We often get from patients, "How exactly do I avoid arthritis?" or actually "How do
I avoid a total knee replacement all together?" Well, first off, you got to
start with the anatomy of a patient, okay? Just to simplify things, if we just did
stick figures here and just drew a regular person here, you got to look at the knee
and the alignment of the knee. Now, some people are born, naturally, with bowed
legs, okay? Some people are born with knock knee. And both of these patients are
predisposed to different types of arthritis. And the way that you can tell
if you have one or the other, if your knees are bowed or they're knock kneed is
just going ahead and look in the mirror. Just stand there, look at your knees. Are
your knees touching each other? Or do you have a space between your knees when you
bring your feet together? That's one quick way to see if either you're bow legged or
if you're knock kneed.
The majority of us are pretty neutral. We're in between somewhere to these two
extremes here. But the problem with somebody that's, like for instance, bow
legged here is that when you have a joint . . .this is just my hip joint and this is
the knee here. This your leg and this is the foot, okay? This the knee. Your stress
across the body or whatever stress is going across the lower body starts up at
the hip joint, it goes down to the foot, okay? And if you have a more bowed leg,
that stress is going down through what we call the medial side of the knee, okay?
All the people that come in and they got . . . "Oh, I got pain on the inside of my
knee. I've got arthritis, " and they have bowed legs. And then we get an x-ray and
there's just no joint space left here, and that's complete collapse. Okay. The same
thing but opposite occurs in the knock kneed patient, is where the stress occurs
on the lateral joint which is the outside of the joint, okay? And that's because the
stress occurring over here instead of over here.
Well, what do you to decrease your risk of this progressing, okay? Well, first off
you got to determine if you do have a anatomic affinity to one or the other, if
you're bow legged or knock kneed. And if you do, you can do things like bracing
where you actually . . . there are special braces that you can wear that help open up
this joint space here and give you a better alignment. There are things like if
you have a high body mass index, meaning you weigh a lot. If you weigh a lot,
that's more stress going across that joint. That means higher breakdown of the
cartilage, faster progression to arthritis. So a weight loss program is
definitely going to be beneficial. If you already have arthritis and you want to
slow down the progression in general, sometimes you got to take in consideration
the activities that you're doing. If you're doing a lot of excessive pounding
on the knees type of activities, you may want to look at, say, something that's low
impact, maybe elliptical, swimming, biking. Those are going to be better for
your knees just because of the less stress across the knee, especially across where
this alignment, this mechanical axis is occurring across that joint. So you always
want to take those things into consideration.
Typically, when it comes down to early arthritis, the symptomatic treatment for
that is more anti-inflammatories, ice, compression, elevation. If you start to
have symptoms such as locking or pain with twisting and turning, those are what we
call mechanical symptoms. And that would mean that there's something physically
getting stuck in the joint, which means that you may have meniscus tear or a
cartilage flap or a loose body. And you would need an MRI to confirm that. If it's
more like a pain at the end of the day or pain when you're just on your feet for
long periods of time, it's not like that sharp pain that gives you some sort of
instability but more of a dull, aching kind of pain, that's more arthritic
symptoms. And you just want to be aware of that. So, as far as different procedures
that are out there if you catch arthritis early. Let's just say you catch a chondral
lesion or a little bit of a breakdown in the cartilage, there are certain
procedures that you can do to kind of give you or repair that cartilage that's eroded
away. But it all depends on the size of the lesion. So, for instance, if you have
a knee joint, and you have diffuse arthritis everywhere, okay. Arthritis is
basically where the cartilage is gone, okay? There is no cartilage left. It's
bone and exposed bone. If you get to this point here, there's not a lot of good
options.
I mean, there are some injections that you can try. There's viscosupplementation
which is a lubricant type of injection which can help with pain and inflammation.
There's some doctors using a lot of the platelet-rich plasma or even stem cell
injections. Although, that's still being debated on how beneficial that is
long-term. And there are some resurfacing options such a like a patella resurfacing
or a partial knee replacement or a total knee replacement. But those are all where
you actually have to remove the cartilage and put in an implant. Now, if you do
have, let's say, smaller lesions that are isolated, then it comes down to how big
that lesion is and what you can do for it. If you have a very small lesion that's
like exposed bone but it's less than two centimeters, there are some options for
that lesion. And on of them involves us drilling some holes into that area. It's
called micro fracture. And what that does is it's creates a little bit of a, almost
like a, scab over that exposed area of bone to kind of give you a cartilage-like
substance over it. It's call hyaline-like cartilage. There's also some newer
techniques where we actually combine the micro-fractured drilling with a cartilage
from cadavers are actually creating a scaffold for the cartilage cells.
So we actually get a powder of cartilage cells and we put it in this area here, and
you glue a cover over that area, like a cap. And it basically uses the bone marrow
cells from those drillings and uses the cartilage cells from the cadaver. And it
creates, once again, a very stable cartilage-like construct. There's also, if
you have a larger lesion, if you're greater than two centimeters and you start
to get in about a two to five centimeter lesion or even a little bit larger than
that, you can do what's called autologous chondrocyte implantation where you
actually take a biopsy of cartilage from that knee. You send it off, get cartilage
cells. You go back into the knee a second time. You implant those cells, and then
you sew a covering on top of that to give you more of a cartilage type of covering
across that area that's involved. Now, there's even the option of what's called
an osteochondral autograph or allograft transfer where, let's just say, you have a
larger lesion, or you've done one of these two options here previously, okay? You've
already done one of these, and it's not working. Well, there is an option where
you can go and you can get a cadaver cartilage plug. And you actually just make
a plug and put a plug here and you can put a plug here and you can put a plug here.
And you can actually plug in these defects with cartilage plugs from a cadaver. Or
sometimes, if they're small enough, you can take a plug from your own bone and
plug in those defects with the cartilage from your own bone.
But usually you don't want to do that for larger lesions, because you don't want to
take too much cartilage from your own bone to plug up these defects. Once these all
fail, or once these all stop working, then you got to fall back on the injection
therapy we mentioned before and eventually some sort of a long-term type of implant
option where it's either a partial knee replacement, a patella femoral resurfacing
or a total knee replacement. So I'm hoping this shed a little bit of light on
arthritis and what to do. And one more thing that you can do that you may read
about also in regards to the alignment issue. If you do have a patient that's
young and has a very bowed knee, you can basically do what's called a high tibial
osteotomy where you actually make a cut into the tibia here. And you actually
realign that tibia by swinging it out this way and giving you a straighter alignment
of that knee. It's called a high tibial osteotomy. And you put a plate over here
to hold it in position. It's a bigger procedure, but long-term, it's beneficial
because you're keeping all of your joint as it is. You can combine this type of
procedure with one of these type of procedures that we did over here.
The benefit of this is that you're taking that stress away from the medial part of
the joint, and you're moving it more centrally. So you no longer have that
breakdown on the inside aspect of the joint. And from a long-term perspective,
that's an ideal situation. You want to unload this joint area. So I'm hoping that
this shed some light on some of the questions regarding arthritis in the knee
and what some options are. But, once again, as always, I recommend discussing
these with your orthopedic surgeon or coming in for an evaluation with us. And
we'd be happy to give some recommendations based on your x-rays and your alignment.
Thank you.