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.

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.

Which Knee Injection is “Better” for Knee Arthritis?

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Knee injection photo

Have you tried taking oral medications for your knee arthritis but to no avail? Are you not getting the relief that you need from these meds? A knee injection can be a great option. Injection is beneficial to patients who had no relief from taking medications but are not quite ready to undergo surgery. Since there are various kinds of injection for knee arthritis, the question really is: which is better?

Hyaluronic Acid Vs. Corticosteroid

Patients with mild to moderate knee arthritis commonly receive injections for relief of knee pain and knee stiffness associated with arthritis. Patients with severe or “bone on bone’ knee arthritis were excluded from this study since these patients do not respond as well to these two treatments. The two common options for injection treatment of knee arthritis are hyaluronic acid (HA, visco supplementation) and corticosteroid (steroid). Patients often ask which option “is better.” A comparison study of these two treatments was published recently.

According to studies, there are no significant differences noted between patients who were injected with hyaluronic acid and those injected with corticosteroid. Both knee injection treatments provide improvements in patients with knee arthritis, relieving their pain and improving their function. However, of the two, hyaluronic acid is more expensive.

Hyaluronic Acid/Viscosupplementation

Hyaluronic acid injection is also known as viscosupplementation. This is a medical procedure which involves injecting lubricating fluid into the joint of the affected knee. This is used to treat the pain and other symptoms of knee osteoarthritis. The hyaluronic acid is naturally found in healthy joints. However, there’s a significant reduction in this joint fluid when the knees are affected by arthritis. Hence, there is a need to inject the joint with such acid.

This knee injection helps in facilitating better knee movement and function, reducing pain and other symptoms, and slows the progression of the knee arthritis. However, in order for the hyaluronic acid injection to work better, it must be coupled with a strong rehabilitation program.

Corticosteriod

Corticosteroids are similar to the hormone substances that our body naturally produces to reduce inflammation. The primary function of corticosteroid is to reduce the inflammation by decreasing our body’s immune response. Because of this, this medication is now used as a knee injection for arthritis. Low doses of corticosteroids are injected into the affected joint. The shots can increase the function, reduce the inflammation and relieve the pain of the patients. These effects may last from weeks to months.

The Results

Both Triamcinolone (corticosteroid) and SynviscOne (hyaluronic acid) provided successful and similar improvement in pain relief, function and range of motion at the 6 month interval. There are no significant differences when it comes to the pain relief and improvement of function in patients. So which knee injection is better? That depends on your preference and that of your health provider. Both treatments, as proven by studies, are equally effective and safe.

If you need help your arthritis or knee problem, make an appointment. Contact Tarlow Knee today and we will help you regain your normal function and relieve your pain.

Acupuncture Effect on Knee Arthritis Pain

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Acupuncture photo

Acupuncture is a popular alternative medicine. A key component of traditional Chinese medicine, acupuncture involves inserting thin needles into the body. This technique is believed to promote the balance of the flow of energy and the chi. It is commonly used to treat different kinds of pain.

Acupuncture for Arthritis

Acupuncture has traditionally been used to treat various conditions, including arthritis. People suffering from arthritis may consider acupuncture as an option to manage and relieve the pain. It may not cure the condition, but can naturally relieve the arthritic symptoms, particularly the inflammation in the joints and the pain.

This technique dates back more than 2,000 years ago. The Chinese have continually used this for various conditions since then. As such, it is considered to be one of the oldest traditional medical procedures. As already mentioned earlier, the main goal of acupuncture, aside from alleviating certain symptoms, is to resolve energy imbalances and promote a well-balanced chi.

But how can acupuncture help arthritis? Acupuncture involves the insertion of fine needles into the skin. These needles are not just inserted anywhere, but at specific locations called “acupoints.” When these “acupoints” are inserted with needles, our body releases endorphins, which are natural pain-killing chemicals; thus, the pain is relieved. It also helps alleviate discomfort and other symptoms because acupuncture is said to affect the body’s serotonin, which is a brain chemical responsible for promoting good mood. This way, the technique helps alleviate the pain and other symptoms associated with arthritis.

Acupuncture Treatment for Knee Arthritis

Knee pain is now being treated using acupuncture. This is because this traditional Chinese medicine is known for its ability to promote comfort and relieve pain. But how effective is it and how long does the relief last?

There have been studies that confirm the benefits of acupuncture in reducing knee pain, inflammation, immobility and stiffness. Patients with knee problems experienced comfort and relief after trying out acupuncture.

