Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

A Comprehensive Guide to Understanding Patello-Femoral Replacement Surgery

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old man with osteoarthritis

In the realm of knee surgery, patello-femoral replacement surgery stands as a vital solution for individuals grappling with knee pain and restricted mobility. This comprehensive guide delves deep into the intricacies of patello-femoral replacement surgery, unraveling the underlying anatomy, the surgical procedure itself, and the issues it targets to address. Whether you’re a patient seeking insights into this procedure or a medical enthusiast, this article provides an informative guide to comprehending the nuances of patello-femoral replacement surgery.

Understanding the Patello-Femoral Joint

patellofemoral osteoarthritis

The patello-femoral joint, between the patella (knee cap) and the femur (thigh bone), plays a pivotal role in knee movement and stability. However, wear and tear, injury, or conditions like osteoarthritis can result in pain and hindered function within this joint. Patello-femoral replacement surgery, or patello-femoral arthroplasty or patello-femoral joint replacement, comes into play as a targeted solution to restore optimal joint function and alleviate discomfort.

The Surgical Procedure

knee doctor in surgery

Patello-femoral replacement surgery is a meticulously crafted procedure to replace damaged patello-femoral joint surfaces. It involves removing a small portion of the patella and femur then replacing them with prosthetic components, typically made from metal and plastic. The prosthetic components are engineered to replicate the natural joint’s movement and function, promoting smoother gliding and reducing friction within the joint. This surgical intervention aims to relieve pain, improve mobility, and enhance the overall quality of life for individuals grappling with patello-femoral joint issues.

Identifying Candidates

painful knee

Ideal candidates for patello-femoral replacement surgery are individuals who have exhausted conservative treatment options and continue to experience persistent knee pain, limited mobility, and a reduced quality of life due to patello-femoral joint problems. Before proceeding with the surgery, a thorough evaluation is conducted to determine if the patient’s condition aligns with the potential benefits of this procedure.

Benefits and Expected Outcomes

healthy old couple

Patello-femoral replacement surgery offers a range of potential benefits, including reduced pain, improved joint stability, enhanced mobility, and an overall quality of life. Patients who undergo this surgery often experience a significant reduction in pain, allowing them to engage in daily activities more easily. Additionally, restoring proper joint function can lead to a renewed sense of independence and an increased capacity to participate in physical activities.

Post-Surgery Rehabilitation

knee rehab old man

Following patello-femoral replacement surgery, a structured rehabilitation program is essential to optimize surgical outcomes. Physical therapy is pivotal in helping patients regain strength, flexibility, and functionality in the treated joint. The rehabilitation process is tailored to the individual’s condition and progress, gradually transitioning them back to regular activities and routines.

In conclusion, patello-femoral replacement surgery emerges as a beacon of hope for individuals seeking relief from knee pain and compromised mobility due to patello-femoral joint issues. By replacing damaged joint surfaces with prosthetic components, this surgical procedure aims to restore function, reduce pain, and improve the overall quality of life for patients. Whether you’re exploring treatment options or merely seeking to broaden your medical knowledge, understanding the fundamentals of patello-femoral replacement surgery provides valuable insights into this remarkable advancement in knee surgery.

Ready to Take the First Step?

If you or a loved one is considering patello-femoral replacement surgery as a solution to knee pain and mobility challenges, we are here to help. Contact us at Advanced Knee Care to schedule a consultation and explore the best course of action tailored to your unique needs. Our dedicated team of orthopedic specialists is committed to guiding you toward a life of enhanced mobility, comfort, and vitality.

Evidence Based Treatments for Knee Osteoarthritis

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What works:

Strengthening Exercises with neuromuscular education*

NSAID (pills such as ibuprofen and naproxen)

Appropriate weight loss if BMI > 25

Total or partial Knee Replacement

Cannot Recommend for or against:

IA steroid injection

Acetaminophen

Manual therapy, electrotherapeutics

Knee arthroscopy for meniscus

Cannot Recommend:

IA Hyaluronic Acid (viscosupplementation)

Braces

Arthroscopy – clean out

Glucosamine and Chondroitin

Acupuncture

Insoles

*The Alexander Technique (AT) is a method of neuromuscular re-education which aims to teach individuals how to improve postural support, reduce potentially harmful patterns of muscle tension and improve control of response. AT lessons provide an individualised approach to developing skills that help people recognise, understand, and avoid poor habits adversely affecting postural tone and neuromuscular coordination.

