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Osteotomy for Osteoarthritis of Knee INR   0 INR  0
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Osteotomy for Osteoarthritis of Knee

Osteoarthritis is essentially loss of the articular cartilage on the bone surfaces of a joint. Articular cartilage (also known as hyaline cartilage) is normally a very smooth surface with special biomechanical properties that make it particularly suitable as a bearing surface. However when the surface is disrupted, a process of breakdown commences and eventually the articular cartilage coating is worn off the bones. Unfortunately, articular cartilage has a poor capacity to heal. For treatment purposes, the knee joint can be considered to consist of three compartments. One compartment is between the patella and the femur (patellofemoral compartment), and the other two are between the tibia and femur. One is on the medial (inside) half of the knee, and the other is on the lateral (outside) half of the knee. If the osteoarthritic process is isolated to either the medial or lateral compartment, one surgical option for treating significant symptoms is an osteotomy. The principle of an osteotomy is to realign the lower limb in order to shift the line of weight bearing away from the affected half of the joint and into the good half of the joint. In other words, if the osteoarthritis is isolated to the medial compartment, the aim is to shift the line of weight bearing into the lateral compartment. The main aim of this realignment is to reduce the symptoms from the osteoarthritis and delay the need for joint replacement surgery. Realignment may also slow down the rate of its progression of the osteoarthritis. It is important to be aware that realigning the leg will result in an altered appearance of the shape of the leg. If people have medial compartment osteoarthritis, they are usually somewhat bow-legged and the osteotomy will make the leg slightly knock-kneed. The opposite applies for lateral compartment osteoarthritis. Prior to surgery the person is usually knock-kneed, but after surgery the leg is straight or slightly bow-legged. Osteotomies can be performed above or below the knee joint. For medial compartment osteoarthritis, osteotomies are most commonly performed by operating on the upper tibia. If the osteoarthritis is in the lateral compartment, the osteotomy is usually performed in the lower femur. The osteotomy procedure itself involves cutting the bone virtually completely. There are then two ways of realigning the bone. One is to take out a wedge of bone and the other is to make a cut and open up a wedge and fill it with either bone or a bone substitute. If bone is used it can either be allograft bone which is taken from a cadaver, or autograft bone which is taken from the patient, usually from the hip region. Some kind of metallic fixation device, usually a plate with screws, is then used to stabilise the osteotomy while it heals. In general there has been a trend moving away from so-called closing wedge osteotomies, where a wedge of bone is taken out, towards opening wedge osteotomies, where a cut is made and the wedge is opened. There are potential advantages and disadvantages of each technique and a decision regarding the most appropriate method will be based on your individual situation.The surgery is usually undertaken under spinal anaesthetic. You are usually admitted on the day of surgery. Most people are in hospital for 2 or 3 nights. After surgery there is usually a drain tube in the wound, which is removed the morning following surgery. Depending on your surgeon’s preference, a brace may or may not be fitted after surgery. Initially you will commence walking with the aid of crutches. You may be able to partially weight bear immediately or remain non-weight bearing for up to 6 weeks following the procedure, depending upon your surgeon’s preference. An X-ray will be taken at about 6 weeks after surgery and depending on how things are progressing, you should be able to gradually increase your weight bearing and discard your crutches over the next 2-6 weeks. COMPLICATIONS Like all surgery, osteotomies are associated with the risk of complications. The specific risks of an osteotomy include delayed healing of the osteotomy, infection, deep venous thrombosis, and incomplete pain relief. DELAYED OR NON-UNION Because a cut is made through the bone, there is effectively a fracture of the bone, which needs to heal. With opening wedge osteotomies in particular, this process can be relatively slow. If the osteotomy fails to heal, further surgery is necessary to encourage the process. INFECTION Infection is a risk of any surgery, not specifically related to osteotomy. Should infection occur, this will usually either be treated with oral antibiotics (tablets) or occasionally with intravenous antibiotics. Occasionally further surgery will be required to clean up the infection. This involves admission to hospital for a number of days during which intravenous antibiotics are given. DEEP VEIN THROMBOSIS (DVT) This is a blood clot in the veins of the leg. Precautions are taken to reduce the risk and this usually involves the administration of a daily injection of a blood-thinning agent (low molecular weight heparin). Additional measures may be taken if it is felt that you are at greater risk than the average person undergoing surgery. If a venous thrombosis does occur this will usually need to be treated with anticoagulant tablets (Warfarin), which would need to be continued for at least three months. A small but nonetheless important risk for venous thrombosis