Moreover, a study in the September 2016 JBJS looked at how acupuncture lowered pain and improved function in patients with osteoarthritis of the knee. The acupuncture group had better knee function at both 13 and 26 weeks compared to controls. The acupuncture group had superior pain improvement after 13 weeks but not after 26 weeks.

So what does this imply? There is no question that acupuncture can help bring pain relief and comfort to the patient. However, it does not really cure the condition and the effect is only temporary.

The Bottom Line

My take on acupuncture is that it is beneficial as temporary treatment. Patients that need short term pain relief should consider acupuncture as a viable treatment option. There’s no harm in trying, especially if all you really want is to be relieved from the pain even just for a while. However, if you want long-lasting relief, there are other options you can try to treat your knee pain and other arthritis symptoms.

If you have arthritis and are looking for other treatment options, contact a professional. Make an appointment with me to discuss your arthritis and what treatment is right for you.

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.

Knee Surgery for Obese Patients: Problems and Solutions

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Why Obesity Poses Greater Risks for Surgical Complications

A literature review published in the May issue of the Journal of Arthroplasty attempts to define and identify areas of concern for obese patients undergoing total joint arthroplasty (TJA). “Obesity risk assessment is compounded by the fact that obesity is rarely an isolated diagnosis,” the authors write, “and tends to cluster with other co-morbidities that may independently lead to increased risk such as diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, and sleep apnea.” Among the authors’ findings:
    • Despite improvements in patient-related outcome measures, all obese patients undergoing total joint arthroplasty are at increased risk for perioperative complications.
    • Patients with a body mass index greater than or equal to 40 who undergo total knee arthroplasty are at risk for the majority of perioperative complications.
  • Published data on perioperative complications among obese patients undergoing total hip arthroplasty appear to be less clear.

New Procedure Offers Treatment Option for Obese Patients With Knee Pain

Subchondrplasty Joint Preservation Treatment Less Invasive Than Joint Replacement Surgery.
 
Photo of MRI of BME-Xray normal From Zimmer Institute
MRI of BME-Xray normal
From Zimmer Institute

Subchondroplasty® Procedure is the innovative new joint preservation procedure developed by Zimmer Knee Creations to treat the microfractures that develop just under the joint surface in painful knees.  These lesions are similar to stress fractures and develop due to overload of the bones that make up the knee joint.

 
Rather than replacing the entire knee, this treatment aims to stimulate nature to heal the bone lesion which can lead to reduced knee pain and better knee function.   Subchondroplasty is an arthroscopic knee surgical procedure done as an outpatient.  This is a safer and less invasive procedure than Total or Partial knee replacement and as such may be carried out in higher risk surgical patients, such as the obese patient,  with less fear of an adverse outcome such as infection or blood clot.
 
BML-MRI image
BML-MRI image
From Zimmer Institute
Bone Marrow Edema (BME), or Bone Marrow Lesions (BML) are thought to cause pain in knees with early or late osteoarthritis.  These lesions can only be diagnosed with high resolution 3 T MRI scans.  In 2001 Felson identified BME/BML as the strongest predictor of the presence of pain associated with knee OA.  They also determined that arthroscopy alone will not predictably relieve knee pain associated with arthritis.
 
 
This observation has been confirmed by other investigators.   However, the novel Subchondroplasty® Procedure is a percutaneous outpatient intervention that addresses the painful defects associated with subchondral bone marrow lesions (BME/BML). BMLs are related to stress fractures or micro-fractures, that can only be visualized using MRI scans. Left untreated, these defects have been shown to lead to cartilage degeneration, limited function, pain and greater risk for joint deterioration.
Theoretically, mechanical enhancement and/or biologic stimulation of chronically damaged and structurally compromised SubChondral bone, juxtaposed to a region of the joint with deficient cartilage, will relieve Knee pain emanating from the SubChondral bone and slow progression both bone and cartilage deterioration.
 
SCP Surgical Procedure Photo
From Zimmer Institute
 
 
In this minimally invasive, arthroscopically-assisted procedure, navigation instruments are used to inject specialized Ceramic Calcium Phosphate bone filler (Etex), without violating the joint. As the bone filler is resorbed, the pain due to BML subsides as the lesion is replaced with new, healthy bone.  The substitution of abnormal bone with healthy bone is the reason patients experience pain relief.    The Subchondroplasty Procedure is the first procedure to treat bone-based changes within a painful joint, and addresses an unmet clinical need between early interventions, such as NSAIDs and joint arthroscopy, and total joint replacement. Subchondroplasty was introduced in November 2010.  This procedure is now available in the Greater Phoenix area from Makoplasty Surgeon Stefan D. Tarlow, M.D. of Advanced Knee Care, PC.

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