Knee Joint

The patella or kneecap is one of three bones, along with the shin bone of leg and thigh bone, which make up the knee joint. All of these bones are covered with a layer of cartilage at points where their surfaces come into contact. This lining helps frictionless smooth gliding movement between the bones. Furthermore, the patella is wrapped up inside a tendon. This tendon connects the muscle of the thigh to the shin bone below the knee joint.

 

The patella is important functionally because it increases the leverage of the knee joint. Patella transmits enormous amounts of stresses during this leverage which can affect its lining. The most common symptom of patellar irritation is pain associated with prolonged sitting and descending stairs. The reason the pain is more severe when descending stairs rather than climbing is due to the mechanics of the knee joint. The basic explanation is that the force burdened by the patella is about two times body weight when climbing up stairs, and seven times body weight when descending. This increased burden on the kneecap when going downstairs causes a magnification of pain during that activity.

 

 

Types of Knee Cap or Patella Injuries

Chondromalacia Patellae (Runner’s Knee): The most common disorder is known as chondromalacia patellae, often called Runner’s Knee. Chondromalacia occurs because of irritation of the articular cartilage on the undersurface of the kneecap. Chondromalacia is often seen in cases of arthritis.

 

Prepatellar Bursitis (Housemaid’s Knee): Prepatellar bursitis, or Housemaid’s Knee Syndrome, is a condition of swelling and inflammation over the front of the knee. This is commonly seen in patients who kneel for extended periods, and also after minor but direct injuries on knee cap which may lead to the collection of blood/fluid under the skin over the kneecap.

 

Patellar Subluxation/Dislocation: Also called an unstable kneecap, patients who experience this painful knee condition have a patella that does not track evenly within its groove on the femur. If it is going out of its track surgical correction is necessary.

 

Patellar Tendonitis (Tendonitis of the Knee Cap): Patellar tendonitis occurs when the tendon and surrounding tissue become irritated and inflamed. This is common in athletes who jump but can also be seen in other athletes. The pain is normally centralized over the tendon and there may be some swelling around the tendon.

 

Symptoms:

Dull pain aggravated with prolonged sitting with a bent knee, squatting on the floor, on stairs, walking on slopes, and activities like jogging/running. Another important symptom is pseudo instability. The knee may buckle or “give way” when you walk but there would not be any actual ligament problem. This is due to sudden pain in front of the knee, the thigh muscle stops supporting the knee for a moment. You may experience tenderness, swelling, and bruising around the joint. A dislocated knee cap is very obvious with deformity and pain.

 

Causes:

Osteoarthritis or just the wear and tear of normal aging can soften cartilage under the kneecap. In addition, some people are born with slightly misaligned bones, imbalanced quadriceps muscles, or shallow patella femoral grooves that increase the chances of cartilage damage or knee dislocation. This is more common in young people especially in women and in athletes. Chondromalacia of knee cap is due to these causes but in many, the exact cause is difficult to ascertain. A patellar dislocation can also occur when a person twists his knee, changes direction, or suffers a direct blow to the knee while playing sports.

 

Diagnosis:

Proper symptomatic description by the patient may suggest the kneecap problems. X-ray and in certain cases MRI scan also help in diagnosis.

 

Treatment:

Treatment of these various kneecap conditions depends on the diagnosis. But there are some general guidelines that can be followed. In acute cases, rest and pain medication followed by physiotherapy and in long-standing cases appropriate tests to find out the cause will help in the treatment. Even long-term knee pain cases initially will be managed conservatively, but surgery may be necessary for some.

 

Healthy Joint Club says:

Many cases of knee cap problems can make life miserable as it may get difficult even to negotiate a small step without the fear of a fall, or a catching sensation. But many cases of Chondromalacia from late teens the to early thirties can be managed adequately with treatment. Complete relief of pain may be not possible in all cases but enough relief can be obtained in most patients to be able to manage normal daily activities. One doesn’t need to worry about ‘Catching’ arthritis, though the same symptoms from mid-thirties might indicate the onset of osteoarthritis in the knee especially in obese individuals. Simple lifestyle changes with stress on exercise and diet changes would go a long way in helping these patients.

Injury to the knee joint can cause fractures of one or all the three bones forming the joint. However, knee joint has some special soft tissue structures within and just outside the joint which can get damaged without any bony fracture. In this section, we deal with only these soft tissue injuries.