is the potential of the blood clot to break off and lodge in the lungs (pulmonary embolus). This can cause significant breathing problems and very rarely can be fatal. ONGOING PAIN Osteotomy is a useful procedure for people with unicompartmental osteoarthritis who are not suitable for joint replacement, usually because of their relatively young age. However, the outcome of surgery is probably less predictable than a joint replacement. Although most patients are happy with the result, pain relief is not always complete. In the longer term the underlying osteoarthritis will progress and one can expect knee pain to return. In addition, surgery around the front of the knee is often associated with difficulty kneeling. This is more of a problem with tibial osteotomies than with femoral osteotomies. The metallic plate that is used to fix the osteotomy can be prominent, particularly in thin people. If this is the case the metallic hardware can be removed after about 12 months following surgery. This is usually done as a day or overnight case. Sometimes the metallic hardware is removed routinely after 12 months, although this is at the discretion of your surgeon. However, if a knee replacement is planned the hardware will need to be removed prior to this procedure.

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Knee Arthroscopy. INR   0 INR  0
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Knee Arthroscopy.

The knee joint is a frequent source of problems requiring the attention of an orthopaedic surgeon. The joint is primarily formed by the two large bones of the lower limb, the femur (thigh bone) and the tibia (shin bone). The patella (kneecap) articulates with the femur at the front of the knee. The fibula joins with the tibia on the lateral (outside) side of the knee. Together, the femur, tibia and patella make three compartments (medial, lateral and patellofemoral). Each of the bones has a bearing surface of articular or hyaline cartilage. In addition there is a meniscus in each of the medial and lateral compartments. The menisci are like cushions or spacers and are made of fibrocartilage. They often simply referred to as the cartilages. The direction of movement of the bones is controlled by the ligaments and the muscles make the joint move. The major ligaments are the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments. In addition, the collateral ligaments have important associated ligaments towards the back of the knee. The major muscle groups are the quadriceps at the front of the thigh and the hamstring muscles at the back. Muscles attach to bones via tendons. The main tendons around the knee are the quadriceps and patellar tendons which attach to the top and bottom of the patella respectively. The iliotibial band is like a tendon on the lateral side of the knee. There is a wide range of pathology and problems in the knee. The menisci can be torn as a result of an injury, although most meniscal tears are the result of a degenerative process and a specific injury may not be recalled. Not all meniscal tears require treatment, but if they do, this is usually done by arthroscopy. The tear can either be resected (cut out) or repaired. The articular cartilage can wear away. This is called osteoarthritis. Treatment depends on the severity of the disease and can range from quadriceps strengthening exercises to a realignment procedure called an osteotomy or to joint replacement. Isolated injuries may also occur causing local defects for which there may be specific treatment to try to restore the surface. Osteochondritis dissecans is a condition that involves an area of articular cartilage and the underlying bone and usually occurs in teenagers. The appropriate treatment depends on many factors. The bone underlying the articular cartilage may occasionally be affected by a condition called avascular necrosis in which the blood supply to an area of bone becomes disrupted. It may recover spontaneously or deteriorate to the point that intervention such as joint replacement may need to be considered. The cause of avascular necrosis is poorly understood. Ligaments can be torn. Medial collateral ligament injuries usually heal without surgery but may require bracing. Anterior cruciate ligament injuries are often treated by reconstruction, but there are also situations in which they do not need surgical intervention. Posterior cruciate ligament injuries are not usually treated with reconstruction unless they are combined with other injuries or have been causing instability. Lateral ligament injuries are often associated with other injuries and may require surgery. The patellofemoral joint is a frequent source of problems. There can be the same articular cartilage problems as in other parts of the knee. In addition there can be problems with instability of the patella as well as maltracking of the patella in its groove in the femur. Physiotherapy is often the first line treatment for many of these problems, but surgery may be required for recurrent dislocation of the patella. There are a variety of stabilization procedures that can be used depending on the specific problems of an individual.Tendons can be torn and usually require repair. However the more common problem is tendinopathy that results in local pain and which is usually treated without surgery, although surgical intervention may occasionally be required for symptoms that fail to resolve. The iliotibial band can impinge on the lateral aspect of the femur causing pain with running. It can usually be managed without surgery but surgical release is sometimes performed in chronic situations.

