The most common question we Orthopaedic surgeons face in our Out-Patient department is, Doctor do I have Knee Arthritis? The apprehension of the patient is valid keeping in mind the strange views related to arthritis prevalent in the society.

First and foremost is to understand that arthritis or inflammation of the joints is not just one disease but a group of diseases with different etiologies and manifestations. Broadly, we can classify arthritis into Osteoarthritis(OA) (Primary & secondary Osteoarthritis) and Inflammatory arthritis.

Degenerative arthritis of the elderly or Primary Osteoarthritis is the commonest and is due to degenerative process of the joint cartilage akin to ageing process. It is a bitter truth that degenerative arthritis will come to every individual very much like greying of the hairs. However, the presentation is different in all individuals with respect to progression, severity and symptoms. In other words, an individual may be having severe degenerative arthritis of knee at 45 years of age with significant symptoms and deformities making movements difficult for him and on the other hand, a 75-year-old individual may be having minimal arthritis of knees, with minimal or no symptoms at all. To add to this irony are the individuals with significant arthritis on x rays having very minimal symptoms, leading a near normal life.

The inflammatory arthritis is due to different inflammatory diseases like rheumatoid arthritis and the cause, presentation and course of the disease is significantly different. 

The degenerative arthritis in Knee develops as the protective healthy cartilage gets damaged or worn out, which leads to rubbing of underlying bones with resulting pain, progressive destruction of joint and deformities.

The million-dollar question still remains that what makes degenerative knee arthritis behave so differently in different patients?

THE FACTORS

The factors which are known to us, that may contribute to variation in symptomology and progression of Osteoarthritis in different individuals are

1.        Genetics

2.        Higher level of activities leading to joint strain.

3.        Age (75% over the age of 70 have radiological evidence)

4.        Weight/BMI, obesity is very important factor.

5.        Nutritional factors

6.        Lifestyle (Lack of exercises)

7.        Trauma

8.        Neuromuscular disorders

9.        Metabolic disorders

COMMON SYMPTOMS

• The most common symptom presented by the patient is pain in medial or inner side of the knee joint especially following activity. The pain is related to increased use and worsens during the day.

• Minimal morning stiffness (<20 min) and after inactivity. 

• Range of motion progressively decreases with increase in crepitus (crackling sound from the joint) eventually leading to restricted range of motion.

• Joint instability with eventual bony enlargement with Variable swelling and/or instability.

INVESTIGATIONS

·        A standard weight bearing radiograph (anteroposterior view and lateral view with or without skyline view) is standard diagnostic tool for OA knees. The X ray findings include

•         Joint space narrowing

•         Marginal osteophytes, Subchondral cysts with Bony sclerosis.

•          Malalignment and deformities.

GENERAL MANAGEMENT PROTOCOL

• Modifications in ADL with Moderation of activities.

• Avoiding Cross legged sitting, squatting and sitting on floor, all of which can increase the intra-articular pressure in the knee upto 3 to 5 times the normal.

• Diet management and weight loss is an integral part of the treatment.

• Bracing and/or Walking stick in selective cases.

 PHARMACOLOGICAL MANAGEMENT

• Non-opioid analgesics like Paracetamol is the first line with pain relief comparable to NSAID and with minimal side effects.

• NSAIDs

• Topical agents

• Opioid analgesics

• The role of Nutritional supplements like Glucosamine etc is highly questionable and not evidence based. Rather these may lead to gastrointestinal side effects.

INTRA-ARTICULAR AGENTS

Ø Intra-articular steroids

Good pain relief but unpredictable and may be very short-lived benefit.

With frequent injections there is risk of infection, worsening diabetes, or Cardiac effects.

Ø Hyaluronate injections 

May provide some symptomatic relief with improved function in early OA, however, multiple doses are required, these are expensive and results are unpredictable with no evidence of long-term benefit.

 RECONDITIONING AND STRENGTHENING REHABILITATION PROGRAM

This is the backbone of Knee OA management and is the mainstay of treatment.

This constitutes strengthening and balancing of the muscles around the knee joint and regular active knee exercises. 

SURGICAL TREATMENT

 Ø ARTHROSCOPIC MANAGEMENT

• •  May reveal unsuspected focal abnormalities

  • Joint lavage and cleaning

  • Significant short term symptomatic benefit demonstrated, however long term benefit is doubtful and unpredictable.

Ø OSTEOTOMIES AROUND KNEE TO CHANGE THE BIOMECHANICS

Osteotomies around the knee joint or Joint distraction combined with arthroscopic modalities may be helpful in young patients with knee osteoarthritis.

Ø TOTAL/PARTIAL JOINT REPLACEMENT

When pain is severe and function significantly limited, knee replacement either partial or total is the treatment of choice. The Longevity of the implant is anywhere between 15 to 20 years depending on the patient compliance. Hence it is always prudent to delay the joint replacement surgeries till the patient can be made comfortable with conservative means in order to buy time.   

MYTHS BUSTED

MYTH: I Have Osteoarthritis-I am doomed!!?

FACT: Osteoarthritis is a universal phenomenon which will come to all, although some may get it early, with a rapid progression. Early treatment can very well take care of the symptoms in early arthritis.

MYTH: Certain Yoga practices will cure me of my arthritis.

FACT: Yoga practiced since childhood may prevent early symptomatic primary osteoarthritis and prevent its progression in selective individuals, however, once Osteoarthritis has developed certain Yogic posture can actually increase the knee joint pressure and lead to rapid progression of arthritis and deformities.

MYTH: Food supplements like Glucosamine or Hyaluronate injections in knee joint will cure Osteoarthritis.

FACT: There is no cure for Osteoarthritis however only treatment is possible. Oral Glucosamine or Knee joint injections of Hyaluronate have no evidence based significant benefit in Osteoarthritis and the effect is largely attributed to Placebo effect.

MYTH: Osteoarthritis can result from Calcium or Vitamin D deficiency.

FACT: Osteoarthritis results from degenerative loss of cartilage, which is not related to Vit D or Calcium deficiency. However, Osteoarthritic joints with weak bones may become more symptomatic.

MYTH: My mother and/or father had Osteoarthritis, so I will definitely get it.

FACT: There may be higher chance of getting Osteoarthritis in individuals if their parents had it, but such an occurrence is highly unpredictable and variable in different individuals. A routine muscle strengthening and balancing exercise schedule will keep Osteoarthritis at bay.

 MYTH: Joint replacement surgeries have a high failure rate.

FACT: In a well-established Osteoarthritis, Joint replacement surgery is the only treatment of choice with a success rate of around 98%.