Myths about Total Knee Replacement

Osteoarthritis of the knee joint is one of the most common diseases prevalent in the Indian society. Arthritis is fast emerging to be the most common disease and it is estimated that by 2013 more than 65 crore population will be suffering from it.

With the rapid changes in the lifestyle of the Indian society the age group being affected by it is getting younger and younger. Nowadays, middle age men & women start suffering with knee pain in their 40’s. The main cause for it is a lack of exercise, sedentary lifestyle, obesity, and diet changes that include higher amounts of unhealthy junk foods in the diet replacing healthy foods.

The disease generally starts with pain in the knee on exertion with mild swelling and difficulty in stair climbing. Gradually it progresses to causing pain at rest, swelling, and severe difficulty in standing and walking. If diagnosed early the patient can be treated with medicines, exercise and physiotherapeutic modalities. For correct treatment the patient must consult an orthopaedic surgeon for medications and physiotherapist for exercises.

The physiotherapy treatment should include exercise as the mainstay of treatment and not just modalities. Heat, cold, Ultrasonic therapy and other physical therapy treatment provide quick pain relief and exercises that include stretching and strengthening give a more permanent effect. The exercises include strengthening of the hip and leg muscles and stretching of the tight muscles around the hip and knee.

When all fails then knee replacement is the best treatment option available. The misconception among people suffering from knee problem about “dangers” of knee replacement has to change. Patients and their family need to understand that knee replacement is their best shot in regaining mobility and leading a normal family and social life.

Their are several myths related to knee replacement surgery. In this article we shall discuss a few in brief.

Myth: A patient with knee replacement does not regain mobility by atleast 6 months post surgery and will walk with a walker.

Fact: A patient with Knee surgery who undergoes quality physiotherapy post knee replacement generally walks independently within the first two weeks of rehabilitation. The strengthening and mobility exercises in the early phase of rehabilitation helps in quicker recovery. The post operative condition of the patient depends on his pre operative conditioning. That is a patient with good muscle strength and cardiovascular status previous to surgery recovers faster.

Myth: Another myth arises because off the name of the procedure. The name total knee replacement is a misnomer. The knee of the patient is not totally removed and replaced with an artificial joint.

Fact: In the ‘total knee replacement' surgery, the knee is not replaced. It is only ‘resurfaced'. The normal knee has an articular cartilage that covers the knee bones. In an arthritic knee, the cartilage covering the bone ends is destroyed leading to the bone rubbing against bone. In the surgery the rubbed and damaged bone ends of both the femur and the tibia are covered with caps or implants that prevent further damaging and also allow for smoother movements between the artificial surfaces.

Myth: Every patient receives custom-made specific knee prosthesis.

Fact: This is not true. Before the surgery the surgeons take several scans of the leg and knee to assess various mechanical angles of the knee and leg. To correct these, surgeons perform certain additional procedures to correct the malalignment. This helps in proper fitting and action of the implant. There are a set of five sizes of implants, one of which fits every human.

Myth: It is not a long term solution but only temporary.

Fact: This is not true either. Most cases (around 90%) have the ease of mobility and function for a period of almost 15 years. Cases fail either due to improper fitting of implant, lack in rehabilitation causing lack of mobility or in some cases due to weak bones and extreme amounts of damage to the surrounding structures. In case of a Replacement failure, an artificial knee can come out earlier, requiring a second surgery.

Myth: It should not be done in over weight patients.

Fact: Obesity or being overweight is one of the major causes of Knee arthritis. Once the patient has arthritis and is obese, it is very difficult to break the vicious cycle of weight gain and arthritis. Thus a heavy patient opting for replacement helps in easing of the pain, gaining mobility and strength and thus the ability to exercise and lose weight. It is almost impossible to exercise and lose weight in a painful knee condition.

Myth: Wait and avoid surgery as long as possible.

Fact: This is incorrect. More time the patient loses and lives with pain, higher is the degree of deformity and muscle weakness in the knee. This makes the road to recovery post surgery a bumpy one. Patients who could erase pain from their lives and attain considerable mobility wait too long damaging knees enough to get poorer results out of a surgery.

