The Legend of King Arthur-itis and the Knights of the Knee Arthroplasty
Welcome to the forth edition of an ongoing series built to break down common medical conditions and emergencies so all of us can have a better understanding of just why doctors do what they do.
Thankfully I've been overwhelmingly healthy and issue free for my entire life. Good genes and luck more than wisdom and disciplined living.
There are some patient presentations that trigger powerful feelings of empathy -- gout flares and osteoarthritis flares, in particular. I've had a couple gout flares -- the worst manifesting in my knee during my first semester of medical school. I didn't know what was going on and the pain was extraordinary.
A solid decade of avid skateboarding will teach one to tolerate pain, but that gouty knee was terrible. Gout is nothing more than an acute arthritis caused by purine crystal formation in the fluid of the joint, which look like barbed wire under the microscope. The sharp, powerful sensations of pain do not disappoint, in that barbed wire is a fitting description.
For a brief moment in time I thought about being an orthopedic surgeon and as such spent an extra four weeks with a group. A lot of surgeries. Open Reductions Internal Fixations (ORIFs), replacements of all major joints, arthroscopic trim jobs, revisions -- the list goes on.
I've had to scrub in on what feels like way too many surgeries, of all kinds, during residency. Dozens of knee and hip replacements. On my actual orthopedic surgery rotation in residency, where scrubbing into surgeries is to be expected and appropriate, I had the benefit of working with a surgeon who took the time to explain procedures, identifying anatomic structures and answering questions. I've always enjoyed orthopedic procedures compared to especially general surgery.
All this to say I know what osteoarthritis looks like from inside the joint, and I see what it does to patients over time. I feel it in my own feet and knees.
Osteoarthritis (OA), a term we apply to a joint that has undergone degradation of the cartilage that forms the smooth, slippery surface allowing us to navigate the world. This is in contrast to rheumatoid arthritis (RA), which is a process that sees the body's own immune system attack the articular cartilage in our joints. A terrible and devastating pathology, to be sure, but not one that will be part of the discussion today.
A young, healthy knee has thick layers of cartilage on both sides of the knee. The distal end of the femur ends in something called the condyle, which is broken up into medial and lateral components -- medial meaning middle and lateral meaning the outside.
The femur is the thigh bone, so to speak and unlike the lower leg, is lonely, living the bachelor life that thighs are wont to do. The lower leg has two bones -- the fibula and tibia -- and is much more well behaved compared to the femur.
The Tibia is kid of like the main bone, in that the end further from the ground (proximal) is where the bottom half of the knee joint is. The tibial plateau is where the meniscus sits, which is the name for the articular cartilage on the bottom of the joint.
All in all, OA is fairly straightforward. Our brake pads wear out on our car. Rubber seals of all kinds have to be changed with time.
Sometimes knees need to be replaced.
As mentioned earlier, I've been in many of these replacement surgeries. They are fun, compared to many types of surgeries, but brutal affairs. Dissecting, sawing and hammering galore. The end of the femur and the top of the tibia are sawed off. The patella is pushed aside. The rest of the knee, including all of the ligaments are thrown away. The replacement joint is hammered into place, and the patella is pulled back over the new joint. All that's left is to sew that puppy up.
For an experienced orthopedic surgeon this surgery is bed and butter -- not a big deal. To the patient, however, the struggle begins after the anesthesia wears off. I've never seen a good outcome in a person who did not participate in rehab. It is necessary to get the joint working.
I was probably ten or eleven years old when I started to have knee pain. I was active. I was growing. The doctor diagnosed me with osgood-schlatters disease (OSD) which I surprisingly remember quite well. My aunt married into a family of Schlatters, and I knew a lot of Schlatters -- it as always been easy to remember this disease.
I've heard the argument that this isn't really a disease, but just a part of growing up. Basically, the bottom of the patella tendon, where it attaches to the tibia, pulls parts of the bone off of the tibia and a big bump can appear. Usually they disappear once finished growing. Unfortunately my right knee still has the big bump, but it did resolve in my left knee.
From that time forward my knees have been problematic and I'm aiming to nurse them along, with the wanton destruction with no regard to a meniscus or inflammatory cascade response being in my past. I've avoided surgery thus far and hope to postpone as long as possible.
