SURGERY FOR A BAD KNEE ARTHRITIS PERSPECTIVE

by DR.PARAG SANCHETI, DR.KAILASH PATIL, DR.SUNNY GUGALE.

INTRODUCTION:

One of the most debilitating disorders or rather diseases of the body are arthritis of different joints. This can lead to multiple issues in a patient's day to day life and lead to loss of function and loss of socioeconomic standing. 

However, we need to understand the treatment modalities and its outcomes in order to overcome these issues. Most commonly affected joints in these are the knees, hips and the small joints of the body.

Arthritis is an inflammation of the joints, that can cause debilitating joint pain. There are more than 100 kinds of arthritis and related conditions. Arthritis affects more than 50 million adults and 300,000 children. In America, according to the arthritis foundation. The causes and treatment options available vary from one type of arthritis to another.

Arthritis is usually a chronic condition and sometimes can lead to disability. However, there are many ways you and your doctor can lessen these problems. One of the ways may be surgery.

Joint surgery can offer several benefits: relief of pain is the most important benefit of joint surgery.

Many people with arthritis have constant pain. Some of this pain can be relieved by rest, heat and cold treatments, exercise, splints, and medication.

When these therapies don't lessen the pain, surgery may be considered. Improved movement and use of a joint are also important benefits of joint surgery. Continuous inflammation and the wearing away of bone and cartilage can cause joints, tendons, and ligaments to become damaged or pulled out of place. Losing the use of a joint, such as a hip, knee, hand, elbow or shoulder, can seriously hamper a person's activities. When this happens, surgery to replace or Stabilize the joint may be suggested. An improvement in the appearance of deformed joints, especially in the hand, can be expected with some types of surgery.

SURGCAL TREATMENT FOR KNEE ARTHRITIS

If conservative measures don't help, we may suggest surgery, such as:

Joint repair. In some instances, joint surfaces can be smoothed or realigned to reduce pain and improve function. These types of procedures can often be performed arthroscopically through small incisions over the joint.

• Joint replacement. This procedure removes the damaged joint and replaces it with an artificial one. Joints most commonly replaced are hips and knees.
• Joint fusion. This procedure is more often used for smaller Joints, such as those in the wrist, ankle and fingers. It removes the ends of the two bones in the joint and then locks those ends together until they heal into one rigid unit.

SURGICAL APPROACHES

• Although arthritis is generally an inflammatory process of the synovium, structural or mechanical derangement is a frequent cause of pain or loss of joint function. Pain and joint mobility may be improved by a surgical approach. The primary physician, the rheumatologist, and the orthopedist all help the patient to understand the risks and benefits of the surgical procedure. The decision to have surgery is a complex one that must take into consideration the motivation and goals of the patient, their ability to undergo rehabilitation, and their general medical status.
• Synovectomy is sometimes appropriate for patients with rheumatoid arthritis, though in many patients the relief is only.

A TEAM APPROACH FOR THE SURGICAL PATIENT

To deal with the complexities of treating those patients with inflammatory arthritis who do require orthopaedic surgery, a collaborative approach is used.

Orthopaedic surgeons work closely with a team that includes a rheumatologist (the physician who oversees the non-surgical treatment of the disease), an anaesthesiologist, a physical therapist, a social worker, and in some cases, psychologists or psychiatrists, and a biomechanical engineer. In addition to the systemic nature of the disease, and the effect of medications, this group must consider:

• the effect the disease can have on multiple joints
• physical limitations
• psychosocial challenges
• complex deformities
• poor bone quality
• higher complication rates

Total joint arthroplasties, particularly of the knee, hip, wrist, and Elbow, are highly successful.

Arthroplasty of the metacarpophalangeal (knuckle). Other operations include release of nerve entrapments (e.g., carpal tunnel syndrome), arthroscopic procedures, and, occasionally, removal of a symptomatic rheumatoid nodule. One of the most rewarding factors for the arthritic joint is the return to normal or near normal function as early as possible. This can be achieved by an appropriate type of surgical intervention and we can have a good functional outcome for the patient.