Knee Osteoarthritis Treatment Ranked for Pain and Function

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Non surgical treatment for osteoarthritis of the knee is most successful for mild to moderate disease.  Usually the pain and function from severe knee OA requires partial or total knee replacement surgery.

Patients need to know how likely a particular treatment is.  This study ranked the effectiveness of oral pill treatment and intra articular injections categorized based on pain symptom relief and knee function improvement.

The 3 most effective treatments for knee OA pain are Intra Articular steroid injection, oral ibuprofen and knee injection with Platelet Rich Plasma.

The 3 most effective treatments for knee OA functional limitations (limp, diminished walking ability) are non steroidal anti inflammatory medications – Naproxen, Diclofenac and Celecoxib.

The 3 most effective treatments for both knee pain and  knee OA functional limitations are oral Naproxen pills, Intra Articular steroid injection and knee injection with Platelet Rich Plasma.

Of note, hyaluronic acid (also known as viscosupplementation) injections is at best in the lower half of the effectiveness scale.  Similarly, Tylenol (acetaminophen) is not therapeutic.

This study can be found in the JAAOS, May, 2018.

Opioids and Total Knee Replacement – Preoperative Use Detrimental

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Most patients with advanced arthritis of the knee do not use strong pain pills in the year prior to knee replacement surgery.  America has an opioid epidemic with many accidental deaths and social problems linked to use of this class of drug.  Most of this use can be traced to the abuse of doctor prescribed hydrocodone and oxycodone.

A report published in the Journal of Bone and Joint Surgery calls to our attention an orthopedic concern in people using opioids in the 2 year period prior to Total Knee Replacement surgery. Specifically, the chronic opioid group obtain less pain relief from the joint replacement surgery.  This group of patients had lower satisfaction scores and a greater number of patients in the opioid group had additional knee surgeries for pain and stiffness.

In summary, patients that are on opioids for an extended period of time prior to their joint replacement are at a greater likelihood of having a surgical failure.

Sex Life after Knee Replacement

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tarlow knee sexual functionKnee problems such as osteoarthritis affect millions of Americans every year. Aside from this fact, many people are not that aware that there is a correlation between knee problem and sexual function. Based on a research presented at the annual meeting of American Academy of Orthopaedic Surgeons (AAOS), osteoarthritis of the knee limits sexual activity.

In a survey of Knee Replacement patients, several patients were observed. These patients have undergone knee replacement surgery two years prior. The results and findings of such survey were published in the Journal of Arthroplasty. Before knee replacement, 45% of the patients with knee arthritis said that before knee replacement, their sexual frequency and/or quality was limited. They cited knee pain and limited knee flexions as the major factors that make having sexual activity challenging. After they have undergone knee surgery, 72% of the patients said that they were no longer limited by the aforementioned factors. Postoperatively, patients were able to resume sexual activity at an average of 2 ½ months (ranging from 0-18 months) after the knee replacement operation.

In another study, patients under the age of 70 with a mean age of 57.7 years agreed to participate. The study required them to answer and fill out questionnaires prior their scheduled for primary total knee replacement. They were also asked again six months and then one year after surgery. Out of the 147 patients, 78 of which are women and 68 are men, 65% participated in and completed the three surveys. The result of said study contains the following findings and generalizations:

  • 67% of the patients reported physical problems and limitations regarding sexual activity prior to the surgery. The common problems include stiffness, pain, reduced libido and inability to attain proper sexual position.
  • 91% of the patients answered that they experienced psychological issues related to their knee problem or osteoarthritis. The issues include low sexual self image and diminished sense of general well-being.
  • 90% of the TKR patients reported that they experienced improved overall sexual function after the surgery. More women reported improvement more than men. 42% reported improvement in libido; 41% said that their intercourse frequency has increased; 41% also said that they have increased intercourse duration; 84% of the patients reported that their general well-being improvement; and 55% attested that their sexual self image developed. Only 16% of the patients said that the surgery did not significantly affected their sexual function, particularly due to fear that the replacement joint might get damaged.