 

The injury can be acute following an impact or twisting such as an anterior curiae ligament injury. Injury can be a chronic one i.e. developing slowly due to repeated minor injuries. Pain can be related to overuse where small stresses are repeated a large number of times without allowing adequate recovery, for example running too much too soon or excessive jumping. An overuse injury can also be considered to be acute if it is painful or inflamed.

 

Types of Knee Injuries:

A knee injury can affect any of the ligaments, tendons or fluid-filled sacs (bursae) that surround your knee joint as well as the bones, cartilage, and ligaments that form the joint itself. Some of the more common knee injuries include:

  • ACL injury: An ACL injury is the tearing of the anterior curiae ligament (ACL) — one of four ligaments that connect your shinbone to thighbone. An ACL injury is particularly common in people who play football, basketball or any forceful activity linked to sudden changes in direction.
  • Torn meniscus: The meniscus is formed of tough, rubbery cartilage and acts as a shock absorber between your shinbone and thighbone. It can be torn if you suddenly twist your knee while bearing weight on it.
  • Knee bursitis: Some knee injuries cause inflammation in the bursae, the small sacs of fluid that cushion the outside of your knee joint so that tendons and ligaments glide smoothly over the joint.
  • Patellar tendinitis: Tendinitis is irritation and inflammation of one or more tendons — the thick, fibrous cords that attach muscles to bones. Runners, skiers, and cyclists are prone to develop inflammation in the patellar tendon, which connects the quadriceps muscle on the front of the thigh to the shinbone.

 

Symptoms:

The location and severity of knee pain may vary, depending on the cause of the problem. Signs and symptoms that sometimes accompany knee pain include:

  • Swelling and stiffness
  • Redness and warmth to the touch
  • Weakness or instability
  • Popping or crunching noises
  • “Locking,” or inability to fully straighten the knee

 

Diagnosis:

It is usual to get an X-ray done first which can help detect bone fractures and degenerative joint disease. But it will not show soft tissue injuries which can only be detected by MRI scan.

 

Treatment Options: Treatments will vary, depending upon what exactly is the knee injury.

 

Medications: For pain relief and to reduce the swelling. Splinting to rest the joint and minimizing weight bearing will also relieve pain.

 

Physiotherapy: Initiated as soon as possible to prevent muscle weakness and to joint stiffness.

 

Surgery: If you have an injury that may require surgery, it’s usually not necessary to have the operation immediately. Before making any decision, consider the pros and cons of both nonsurgical rehabilitation and surgical reconstruction in relation to what’s most important to you. The decision depends on the age of the patient, level of activity, severity, and type of injury and the disability of the patient. If you choose to have surgery, it is usually arthroscopic surgery. In cases where there are also advanced changes of osteoarthritis, a knee replacement surgery may be needed.

The aim of this information sheet is to answer questions that may be on your mind about a knee replacement.

 

Do I need a knee replacement?

 

“If pain from a worn out knee is bad enough and not responding to tablets then it needs replacing”. The decision to replace a knee will involve weighing up the risks of the operation and the benefit you will get if the operation is done. The longer and the larger doses of pain medication you take, more are the chances of side effects like damage to stomach, kidney etc.

 

The decision is easy if you are suffering from severe pain and can’t walk far, especially if you are older. Most people having a knee replacement are over the age of 50. Putting off the operation if you have severe arthritis could allow the muscles to become weaker, make the knee more stiff and deformed and will reduce the chance of success. If you are under the age of 50 you are highly likely to need a further operation later in life.

 

What can I expect from a knee replacement?

About 90% of replacement knees last for more than 10 years. However, there are many factors which determine the success of a knee replacement and people’s expectations vary greatly. Most people have very little pain after the first 6 months but, even for those who do, it usually improves over two years. Most people are able to walk with little pain for 30 minutes, but a few may need a walking stick. The improvement in walking also helps the heart and lungs and people are generally fitter a year after surgery.

 

Giving way (jerking) of the knee should get better in 7 out of 8 patients after surgery. 2 out of 3 patients can easily go out for their household shopping. After a knee replacement, 4 out of 5  people can use stairs with relative ease. For younger people, a knee replacement will probably not be comfortable enough to get back to heavy manual work. Do not expect your knee to bend fully,  especially if it was stiff before.

 

What is the new joint and how does it work?

The worn out ends of the bones are removed and would be replaced with metal and plastic. These materials have been successfully tried and tested for many years. The end of the thigh bone (femur) is replaced by a single curved piece of metal. The top end of the shin bone (tibia) is replaced by a flat plate of metal. Plastic is fixed to this flat plate to act like cartilage and help the bones move easily. The components of a knee replacement are usually cemented into the bone. It is also possible to correct any ‘bow leg’ or ‘knock knee’ deformity of the knee to some extent while putting in the new joint.