I'm postponing in hopes that medical science can figure out a way to regrow the cartilage in joints of the human body. Even surgical replacement or something would be so much better than large joint replacements via surgery. Chondroitin and glucosamine are touted by supplement companies. They don't hurt, but rest assured, you're body isn't taking something in a pill and then directly depositing it in your swollen knee. If nothing else, your body has the building blocks to make more cartilage.
I honestly don't know what is coming down the pipeline in this field, but undoubtedly the payoff would be immense considering the comprehensive costs of joint replacement surgeries.
What will life look like between onset of OA and (quite possibly) the knee replacement in the future? Weight loss is huge. This article is interesting as it outlines how we computed the forces in the knee, and now are able to verify these with orthopedic orthoplastic appliances.
With normal walking, forces transmitted across the joint range from 2 -3x our body weight. Running and jumping can transmit forces 20x body weight.
These activities will be reduced necessarily secondary to pain. Oral anti-inflammatories can be a tool. I find that many people don't think about popping an NSAID or acetaminophen, for that matter. NSAIDs specifically, have by far the most efficacy when thrown down the pile hole at the first hints of an OA (or other inflammatory process) flare. It is much easier to stop the stepwise process of inflammation than roll it all back. Same principle applies to opioids too.
NSAIDs should be taken with food. Gastric ulceration is a concern as some elements that protect the stomach lining are blocked along with the inflammatory components.
The OA will continue to progress, especially if the weight stays on. The next step may be a steroid injection into the knee joint itself. Roughly every three months you can get these shots. They're not too painful; it helps that lidocaine is usually in the mix -- numbs up the whole thing for a little bit.
Too frequent of injections will cause accelerated degradation of the joint.
Ice, heat will help. Turmeric is a surprisingly good anti-inflammatory. I recommend it to many patients.
Osteoarthritis is one of those things in life makes the sufferer feel as if all their poor life decisions are returning to haunt their life. I think back to the skateboarding, all the basketball in skate shoes, the floor installing years, picking up running and perhaps worst -- packing on some pounds in medical school.
Definitely a game of prevention's worth eclipsing late stage intervention.
Thankfully I've been overwhelmingly healthy and issue free for my entire life. Good genes and luck more than wisdom and disciplined living.
There are some patient presentations that trigger powerful feelings of empathy -- gout flares and osteoarthritis flares, in particular. I've had a couple gout flares -- the worst manifesting in my knee during my first semester of medical school. I didn't know what was going on and the pain was extraordinary.
A solid decade of avid skateboarding will teach one to tolerate pain, but that gouty knee was terrible. Gout is nothing more than an acute arthritis caused by purine crystal formation in the fluid of the joint, which look like barbed wire under the microscope. The sharp, powerful sensations of pain do not disappoint, in that barbed wire is a fitting description.
For a brief moment in time I thought about being an orthopedic surgeon and as such spent an extra four weeks with a group. A lot of surgeries. Open Reductions Internal Fixations (ORIFs), replacements of all major joints, arthroscopic trim jobs, revisions -- the list goes on.
I've had to scrub in on what feels like way too many surgeries, of all kinds, during residency. Dozens of knee and hip replacements. On my actual orthopedic surgery rotation in residency, where scrubbing into surgeries is to be expected and appropriate, I had the benefit of working with a surgeon who took the time to explain procedures, identifying anatomic structures and answering questions. I've always enjoyed orthopedic procedures compared to especially general surgery.
All this to say I know what osteoarthritis looks like from inside the joint, and I see what it does to patients over time. I feel it in my own feet and knees.
Osteoarthritis (OA), a term we apply to a joint that has undergone degradation of the cartilage that forms the smooth, slippery surface allowing us to navigate the world. This is in contrast to rheumatoid arthritis (RA), which is a process that sees the body's own immune system attack the articular cartilage in our joints. A terrible and devastating pathology, to be sure, but not one that will be part of the discussion today.
A young, healthy knee has thick layers of cartilage on both sides of the knee. The distal end of the femur ends in something called the condyle, which is broken up into medial and lateral components -- medial meaning middle and lateral meaning the outside.
The femur is the thigh bone, so to speak and unlike the lower leg, is lonely, living the bachelor life that thighs are wont to do. The lower leg has two bones -- the fibula and tibia -- and is much more well behaved compared to the femur.
The Tibia is kid of like the main bone, in that the end further from the ground (proximal) is where the bottom half of the knee joint is. The tibial plateau is where the meniscus sits, which is the name for the articular cartilage on the bottom of the joint.