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Osteoarthritis of the Knee INR   0 INR  0
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Osteoarthritis of the Knee

KNEE Osteoarthritis of the knee is a common condition and is becoming an increasingly important problem for the community as a whole. In the normal knee joint the ends of the bones are covered with a type of gristle called articular cartilage. This surface has special characteristics that make it an ideal bearing surface. The articular cartilage needs to be distinguished from the meniscus, commonly called “the cartilage” The meniscus is like a gasket around the margins of the joint and fills in the gap between the rounded end of the femur and the relatively flat surface of the tibia. Osteoarthritis is a condition where the articular cartilage breaks down and is essentially worn away leaving the underlying bone exposed. On an X-ray this appears as a loss of the space between bones. There are many factors that can contribute to the development of osteoarthritis. Some individuals probably have a hereditary predisposition to the condition, as it does seem to run in some families. Females are more at risk of developing osteoarthritis than males. Obesity is a very important contributory factor as the biomechanics of the knee are such that the effect of extra weight is magnified in the knee joint. The effect is like a stiletto heel, where all the force goes through a very small area. Injuries to the knee can also contribute to the development of osteoarthritis. Such injuries include damage to the meniscus or articular surface itself and a tear of the anterior cruciate ligament. The treatment of osteoarthritis depends on the severity of the condition, the symptoms, the lifestyle of the individual, as well as their age and general health. In general, treatment can be divided into non-surgical and surgical options. As a basic principle it is always better to try all non-surgical options before proceeding down a surgical path. NON-SURGICAL TREATMENT SIMPLE MEASURES Strengthen thigh muscles. Lose weight. Analgesics. Non-surgical treatment starts with ensuring that there is adequate strength in the muscles around the knee and in particular the quadriceps muscle at the front of the thigh, and getting one's weight back to a normal level. Obviously it is difficult for many patients with osteoarthritis of the knee to exercise because of their pain. However, riding an exercise bike is a good way of strengthening the quadriceps muscle and at the same time burning calories, which will help in efforts to lose weight. However, dietary intake also needs to be modified and it may be helpful to seek specific advice from a dietician. As one loses weight and builds up strength in the quadriceps muscle it generally becomes easier to walk and this in turn will help with losing weight. Using simple painkillers can be a very effective way of relieving symptoms and improving function. Paracetamol should be the mainstay of pain relief. Various formulations are available but the basic principle is that the total dose should not exceed 4 grams per day (8 standard 500mg tablets). It is often helpful to take a larger dose (1000 - 1500 mg) in the morning and again at night. This will help get over morning stiffness and pain and relieve night pain, two of the most troublesome symptoms of osteoarthritis. OTHER OPTIONS Anti-inflammatories. Nutraceuticals (glucosamine, chondroitin sulphate, fish oil, Lyprinol). Cortisone injection. Viscosupplementation. Anti-inflammatory medications can also provide good relief of symptoms, both pain and swelling. However, they can all be associated with significant side-effects including indigestion and stomach ulcers, aggravation of high blood pressure and heart disease, and impairment of kidney function. They should therefore not be used indiscriminately and preferably only for short-term benefit. If your knee causes you most difficulty with activities such as golf or tennis, one strategy is to take anti-inflammatory medication on the day you are playing sport and perhaps the following day but then not again until you play sport the next time. There are a number of so-called nutraceutical preparations that have become very popular. These include glucosamine, chondroitin sulphate, fish oil and green-lipped mussel extract (Lyprinol). Some individuals find that they