Sexual function is also a vital part of one’s life. It is only justifiable to include sexuality and sexual activity in the evaluation of the outcome of total knee replacement and other knee surgery. Sexual experience is part of one’s overall health and lifestyle, which is why it is great to note that knee surgery has something to offer as regards one’s overall sexual function.

But there must be a balance between sexual function and taking care of the knee replacement. This is better discussed personally with your surgeon or knee professional. If you need to learn more about knee surgery or if you want to undergo the same, contact Tarlow Knee. Make an appointment with us today.

Stem Cell Therapy for Knee Osteoarthritis and Focal Cartilage Defects

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Stem cell treatment knee osteoarthritis

Stem cell therapy is a modern and novel procedure which is used to treat certain orthopedic knee )conditions and diseases. It makes use of stem cells, most commonly those derived from the patient’s bone marrow. This therapy works by adding new cells to the defected, diseased or damaged knee. Stem cells are helpful because they actively signal, recruit and produce healing cells and proteins from your body in just two to six weeks’ time. This helps in the regeneration of the cells and the healing of the affected area.

Stem Cell Treatment for Arthritis

Stem cell therapy is a treatment with potential promise and high public interest. However, there is little basic science to support its use as an injection to the knee in 2017.

Because of the potential of stem cell treatment, some doctors now use it to treat arthritis. Researchers think that applying stem cells to the arthritic joint can help in the development of the cartilage cells, release proteins which are helpful for the pain and the cartilage degeneration and suppress inflammation.

However, many still do not consider this as standard practice. The effectiveness of stem cell therapy remains controversial and undecided among medical professionals. Critics say that this treatment only works like a placebo, and that there is no concrete proof yet as to its effectiveness. Nevertheless, stem cells for arthritis are considered safe. That is why, many adults, despite the absence of standard procedure and studies, still use stem cell treatment for their arthritis.

Stem Cell Therapy for Knees

Adult stem cells have the ability to renew themselves, reproduce and differentiate (turn into other cells). They are found in the body, particularly in various tissues and in the bone marrow. Normally, their function is to repair damage in the body. This is why they are now extracted and injected into a damaged or defected area. This procedure is known as stem cell therapy.

Stem cell populations can be derived from the patient (autologous) or a donor human (allogenic). Sources include bone marrow aspirate, adipose tissue, blood progenitor cells and even amniotic tissue. These cells can then be manipulated or concentrated and injected into the knee.

Stem cell therapy is now used to treat knee injuries, focal cartilage defects, knee osteoarthritis and other knee pain and problem. Some researchers and practitioners attest to the effectiveness of stem cell therapy for pain, despite the fact that there are also other professionals who oppose such claims.

Believers of stem cell treatment say people with knee injuries are good candidates for such treatment.   Stem cells are now used as an alternative to traditional options like total knee joint replacement and arthroscopic knee surgery. With stem cells, the recovery period is said to be faster and better compared to surgery.

My Final Word on Stem Cell Therapy

A review of the English scientific literature was published recently. The efficacy of these treatments has not been established. In theory, stem cells are beneficial to knee injuries and arthritis. However, as already mentioned, this is not widely accepted yet as standard practice and there are still debates as regards its effectiveness. Nevertheless and fortunately, this treatment is safe and there are no associated risks for the patients. Still, it is important for prospective patients to become familiar with the science behind this treatment before seeking cellular-based therapies.

Aside from stem cell therapy, there are other surgical treatments using autologous stem cells and a biologic scaffold (hylofast) that is implanted directly into focal chondral lesions of the knee. This is a different treatment altogether and may hold promise in the near future. Meanwhile, we will just wait for further developments regarding stem cell therapy in general.

If you’re interested in seeking treatment for your knee arthritis, please make an appointment with my office so we can talk about the best scientifically validated treatments out there.

 

Knee Arthritis: A Primer

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Facts About Arthritis of the Knee

A 15 year study of middled aged (avg 53 years) of normal body weight (BMI avg 25) from the United Kingdom provides insight on the incidence and severity of symptomatic Knee OsteoArthritis.

