out of a car, climbing stairs and getting on and off the commode. The ideal candidate for knee replacement is a patient with bi- or tri- compartmental arthritis, who is over 65, not overly active, with normal mental capacity, and who is not overweight. The converse of this represents the high risk patient for knee replacement, i.e. those who are under 65, overweight, very active, or who had a previous knee that has failed.
The implant (prosthesis) design may vary according to your needs, but commonly consists of three components:
- The tibia component consists of a high density polyethylene and may be supported by a metal tray.
- The femoral component is made of highly polished metal (cobalt chrome).
The patella is made up of a high-density polyethylene, which offers tremendous durability and strength.
The patient who undergoes knee replacement surgery has a 95% chance of having good or excellent results. This means improved range of motion, and complete or near complete relief of pain. Knee replacements are not normal knees, however, and a percentage of patients occasionally experience minor pain with activity, stiffness, and/or swelling.
Always ask your orthopedic surgeon if you are an ideal candidate for total knee replacement surgery and what risks are involved.
Surgical alternatives to total knee replacement.
Arthroscopyis a minimally invasive procedure used to view, diagnose and treat problems inside the knee joint. The orthopedic surgeon makes a small incision in the patient’s skin and then inserts the arthroscope, a miniature lens and lighting system, which magnifies and illuminates the structures inside the joint. An intense, cool light is transmitted through fiber optic cables to the end of the arthroscope that is inserted into the joint. By using a miniature video camera attached to the arthroscope, the surgeon is able to see the interior of the knee joint on a television screen. The surgeon can then wash out loose debris and trim frayed or torn cartilage in the knee. The patient can return home the same day.
This procedure is usually performed in patients with:
- Mild to moderate arthritis.
- Small amounts of deformity.
- Mechanical symptoms indicating torn or loose cartilage.
Some of the most frequent conditions found during arthroscopic examination of the knee joint are:
- Damaged joint surface (articular cartilage).
- Inflammation of the joint lining.
- Large plica bands.
- Loose fragments of cartilage or bone.
- Maltracking and tilted kneecap.
- Torn cruciate ligaments.
- Torn or degenerated meniscus or menisci.
In an Osteotomy, the surgeon actually cuts the bone and removes a wedge to realign the leg and relieve knee pain. This procedure usually results in 85-90% pain relief and is very durable but involves a lengthy post-operative recovery period of up to 3-4 months and could include immobilization of the leg. This procedure is usually reserved for younger, more active patients (40s and 50s) with only a single compartment of the knee affected by arthritis, non-smokers, and people without significant health problems such as diabetes, rheumatoid arthritis or heart disease.
Uni-compartmental Knee Replacement involves resurfacing only one part of the knee joint with plastic and metal parts. This usually results in greater than 90% pain relief. One potential problem is that the parts may wear or loosen early on, leading to more surgery. Some studies have shown better longevity of this procedure in older, thinner, sedentary people.
UniSpacer Knee System was designed to delay the need for total knee replacement. The UniSpacer is intended to restore stability and alignment for patients whose arthritis is primarily located on the inside half of the knee. It is inserted into the knee and provides a smooth surface for the bones to glide where the cartilage has worn away.
Typically used for younger patients who are not candidates for total knee replacements and are willing to live with incomplete pain relief. The UniSpacer is designed for with arthritis in the media (inside) portion of the knee. People with mild arthritis of the other compartments of the knee may get the UniSpacer, but if the arthritis in these other two compartments were severe, the UniSpacer is not indicated. At the AAOS conference in 2002 they had 120 patients showing a 10% failure rate at the end of the first year. Since this procedure is relatively new, they lack any long-term outcome studies.
Other considerations of this surgery include:
- Recovery and rehabilitation are slow.
- Like any surgery, you must undergo anesthesia, which has risks.
- Patients need extreme caution to avoid swelling of the knee.
- Patients need to be diligent with their exercises to avoid stiffness in their knee.
Activities like running and tennis should be limited to short periods.
The patient ultimately needs to decide if having a little less pain, enduring surgery and a slow recovery is worth the risk and effort.
Arthrodesis or fusion of the knee involves cutting the ends of the bones of the knee and fixing them rigidly together with either internal plates and screws or a rod placed in the canal of the bones then letting the two bones heal together. This gives the patient a stiff, painless knee. The operative leg is left shorter so walking on flat surfaces is not usually a problem. Activities such as stair climbing may be more difficult, but not impossible. This procedure is reserved for the very young patient (< 35 yrs) with severe arthritis in more than one compartment of the knee, frequently related to trauma. Fusion of the knee can lead to arthritis of the back and/or hip on the same side and is performed relatively infrequently.
Dr. LaButti takes time to talk with you and gives knowledgeable patient knee education.