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Total Knee Replacement


At the bone to bone stage, where the cartilage is permanently damaged and severe pain with limitation of day to day activities, the only option is surgical – which is total knee joint replacement.

Ancillary methods of treatment (not proven to be very effective, although not harmful, provide minimal pain relief)

  • Physical therapy
  • Acupuncture
  • Knee taping
  • Joint aspiration – removal of excess synovial fluid (decrease swelling and pain)
  • Moderate walks, swimming, cycling, yoga, Tai chi are the exercises recommended in general

Intermediate Stages


  • ​Gaps in the cartilage widen
  • Gradual thinning of the cartilage creates more stress on the ends of the bone causing tiny bony projections called Osteophytes
  • Pieces of cartilage break causing crepitus (grating, popping sound) while walking.
  • Synovial fluid seeps through cracks in the cartilage.
  • Eventually the body produces more synovial fluid as a natural defense mechanism in an attempt to maintain the gap between the bones, which ultimately causes swelling of the joint.

Pathophysiology 

There is no universal staging system for osteoarthritis, I am going to break this down into various stages for easier understanding. 

Arthritis is a joint disorder (inflammation of the joints). There are several types of arthritis

  • Degenerative (Osteoarthritis)
  • Autoimmune (Rheumatoid, Psoriatic, lupus etc.…)
  • Infectious
  • Crystal Deposits (Gout etc...)

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The intensity of pain depends on the degree of damage done to the joint. Patients become functionally impaired eventually, causing an increase in overall morbidity and mortality.

For the major part of this discussion I will be concentrating on


Knee Cartilage

Is mainly composed of tough connective tissue (supporting tissue) and water. Allows bones to slide easily and provides cushion within the joint spaces. It acts as a shock absorber. It has no blood supply, so an injured cartilage takes a long time to heal and a damaged (lost) cartilage never gets regenerated naturally.

Synovial Fluid

Synovial fluid is a yolk like fluid that is produced by the synovial membrane that surrounds the inner linings of the joint. Less than 3.5 ml of synovial fluid is needed for the cartilage to slide freely inside the joint between the bones. Synovial fluid production is directly dependent on the usage of the joint. It is composed of hyaluronic acid which is a dense (viscous) substance that helps with the lubrication of the joint.

Knee Osteoarthritis


​Internal Medicine 

Stereotypes and Myths

There is a myth among people that physical activity causes osteoarthritis. As mentioned earlier exercise is necessary for adequate production of synovial fluid and reduces joint stiffness. Exercise and diet go hand in hand. Moderate physical activity combined with balanced diet and optimal fluid intake is recommended. People who do heavy physical activity must definitely be more cautious about their diet and fluid intake as they are prone to more wear and tear in the joints. 

Increase – water intake, activity, sunlight exposure, nutritious food

Early Stages


  • As a normal physiologic process of aging, synovial fluid production decreases.
  • Thinning of the cartilage occurs, cracks form on the cartilage surface due to decreased lubrication.


 

 

By. Dr. Vishalakshmi Batchu, M.D.

Board Certified Internal Medicine

Prevention


The degeneration can be slowed down in asymptomatic and minimally symptomatic people (early stages of the disease). Here are some preventive measures I suggest.


  • Fluid Intake

As mentioned earlier, the cartilage is made of water. So optimal fluid intake is essential for optimal cartilage functionality. At least 2 to 3 liters of water a day is advised (Patients with chronic kidney and heart diseases must consult with their physicians about fluid intake)

  • Exercise

Regular physical activity is needed for optimal synovial fluid production and lubrication of the joint. Lack of exercise, decreases the synovial fluid production and causes stiffness in the joint.


  • Sodium intake (salt)

Excess sodium intake causes stiffness of the joints accelerating the disease process.
Sodium intake is dependent on individual’s metabolism and co existing chronic medical conditions.


  • Obesity

Accelerates the disease process as the entire weight falls on the knee causing damage to the joint.


  • Vitamin D and Calcium

Vitamin D and calcium is needed for proper bone growth function. Correcting vitamin D deficiency and optimal calcium intake helps to prevent progression of disease process. Sunlight is the best source of Vitamin D, however, supplementation may be necessary in case of deficiency



The above preventive measures helps slow down the disease progression.


Consuming more fresh produce (vegetables and fruits) helps provide essential vitamins, micronutrients and minerals needed for a healthy joint functionality.

Excessive consumption of processed (frozen, packed, canned, fast food, fried) foods combined with sedentary lifestyles are a major contributors for quicker disease progression.  Excess salt is used as a preservative for storing and freezing purposes as it inhibits the bacterial growth and increases the shelf life of foods but causes damage to the joint. It is always good to consume fresh cooked food and avoid stored food to minimize excess salt consumption.

Daily exercise is essential. Exercise improves the body metabolism, boosts up the immune system by improving the blood supply to all parts of the body. Recommended exercises in osteoarthritis are swimming, moderate cycling and walking and tai chi.

Sugary drinks, sodas, artificial drinks must be replaced by water. Drink water throughout the day. Water lubricates the joints and contributes to cartilage health. Water helps excrete excess salts.

Osteoarthritis of the knee is the most common joint disability


It is considered to be a normal process of aging. It is common among the older age groups but in the recent years there has been a trend towards the middle age groups, and in the coming years this trend could be moving towards the younger age groups specifically due to lifestyles.


My attempt is to explain this process to a common man in the simplest way possible. My emphasis is on disease process and prevention.

First let’s look at the physiology inside a normal knee joint to better understand the disease process.


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Treatment

Resting the joint for a few days is the only option during acute episodes.

Options include both medical and surgical.

  • Pain medication (analgesics) during episodes of flare-ups and as needed for the pain
  • Steroid injections into the joint space (decrease inflammation)
  • Glucosamine, Chondroitin supplements (not proven to be very effective)
  • Hyaluronic acid injections (The density of Hyaluronic acid decreases in the old age as a result decreasing lubrication in the joint)  (not proven to be very effective)

Decreasesedentary lifestyle, excessive salt, processed food and drinks

Final Stages

  • The cartilage is completely damaged, causing the bones to grind against each other (bone to bone stage)
  • Due to friction bones get deformed.

Knee joint primarily comprises of


  • Femur (thigh bone)
  • Tibia (shin bone)
  • Fibula (calf bone)
  • Patella (knee cap)
  • Cartilage & Meniscus (thin fibrous cartilage)
  • Ligaments
  • Joint capsule
  • Synovial membrane
  • Synovial fluid
Dr. VISHALAKSHMI BATCHU , MD
Internal Medicine