These data are gender specific and since this is a normal weight population can not be extrapolated to the obese population. The annual rate at which middle-age women develop knee osteoarthritis (OA) is fairly low, but progression is common when x-ray changes in the joint are already present, a community-based cohort study found.
During 15 years of follow-up there is a 49% lifetime risk of developing symptomatic (not necessarily severe OA of the knee). 51% of normal weight women never develop knee arthritis.

Among the entire cohort, 561 had undergone knee radiography at baseline and then at years 5, 10, and 15.
High body mass index also was associated with an increased incidence, with a nearly 20% greater incidence by year 10 among obese women.

At 15 year followup nearly 30 % of those women with knee arthritis had the disease in both knees.  70 % had symptomatic arthritis in only one knee.
The rate of total knee replacement by year 15 was about 10 %.
The also know risk factors in order of significance are genetics, obesity, female gender, serious knee injury (bone or ligament or meniscus).

Knee Osteoarthritis Treatment Options – AUC from AAOS A Guide

AUC (appropriate use criteria) are meant to augment—not supersede—clinician expertise and experience or patient preference. The scope of this AUC includes nonpharmacologic and pharmacologic interventions for symptomatic OA of the knee as well as surgical procedures less invasive than total or partial knee replacement.
  • The new appropriate use criteria (AUC) on nonarthroplasty treatment of patients with OA of the knee covers 10 different treatment options and more than 500 patient scenarios.
  • A web-based application (www.aaos.org/aucapp) enables clinicians to submit a patient profile based on specific clinical findings and receive feedback on the appropriateness of various treatment options.
  • Although the AUC addresses the most common clinical scenarios, it does not include all of the possible indications, and is not meant to supersede clinician expertise and experience or patient preference.
The full AUC can be found on the website of the American Academy of Orthopedic Surgeons.  Try it yourself.
Open the AUC.  Enter the patient specific information detailing knee pain, knee range of motion, knee stability, knee xray findings, knee aligment (bow legged or knock kneed), meniscal symptoms and patient age.  Enter submit and treatment options categorized as appropriate, may be appropriate and rarely appropriate will be shown.  These options now provide a basis for an intelligent conversation between the patient and the orthopedic surgeon with respect to non surgical and surgical treatment options.

Viscosupplementation for Knee Arthritis

Dr. Tarlow’s opinion – About half of my patients with mild to moderate osteoarthritis of the knee Visco injections report less pain and better function for 6-12 months following a series 3 weekly injections – brand of Visco does not matter in outcome. Patients with severe OA rarely benefit from type of injection.
OA is the death of the articular cartilage cells that cover the bone.

 Here is a summary of the recent literature review:

Hyaluronic acid has little effect on pain, none on function, new review states

Tuesday, June 12, 2012

If the first series of injections help then it is likely a repeat series will be successful. Not all insurers reimburse for this medication – so many patients pay out of pocket for the drug and come to the office for the doctor to inject the drug into their knee.

Another unknown is how and why this medication decreases pain – the mechanism is not clear at this time.

escribe injections of hyaluronic acid, also called viscosupplementation.
There is no evidence to suggest that viscosupplementation results in any relevant reduction in symptoms in patients with knee osteoarthritis, said study co-author Dr. Peter Juni, professor of clinical epidemiology at the University of Bern in Switzerland.
The U.S. Food and Drug Administration in 1997 approved the injections, which are commercially available from several companies and much more costly than pain relievers.
For the study, Juni’s team reviewed 89 studies that compared injections with either a placebo treatment or no treatment. In all, the studies involved more than 12,000 adults aged 50 to 72.
The effect on pain was minimal, and the injections had no effect on functioning, the researchers found.
In some of the studies, the injections reached peak effectiveness at eight weeks, then declined.
“Viscosupplementation therapy for the knee appears to have some transient improvement in a relatively small number of patients for variable periods of time — most often six to 12 months,”
Look at the pros and cons from a patient’s perspective. Many turn to the injections to avoid surgery or medications, which can have their own harmful side effects, he said.
“Some patients, however — particularly patients with earlier stage arthritis — benefitted from viscosupplementation for periods of time sufficient to continue the use of this therapy,” he said.

