• How to Avoid Total Knee Replacement Surgery

    by Dr. J. Michael Bennett
    on Aug 12th, 2015

Call 281-633-8600 for an appointment.  If you’re suffering from knee arthritis, is it inevitable that you’ll need to have a total knee replacement?  Maybe not.  Dr. J. Michael Bennett talks about options for treating knee arthritis can can delay or even prevent total knee replacement surgery.

This is a summary of Dr. Bennett’s video on how to avoid a total knee replacement.

Are You Knock-Kneed or Bow Legged?

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.  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.  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 looking 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. 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. 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.

Can You Lose Weight or Change Your Activities to Reduce the Stress on Your Knees?

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.

What Are Signs of Arthritis Compared to Other Knee Injuries?

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.

With Small Cartilage Lesions You Have More Options

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 one 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.

Don’t Ignore Knee Pain from Arthritis

If you have knee pain, you shouldn’t ignore it.  Call 281-633-8600 for an appointment with Dr. J. Michael Bennett.  Dr. Bennett will evaluate your knee and give you options for treatment.  He’s a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports Medicine Specialist.  Dr. Bennett has extensive experience treating arthritis and knee problems.

Dr. Bennett has offices in Houston, near the Houston Galleria, and in Sugar Land, near First Colony Mall.

Author Dr. J. Michael Bennett

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