Arthritis of the Knee

Arthritis of the knee occurs in varying degrees and can be treated by conservative means or in more severe cases by surgery. To view all the information on the arthritis of the knee please view the following: non-surgical treatment, surgical treatment, preparing for surgery, surgery, after surgery, rehabilitation, and frequently asked questions.

Three basic types of arthritis may affect the knee joint.

1. Osteoarthritis (OA) is the most common form of knee arthritis. OA is usually a slowly progressive degenerative disease in which the joint cartilage gradually wears away. It most often affects middle-aged and older people.
2. Rheumatoid arthritis (RA) is an inflammatory type of arthritis that can destroy the joint cartilage. RA can occur at any age. RA generally affects both knees.
3. Post-traumatic arthritis can develop after an injury to the knee. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, ligament injury or meniscus tear.

Symptoms of arthritis
Generally, the pain associated with arthritis develops gradually, although sudden onset is also possible. The joint may become stiff and swollen, making it difficult to bend or straighten the knee. Pain and swelling are worse in the morning or after a period of inactivity. Pain may also increase after activities such as walking, stair climbing or kneeling. The pain may often cause a feeling of weakness in the knee, resulting in a "locking" or "buckling." Many people report that changes in the weather also affect the degree of pain from arthritis.  

Making the diagnosis
Our doctors will perform a physical examination that focuses on your walk, the range of motion in the limb, and joint swelling or tenderness. X-rays typically show a loss of joint space in the affected knee. Blood and other special imaging tests such as an MRI may be needed to diagnose RA.

Treatment options - Non-surgical and Surgical

Non-surgical

In its early stages, arthritis of the knee is treated with non-surgical measures.

• Lifestyle modifications can include losing weight, switching from running or jumping exercises to swimming or cycling, and minimizing activities such as climbing stairs that aggravate the condition.
  
• Exercises can help increase range of motion and flexibility as well as help strengthen the muscles in the leg.
  
• Using supportive devices such as a cane, wearing energy-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful.
  
• Other measures may include applications of heat or ice, water exercises, liniments or elastic bandages.
  
• Several types of drugs can be used in treating arthritis of the knee. Because every patient is different, and because not all people respond the same to medications, your orthopaedic surgeon will develop a program for your specific condition.
  
• Anti-inflammatory medications can include aspirin, acetaminophen or ibuprofen to help reduce swelling in the joint.
  
• Glucosamine and chondroitin (kon-dro'-i-tin) sulfate are oral supplements may relieve the pain of osteoarthritis.
  
• Corticosteroids are powerful anti-inflammatory agents that can be injected into the joint.
  
• Hyaluronate (hi-a-lou'-ron-ate) therapy consists of a series of injections designed to change the character of the joint fluid.
  
• Special medical treatments for RA include gold salt injections and other disease-modifying drugs.
  

Surgical Treatment

If your arthritis does not respond to non-surgical treatments, you may need to have surgery. There are four types of surgery. To learn more about each type of surgery and what to expect simply click on its link.

1. Arthroscopic surgery uses fiber optic technology to enable the surgeon to see inside the joint and clean it of debris or repair torn cartilage.
2. An osteotomy cuts the shinbone (tibia) or the thighbone (femur) to improve the alignment of the knee joint.
3. Partial or total knee replacement (also known as total or partial knee arthroplasty) replaces the severely damaged knee joint cartilage with metal and plastic.
4. Cartilage grafting is possible for some knees with limited or contained cartilage loss from trauma or arthritis.

Our orthopaedic surgeons are continuing to search for new ways to treat arthritis of the knee. Current research is focusing on new drugs as well as on cartilage transplants and other ways to help slow the progress of arthritis.

Preparing for Total Knee Replacement Surgery

If you decide to have surgery, you may be asked to have a complete physical by your family physician several weeks before surgery to assess your health and to rule out any conditions that could interfere with your surgery.

Tests . Several tests-such as blood samples, a cardiogram and a urine sample-may be needed to help your orthopaedic surgeon plan your surgery.  

Preparing Your Skin . Your knee and leg should not have any skin infections or irritation. Your lower leg should not have any chronic swelling. Contact your orthopaedic surgeon prior to surgery if either of these conditions is present for a program to best prepare your skin for surgery.

Blood Donation . You may be advised to donate your own blood prior to the surgery. It will be stored in the event you need blood after your surgery.  

Medications. Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.  

Dental Evaluation . Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. Treatment of significant dental diseases (including tooth extractions and periodontal work) should be considered before your total knee replacement surgery.

Urinary Evaluations. A preoperative urological evaluation should be considered for individuals with a history of recent or frequent urinary infections. For older men with prostate disease, required treatment should be considered prior to knee replacement surgery.

Social Planning. Though you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing and doing laundry. If you live alone, your surgeon's office and a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.

Home Planning. Several suggestions can make your home easier to navigate during your recovery. Consider:

• Safety bars or a secure handrail in your shower or bath
• Secure handrails along your stairways
• A stable chair for your early recovery with a firm seat cushion (height of 18-20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
• A toilet seat riser with arms, if you have a low toilet
• A stable shower bench or chair for bathing
• Removing all loose carpets and cords
• A temporary living space on the same floor, because walking up or down stairs will be more difficult during your early recovery
  

Surgery

You will most likely be admitted to the hospital on the day of your surgery. After admission, a member of the anesthesia team will evaluate you. The most common types of anesthesia are general anesthesia, in which you are asleep throughout the procedure, and spinal or epidural anesthesia, in which you are awake but your legs are anesthetized. The anesthesia team will determine which type of anesthesia will be best for you with your input.