As you can see above, I like my anatomical models. I like collecting them almost as much as I do collecting books.
The blue part in the middle of the joint is called the meniscus, and acts as a shallow cup for with the condyles of the femur sit in and rock back and forth with the bending of the knee.
Tearing of the meniscus is common, and can cause problems if the flap folds back on itself, such as locking the knee in a certain position. It can cause a little bit of pain, too. It is easy to go in and trim it down, cutting the torn part off.
One can imagine that this only serves to hasten the degradation of the cartilage in the joint.
 |
| https://www.healthlinkbc.ca/health-topics/zm6052 |
All in all, OA is fairly straightforward. Our brake pads wear out on our car. Rubber seals of all kinds have to be changed with time.
Sometimes knees need to be replaced.
As mentioned earlier, I've been in many of these replacement surgeries. They are fun, compared to many types of surgeries, but brutal affairs. Dissecting, sawing and hammering galore. The end of the femur and the top of the tibia are sawed off. The patella is pushed aside. The rest of the knee, including all of the ligaments are thrown away. The replacement joint is hammered into place, and the patella is pulled back over the new joint. All that's left is to sew that puppy up.
For an experienced orthopedic surgeon this surgery is bed and butter -- not a big deal. To the patient, however, the struggle begins after the anesthesia wears off. I've never seen a good outcome in a person who did not participate in rehab. It is necessary to get the joint working.
I was probably ten or eleven years old when I started to have knee pain. I was active. I was growing. The doctor diagnosed me with osgood-schlatters disease (OSD) which I surprisingly remember quite well. My aunt married into a family of Schlatters, and I knew a lot of Schlatters -- it as always been easy to remember this disease.
I've heard the argument that this isn't really a disease, but just a part of growing up. Basically, the bottom of the patella tendon, where it attaches to the tibia, pulls parts of the bone off of the tibia and a big bump can appear. Usually they disappear once finished growing. Unfortunately my right knee still has the big bump, but it did resolve in my left knee.
 |
| https://en.wikipedia.org/wiki/Osgood%E2%80%93Schlatter_disease |
From that time forward my knees have been problematic and I'm aiming to nurse them along, with the wanton destruction with no regard to a meniscus or inflammatory cascade response being in my past. I've avoided surgery thus far and hope to postpone as long as possible.
I'm postponing in hopes that medical science can figure out a way to regrow the cartilage in joints of the human body. Even surgical replacement or something would be so much better than large joint replacements via surgery. Chondroitin and glucosamine are touted by supplement companies. They don't hurt, but rest assured, you're body isn't taking something in a pill and then directly depositing it in your swollen knee. If nothing else, your body has the building blocks to make more cartilage.
I honestly don't know what is coming down the pipeline in this field, but undoubtedly the payoff would be immense considering the comprehensive costs of joint replacement surgeries.
What will life look like between onset of OA and (quite possibly) the knee replacement in the future? Weight loss is huge. This article is interesting as it outlines how we computed the forces in the knee, and now are able to verify these with orthopedic orthoplastic appliances.
With normal walking, forces transmitted across the joint range from 2 -3x our body weight. Running and jumping can transmit forces 20x body weight.
These activities will be reduced necessarily secondary to pain. Oral anti-inflammatories can be a tool. I find that many people don't think about popping an NSAID or acetaminophen, for that matter. NSAIDs specifically, have by far the most efficacy when thrown down the pile hole at the first hints of an OA (or other inflammatory process) flare. It is much easier to stop the stepwise process of inflammation than roll it all back. Same principle applies to opioids too.
NSAIDs should be taken with food. Gastric ulceration is a concern as some elements that protect the stomach lining are blocked along with the inflammatory components.
The OA will continue to progress, especially if the weight stays on. The next step may be a steroid injection into the knee joint itself. Roughly every three months you can get these shots. They're not too painful; it helps that lidocaine is usually in the mix -- numbs up the whole thing for a little bit.
Too frequent of injections will cause accelerated degradation of the joint.
Ice, heat will help. Turmeric is a surprisingly good anti-inflammatory. I recommend it to many patients.
Osteoarthritis is one of those things in life makes the sufferer feel as if all their poor life decisions are returning to haunt their life. I think back to the skateboarding, all the basketball in skate shoes, the floor installing years, picking up running and perhaps worst -- packing on some pounds in medical school.
Definitely a game of prevention's worth eclipsing late stage intervention.
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