Disabling Knee Pain Research Articles

Robotic-Arm-Assisted Lateral Unicompartmental Knee Arthroplasty with a Fixed-Bearing Implant.

Approximately 5% to 10% of patients with knee arthritis have isolated lateral compartment arthritis; however, lateral unicompartmental knee arthroplasty (UKA) comprises just 1% of all knee arthroplasties1. This low proportion is partly because of the perceived complexity of lateral UKA and concerns over implant longevity and survivorship compared with total knee arthroplasty (TKA)2,3. With an improved understanding of knee kinematics alongside advances in implant design and tools to aid in appropriate restoration of limb alignment, lateral UKA can be an appealing surgical alternative to TKA for certain patients with lateral knee arthritis4,5. In appropriately selected patients, lateral UKA has been associated with reduced osseous and soft-tissue resection, more natural knee kinematics, less pain, shorter hospitalization, decreased blood loss and infection rates, and excellent survivorship and patient-reported outcomes6-9. This surgical approach and technique described for lateral UKA utilizes robotic-arm assistance and modern fixed-bearing implants10. The specific steps involve appropriate patient evaluation and selection, extensive radiographic and computed-tomography-based preoperative templating, a lateral parapatellar approach, intraoperative confirmation of component position and alignment, and robotic-arm assistance to perform osseous resections to achieve limb alignment and kinematic targets10. Final implants are cemented in place, and patients typically are discharged home on the day of surgery10. Nonoperative treatment for end-stage knee arthritis includes weight loss, activity modification, assistive devices, bracing, nonsteroidal anti-inflammatory medications, and various injections11. Alternative surgical treatments include TKA4 and, in certain patients, an offloading periarticular osteotomy12. Lateral UKA is an appealing surgical option for nonobese patients who have disabling knee pain isolated to the lateral compartment, good preoperative range of motion, and a passively correctable valgus limb deformity10,13. Patients are typically discharged home on the day of surgery, or occasionally on postoperative day 1 if medical comorbidities dictate hospital monitoring overnight10. Patients return to light activities, including walking, immediately postoperatively. By 3 months postoperatively, patients will generally have returned to all desired activities9. The mid-term outcomes of this procedure, as performed by the corresponding author, have been published recently14,15. The 5-year survivorship of 171 lateral UKAs was 97.7%, with 72.8% of patients reporting that they were very satisfied with their procedure and 19.8%, that they were satisfied14. Only 3.8% of patients reported dissatisfaction with their lateral UKA14. The mean Knee Injury and Osteoarthritis Outcome Score (KOOS) and standard deviation were 85.6 ± 14.314. These outcomes did not differ from those observed in 802 medial UKAs, which showed a survivorship of 97.8% and KOOS of 84.3 ± 15.914. These findings are generally in line with previously published studies, which have demonstrated excellent survivorship and patient-reported outcomes with fixed-bearing lateral UKA16-19. Component position and alignment are critical to achieve target knee kinematics.Target postoperative alignment is 1° to 4° of valgus.A meticulous cementation technique is required for optimal fixation and avoidance of excess residual cement in the posterior knee. ACL = anterior cruciate ligamentAP = anteroposteriorBMI = body mass indexCT = computed tomographyCAT = computed axial tomographyIT = iliotibialKOOS JR = Knee Injury and Osteoarthritis Outcome Score for Joint ReplacementMCL = medial collateral ligamentMRI = magnetic resonance imagingOR = operating roomPFJ = patellofemoral jointpoly = polyethyleneROM = range of motionTKA = total knee arthroplastyUKA = unicompartmental knee arthroplasty.

Total Knee Replacement in Alkaptonuric Ochronosis.

Alkaptonuria is a rare disease characterized by the accumulation of homogentisic acid (HGA). Over time, these patients may develop disabling ochronotic arthropathy. We present 2 cases of patients with end-stage arthropathy treated with total knee arthroplasty (TKA). Both patients complained of disabling knee pain and reported limited walking distance (200-300 m). One had a history of osteotomy for medial knee arthtritis and ignored his underlying condition. The other presented with valgus gonoarthrosis and diagnosis of alkaptonuria. Intraoperatively, the characteristic dark-blue color in the joint was observed. Both patients evolved favorably after TKA with excellent results according to the Knee Society Scores (KSS) at three years of follow-up. We believe TKA is the right treatment for patients with end-stage disease because it offers considerable relief from pain and allows patients to recover function.