The procedure itself takes about two hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position the new metal and plastic joint surfaces to restore the alignment and function of your knee.

After surgery, you will be moved to the recovery room, where you will remain for one to two hours while your recovery from anesthesia is monitored. After you awaken, you will be taken to your hospital room.

You will most likely stay in the hospital for several days. After surgery, you will feel some pain, but medication will be given to you to make you feel as comfortable as possible. Pain management is an important part of your recovery, so talk with your surgeon if postoperative pain becomes a problem. Walking and knee movement are important to your recovery and will begin immediately after your surgery.

To avoid lung congestion after surgery, you should breathe deeply and cough frequently to clear your lungs.

Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling, such as special support hose, inflatable leg coverings (compression boots) and blood thinners.

To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device, called a continuous passive motion (CPM) machine, decreases leg swelling by elevating your leg and improves your venous circulation by moving the muscles of your leg.

Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots. Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

After Surgery

The complication rate following total knee replacement is very low. Serious complications, such as a knee joint infection, occur in less than 2 percent of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit your full recovery.

Blood clots in the leg veins are the most common complication of knee replacement surgery. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings and medication to thin your blood.

Although implant designs and materials as well as surgical techniques have been optimized, wear of the bearing surfaces or loosening of the components may occur. Additionally, although an average of 115 degrees of motion is generally anticipated after surgery, scarring of the knee can occasionally occur and motion may be more limited. This is particularly true in patients with limited motion before surgery. Finally, while rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

The success of your surgery also will depend on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery. You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal. Avoid soaking the wound in water until the wound has thoroughly sealed and dried. The wound may be bandaged to prevent irritation from clothing or support stockings.

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength.

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within three to six weeks following surgery. Some pain with activity and at night is common for several weeks after surgery. Your activity program should include:

• A graduated walking program to slowly increase your mobility, initially in your home and later outside
• Resuming other normal household activities, such as sitting and standing and walking up and down stairs
• Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.

Driving usually begins when your knee bends sufficiently so you can enter and sit comfortably in your car and when your muscle control provides adequate reaction time for braking and acceleration. Most individuals resume driving about four to six weeks after surgery.

Avoiding Problems After Surgery

Blood Clot Prevention. Follow your orthopaedic surgeon's instructions carefully to minimize the potential of blood clots that can occur during the first several weeks of your recovery.

Warning signs of possible blood clots in your leg include:

• Increasing pain in your calf
• Tenderness or redness above or below your knee
• Increasing swelling in your calf, ankle and foot

Warning signs that a blood clot has traveled to your lung include:

• Sudden increased shortness of breath
• Sudden onset of chest pain
• Localized chest pain with coughing

Notify your doctor immediately if you develop any of these signs.

Preventing Infection. The most common causes of infection following total knee replacement surgery are from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.

For the first two years after your knee replacement, you must take preventive antibiotics before dental or surgical procedures that could allow bacteria to enter your bloodstream. After two years, talk to your orthopaedist and your dentist or urologist to see if you still need preventive antibiotics before any scheduled procedures.

Warning signs of a possible knee replacement infection are:

• Persistent fever (higher than 100 degrees orally)
• Shaking chills
• Increasing redness, tenderness or swelling of the knee wound
• Drainage from the knee wound
• Increasing knee pain with both activity and rest

Notify your doctor immediately if you develop any of these signs.

How long is the recovery period?
After total knee replacement you will have to use crutches and wear a knee brace or immobilizer the first three to four weeks after surgery. This gives the transplanted tissue time to become firmly attached to the bone. If you work in an office and have a basically sedentary job, you should be able to return to work a week after your surgery. If you have a more active job, you may not be able to resume all your job duties for two to three months.

After a month, you can start an exercise therapy program that involves weight-bearing exercises. In many cases, you may be able to return to running after three or four months, and to other recreational activities after five or six months. You should not do certain kinds of activities, such as squatting, bicycling or swimming, for at least six months after surgery.

Rehabilitation

Physical therapy plays a key role in treating and rehabilitating the knee after surgery, but you and your attitude toward recovery are the biggest factor in achieving a successful outcome.

Our licensed physical therapists will design a phased treatment plan with two main components:

1. Maximum protection , a series of exercises designed to help motion. Activities in this phase might include water walking, leg presses, and mini-squats; and

2. Return to function and maintenance , an exercise sequence to restore strength. These activities are a functional progression, that is, a gradual return to normal activities using exercises that simulate the knee stresses of your normal activities.

Frequently Asked Questions

• How soon after surgery can I get my knee wet?
• What about my medications?
• How do I use crutches?
• What are the warning signs of blood clots?
• How can I tell if my knee is infected?
• When can I drive?
• When are my stitches going to be removed?
• Can I put a bandage on my wound so my clothes don't rub it?
• It's been a week, should I still feel pain? For how long should I feel pain?