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KNEEPAIN ByTomasPevny,MD Oneofthemostcommoncausesofkneedysfunctionisarthritis.Thisinessenceistheknee wearingout,similartoatirelosingitstread.Variousconditionssuchasprevioustrauma,infection, inflammation(rheumatoid,psoriasis,scleroderma,gout,etc),meniscalandarticularcartilageinjurycan leadtoarthritis.Idiopathicarthritisoccurswithoutanyprecedinginjuryorsurgeryandmaybe secondarytoalignmentissuesorafamilyhistoryofarthritis.Thenon-inflammatoryformofarthritisis commonlyreferredtoasosteoarthritis. Osteoarthritis(OA)occurswhenthecartilageontheendofabonewearsout.Articularcartilage isaveryefficientbearingsurfaceandwhennotfunctioningproperlyleadstopain,stiffness,andlossof jointfunction.OAistheleadingcauseofphysicaldisabilityintheU.S.limitingeverydayactivityformore than10millionpeople.ItcoststheUSeconomybillionsofdollarsintreatmentandlostwagesandhasa negativeimpactonqualityoflife.Thekneeisthemostcommonjointinvolvedandapproximately 1,000,000partialandtotalkneereplacementsareperformedintheU.S.eachyear.AstheU.S. populationagesthenumberofreplacementsisexpectedtoquadrupleoverthenext10-20years. OAistypicallydiagnosedbyapatienthistoryofincreasingpainwithweightbearingactivity,a physicalexamconsistentwithswelling,stiffness,andoccasionallymalalignmentofthelimb.X-raysare alsohelpfulandusuallyprovidemoreinformationthanaMRIfordiagnosingOA.X-rayscanshow narrowingbetweenthefemurandtibia,bonespurs,alignmentoftheknee,andtheoverallseverityof theOA. TreatmentofOAdependsontheseverityofthesymptoms.Themainsymptombeingpain.In generaltreatmentcanbedividedintonon-surgicalandsurgicalapproaches. Non-operativetreatmentisdirectedatpatientswithnewonsetofsymptomsorpatientswith mildtomoderatesymptomsandx-raychanges.Thisisusuallyaimedatreducinginflammation,and improvingmotionandstrength.InitialtreatmentencouragestheuseofNSAID’ssuchas Ibuprofen(MotrinandAdvil),Naprosyn(Aleve),orCelebrex.Acetamenophin(Tylenol)isrecommended forpatientswhodonottoleratetheNSAID’s.Thesemedicationstreatthesymptomsbutdonotcure arthritis. PhysicalTherapy(PT)isveryusefultoimprovemotion,strength,andfunction.Exercisecanalso leadtoweightlosswhichdecreasesjointreactionforcesontheknee.Evena5poundsreductionin weightcansignificantlyreducestressontheknee. IfPT,medications,andactivitymodification(lessimpactactivitiesie.Bikingandsimming)arenot effectivetheninjectiontherapymayhelp. Injectiontherapyconsistsofintroducingmedicationdirectlyintothekneejointtodecrease inflammationandpotentiallyalterthebiologyofarthritis.Traditionally,theinitialinjectioniscortisone. Cortisoneisasteroidwhichdecreasesinflammationintheknee.Itisusuallywelltoleratedandcanbe repeated3-4timesannually. HyaluronicAcid(Synvisc,Orthovisc,Euflexxa)isanormalconstituentofjointcartilageandjoint fluid.InindividualswithOAthequalityandquantityofhyaluronicacidisdiminished.Theseinjections canbedoneevery6monthsandhelpdecreaseinflammationandrestoreamorenormalenvironmentin theknee.StudieshaveshownHAtobeeffectiveformildtomoderateOAbutnotsevereOA. OneofthemorerecentandintenselydiscussedtreatmentsforOAisPlateletRichPlasma(PRP) andStemCell(SC)injections.Botharestillconsideredexperimentalandthusarenotcoveredby insurancecompaniesandmedicare.However,recentstudiesareshowingpromisingresultswithboth PRPandSC’s.Ibelieveinthenext3-5yearsthiswillbecomecommontreatmentformildtomoderate OA,especiallyinyoungerpatientsandthosenotcandidatesforsurgery.Theseinjectionshavethe potentialtobegamechangersinthetreatmentofOAastheycanpossiblychangethebiologyinthe kneetostimulatenewcartilagegrowthandregeneration. Onceapatienthasfailednon-operativetreatmentthedefinitivesurgicalproceduretoridthe kneeofarthritisisapartialortotalkneereplacement.Thismeansreplacingthedamagedboneand cartilagewithmetalandplastic.Withnewtechnologysuchasrobotics,computerassistance,3D printing,patientspecificimplantsandimprovedmaterialsreplacementsaredependable,reproducible, andsuccessfuloperations. Arthritisisaconditionthatleadstosignificantpainandfunctionallimitationformillionsof individuals.Varioustreatmentoptionsnowexistwhichcanreducesymptomsandslowtheprogression. Biologictherapy(PRP,SC’s)isanexcitingnewfieldwhichhasthepotentialtochangethewaywetreat arthritisinthefuture.Jointreplacementisthedefinitivetreatmentonceallothersfail.
