• Question arises if it can be avoided or delayed without any surgery?
• How it can be avoided and by what means?
• Is there any alternative surgical procedure to prolong the necessity for total knee replacement?
• When a total knee replacement becomes a necessity?

Osteoarthritis (OA) is mainly of two types:-

Primary osteoarthritis:

it occurs generally in old age adults and is considered to be an ageing process or may be a result of wear and tear of joint.

Secondary osteoarthritis:

It may be caused due to an underlying disease which may lead to degeneration of the joint. Factors like previous ignored injuries, any deformity and misalignment in knee, rheumatoid arthritis, ignored ligament injuries which causes further instability in the knee, obesity etc.

As soon as the osteoarthritis sets in, the already torn and eroded articular cartilage exposes the underlying bones to rub with each other with every movement of the knee. It ultimately causes inflammation, disturbance of distribution of body weight at the joint and new bone formation at the joint margins known as the osteophytes which causes a decrease in joint space.
This ultimately causes increase in compression forces either at the whole knee or at one compartment (side) of the knee leading to deformities like genu varum (bow legs) which is most common and genu valgum (knock knees).
A part of torn cartilage can get detached from itself and remain as a loose body in the knee which can also creates a hindrance in normal knee movement and can even cause a painful movement.

Two meniscuses (medial and lateral) rests on the upper end of shin bone on which the lower part of thigh bone sits, glides and move during the knee movement. These pad like structures act as shock absorbers, maintain joint congruency and provides smooth surface for the bones to move.
Alteration of any angulations between femur (thigh bone) and tibia (shin bone) like in case of mild genu varum (bow legs) increases compression force on medial meniscus by 25% which in turn will further deteriorate the joint and cause abnormal weight distribution on the already affected knee.
And for example five degrees of genu varum (bow legs) will increase the compressive force on the knee by 50%.

Following signs and symptoms are usually seen in OA knee:-

• Pain
• Joint stiffness and decreased range of motion
• Crepitus (crackling sound heard when the knee is flexed or straightened which is due to rubbing of bones during movement).
• Muscles tightness and muscle weakness.
• Deformities like bow legs and knock knees.
• Inability to walk or stand for a longer time.
• Swelling and inflammation.
• Flexor deformity in which the knee tends to remain in flexed position due to tight hamstring muscle.

There are several factors which are considered in aggravating the progression of knee arthritis:-

• Obesity

  – which puts more than normal stress on your knees and other weight bearing joints like hip and spine whenever you stand, walk or run.

• Lifestyle

  – sitting in cross legged position, using Indian style toilets, sitting on low height (chair, bed, sofa etc.), keeping in prolong or frequent squatting position other than exercise.

• Lack of exercise

  – whether it is primary or secondary OA, the knee will get damaged more rapidly if the muscles around it are weak. Hence regular exercising and muscle strengthening is very much important as strong muscles around the damaged joint will compensate the strain occurring at the joint.

  All the above mentioned factors can deteriorate your knee joint faster than it is supposed to be and one will have to go for a Total knee Replacement if these factors will go ignored and unnoticed.

TKR can be delayed and avoided by following methods:-

Management of osteoarthritis of knee varies according to the extent of degeneration of the joint:

Conservative treatment includes treatment with analgesics, anti-inflammatory drugs, physiotherapy, and corrective walking aids like knee braces.

In order to avoid Total Knee Replacement once your arthritis has begun or even before it, you can follow certain lifestyle modifications and exercise protocol which can help in prevention of further damage to the joint:-

Avoid sitting on low height (chair, bed etc).

Do not use Indian style toilets and do not sit cross legged or in a full squatting position.

Have a balanced diet and try to maintain weight within normal limits.

Always use chair with arm support: getting up from a chair without arm support increases the compressive force on knee up to 7 times the body weight whereas using a chair with arm support reduces the compressive force to less than half the body weight.

Avoid repetitive stair climbing during which the force on knee becomes 4.25 times the body weight.

If you feel pain in a specific posture, avoid keeping yourself in that posture.

Vigorous activities like jumping, twisting your knee should also be avoided.

Following are some exercises which can help in strengthening the muscles of knee joint and some corrective measures through which you can prevent further deterioration of knee.