Diet + Exercise Effective

Report in JAMA September 25, 2013 (Journal of the American Medical Association) concludes Diet and Exercise is Effective in Improving quality of life (diminishing symptoms of pain, improving function/mobility) compared to exercise alone in overweight and obese patients with Osteoarthritis of the knee. Weight loss was greater in the Diet/Exercise group (11 %) compared to Exercise group (2%).

Details: According to a study published in the Sept. 25 issue of JAMA, diet and exercise may improve quality of life more than exercise alone for overweight and obese adults with knee osteoarthritis (OA). The authors conducted a randomized, single-blind trial of 399 patients who were allocated to one of three groups: diet, exercise, and diet plus exercise. At 18-month follow-up, the authors found that mean weight loss was 11.4 percent for participants in the diet plus exercise cohort, 9.5 percent in the diet group, and 2.0 percent in the exercise group. In addition, knee compressive forces were lower in diet participants compared with exercise participants, and concentrations of IL-6 were lower in diet plus exercise and diet participants compared against exercise participants. Finally, patients in the diet plus exercise group had less pain and better function than those in the diet group or the exercise group, and the diet plus exercise group had better physical health-related quality of life scores than those in the exercise group.

Link to Abstract – https://jama.jamanetwork.com/article.aspx?articleid=1741824.

Dr. T Speaks —– Hello People. There are simple measure that are dramatically effective in helping you treat yourself with medications, injections, or surgery. Make the effort to convert America into a healthier place. This is an easy way to treat a common problem that is effective and will lower health care costs. Take ownership of your own well being.

Physical Activity

Research suggesting that physical activity could help prevent Knee Osteoarthritis has been presented this week at the AVS 62nd International Symposium and Exhibition, in San Jose, CA.

Researchers including Dr. Burris at the University of Delaware found that as the sliding speed increased toward typical walking speeds cartilage thinning was reversed. At slow sliding speeds (less than would occur in a joint at typical walking speeds) cartilage thinning and an increase in friction occurred over time. This may explain why walking or cycling can mitigate knee pain in patients with osteoarthritis of the knee.
A healthy joint surface is composed of 80 % synovial fluid (water and proteins). To investigate whether hydrodynamic pressurization could refill deflated cartilage, the researchers placed larger-than-average cartilage samples against a glass flat to ensure that there would be a wedge. Pressure forced fluid back into the articular cartilage stopping the joint surface from deflating. If movement occurs faster than the fluid can diffuse then continuous knee movement could prevent deflation.
Articular Cartilage is a firm, porous, rubbery material covering the ends of the bones in the knee joint. It reduces friction in the joint and acts as a “shock absorber.” Loss of synovial fluid occurs when articular cartilage is damaged or diseased. Osteoarthritis is a degenerative disease resulting from a reduction in the articular cartilage thickness, leading to an increase in friction, inflammation, pain and deformity of legs.

When cartilage becomes damaged or deteriorates, it limits the knee’s normal movement and can cause significant pain, and eventually the need for knee replacement surgery.

Surface damage to articular cartilage in a knee

Knee Braces

Non Operative Treatment of Knee Pain/Arthritis with BracingAdvanced Knee Care offers a custom bracing service to patients. This service includes a brief physician visit to confirm the diagnosis and need for the brace, a confirmatory x-ray of the knee and a detailed visit with our bracing specialist, Megan. The charge for this screening visit is $50 (insurance will be billed, if applicable).

The concept for this service is that there are many people that can be treated without surgery. A knee brace may be just what is needed to keep one active for years—no surgery required. This treatment is for people with Knee Pain and Knee Arthritis (either in the main joint or in the patellofemoral joint) that do not want a complex or expensive work up by the doctor, have already tried the myriad of other options for knee arthritis (pills, injections, Physical Therapy, Arthroscopic Surgery) and want a streamlined way to purchase a knee brace to help improve their knee function, help them be more active, and help them exercise to stay fit. There are also good bracing applications for runners with knee pain.