 

About the operation and your stay in the hospital

During the first 24 hours after surgery, your pain will be controlled by the drugs or injections. After the first day, it is likely that the various plastic tubes for fluids, medication, and drainage will be removed. You will be encouraged to take normal diet. The physiotherapist will help you to start walking. Within a day or two, you will be sitting on the side of the bed and you will be encouraged to bend and straighten your knee. If you have had both knees replaced you will be less mobile at first. You will be taught exercises of the knee to strengthen the muscles and also to mobilize the knee which in the beginning can be painful.

Everyone is different and some people progress faster than others. If you had good muscles before surgery and your knee is not very bruised, you will be up and about walk using a frame from the first postoperative day. But people who are very heavy or who have weak muscles may take a day or two more to walk and to gain proper control of the knee. This is especially likely if you have rheumatoid arthritis. Some patients are a little too over-enthusiastic and cause more bruising by being too active. Then you may be advised to slow down a little! The main priority is to make sure that the wound heals properly in the first two weeks.

 

It is very likely that you will be able to walk along the corridor without help, just using a frame or crutches for support. If everything is well you will be able to go home in about 5 days. You will need to see the doctor at the end of the second week for a wound check and suture removal.

 

The first few weeks at home

You may need painkillers because exercise can be painful. You need to carry out exercises to build up the muscles and recover the range of movement. Good supportive outdoor shoes (not slippers) are best worn in the early days to help your walking.

 

About 6 weeks after the operation it is likely that you will be seen again in the clinic.  If you were using one stick before the operation, you will probably no longer need it. If you were using two sticks or a frame you will probably now only need one stick. You will probably be able to go out from your home independently 6 weeks after surgery and return to light office work. If your work involves a lot of standing and some light lifting you will not be ready until about three months after surgery.

 

What are the main risks of the operation?

Total knee replacement is a major operation which by and large is a safe surgery but has risks like any other major operation. There are the risks of complications at the knee joint itself. For example, in 1 in 10 patients the healing of the wound takes longer than normal, requiring dressings and possibly an extra week in the hospital. Or, a wound infection may occur, requiring antibiotics, but a deep wound infection is very rare. However, if a deep wound infection happened it might need further ‘revision’ surgery and very occasionally the new knee joint will need to be removed altogether.

 

There are also the general risks of having a major operation. Most people come through surgery without a problem and the risks of a stroke, a heart attack or death are very low (the risk of death is less than 1 in 100) following a total knee replacement.

 

Stiffness:

Sometimes the knee becomes very stiff in the weeks after the operation for no apparent reason. The harder you try to exercise the knee, the stiffer and more painful it becomes.  A few days without exercises – just resting the knee – may make all the difference. Occasionally, if your knee is not progressing well at about 6 weeks, your surgeon may feel it best to ‘manipulate’ your knee. However, you need to have realistic expectations. If you had a knee that was very stiff before surgery, you are not likely to be fully mobile after knee replacement.

 

Can an artificial knee be replaced with another one?

Yes, it can. If a replaced knee wears out (this will usually be after more than ten years) then it can be replaced with another replacement- a ‘revision’ operation, and this is difficult than the first. However many patients have had successful revision surgeries and some have had three or more replacement joints.

Finally, it is needless to say that these joint replacement surgeries have transformed the lives of patients who otherwise would have remained crippled and forced to lead an indoor life with a detrimental effect on general health and well being of a patient and a burden on the family.

Ligaments are like strong ropes that help connect bones together and provide stability to joints. In the knee, there are four main ligaments. On the inner aspect of the knee is the medial collateral ligament (MCL) and on the outer aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These paired ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The MCL and the LCL work together with ACL and the PCL to keep the knee joint stable during movement. The MCL and LCL provide support at the inner and outer aspects of the knee while the ACL and the PCL lend support at the center of the knee.

 

Types of Ligament Injuries:

The above ligaments of the knee can get damaged with injury, from a simple sprain to a total tear. The severity of the injury can be assessed by checking how much abnormal movement is there at the joint. A small tear may allow 5 mm of excess movement and a complete tear may allow gross abnormal movement.

 

Symptoms:

The symptoms are pain and swelling from the injury. But when the person tries to weight bear or walk then the knee may feel ‘wobbly’ – instability- and you may feel like your knee is giving way or it is locking

 

You may feel or hear a popping or snapping sensation at the time of the injury. You may also find that you cannot stand properly on the affected leg or put your full weight on it.