Main muscle which supports the knee is quadriceps (anterior thigh) which helps in straightening the knee when it is bent.

Hamstring muscle which helps in bending the knee when it is straight is also an important muscle of knee joint.

Muscle strengthening can be done by following ways:-

Quadriceps strengthening:

lie flat on your back with your legs straight. Place a rolled towel under one knee and press the knee down for 5 seconds and release. Repeat 10 times and do it with other knee.

Straight leg raise:

lie flat on your back with the legs straight. Press your knee down, pull your foot towards yourself and lift the leg up to 45 degrees, hold for 10 seconds then release. Repeat 10 times and do it with other leg also.

Speedy isometrics:

in the presence of effusion or swelling, speedy knee isometrics or knee presses are useful. Lie on your back with the legs straight, press and release the knee in a rapid manner.

Dynamic quadriceps strengthening:

sit on a chair with your back straight and legs hanging, with one leg pull your foot and lift your lower leg in front so that the leg gets completely straight. Hold for 5-10 seconds and take the leg down or release. Repeat for 10 times with each leg alternatively.

Hamstring stretching (back of thigh):

to prevent flexor deformity to develop in the knee, hamstring stretching is very much important. Following is a simple way to stretch this muscle:-
a) Sit straight on a bed with your back straight and supported with back rest, with your legs straight so that the back of knees are touching the mattress. Lean forward and touch your feet with both of your hands such that you feel stretch at back of your thigh. Hold for 10 seconds and release. Repeat 10 times. Remember when you lean forward your knees should not get lifted up.

Swimming:

swimming is considered as a very useful exercise to strengthen core muscles of the body.

Static cycling:

if the knee permits and there isn’t significant deformity, pain and acceptable amount of joint range of motion, practicing static cycling will help you lose weight and gain muscle strength.

Wedge shoe insole:

In case of deformity in knee either genu varum(bow legs) and genu valgum(knock knees) where the compressive force is higher at one end of the knee and tensile force on the opposite side, having a properly measured wedge shoe insole provides significant relief from pain and thereby further decreasing the forces on the knee. A sloping wedge shoe insole of 7-12 mm may be tried on the outer or lateral aspect of foot sloping down towards medial or inner side in case of genu varum (bow legs) and vice versa in case of genu valgum (knock knees.

Hot fomentation:

applying hot packs 2-3 times in a day over the knees can help increase blood circulation and thereby decrease the pain to some extent.

Alternatives surgical procedures which can be chosen apart from TKR:-

High tibial osteotomy or wedge osteotomy:-

A surgical procedure in which a part of shin bone out of the joint is cut from the damaged side of the knee in order to realign the knee and shift the patient’s body weight off the damaged area and shift it to healthier side of the knee .

It resembles like surgically correcting the bow legs into knock knees kind of alignment. This procedure is indicative in young patients and at earlier stages of OA Knee and it can prolong the requirement of TKR up to 10 years.

Main objectives of this procedure are:-

• Considerable relief of pain.
• Shifting body weight towards healthy part of knee.
• Increasing the life span of knee.
• Correcting the poor knee alignment up to some extent.

• Medial or inner side of knee.
• Lateral or outer part of knee.
• Patellofemoral or knee cap and thigh bone.

The main advantages of this kind of surgery are :-

• Pain relief
• Lesser blood loss as compared to TKR.
• Soft tissues like cartilage and ligaments in the remaining part of knee are kept or retained, so the un-operated part feels normal.

When one should go for a TKR or when TKR becomes a necessity:-

• If the knees are so damaged that one has to consume pain killers on daily basis, functional activities have been reduced significantly so that normal walking for a short distance is difficult, legs or knees are deformed, normal alignment of knees has been disturbed e.g. bow legs and knock knees.
  All these factors are indicative of opting for a TKR.
• There is a potential chance that a TKR may be required in future even after going through procedures like wedge osteotomy and UKR , so a genuine surgeon can only guide a patient whether to go for one of above stated surgeries or directly recommending for a TKR.
  Hence it is advised that whenever these symptoms begin, one should visit an orthopaedic surgeon in time who will guide in a better way without delaying the treatment and avoiding TKR if possible.