A Preliminary Measurement and Understanding of Movement-Evoked Pain in African American Elder Adults

Osteoarthritis (OA) is a principal cause of disabling knee pain, and movement is a known exacerbator of pain in African Americans (AAs). Still, research has neglected to understand the relationship between pain with movement and its impact on function and mobility. Our previous study found significantly higher movement-evoked pain between AAs and White American (WAs). Therefore, this case-control observational study investigated inter-racial and intra-racial differences in movement-evoked pain in AAs and WAs (N= 28) who were 55-78 years-of-age (M= 65.75, SD= 6.23). We measured pain intensity (0-10) pre/ante/post multiple performance-based functional activities; we report preliminary results for 7-meter GAITRite® walk and Stair climbs. Pain intensity was higher before and after the 7-meter walk and stair climbs in AAs, although not significantly different than WAs. We will conduct additional statistical tests for the remaining functional activities to identify potential differences and ethnic-specific factors that distinguish movement-evoked pain and function by race.

Different Components of Subjective Well-being Are Associated With Chronic Nondisabling and Disabling Knee Pain: ELSA-Brasil Musculoskeletal Cohort.

Chronic knee pain (CKP) is a common pain complaint in older adults that is often associated with disability. This study investigated the relationship between 2 components of subjective well-being (depressive symptoms and life satisfaction) and CKP phenotypes based on the presence of knee disability. A cross-sectional study was performed at baseline of ELSA-Brasil Musculoskeletal cohort (2012-2014). Chronic knee pain phenotypes were identified according to the presence of CKP that was accompanied or not by disability, which was assessed by a question on pain-related limitations to perform everyday activities (overall), Western Ontario and McMaster Universities Osteoarthritis Index's physical function subscale (daily tasks) and 5-times sit-to-stand test (objective). Depressive symptoms were assessed by the Clinical Interview Schedule-Revised and life satisfaction by the Satisfaction With Life Scale. Multinomial logistic regressions used CKP phenotypes as response variables (no CKP as reference). The sample comprised 2898 participants (mean age, 55.9 ± 8.9 years; 52.9% were female). After adjustments for sociodemographic and clinical factors, depressive symptoms were associated with daily tasks disabling CKP (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.45-3.66) and objective disabling CKP (OR, 1.95; 95% CI, 1.29-2.93) and with nondisabling CKP for the overall disability measure (OR, 1.54; 95% CI, 1.17-2.04). Life satisfaction was inversely associated with all phenotypes in fully adjusted models, with strongest magnitude of associations observed for disabling CKP. The association of depressive symptoms and life satisfaction with CKP phenotypes suggest the need to address both negative and positive components of subjective well-being in the assessment of individuals with knee complaints.

Evaluation of lateral closed wedge high tibial osteotomy for medial compartment osteoarthritis

Introduction: Osteoarthritis of the knee is a common orthopaedic condition. Medial compartment osteoarthritis results from undue stress on the medial compartment of the knee joint following varus deformity. High tibial osteotomy (HTO) has been a long-standing treatment for osteoarthritis of the medial compartment of the knee. Although knee replacement has gained wide popularity for its treatment, still HTO is a good and cost effective procedure for young patients having good range of motion and uni-compartmental involvement. Objective: To evaluate the results of HTO in medial compartment osteoarthritis. Methods and Material: This study was conducted in a tertiary care teaching hospital of North India over a period of 3 years. The patients with disabling knee pain due to medial compartment osteoarthrosis with genu varus deformity refractory to conservative treatment were treated by High Tibial Osteotomy. Results: Overall 40 patients with medial compartmental osteoarthritis were treated with HTO. Patients were evaluated for the severity of pain as per Visual Analogue Score (VAS). There was satisfactory pain reduction (up to 80%) in most of the patients. Conclusions: HTO is a good procedure for young patients with good range of motion and changes confined to one compartment only.Bangladesh Journal of Medical Science Vol.14(4) 2015 p.389-392