get good relief from these types of preparations but it is difficult to predict who will respond positively to them. At present there is little in the way of good quality scientific evidence to support their use. Fortunately they do not seem to have any significant side effects, so there is little harm in trying them. It would seem logical to try only one at a time. If it is unclear whether the preparation is helping, then it is probably worth taking it for 3 to 4 months and then ceasing it. If your symptoms do not deteriorate once you stop taking the preparation then there is little reason to recommence it. There is no convincing evidence to suggest that one formulation of glucosamine is better than another, or whether the addition of chondroitin sulphate provides an additional benefit. There are two groups of injections that can also be used in the treatment of the osteoarthritis. The first are cortisone preparations and these can be used for the relief of an exacerbation of symptoms, particularly if there is significant swelling. It is probably not a good idea to have a lot of injections of cortisone into the knee, as each injection is associated with a very small risk of infection of the joint. The second group of injections are the so-called viscosupplements. These are basically preparations of hyaluronic acid, which is one of the substances that make up the articular cartilage. There is some evidence to indicate that the use of viscosupplementation provides relief that is similar to that achieved with the use of anti-inflammatory medication or cortisone injections for up to 3 to 6 months. It is very important to realise that the use of anti-inflammatory tablets, cortisone injections, or viscosupplementation does not affect the progression of osteoarthritis in the longer term. These options are simply to provide relief of pain. SURGICAL OPTIONS Surgical options can be divided into three groups: arthroscopy, realignment procedures, and joint replacement. Whilst arthroscopy is a relatively small and simple procedure and the idea of a “clean-up” operation seems attractive, there is increasing evidence to suggest that the use of arthroscopy for the treatment of the osteoarthritis provides little benefit compared to non-surgical options over a period of a couple of years. It does however still have a role in some situations. It seems to work better if there is swelling of the knee. It can be useful to address associated pathology such as a tear of the meniscus. It can also be useful by allowing unstable articular cartilage to be removed along with fragments floating in the joint. Once again, an arthroscopy is only aimed at relieving symptoms and does nothing to slow the progression of the osteoarthritis. Indeed, it occasionally seems to aggravate the process and may bring on the need for a knee replacement more quickly than if the arthroscopy had not been performed all. Realignment procedures are called osteotomies. These involve cutting the tibia or femur bone and changing the overall alignment of the leg to make it more “knock-kneed” or sometimes more “bow-legged”. The aim is to take weight away from the part of the knee that is affected by osteoarthritis. Such procedures can only be used in certain patterns of osteoarthritis and are better suited to people under the age of 55. They can however provide good long-term relief and put off the need for joint replacement, whilst at the same time allowing an individual to remain quite active. Replacement involves shaping or cutting the bone ends and applying a metal or polyethylene component to the surface. Usually both sides of the joint are replaced. One can either replace all parts of the knee, which is a total knee replacement or just one part of the knee, which is a partial replacement. Like osteotomies, partial replacement can only be used for certain patterns of osteoarthritis. In general we try to put off joint replacement procedures for as long as possible because of concerns about long-term wear and loosening. In addition, replacement procedures are only compatible with low impact sporting activities. Golf, social or doubles tennis, cycling, and snow skiing are reasonable whereas running, basketball, netball, or any type of football should not be considered, because of the risk of premature wear and loosening of the prosthesis

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