Treat Depression

A Korean study published in March, 2011 concludes that depression is linked to knee arthritis symptoms. The authors evaluated 660 patients aged 65 years or older; severity of knee OA was assessed based on radiographs and symptoms and depression was assessed based on interviews and patient questionnaires. The presence of a depressive disorder was associated with increased risk of symptomatic knee OA among patients with a radiographic severity of minimal to moderate OA.

Mental well being and a positive outlook help people cope with and tolerate symptoms of disease. In this study, a person with minimal to moderate Knee Osteoarthritis was more likely to have moderate to severe symptoms, and the reason for the increased dysfunction was thought to be due to poor mental health, not poor physical health.

This is a good lesson for both patients and doctors. Always consider a person’s overall health when formulating treatment plans. In some cases treatment should be directed at the cause of symptoms (treat depression, not knee arthritis) for the best outcome.

Improving Your Knee Replacement Results

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How to Improve Total Knee Replacement (TKR) Results

Here are five “fun facts” about Total Knee Replacement.

1.  Have the same surgical team for every case (Surgeon, Assistant Surgeon, Circulating Nurse, Scrub Tech, Second assistant, and anesthesia).  30 day readmission rates due to complications are lower when consistent teams are used.

2.  Use Saphenous Nerve blocks (adductor canal blocks).  This provides better post op pain relief and shorter hospital stays or allows for same day Total Knee surgery.

3.  Emphasize the importance of post op rehabilitation.  Stronger quadriceps muscles are correlated with increased patient satisfaction after TKR.

4.  Unexplained knee pain 6 months after TKR surgery predicts a poor functional outcome at 2 years post op.

5.  Total Joint clinics see a higher percentage of obese people than are present in the total population.  Obesity is a modifiable risk factor for hip and knee osteoarthritis.

Research suggests spinal and epidural anesthesia, peripheral nerve blocks safe to use

Released: 2/14/2014 4:00 PM EST
Source Newsroom: American Society of Anesthesiologists (ASA
Citations Anesthesiology
Newswise — Two types of regional anesthesia do not make patients more prone to falls in the first days after having knee replacement surgery as some have previously suggested, according to a study based on nearly 200,000 patient records in the March issue of Anesthesiology.
Regional forms of anesthesia – spinal or epidural (neuraxial) anesthesia and peripheral nerve blocks (PNB) – which only numb the area of the body that requires surgery, provide better pain control and faster rehabilitation and fewer complications than general anesthesia, research shows. But some surgeons avoid using them due to concerns regional anesthesia may cause motor weakness, making patients more likely to fall when they are walking in the first days after knee replacement surgery.
“We found that not only do these types of anesthesia not increase the risk of falls, but also spinal or epidural anesthesia may even decrease the risk compared to general anesthesia,” said Stavros G. Memtsoudis, M.D., Ph.D., professor of anesthesiology and public health and director of critical care services, Hospital for Special Surgery, New York, and lead author. “This work suggests that fear of in-hospital falls is not a reason to avoid regional anesthesia for orthopedic surgery.”
Researchers analyzed the types of anesthesia used in 191,570 knee replacement surgeries in the Premier Perspective database: 76.2 percent of patients had general anesthesia, 10.9 percent had spinal or epidural anesthesia, and 12.9 percent had a combination of neuraxial and general anesthesia. In addition, 12.1 percent of all patients had PNB. Researchers then analyzed the type of anesthesia used for those who suffered a fall in the hospital. Of patients who had general anesthesia, 1.62 percent fell, compared to 1.3 percent of those who had neuraxial anesthesia and 1.5 percent who had general and neuraxial anesthesia. Patients who also received a PNB had a fall rate of 1.58 percent.
When patients fall during recovery, they are more likely to have worse outcomes, including more heart and lung problems and higher rates of death within 30 days of surgery. Spinal or epidural anesthesia and PNB are used far less often than general anesthesia because of concern that regional forms of anesthesia – particularly PNB – may increase muscle weakness and make patients more prone to falls. However, there has never been a large study based on real-world practices to determine if that is true.
“In this study using data from a wide range of hospital settings we found this concern seems unfounded, especially because hospitals and physicians performing these procedures use fall-prevention programs and are able to reduce the impact of other factors shown to increase fall risk, such as higher narcotic use,” said Dr. Memtsoudis.

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