Quickly progressive amyotrophy of the thigh: An unusual cause of rapid chondrolysis of the knee

While rapidly destructive OA is more recognized in hip, we report the case of a 50-year-old woman who presented a rapid chondrolysis in the patellofemoral joint in a context of rapid loss of muscular strength. She had arthralgia, myalgia and proximal muscular deficit of the limbs. Creatine phospho kinase level was elevated and electromyogram exam showed a myogenic syndrome. Neither immune nor visceral disease was highlighted. As we suspected a polymyositis, we started corticosteroids and physiotherapy, then methotrexate and intravenous immunoglobulin. Concomitantly to the worsening of the muscular deficit and atrophy of hamstrings, she developed a persistent and disabling knee pain. Initial radiographs and magnetic resonance imaging (MRI) showed only a patellofemoral dysplasia and tiny cartilage damages. Because of aggravation of myalgia, we treated by mycophenolate mofetyl then rituximab. One year later, the knee remained painful and swollen. MRI showed signs of advanced osteoarthritis including an important loss of cartilage with an atrophy of hamstrings. Several articular corticosteroids injections were done. In the same time, the evolution of the muscular disease was unusual. Another histological analysis of muscle has highlighted a genetic myopathy due to mutation of calpain. Immunosuppressive treatments were stopped and a total joint replacement was performed. We show for the first time a case of rapid chondrolysis of patellofemoral joint related to a severe genetic myopathy.

A Systematic Approach to Evaluating Knee Radiographs with a Focus on Osteoarthritis

Arthritis of the knee is commonly encountered in primary care and specialty settings. The initial work up and treatment of these patients requires a thorough evaluation and complete series of plain radiographs. Despite increased use of advanced imaging modalities, plain films remain the most instructive, available, and affordable diagnostic test. The evaluation of patients with arthritis can be challenging, by using a standardized approach one can perform a quick and adequately comprehensive evaluation. Here we outline an approach appropriate for the evaluation of these patients in any setting. Particularly, we advocate a complete history and physical exam augmented by a four view radiographic series: A weight bearing anterior-posterior (AP) of the knee, a 45 degree weight bearing posterior-anterior (PA) view of the knee, a standing lateral, and a Merchant view. Through our described systematic evaluation of these views, a great deal of information can be obtained often helping guide treatment plans created with the patient, and helping avoid a potential missed or delayed diagnosis. Background Osteoarthritis (OA) is the most common form of arthritis, and the knee is the principal large joint affected by this process [1]. In men and women over the age of fifty-five, an estimated ten percent develop disabling knee pain from OA; 25% of those affected are considered severely disabled [2]. The incidence of osteoarthritis of the knee increases with age, is strongly associated with obesity [3], and more commonly affects women [4]. OA is the single greatest contributor to disability [5,6], and in the elderly, its overall risk of disability is comparable to that of cardiovascular disease. The precise etiology, pathogenesis, and progression of OA are not yet completely understood. Taking a thorough history and performing a detailed physical examination is necessary when evaluating a patient with presumed osteoarthritis of the knee. The most common presenting symptom is pain, often associated with activity and relieved by rest. Additional symptoms include crepitus, swelling, limping, stiffness that typically improves after a brief period of activity [7], and progressive lower extremity deformity (e.g. bow-legged or knock-knee deformity). Patients should be asked about their occupation, history of trauma, and presence of previous knee pathology. Due to the fact that there is a 50% risk associated with genetic predisposition to OA, a careful family should be documented [8-10]. Physical exam may reveal genu valgum (knock-knee) or genu varum (bow-legged), an extensor mechanism lag, a leg-length discrepancy, or a flexion contracture. Arthritis is categorized as primary or secondary. Primary arthritis is an idiopathic condition that is thought to result from mechanical wear of the joint beyond the body’s reparative capabilities. In contrast, secondary arthritis is due to another condition or disease, such as trauma, autoimmune disorders, crystalline arthropathy, and congenital anomalies. The radiographic hallmarks of primary and secondary arthritis differ. Identifying these differences correctly can lead to significant adjustments in the approach to patient care and are one important aspect of radiographic evaluation of the patient with osteoarthritis. When evaluating both primary and secondary arthritis of the knee, weight-bearing radiographs from multiple views are essential to allow visualization of the functional joint space. The specific purpose of this review is to provide Internists, Physiatrists, Rheumatologists, and Orthopaedic Surgeons with a systematic method for evaluating radiographs to help guide appropriate treatment in the patient with osteoarthritis of the knee. Systematic Evaluation of the Arthritic Knee In the evaluation of the adult patient with degenerative joint

Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis

Knee osteoarthritis (OA) is common in older adults. Determination of risk factors for onset of knee OA may help in its prevention. The objective of this systematic review, and meta-analysis, was to determine the current evidence on risk factors for knee OA. A systematic literature search was carried out for cohort and case-control studies evaluating the association of demographic, comorbid, and other patient-determined factors with onset of knee OA. A scoring tool was developed to assess the quality of studies. Heterogeneity of studies was examined. Where possible studies were pooled to give an overall estimate of the association of factors with onset of knee OA. Of the 2233 studies screened, 85 were eventually included in the review. Study quality tended to be moderate. The main factors consistently associated with knee OA were obesity (pooled OR 2.63, 95% CI 2.28-3.05), previous knee trauma (pooled OR 3.86, 95% CI 2.61-5.70), hand OA (pooled OR 1.49, 95% CI 1.05-2.10), female gender (pooled OR 1.84 95% CI 1.32-2.55) and older age. Smoking appeared to have a moderate protective effect, however this was not evident once the analysis was restricted to cohort studies only. Whilst certain factors have been extensively reviewed (for example, body mass index), more longitudinal studies are needed to investigate the association of physical occupational and other patient-determined factors with future knee OA. The quality of such studies also needs to be improved. However, there are identifiable factors which can be targeted for prevention of disabling knee pain.

Knee Pain

Knee pain is a common presenting symptom in primary care. Around 4.5 million people in the UK, over 100 patients per GP, have severe or disabling knee pain. About 25% of people over the age of 55 years complain of chronic knee pain which is usually diagnosed as osteoarthritis. At the other end of the age spectrum, knee pain affects as many as one in three teenagers and young adults at some time or other.

Knee pain and osteoarthritis in the general population: what influences patients to consult?

We examined the relationship between predisposing factors, enabling factors and need-related factors with consultation for knee pain in general practice. This was a retrospective review of computerized medical records for knee-related consultations in the 18 months before baseline assessment of individuals aged over 50 years reporting knee pain in the previous 12 months. The association between each factor and consultation for consulters compared to non-consulters was summarized using odds ratios (ORs). Interaction between each variable and chronic pain grade was investigated. The association between knee-related consultation and the number and type of other co-morbid consultations was then determined. In total, 742 participants were assessed. Of these, 209 (28%) had a knee-related consultation in the previous 18 months. Recent onset of pain [OR 3.2; 95% confidence interval (95% CI) 1.8, 5.7] and severity of pain, Grade III/IV (OR 3.4; 95% CI 2.1, 5.6), were associated with knee-related consultation. Those rating their knee problem as a health priority were more likely to consult (OR 3.2; 95% CI 1.6, 6.7). Irrespective of knee pain severity, there was no difference in the median number of co-morbid consultations between knee consulters and knee non-consulters. Need-related factors appeared to be associated with the decision to consult about knee pain. Neither the presence of self-reported selected co-morbid conditions nor the total number of co-morbid conditions was related to consultations for knee pain. Nevertheless, 50% of those with severely disabling knee pain still did not consult for it. Further investigation of this is important in order to optimize care for patients with knee pain and co-morbid disease.

Disabling knee pain--another consequence of obesity: results from a prospective cohort study.