 

Along with ligaments, there may be damage to cartilage cushions of the knee joint. There may not be any pain if you injure the cartilage of the knee, but you may have some pain or discomfort from the swelling that follows an injury. Pain may be on the inside or outside of the knee joint depending on which part of the cartilage got damaged.

 

Causes:

You may injure your knee ligament if:

  • It receives an impact or is moved beyond its usual range of movement, for example, if you have a fall or land awkwardly
  • During sports that combine running, jumping and stopping with quick changes of direction, such as football
  • Your knees hit the dashboard in a car accident – posterior cruciate ligament damage is sometimes called the ‘dashboard injury’ as this is often how it occurs

 

Diagnosis:

Gentle examination often helps but it may not be possible to fully examine in acute injuries due to severe pain. But in chronic injuries, it is possible to come to a conclusion after the examination. X rays and MRI scans help further to diagnose more complicated or severe injuries.

 

Treatment Options:

The treatment you receive will depend on what damage you have done and how bad the damage is. In acute injury, it is always – Rest, Ice application, elevation, and immobilization. In chronic injury– Stretching and strengthening physiotherapy and splinting.

 

In some situations, you may need to have surgery to repair the ligaments. This is likely to be the case if you have torn a lateral collateral ligament, ACL especially in active people and there is a torn cartilage. Most medial collateral ligaments heal well with splinting but may rarely need repair. If there are more than two ligaments torn then it is best to repair them both. If PCL injuries remain chronically painful not responding to physiotherapy, need surgery.

It is a very common problem. The symptoms start when the lining of the bones begins to wear out. During this process patient may develop tears of cushions (menisci) and problems due to weak or tight ligaments and ultimately deformed knees (bow legs).

 

Risk factors

Common in people over 50 years of age, particularly in women. But both knees need not be affected at the same time. The wear is more common on the inner side of the knee. The risk is higher in individuals who played intense physical sports, such as football, any previous injury, obese people (Body Mass Index>30), certain physical occupations that involve prolonged squatting or kneeling, carrying more than 25kgs regularly, and any other repetitive strain of the knee over a long period of time. Crystal Deposits such as uric acid accumulation also damages the joint.

 

Symptoms:

Osteoarthritis need not be considered as a disease. Various treatments can be tried to slow down the progression of the condition and to make life more comfortable:

Knee OA develops slowly over several years. In the beginning, you may notice some discomfort after a long walk or some exertion. Later on, you may notice stiffness after sitting for some time and early in the mornings. As the condition progresses, pain can interfere with simple daily activities. The joint may swell up and make clicking or grinding noises while bending or walking. In the late stages, the pain can be continuous and even affect sleep patterns. Muscles may become weak and thin. The patient may also develop bow legs or knock knees.

 

Treatment Options:

  • Knee Supports/Braces – Provide pain relief but may be uncomfortable to wear.
  • Assistive Devices – Such as cane or walker can be used to help in walking
  • Medications – To control pain and to nourish cartilage (dietary supplements).
  • Topical Creams – Topical creams provide an alternative to oral medications.
  • Heat and Cold fomentations – Relieved pain and inflammation after exercise.
  • Weight Loss – Slows the progression of joint wear and reduces the suffering.
  • Exercise Program – Maintains healthy cartilage, improves joint movements, keeps the muscles and tendons conditioned and strong which will aid in the joint’s stability. Hydrotherapy may be useful to reduce the stress on the joints.
  • Viscosupplementation – This injection into the joint helps to lubricate the knee joint and decreases the amount of inflammation.
  • Arthroscopy – This procedure takes care of locking symptoms.
  • Knee Replacement Surgery- Has proven it’s placed and is hugely successful all over the world in relieving the symptoms from advanced osteoarthritic knees and also in improving the quality of life.

 

Healthy Joint Club says:

Osteoarthritis of the knee is, unfortunately, becoming more common. There may be various reasons for this rise but the main culprit undoubtedly is our weight. Changes in the dietary habits go a long way in helping yourself. This will also help your doctor to treat you well as you respond better to the treatment given. There is no need to get depressed about it without doing your bit to help yourself. The healthy joint club recommends ‘Multimodal treatment’ which is a holistic way of treating a patient and there is no reason for the patient to suffer unnecessarily from pain in these days. We now have the techniques and expertise to treat the patient at any stage of the disease, by nonoperative means in early and middle stages and with operations in the advanced stages. The role of surgery is well established and patients need not have any apprehensions about the same.

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