This option is the best option for patients with inflammatory arthritis like rheumatoid arthritis. We will have a look at each option one by one.

ARTHROSCOPY

Arthroscopy is a process that allows a doctor to see directly into the joint through an instrument called an arthroscope. This is a very thin tube with a light at the end. The arthroscope is connected to closed – circuit television.

Arthroscopic surgery can be used to find out what kind of arthritis exists and how much damage is present. Also, the surgeon can perform many other procedures such as biopsy, cutting away a loose piece of tissue that is causing pain, repairing a torn cartilage, or smoothing a Joint where the surface has become rough.

Extensive surgery, such as synovectomy or reconstruction of ligaments, is also performed through an arthroscope. The advantage of arthroscopic surgery is that it does not require as much anaesthesia or as much cutting as a standard operation.

A person can recover from it much more quickly and start walking sooner.

The procedure is most often done on the knee or shoulder, but is being used more often on other joints such as the elbow, wrist, and ankle.

Arthroscopic synovectomy –

Synovectomy is the removal of diseased synovium. This reduces the pain and swelling of rheumatoid arthritis and prevents or slows down the destruction of joints. However, the synovium often grows back several years after surgery and the problem can happen again. Although arthroscopic synovectomy of the knee has still a role as a salvage procedure in the treatment of RA Synovitis with initial joint degeneration (less than Larsen grade iii) and good rom, high revision rates and limited survivorship are reported.

We do a specialised technique for the procedure called as the six Portal technique. Six portal arthroscopic synovectomy could increase the quality of life, decrease disease activities, and improve joint functions in patients with RA. More benefits were observed in patients with early disease developments.

Osteotomy -

Osteotomy is the correction of bone deformity by cutting and repositioning the bone, then resetting it in a better position. Osteotomy of the tibia (shinbone) is occasionally performed to correct curvature and weight-bearing position of the lower leg in people with particularly osteoarthritis of the knee.

Resection -

Resection is the removal of part or all of a bone. This is often done when diseased joints in the foot make walking very painful and difficult. Resection is also done to remove painful bunions. Resection on parts of the wrist, thumb, or elbow can help improve function and relieve pain.

Arthroplasty -

Arthroplasty is the rebuilding of joints. This can be done by resurfacing or relining the ends of bones where cartilage has worn away and bone has been destroyed. Arthroplasty also refers to total joint replacement, where all or part of an arthritic joint is removed and replaced with metal, ceramic, and plastic parts. Total joint replacement has been widely used for many years, and the results are usually excellent, especially in hips and knees. Other joints, such as the shoulders, elbows, ankles, and knuckles, may also be replaced. With new materials, improved surgical methods, and a better understanding of replacement joint function, this procedure has enabled many people who were severely disabled to become more active again. Most patients need to continue taking medication to protect their other joints. In some cases, however, if the most problematic joint is treated successfully, the dose of medication taken may be reduced.

Arthrodesis-

Arthrodesis, or bone fusion, is done to relieve pain, usually in the ankles, wrists, fingers, and thumbs. The two bones forming a joint are joined together so that the resulting fused joint loses flexibility. However, a fused joint can bear weight better, is more stable, and is no longer painful. The procedure greatly limits movement but increases stability and reduces pain in the affected joints.

Conclusion:

In recent years, medical treatments for these conditions have expanded considerably. Drugs that reduce inflammation, those that suppress the immune response, and a group of biologic agents called DMARD'S (disease modifying anti-rheumatic drugs), have helped many patients with inflammatory arthritis control their symptoms and eliminated or delayed the need for surgery on joints damaged by disease.

The success of any surgical procedure is dependent upon a multitude of factors including the patient's overall health, their ability to adhere to a physical therapy regimen and the surgeon's skill, to name just a few. But for patients with inflammatory arthritis, a range of systemic diseases involving the immune system, surgery involves a particularly complex set of considerations that arise from both the illness itself and the medications used to treat it.