It is true that knee replacement is not the solution for every patient with knee arthritis. Patient selection, accurate execution of the operation, and pre- and post-op rehabilitation are the three most important parameters to give a successful result.

Knee Pain@25

When was the last time you suffered with pain in the knee while walking or maybe using the stairs? Not too long ago I guess and all you did was neglect it. Knee pain or rather any pain should never be neglected. Pains’ always occurs because of some under lying pathology and the more quickly it is diagnosed, better are the results.

Normally we associate pain with old age but it is not so. There are numerous causes for knee pain at different age groups. The patient's age and the anatomic site of the pain are two factors that can be important in achieving an accurate diagnosis.

Common Causes of Knee Pain by Age Group

Children and adolescents

• Patellar subluxation
• Tibial apophysitis (Osgood-Schlatter lesion)
• Jumper's knee (patellar tendonitis)
• Osteochondritis dissecans

Adults

• Patellofemoral pain syndrome (chondromalacia patellae)
• Medial plica syndrome
• Pes anserine bursitis
• Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear
• Inflammatory arthropathy: rheumatoid arthritis, Reiter's syndrome

Older adults

• Osteoarthritis
• Crystal-induced inflammatory arthropathy: gout, pseudogout
• Popliteal cyst (Baker's cyst)

KNEE PAIN @ 25

Case Study A patient presented at my clinic with bilateral anterior knee pain since 3 months. He had taken treatment from various doctors and clinics but got no result. Medicines made him temporarily better. Finally an orthopaedic surgeon referred him to us for physiotherapy. The patient was 24 years old, a little overweight and he presented with pain on stair climbing and on walking after prolonged sitting. He gave a history of performing squatting exercises at the gym. On examination of the knee, there was mild effusion (swelling) and pain on palpating the anterior aspect of patella. Crepitus (Grinding sound) was present in both the knees. The patella was slightly shifted laterally and quadriceps was weaker.

On doing a detailed assessment of the patient we observed that the lateral structures of the thigh were tight (esp. the iliotibial band) and also the patient had flat foot. The foot was also in over pronation. Assessing these bits made our treatment with him more comprehensive and permanent. Exercises were done to strengthen the Quadriceps femoris and gradually putting stress on the Vastus Medialis Oblique. Patellar Mobilisation and stretching of the tight structures around the hip and knee joint were also done. To correct the flat foot, intrinsic of the foot were strengthened and the patient given a medial arch support. Within 2 months, and having alternate day sessions, the patient had full recovery. The pain was gone and 3 months follow up was done. The patient was following the home exercise program and was on the road to recovery.

Chondromalacia patella is the softening and breakdown of the tissue (cartilage) that lines the underside of the kneecap (patella) and it is a common cause of anterior knee pain in young adults.

The patella is the bone that connects the most important muscle of the hip and thigh to its attachment at the tibia. When we bend the knee the patella traverses around a patellar groove on the femur or thigh bone. Anterior Knee pain starts when the patella is at an abnormal position due to biomechanical changes of muscle weakness and muscle tightness.

The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadricep retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint.

The disease starts with mild pain at the anterior aspect of the knee

Symptoms

· grating or grinding sound

· pain on stair climbing

· pain on walking after prolong sitting

· mild knee swelling

· lateral patellar tracking (J Sign)

Physical Therapy Treatment

Rest

Patellofemoral pain syndrome may also result from overuse or overload of the PF joint thus individuals should rest the knee and engage in activities like swimming rather than jogging.

Strengthening

o Quadriceps esp. VMO

o Adductors of the hip

o Intrinsics of the foot

o Gastronemius Soleus & Tibialis Posterior Strengthening to correct flat foot and Over pronation

Stretching

o Lateral Retinaculam and Iliotibial Band

o Hamstring

o Quadriceps

o Gastroc-Soleus Complex

Orthoses

Flat foot leads to over pronation and thus increasing the Q angle and genu valgus. Poor lower extremity biomechanics may cause stress on the knees and ultimately patellofemoral pain syndrome. Arch supports and custom orthotics may also help to improve lower extremity biomechanics.

Taping

Taping the patella medially helps in better congruence of the patella to its groove thus decreasing the pain considerably and also improving biomechanics.