BackgroundObesity is linked to knee osteoarthritis (OA) and knee pain. These are disabling problems that are more prevalent in older adults. No prospective study has estimated the impact of excess weight avoidance on the occurrence of knee pain in the general older population. The aim of this study was to investigate the influence of overweight and obesity on the onset and progression of knee pain and disability in older adults living in the community.MethodsA prospective cohort study of people aged 50 and over registered with three general practices in North Staffordshire, UK. 5784 people who had responded to a survey in March 2000 were mailed a follow-up questionnaire in March 2003. The main outcome measures were self-reported knee pain and severe knee pain and disability at 3 years measured by the Western Ontario and McMaster Universities Osteoarthritis index.ResultsAdjusted response to follow-up was 75%. Among responders with no knee pain at baseline, obesity predicted onset of severe knee pain (relative risk 2.8; 95% CI 1.8, 4.5 compared to normal body mass index (BMI) category). Considering overweight and obese categories together, 19% of new cases of severe knee pain over a 3-year period could potentially be avoided by a one-category shift downwards in BMI; this includes almost half of the new cases that arose in the obese group.ConclusionObesity accounts for a substantial proportion of severe disabling knee pain. As knee pain is a common disabling condition in older adults living in the community, effective public health interventions about avoidance of excess weight could have a major impact on future lower limb disability in older adults.

Anatomy of patellar dislocation

Acute patellar dislocation is a common injury that can lead to disabling knee pain and/or recurrent instability. In the past 10 years, research has begun to focus on the injuries associated with acute patellar dislocation, and the specific contributions the injured structures make to patellar stability in intact knees. The implication is that injury to specific structures may have important consequences in converting a previously asymptomatic, although perhaps abnormal, patellofemoral joint into one that is painful and/or unstable. These studies have been intended to improve the precision of surgical treatment for patellar instability, and their results are driving refinements in our surgical indications as well as technique.

Treatment of deep cartilage defects of the patella with periosteal transplantation.

Twenty-six consecutive patients (19 men and 7 women) with a mean age of 31.5 years (range 19-52 years) who suffered from an isolated full-thickness cartilage defect of the patella (area ranged from 0.75 to 20.0 cm2) and disabling knee pain were treated with autologous periosteal transplantation (without any chondrocytes). The duration of symptoms was 59 months (range 11-144 months). During the first 5 postoperative days all patients were treated with continuous passive motion (CPM). This was followed by active motion, slowly progressive strength training, and slowly progressive weight-bearing. After a mean follow-up of 42 months (range 24-76 months), 17 patients (65%) were graded as excellent (were painfree), 8 patients (31%) as good (had pain with strenuous knee-loading activities), and 1 patient as poor (had pain at rest). Twenty-two patients (85%) had returned to their previous occupation. Twelve patients (46%) had resumed sports or recreational activities at their former level. Repeated magnetic resonance imaging (MRI) investigations showed progressive, and finally complete, filling of the articular defects. Biopsies taken in five randomly selected cases showed hyaline-like cartilage. Patients with full-thickness cartilage defects of the patella and disabling knee pain can be treated with autologous periosteal transplantation (without any chondrocytes), followed by CPM, and slowly progressive strength training and weight-bearing. We believe this is a good method to accomplish regeneration of articular cartilage and satisfactory clinical results.

Meniscal allograft transplantation for unicompartmental arthritis of the knee.

Sixty-seven meniscal allografts were transplanted in the knees of 63 patients between 1988 and 1994. Before surgery, all patients experienced refractory disabling knee pain secondary to a prior total meniscectomy with advanced unicompartmental osteoarthritic changes as verified by arthroscopy. At a mean followup of 31 months (range, 1.0-5.5 years), 58 knees (86.6%) attained a good to excellent results-Twenty-one knees received isolated meniscal allografts, with 19 achieving good to excellent results (90.5%). Five knees received a medial or lateral meniscal allograft with an anterior cruciate ligament reconstruction, and 4 (80.0%) obtained good to excellent results. Thirty-four knees received a meniscal allograft in combination with either a valgus high tibial osteotomy, varus high tibial osteotomy, or varus distal femoral osteotomy to correct for preoperative varus or valgus deformities, with 29 (85.3%) attaining good to excellent results. The remaining 7 knees underwent a combined medial meniscal allograft, valgus high tibial osteotomy, and anterior cruciate ligament reconstruction with 6 (85.7%) attaining good to excellent results. The most frequent complication was a traumatic posterior horn tear in 6 knees at a mean of 21 months after surgery (range, 9-43 months), most likely the consequence of unsuccessful healing of the posterior horn of the graft.