STROKE- Prevention and Early Recognition

A stroke or a cerebrovascular accident (CVA) is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. The disturbance can be due to two particular reasons:

1. Ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism)

2. Hemorrhage (leakage of blood).

Both these incidences lead to the inability of the affected area of the brain to function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field

Ideally the treatment of Stroke uses a multi dimensional array of professionals and expertise.

For a stroke patient TIME = BRAIN

In a patient who has suffered a brain attack or a stroke every minute counts. Permanent neurologic damage is more likely to occur the longer a stroke goes untreated. The Golden Hour in medicine describes the magical window of time that can determine whether a patient lives or dies. For a stroke patient the first hour is most important wherein he should receive complete treatment to prevent neurological damage.

Initial treatment varies according to the cause of the stroke. An ischemic stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"), and some hemorrhagic strokes benefit from neurosurgery. Treatment to recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and involving health professions such as speech and language therapy, physical therapy and occupational therapy.

Therapy plays an important role in helping a stroke patient recover. The sessions with a physiotherapist should start as soon as possible and should include passive and active exercises to maintain range of movement, recover strength and to attain normal gait and functions. Occupational therapists work on the functional impact of the disease and assist the patient in retaining his activities of daily living. The speech therapist works on patients that end up having speech alterations. Bringing a patient back from a stroke requires team effort and every health care provider plays a major role. The patient and his family interaction has to be motivational for quick recovery. A time frame of 6 months post stroke gives maximum result and recovery is generally seen up to 18 months.

Prevention of recurrence may involve the administration of antiplatelet drugs such as aspirin, control and reduction of hypertension, and the use of statins.

Stroke could soon be the most common cause of death worldwide. Stroke is currently the second leading cause of death in the Western world, ranking after heart disease and before cancer, and causes 10% of deaths worldwide.

The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. A person's risk of dying if he or she does have a stroke also increases with age. However, stroke can occur at any age, including in childhood.

Immediate Symptoms

· The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not know that he or she has had a stroke.

· Symptoms usually develop suddenly and without warning. Or, symptoms may occur on and off for the first day or two. Symptoms are usually most severe when the stroke first happens, but they may slowly get worse.

· A headache may occur, especially if the stroke is caused by bleeding in the brain. The headache:

o Starts suddenly and may be severe

o Occurs when you are lying flat

o Wakes you up from sleep

o Gets worse when you change positions or when you bend, strain, or cough

o Other symptoms depend on how severe the stroke is and what part of the brain is affected.

Symptoms may include:

· Change in alertness (including sleepiness, unconsciousness, and coma)

· Changes in hearing, taste

· Changes that affect touch and the ability to feel pain, pressure, or different temperatures

· Confusion or loss of memory

· Difficulty swallowing, writing, reading

· Dizziness or abnormal feeling of movement (vertigo)

· Lack of control over the bladder or bowels

· Loss of balance and coordination

· Muscle weakness in the face, arm, or leg (usually just on one side)

· Numbness or tingling on one side of the body

· Personality, mood, or emotional changes

· Problems with eyesight, including decreased vision, double vision, or total loss of vision

· Trouble speaking or understanding others who are speaking

· Trouble walking

STROKE RISK FACTORS

· High blood pressure is the number one risk factor for strokes. The other major risk factors are:

o Atrial fibrillation

o Diabetes

o Family history of stroke

o High cholesterol

o Increasing age, especially after age 55

o Race (black people are more likely to die of a stroke)

I read this on facebook today (shared by Takuya Umeki) and she deserves a special thanks for it.

STROKE IDENTIFICATION:

A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.

RECOGNIZING A STROKE

Remember the '3' steps, STR . Read and Learn!

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster.

The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke.

Now doctors say a bystander can recognize a stroke by asking three simple questions :

S * Ask the individual to SMILE ..

T * = TALK. Ask the person to SPEAK A SIMPLE SENTENCE (Coherently)

R * Ask him or her to RAISE BOTH ARMS .

If he or she has trouble with ANY ONE of these tasks, call the ambulance and describe the symptoms to the dispatcher.